Fibromyalgia

Fibromyalgia is a common cause of chronic musculoskeletal pain. Fibromyalgia is caused by abnormal processing of pain mechanisms within the brain and the spinal cord.

The recommended diagnostic criteria were quite simple:

• Widespread musculoskeletal pain
• Excess tenderness in at least 11 of 18 predefined anatomic sites . Excess tenderness is defined by an abnormally low threshold for pain is considered to be present in a patient when pain is elicited at a tender point from pressure that blanches the finger nail.

Other features includes:

• Muscle tightness, often noted as muscle co-contraction or give way wekness.
• Dermatographia
• Non-anatomical sensory symptoms ( numbness, pins and needles, numbness and burning )

Although the diagnosis of fibromyalgia is usually straightforward the condition often co-exists with other conditions and presenting symptoms may be similar. Reg flags must always be considered and if present, it requires to investigate further.

• Older age at new symptom onset
• Weight loss
• Fever or night sweat
• Focal pain
• Night pain
• Neurological features
• History of malignancy

Investigation that may be required for initial work up includes: FBC, U&E, LFT, CRP, ESR, CK, TFT, Vitamin D level, Rheumatoid factor and antinuclear antibody.

Management:

Education, exercise and psychological strategies must be initiated in all patients with fibromyalgia. The importance of these measures cannot be overemphasized.

Analgesia
Paracetamol: is often not effective.
NSAIDs: may help some patients.
Opiods: in general pure opioid mediations are not clinically useful in the sensitised pain system that characterises fibromyalgia. There are no available trials of pure opioid medication use. Tramadol has combined opioid and serotonin noradrenaline reuptake inhibitory action, and it has been shown to be effective in pain control and improves function in patient with fibromyalgia.
Pain System Modulator: Tricyclic antidepressants and Serotonin Noradrenaline reuptake inhibitors are now more frequently used. However, SSRI has much less effective in management of fibromyalgia.