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1. Fibromyalgia is an unfortunately common disease in the United States that frequently goes misdiagnosed for many years. It was considered a "wastebasket diagnosis" after the term had been coined in 1976, and it was not until 1987 when it was formally acknowledged by the American Medical Association as a true illness. Even with an increase in the awareness of fibromyalgia, patients typically suffer for many years before being properly diagnosed, and many times are exposed to needless, expensive, and invasive procedures or medications along the way.
2. Unfortunately, there are limited data about the exact prevalence of fibromyalgia in the United States. The estimated prevalence is 2%, affecting roughly 5 million adults. Prevalence is much higher in women (3.4%) than in men (0.5%). This leads to 2.2 million ambulatory care visits per year at an average cost of almost $6000 per person.
3. There is a significant amount of overlap between chronic pain disorders, central sensitivity syndromes (eg, chronic fatigue syndrome, irritable bowel syndrome, posttraumatic stress disorder, primary dysmenorrhea), and anxiety disorders. In addition, many patients suffer concomitantly from fibromyalgia and systemic inflammatory illnesses, such as rheumatoid arthritis, chronic hepatitis C, and systemic lupus erythematosus. The diagnosis applied to a given patient is often the result of the type of specialist first seen by the patient. In fibromyalgia, however, pain can be elicited by the application of pressure (approximately 4 kg/cm2) at 1 of 14 specific points.
4. The etiology of fibromyalgia is multifactorial and not completely understood, but a biopsychosocial model provides a useful framework for organization. A number of biological variables have been identified, including genetics, female sex, age, poor sleep, trauma, deconditioning, autonomic dysregulation, chronic infection, abnormal nociceptive processing, and stress. Identifiable psychological variables include hypervigilance, feelings of helplessness, poor coping strategies, depression, anxiety, certain personality traits and styles (ie, neuroticism, perfectionistic/compulsive), and excessive pain behaviors. Environmental and sociocultural variables associated with fibromyalgia include family support, job satisfaction, childhood abuse, and family members or friends with chronic pain.
5. The pathophysiologic sequence of events that leads to the development of fibromyalgia is not well elucidated; however, a number of discrete cellular and biochemical abnormalities have been identified. The volume of abnormalities discovered in patients with fibromyalgia is enough to substantiate the claim that it is not a subjective pain condition. When viewed collectively, these abnormalities suggest that fibromyalgia is a disorder of central sensitization or abnormal central processing of nociceptive pain input.
6. Patients with fibromyalgia present with a whole host of complaints, in addition to chronic pain. Pain is typically described as radiating diffusely from the axial skeleton over large areas of the body, predominantly involving the muscles and joints. Fatigue and poor sleep are nearly universal, and most patients with fibromyalgia also meet the classification for chronic fatigue syndrome. Cognitive problems, known as "fibrofog," produce impairments in memory equivalent to 20 years of aging. Other less commonly reported symptoms of fibromyalgia are shown above. Image courtesy of Wikimedia Commons.
7. The diagnosis of fibromyalgia must include a thorough clinical and laboratory evaluation to identify alternative or coexisting diagnoses for chronic pain. Laboratory studies to look for hypothyroidism (thyroid-stimulating hormone [TSH]), inflammatory myopathies (creatine phosphokinase [CPK]), polymyalgia rheumatica (erythrocyte sedimentation rate [ESR]), lupus (antinuclear antibody [ANA]), and chronic infections (complete blood count with differential) are appropriate initial work-ups. Depending on the constellation of presenting symptoms, sleep studies and joint fluid analysis may be helpful. The use of a dolorimeter (shown) can provide reproducible pressure measurements in the evaluation of fibromyalgia tender points.
8. Fibromyalgia research has demonstrated that patients with fibromyalgia have a lower threshold for pain stimuli. Data from one study published in Arthritis & Rheumatism is shown. The graph on the right shows that a low-intensity stimulus produces severe pain in patients with fibromyalgia. Functional magnetic resonance imaging (fMRI) data show overlap between the low-intensity stimuli in patients with fibromyalgia and the high-intensity stimuli in normal patients. Image courtesy of Rick Gracely.
9. Treatment for fibromyalgia is multifactorial: psychological and behavioral therapy, physical therapy, and pharmacotherapy. Achieving a satisfactory clinical response is difficult to achieve, but combination therapy has proven to be more effective than monotherapy alone. Psychological and behavioral therapy includes aggressive depression treatment, cognitive-behavioral therapy, operant-behavioral therapy, relaxation training, sleep hygiene, coping skills, and distraction strategies.
10. Exercise has been proven to provide both subjective and objective improvements in pain and overall sense of well-being. Deconditioning is a major contributing factor to pain. Graded aerobic activity with aerobics, aquatherapy (shown), or stationary bicycles can be transitioned to more rigorous endurance and strength training. Heat and massage provide symptomatic relief for many forms of chronic pain, including fibromyalgia. The role of trigger point injections, acupuncture, chiropractic manipulations, and myofascial release are not current evidence-based approaches to therapy. All therapeutic approaches should emphasize self-sufficiency in pain control, rather than reliance on others for symptomatic relief. Image courtesy of Wikimedia Commons.
11. Pharmacotherapy is complex and depends on the specific symptomatic profile of a given patient. It is most effective if combined with nonpharmacotherapeutic strategies. A number of general principles are evident. Many patients with fibromyalgia are taking large doses of pain medications, but they have limited efficacy in fibromyalgia and should mainly be reserved for patients with concomitant nociceptive pain generators (eg, osteoarthritis). Aggressive treatment for comorbid depression and poor sleep is mandatory. Steroids are useful only for patients with coexisting inflammatory processes. Selective estrogen receptor modulators may be helpful for postmenopausal women. Identification of complementary and alternative medicine treatments used by patients is important to avoid potential drug-drug interactions.
12. Contributor Information
Author Lars Grimm, MD, MHS House Staff Department of Internal Medicine Duke University Medical Center Durham, North Carolina Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships. Editor John Buckner Winfield, MD Herman and Louise Smith Distinguished Professor of Medicine in Arthritis Emeritus, Department of Medicine, Senior Member, Neurosensory Disorders Center, University of North Carolina at Chapel Hill; Consulting Rheumatologist, Appalachian Regional Rheumatology Chapel Hill, North Carolina Disclosure: John Buckner Winfield, MD, has disclosed the following relevant financial relationships: Served as an advisor or consultant for: Jazz Pharmaceuticals, Inc. Received grants for clinical research from: Eli Lilly and Company; Forest Laboratories, Inc. Served as a speaker or a member of a speakers bureau for: Pfizer Inc; Eli Lilly and Company
