Fibromyalgia

Patients typically present with chronic, widespread body pain and almost always have accompanying comorbid symptoms such as fatigue, memory difficulties, and sleep and mood difficulties.

Physical examination is typically normal but there is often diffuse tenderness, which may be assessed by counting the number of tender points or by palpating several areas of the body.

Many therapies have been shown to be beneficial. Nonpharmacologic therapies include patient education, exercise, and cognitive behavioral approaches. Pharmacologic therapies include tricyclic antidepressants, gabapentinoids, and serotonin-norepinephrine reuptake inhibitors. Patients often fare better when several different types of treatments are used together.

Even though practitioners may have a problem recognizing fibromyalgia as a discrete disorder, they should understand the diagnostic and therapeutic importance of "centralization" of pain as exemplified by a typical fibromyalgia patient. When a patient with any chronic pain state develops evidence of centralization of pain, it is likely that treatments that work well for acute pain or pain primarily due to nociceptive input (NSAIDs, opioids, anti-inflammatories, immunosuppressives, injections, surgical procedures) will be less effective.

Fibromyalgia is a chronic pain syndrome diagnosed by the presence of widespread body pain.

The 1990 American College of Rheumatology criteria for the classification of fibromyalgia required that an individual had widespread pain (front and back, right and left, both sides of the diaphragm) for at least 3 months in addition to tenderness (digital palpation at an approximate force of 4 kg) of at least 11 out of 18 designated tender point sites.[1]Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990 Feb;33(2):160-72. https://onlinelibrary.wiley.com/doi/epdf/10.1002/art.1780330203 http://www.ncbi.nlm.nih.gov/pubmed/2306288?tool=bestpractice.com Subsequent criteria do not require a tender point examination by performing a tender point count, and focus on identifying widespread pain in combination with fatigue and memory and sleep difficulties.[2]Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010 May;62(5):600-10. https://onlinelibrary.wiley.com/doi/full/10.1002/acr.20140 http://www.ncbi.nlm.nih.gov/pubmed/20461783?tool=bestpractice.com [3]Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016 Dec;46(3):319-29. http://www.ncbi.nlm.nih.gov/pubmed/27916278?tool=bestpractice.com [4]Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 2011 Jun;38(6):1113-22. https://www.jrheum.org/content/38/6/1113.long http://www.ncbi.nlm.nih.gov/pubmed/21285161?tool=bestpractice.com Although there is not likely to be any single cause, substantial evidence suggests that this is in part a central nervous system-driven pain amplification syndrome.