Fibromyalgia

A chronic clinical syndrome characterised by widespread non-inflammatory musculoskeletal pain, accompanied by:
- Fatigue
- Non-restorative sleep
- Cognitive dysfunction (“fibro fog”)
- Mood disturbances (e.g., depression, anxiety)
- Gastrointestinal (e.g., IBS) and urogenital (e.g., irritable bladder) symptoms
Pathophysiology
- Not fully understood
- Believed to be due to central sensitisation: abnormal pain processing in the CNS
- No evidence of tissue inflammation or structural pathology
Epidemiology
Parameter | Data |
---|---|
Gender | Female predominance (F:M > 3:1) |
Age of Onset | Peak: 20–60 years; typically 25–45 years |
General Population Prevalence | 2–5% |
Female Population | 2–3% |
Rheumatology Clinics | ~15% of patients |
Second only to osteoarthritis in prevalence | |
Common cause of chronic diffuse pain in women aged 20–55 |
🌟Clinical Features
Core Symptoms
- Widespread pain: Bilateral, above and below the waist, including axial skeleton
- Fatigue: Often severe, not relieved by rest
- Non-restorative sleep: Difficulty initiating and maintaining sleep, unrefreshing sleep
- Cognitive dysfunction: Poor concentration, memory lapses (“fibro fog”)
Associated Symptoms
- Morning stiffness >15 minutes
- Paresthesias (atypical, patchy)
- Migraines, tension-type headaches
- Irritable bowel syndrome (30–70%)
- Dysmenorrhea
- Anxiety (48%), depression (31%)
- Urinary urgency (26%), dry mouth (36%)
- Sleep disorders: Sleep apnea, restless leg syndrome, nocturnal myoclonus
- Raynaud’s phenomenon or cold sensitivity (17%)
Aggravating Factors
- Physical exertion
- Emotional stress or psychological trauma
- Poor sleep hygiene
🌟Diagnosis
General Principles
- Diagnosis of exclusion
- Symptoms must be present for ≥3 months
- Rule out inflammatory, endocrine, neurological, and other chronic pain conditions
1990 ACR Criteria
- Widespread pain in all 4 body quadrants for ≥3 months
- Pain in ≥11 of 18 tender points with 4 kg pressure
2010 ACR Criteria (Updated)
Component | Description |
---|---|
Widespread Pain Index (WPI) | Count of painful areas (0–19) |
Symptom Severity Scale (SSS) | Measures fatigue, sleep disturbance, cognitive symptoms (0–12) |
Diagnostic Threshold | WPI ≥7 & SSS ≥5, or WPI 3–6 & SSS ≥9 |
Duration | Symptoms present ≥3 months |
Exclusion | No alternative diagnosis that better explains symptoms |
🌟Differential Diagnoses
Condition | Distinguishing Features |
---|---|
Rheumatoid Arthritis | Inflammatory joint changes RF/ACPA positive |
SLE | Multisystem involvement ANA positive |
Hypothyroidism | Weight gain cold intolerance abnormal TSH |
Chronic Fatigue Syndrome | Fatigue predominates over pain |
Sleep Disorders | Polysomnography abnormalities e.g., OSA |
Mood Disorders | Depression/anxiety may mimic or exacerbate symptoms |
Red Flags (Suggest alternative diagnosis)
- Onset >65 years
- Weight loss
- Night pain or focal pain
- Fever, sweats
- Neurological deficits
- Malignancy history
Yellow Flags (Psychosocial contributors)
Domain | Examples |
---|---|
Pain profile/ Somatic Load | Widespread pain index > 12 or baseline pain ≥ 7/10 Symptom duration > 2 y before diagnosis Higher baseline pain and longer untreated duration predict poorer response to therap ≥ 3 co-existing functional pain disorders (e.g. IBS, migraine, TMJ dysfunction) High somatic symptom burden on PHQ-15 – Multiple somatic symptoms predict refractory pain and poorer quality-of-life trajectories |
Psychological | Catastrophizing: Exaggerated negative thoughts about pain and its life impact. Depression and Anxiety: Emotional distress worsens symptoms and reduces coping. Fear-Avoidance Beliefs: Avoiding movement due to fear of exacerbating pain. Low Self-Efficacy: Limited confidence in managing pain or daily activities. High Stress Levels: Triggers symptom flares and affects overall wellbeing. |
Social | Social Isolation: Poor support systems worsen emotional health and pain experience. Unstable Home Environment: Family conflict increases stress and symptom burden. Occupational Stress: Work-related pressures can provoke flare-ups or impair recovery. |
Behavioural | Poor Coping Strategies: Maladaptive behaviors (e.g., medication overuse, avoidance). Sleep Disturbances: Non-restorative sleep perpetuates fatigue and pain. – Higher baseline pain and longer untreated duration predict poorer response to therapy |
Cognitive | Negative Pain Beliefs: Viewing pain as uncontrollable or dangerous worsens symptoms. Unrealistic Expectations: Expecting complete/rapid relief may cause treatment disengagement. • Prominent “fibro-fog”, memory or executive-function complaints – Cognitive dysfunction correlates with larger functional impact and slower recovery with rehab |
Lifestyle & physical status | Sedentary behaviour or exercise intolerance BMI ≥ 30 kg/m² (obesity) Current opioid or benzodiazepine use – Obesity and baseline opioid use independently reduce the likelihood of improvement with exercise or CBT programmes |
To identify these yellow flags in patients with fibromyalgia, consider asking the following questions during clinical assess – Key Screening Questions
- “How do you feel about your ability to manage your pain?”
- “Do you believe physical activity might worsen your pain?”
- “How much support do you have from family or friends?”
- “Have you been feeling down, stressed, or anxious lately?”
- “How well are you sleeping? Do you wake feeling rested?”
- “What strategies do you use to cope with pain and stress?”
- “Are there any significant stressors in your life right now?”
- “How do you think pain is affecting your life and your future?”
Fibromyalgia Management
First-diagnosis conversation: evidence-based communication techniques
Goal | Practical approach | Why it matters |
---|---|---|
Validate and legitimise symptoms | • Begin with Ask-Tell-Ask: “Can you describe in your own words how the pain affects your day?” → summarise → “Does that fit with what you’re experiencing?” | Reduces perceived dismissal and is therapeutic in itself RCP |
Use clear, biopsychosocial explanations | • Explain central pain processing in non-technical language: “Your nerves have become oversensitive—like a volume knob stuck on high.” | Improves illness coherence and engagement with non-drug therapies aafp.org |
Normalise uncertainty but give hope | • Acknowledge that fibromyalgia is invisible on scans, yet very real and manageable • Emphasise reversible neuroplasticity and high odds of improvement with active self-management | Re-frames prognosis from “incurable” to “treatable”, countering catastrophising ScienceDirect |
Shared decision-making (SDM) | • Present the stepped-care options (education → graded exercise → CBT ± targeted meds) and elicit patient values • Use decision aids or written handouts (e.g. RCP patient sheet) | SDM increases adherence and satisfaction; recommended in Australian fibromyalgia care models Fibromyalgia AustraliaRCP |
Teach-back for understanding | • “Just so I know I explained this well, can you tell me what fibromyalgia means to you and the first step we agreed on?” | Confirms comprehension and corrects misconceptions, aligning with Australian safety-and-quality communication standards Safety and Quality in Health Care |
Empathic, strength-based language | • Avoid “psychogenic” or “it’s all in your head” • Highlight existing coping strategies and resilience | Enhances therapeutic alliance and counters stigma ScienceDirect |
Written resources & follow-up plan | • Provide reputable Australian websites/support groups, exercise diaries, sleep-hygiene tips • Schedule review within 4–6 weeks to revisit goals and barriers | Continuity reinforces education and identifies early setbacks Fibromyalgia Australia |
🌟Non Pharmacological
1. Patient Education
- Nature of Condition:
- Fibromyalgia is a benign, non-deforming, and non-progressive condition.
- Pain is real, but not due to ongoing tissue damage.
- Expectations:
- Symptoms often fluctuate, leading to patient frustration.
- Treatment goal: improve function and quality of life, not complete pain elimination.
2. Exercise and Physical Therapy
- Core Principle: Regular low-impact aerobic exercise is foundational in symptom control.
- Recommended Activities:
- Swimming or water aerobics
- Fast walking
- Stationary or outdoor cycling
- Physiotherapy:
- Tailored programs to improve muscle strength, flexibility, and postural support.
- Focus on core stability and neck/back support (e.g., strengthening abdominal and paraspinal muscles).
3. Diet and Nutrition
- Dietary Triggers:
- Some individuals report symptom exacerbation from specific foods.
- Dietary Management:
- Encourage a well-balanced diet.
- Consider referral to a dietitian for elimination trials and nutritional optimisation.
4. Sleep and Ergonomic Support
- Neck and back support:
- Use proper neck pillows and mattress support.
- Strengthen core muscles to enhance posture and reduce mechanical strain.
5. Stress Reduction and Psychological Support
- Mind-Body Therapies:
- Mindfulness meditation
- Deep breathing and relaxation techniques
- Yoga or tai chi
- Cognitive Behavioural Therapy (CBT):
- Shown to improve coping, reduce negative thinking, and enhance functional outcomes.
6. Social and Occupational Support
- Support Groups:
- Peer support groups provide emotional reassurance and practical advice.
- Workplace Adjustments:
- Modify tasks and schedules as needed (e.g., ergonomic adjustments, reduced hours).
- Encourage regular walking/stretching breaks every 2–3 hours.
- Educate employers on fibromyalgia and refer to vocational rehabilitation (e.g. “Return to Work” programs, work hardening schemes).
🌟 Pharmacological Management
Aim: Improve function and quality of life rather than solely focusing on pain reduction.
Analgesics
- Paracetamol:
- Widely used; expert consensus rather than strong evidence.
- Tramadol:
- May help due to SNRI properties; use with caution due to dependency risk.
- NSAIDs:
- Commonly used, but limited evidence for efficacy in fibromyalgia.
Antidepressants
- Amitriptyline (10–75 mg nightly):
- Effective for pain and sleep improvement.
- Duloxetine (60–120 mg daily):
- Reduces pain, improves mood and quality of life.
- Analgesic effect independent of antidepressant effect.
- Milnacipran:
- SNRI shown to reduce pain and improve functional outcomes.
Anticonvulsants
- Pregabalin & Gabapentin:
- Modulate central pain processing; reduce neurotransmitter release.
Low-Dose Naltrexone (off-label):
- Shows promise in small studies for symptom improvement (e.g., Wulz 2019), but more robust trials are needed.
🌟 Prognosis and Predictors of Poor Outcome
Chronic Course:
- Most patients continue to experience persistent pain and fatigue.
- Tertiary care referrals often correlate with worse outcomes compared to management in primary care.
Negative Prognostic Factors:
- Female sex
- Low socioeconomic status
- Obesity
- Unemployment
- Untreated depression or anxiety
- History of physical or emotional trauma
- Long-standing work avoidance
- Substance use disorder
- High functional impairment
🌟 Complications
- Cognitive Dysfunction (“Fibro Fog”): Difficulty with memory, focus, and executive function.
- Myofascial Trigger Points:
- Localised muscle tenderness and referred pain.
- Treated with local anaesthetic injection (e.g., 5–8 mL lignocaine 1%), followed by massage and exercise.
- Increased Hospitalisation Risk: Higher hospitalisation rates than the general population.
Myofascial Trigger Points
Definition
- First described by Travell and Rinzler in 1952.
- Defined as hyperirritable spots in skeletal muscle associated with palpable nodules in taut bands of muscle.
- Not exclusive to fibromyalgia but may co-exist in patients with chronic pain.
Clinical Features
- Local muscle tenderness.
- Muscle twitch response upon palpation or needling (“jump sign”).
- Referred pain pattern when pressure is applied.
- Sometimes associated with limited range of motion or muscle stiffness.
Diagnostic Reliability
- Inter-examiner reliability is low under blinded conditions.
- Identification of MTrPs is clinically subjective and operator-dependent.
Management
Trigger Point Injection
- Locate the most tender point in the affected muscle.
- Inject 5–8 mL of 1% lignocaine/lidocaine (local anaesthetic).
- Avoid corticosteroids – not recommended for MTrPs.
Post-Injection Care
- Massage the area gently to distribute anaesthetic and break up spasm.
- Initiate or resume stretching and strengthening exercises to maintain benefit.
