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Fibromyalgia and musculoskeletal pain syndromes

In this new series, experts give tips on diagnosis and management for a range of musculoskeletal problems. Here, Dr Anthony Bradlow focuses on the thorny issue of fibromyalgia

In this new series, experts give tips on diagnosis and management for a range of musculoskeletal problems. Here, Dr Anthony Bradlow focuses on the thorny issue of fibromyalgia

Fibromyalgia is a specific type of generalised pain/fatigue syndrome that is defined by two cardinal features: chronic widespread pain (involving all four body quadrants and the spine) and tenderness at 11 or more of 18 defined anatomical sites.

Other features include poor sleep, fatigue, headache, urinary symptoms, tingling in hands and feet, stiffness, irritable bowel syndrome and migraine. All of these can occur in association with rheumatoid arthritis and many other causes of ill-health, so normal investigations are not required for the diagnosis of fibromyalgia.

A pain syndrome is defined as a 'condition of pain and resulting disability significantly out of proportion to any demonstrable physical disease and which has no pathological explanation'.

However, a broader definition may be more appropriate: sometimes an underlying pathological condition is present. Attempts to decide whether a sufferer's distress is 'appropriate' to the degree of objective abnormality are futile because suffering is so subjective.

The practitioner often struggles to decide whether the pathology seen is the cause of the patient's symptoms. This extended definition includes chronicity of the condition, difficulty in identifying the organic component of the patient's illness, failure of multiple treatments and, frequently, distress on the part of the patient, friends and relatives.

This distress may reflect cultural and personal factors but also frustration at an apparent lack of command of the problem by the doctor. This broader definition will therefore encompass many cases of longstanding 'mild cervical spondylosis' as well as most cases of chronic back pain, unexplained chronic leg and arm pain and, especially in young women, wrist pain.

Epidemiology of musculoskeletal pain syndromes

Musculoskeletal pain syndromes are common.

Fibromyalgia as defined above affects 2 per cent of the US population, with a higher prevalence in older women.

Nearly 5 per cent of the UK population is affected by chronic widespread pain. Pain syndromes can carry large disablement costs and are capable of swallowing medical resources and thus need to be managed in a disciplined way.

A typical case of pain syndrome

A 45-year-old man has had continuous pain in his forearms for three years. No precipitating factors are apparent. Many examinations and tests arranged by his GP have been normal.

Multiple treatments have been tried unsuccessfully. His expectations are that the specialist should diagnose and find a cure for his symptoms.

On further questioning, he suffered from irritable bowel syndrome in his 20s and he has had unexplained intermittent facial pain for many years. In his 30s he had depression. Examination is normal.

In this situation I would explain to the patient that I will seek any significant cause, but that it is unlikely that any such cause will be found, that at this stage there is no cure, that the aim therefore is to help the patient to feel and cope better and that physical treatments are likely to be more effective than drugs.

The specialist can only see a snapshot of the whole problem. This is where the GP's knowledge of the patient comes into its own as a vital diagnostic tool.

Are these symptoms similar to anything the patient has had before? Does the GP strongly suspect that the symptoms are not going to be cured by whatever treatment is given?

If the answer to both is yes the chances that this is a pain syndrome are increased. However, distress reactions and exasperating illness-related behaviour are also common in patients with significant physical illness.

Distinguishing a pain syndrome from a significant physical pathology

This can only be achieved by a thorough search and by the passage of time – the longer the duration of symptoms the less likely the patient is to have an identifiable pathology.

It is not safe to diagnose a pain syndrome if symptoms have been present for less than six months.

Key pointers to a pain syndrome are: the provocation of anguish and long-lasting pain by even modest fingertip examination pressure; previous irritable bowel syndrome or other pain syndromes; known social conflict; failure to respond at all to multiple therapies; and the presence of obvious depression.

Even if all of these are present there could still, however, be a significant organic pathology underlying the pain.

When can I stop searching for a significant pathology?

There is no clear answer to this, as the search is partly patient driven.

If reasonably thorough investigations are normal and one is confident there is no significant pathology, the patient should be advised to wait to see if any new clinical pointers develop, with periodic review of basic tests such as bone biochemistry, ESR and CRP.

If the patient does not feel happy with this approach a second opinion should be sought.

Prognosis

Fibromyalgia symptoms are likely to wax and wane over the years but patients are better able to cope as time goes by.

The proportion of sufferers claiming sickness benefit depends on the prevailing welfare system. Some will change employment but continue to work.

Management

A positive approach is essential. The practitioner should establish what might help the patient most and try to offer it within ethical, safe and realistic boundaries. This can be extraordinarily difficult and time-consuming.

Physical treatments such as heat or cold applications, rubefacient rub-ins and graduated aerobic exercise are often the most effective.

It is offensive to most people to hint that their problem is 'in the mind' or 'imaginary'. Cognitive behaviour therapy may be helpful if available and if the patient is suffering a great deal.

Amitriptyline, gabapentin and sodium valproate also have a role in some cases, but the role of acupuncture in the treatment of fibromyalgia remains uncertain.

The rheumatology clinic

The role of the rheumatology department is to establish or refute the diagnosis of a musculoskeletal pain syndrome, to reassure the patient that there is no impending greater disability, to advise graduated aerobic exercise and to discharge the patient.

Repeated follow-up can breed dependency and false expectation on the part of the patient.

Most practitioners also operate within a rationed service and thus need to put the patient's problems into the context of the problems of their other patients.

What do you tell the patient?

It is important to emphasise that the problem will wax and wane, that exacerbations can be ameliorated and that increasing disability and conversely total disappearance of the problem are both unlikely.

In conclusion, fibromyalgia and musculoskeletal pain syndromes are unlikely to cause progressive disability, are unlikely to disappear, will usually defy cure, but can be improved with graduated aerobic exercise regimes and cognitive behaviour therapy (if available).

Drugs should be used sparingly.

Anthony Bradlow is a consultant rheumatologist at the Royal Berkshire Hospital in Reading

Competing interests Dr Bradlow has occasionally lectured at meetings sponsored by pharmaceutical companiesKey papers

Key points

• Fibromyalgia has two cardinal features: chronic widespread pain and tenderness at 11 or more specified anatomical sites

• Other features include: poor sleep, fatigue, headache, urinary symptoms, stiffness, IBS and migraine

• Nearly 5 per cent of the UK population is affected by chronic widespread pain

• It is not safe to diagnose a pain syndrome if symptoms have been present for less than six months

• Physical treatments such as heat/cold applications, rubefacient rub-ins and graduated aerobic exercise are often most effective

• Cognitive behaviour therapy may be helpful if available

• Amitriptyline, gabapentin and sodium valproate have a role in some cases•

The role of acupuncture remains uncertain

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