RHEUMATOLOGY

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

ParameterData
GenderFemale predominance (F:M > 3:1)
Age of OnsetPeak: 20–60 years; typically 25–45 years
General Population Prevalence2–5%
Female Population2–3%
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)

ComponentDescription
Widespread Pain Index (WPI)Count of painful areas (0–19)
Symptom Severity Scale (SSS)Measures fatigue, sleep disturbance, cognitive symptoms (0–12)
Diagnostic ThresholdWPI ≥7 & SSS ≥5, or
WPI 3–6 & SSS ≥9
DurationSymptoms present ≥3 months
ExclusionNo alternative diagnosis that better explains symptoms

🌟Differential Diagnoses

ConditionDistinguishing Features
Rheumatoid ArthritisInflammatory joint changes
RF/ACPA positive
SLEMultisystem involvement
ANA positive
HypothyroidismWeight gain
cold intolerance
abnormal TSH
Chronic Fatigue SyndromeFatigue predominates over pain
Sleep DisordersPolysomnography abnormalities
e.g., OSA
Mood DisordersDepression/anxiety may mimic or exacerbate symptoms
  • Onset >65 years
  • Weight loss
  • Night pain or focal pain
  • Fever, sweats
  • Neurological deficits
  • Malignancy history
DomainExamples
Pain profile/ Somatic LoadWidespread 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
PsychologicalCatastrophizing: 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.
SocialSocial 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.
BehaviouralPoor 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
CognitiveNegative 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 statusSedentary 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

GoalPractical approachWhy 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.

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