Applied Evidence

Exercise and antidepressants improve fibromyalgia

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References

Practice recommendations
  • Fibromyalgia is diagnosed based on a patient’s report of widespread pain of 3 months’duration or longer, and identification of 11 of 18 possible tender points (C).
  • Fibromyalgia is functionally disabling and diminishes well-being; therefore, supportive care and evidence-based interventions should be offered (C).
  • Aerobic exercise and antidepressants have been shown to moderately relieve symptoms of fibromyalgia in the short term (A).

When a patient complains of pain “all over,” consider fibromyalgia, which typically causes a well-documented pattern of pain and characteristic points of tenderness observable on physical exam. Once alternative diagnoses have been ruled out, offer the patient a 2-pronged therapeutic regimen that has proven successful at moderately relieving symptoms.

First rule out concomitant or mimicking disorders

Consider the differential diagnosis carefully.1 A person who meets the criteria for fibromyalgia may have yet another cause of chronic pain, such as rheumatoid arthritis, or may instead have a different treatable condition that mimics fibromyalgia.

Drug-induced myopathy. Pain suggestive of fibromyalgia should prompt a review of the patient’s medicines. Drug-induced myopathy may occur in persons taking colchicine, statins, corticosteroids, or antimalarial drugs.

Connective tissue, autoimmune, and rheumatologic disorders. Consider this group of disorders next. In 1 study, one fourth of persons referred to a rheumatology clinic with presumed fibromyalgia instead had a spondyloarthropathy.2

Dermatomyositis and polymyositis may present with muscle pain and tenderness but, unlike fibromyalgia, cause proximal muscle weakness.

Systemic lupus erythematosus, rheumatoid arthritis, and polymyalgia rheumatica can also lead to widespread pain.

Blood tests such as antinuclear antibody (ANA), C-reactive protein, or erythrocyte sedimentation rate (ESR) may prove helpful when a patient has a history of unexplained rashes, fever, weight loss, joint swelling, iritis, hepatitis, nephritis, or inflammatory back pain (onset before age 40, insidious onset, present for more than 3 months, associated with morning stiffness, improvement with exercise).3 In the absence of these signs, ANA, rheumatoid factor, and ESR testing in persons with fatigue and diffuse musculoskeletal pain have low positive predictive value.4 The rate of false-positive ANA results may be as high as 8% to 11%, especially at low titers.5,6

Hypothyroidism. Widespread musculoskeletal pain has also been associated with hypothyroidism (level of evidence [LOE]: 2, case-control design),7,8 supporting the inclusion of a thyroidstimulating hormone in the work-up of fibromyalgia (strength of recommendation [SOR]: B). More recent research suggests that musculoskeletal pain is more related to thyroid microsomal antibodies than to hypothyroidism,9 but there has been no further evaluation of antithyroid antibodies in persons with fibromyalgia.

Diagnosis: mostly by clinical judgment

Persons with fibromyalgia have widespread pain, often worst in the neck and trunk.1 Additional symptoms include fatigue, morning stiffness, waking unrefreshed, paresthesias, and headache.1,10-15 (See “The toll of fibromyalgia.”)

The toll of fibromyalgia

In community-based studies, 2% of adults16 and 1.2% to 6.2% of school-age children screened positive for fibromyalgia.17-19 Females are at higher risk than males, and risk increases with age, peaking between 55 and 79 years.

Morbidity associated with fibromyalgia is considerable.16,20,21 In one report,persons with fibromyalgia scored lower on a well-being scale than persons with rheumatoid arthritis or advanced cancer.22

Persons with fibromyalgia use an average of 2.7 drugs at any one time for related symptoms, and they make an average of 10 outpatient visits per year and are hospitalized once every 3 years.23

Fibromyalgia has been associated with osteoporosis.24 Compared with other rheumatic diseases, fibromyalgia results in a high rate of surgery, including hysterectomies, appendectomies, back and neck surgery, and carpal tunnel surgery.23,25 Among adults who seek medical attention, fewer than 30% have been reported to recover from fibromyalgia within 10 years of onset.26-29

However,symptoms tend to remain stable27 or lessen over time,28,30-32 with no increase in 10-year mortality.33 Children appear much more likely to recover from fibromyalgia, with complete resolution in more than 50% by 2 to 3 years in several studies.13,18,34,35

Cormorbid conditions

Compared with other rheumatologic conditions, persons with fibromyalgia more often suffer from comorbid conditions,23 including chronic fatigue syndrome, migraine headaches, irritable bowel syndrome, irritable bladder symptoms, temporomandibular joint syndrome, myofascial pain syndrome, restless legs syndrome, and affective disorders.23,36,37

Accepted criteria

The diagnosis of fibromyalgia is based on 2 criteria:

1. A patient’s report of widespread pain (right and left sides of the body, above and below the waist, and including the axial skeleton) persisting for at least 3 months

2. The clinician’s identification of at least 11 of 18 potential tender points as specified in the American College of Rheumatology (ACR) 1990 Criteria for the Classification of Fibromyalgia (Figure) (LOE: 3, case-control design, nonindependent reference standard).1

These criteria do not exclude persons with rheumatic diseases or other chronic pain conditions.1,37-39

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