Technical Information: Guidelines for the Diagnosis and Treatment of Fibromyalgia.

Edited By: Gregory C. Gardner, M.D.
Last updated Friday, January 07, 2005

About fibromyalgia

Definition

Fibromyalgia Syndrome (FMS) is a constellation of symptoms and signs that includes widespread body pain (above and below the waist and on both sides of the body) for at least 3 months, and the presence of tender points in characteristic locations of the body. The patient should identify these points as painful (not just pressure) when pressure of 4 kg is applied. This is about equal to the thumbnail turning white when pushing on one of the tender points. For study purposes, 11 of the 18 agreed upon tender points need to be present for classification as FMS (see chart for location of tender points). Common associated features include fatigue, disturbed sleep (patient waking feeling unrefreshed), and exercise intolerance (physical activity may exacerbate symptoms).

Incidence and demographics

FMS is predominately a syndrome of women. It is estimated that 3.5% of women in the U.S. are affected by FMS compared to less than 0.5% of men. These figures are not uniform and the prevalence may vary widely worldwide depending socioeconomic and cultural factors. All ages can be affected with the highest prevalence in middle aged women.

Common associated illnesses and/or experiences

Many patients with FMS have history of other somatic illnesses such chronic headaches, chronic pelvic pain, irritable bowel syndrome and mood disorders (depression, anxiety). Many patients with chronic fatigue syndrome also qualify for the diagnosis of FMS.

It has been recognized in recent years that childhood neglect and victimization may contribute to adult somatic illness such as FMS and irritable bowel syndrome and may be important issues to address with patients.

Conditions with similar symptoms

Certain medical illnesses may mimic symptoms of FMS. These include hypothyroidism, anemia, hypercalcemia, myopathies, and inflammatory joint diseases. Most of these are easy to rule in/rule out with examination and a few simple laboratory tests. Other illness might lead to FMS such as sleep apnea (in either the patient or sleep partner) or inflammatory arthritis (due to nighttime stiffness and pain that can disturb sleep).

History/ROS

Important features for history: Core symptoms

  • Widespread pain for 3 months (refer to pain diagram)
  • Exercise intolerance (Do you feel better or worse after more than usual activity?)
  • Fatigue (Do you run out of energy during the day? If so what time?)
  • Sleep disturbance (Do you awake rested or tired? Is regular sleep interrupted repeatedly? Disturbing nocturnal myoclonus or restless legs?)

Associated symptoms

  • Headaches
  • Bowel irritability (constipation alternating with diarrhea)
  • Pelvic pain
  • Low back pain
  • Non-dermatomal parathesias (i.e. whole arm or leg tingles)

Query mood disorders

  • Family history of mood disorders
  • Personal history of anxiety/depression
  • Current mood
  • Childhood/adult history of abuse/neglect
  • Current stressors

Mimics

  • Hypothyroid ROS (i.e. cold intolerance, weight gain, skin dryness, etc…)
  • Hypercalcemia (i.e. bones, stones, groans)
  • Anemia (heavy periods, dietary habits, previous CBCs)
  • Sleep apnea (AM headaches, sleep while at desk or chair during day, sleep partner report)
  • Inflammatory arthritis (AM stiffness improves with exercise, joint swelling)

Examination

Focus on positives of history/ROS and possible medical mimics plus:

  • Evaluate for joint swelling/ROM
  • Muscle weakness (true weakness vs giveway)
  • Tenderpoint examination

Basic laboratory tests

  • CBC
  • ESR
  • Basic chemistry panel including calcium
  • TSH
  • +/-CPK
  • +/- Hepatitis C

ESR can be mildly elevated in people who are heavy and remember that the upper limit of ESR is (age + 10)/2 for women and age / 2 for men.

DO NOT check rheumatoid factor or ANAs without a high degree of suspicion for an autoimmune illness, as the false positive rate is sufficiently high to forever label patients incorrectly. Remember that ANAs of titer 1:40 or 1:80 are rarely of any clinical significance.

Treatment

Treatment consists of three parts; understanding sources of stress that cause the patient distress, address sleep disturbance, and address stretching and reactivation.

There are currently only theories on what causes FMS but most now focus on a central causes such as neuroendocrine abnormalities. Whether biological or psychological or some combination of both, our role as health care providers is to give our patients the best care available to maximize health and quality of life. In a few years it is hoped that these guidelines will be updated to reflect important breakthroughs in the understanding and treatment of FMS.

Stress and distress

It is important to know the patient and how they deal with stress and what sources of stress are present in their lives. Patients may benefit from the care of a pain psychologist or counselor to help sort these issues out. Patients with mood disorders should of course be treated, as few patients with active depression/anxiety will get better without therapy.

Sleep disturbance

Try to understand why the patient feels they don’t sleep well. It may be related to anxiety or depression and if so treatment for these may make a difference. If sleep apnea is possible it should be addressed with a sleep study. Sleep hygiene includes taking time to relax before trying to sleep and avoid vigorous exercise within several hours of initiating sleep. Medication for sleep should be given if the above issues are not identified. Medications are selected for the ability to induce sleep and not disturb stage four sleep. Medication for sleep can include the following:

For mild cases suggest melatonin or low dose diphenylhydramine (Benadryl). Tylenol PM is an easy dosing form for diphenylhydramine.

  • Cyclopenzaprine, a muscle relaxant; begin with 5-10 mg/night and may increase as needed to maximum of 40-50 mg/night.
  • Low dose tricyclic antidepressant i.e. amytriptyline 10-75 mg/night, nortriptyline 10-75 mg/night, trazadone 25-100 mg/night.
  • Effexor has been used for sleep and for chronic pain.
  • Ambien is an expensive medication but can be used if all else fails. Doses of 5-20 mg can be used.
  • Neurontin can help with sleep and has been used for chronic pain as well. Dose of 300 to 1200 mg may be reasonable.

Stretching and reactivation

This is one of the most important aspects of treatment. Aerobic conditioning improves pain control by raising pain thresholds, improves physical stamina, and can even lower anxiety and depression scores. If done progressively, it also helps to restore confidence in the ability to be active. It is useful to send the patient to physical therapy for initiation of the AM stretching program and to help them develop a slowly progressive aerobic program. Occasionally more intense physical therapy program may be helpful to initiate exercise or to treat a flare. Generally though, weeks of physical therapy are not useful treatment should be directed to make patients independent of the medical system. Occasional massage therapy may be useful for some patients. Cognitive behavioral therapy has emerged as a potentially useful form of therapy to address somatic illness. It entails stretching, reactivation, stress management, and non-pharmacological pain management techniques.

Other issues

Opiates should be avoided. Rarely a small bank account of low potency narcotics can be provided i.e. 10 Tylenol #3 with the understanding that these will be refilled only once a month. Tramadol or Ultram can also be used as an alternative. We rarely recommend more than 3 per day. NSAIDs rarely work in FMS and most patients have previously tried them. Patients who feel they need continuous narcotics should be referred to a pain clinic for multidisciplinary care including psychological evaluation. In general, patients with FMS and other somatic pain syndromes feel under-treated with narcotics no matter the dose.

When to refer

Referral to a pain specialist or multidisciplinary pain clinic should be done only after the primary care provider has exhausted efforts on behalf of the patient. Keeping people with FMS in the primary care setting may lessen sense of disability. It is important for the primary care provider to give the person with FMS the majority stake in their own improvement. Stretching, exercising, staying involved in life without overscheduling, and seeking counseling for personal or family issues are to be done by the patient as part of the overall therapy. Goals should be modest i.e. 50-75% improvement but a motivated patient may achieve more than this. DO NOT consider success a return to pre-FMS pain and fatigue levels. If the patient is unable to assume these responsibilities, then a referral to a pain specialist may be warranted to give the patient greater assistance.

Final thought: Sir William Osler taught us that “It is more important to know what sort of patient has a disease than what sort of disease a patient has.” This patient centered focus is very important when trying to help our patients with fibromyalgia.

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