Fibromyalgia

Fibromyalgia (FM) is a syndrome is characterised by widespread chronic pain, fatigue, unrefreshed sleep and systemic symptoms in the absence of an organic disease [1]. Although currently no ‘gold standard’ test exists for FM diagnosis, an updated publication from the American College of Rheumatology (ACR) and Canadian guidelines on FM diagnosis has emphasised the importance of diagnosis in the primary health care setting [2, 3]. Physiotherapists, as first contact practitioners therefore need to be able to identify and differentially diagnose FM from similarly presenting syndromes.

Presentation and Diagnosis

FM is most common between the ages of 25 and 55 years but can occur across all age groups [1, 4]. It is most common among women (80-90%). Fibromyalgia is a widespread syndrome that presents with pain in numerous anatomical locations. A recent publication from the ACR [3] has identified the following locations in the diagnostic criteria of FM; left and right shoulder girdle, upper arm, lower arm, hip (buttock, trochanter), upper leg, lower leg, and jaw; as well as the chest, abdomen, neck, upper back and lower back. Patient symptoms may commonly present in some or all of these locations, but are not limited to other body regions. The primary symptom of FM is a diffuse muscular pain, often described as; aching, burning, gnawing, tingling, deep and ‘hurts all over’ [1, 4]. FM pain is constant, however it is often described as waxing and waning and the pain locations can be migratory [1]. In addition FM patients may also present with a variety of non-specific symptoms, including: irritable bowel and bladder, abdominal pain, visual problems (blurred vision, diplopia), headaches, cognitive problems (poor concentration and short-term memory), heat/cold intolerance and anxiety [1, 4].

Diagnosis of FM is considered if the patient presents with the aforementioned pain for at least 3 months [2]. It is usually of a slow onset although may have potential triggers, such as; prolonged stress and anxiety, infection and physical trauma [1, 4].

Commonly aggravating activities for FM include: emotional distress, weather changes, sleeping problems, strenuous activity and mental stress [5]. FM patients often report morning stiffness lasting greater than 30 minutes and sleep disturbances; ‘light’ sleeping, waking frequently and difficulty returning to sleep [5, 6]. Most notably FM patients will present with non-restorative sleep, feeling fatigued and exhausted in the morning [4]. There are no laboratory tests or imaging investigations that can be used to determine the presence of FM [4].

Assessment

The majority of information necessary to determine a differential diagnosis of FM are obtained through the patient history as mentioned above. Further information to confirm diagnosis can be obtained from an objective examination. FM unless concurrent arthritis is present will not have any joint swelling and ROM is commonly normal [6]. Despite this, patient irritability and pain may limit ability to reach full ROM. ACR criteria from 1990 indicated 19 tender points that were painful when palpated [7]. A new ACR criterion identifies that palpation of a number of locations in the limbs and trunk (stated previously) that often result in hyperalgesia or allodynia [2]. A neurological examination for FM will reveal normal reflexes and non-dermatomal areas of hypersensitivity and allodynia to light touch. Muscular palpation for FM patients is also described as ‘nodular’ or ‘ropy,’ without atrophy or increased tone [8]. Muscle strength is commonly normal with no true neurological weakness, however it may be reduced or difficult to interpret due to pain and stiffness [4].

Management of Fibromyalgia

Best practice management for a patient diagnosed with fibromyalgia should incorporate a multidisciplinary approach of pharmacological treatment, exercise, cognitive-behavioural therapy (CBT) and education [1]. Prognosis for FM patients is variable; often those with mild symptoms can have complete remission, however many will experience persistent or recurrent symptoms for years or life [4]. The goals of FM treatment should be highly individual and developed with the patient using the SMART principle. Suitable short-term goals should be aimed at establishing a stable patient baseline, whereby they can complete desired daily tasks [8]. This is primarily through goals of; decrease pain, improve restorative sleep and decrease fatigue [1]. In the long term the patient should aim to improve this stable baseline level, enabling greater physical and cognitive functioning.

Pharmacological management of FM could incorporate tricyclic antidepressants to aid control of symptoms, with serotonin and norepinephrine uptake inhibitors having the best efficacy for FM [1]. Strong evidence also suggests Tramadol is an effective pain reliever in FM management [1]. CBT is effective in reducing patient pain and sleeping difficulties [4]. The employment of a psychologist and CBT will assist in managing depression, anxiety and altered coping mechanisms associated with FM [8].

The most effective patient education should include information regarding; the key features of FM and basic physiology, prognosis and management strategies [8]. This education, combined with CBT and pharmacological treatment lays a framework to begin increasing physical activity.

Initially FM patients should be encouraged to perform activity self-management before progressing into an individually prescribed and supervised exercise program, which incorporates flexibility, strength and aerobic training [9]. Strong evidence exists for the implementation of a low-to-moderate intensity (50-85%HRMAX) aerobic exercise program, 2-3 times per week, for at least 30 minutes [9]. Initially a FM patient may wish to begin with water-based exercise to reduced stress placed upon the muscles and joints. Moderate evidence also supports the use of a low-moderate intensity strength-training program, for 60 minutes, twice a week [9]. This should target major muscle groups and begin with low sets (2-4) and low intensity (40% MVC) and gradually progress. Progressions for all exercises should be based on patient limitations and resources, with disabling pain indicative of the need to decrease intensity. However, the frequency of exercise should be maintained despite days of increased pain [10]. The use of passive treatments such as massage therapy, transcutaneous electrical nerve stimulation and myofascial release are not currently recommended in primary care physiotherapy management of FM [10].

Lewis Craig (APAM)
POGO Physiotherapist
Masters of Physiotherapy

Featured in the Top 50 Physical Therapy Blog

References

1. Bellato, E., Marini, E., Castoldi, F., Barbasetti, N., Mattei, L., Bonasia, D. E., & Blonna, D. (2012). Fibromyalgia syndrome: etiology, pathogenesis, diagnosis, and treatment. Pain Res Treat, 2012, 426130. doi: 10.1155/2012/426130
2. Wolfe, F., Clauw, D. J., Fitzcharles, M. A., Goldenberg, D. L., Katz, R. S., Mease, P., . . . Yunus, M. B. (2010). The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken), 62(5), 600-610. doi: 10.1002/acr.20140
3. Fitzcharles, M. A., Ste-Marie, P. A., Goldenberg, D. L., Pereira, J. X., Abbey, S., Choiniere, M., . . . National Fibromyalgia Guideline Advisory, P. (2013). 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag, 18(3), 119-126.
4. Goodman, C. C., & Fuller, K.S. (2009). Pathology: implications for the physical therapist (3rd Edition ed.). St Louis, Mo: Saunders/Elsevier.
5. Bennett, R. M., Jones, J., Turk, D. C., Russell, I. J., & Matallana, L. (2007). An internet survey of 2,596 people with fibromyalgia. BMC Musculoskelet Disord, 8, 27. doi: 10.1186/1471-2474-8-27
6. Goldenberg, D. L. (2009). Diagnosis and differential diagnosis of fibromyalgia. Am J Med, 122(12 Suppl), S14-21. doi: 10.1016/j.amjmed.2009.09.007
7. Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., . . . et al. (1990). The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum, 33(2), 160-172Chaitow, L. (2000). Fibromyalgia Syndrome: a practitioners guide to treatment. London, UK: Churchill Livingstone.
8. Chaitow, L., Fibromyalgia Syndrome: a practitioners guide to treatment. 2000, London, UK: Churchill Livingstone.
9. Winkelmann, A., Hauser, W., Friedel, E., Moog-Egan, M., Seeger, D., Settan, M., . . . Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen, F. (2012). [Physiotherapy and physical therapies for fibromyalgia syndrome. Systematic review, meta-analysis and guideline]. Schmerz, 26(3), 276-286. doi: 10.1007/s00482-012-1171-3
10. Nijs, J., Mannerkorpi, K., Descheemaeker, F., & Van Houdenhove, B. (2010). Primary care physical therapy in people with fibromyalgia: opportunities and boundaries within a monodisciplinary setting. Phys Ther, 90(12), 1815-1822. doi: 10.2522/ptj.20100046

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