Musculoskeletal disorders
QUICK LESSON
ICD-9 729.1
ICD-10 M79.7
Authors Penny March, PsyD
Cinahl Information Systems, Glendale, CA
Bryan Boling, RN, DNP, CCRN-CSC Cinahl Information Systems, Glendale, CA
Reviewers Eva Beliveau, RN, MSN, CNE
Professor of Nursing, Northern Essex Community College
Alysia Gilreath-Osoff, RN, BSN, CEN, SANE
Cinahl Information Systems, Glendale, CA
Nursing Practice Council Glendale Adventist Medical Center,
Glendale, CA
Editor Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
February 23, 2018
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Fibromyalgia
Description/Etiology Fibromyalgia is a chronic soft tissue pain disorder of unknown etiology characterized by persistent widespread pain, specific tender points, fatigue, and disrupted, unrefreshing sleep. The condition is extremely debilitating and typically presents in young or middle-aged women. Once dismissed as a psychological disorder, fibromyalgia is now considered a neurosensory disorder. Though the etiology of fibromyalgia is unclear, is it likely multifactorial, and includes CNS sensitization, abnormalities of descending inhibitory pain pathways, neurotransmitter abnormalities, hypothalamic-pituitary-adrenal (HPA) axis dysfunction, and peripheral sensitization.
In order to be diagnosed with fibromyalgia, a person must have had chronic, widespread pain for 3 months or longer and moderate pain on palpation in at least 11 of 18 locations classified as “tender points.” Widespread pain is defined as pain on both sides of the body above and below the waist. The patient must also have pain in the cervical, thoracic, or lumbar spine. The practitioner uses his/her thumb to palpate the tender point locations with less than 4 kg of force; locations include the occiput (suboccipital muscle insertions); lower cervical (anterior aspects of the intertransverse spaces at C5–7); second rib (second costochondral junctions); supraspinatus (origin above the medial border of the scapular spine); upper trapezius (midpoint of the upper border); lateral epicondyle of the elbow (2 cm distal to the epicondyles); gluteal (upper outer quadrants of buttocks); greater trochanter (posterior to the trochanteric prominence); and knee (medial fat pad proximal to the joint line).
There is no cure for fibromyalgia; treatment is symptom-driven and supportive. Commonly prescribed medications include antidepressants (e.g., tricyclic antidepressants, selective serotonin reuptake inhibitors [SSRIs], serotonin and noradrenaline reuptake inhibitors [SNRIs]), monoamine oxidase inhibitors (MAOIs), NSAIDs, anticonvulsants, dopamine agonists, and muscle relaxants. Physical therapy can include ultrasound, hot/cold packs, aquatic therapy, electrical stimulation, and therapeutic exercise. Cognitive behavioral therapy (CBT) can improve coping with pain and reduce depressed mood. Prognosis is uncertain; symptoms may persist throughout life, although sometimes intermittently, despite aggressive and multifaceted treatment.
Facts and Figures Fibromyalgia is the second most common condition seen by rheumatologists, accounting for 15% of evaluated patients. Among patients treated in primary care clinics, 8% have fibromyalgia. The disorder affects approximately 3–5% of women and 0.5–1.6% of men, or ~ 5 million adults, in the United States. The female-to-male ratio is 7–9:1.Fibromyalgia is most often diagnosed between the ages of 20 and 50 years but is also observed in pediatric populations and older adults. Fibromyalgia results in disability in 9–44% of patients. Fibromyalgia is associated with a 10-fold increased risk of suicide and with estimated annual costs to the U.S. economy of $9 billion.
Risk Factors Risk factors for fibromyalgia include female gender, family history/genetic predisposition, abuse or other trauma during childhood, persistent emotional stress or distress, and physical deconditioning. Onset often follows childbirth, trauma (especially to the trunk), surgery, or
illness such as infection (e.g., Epstein-Barrvirus, parvovirus, Lyme disease). Fibromyalgia commonly coexists with conditions associated with systemic inflammation, including rheumatoid arthritis, systemic lupus erythematosus, and chronic hepatitis C, and is also more common in people with chronic fatigue syndrome, irritable bowel syndrome (IBS), and chronic headaches.
Signs and Symptoms/Clinical Presentation The characteristic symptoms of fibromyalgia are widespread pain, sleep disturbances, and chronic fatigue (which affects more than 90% of patients). Other common symptoms include anxiety, depression, morning stiffness, headache, IBS, exercise intolerance accompanied by muscle deconditioning, restless leg syndrome, noncardiac chest pain, weight fluctuations, allergic symptoms (e.g., nasal congestion), hypersensitivity to environmental stimuli and medications, dizziness, syncope, shortness of breath, intolerance to cold, and increased urinary frequency and urgency. Cognitive impairment, commonly known as “fibro fog,” includes memory loss and groping for words. Symptoms can vary in intensity from day to day and worsen as a result of physical or emotional stress, cold and humid weather, poor sleep, hormonal fluctuations, and lack of exercise.
Assessment › Patient History
• Determine types and duration of symptoms; assess for family history of fibromyalgia as well as for the presence of other risk factors
› Physical Findings of Particular Interest • Pain is described as exhausting, deep, gnawing, aching, burning, miserable, or unbearable
› Laboratory Tests That May Be Ordered • Laboratory tests are usually normal, including CBC, erythrocyte sedimentation rate (ESR), phosphokinase, antinuclear
antibody (ANA) test, creatinine, TSH, T3 resin uptake, and T4 › Other Diagnostic Tests/Studies
• Laboratory sleep assessment studies to evaluate sleep dysfunction may be beneficial • All other diagnostic tests (e.g., X-rays, electromyogram, bone scans) are usually normal
Treatment Goals › Alleviate Symptoms and Promote Optimal Functional Status
• Administer prescribed medications, which may include NSAIDs, long-acting opioids, tricyclic antidepressants (e.g., amitriptyline), SSRIs (e.g., FLUoxetine, citalopram), SNRIs (e.g., DULoxetine, milnacipran), MAOIs (e.g., moclobemide, pirlindole), anticonvulsants (e.g., pregabalin), dopamine agonists (e.g., pramipexole), and/or muscle relaxants (e.g., cyclobenzaprine) – Duloxetine, milnacipran, and pregabalin are the only drugs approved for the treatment of fibromyalgia by the U.S. Food
and Drug Administration (FDA) • Request clinician referral to physical therapy for evaluation and formulation of an individualized treatment plan to reduce
symptom severity and promote optimum function • Assess for IBS and urinary symptoms; treat as prescribed (e.g., with loperamide or diphenoxylate and atropine for diarrhea;
bisacodyl for constipation; oxybutynin, flavoxATE, or hyoscyamine to control bladder symptoms) – Recommend avoiding potentially aggravating foods, consuming adequate fiber, and establishing a regular bowel routine – Teach patient to perform Kegel exercises to strengthen the pelvic floor
› Promote Emotional Well-Being and Educate • Assess patient’s anxiety level and coping ability; provide emotional support and request referral to a mental health
clinician, if appropriate, for CBT and other supportive counseling strategies for coping with a chronic, painful condition • Educate patient on all aspects of the syndrome, including adverse effects of medications • Advise/recommend the following:
– Avoidance of all food and drinks containing caffeine – Avoidance of exercise and watching television for several hours before bedtime – Establishment of a regular sleep schedule and routine (avoid napping) – Establishment of a regular physical exercise program, which can include guidance by an exercise physiologist and/or
physical therapist
Food for Thought › Limiting sedentary time by increasing light physical activityis associated with decreased levels of pain and fatigue in women
with fibromyalgia › Men with fibromyalgia tend to perceive that they have poorer health and more physical limitations than women with
fibromyalgia; women have greater pain sensitivity and may experience greater interference in ADLs due to pain › In recent years Cochrane reviewers analyzing the literature related to treatment of fibromyalgia found
• low- to moderate-quality evidence that acupuncture improves pain and stiffness in patients with fibromyalgia (Deare et al., 2013)
• that, of the antiepileptic drugs that have been compared to placebo in neuropathic pain and fibromyalgia, only gabapentin and pregabalin have been shown to be effective, although only a minority of people achieve good pain relief (Wiffen et al., 2013)
• pregabalin also has a small benefit over placebo in reducing sleep problems (Üçeyler et al., 2013)
Red Flags › Patient characteristics associated with poor prognosis include high levels of distress, long-standing fibromyalgia, major
mental illness (e.g., severe depression or anxiety), a pattern of work avoidance, marked functional impairment despite a multidisciplinary approach to therapy, and alcohol or opioid dependence
› Deep massage and massage of tender points are contraindicated in fibromyalgia › Women with fibromyalgia who are pregnant or breastfeeding can require additional psychosocial support and should be
educated about potential adverse effects of prescribed medications on the fetus or infant
What Do I Need to Tell the Patient/Patient’s Family? › Advise patient of recommended changes in diet (↓ caffeine intake and avoidance of aggravating foods) and activity (↑
appropriately timed exercise) that positively affect fibromyalgia outcomes › Encourage attending a fibromyalgia support group for contact with others who face similar health challenges. The National
Fibromyalgia Association Web site at http://www.fmaware.org/ contains a national directory of such groups
References 1. Boomershine, C. S. (2017, November 4). Fibromyalgia. Medscape. Retrieved February 13, 2018, from http://emedicine.medscape.com/article/329838-overview
2. Deare, J. C., Zheng, Z. X., Xue, C. C., Liu, J. P., Shang, J., Scott, S. W., & Littlejohn, G. (2013). Acupuncture for treating fibromyalgia. Cochrane Database Syst Rev, Issue 5. Art. No.: CD007070. doi:10.1002/14651858.CD007070.pub2
3. Fitzcharles, M.-A., Ste-Marie, P.A., Goldenberg, D.L., Pereira, J.X., Abbey, S., Choinière, M., ... Shir, Y. (2012). 2012 Canadian guidelines for the diagnosis and management of fibromyalgia syndrome. Retrieved February 13, 2018, from http://www.fibromyalgie-sqf.org/2012_fm.pdf
4. Mbuyi, N. (2018). Fibromyalgia. In F. F. Ferri (Ed.), 2018 Ferri’s Clinical Advisor (pp. 491-492). Philadelphia, PA: Elsevier.
5. Segura-Jiménez, V., Borges-Cosic, M., Soriano-Maldonado, A., Estévez-López, F., Álvarez-Gallardo, I. C., Herrador-Colmenero, M., ... Ruiz, J. R. (2017). Association of sedentary time and physical activity with pain, fatigue, and impact of fibromyalgia: The al-Ándalus study. Scandinavian Journal of Medicine & Science in Sports, 27(1), 83-92. doi:10.1111/sms.12630
6. Üçeyler, N., Sommer, C., Walitt, B., & Häuser, W. (2013). Anticonvulsants for fibromyalgia. Cochrane Database of Systematic Reviews, Issue 10. Art. No.: CD010782. doi:10.1002/14651858.CD010782
7. Wiffen, P.J., Derry, S., Moore, R.A., Aldington, D., Cole, P., Rice, A.S.C., ... Kalso, E.A. (2013). Antiepileptic drugs for neuropathic pain and fibromyalgia - an overview of Cochrane reviews. The Cochrane Database Of Systematic Reviews, Issue 11. Art. No.: CD010567. doi:10.1002/14651858.CD010567.pub2