Fibromyalgia: Pathophysiology

FIBROMYALGIA
This is a common cause of generalised regional pain and disability, and is

frequently associated with medically unexplained symptoms in other systems .
Although fibromyalgia can occur at any age, including adolescence, it increases

in prevalence with age, to reach a peak of 7% in women aged over 70.
There is a strong female predominance of around 10 : 1. Risk factors include life

events that cause psychosocial distress, such as marital disharmony, alcoholism
in the family, injury or assault, low income and self-reported childhood abuse It
occurs in a wide variety of races and cultures.
Pathophysiology
The cause of fibromyalgia is poorly understood but two abnormalities that may
be interrelated have been consistently reported in affected patients are
disturbed, non-restorative sleep and pain sensitisation, probably caused by
abnormal central pain processing.
Clinical features
The main presenting feature is widespread pain, which is often worst in the neck
and back :
Usual symptoms
• Widespread pain
• Fatiguability
• Disability
• Broken, non-restorative sleep
• Low affect, irritability, poor concentration
Variable locomotor symptoms

• Early-morning stiffness
• Feeling of swelling in hands
• Distal finger tingling
Additional, variable, non-locomotor symptoms
• Non-throbbing bifrontal headache (tension headache)
• Colicky abdominal pain, bloating, variable bowel habit (IBS)
• Bladder fullness, nocturnal frequency (irritable bladder)
• Hyperacusis, dyspareunia, discomfort when touched (allodynia)
• Frequent side-effects with drugs (chemical sensitivity).
pain is characteristically diffuse and unresponsive to analgesics and NSAIDs.

Physiotherapy often makes FM pain worse.
Fatiguability, most prominent in the morning, is another major problem and

disability is often marked.
Although people can usually dress, feed and groom themselves, they may be
unable to perform tasks such as shopping or housework.
They may have experienced major difficulties at work or may even retire
because of pain and fatigue. Examination is unremarkable, apart from the
presence of hyperalgesia on moderate digital pressure (enough just to whiten
the nail) over multiple sites
Investigations
There are no abnormalities on routine blood tests or imaging but it is important
to screen for other conditions that could account for all or some of the patient’s
symptoms
Extensive imaging is not recommended but bone scintigraphy can identify many
conditions that can contribute to widespread pain and is a useful ‘negative’ test.
The aims of management are to educate the patient about the condition,
address unresolved psychological issues, achieve pain control and improve
sleep. Wherever possible, education should include the spouse, family or carer.
It should be acknowledged that the cause of FM is not fully understood but the
widespread pain does not reflect inflammation, tissue damage or disease.
The model of a self-perpetuating cycle of poor sleep and pain is a useful
framework for problem-based management.
Understanding the diagnosis can often help the patient come to terms with the
Symptoms.
Repeat or drawn-out investigation may reinforce beliefs in occult serious
pathology and should be avoided.
Treatment
Low-dose amitriptyline (10–75 mg at night), with or without fluoxetine, may
help by encouraging delta sleep and reducing spinal cord wind-up.
Many people with FM, however, are intolerant of even small doses of
amitriptyline. There is limited evidence for the use of tramadol, serotonin–
noradrenaline (norepinephrine) re-uptake inhibitors (SNRIs) such as duloxetine,
and the anticonvulsants pregabalin and gabapentin.
A graded increase in aerobic exercise can improve well-being and sleep
quality.
The use of self-help strategies and a cognitive behavioural approach with
relaxation techniques should be encouraged.
Sublimated anxiety relating to distressing life events should be specifically
explored with appropriate counselling.
There are patient organisations that provide additional information and
support. Although treatment may improve quality of life and ability to cope,
most people remain symptomatic for many years.

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FIBROMYALGIA

This is a common cause of generalised regional pain and disability, and is

Although fibromyalgia can occur at any age, including adolescence, it increases

There is a strong female predominance of around 10 : 1. Risk factors include life

Variable locomotor symptoms

pain is characteristically diffuse and unresponsive to analgesics and NSAIDs.

Fatiguability, most prominent in the morning, is another major problem and

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