1. The jury is in on fibromyalgia. It’s a real condition affecting perhaps 1 in 50. The vast majority are women, with middle age the peak time for onset. It’s a chronic disease but not a progressive one. The causes of fibromyalgia remains mysterious, but consensus holds that it’s a process of central sensitization, by which the brain comes to feel normal sensations as painful.

2. The great difficulty has always been diagnosis. But we have clear and simple critieria, from the American College of Rheumatology. Don’t be shy in making the diagnosis — if patients have prolonged widespread musculoskeletal pain not explained by another condition, and pain on palpation in 11 of 18 specified sites, they have fibromyalgia.

3. These sites are (all bilateral): occiput — at the suboccipital muscle insertions, low cervical — at the anterior aspects of the intertransverse spaces at C5-C7; trapezius — at the midpoint of the upper border; supraspinatus — at origins, above the scapula spine near the medial border; second rib — upper lateral to the second costochondral junction; lateral epicondyle — 2 cm distal to the epicondyles; gluteal — in upper outer quadrants of buttocks; greater trochanter — posterior to the trochanteric prominence; knee — at medial fat pad proximal to joint line.

4. Press each point hard enough that your thumbnail blanches (about 4 kg). If this elicits real pain, not just tenderness, it’s positive.

5. There’s a lot of exclusion to do when diagnosing fibromyalgia. Your investigation should include FBC, LFTs, ALP, CRP, ESR, CK, calcium and autoimmune screening. One disease that’s especially tough to differentiate is polymyalgia rheumatica. But this typically manifests extreme morning stiffness, so much that patients have to roll out of bed.

6. Patients may be bothered by noise, light, alcohol, or everyday bodily sensations. The pain is not a symptom of actual musculoskeletal pathology. The clinician must find a way to tell the patient this without saying “it’s all in your head.” It may be usefully described as a central pain processing disorder.

7. Pain shouldn’t be allowed to interfere with activities, especially since exercise shows proven benefits. Gentle water-based exercises, ideally in a heated pool, have done best in trials. The amount of exertion should start low and increase slowly — aim for 10% a month.

8. Most patients will also fulfil criteria for chronic fatigue syndrome. Patients follow the boom and bust pattern of CFS: their worst days often follow their best, when they take on too much activity. Pacing is vital, and should be taught as a coping strategy.

9. One way to do this is through cognitive-behavioural therapy. CBT is a useful adjunct to exercise, but even together, in trials they brought functional improvement to only a minority of patients. CBT is somewhat more effective against pain, helping about half of patients.

10. As for drug therapy, standard analgesics rarely help much. Steroids and strong opioids aren’t recommended. Moderate opiates like codeine and tramadol can be useful in flare-ups. Low-dose nightly amitriptyline often helps with both pain and disturbed sleep. The SNRI duloxetine has been shown to help with central pain processing disorders and is approved for fibromyalgia in the U.S. (nausea is sometimes an issue). As of last year, pregabalin is approved for fibromyalgic pain in Canada; it may also help with the anxiety so prevalent in this disease. But remember — fibromyalgia patients tend to be unusually vulnerable to drug adverse effects, so with all drugs, start low and titrate slow.

 

Distribution of this educational supplement is sponsored by Pfizer Canada Inc.