Fibromyalgia

A RESIDENT’S CRASH COURSE

 WHAT EXACTLY FIBROMYALGIA IS
PATHOPHYS THEORIES
Overview HOW WE DIAGNOSE IT
SOME TREATMENT OPTIONS

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 Syndrome of ‘chronic widespread noninflammatory
musculoskeletal pain’
 + various symptoms incl fatigue, sleep disturbance & other pain
presentations

 2-6% population prevalence, US literature suggests

 Probable risk factors:

 Female*; 1st deg relative; lower SES
 Obesity
 Early life physical & sexual abuse
 Associated symptoms

 GIT incl IBS, nausea  Fatigue: physical, mental

 Other pain presentations:  Insomnia & other sleep disturbances
 Headaches
 Cognitive dysfunction
 Abdominal/visceral
 Psychological: mood & anxiety disorders
 Hyperalgesia & other altered responses to stimuli
 Also: jaw, throat, dysmenorrhoea
Associated disorders

 Chronic Fatigue Syndrome (CFS)  & Myalgic Encephalomyelitis (ME)

 The same thing? Depends who you ask
 Multiple chemical sensitivities
 Irritable Bowel Syndrome
 Depression: 90% lifetime prevalence of depressive sx in FM pts (at least 2/3rds meet MDE criteria)
 Anxiety: Lifetime prevalence of anxiety sx in FM: ~78% mixed mood/anxiety; Up to 50% PTSD sx;
27% panic disorder
 SURVEY OF FIBROMYALGIA
SUPPORT NETWORK MEMBERS IN
Loss of function WA:

large part of  56.9% HAD REDUCED OR

CEASED WORK W/IN 5YRS OF DX
burden  35.1% ON PENSION RE: FM
SYMPTOMS
Predisposed individual exposed to stressors

 Genes:
 No individual genes w/ sizeable effect thus far - probably a bunch of genes.
 Possibly polymorphisms of genes involved with pain modulation eg serotonin, dopamine & catechol-O-
methyl-transferase (COMT)
 Proposed stressors:
 Infection incl infamous lyme disease, brucellosis, parvovirus, EBV
 Physical trauma
 Ongoing MSK pathology eg arthropathy
 Psychological: Isolated trauma eg child abuse, war, cumulative stressors
 ~88% of Australian outpatients in a FM clinic in 2012 associated onset or significant worsening of
their symptoms with triggering event/s
CNS sensitisation theory

 Ongoing perception of pain in absence of or disproportionate to nociceptive stimuli

 Abn repetitive stimulation of peripheral sensory fibres via dorsal horn
 Problem with thalamus & cortex’s descending modulation of pain
 Underactive modulation via neurotransmitters:
 Noradrenaline & serotonin
 Binding of opioid receptors (?why FM predisposed to opiate hyperalgesia?)
 Glutamate & gabba, cytokines, probably a bunch more we think
 Hypothalamic axis dysregulation incl abn cortisol responses
Early years of diagnosis

 Designed for research

 Narrow and rigid
 American College of Rheumatology 1990:
 widespread pain
 at least 11 of 18 specific ‘tender points’
Shift towards positive diagnosis

 ‘Diagnosis of exclusion’
 Significant body of literature detailing suffering assoc with Medically Unexplained Symptoms
 So far no oncrete evidence of adverse effects from a FM dx
 2002 cohort study followed 72 newly dx’d ACR criteria pts over 36mo:
 Health satisfaction unchanged or improved
 Slight progressionin sx severity
 Rx prescriptions unchanged but not stat sig
 After 1st 18mo  tended to see GPs, specialists & get admitted less often
 ED about same
 Disability status claims & pensions inc ~20 to 30% but not stat. sig.
 It seems receiving a positive dx assoc w/ reduced distress
ACR 2010 criteria

Removed requirement for specific tender points

Added multi-domain scores
 Widespread Pain Index (WPI) score 0-19 of different parts of body
 Composite Symptom Severity Scale (SS), score 0-12
 Fatigue
 Cognitive clouding
 Tired
 Abdo pain
 Headache
 Depression
Modified ACR 2010 criteria

 Patient reported & captures even more non-MSK sx

 Need to meet 3 conditions
 Severity:

Widespread Pain Index at least 7 out of 19; AND Symptom Severity

Score at least 5
OR WPI 3-6 AND SS at least 9
 Duration: at least 3mo of sx at this level
 No other disorder that explains the pain
 Scored out of 31: WPI out of 19; SS out of 12
Diagnostic considerations

 Dx tends to take >2yrs

 Starting with multi-focal pain, but not always
 Usually closely associated with other non-pain complaints
 Typically onset early middle age and/or in relation to psychological or
physical stressor
 Can co-exist w other MSK: consider FM w/ disproportionate sx burden
 Red flag features: older age; neurological symptoms; well localised pain;
PMH of malignancy; systemic sx
What might be
some differentials
for FM?
Some other ddx’s w/ widespread pain

 Rheum incl OA; inflammatory arthritis; spondyloarthritis;

vasculitic syndromes
 Systemic: infection; hypothyroidism
 Psychological: eg depression
 Medication SEs & Aes

 What else?
Management principles

 2017 European League Against Rheumatism (EULAR)

recommendations for managing fibromyalgia
 Strong recommendation: only exercise
 Also recommends non-pharmacological therapies are used 1st
 Weak recommendations only for all pharmacological classes
Exercise & movement therapy

 Aerobic exercise: 2-3 times a week, moderate evidence 2017 Cochrane

 Moderate effect on pain & function
 Sx often initially worse
 Land vs hydrotherapy similar results
 Similar results to strength training
 Vibration based: 2017 Cochrane review - low quality evidence, uncertain whether better
than mixed exercise + relaxation for pain/sx/function
 Meditative movement incl tai chi & yoga: mild evidence of modest short term effect on
sleep & fatigue &function.
 May be similar to aerobic exercise
Psychotherapy

 EULAR suggests focus on mood and coping strategies

 CBT: low quality evidence for improved function
 Most ~10wks long
 Most face to face
 Acceptance & commitment therapy: 2017-2018 modest effect on anxiety, mood & pain
acceptance - but not pain or FM sx. No comparison to CBT
 Mindfulness & similar: pain/mood/QoL but not better than control; low quality evidence,
heterogenous programs
 Trauma based therapy: good in theory, little research, many pts report flares of sx with
acute distress
Other physical therapies

 Acupuncture: 8 moderate sized reviews w mild effect on pain &

fatigue, moderate evidence
 Massage: low to mod evidence with mixed results
 Transcranial magnetic stimulation: little difference between it &
sham thus far
 Transcutaneous Electrical Nerve Stimulation (TENS): 2017
Cochrane review of 7 RCTs inconclusive
TCAs & related

 Low dose amitriptyline (10-50mg):

 weak evidence; mild effect on pain and sleep, small effect on fatigue;
 ?effect on bladder and bowel sx
 possibly not sustained
 Cyclobenzaprine (muscle relaxant, 10-40mg)):
 moderate evidence from 5 studies
 v small effect on sleep close to placebo; nil on pain
 85% rate of SEs
SNRIs

 2018 Cochrane review of 18 studies. Mostly…

 Duloxetine (60-120mg): most studied, 8 SRs biggest one n=2249
 Mild pain reduction, moderate evidence
 Little effect at 20-30mg
 Not difference 60 vs 120mg
 Small effect on sleep and function
 >milnacipran for mood, pain?
 Milnacipran (100-200mg): 7 SRs
 TG approved but not on PBS
 Moderate evidence for modest effect on pain
 More adrenergic: >duloxetine for fatigue but debateable
Other antidepressants

 Mirtazapine (15-45mg):
 High dose SSRIs - several small studies moderate quality that lump
fluoxetine/paroxetine/citalopram together. Mild effect on pain/sleep. Nil on fatigue.
 MAOIs: not recommended as only weak effect on pain in a few studies + potential for
interactions
 Terguride: serotinin antagonist & partial dopamine agonist. No effect on pain/tender
points/depression/QoL in small 2010 RCT
Anticonvulsants

 Pregabalin (150-600mg) 2017 Cochrane review moderate evidence

 Modest pain reduction
 Small effect on fatigue and sleep.
 No effect on function.
 Gabapentin (800-2400mg): weak evidence, from a single n=150 study
 Mild pain reduction also
 Small effect on sleep
 Moderate effect on function.
Analgesics

 Tramadol 37.5mg with paracetamol QID: mild effect on pain, weak evidence
 Low dose naltrexone: 1 very small study with 10% greater improvement in pain vs
placebo; & slight improvement in mood & health satisfaction.
 NSAIDs (Ibuprofen & tenoxicam): 2017 Cochrane review 6 small trials w/ no effect on
pain or function.
Other medications

 Quetiapine (50-300mg): 4 v low quality studies w mild effect on

pain/sleep/mood/anxiety over up to 12wk course
 Growth hormone: 2 tiny studies with barely significant effect on pain; no effect on
function & all sorts of safety concerns
 Cannabinoid palmitoylethanolamide (PEA): mild at best effect on pain in mixed chronic
pain pts, ?dosing, very little literature on FM pts, riddled with bias
 2018 COCHRANE REVIEW: COMBO
THERAPY MIGHT ACHIEVED
Combination IMPROVED PAIN; NO
RECOMMENDATIONS FOR
pharmacology PARTICULAR CLASS COMBOS
In summary

 Take descriptive histories

 Be prepared to revisit diagnoses
 Real doctors diagnose FM
 There are a range of management options – some with more evidence than others
 Patient ownership is key
References

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