Fibromyalgia syndrome

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Fibromyalgia syndrome

• Dr Helen Allcock

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Definition

• History of widespread pain
• Pain in the left and in the right side of the
  body, pain above and below the waist.
• In addition, axial skeletal pain (cervical spine
  or anterior chest or thoracic spine or low back)
  must be present.

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Pain in 11 of 18 tender point sites on digital
palpation

• occiput bilateral, at the suboccipital muscle
  insertions
• low cervical bilateral, at the anterior aspects
  of the intertransverse spaces at C5-7
• trapezius bilateral, at the midpoint of the
  upper border
• supraspinatus bilateral, at the origins, above
  the scapulae spine near the medial border

4

• second rib bilateral, at the second
  costochondral junctions, just lateral to the
  junctions of the upper surface
• lateral epicondyle bilateral, 2cm distal to the
  epicondyles
• gluteal bilateral, in outer quadrants of
  buttocks in anterior fold of muscle
• greater trochanter bilateral, posterior to the
  trochanteric prominence
• Knee bilateral, at the medial fat pad proximal
  to the joint line

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Digital palpation

• Should be performed with an approximate force of
  4kg.
• For a tender point to be considered 'positive'
  the subject must state that the palpation was
  painful. 'Tender' is not considered painful.
• For classification purposes, patients will be
  said to have fibromyalgia if both criteria are
  satisfied.
• Widespread pain must have been present for at
  least 3 months.
• The presence of a second clinical disorder does
  not exclude the diagnosis of fibromyalgia

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Prevalence

• just above 10 (ACR) 1990 definition has been
  used?about 5 if the more stringent 'Manchester
  definition' used
• twice as high for women as for men
• The prevalence of fibromyalgia?0.7 to 4.8 in
  comparable studies using the ACR 1990 criteria
• female to male ration between 31 and 71

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Pathogenesis

• Probably multiple factors
• However the sleep disturbance is thought to be of
  major importance
• there is a loss of non-REM sleep
• a fibromyalgia-like syndrome may be induced in
  normal volunteers be depriving them of non-REM
  sleep
• Reduced aerobic fitness may also be important
• Affective symptoms are associated with the
  fibromyalgia syndrome but whether they are
  primary or secondary is unknown
• A viral cause for the fibromyalgia syndrome is
  not supported by any evidence.

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Symptoms

• Include
• pain in back and neck
• worse in cold weather
• hyperalgesia with multiple trigger areas
• non-restorative sleep
• Fatiguability
• Headaches
• abdominal pains
• urinary frequency with urgency

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Signs

• Include
• absence of objective cause for pain
• no objective neurological deficits
• multiple hyperalgesic sites
• especially over bony protuberances e.g. greater
  trochanter of the femur
• tenderness to rolling the skin e.g. mid-trapezius

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Differential diagnosis

• Hypothyroidism
• systemic lupus erythematosus
• inflammatory myopathy
• Hyperparathyroidism
• osteomalaciaism

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Management

• Explanation to patient and the family relieves
  concerns about sinister causes for pain
• patients can rationalize pain in terms of lack of
  fitness and sleep
• avoid unnecessary investigations
• increase aerobic exercise
• low dose amitriptyline
• initially on a trial for 4-6 weeks - dose is
  lower than for depres

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Prognosis

• Poor 20 will be symptom-free at 5 yr
• Treatment may help with coping strategies