Fibromyalgia is a disease with widespread
and chronic pain syndromes in which the patients experience an increase in pain
sensations. Its pathophysiology is poorly understood and can occur at any age.
However, it is more common among the female population with dominance ratio of
10:1. (Wolfe et al., 1990).
There is evidence of association
of psychosocial stressors with the development of the disease and the common documented
psychosocial stressor is sleep
abnormality. Another accepted theory for its development is an abnormality in the
processing of both central and peripheral pain which leads to reduction of the
threshold for pain (McCance et al., 2014). The majority of the affected
population is usually aged between 30 and 60 years with the prevalence in the
US and UK estimated to be close to 2% – 5% according toWolfe et al., 1990.
SIGNS AND SYMPTOMS SEEN
The commonest presenting
feature of fibromyalgia is often pain which is regional and affecting the
muscle and joints of the back, neck and chest and occursfor more that3 months. The
pain is commonly felt all over the body and rarely responds to common
analgesics and other NSAIDS such as paracetamol (Goolsby et al., 2014). Symptoms
at times occur throughout the day and are associated with general fatigue and inability
to do normal work since even activity would aggravate the symptoms.
These patients commonly
experience stiffness more so in the morning accompanied by major disability, sensations
of tingling in the fingers with ocassional swelling of hands and fingers (Wolfe
et al., 1990). Some symptoms are not
musculoskeletal in nature and include disturbances of sleep, poor or lack of
concentration, decreased affect, headaches which are usually described as bi-frontal
and unsatisfactory sleep. Other patients
have features of Irritable Bowel Syndrome like bloating and cramoing abdominal
There is usually an exaggerated
response to non-noxious stimuli like touch
ASSESSMENT TOOLS AND DIAGNOSTIC TESTS
Fibromyalgia symptoms usually are
difficult to explain in terms of medical causes (Goolsby et al., 2014). It is
however important to rule out other medical conditions that might be responsible
for some of the patient’s symptoms such as thyroid disease, SLE, rheumatoid
arthritis and myopathies such as polymyositis.
Diagnosis of fibromyalgia based
on the modified 2010 ACR criteria which advocate for the administration of a
questionnaire to affected patients to assess themselves. It considers three
aspect of the disease; distribution of pain over 19 body areas described in a
Widespread Pain Index (WPI). For each painful area, a score of 1 point is given
making a maximum score of 19. The second aspect considers how severe the
symptoms are in terms of fatigue, disturbance of sleep and dysfunction of the
cognitive system. Its scores range from 0 to 3 with 0 being no disturbance
while 3 is very severe disturbance. (Medscape)
The third aspect takes into
consideration non-musculoskeletal symptoms cramping abdominal pains, depressed
states, headaches and urinary dysfunction over past 6 months. Presence of any
of the above symptoms would score a point.
The second and third aspects of
the criteria form the Severity Scale (SS) that sums to 12 and adding these to
the WPI creates a total score index of 31. If a patient scores 13 or more and
other possible causes of symptoms have been ruled out then a fibromyalgia is is
likely the diagnosis.
As part of the screening,
physical examination that maps tender points (which are usually 19) can also be
conducted. Pain in 11 or more of these points can be considered diagnostic.
Other assessment options include Full Blood Count to rule out anemia and lymphopenia
(due to Systemic Lupus Erythematosus (SLE)). Others are Erythrocyte
Sedimentation Rate and C – reactive protein levels to rule out inflammatory
causes, Thyroid Function Tests to rule out thyroid disease and Anti-Nuclear
Antibodies to rule out SLE.
The physical examinations are mostly
normal without underlying pathologies and as such the diagnosis of fibromyalgia
is usually one of exclusion (Goolsby et al., 2014).
PLANS BASED ON CURRENT CLINICAL PRACTICE GUIDELINES
exercise that is graded has recently been shown to improve symptoms by improving
sleep quality. Also patients who are educated about the condition seem to fair
well compared to non-educated ones. Holding group sessions also seem to help
improve energy levels of the patients, sleep and quality of life (Burckhardt, C. S.et al., 1991). Strong
evidence also exists in support of Cognitive Behavior Therapy and hypnotherapy
especially when the programs are individualized. It helps to reduce pain and
greatly improve mood and functions.
Pharmacologic: There exists strong evidence for the use of Tricyclic
Anti-depressants such as Amitriptyline, dosed at 25-50 mg at bedtime. Other medications
with strong efficacy include Pregabalin which helps to reduce pain and improve
sleep, given 300-450 mg per day (Woo., et al, 2012), Gabepentin, given 1600-2400
mg daily and Duloxetine at 60-120 mg daily (Woo., et al, 2012). Raloxifen (Evista)
which is a selective estrogen receptor modulator given 60mg daily improves
pain, fatigue and day to day functions in post-menopausal women who have
Burckhardt, C. S., Clark, S. R.,
& Bennett, R. M. (1991). The fibromyalgia impact questionnaire:
development and validation. J
rheumatol, 18(5), 728-733.
Jo, M., Grubbs, Laurie. (2014). Advanced Assessment: Interpreting Findings and
Formulating Differential Diagnoses, 3rd Edition.
McCance, K., Huether, S., Brashers, V. & Rote, N. (2014). Pathophysiology:
The Biologic Basis for Disease in Adults and Children.
Medscape phone app
Woo, T. M., & Wynne, A. L. (2012). Pharmacotherapeutics for nurse
practitioner prescribers (3rd ed.). Philadelphia, PA: F.A. Davis Co.
Wolfe, F., Smythe, H. A., Yunus, M.
B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., …
& Fam, A. G. (1990). The American College of Rheumatology
1990 criteria for the classification of fibromyalgia. Arthritis &
Rheumatology, 33(2), 160-172.