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Fibromyalgia

Fibromyalgia is a chronic syndrome characterised by widespread pain, fatigue, and sleep disturbances. The condition affects about 2–4% of the population, with women being affected twice as often as men.

The exact cause is unknown, but it is believed to involve a combination of genetic and environmental factors. Since the pain is thought to result from processes in the central nervous system, fibromyalgia is often referred to as a "central sensitisation syndrome".

Signs and Symptoms

The primary symptoms of fibromyalgia include chronic widespread pain, fatigue, and sleep disturbances. The pain can manifest as an ache, burning sensation, or sharp, stabbing pain and can be exacerbated by the slightest touch. Patients often experience heightened sensitivity to pain (allodynia) and other stimuli like bright lights and loud noises.

Cognitive problems, known as "fibrofog," are also common, characterised by difficulties in concentration, memory, and multitasking. Other symptoms may include musculoskeletal stiffness, environmental sensitivity, hypervigilance, sexual dysfunction, and visual symptoms. Some patients experience post-exertional malaise, where symptoms flare up after physical exercise.

The nine possible pain sites of fibromyalgia according to the American Pain Society
The nine possible pain sites of fibromyalgia according to the American Pain Society

Diagnosis

Diagnosing fibromyalgia can be challenging due to the lack of a specific pathological feature or laboratory test. The diagnosis is generally based on patient history, symptom patterns, and the exclusion of other conditions. The American College of Rheumatology (ACR) has provided guidelines that have evolved over time. The latest criteria from 2016 require generalised pain in at least four of five regions, symptoms present for at least three months, and a combination of widespread pain index (WPI) and symptom severity scale (SSS) scores.

The location of the nine paired tender points that comprise the 1990 American College of Rheumatology criteria for fibromyalgia
The location of the nine paired tender points that comprise the 1990 American College of Rheumatology criteria for fibromyalgia
Widespread pain index (WPI) areas
Widespread pain index (WPI) areas

Pathophysiology

The pathophysiology of fibromyalgia involves abnormalities in pain processing within the central nervous system, often termed as nociplastic pain. This condition is associated with dysregulation in neurotransmitters such as serotonin and dopamine, oxidative stress, and potential abnormalities in the autonomic nervous system. Some studies suggest an association with small fibre neuropathy, although this is not universally accepted.

Treatment

Treatment for fibromyalgia is symptomatic and multidisciplinary, focusing on improving the quality of life. The European League Against Rheumatism (EULAR) strongly recommends aerobic and strengthening exercises as the primary non-pharmacological treatment. Meditative exercises like tai chi, yoga, and qigong are also beneficial for improving sleep and quality of life. Psychological therapies such as cognitive-behavioural therapy can help in managing symptoms, especially in patients with mood disorders or unhelpful coping strategies.

Medications may be used to manage severe symptoms, though their effectiveness is debated. Commonly prescribed medications include serotonin-norepinephrine reuptake inhibitors like duloxetine and milnacipran, and anticonvulsants like pregabalin and gabapentin. Supplements like Q10 coenzyme and vitamin D may also reduce pain and enhance quality of life. However, strong opioids and steroids are generally not recommended due to the lack of efficacy and potential side effects.

Prognosis

Fibromyalgia is a persistent condition but does not lead to tissue damage or shorten life expectancy. While many patients experience chronic symptoms, effective management strategies can help improve their quality of life. There is considerable variability in symptom severity among patients, with some showing substantial improvement over time.


Self-assessment MCQs (single best answer)

What is fibromyalgia primarily characterised by?




Which gender is more commonly affected by fibromyalgia?




What is the term used to describe the heightened sensitivity to pain experienced by fibromyalgia patients?




Which of the following is a common cognitive symptom of fibromyalgia?




What is the primary non-pharmacological treatment recommended by the European League Against Rheumatism (EULAR) for fibromyalgia?




Which of the following medications is commonly prescribed for managing severe fibromyalgia symptoms?




What is the term used to describe the abnormalities in pain processing within the central nervous system in fibromyalgia?




Which diagnostic criteria are used to diagnose fibromyalgia according to the American College of Rheumatology (ACR)?




What is a common non-pharmacological therapy that can help manage fibromyalgia symptoms, especially in patients with mood disorders?




What is the prognosis for patients with fibromyalgia?




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