CHAPTER 8 Sarah Ryan1 and Andrew Hassell2 1 Staffordshire and Stoke on Trent Partnership NHS Trust, Haywood Hospital, Stoke on Trent, UK 2 Staffordshire and Stoke on Trent Partnership NHS Trust; Keele University School of Medicine, Keele, UK Chronic widespread pain is very common in the general population, with an estimated point prevalence of 11% in the United Kingdom. Living with pain has a significant impact on the individual and society, in terms of reduced physical functioning, depressive symptoms, increased use of healthcare resources and work productivity loss. The focus of this chapter will be fibromyalgia as the prototype condition that manifests with chronic widespread pain and fatigue Fibromyalgia or fibromyalgia syndrome (FMS), a heterogeneous pain syndrome of unknown aetiology, affects 0.5–5% of the population and is much more common in women. As the treatment effects of single interventions are modest at best, the European League against Rheumatism (EULAR) recommends a multidisciplinary approach to the management of fibromyalgia tailored according to symptom intensity, patient function and associated features. The aim of management is to optimize physical, psychological and social functioning. As there are currently no diagnostic tests for FMS, the diagnosis is exclusively clinical. Most patients will have had symptoms for 2–3 years before a diagnosis is made. The main symptoms are chronic widespread musculoskeletal pain, muscle stiffness, non‐restorative sleep and fatigue, in the absence of an alternative explanation such as active inflammatory arthritis, endocrine or metabolic disorder. Commonly associated physical, psychological and cognitive symptoms are identified in Box 8.1. The original American College of Rheumatology (ACR) criteria for fibromyalgia have been considered the gold standard for diagnosis for research studies since their introduction in 1990. The criteria include the presence of widespread pain of at least 3 months’ duration and pain at 11 of 18 designated tender points when finger pressure (just enough to blanch the clinician’s fingertips) is applied (Figure 8.1). These criteria have not been widely used in clinical practice, perhaps owing to the reliance on tender spots and the lack of consideration of other symptoms. In 2010, the ACR proposed an additional/alternative set of diagnostic criteria for use in primary care, recognizing perhaps that fibromyalgia is a common spectrum disorder rather than a discrete one. The new criteria do not require tender point examination. They include a widespread pain index (number of defined areas, between 0 and 19, in which a patient has had pain in the previous week) and a symptom severity score (0–9) which includes fatigue, waking unrefreshed and cognitive symptoms identified in Box 8.1. Figure 8.1 Distribution of tender points The aetiology of fibromyalgia is unknown and has been the subject of some controversy with, at the two ends of a spectrum, some believing that there is an entirely physical explanation, for example a viral infection, and others proposing that it represents a somatization syndrome. Our current understanding is that the primary abnormality is in pain processing within the central nervous system resulting in maladaptive pain responses. Patients can experience pain from sensory stimuli including heat, touch and auditory tones. This dysfunctional pain processing results from a number of factors including central sensitization, blunting of inhibitory pain pathways, altered neurotransmitters and psychological stressors. Predisposing factors may include anxiety, depression, viral infection or exposure to physical and/or emotional trauma. Psychological factors have been identified as contributing to the symptoms of fibromyalgia including previous pain conditions, anxiety and stressful life events. Fibromyalgia is not solely a pain syndrome and patients often experience stiffness, fatigue and sleep disturbance among other physical, psychological and cognitive symptoms (see Box 8.1). A typical patient will tend to be female aged 30–50 years with long‐standing diffuse pain. She will describe pain in the muscles and joints. Fatigue will be pronounced (there is considerable overlap with chronic fatigue syndrome and 55% of chronic fatigue syndrome patients fulfil the diagnostic criteria for fibromyalgia). She will often have a history of previous physical or psychological trauma. She will describe a disturbed sleep pattern and difficulties in concentration and short‐term memory recall. Her symptoms are always present and are exacerbated when she encounters a period of stress. She is anxious and low in mood as her symptoms are affecting her work and social activities. Often, she will have tried a number of analgesics and non‐steroidal anti‐inflammatory tablets without any improvement. There are no confirmatory investigations to arrive at a diagnosis of fibromyalgia but it is important that investigations are carried out to exclude other causes of musculoskeletal pain (Box 8.2). It is helpful to explain to the patient why these investigations are required and the expectation that they will be normal. Patients often feel that normal investigation results reduce the validity of their condition and the clinician can help by validating that their symptoms are genuine and recognized, irrespective of the investigation results. Useful investigations to exclude other disorders are listed in Box 8.3.
Fibromyalgia Syndrome and Chronic Widespread Pain
Diagnosis
Aetiology and symptoms
Investigations
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