Fibromyalgia is a rheumatologic
disease with chronic widespread pain syndromes in which the patients have an
increased sensitivity to pain. Its pathophysiology is poorly understood and can
occur at any age. However, it is more common in the female population with predominance
of 10:1. (Wolfe et al., 1990).
There is evidence of association
of other psychosocial stressors with the development of the disease and the most
documented stressor is sleep abnormality. Another floated theory for its
development is an abnormality in the processing of both central and peripheral
pain leading to a lowering of pain threshold (McCance et al., 2014). The
majority of the affected population is usually aged between 30 and 60 years
with the prevalence in the US and UK estimated to be around 2% – 5% (Wolfe et
SIGNS AND SYMPTOMS SEEN
The commonest presenting
feature of fibromyalgia is usually pain that is regional especially affecting
the muscle and joints of the back, neck and chest and lasts for more that3
months. The pain is usually widespread and does not respond to common
analgesics and other NSAIDS such as paracetamol and Aspirin (Goolsby et al., 2014).
Symptoms can sometimes occur throughout the day and is associated with general
fatigue and inability to do normal work since activity would aggravate the
These patients commonly
experience morning stiffness with pronounced disability, tingling sensations in
the fingers and sometimes swelling of hands and fingers (Wolfe et al., 1990). Some symptoms are not musculoskeletal in
nature and include disturbances of sleep, poor or lack of concentration,
decreased moods, headaches which are usually described as bi-frontal and
non-refreshing sleep. Other patients has
features of Irritable Bowel Syndrome such as bloating and colicky abdominal
There is usually a painful response
to non-noxious stimuli like touch
ASSESSMENT TOOLS AND DIAGNOSTIC TESTS
Fibromyalgia symptoms usually are
difficult to explain medically (Goolsby et al., 2014). It is however important
to rule out other medical conditions that could be responsible for some of the
patient’s symptoms such as thyroid disease, SLE, rheumatoid arthritis and
myopathies like polymyositis.
Diagnosis of fibromyalgia based
on the modified 2010 ACR criteria involves administering a questionnaire to
patients for self-assessment. It considers three aspect of the disease; pain
distribution over the body in 19 areas described in a Widespread Pain Index (WPI).
Each painful area scores 1 point making a maximum score of 19. The second
aspect considers how severe the symptoms are in terms of fatigue, sleep
disturbance and dysfunction of the cognitive system. Its scores range from 0 to
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 symptoms over past 6 months. Presence of each of
these symptoms scores a point.
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 a diagnosis of
fibromyalgia is made.
As part of the screening,
physical examination to map out tender points (usually 19) can also be
conducted. Pain in 11 or more of these points can be considered diagnostic.
Other assessment options include Full Blood Count to rule out anemia and lymphopenia
(due to Systemic Lupus Erythematosus (SLE)), Erythrocyte Sedimentation Rate and
C – reactive protein levels to rule out inflammatory causes, Thyroid Function Tests
to rule out thyroid disease and Anti-Nuclear Antibodies to rule out SLE.
The physical examinations are mostly
normal without underlying pathologies and as such the diagnosis of fibromyalgia
is usually one of exclusion (Goolsby et al., 2014).
PLANS BASED ON CURRENT CLINICAL PRACTICE GUIDELINES
exercise has been shown to improve symptoms by improving sleep quality. Also
patients who are educated about the condition seem to fair well compared to
non-educated ones. Holding group sessions also seem to help improve patients’
energy levels, sleep and quality of life (Burckhardt, C. S.et al., 1991). There is also strong
evidence in support of Cognitive Behavior Therapy and hypnotherapy especially
when the programs are individualized. It helps to reduce pain and greatly
improve mood and functions.
Pharmacologic: there is strong evidence for the use of Tricyclic
Anti-depressants such as Amitriptyline, given 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., et al, 2012), Gabepentin, given 1600-2400
mg daily and Duloxetine at 60-120 mg daily (Woo., et al, 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
Burckhardt, C. S., Clark, S. R.,
& Bennett, R. M. (1991). The fibromyalgia impact questionnaire:
development and validation. J
rheumatol, 18(5), 728-733.
Jo, M., Grubbs, Laurie. (2014). Advanced Assessment: Interpreting Findings and
Formulating Differential Diagnoses, 3rd Edition.
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.