Fibromyalgia in focus

Fibromyalgia is one of the most common chronic pain disorders, but remains poorly understood and under-treated

Fibromyalgia is a chronic pain disorder, characterised by widespread musculoskeletal pain. It is a disorder of pain regulation and a neurosensory disorder where the individual is unable to process pain in the brain. People with fibromyalgia perceive pain from noxious stimuli at higher than normal levels of intensity compared to other individuals.1,2

The exact cause of fibromyalgia is unknown, but is believed to involve a combination of genetic, environmental, and psychological factors. The condition tends to run in families, so genetic factors are likely to contribute to the disorder, but no specific genes have been identified to date.2 Fibromyalgia is often associated with other comorbidities, such as depression, anxiety, irritable bowel syndrome (IBS), and chronic fatigue syndrome. It is thought to be triggered or aggravated by multiple physical and emotional stressors and is a heterogeneous condition that is often associated with specific diseases, such as infections, psychiatric or neurological disorders, diabetes, and rheumatic pathologies.3,6

Fibromyalgia is more common in women than men and the associated risk is higher for people with an existent rheumatic disease.2 It can affect people of any age, including children, but usually starts in middle age, and the risk of developing it increases with age.4

A major literature review (2017) on the prevalence of fibromyalgia shows that it ranges from 0.2-to-6.6 per cent in the general population, from 2.4-to-6.8 per cent in women, from 0.7-to-11.4 per cent in urban areas, from 0.1-to-5.2 per cent in rural areas, and from 0.6-to-15 per cent in special populations. This literature review update highlighted a significant increase in fibromyalgia prevalence globally in recent years.12

Pathophysiology

The pathophysiology of fibromyalgia is not completely understood, but is thought to involve dysregulation of the central nervous system (CNS), including alterations in neurotransmitter levels and abnormal processing of pain signals. One proposed mechanism is the dysfunction of the hypothalamic-pituitary-adrenal axis (HPA), which plays a key role in the body’s response to stress and inflammation. Studies have shown that people with fibromyalgia have lower levels of cortisol, which is involved in the regulation of the HPA axis. This can lead to a state of chronic inflammation and immune dysregulation, contributing to the symptoms of fibromyalgia. Another proposed mechanism is the alteration of neurotransmitters, such as serotonin and norepinephrine, which are involved in the regulation of pain, sleep, and mood. Other studies have shown that people with fibromyalgia have altered pain processing in the CNS, including abnormal responses to stimuli and increased sensitivity to pain, which may be due to changes in the function of the dorsal horn of the spinal cord and brainstem. Further research, however, is required to fully understand the underlying mechanism of fibromyalgia.11

Symptoms

The main symptom of fibromyalgia is widespread musculoskeletal pain, bilateral in nature and involving both the upper and lower parts of the body. The pain may be localised initially, commonly in the neck and shoulders. Pain is often felt in the arms, legs, head, chest, abdomen, back, and buttocks, and often described as aching, burning, or throbbing. The predominant symptom is muscle pain, but patients may also complain of joint pain.2

Fatigue, especially when waking from sleep, but also in the mid-afternoon, is a common complaint. Minor activities may aggravate the pain and fatigue, although inactivity for prolonged periods can also increases the symptoms. There is stiffness on waking in the morning and patients often complain of sleeping lightly with frequent wakenings and feeling unrefreshed in the morning even if they have eight-to-10 hours of sleep.2

Cognitive disturbances referred to as ‘fibro fog’ is a common symptom, whereby patients have difficulty with attention and doing tasks that require rapid changes in thought.2

Other symptoms include anxiety and/or depression, and headaches, which include migraines and tension types. Patients often complain of paraesthesia, particularly in both arms and legs, although detailed neurologic evaluations are often normal. IBS commonly correlates with fibromyalgia, and gastro-oesophangeal reflux disease (GORD) occurs more commonly in patients with fibromyalgia compared to the general population. Patients may also complain of dry eyes, dyspnoea, dysphagia, and palpitations.2

Diagnosis

Fibromyalgia is a disorder that is often misunderstood and misdiagnosed due to its elusive and varied symptoms. Despite advances in the understanding of the pathologic process, fibromyalgia remains undiagnosed in up to 75 per cent of people with the condition.6 In 2019, an International  Association for the Study of Pain (IASP) Working Group in cooperation with the World Health Organisation developed a classification system, included in the International Classification of Diseases (ICD-11), where fibromyalgia was classified as chronic primary pain, to distinguish it from pain which is secondary to an underlying disease.7

Diagnosis is based on clinical features and criteria that lack either a gold standard or supportive laboratory findings.7 There are no specific imaging studies or tests to confirm a diagnosis of fibromyalgia, and clinicians rely on the patient’s specific symptoms and a physical examination to help form their diagnosis. Blood and other tests may be ordered to rule out other conditions, but no specific blood test, x-ray or scan exists that can confirm a diagnosis, and typically, people with fibromyalgia will have normal results. Laboratory findings along with the patient’s history and physical examination can help differentiate fibromyalgia from other differentials.9,10

Brain imaging studies and other research have uncovered evidence of altered signalling in neural pathways that transmit and receive pain in people with fibromyalgia. These changes may also contribute to the fatigue, sleep disturbances, and cognitive problems that many people with the disorder experience.4

Until recently, the diagnosis of fibromyalgia was based on the presence of specific tender points in certain areas of the body. However, healthcare professionals are now advised to consider the following when making a diagnosis of fibromyalgia – widespread pain lasting three months or more; fatigue and/or waking up feeling unrefreshed; cognitive symptoms and problems with thought processes like memory and understanding. Pain is considered widespread when it affects all four quadrants of the body, ie, pain on both the right and left sides, as well as above and below the waist.9

Treatment

Because of the subjective nature of fibromyalgia symptoms, absence of a diagnostic test and often modest response to treatments, fibromyalgia remains a challenge for treating healthcare professionals. However, there are a number of international treatment guidelines, including the 2017 EULAR revised recommendations for the management of fibromyalgia.1

Treatment for fibromyalgia focuses on relieving symptoms and improving quality-of-life. There is no cure for the condition, but a combination of medication, cognitive behavioural therapy, and lifestyle modifications can be effective in managing symptoms. The cornerstone of treatment is a combination of education, exercise, and pharmacological and psychological therapies. Medications, such as antidepressants, anticonvulsants, muscle relaxants, and analgesia, may be prescribed to reduce pain, improve sleep, and alleviate other symptoms. Antidepressants include tricyclic medications such as amitriptyline and other selective serotonin reuptake inhibitors (SSRIs) and norepinephrine reuptake inhibitors (SNRIs). Therapy most often initiates with tricyclic antidepressants. An SNRI or one of the anticonvulsants is an option in patients with inadequate response or intolerance to tricyclic antidepressants. Beneficial anticonvulsants include gabapentin and pregabalin.2,10

Living with fibromyalgia can be challenging, but there are steps that people can take to help manage their symptoms and improve their quality-of-life. Exercise, such as low-impact aerobics or swimming, can help to improve muscle strength and flexibility, reduce fatigue, and promote relaxation. Lifestyle modifications, such as stress reduction, adequate sleep, and a healthy diet may be helpful. Psychological therapies aim to change negative thoughts, introduce behaviour modification, and improve coping. Additionally, they can help relieve pain, improve health-related quality-of-life, and reduce negative mood and disability. Therapies such as acupuncture, massage, and chiropractic care may also be helpful for some people with fibromyalgia and help reduce pain, improve their range of motion, and promote relaxation. Joining a support group or seeking counselling may also be beneficial for some.

However, treatment is often challenging, and many people with fibromyalgia continue to experience chronic pain and other symptoms.4,5 As some patients with fibromyalgia turn to integrative, complementary, and alternative medicine, healthcare professionals should be knowledgeable about the safety and efficacy of such therapies and educate patients to prevent any potential harm.

The lack of visible signs of the condition can result in a lack of understanding by others of the pain and fatigue being experienced by the person living with fibromyalgia, which in turn can lead to increased feelings of frustration and depression. Patients with fibromyalgia must be educated about their condition and reassured that their illness is real. Education is well received when it is interactive, ongoing, goal-oriented, and anchored with shared decision-making. Patients who are fully informed about their condition and the available treatment options can take charge and learn to live with fibromyalgia in the best way possible. It is important that patients are managed by an interprofessional team, dedicated to pain management, alleviating the symptoms, and improving quality-of-life. The key is to develop a trusting relationship with the patient so that compliance is maintained with treatments. Patients must be willing to engage with their treatment and play an active role in controlling their fibromyalgia, working closely with their healthcare professionals.2

Outlook

Because of the litany of often severe symptoms, people affected with fibromyalgia are often referred to specialists and numerous medical providers over several years, before receiving an accurate diagnosis. Such a delay in diagnosis may occur because of complicated presentations and a lack of unified diagnostic guidelines for fibromyalgia.

Many demographic and psychosocial factors can significantly impact the prognosis and outcome of patients with fibromyalgia, including female gender, low socioeconomic status, unemployment, obesity, depression, and history of abuse. Factors associated with poor prognosis include a long duration of disease; high-stress levels; the presence of depression or anxiety that has not been adequately treated; long-standing avoidance of work; alcohol or drug dependence; and moderate-to-severe functional impairment.2

Recent advances in research and a growing understanding of the underlying mechanisms that contribute to the condition have led to improved approaches in treatment, providing hope for people living with fibromyalgia. New medications are being developed that target specific neurotransmitters and immune cells involved in fibromyalgia, and may provide more targeted and effective treatments for fibromyalgia in the future. Research in to the use of biomarkers to identify people at risk of developing fibromyalgia may also be able to develop new diagnostic tools and personalised treatment plans.13,14 While there is still much to learn about the condition, new treatments and care approaches are emerging that offer the potential for improved outcomes and quality-of-life for people with fibromyalgia. With continued research and advocacy, the outlook for the future of fibromyalgia is promising.

Support

Living with a chronic condition like fibromyalgia can be challenging. For further information and supports on fibromyalgia, the Arthritis Ireland website, www.arthritisireland.ie, is a useful resource for both patients and healthcare workers.

FibroIreland is a patient-led initiative created by people in Ireland affected by fibromyalgia. It provides information on the latest research and where to get support in Ireland. FibroIreland has supported several research projects and aims to see the development of a patient registry for the Republic of Ireland. See https://fibroireland.com for more information.

Theresa Lowry-Lehnen
RGN, PG Dip Coronary Care, RNP, BSc, MSc, PG Dip Ed (QTS), M Ed, PhD, and Clinical Nurse Practitioner and Associate Lecturer, South East Technological University