Fibromyalgia
A Clinical Review

JAMA. 2014;311(15):1547-1555.

ABSTRACT

Importance Fibromyalgia is present in as much as 2% to 8% of the population, is characterized by widespread pain, and is often accompanied by fatigue, memory problems, and sleep disturbances.

Objective
To review the epidemiology, pathophysiology, diagnosis, and treatment of fibromyalgia.

Evidence Review
The medical literature on fibromyalgia was reviewed from 1955 to March 2014 via MEDLINE and the Cochrane Central Registry of Controlled Trials, with an emphasis on meta-analyses and contemporary evidence-based treatment guidelines. Treatment recommendations are based on the most recent evidence-based guidelines from the Canadian Pain Society and graded from 1 to 5 based on the level of available evidence.

Findings
Numerous treatments are available for managing fibromyalgia that are supported by high-quality evidence. These include nonpharmacological therapies (education, exercise, cognitive behavioral therapy) and pharmacological therapies (tricyclics, serotonin norepinephrine reuptake inhibitors, and gabapentinoids).

Conclusions and Relevance

Fibromyalgia and other “centralized” pain states are much better understood now than ever before. Fibromyalgia may be considered as a discrete diagnosis or as a constellation of symptoms characterized by central nervous system pain amplification with concomitant fatigue, memory problems, and sleep and mood disturbances. Effective treatment for fibromyalgia is now possible.

Case study

Dr Tess Ms P is a 64-year-old woman who has ongoing diffuse muscle pain and fatigue. She developed chronic back pain in 1991, followed by chronic ankle pain after a motor vehicle collision. In 2009, she developed a deep ache in her lower extremities and back that worsened over several months. Her pain is aggravated by touch or pressure and relieved by rest and topical heat. The pain has limited her ability to exercise. She was diagnosed as having fibromyalgia and given numerous medications (gabapentin, venlafaxine, pregabalin, and hydrocodone/acetaminophen), most of which resulted in significant adverse effects. She currently undergoes treatment with acupuncture therapy along with pregabalin, hydrocodone/acetaminophen, and cyclobenzaprine.

Over the past several years, she has experienced loss of energy, weight gain, occasional headaches, insomnia, and occasional depressed mood. Pain and fatigue limit her physical activity to not more than a few contiguous hours. She does not have paresthesias.

Ms P has hypertension, Graves disease with hypothyroidism, degenerative disk disease, migraines, hyperlipidemia, fibroadenomatous breast disease, eczema, gastroesophageal reflux disease, and carpal tunnel syndrome. She takes amlodipine, cyclobenzaprine, hydrochlorothiazide, hydrocodone-acetaminophen, levothyroxine, moexipril, pantoprazole, pravastatin, pregabalin, aspirin, and multivitamins. She is a former nurse who no longer works because of her physical limitations.

During the physical examination, Ms P was found to be afebrile and had normal vital signs. She did not have alopecia, oral ulcers, or exudates. There were no skin lesions or rashes and her nails were normal. There were many areas of tenderness with palpation, including her upper and lower back, near lateral epicondyle, upper chest, and trochanteric prominences. Her joint examination results were normal, as was the remainder of her physical examination.

Her complete blood count, chemistries, and liver function tests yielded normal results. Antinuclear antibody, anticytoplasmic antibody, serum protein electrophoresis, urine protein electrophoresis, and Lyme serology test results were all unremarkable. Her erythrocyte sedimentation rate was 33 mm/h.

Ms P now asks if there is a treatment regimen that will allow her to be more functional while avoiding adverse effects.

What are the answers? Interested- request more .

Dr G Mohan.