Fibromyalgia is a disease of
rheumatology whose main presentation is with pain that is chronic and
widespread with increased pain sensations. Its pathophysiology is not properly
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 positive association
between psychosocial stressors and the occurrence of the disease. The common documented
psychosocial stressor is abnormality of sleep. Another possible explanation 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,
Huether, Brashers, & Rote, 2014). The
majority of the population affected is usually aged between 30 and 60 years
with the prevalence in the US and UK estimated to be close to 2% – 5%, (Wolfe
et al., 1990).
SIGNS AND SYMPTOMS SEEN
The commonest presenting
feature of fibromyalgia is often pain which is regional and affecting the
muscle and some joints of the back, neck and chest and often has existed for at
least 3 months or more. The pain is commonly felt all over the body and mostly
does not respond to commonly used analgesics or other NSAIDS such as
paracetamol (Goolsby, &
Symptoms at times occur all day and are associated with general fatigue with inability
to do normal work since even activity would aggravate the symptoms.
These patients also do
experience stiffness worse in the morning accompanied by major disability, sensations
of tingling in the fingers with occasional swelling of hands together with
fingers (Wolfe et al., 1990). Some symptoms
dot not have a musculoskeletal origin and include disturbances of sleep, poor
or lack of concentration, decreased affect, headaches which are usually
described as bi-frontal and throbbing together with unsatisfactory sleep. Other patients present with features of
Irritable Bowel Syndrome like bloating and cramping abdominal pains (Medscape)
There is usually an exaggerated
response to non-noxious stimuli like touch
ASSESSMENT TOOLS AND DIAGNOSTIC TESTS
The symptoms observed in
fibromyalgia are often difficult to explain medically. (Goolsby, & Grubbs, 2015). 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 and other immune disorders like rheumatoid
arthritis, SLE and myopathies such as polymyositis and rhabdomyolysis.
Diagnosis of fibromyalgia based
on the modified 2010 ACR criteria which advocate for the administration of a
questionnaire to patients to facilitate self-assessment. It considers three
aspect of fibromyalgia; distribution of points of pain in 19 body areas as described
in a Widespread Pain Index (WPI). For every painful area documented, a score of
1 is awarded until a maximum score of 19. The second aspect considers how
severe the symptoms are in terms of fatigue, disturbance of sleep and
dysfunction involving the cognitive system. It has scores ranging from 0 – 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. The symptoms must have persisted
throughout past 6 months. Presence of any symptoms above would score a point in
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 fibromyalgia is likely
As part of the screening,
physical examination that maps tender points in the body (which are usually 19)
can also be conducted. Pain in 11 or more of these body points can be
considered diagnostic. Other assessment options include a Full Blood Count to
rule out anemia and lymphopenia (due to Systemic Lupus Erythematosus (SLE)).
Others include Erythrocyte Sedimentation Rate and C – reactive protein to rule
out inflammatory causes, Thyroid Function Tests to disqualify thyroid disease
and Anti-Nuclear Antibodies testing to disqualify SLE.
The physical examinations are mostly
normal without underlying pathologies and as such the diagnosis of fibromyalgia
is usually one of exclusion (Goolsby, & Grubbs, 2015).
PLANS BASED ON CURRENT CLINICAL PRACTICE GUIDELINES
exercise that is graded has been shown to improve patient status by improving
their sleep quality. Also patients who are educated about the condition seem to
cope better in contrast to their non-educated counterparts. Holding of group
sessions also help improve energy levels of the patients, sleep and quality of
life (Burckhardt, Clark, & Bennett, 1991). Strong
evidence do exists in support of Cognitive Behavior Therapy and hypnotherapy which
are more effective 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 & Wynne, 2012), Gabepentin, dosed at 1600-2400
mg daily and Duloxetine dosed at 60-120 mg daily ((Woo & Wynne, 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 fibromyalgia (Medscape).
Burckhardt, C. S., Clark, S. R.,
& Bennett, R. M. (1991). The fibromyalgia impact questionnaire:
development and validation. J
rheumatol, 18(5), 728-733.
Goolsby, M. J., &
Grubbs, L. (2015). Advanced assessment: interpreting findings and
formulating differential diagnoses. Third edition. Philadelphia, PA: F.A.
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.