Ep 127 – Fibromyalgia

Fibromyalgia is a condition characterised by chronic widespread pain together with multiple muscular tender points or associated fatigue, sleep disturbance or cognitive dysfunction in the absence of a well-defined underlying organic disease. The majority of patients present with both tender points and associated symptoms, although the exact aetiology of fibromyalgia is unknown. In this episode, Dr Roger Henderson takes a look at possible triggers, diagnostic approaches, possible treatments (including non-pharmacological methods) and the prognosis for patients with this often poorly understood and underdiagnosed condition.

Key references

1. Rahman A, et al. Fibromyalgia. BMJ. 2014;348:g1224. doi: 10.1136/bmj.g1224.
2. NICE. 2021. https://www.nice.org.uk/guidance/ng193.
3. NICE. 2022. https://www.nice.org.uk/guidance/ng215.
4. Busch AJ, et al. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003786. doi: 10.1002/14651858.CD003786.pub2.
5. Bennett RM, et al. Arthritis Res Ther. 2009;11(4):R120. doi: 10.1186/ar2783.
6. Wolfe F, et al. Semin Arthritis Rheum. 2016;46(3):319-329. doi: 10.1016/j.semarthrit.2016.08.012.
7. Siracusa R, et al. Int J Mol Sci. 2021;22(8):3891. doi: 10.3390/ijms22083891.
8. Fitzcharles MA, et al. CMAJ. 2013 ;185(13):E645-E651. doi: 10.1503/cmaj.121414.

Key take-home points

• Fibromyalgia is a condition characterised by chronic widespread pain together with multiple muscular tender points or associated fatigue, sleep disturbance, or cognitive dysfunction in the absence of a well-defined underlying organic disease.
• The exact aetiology of fibromyalgia is unknown.
• There are probably multiple factors involved in the pathogenesis of fibromyalgia syndrome. Sleep disturbance is thought to be of major importance.
• A viral cause for fibromyalgia is not supported by any evidence.
• Symptoms of fibromyalgia are vague and generalised and usually wax and wane over time, but seldom disappear.
• Pain is the primary complaint. The pain may be intermittent initially, and then progress and become more persistent. The location and intensity of pain may vary from day to day.
• Factors such as weather or stress may affect the pain.
• Other symptoms include fatigue, sleep disturbance (sleep may exacerbate symptoms and contribute to depression), morning stiffness, a feeling of swollen joints (with no objective swelling) and problems with cognition (such as memory disturbance or difficulty with word finding).
• A patient fulfils the diagnostic criteria for fibromyalgia if the following three conditions are met:
  • Widespread pain index (WPI) ≥7 and symptom severity (SS) scale score ≥5, or WPI is 3–6 with SS scale score ≥9.
  • Symptomatology has been present at a similar level for at least three months.
  • The patient does not demonstrate any signs or symptoms of another disorder that would otherwise explain the pain.
• Most physicians rely on a combination of symptoms and normal blood testing to diagnose fibromyalgia.
• Only limited laboratory testing should be conducted for most patients.
• There is no cure for fibromyalgia.
• Treatment should focus on improving symptoms and maintaining optimal function.
• The ideal management plan should include a combination of non- pharmacological and pharmacologic treatments in a multimodal approach, tailored to the individual patient.
• Exercise programs have been helpful in improving general well-being, physical function and pain, and they are currently recommended as the first step of a multimodal treatment strategy.
• Antidepressants are associated with improvements in pain, depression, fatigue, sleep disturbances, and health-related quality of life in patients with fibromyalgia.
• Medication should be kept to a minimum whenever possible.
• Strong analgesics, including opioids, should be avoided.
• The prognosis remains poor for the majority of patients with fibromyalgia.