Fibromyalgia SANGITA CHAKRABARTY, MD, MSPH, Meharry Medical College, Nashville, Tennessee ROGER ZOOROB, MD, MPH, Meharry Medical College and Vanderbilt University, Nashville, Tennessee Fibromyalgia is an idiopathic, chronic, nonarticular pain syndrome with generalized tender points. It is a multisystem disease characterized by sleep disturbance, fatigue, headache, morning stiffness, paresthesias, and anxiety. Nearly 2 percent of the general population in the United States suffers from fibromyalgia, with females of middle age being at increased risk. The diagnosis is primarily based on the presence of widespread pain for a period of at least three months and the presence of 11 tender points among 18 specific anatomic sites. There are certain comorbid con- ditions that overlap with, and also may be confused with, fibromyalgia. Recently there has been improved recognition and understanding of fibromyalgia. Although there are no guidelines for treatment, there is evidence that a multidimensional approach with patient education, cognitive behavior therapy, exercise, physical therapy, and pharmacologic therapy can be effective. (Am Fam Physician 2007;76:247-54. Copyright © 2007 American Academy of Family Physicians.) This article exemplifies ibromyalgia is an idiopathic, chronic, gesting the contribution of both genetic and the AAFP 2007 Annual nonarticular pain syndrome defined environmental factors.4 Clinical Focus on manage- ment of chronic illness. by widespread musculoskeletal Demographic and social characteristics ▲ pain and generalized tender points associated with the presence of fibromyalgia See editorial on F(Table 1). Other common symptoms include are female sex, being divorced, failing to com- page 290. ▲ sleep disturbances, fatigue, headache, morning plete high school, and low income. Psycho- Patient information: Handouts on fibromyalgia stiffness, paresthesias, and anxiety. logical factors associated with this syndrome are available at http:// Initially called fibrositis, the name was include somatization disorder, anxiety, and familydoctor.org/070.xml changed to fibromyalgia when it became personal or family history of depression.5 and http://familydoctor. evident that inflammation was not a part org/061.xml. of this condition.1 The American College of Pathophysiology The online version Rheumatology (ACR) 1990 criteria for the The pathophysiology of fibromyalgia is of this article classification of fibromyalgia was the prod- unclear. Fibromyalgia clusters in families, includes supple- uct of the first well-designed, multicenter suggesting a genetic predisposition. Envi- mental content at http:// www.aafp.org/afp. study on fibromyalgia and remains a corner- ronmental and psychological factors, which stone for the diagnosis.2 Epidemiology Table 1. Characteristics and Fibromyalgia is a common rheumatologic Associated Features of Fibromyalgia disorder that is underdiagnosed. Using the 1990 ACR classification criteria, the preva- Characteristic features lence of fibromyalgia in the general popula- Chronic widespread pain for at least tion of the United States is reported to be three months 3.4 percent in women and 0.5 percent in Tender points in 11 of 18 specific men.3 Prevalence increases steadily through anatomic locations 80 years of age, and then declines. This con- Associated features dition affects women 10 times more often Anxiety than men.3 Fibromyalgia is usually consid- Cognitive difficulties ered a disorder of women 20 to 50 years Fatigue of age; however, it also has been observed Headache in males, children, adolescents, and older Paresthesias persons. Fibromyalgia is more common in Sleep disturbance relatives of patients with fibromyalgia, sug- Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2007 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Fibromyalgia SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Comments Treat fibromyalgia with a multidimensional clinical approach A 22 Based on five RCTs comprising patient education, cognitive behavior therapy, pharmacotherapy, and exercise. Use antidepressant medications to improve pain, sleep quality, and B 23 Based on few RCTs global well-being in patients with fibromyalgia. Prescribe cyclobenzaprine (Flexeril) 10 to 30 mg at bedtime to improve A 31 Systematic review of RCTs sleep and decrease pain in patients with fibromyalgia. Advise patients that aerobic exercise training has beneficial effects on A 35, 36 Systematic review of RCT fibromyalgia symptoms. RCT = randomized controlled trial. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 176 or http:// www.aafp.org/afpsort.xml. could impact various members of the same ory problems, groping for words, and poor family, may contribute to the symptom- vocabulary. Headaches, including migraine atology of the disease.6 Current theories of type, also are common. Other manifesta- pathogenesis include central sensitization tions include episodes of light-headedness, and hypothalamic-pituitary-adrenal axis dys- dizziness, anxiety, or depression. Symptoms regulation; however, more research is needed are aggravated by cold and humid weather, to determine a definite pathophysiology. poor sleep, and physical or mental stress. They are improved by warm and dry weather, Clinical Features moderate physical activity, adequate sleep, Presenting complaints include pain at mul- and relaxation.2 tiple sites, fatigue, and poor sleep. Patients Assessment of physical activity is impor- often complain of low back pain, which tant because functional impairment is com- may radiate into the buttocks and legs. Oth- mon in patients with fibromyalgia. The ers complain of pain and tightness in the Fibromyalgia Impact Questionnaire (http:// neck and across the upper pos- www.myalgia.com/FIQ/fiq.pdf) is a use- terior shoulders. The pain may ful tool in assessing functional abilities The Fibromyalgia Impact be described as a burning or in daily life and measures patient status, Questionnaire is a useful gnawing soreness, stiffness, or progress, and outcomes (see online figure).8 tool in assessing functional aching. Stiffness is typically It is a self-administered instrument that is abilities in daily life and present on arising in the morn- composed of 10 items and can be completed measures patient status, ing; for most patients, stiffness in about 10 minutes. This questionnaire has progress, and outcomes. improves as the day progresses. been translated into numerous languages Patients complain of feeling and has been shown to retain its validity.8 exhausted, even upon waking. Relevant social, personal, and family his- Many patients awaken frequently at night tory is helpful in establishing the diagnosis of and have difficulty falling back to sleep. fibromyalgia. A history of trauma, childhood A subjective swollen joint feeling without abuse, anxiety, depression, or sleep disorder objective swelling, and paresthesias without is useful for a comprehensive evaluation objective neurologic findings, are two impor- because there is evidence that fibromyalgia tant features of fibromyalgia.7 may be triggered by emotional stress, medi- Many patients with fibromyalgia com- cal illness, surgery, or trauma. Patients with plain of cognitive difficulties such as mem- high tender point counts are more likely to 248 American Family Physician www.aafp.org/afp Volume 76, Number 2 ◆ July 15, 2007 Fibromyalgia report adverse childhood experiences like Diagnosis loss of a parent or abuse.9 Although physical Fibromyalgia is not a diagnosis of exclusion trauma, especially cervical spinal injury, is and should be identified by its own charac- associated with onset of fibromyalgia symp- teristics. The ACR criteria have two compo- toms, further studies are needed to deter- nents: (1) widespread pain involving both mine whether it has a causal role in the sides of the body, above and below the waist development of fibromyalgia.10,11 A family as well as the axial skeletal system, for at least history of fibromyalgia or presence of any of three months; and (2) presence of 11 tender the comorbid conditions increases the likeli- points among the nine pairs of specified sites hood of a diagnosis of fibromyalgia. (18 points) as shown in Figure 1.2 Insertion of nuchal Anterior aspects of the C5, muscles into occiput C7 intertransverse spaces Muscle attachments to upper Upper border of trapezius, medial border of scapula mid portion Second rib space – about 3 cm lateral to the sternal border Muscle attachments to lateral epicondyle Upper outer quadrant of gluteal muscles Muscle attachments just posterior to greater trochanter Medial fat pad of knee proximal to joint line ILLUSTRATION BY DAVE KLEMM Figure 1. The American College of Rheumatology 1990 Criteria recommended anatomic tender point locations for diag- nosis of fibromyalgia. Information from reference 2. July 15, 2007 ◆ Volume 76, Number 2 www.aafp.org/afp American Family Physician 249 Fibromyalgia An important portion of the physical a defect in the serotonergic and adrenergic examination for a diagnosis of fibromyalgia systems. A parallel dramatic