Myofascial

Fibromyalgia

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Fibromyalgia, Fibrositis

  • See Also
  1. ACR Fibromyalgia Diagnostic Criteria (ACRFDC)
  2. Tender Points
  3. Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)
  • Epidemiology
  1. Women account for more than 75-85% of Fibromyalgia patients
  2. Peak Incidence: ages 20 to 60 years old
    1. Incidence increases with age
  3. Most common rheumatic cause of chronic diffuse pain
    1. Most common cause of Chronic Pain in women ages 20 to 55 years old
  4. Incidence
    1. Rheumatology patients: 15%
      1. Only Osteoarthritis is more common in rheumatology practice
    2. General medical patients: 5%
    3. General female population: 2-3%
  • Pathophysiology
  1. Increased central sensitivity to peripheral sensation (as with other functional pain syndromes)
  2. Pain system dysfunction related to abnormalities in the forebrain
  • Risk Factors
  1. Post-Traumatic Stress Disorder (present in up to 45% of Fibromyalgia patients)
  2. Sexual abuse or rape
  • Associated Conditions
  • Common Comorbid Chronic Conditions
  1. Rheumatoid Arthritis
  2. Osteoarthritis
  3. Lyme Disease
  4. Sleep Apnea
  • Associated Conditions
  • Augmented pain and sensory processing disorders
  1. Chronic Fatigue Syndrome
  2. Tension Headache
  3. Migraine Headache
  4. Primary Dysmenorrhea
  5. Restless Legs Syndrome
  6. Periodic Limb Movement disorder
  7. Temporomandibular Joint pain
  8. Myofascial Pain Syndrome
  9. Interstitial Cystitis
  10. Irritable Bowel Syndrome
  11. Endometriosis
  12. Non-cardiac Chest Pain
  13. Chronic back pain
  14. Reduced functional ability
  15. Aerobic deconditioning
  16. Vulvodynia
  17. Post-Traumatic Stress Disorder
  • Associated Conditions
  • Symptoms
  1. Severe Fatigue (81%)
  2. Morning stiffness longer than 15 minutes (77%)
  3. Sleep Disorder (75%)
    1. Non-restorative sleep (alpha-delta sleep)
    2. Sleep Apnea
    3. Nocturnal Myoclonus
    4. Restless Leg Syndrome
  4. Atypical Paresthesias (63%)
  5. Anxiety (48%)
  6. Dry Mouth (36%)
  7. Recurrent Headaches (53%)
  8. Dysmenorrhea (41%)
  9. Past History of Major Depression (31%)
  10. Irritable Bowel Syndrome (30-70%)
  11. Urinary urgency (26%)
  12. Cold sensitivity or Raynaud's Phenomenon (17%)
  • Exacerbating Factors
  1. Post-exertional increase in muscle pain
  2. Emotional Stress or Abuse
  • Signs
  1. See Diagnosis below
  • Differential diagnosis
  1. Other Myofascial Conditions
    1. See Associated Conditions listed above
    2. Myofascial Pain Syndrome
    3. Chronic Fatigue Syndrome
  2. Psychiatric Conditions
    1. Masked Major Depression
    2. Somatoform Disorder
  3. Rheumatic, Endocrine and Neurologic Conditions
    1. Systemic Lupus Erythematosus (SLE)
    2. Rheumatoid Arthritis
    3. Polymyalgia Rheumatica (esp. age >60 years old)
    4. Polymyositis
    5. Diabetes Mellitus
    6. Myopathy or Neuropathy
    7. Myotonic Dystrophy
    8. Multiple Sclerosis
    9. Hypothyroidism
    10. Hyperparathyroidism
    11. Ankylosing Spondylitis
    12. Disc Herniation with radiculopathy
    13. Paraneoplastic Neuropathy
    14. Parkinson's Disease
  4. Infectious Conditions
    1. Epstein-Barr Virus (Mononucleosis)
    2. Parvovirus
    3. Q Fever
    4. Lyme Disease
  5. Miscellaneous Conditions
    1. Vitamin D Deficiency
    2. Statin-Induced Myopathy
    3. Eosinophilia-Myalgia Syndrome (rare, likely toxin related, such as L-Tryptophan ingestion)
  • Labs
  1. Labs are normal in isolated Fibromyalgia
  2. Standard Evaluation
    1. Complete Blood Count (CBC)
    2. Basic Metabolic Panel (e.g. Chem8)
    3. Thyroid Stimulating Hormone (TSH)
  3. Additional tests when indicated (non-specific tests, order judiciously)
    1. Erythrocyte Sedimentation Rate (ESR)
    2. C-Reactive Protein (C-RP)
    3. Antinuclear Antibody (ANA)
    4. Rheumatoid Factor (RF)
    5. Creatinine Phosphokinase (CPK)
  • Diagnosis
  • General Criteria
  1. Fibromyalgia is a diagnosis of exclusion
  2. Widespread musculoskeletal pain ("I hurt all over")
  3. Regional: Each of 4 body quadrants involved
    1. Pain on left and right side of body
    2. Pain above and below waist
  4. Axial skeleton pain present
    1. Cervical Spine
    2. Anterior chest
    3. Thoracic Spine
    4. Low back
  5. Pain worse in the morning and at the end of the day
  6. Symptoms persist at least 3 months
  • Diagnosis
  • Specific diagnostic tools
  1. New criteria (2010)
    1. See ACR Fibromyalgia Diagnostic Criteria (ACRFDC)
  2. Older criteria (1990)
    1. See Tender Points (11 of 18 present)
  • Management
  1. See Fibromyalgia Non-Pharmacologic Management
  2. See Fibromyalgia Pharmacologic Management
  3. Fibromyalgia Impact Questionnaire
    1. Assess for associated functional Impairment
  • Resources
  • Patients
  1. Fransen (1997) Fibromyalgia Help Book, Smith House
    1. Paid link to Amazon.com (ISBN 0961522143)
  2. Starlanyl (1996) Fibromyalgia and Myofascial Pain, NHP
    1. Paid link to Amazon.com (ISBN 1572240466)
  • Resources
  • Organizations
  1. Arthritis Foundation
    1. http://www.arthritis.org
  2. National Fibromyalgia Research Association
    1. http://www.teleport.com/~nfra
  3. USA Fibromyalgia Association
    1. http://www.fibromyalgiaassnusa.org
  4. UK Fibromyalgia Association
    1. http://www.community-care.org.uk/charity/fmauk.html
  • References
  1. Money and Glauser (2017) Crit Dec Emerg Med 31(1): 15-21
  2. Klippel (1997) Primer Rheumatic Diseases, p.124-7
  3. Yunus (1996) Consultant, p. 1260-74
  4. Yunus (1996) Consultant, p. 1279-85
  5. Berman (1999) J Fam Pract 48(3):213-18 [PubMed]
  6. Gremillion (1998) Phys Sportsmed, 26(4) 55-65 [PubMed]
  7. Hadler (1997) Postgrad Med 102(2):161-77 [PubMed]
  8. Kodner (2015) Am Fam Physician 91(7): 472-8 [PubMed]
  9. Reiffenberger (1996) Am Fam Physician 53(5):1698-1704 [PubMed]
  10. Wilke (1996) Postgrad Med 100(1):153-70 [PubMed]