1. Fibromyalgia
Erin Fouch
October 31, 2005

2. Diagnostic Criteria
American College of Rheumatology Diagnostic Criteria (1990)1
Pain in all 4 quadrants of body and axial skeleton.
Tenderness in 11/18 previously defined “tender points.”
Fulfillment of both criteria results in approximately 80% sensitivity and specificity for diagnosis.

3. Tender Points
Appropriate pressure is 4 kg/cm– approximately enough to turn the examiner’s nailbed white.

4. Case Presentation
A 35-year-old woman presents to your office complaining of diffuse “joint pain” for the past several months. On further questioning, she states that the pain is all over her body, in her muscles and joints. It is there throughout the day, and worsened by exercise.
She gets minimal relief with acetaminophen.

5. Epidemiology
Most common cause of musculoskeletal pain in women aged 20-55
Prevalence ~3.5% in women, ~0.5% in men
Some familial aggregation
50% of cases preceded by a stressor (injury, viral illness– e.g. Lyme disease)
Patients with FM have a 50% lifetime hx of depression, although only 25% meet criteria at the time of diagnosis

6. Case Cont’d
ROS: Positive for daytime fatigue, constipation, and occasional palpitations.
PMH: None.
Meds: Acetaminophen prn
FH: Mother has RA, sister has hypothyroidism.

7. Case Cont’d Physical Exam T 36.5; BP 125/78; P 65
Genl: WNWD, thin woman, NAD, slightly flat affect
Neck: No thyromegaly, no LAD.
CV: RRR, no murmur
Lungs: Clear
Abd: Soft, slightly tender throughout, ND
MSK: No joint swelling nor erythema. Normal range of motion in all joints. 8/18 tender points positive
Skin: No rashes.

8. Case Cont’d What is your differential diagnosis?
What further work-up does she need?

9. Differential Diagnosis
Polyarticular arthritis
Rheumatoid arthritis
SLE
Polymyalgia rheumatica
Endocrine disorders
Hypothyroidism
Hyperparathyroidism (hypercalcemia)
Myopathies
Polymyositis
Rhabdomyolysis

10. Differential Diagnosis
Neuropathies
Depression
Chronic fatigue syndrome
Myofascial pain syndrome
Anemia

11. Case Cont’d
What further work-up does our patient need?

12. Diagnostic Evaluation
Careful history and physical
This is the most important component and often leads to the diagnosis
Labs to evaluate for:
Causes of fatigue (CBC, TSH)
Causes of myalgias (CK, ? Chemistry panel)
Evidence of inflammation (ESR)

13. Diagnostic Evaluation
Generally NOT recommended
ANA, Rheumatoid factor

14. Diagnostic Evaluation Differentiating FM from other disordersRA
Elevated RF, ? ESR, joint swelling/deformity, systemic symptoms
SLE
Systemic symptoms, ESR
PMR
Stiffness, ESR. Usually older patients.
Myositis/Rhabdo
Weakness, elevated CK
Depression
Tender points negative
Myofascial pain syndrome
Localized pain
Chronic fatigue syndrome
Fatigue > pain

15. Case Cont’d
Your patient’s CBC, Chem 7, TSH, and ESR are normal. She returns to clinic for a follow-up visit to review her labs. You are about to begin explaining her diagnosis of fibromyalgia when she tells you that she forgot to mention last time that she has joint swelling in her hands, wrists, knees, and ankles, as well as mild shortness of breath with exertion.

16. Case Cont’d
Concerned, you repeat an exam. She states that the joint swelling is present now, but you see no synovitis. Lungs are clear, but you remain worried that you have made the wrong diagnosis.

17. Overlapping Syndromes and Symptoms Common Comorbidities:
Osteoarthritis (7%)
Depression
Migraine headaches
OSA
Restless legs
Rheumatoid arthritis (12%)
SLE
Hepatitis C
Myofascial pain syndrome
TMJ
IBS

18. Overlapping Syndromes and Symptoms
Common symptoms
Fatigue
Subjective joint/muscle swelling
Difficulty sleeping
Night sweats
Dyspnea
Palpitations
Pelvic pain
Dysmenorrhea
Non-cardiac chest pain
Diarrhea/constipation (IBS)

19. Case Cont’d
In young, otherwise healthy patients with a variety of diffuse complaints and a relatively straightforward diagnosis of fibromyalgia, it is reasonable to monitor most symptoms rather than investigate exhaustively.

20. Case Cont’d
You inform your patient that you believe she has fibromyalgia. She becomes tearful and says that she has read about this disease on the internet and it is clearly not a real illness. Furthermore, she has read that fibromyalgia is strongly associated with depression, and she adamantly states that she is not depressed. She would love to get back to the activities she used to enjoy, if only she did not have so much pain. She demands a referral to a rheumatologist for further evaluation.

21. Depression and Fibromyalgia
Of patients with fibromyalgia, 50% have had or will have depression at some time in their lives
25% of FM patients will meet criteria for depression at the time of diagnosis
This means that 75% of patients will NOT be depressed when diagnosed with fibromyalgia
Disturbed sleep and fatigue could be symptoms of either illness
Some antidepressants have been used to treat fibromyalgia

22. Case Cont’d
Your patient accepts that you are not diagnosing her with depression, and asks you what treatments are available. Her friend is on oxycodone for her chronic pain, and your patient would like a prescription for this as it is the only thing that has helped her friend.

23. Treatment of Fibromyalgia
Patient Education
Patients generally have fewer symptoms if they are told their diagnosis
Group sessions (6-17 sessions), lectures, written materials seem to improve quality-of-life, pain, sleep, energy levels3; improvements lasted 3-12 months
One 1.5-day educational session improved energy, stiffness, pain severity, and depression4

24. Treatment of Fibromyalgia
Aerobic Exercise
A 2002 Cochrane review5 found that aerobic exercise is an effective treatment for fibromyalgia. Patients had improved pain thresholds, decreased pain, and improved aerobic exercise capacity.
Strengthening exercises appear to provide some improvement.
Both aerobic exercise and strengthening exercises appear to be more effective than stretching.

25. Treatment of Fibromyalgia
Aerobic Exercise
Patients should be counseled to start slowly– they will often feel worse if they embark on a strenuous exercise regimen quickly.
Swimming and water sports appear to be well-tolerated.

26. Treatment of Fibromyalgia
Cognitive-Behavioral Therapy
A review by Goldenberg et al concluded that patients receiving CBT had decreased pain and improved function over 6-30 month follow-up.3

27. Treatment of Fibromyalgia
Medications-- SSRIs
Variable results with fluoxetine, but it appears to improve pain when providers are allowed to escalate the dose to up to 80 mg/day6
No improvement found with a fixed dose of fluoxetine (20 mg/day)7
Pain appears to improve regardless of improvement in mood

28. Treatment of Fibromyalgia
Medications– Tricyclic antidepressants
Amitriptyline mg qhs effective in multiple RCTs
Cyclobenzaprine (Flexeril) mg qhs also effective in multiple RCTs
Patients should be allowed to determine the maximum effective dose
Side effects limit use and dose escalation

29. Treatment of Fibromyalgia
Medications-- Other
Pregabalin (a new anticonvulsant) was found to decrease severity of pain in one RCT8
Combination of carisoprodol (Soma), Tylenol, and caffeine improved sleep, pain, and pain threshold more than placebo9
Tramadol 75 mg q 6 hrs appears to improve pain; effect may be greater with Acetaminophen 650 mg q 6 hrs10

30. Treatment of Fibromyalgia Medications with “strong” or “moderate” evidence for efficacy3
Amitriptyline
Cyclobenzaprine
Tramadol
Fluoxetine
Venlafaxine
Duloxetine
Pregabalin

31. Treatment of Fibromyalgia
Ineffective Medications
Corticosteroids
Opioids
NSAIDs
Benzodiazepines
Guaifenesin
Levothyroxine
Cacitonin
Melatonin
Magnesium

32. Case Continued
You work out a treatment plan with your patient. She agrees to exercise daily, and try Amitriptyline at night. She asks you if she should take time off work or expect to be debilitated from her illness.

33. Natural history of fibromyalgia
Patients should be reassured that fibromyalgia is not life-threatening.
Most patients have waxing and waning symptoms throughout life, but generally remain very functional.
Most patients report that they are able to work full-time.
Patients should be encouraged to take an active role in disease management.

34. Fibromyalgia: take-home points
Defined as diffuse pain and 11/18 positive tender points, though some patients will not strictly meet criteria
Check CBC, ESR, TSH, CK depending on symptoms
Most effective treatments: Patient education; aerobic exercise; CBT; TCAs
Most patients will continue to have some pain but will function relatively normally

35. References
Wolfe F, Smythe HA, Yunus MB, Bennett RM, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990; 33:160
Fibromyalgia Information website:
Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004; 292 (19); 2388
Pfeiffer A, Thompson JM, Nelson A, et al. Effects of a 1.5-day multidisciplinary outpatient treatment program for fibromyalgia: a pilot study. Am J Phys Med Rehabil. 2003; 82: 186.
Busch A, Schachter CL, Peloso PM, Bombardier C. Exercise for treating fibromyalgia syndrome. Cochrane Review Datatbase Systematic Review. 2003; 3.
Arnold LM, Hess EV, Hudson JI, Berno SE, Keck PEA. Randomized, placebo-controlled, double-blind study of fluoxetine in the treatment of women with fibromyalgia. Am J Med. 2002; 112: 191.
Wolfe F, Cathey MA, Hawley DJA. Double-blind placebo controlled trial of fluoxetine in fibromyalgia. Scand J Rheumatol. 1994; 23: 255.
Crofford L, Russell IJ, Mease P, et al. Pregabalin improves pain associated with fibromyalgia syndrome in a multicenter, randomized, placebo-controlled monotherapy trial. Arthritis Rheum. 2002; 46: S613.
Vaeroy H, Abrahamsen A, Forre O, Kass E. Treatment of fibromyalgia (fibrositis syndrome): a parallel double blind trial with carisoprodol, paracetamol and caffeine versus placebo. Clin Rheumatol. 1989; 8:245.
Bennett RM, Kamin M, Karim R, Rosenthal N. Tramadol and acetaminophen combination tablets in the treatment of fibromyalgia pain: a double-blind, randomized, placebo-controlled study. Am J Med. 2003; 114:537.
Goldenberg DL. Clinical manifestations and diagnosis of fibromyalgia in adults. UpToDate 2005.
Goldenberg DL. Differential diagnosis of fibromyalgia. UpToDate
Goldenberg DL. Treatment of fibromyalgia in adults. UpToDate
Tofferi JK, Jackson JL, O’Malley PG. Treatment of fibromyalgia with cyclobenzaprine: a meta-analysis. Arthritis Rheum. 2004: 51:9.
Klippel JH. Primer on the Rheumatic Diseases, Edition 12.