• What is it?
• What causes fibromyalgia?
• How do you treat it?
• Specific Approaches
• What of Complex Fibromyalgia?
• The Bottom Line
• Case Studies

• Fibromyalgia is a term applied to a subset of the population [3-5%] who have pain and abnormal tenderness, which is not due to tissue damage.
• Fibromyalgia has been subject to significant scientific scrutiny with over 1000 publications in peer-reviewed journals published in the last ten years
• The tender point sites are reliable and clinically useful sites for assessment of lowered pain threshold, the key feature of fibromyalgia.
• Many fibromyalgia patients are emotionally distressed or react to stress in an adverse way.
• Organic conditions can mimic fibromyalgia and fibromyalgia can occur with organic conditions.
• The majority of patients are best treated with education, aerobic exercise and stress management with an expected good outcome.

• Fibromyalgia is a relatively common disorder
• Fibromyalgia is best managed in the primary care setting
• Depression is not a cause of fibromyalgia but it may be a consequence of the chronic pain and disability that accompanies disorder

• Common musculoskeletal pain syndrome paradigms
• Overlapping syndromes
• Where does fibromyalgia fit in?
• What is a tender point?
• Symptoms and signs in fibromyalgia

Fibromyalgia is a chronic musculoskeletal disorder that is characterised by widespread pain, exquisite tenderness at multiple anatomical sites, and other clinical manifestations such as fatigue and sleep disturbance. It primarily affects women. Chronic widespread musculoskeletal pain occurs in approximately 10% of the population and chronic regional pain in about 20-25% [1]. Fibromyalgia is a term applied to a subset of this population who have pain and abnormal tenderness, which is not due to tissue damage.

Common musculoskeletal pain syndrome paradigms
From a simple perspective one can specify two types of chronic musculoskeletal pain syndromes – those that involve pain generation and those that involve pain amplification [2].

Myofascial pain syndrome is a term that refers to pain arising from muscle. This syndrome is characterised by taught palpable bands in muscle, usually around the mid-belly area, which in turn contain areas, which are exquisitely tender to palpation. These are known as trigger points. Pressure on this site leads to pain which is familiar to the patient. These problems are usually related to chronic postural strain or muscle injury and are particularly prevalent around the neck/trapezius area and low back/ buttock region.

Segmental spinal dysfunction syndromes relate to pain generated in deep tissues around the spine. These syndromes are characterised by change in function of the relevant spinal segment with restriction in range of motion, localised tenderness on deep palpation around the spine and abnormal resistance on movement of that segment. An example is a stiff neck, which might be present when one awakens in the morning. The pain generated by the deep spinal tissues is referred to the surface giving rise to pain and tenderness in the muscles and skin, which relate to that spinal segment. The segmental symptoms and signs are due to referred reflex mechanisms and not due to neural entrapment or dysfunction.

Pain amplification syndromes include fibromyalgia, which usually indicates widespread pain accompanied by widespread lowering of pain threshold.

A variation on fibromyalgia is regional pain syndrome where there is pain and abnormal tenderness typically in a quadrant of the body, say in the neck/ shoulder/ arm area, for example. Synonyms include localised fibromyalgia or regional fibromyalgia.

Complex regional pain syndrome indicates more significant pain amplification, which may be segmental or affect a more limited area such as the wrist/ hand or lower leg/foot. Synonyms include reflex dystrophy syndrome and algodystrophy, among a host of others.

Overlapping syndromes
The above terms are not mutually exclusive. Patients with fibromyalgia may have regional muscle tenderness fulfilling criteria for myofascial pain syndrome. Patients with initial segmental spinal dysfunction may develop amplified pain causing a regional pain syndrome. The point of these terms is to identify predominant mechanisms, which contribute to the patient’s pain and hence, hopefully, lead to appropriate management. For instance, simple physical therapy is useful for segmental spinal dysfunction but when significant pain amplification occurs additional or alternative management approaches will be needed.

Unfortunately, many of these paradigms, although discussed with vigour in the literature and acting as a base for a host of specific therapies, from manipulative treatment through to acupuncture, do not have well validated and reliable classification criteria. This does not mean the relevant paradigm is not useful clinically but it does significantly hinder appropriate evidence-based assessment.

Where does fibromyalgia fit in?
Fibromyalgia has been subject to significant scientific scrutiny with over 1000 publications in peer-reviewed journals published in the last ten years – this term has now been accepted by peak bodies such as the World Health Organisation, the International Association for the Study of Pain and most national rheumatology groups [3]. The study of this disorder has been enhanced by development of classification criteria by the American College of Rheumatology, which essentially link the presence of chronic widespread pain to the presence of a large number of abnormally tender sites at predesignated regions in the body [4]. These are termed tender points. Use of these classification criteria has shown that between 2-4% of people in industrial societies have fibromyalgia. However, there is nothing magical about defining this group of individuals. Chronic pain and tenderness occur as a continuum in the population and these criteria merely pick out the top 2-4% of the population who have abnormal tenderness with pain [5, 6]. Nevertheless, it is patients at this end of the spectrum that have significant symptoms and disability associated with their chronic disorder.

What is a tender point?
The term tender point relates to areas in the body, which have been found by empirical observation to be more sensitive to gentle palpation than surrounding regions [7]. Typical examples include the mid-trapezius point, the area adjacent to the insertion of the common extensor muscles to the lateral epicondyle or the medial fat pad of the knee [Figure 1]. If palpation of these regions with a force of around 4kg/sq cm (equating to blanching of the thumb or fingernail) induces pain, then this site is called a tender point. The tender point region is histologically normal as the problem derives from abnormal sensitivity of pain nerves in that area. It is important to be aware that areas between the tender points also have abnormal lowering of pain threshold and hence are abnormally tender in those with fibromyalgia when compared to those without fibromyalgia [8]. The tender point sites are reliable and clinically useful sites for assessment of lowered pain threshold, the key feature of fibromyalgia.

Figure 1: Clinically useful sites for evaluating tenderness. These sites are more sensitive to palpation than adjacent sites in pain-free individuals and significantly more sensitive in patients with widespread pain when they are termed tender points. Regional pain syndromes are associated with increased sensitivity in tender points located within the painful region. Figure with permission G. Littlejohn.

Symptoms and signs in fibromyalgia
Most patients with fibromyalgia have a fluctuating set of symptoms occurring over many months or years with variable degrees of pain and muscular stiffness [7, 9]. These symptoms may vary according to weather change, emotional distress or physical activity. Patients often feel quite fatigued, which also varies in severity, and often sleep poorly wakening unrefreshed in the mornings. Many are emotionally distressed or react to stress in an adverse way. As such, fibromyalgia is often associated with other stress-related changes in function [10]. These are displayed in the Table 1.

Table 1: Associated disorders in fibromyalgia syndrome

• Cognitive dysfunction common
• Dizziness common
• Chronic fatigue syndrome common
• Irritable bowel syndrome 60%
• Irritable bladder syndrome 50%
• Multiple chemical sensitivities 50%
• Restless legs syndrome 30%
• Cold intolerance 30%
• Neurally-mediated hypotension 15%

Apart from the sign of widespread tenderness, which affects a variety of tissues, patients will also demonstrate the sign of dermatographia where lightly stroking the skin over the upper back with the fingernail, will induce a very brisk wheal and flare response, usually visualised within 10 seconds [7]. This reaction is mediated by release of neuropeptide chemicals from the activated pain nerve fibres in the skin of fibromyalgia patients. These substances cause rapid vasodilatation and localised oedema. Patients also complain of regional swelling, perhaps with tightening of rings in the morning or puffiness around ankle or other areas of pain. Muscles are often quite tight and spinal examination reveals limited range of motion of spinal segments. Importantly, examination does not reveal evidence of inflammation, degenerative change, abnormal neurology or a systemic process, which could explain the distribution of symptoms and signs found. Conversely, this is not to say that patients with other organic conditions cannot develop fibromyalgia, as they commonly do. Where a patient presents with a widespread pain, fatigue and abnormal tenderness through the body a diagnosis of fibromyalgia is usually easily elicited. However there are a number of red flags that need to be considered and these are listed in theTable 2. If present search for other abnormalities needs to follow.

Table 2: Red flags that might indicate a more sinister process

• Weight loss
• Fever
• Malaise
• Night pain
• Focal pain
• Neurological signs

How is fibromyalgia diagnosed?
The essential features are widespread pain accompanied by widespread abnormal tenderness. Palpation of tender point sites aids this assessment. Careful consideration of other disorders requires a full history and examination and careful investigation profile which might include full blood examination, erythrocyte sedimentation rate, thyroid function, creatine kinase, routine biochemistry, calcium, rheumatoid factor, and antinuclear antibodies. Other tests and imaging may be required according to the clinical features. The important points are firstly, that organic conditions can mimic fibromyalgia and secondarily, that fibromyalgia can occur with organic conditions [11]. Top of Page

What causes fibromyalgia?

Current evidence indicates fibromyalgia is due to abnormal sensitivity of the pain nerve system [7,12,13]. This sensitisation, which enables subthreshold stimuli to induce pain nerve impulses, occurs predominantly within the spinal cord and more proximally. This leads to the abnormal tenderness as well as the secondary muscular tightness in peripheral and spinal regions. In addition, the nerves subserving proprioception, the mechanoreceptors, also function abnormally through their interaction with the sensitised deep pain transmission neuron system in the dorsal horn of the spinal cord. Through this process normal movement, such as posture and exercise will generate pain through the A-beta mechanoreceptor fibre system. This is of course despite there being no tissue damage in the area. This is called mechanical allodynia and is a feature of fibromyalgia.

The cause for the increased central sensitisation of the pain system is still unclear but likely relates to abnormal activation of the stress axis with change in hypothalamic-pituitary-adrenal function, hormone profiles, and sympathetic nervous system efferent activity.

Fibromyalgia may be triggered by a number of events, which can include a physically mild, but frightening injury. Infection, more likely an unusually named viral infection rather than everyday common upper respiratory infection, may trigger fibromyalgia. Many patients identify stress as a specific precipitator. In other cases stress is deemed to be in the environment of patients with fibromyalgia more commonly than those without. Importantly, stress may relate to another chronic illness such as inflammatory joint disease, lupus or chronically painful disorders such as degenerative neck or back pain. Pain in itself activates the stress response.

Depression is not a cause of fibromyalgia but it may be a consequence of the chronic pain and disability that follows this disorder. There is an increased prevalence of diagnosis of anxiety and depression in patients who have fibromyalgia compared to persons with fibromyalgia who are not attending doctors or therapists [14]. Top of Page

How do you treat it?

When considering treatment options, it is useful to think of fibromyalgia as being either simple or complex [12, 15, 16]. Simple fibromyalgia relates to a patient with mild to moderate symptoms usually occurring after an identifiable trigger and with good family and emotional support and reasonably good coping skills. There may be poor sleep, change in muscle fitness or a recent illness triggering the problem. These patients are best treated with education in regard to the nature of the problem, advice on aerobic exercise program and advice regarding stress management with the expected outcome being very good.

In contrast, complex fibromyalgia indicates patients who have persisting stress, significant psychological trauma, those with poor coping skills or significant lack of understanding of the nature of the problem. Onset after injury is common and often reflects many of the previous situations. Complex fibromyalgia patients often have a poor outcome, at least in the short term. They may need an interdisciplinary approach with significant psychological input. Such patients are often involved in the validation of their symptoms, particularly where medicolegal, compensation or safety net issues are involved.

Who should look after fibromyalgia?
Fibromyalgia is best managed in the primary care setting where the family doctor is familiar with the patient, their family and the nature of stressors and previous reactions to such problems [15]. The family doctor may be well aware of risk factors, so-called yellow flags, for the development of fibromyalgia (see Table 3). If such risk factors are present the family doctor may intervene with counselling early in the course of any new set of symptoms, hopefully decreasing the development of the syndrome with this approach.

Table 3: Risk factors (yellow flags) for fibromyalgia

• Positive family history
• Previous pain syndrome
• Medical condition causing prognostic concern, e.g. SLE or RA
• Current community pain epidemic with perceived environmental attribution
• Pain - related work predicament
• Spine injury
• Poor coping skills
• Difficult life predicament
• Past or present depression/anxiety
• Persisting post-“viral” symptoms
• Sleep disturbance
• Significant emotional distress Top of Page

Specific approaches

• Education
• Exercise
• Cognitive behavioural therapy
• Which analgesics / psychotropics are best?
• Overview of management

Education
The role of education is to validate the patient’s symptoms. An explanation as to the nature of the problem is provided. Some doctors prefer not to use the F-word, fearing that labelling patients with fibromyalgia may make them more prone to chronic pain behaviour. Recent studies have shown that this is not the case. The majority of patients are empowered with the diagnosis of fibromyalgia, assuming they understand the essential nature of the disorder, which it is a pain sensitisation problem and the problem is not due to tissue damage or injury. This diagnosis emphasises the non-destructive nature of the problem, focuses on appropriate self-management and not necessarily a magic cure of the disorder and focuses on improving health and wellness rather than focusing on illness and disability.

Exercise
Low-level aerobic exercise increasing gradually in intensity is almost always of value in fibromyalgia. The key is to start low and built up slowly. Perhaps taking three times longer to achieve fitness compared to a normal non-fibromyalgic patient who is unfit. The biggest issues remain those of exercise tolerance, compliance and adherence to prescription. Exercise should be regarded as a drug and the doctor should be checking on exercise participation characteristics regularly when a patient is reviewed. Exercise is more beneficial if pain control can be introduced some time before an exercise program starts. Stretching exercises by themselves are also helpful and may be useful when combined with relaxation programs such as in yoga, tai chi or more complex interactive techniques such as Feldenkrais. Many patients with fibromyalgia develop regionalised tightness around spinal areas, which can be helped significantly through these techniques thus decreasing pain generation, and as well the relaxation component of these treatments decreases pain amplification.

Other patients may gain help from more physically demanding passive physical treatments but these should be regarded as an adjunct to the overall program rather than being a primary program in themselves.

Cognitive behavioural therapy
This type of therapy has been shown to be extremely beneficial in fibromyalgia. It is a program designed to teach patients techniques to reduce their symptoms, to increase coping strategies and to identify and eliminate maladaptive illness behaviour. The benefit of this approach is seen in many chronic illnesses. Such programs depend very much on the therapist providing the input and just like “physiotherapy” there is no one universal prescription of this type of approach.

It is recommended that the general practitioner should build a network of health care providers who understand the concept of central sensitivity in fibromyalgia and can provide appropriate management input. These may be physical therapists of various types to supervise the exercise program and provide other physical advice, occupational therapists who may provide advice on sleep disturbance, fatigue management skills and simple relaxation therapy or psychologists who might provide advice on cognitive-behavioural therapy approaches. Communication is essential between therapists and the family doctor.

Which analgesics / psychotropics are best?
Simple analgesics are helpful in many patients, but not all. Paracetamol up to 4 gm/day, although a recommended basic strategy, is not often followed by the patient. In general, opioid medication is not favoured as these drugs may aggravate the fogged thinking and bowel disturbance that many fibromyalgia patients have and the opioids are not particularly specific for the type of pain mechanism involved in fibromyalgia.

Fibromyalgia is not a neuropathic pain in that there is no damage to peripheral nerves such as in diabetic neuropathy. Hence, various anti-convulsant medications, membrane stabilisers and similar drugs are of limited use in this disorder.

The change in central pain control associates with decreased serotonin levels, increased substance P and other neuropeptide change.

Low dose tricyclic medication such as Amitriptyline or Nortriptyline in 10-30 mg in the mid-evening some hours before bedtime does help around 30-40% of people, if tolerated. The key is to use very low doses and build very slowly.

The selective serotonin re-uptake inhibitors have not proven as useful as was hoped in this disorder [17]. Certainly if depression is present these drug may be required.
Some patients respond more to the centrally acting adrenergic agonists for fatigue and pain, such as Venlafaxine.

Overview of management
Management should be flexible. Some patients will respond best to simple physical therapy to loosen tight spinal muscles, others will require medication for their sleep disturbance whilst others still will gain benefit from an exercise program. Some require all of these techniques or others again. Fibromyalgia is a syndrome and there is no one universal management approach. All patients require an individual assessment and treatment strategy. Top of Page

What of complex fibromyalgia?

The question of management of complex fibromyalgia and its relationship to injury and disability requires a much longer discussion than is available here [18, 19]. Suffice to say that exiting the safety net system as soon practical best helps many patients with fibromyalgia in this setting. However herein lies the problem. Although it is important to reassure such patients that in the long run the potential for improvement remains good, this potential may not be realised while they are still subject to deliberations regarding causal issues. When these issues have been finalised to the satisfaction of the patient the fibromyalgia invariably improves. If these problems are not finalised to their satisfaction or if significant maladaptive chronic pain behaviour has ensued in the process then longer-term symptoms may follow. It is important to remind patients that there are not hospitals full of fibromyalgia sufferers and the majority of post-injury fibromyalgia patients are able to return to viable household, recreational and work activity, albeit sometimes modified. The provision of disability support in such settings should be carefully considered. It is best to know the patient and their fluctuations in symptoms for several months before providing definitive statements on longer-term outcome, which might dictate that patient’s behaviour and symptoms for a long time to come. Top of Page

The Bottom Line

Fibromyalgia is a relatively common disorder. It exists on a spectrum blending with normal physiological responses on one axis and abnormal psychological response to stressors on another axis. Many doctors do not choose to use the F-word to describe this clinical syndrome but it is important to recognise the problem for what it is [20]. The disorder is one of pain amplification due to increased sensitivity of the pain system. Fibromyalgia links with other sensitivity syndromes, often stress-associated, and management needs to flexible and holistic, focussing on patients' wellness while keeping a close eye on markers of disability. Top of Page

Case Studies

Case Study 1: Simple fibromyalgia
Mary H is age 47 and presents with a history of eight years of aching and pain around the neck/shoulder girdle area and low back/hip/buttock region. The aching is described as deep, discomforting and burning in quality. She has tried various physical therapies over a number of years, with simple physiotherapy being the most helpful. She has an older husband age 57 and a 12-year-old daughter who provide significant stress to her. She sleeps somewhat poorly and expresses concern regarding the situation and where she is heading. She has discussed the issue with her friends and wonders if she has fibromyalgia.

Examination shows widespread tenderness on gentle palpation around the neck, chest wall, upper back, upper outer buttocks, trochanteric and inner fat pad of knee region. Other areas are also more tender than expected. She has mild dermatographia over the upper back, some trigger points through the mid trapezius area and tight cervical spine. General examination is unremarkable. There is no muscle wasting, normal range of motion in peripheral joints, no evidence of degenerative or inflammatory arthritis and no neurological abnormality.

A diagnosis of fibromylagia is made. A routine screen of investigations, to ensure there is no occult underlying problem, includes normal full blood examination, ESR, liver function and routine biochemistry, thyroid function, calcium, creatinine kinase, anti-nuclear antibody and rheumatoid factor.

The diagnosis is confirmed. Advice is given in regard to the nature of the problem. Simple self-help strategies are emphasised with an aerobic exercise program, some relaxation therapy, suggestion to consider tai chi or yoga, advise to consider the Arthritis Foundation Self-Management Program and the suggestion of a referral to a Feldenkrais practitioner to improve postural awareness around the neck and low back.

One month later Mary reports improvement in symptoms but she is still sleeping poorly. A trial of low dose Amitriptyline does not help. Referral to a clinical psychologist for some simple cognitive behavioural therapy is followed by further improvement in symptoms.

Case Study 2: Complex fibromyalgia
Jane aged 35, presents for her monthly Workcover certificate. She has been off for one year following pain in the neck/shoulder area, which came on following a strain when she was doing more overtime on the checkout machine. Her right neck/chest wall/arm remain tender and sore with restricted movements. She is not able to do her normal job. She has tenderness in other areas around the left shoulder girdle and arm and now also in the low back and buttocks.

After some micromanagement problems at work she has been able to get into a modified work situation and is feeling more satisfied and confident about her future. She is slowly building into her aerobic exercise program and continuing to do cognitive- behavioural work with a clinical psychologist. Her concerns about longer-term disability are fading. The program continues with the expectation of further improvement over time. Top of Page

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