Laura Wind

General Medical Conditions

12/4/2015

FIBROMYALGIA

Introduction

Many know fibromyalgia is characterized by wide spread muscle pain, but what most do not

realize is what this is caused by. This pain is wide spread is also characterized by chronic muscle

pain and other symptoms which include, but are not limited to, fatigue, some cognitive

dysfunction, poor sleep, stiffness, and increased tenderness in specific areas of the body.1

However, of the 7%-11% of the population that has chronic wide spread pain, only 1%-5% are

diagnosed with fibromyalgia.2 Fibromyalgia may also be associated with some conditions

including headache, irritable bowel syndrome, and mood disorders.3 There are also multiple

comorbidities involved with fibromyalgia. These comorbid diseases include, migraines,

interstitial cystitis, and allergic reactions.4 It is found in about 2% of the US population, and is a

condition that includes pain spanning all 4 limbs along with the trunk.1,3 Fibromyalgia can

overlap with a variety of other related syndromes related to the central nervous system and its

potential malfunction.5 Diagnosis of this condition is usually determined by a description of

symptoms and point tenderness in 11 to 18 sites on the body.1,6 Classification of this syndrome

bring forth an issue due to the abnormal changes in muscles and connective tissues stemming

from the central nervous system functional problems.2 Since fibromyalgia does come with a

majority of complicated characteristics, there are a variety of different ways to address it

diagnostically and with treatment plans. These can involve a number of pharmacological and

rehabilitative means to manage the disease with no curative option.

Signs and Symptoms

Classifying fibromyalgia, based on studies, can be done by examining pain sensitivity,

psychiatric associations, the condition involving depression, and a somatoform pain disorder.

However, the topic of classification, along with most aspects of this disorder, is associated with

criticism due to the subjectivity of its diagnosis. A rheumatology clinic has laid out a

classification system for this disorder as follows: sub group 1 is fibromyalgia with a large

sensitivity to pain and no psychiatric conditions involved, subgroup 2 is fibromyalgia along with

comorbid depression due to the pain, subgroup 3 is depression with fibromyalgia, and subgroup

4 is fibromyalgia due to somatization. These subgroups can be determined from patients based

on MPI questionnaire responses.7

The signs and symptoms for this disorder, like most aspects of the disorder, can be

subjective based on severity, type of pain, and combination of location. Widespread pain which

is characterized as axial pain, both right and left sided pain, and both upper and lower level pain.

Tender point count is that primary symptom for classification of fibromyalgia.8 This is due to

the lack of visual signs from an objective stand point. However, there are a few more symptoms

that are noted which include fatigue, cognitive associations, sleep disturbances, stiffness, and

some somatic symptoms.1, 6 A study done by Wolfe, et al. examined the diagnostic criteria which

are categorized by several subjective measures when being examined. The measures used in this

particular study include using the widespread pain index (WPI), the seven and symptom severity

scale sore (SS), the five or WPI 3-6 and SS scale score, the length of time that the symptoms

have been present (at least 3 months), and no other disorder which would explain the pain. The

WPI is a system scored between 0 and 19 noting which of each of the following areas has had

pain in the last week. The areas tested are (right and left if applicable) the shoulder girdle, upper

arm, lower arm, hip (buttock/greater trochanter), upper leg, lower leg, jaw, chest, abdomen,

upper back, lower back, and neck. The SS scale score takes into account fatigue, waking

unrefreshed, and cognitive symptoms. For each of those aspects, the severity will be rated on a 0

to 3 scale, 0 meaning no problem, 1 meaning slight to mild or intermittent pain, 2 meaning

moderate problems often present, and 3 meaning severe or life-disturbing problems. Part of the

SS which grades the somatic symptoms is graded by 0 to 3, 0 is no symptoms, 1 is few

symptoms, 2 is moderate symptoms, and 3 is a large amount of symptoms. The sum of each

symptom is added which comes to a final total of 0-12.8 Many environmental factors may play a

part in the presentation and frequency of fibromyalgia symptoms, but the largest issue in

diagnosis is the combination of other disorders that may be causing the widespread pain, the

most common characteristic in fibromyalgia.5

Referral

When diagnosing and managing fibromyalgia, there are multiple different physicians and

help prescribe medications to maintain better sleep habits, antidepressant medications, or just

offer a safe environment to discuss ways to manage the widespread pain and depression caused

by the variety of aspects of fibromyalgia.10 Another important specialist in this disorder is the

pain specialist. Fibromyalgia has the main characteristic of widespread pain which means pain

specialists will play a role in helping to find to root of the pain as well as managing pain in a way

that may be individualized to each patient in order to find the best type of treatment possible for

this highly subjective disorder and diagnosis.2 The final member of the referral team used is the

rheumatologist. Rheumatologists play a very important role because they help with diagnosing

and managing pain in the musculoskeletal areas which are involved. Since pain is the most

common symptom and usually the only symptom that is always a constant, it is very important to

have the input of these specialists or even have them be the head of the fibromyalgia

management team as they have specialized in these and other similar pain disorders. Basically,

because there are many aspects to diagnosing and managing this disorder, it is important to have

the input and support of a variety of specialists to ensure the patient will get the best care

necessary in order to live their life and performs their daily activities to their fullest potential.

Diagnostic Tests

Diagnostic techniques and tools for fibromyalgia, like many aspects of the disease, can have a

large range based on the different ways this may present itself in different people. As mentioned

previously, fibromyalgia is typically determined based on questionnaires that the patient fills out

and a thorough examination of a number of trigger points which help us group or classify

patients in different ways. The initial diagnostic tool for all cases of fibromyalgia, is the use of a

symptom severity scale. In a study by Wolfe et.al, findings showed that 88.1% of cases could be

correctly classified from the symptom severity scale without and physical or tender points

evaluation.8 However, since there are no real diagnostic tools to use to determine the presence of

fibromyalgia in reality, the tender point assessment accompanied with a symptom severity scale,

which is based on the subjects pain scale, is the best way to determine the presence or absence of

the disorder in general. The symptoms involved in the severity scale include not only pain, but

levels of fatigue as well. Since this disorder is so subjective, there is no official gold standard in

conditions, present conditions, and opinions in order to form a proper diagnosis and plan for the

management of fibromyalgia for each individual.

Differential Diagnosis

Due to the general widespread pain and other unexplained symptoms fibromyalgia has many

differential diagnosis possibilities. Widespread pain, which is the major characteristic of this

disorder, may be due to a number of different diseases or conditions to which this symptom is

just the beginning of a much larger issue occurring for the patient.

presence of any of the previously listed conditions should at least a partial indicator that the

disturbance of sleep, widespread pain, and psychosocial involvement may be associated with a

intravenous of a serotonin receptor antagonist tropisetron for analgesic effects.4 Another

effective form of treatment physical therapy which helps manage inflammation with a variety of

modalities and the use of muscles and musculoskeletal junctions involved. With exercise

therapy, it is important for the patient to choose the right form of exercises which usually include

starting with lighter intensities and then working up to moderate and sometimes even vigorous

intensities. Exercise performance, however: is best increased and helpful when the patient

Prognosis

The outlook or prognosis for those with fibromyalgia is not deadly, but it is a disorder that does

found in fibromyalgia and other related central system sensitivity disorders. This is unfortunate,

because it means the onset of fibromyalgia may not be able to be stopped due to the familial

nature of the condition. However, the possible link to genetic findings also means that steps in

the right direction are being taken to find out more about this disorder and what is causing its

uncomfortable symptoms for those afflicted with it.15 A study done by Goldeberg examined the

improvement of symptoms may be achieved by patient education of the disorder, its potential

pathophysiology, its mechanism, and potential exercises used.12 Everyday posture and alignment

assessments may be beneficial to adjust discomforts in everyday activities which will influence

further irritation to the condition itself. Finally, a relaxation techniques intervention will be

helpful to these patients which includes decreasing muscle tension, decreasing anxiety, imagery

techniques which engages multiple body systems, and using biofeedback or electromyogram

activities to initiate relaxation in specific areas that may be causing increased symptoms or

irritation. Since there is no set method of prevention for fibromyalgia, as is a trend in most

aspects of this condition, it is important for the patient to understand what is occurring in order to

manage in properly.

Case Study

To view how fibromyalgia may present, I examined a case study published by Dr. Goldberg,

who was a Professor of Gastroenterology, Public Health, and Clinical Nutrition at Life College

for over 20 years then moved to a current practice in Clinical Nutrition, Natural Hygiene,

Clinical Epidemiology, and Biological Medicine as current Director of The Goldberg Clinic in

Atlanta.

Patient is a 41 year old female suffering from diffuse muscle pain in shoulders, neck, knees,

upper legs, and sometimes through the upper back. She was referred to Dr. Goldberg after

general physician had made diagnosis of fibromyalgia through a tender point assessment. Dr.

Goldberg examined nutrition through complete blood count and blood chemistry to ensure none

of these factors were leading to her fatigue. Patient was also seeing chiropractor to receive

massages and spinal adjustments. Her general physician had suggested seeking psychiatric

counseling if the problem persisted.

For management in this particular case, she was on non-steroidal anti-inflammatory medications,

an antidepressant, and experimenting with herbal formulas and homeopathic products in order to

decrease her muscular pain. She struggled with sleeping and had no sexual drive. After seeing

Dr. Goldberg, he added a more organized dietary plan, a routine bedtime, a swimming program,

an increase of enjoyable activities, and, if necessary after two to three months, a hormonal

examination. After the first ten days, she felt improvement. By six weeks her pains had

diminished about 80% and she had returned to regular activities. She added swim to her regular

routine due to the full success of her plan.12

Conclusion

References

1. Abeles, A.M., Pillinger, M.H., Solitar, B.M., and Abeles, M. (2007), Narrative Review: The

Pathophysiology of Fibromyalgia. 146, 726-734.

2. Hauser, W., Elch, W., Herrmann, M., Nutzinger, D.O., Schiltenwolf, M., and Henningsen, P.

(2009), Fibromyalgia Syndrome. 106(23), 383-391.

3. Mease, P., Arnold, L.M., Bennett, R., Boonen, A., Buskila, D., Carville, S., Chappell, A.,

Choy, E., Clauw, D., Dadabhoy, D., Gendreau, M., Goldenberg, D., Littlejohn, G., Martin, S.,

Perera, P., Russell, L.J., Simon, L., Spaeth, M., Williams, D., and Crofford, L. (2007),

Fibromyalgia Syndrome. 34, 14-25.

4. Lucas, H.J., Brauch, C.M., Settas, L., and Theohardies, T.C. (2006), Fibromyalgia-New

Concepts of Pathogenesis and Treatment.

19(1), 5-9.

5. Buskila, D. and Sarzi-Puttini, P. (2006), Biology and therapy of fibromyalgia. Genetic aspects

of fibromyalgia syndrome. 8, 218.

6. Katz, R.S., Wolfe, F., and Michaud, K. (2006), Fibromyalgia Diagnosis.

54(1), 169-176.

7. Muller, W., Schneider, E.M., and Stratz, T. (2007), The classification of Fibromyalgia

syndrome. 27, 1005-1010.

8. Wolfe, F., Clauw, D.J., Fitzcharles, M.A., Goldenberg, D.L., Katz, R.S., Mease, P.,Russell,

A.S., Russell, I.J., Winfield, J.B., Yunus, M.B. (2010), The American College of Rheumatology

Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity.

62(5), 600-610.

9. Busch, A.J., Webber, S.C., Brachaniec, M., Bidonde, J., Dal Bello-Haas, V., Danyliw, A.D.,

Overend, T.J., Richards, R.S., Sawant, A., and Schachter, C.L. (2011), Exercise Therapy for

Fibromyalgia. 15, 358-367.

10. Schweinhardt, P., Sauro, K., and Bushnell, M.C. (2008), Fibromyalgia: A Disorder of the

Brain? 14(5), 415-421.

11. Bradley, L.A. (2009), Pathophysiology of Fibromyalgia.

122(12), 1-13.

12. Goldberg, Paul. Accessed September 6, 2015. Case Study: Fibromyalgia.

13. Yunus, M.B. (2007), Fibromyalgia and Overlapping Disorders: The Unifying Concept of

Central Sensitivity Syndromes. 36, 339-356.

14. Clauw, D.J., Arnold, L.M., and McCarberg, B.H. (2011), The Science of Fibromyalgia.

86(9), 907-911.

15. Smith, H.S, Harris, R., and Clauw, D. (2011), Fibromyalgia: An Afferent Processing

Disorder Leading to a Complex Pain Generalized Syndrome. 14, 217-

245.

16. Arnold, L.M., Croffored, L.J., Mease, P.J., Burgess, S.M., Palmer, S.C., Abetz, L., and

Martin, S. A. (2008), Patient Perspectives on the Impact of Fibromyalgia.

73(1), 114-120.