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Fibromyalgia / Reading & Sharing

Fibromyalgia is a syndrome with multisystem manifestations and “characterized by chronic, widespread musculoskeletal pain without evidence of soft tissue inflammation” (Mbuyi, 2018, p. 491). Research suggests that fibromyalgia (FM) is a disorder of pain regulation, specifically centralized pain processing (Clauw, 2014). Centralized pain refers to amplified pain that originates in the central nervous system (Clauw, 2014).

As according to Menzies (2016), in the United States, fibromyalgia is estimated to affect up to 15 million people, and is believed to be 80% to 90% of whom are women. Menzies (2016) also reported that fibromyalgia is effecting 2% to 8% of the population worldwide. Ferri (2017) believed the prevalence of fibromyalgia increases with age. He reported that “In the US, fibromyalgia is the most common cause of musculoskeletal pain in women ages 20 to 55 year. Using the 2010 American college of rheumatology diagnostic criteria for fibromyalgia, the female-to-male ratio is approximately 2:1” (p. 475)

Fibromyalgia is a syndrome characterized by chronic, widespread musculoskeletal pain with “a variety of concurrent symptoms such as fatigue, distressed mood (anxiety, depression), cognitive disturbances (memory problems, difficulty concentrating, confusion; sometimes collectively called “brain fog” or “fibro fog”), non-restorative sleep, and muscular stiffness” (Menzies, 2016, p. 24).

The etiology of fibromyalgia is unknown, however contributing genetic and environmental factors have been identified that predispose the development of FM in people (Mbuyi, 2018). Familial history of FM, abnormalities in how the ascending and descending pain pathways operate, shows strong evidence for predisposition to the development of FM under precipitating circumstances or events (Clauw, 2014). According to Hughes, L., Adair, J., Feng, F., Maciejewski, S., & Sharma (2016), it does indicate “changes in the serotoninergic, dopaminergic, and catecholaminergic systems of pain traismission and processing with some evidence of environmental and genetic influence” (p. 317). Thus,  circumstances include “stressful events such as abuse, injury from accidents, illnesses (including autoimmune disorders), infections, surgical procedures, and psychological stressors (Mbuyi, 2018, p. 491) may attribute to fibromyalgia.

Laboratory testing should be focused on excluding conditions that mimic FM or suspected concurrent diseases (Mbuyi, 2018). X-rays may also be ordered to exclude some conditions, if indicated (“Fibromyalgia,” 2017). The following labs should be ordered: “CBC; routine chemistries, TSH; 25 hydroxy vitamin D level (low levels can cause muscle pain); vitamin B12 level (low levels can cause fatigue and pain); iron studies (low levels can cause fatigue and depressive symptoms); and magnesium levels (low levels can cause muscle spasm)” (Mbuyi, 2018, p. 492). It is also important to note that “ESR and CRP are normal in FM. Routine testing for ANA and/or rheumatoid factor should be avoided unless history and physical examination suggest an autoimmune disease” (Mbuyi, 2018, p. 492).

Menzies (2016) stated that in order to meet the criteria of a diagnosis of fibromyalgia, the patient must present symptoms as follow:

  • The patient’s widespread pain index is 7 or greater and symptom severity score is 5 or greater, or widespread pain index score is between 3 and 6 and the symptom severity score is 9 or greater.
  • Symptoms have been present at a similar level for at least three months
  • The patient does not have a disorder that would otherwise explain the pain.

According to Ferri (2017) Patients with fibromyalgia often report the following symptoms:

  • Chronic (>3months) widespread (affecting both sides of the body, above and below the waist, and involving the axial spine) musculoskeletal pain
  • Cognitive disturbances
  • Fatigue and sleep disturbances (e.g., unrefreshed sleep, easy fatigability
  • Psychiatric symptoms (e.g. anxiety, depression
  • Headache (present in more than half of patients with fibromyalgia, this includes migraine and tension-type headaches
  • Paresthesias
  • Associated disorders: irritable bowel syndrome, interstitial cystitis/ painful bladder syndrome

Best approach may be combination of drug and nondrug therapies, Hughes, L., Adair, J., Feng, F., Maciejewski, S., & Sharma (2016) suggested nonpharmacology approaches such as: heated pools, exercise programs, cognitive behavioral therapy, relaxation, and psychological support. And from the pharmacologic realm, amitriptyline is strongly recommended. As according to Hughes, L., Adair, J., Feng, F., Maciejewski, S., & Sharma (2016), “Hauser, Wolfe, Tolle, Uceyler, and Sommer performed a systematic review and meta-analysis of the role of antidepressants in the patient with fibromyalgia. The results were very positive for the use of the tricyclic antidepressant, amitriptyline, and the serotonin norepienephrine reuptake inhibitors, duloxetine and milnacipran, as first –line options for the treatment of fibromyalgia” (p. 318).

Ferri (2017) also reported that best results also received from treatment of tricyclics (low dose amitriptyline and cyclobenzaprine), serotonin –norephinephrine reuptake inhibitors (milnacipran and duloxetine), and gabapentinoids (gabapentin and pregabalin). Second-tier drug classes include SSRIs. Ferri stated that “Start low, go slow” approach is best to avoid side effects from medications.

Patients with FM should be educated about their disease. They need to know that their condition is chronic and that there is no cure. They should be advised to contact their healthcare provider if they are experiencing side effects from medications and not to expect medication alone to reduce pain and fatigue. Sleep, exercise, and stress management are required in order to feel better/relieve symptoms of FM (“Fibromyalgia,” 2017). Patient’s should also be instructed not to take any diet supplements before consulting with their healthcare provider (“Fibromyalgia,” 2017). The following resources should be shared with patients, Arthritis Foundation Tel: (800) 283-7800 Website: http://www.arthritis.org and American College of Rheumatology Tel: (404) 633-3777 Website: http://www.rheumatology.org in order for them to find out more information related to their condition (“Fibromyalgia,” 2017).

Initially, follow up appointments should be scheduled for 2 to 4 weeks to evaluate patient’s response to therapy (Cash, 2017). “Visits may then be scheduled every 3 months to monitor progress” (Cash, 2017, p. 652).

References:

Cash, J. C. (2017). Fibromyalgia. In J. C. Cash & C. A. Glass (Eds.), Family practice guidelines (4th ed., pp. 651-652). New York, NY: Springer Publishing.

Clauw, D. (2014). Fibromyalgia: A clinical review. JAMA, 311(15), 1547-1555. http://dx.doi.org/10.1001/jama.2014.3266

Ferri, F. F. (2017) Ferri’s clinical advisor, 2017, 5 books in 1

Hughes, L., Adair, J., Feng, F., Maciejewski, S., & Sharma (2016) Nurse practitioners’ education, Awareness, and therapeutic approaches for the management of fibromyalgia. National Association of Orthopaedic Nurses. 35 (5). 317-322

Leeds, F. S. (2017). Fibromyalgia. In F. J. Domino, R. A. Baldor, J. Golding, & M. B. Stephens (Eds.), The 5-minute clinical consult 2017 (25th ed., pp. 380-381). Philadelphia, PA: Wolters Kluwer.

Managing your fibromyalgia. (2017). Retrieved from https://coursewareobjects.elsevier.com/objects/elr/ExpertConsult/Ferri/clinicaladvisor2017/PTG/EnglishPTGs/FIBROMYALGIA.pdf

Mbuyi, N. (2018). Fibromyalgia. In F. F. Ferri (Ed.), 2018 Ferri’s clinical advisor (pp. 491-492). Philadelphia, PA: Elsevier.

Menzies, V. (2016) Fibromyalgia syndrome: Current considerations in symptom management, Evidence-based nonpharmacologic and pharmacologic strategies. AJN. 116 (1). 24-32

Wolfe, F., Clauw, D. J., Fitzcharles, M., Goldenberg, D. L., Katz, R. S., Mease, P., … Yunus, M. B. (2010). The Ameican College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care & Research, 62(5), 600-610. http://dx.doi.org/10.1002/acr.20140

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