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D-dimer results are reported as follows.

• Qualitative negative: less than 250 nanograms/mL.

• Qualitative positive: equal to or greater than 250 ng/mL.

• Quantitative: normally less than 250 ng/mL or less than 250 micrograms/L.

Healthcare team roles

A physician orders the FDP tests and interprets them. The testing physician must obtain an accurate patient history, especially to determine if the patient is taking any drugs that can affect the test results and to learn about any recent illness, trauma, or symptoms that could be related to DIC or thrombosis. The procedure should be explained to the patient by the unit nurse, who should be aware of the degree of seriousness of the patient’s condition. FDP tests are performed by clinical laboratory scientists/medical technologists or by clinical laboratory technicians/medical laboratory technicians.

Training

Laboratory technologists performing D-dimer tests will have studied hematology and coagulation, enabling them to understand coagulation and the fibrinolytic system. Hands-on clinical laboratory training will prepare technologists to perform agglutination tests or monoclonal antibody tests for D-dimer. Nursing personnel responsible for patients undergoing D-dimer testing will understand the patient’s condition and will be trained to observe changes that may signal a critical hemostatic event.

See also Blood; Blood coagulation.

Resources

BOOKS Jacobs, David S. Laboratory Test Handbook, 5th ed. Hudson,

OH: Lexi-Comp, 2001. Pagana, Kathleen Deska, and Timothy J. Pagana, eds. Mosby’s

Manual of Diagnostic and Laboratory Tests, 5th ed. Mosby, 2013.

L. Lee Culvert

Fibrinogin test see Coagulation tests

Fibromyalgia Definition

Fibromyalgia is a chronic disorder characterized by widespread pain and inflammation of fibrous or connec- tive tissue (muscles, joints, ligaments, and tendons) and fatigue. Also known as fibromyositis or fibromyalgia

syndrome, the name fibromyalgia is derived from three Latin and Greek words that together mean “pain in the muscles and fibrous tissue.” Fibromyalgia has been considered to be a connective tissue disease, but results of extensive research suggest that it may be a pain processing disorder. The Centers for Disease Control and Prevention (CDC) categorizes fibromyalgia as a type of polyarthritis; however, fibromyalgia does not damage joints or other tissues as do the two main types of arthritis, osteoarthritis and rheumatoid arthritis.

Description

Fibromyalgia is characterized by widespread muscle pain, pain and tenderness at specific points (tender points) on the body (e.g., neck, elbows, shoulders, chest, lower back or sacrum, and knee area), and chronic fatigue. Also accompanied by headaches, insomnia, and a host of other symptoms, it is considered to be a syndrome, that is, a collection of symptoms that usually appear together. Usually the pervasive pain cannot be traced to a single cause, but researchers suggest that a disturbance in brain biochemistry may affect the way the brain processes pain signals and/or the patient’s perception of pain, making fibromyalgia a primary pain processing disorder. Fibro- myalgia may appear either gradually or suddenly. It is frequently associated with other chronic conditions and diseases, including hypothyroidism, irritable bowel syn- drome, rheumatoid arthritis, systemic lupus erythemato- sus, ankylosing spondylitis, polymyalgia rheumatica, certain cardiac conditions, and other inflammatory or autoimmune disorders. The disease has significant effects on lifestyle and cognitive function, and many individuals with fibromyalgia must modify activities, including adjusting work schedules or changing to less demanding jobs.

Causes and symptoms

Causes

The precise cause of fibromyalgia is unknown. Its frequent association with other diseases and conditions, particularly autoimmune diseases such as rheumatoid arthritis, ankylosing spondylitis, and lupus erythematosus, may suggest that it is not an entirely separate disorder. Fibromyalgia has been attributed to a number of different underlying causes, both physical and emotional, including the following:

• genetic predisposition or gene mutations

• a virus that affects the patient’s perception of pain

• a history of childhood abuse or other traumatic events with related stress or emotional issues

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• previous physical trauma, particularly involving neck injuries

• Lyme disease

• high levels of Substance P in spinal fluid. Substance P is a neuropeptide secreted by nerves and inflammatory cells and found in all body organs; it transmits and intensifies pain signals between the sensory nerve to the central nervous system, brain, and the rest of the body.

• female reproductive hormones

• stress, anxiety, and depression

• sleep disorders

• imbalances in mineral composition such as excess calcium and phosphate that affect muscle function

• exposure to environmental toxins

Symptoms

The type and intensity of fibromyalgia symptoms vary among individuals. Symptoms may improve and recur unpredictably. In addition to widespread muscle pain and generalized fatigue, people with fibromyalgia may have any or all of the following symptoms:

• headaches

• dizziness

• intestinal upsets with either diarrhea or constipations (suggestive of irritable bowel syndrome)

• sleep disorders and restless legs syndrome

• numbness or tingling sensations in the hands and feet

• problems with memory and concentration, sometimes called fibro fog

• chronic pain in the chest, abdomen, or pelvic regions

• changes in body weight

• hypersensitivity to light, noises, and odors and allergic reactions

• temporomandibular joint dysfunction

• shortness of breath

• frequent urination

Diagnosis

Although fibromyalgia may be suspected when the classic pattern of symptoms is present, diagnosis is made only by excluding other diseases or conditions. It sometimes goes undiagnosed because symptoms of fibromyalgia are so vague and general and may mimic symptoms of other diseases and conditions. Coexisting autoimmune, nerve, and muscle disorders may further complicate the diagnostic process. No specific laboratory or imaging tests are used to diagnose fibromyalgia; instead, the definitive tests for other chronic diseases must be performed to differentiate fibromyalgia. Diagnostic

tests performed to exclude other diseases with similar symptoms and to diagnose inflammatory diseases that may coexist with fibromyalgia, include:

• complete blood count with differential (to identify cell types)

• erythrocyte sedimentation rate and C-reactive protein to evaluate inflammation

• metabolic panel to evaluate digestive, kidney, and liver function

• urinalysis

• thyroid-stimulation hormone (TSH) level

• vitamin D level, vitamin B12 level

• Iron studies (iron level, total iron binding capacity, serum ferritin)

• magnesium level

• antipolymer antibody (substance P) assay since half of fibromyalgia patients have antipolymer antibodies

The ACR 2016 criteria for diagnosis of fibromyalgia revised the 2010/2011 ACR criteria to improve classifica- tion of fibromyalgia. The newer diagnostic criteria are based on systemic symptoms (i.e., fatigue, sleep dis- turbances, and cognitive function problems) rather than pain alone. A tender point count is no longer included as a criterion. Results of two questionnaires, a fibromyalgia symptom severity scale and a pain scale are used as the basis for evaluating disease severity. The 2016 ACR diagnostic criteria for fibromyalgia are as follows:

• Criterion 1: A widespread pain index (WPI) greater than 7 and a symptom severity scale (SSS) score greater than 5.

• Criterion 2: Generalized pain is present, defined as pain in at least 4 of 5 regions.

• Criterion 3: Symptoms have been present at a similar level for at least three months.

• Criterion 4: A diagnosis of fibromyalgia is valid regardless of other diagnoses. A diagnosis of fibromyalgia does not exclude the presence of other chronic disease or conditions.

The patient may be asked to fill out self-reported questionnaires about pain, fatigue, and mental status. Mood, anxiety, and depression may also be evaluated using questionnaires.

Treatment

Fibromyalgia has no known cure; therefore, the goal of treatment is to manage symptoms successfully. A rheumatologist who specializes in disorders of the joints, muscles, and soft tissue is experienced in treating autoimmune connective tissue or rheumatic diseases and is, therefore, particularly skilled at recommending treat- ment to meet the individual needs of fibromyalgia

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patients. Experience with a range of similar diseases helps the rheumatologist differentiate fibromyalgia symptoms from other connective tissue diseases.

Treatment usually requires a combination of appro- aches, including exercise, diet modification, and pharma- cologic treatment. In some cases the doctor may also recommend psychotherapy to help patients regain a sense of control over their life and to learn better ways to cope with relentless physical pain.

Specific attention to mental health, including behav- ior modification, cognitive therapy, and psychotherapy, may help to address underlying anxiety and depression that may be associated with fibromyalgia. Patients may be referred to a psychologist, psychiatrist, or psychotherapist to address previous psychological trauma or current stress that may be complicating treatment of fibromyalgia. Stress reduction and relaxation techniques may also be a useful adjunct to exercise, diet, and medications.

Physical exercise regimens found to be helpful include a regular stretching program and low-impact aerobic activities that increase the heart rate. Exercise programs ideally include both warm-up and cool-down sessions, with special attention given to avoiding exercises that exacerbate joint pain.

Nutrition is an important component in the manage- ment of this condition. The patient’s diet should include a wide variety of fruits and vegetables to provide trace elements and minerals necessary for healthy muscles. Vitamin and mineral supplements may be needed to ensure intake of essential nutrients.

Adequate rest is essential for anyone with fibromyal- gia. Besides the sleep-inducing effects of some of the medications prescribed for fibromyalgia (e.g., muscle relaxants), it is important to avoid ingesting stimulants (e.g., coffee, tea, caffeinated beverages, alcohol, and certain decongestants) before bed. Sleep therapy may also be helpful to learn ways to ensure getting proper rest.

Better ways to treat fibromyalgia continue to be investigated and developed. As of 2017, two newer forms of brain stimulation therapy demonstrated initial safety and efficacy in treating fibromyalgia. Repetitive transcranial magnetic stimulation (TMS, or transcranial direct current stimulation) is a noninvasive procedure in which a magnetic field generator is used near the patient’s head to stimulate nerve cells in the brain; although the procedure was originally designed to improve symptoms of depres- sion, it also helps to relieve some of the non-pain symptoms of fibromyalgia, including emotional distress and depres- sion. Vagus nerve stimulation (VNS) is a promising chronic pain intervention that was being investigated in human studies as of 2017. Some patients have experienced a complete reversal of their fibromyalgia. VNS applies small,

carefully timed pulses of electrical energy to stimulate the vagus nerve using an implantable device similar to a pacemaker. Pain is reduced because the vagus nerve is a control center for the body’s neuro-endocrine-immune network. Some studies suggest that stimulation of the vagus nerve exerts a neuromodulatory effect that activates protective pathways for relieving pain and restoring health. Although these treatments were experimental, results were exceptionally positive and may lead to greater availability eventually.

Drug therapies

Drug classes that have shown beneficial effects for fibromyalgia include analgesics to control pain, antide- pressant drugs, muscle relaxants, and nonsteroidal anti- inflammatory drugs (NSAIDs). Since 2007, the FDA has approved several medications specifically for treating fibromyalgia.

Narcotic analgesics such as tramadol (Ultram), hydrocodone (Zohydro), oxycodone, fentanyl (Duragesic, Abstryl), or morphine (duramorph, Astramorph) are used to treat moderate to severe pain. Fibromyalgia patients receiving narcotic (opioid) pain relievers require careful monitoring by the prescribing physician given that these drugs can be addictive, and the patient may be depressed or emotionally dependent.

Antidepressant drugs for the treatment of fibromyalgia act by altering the levels of neurotransmitters serotonin and norepinephrine that govern pain perception; these drugs are described as antidepressants and nerve pain medications. Treatment for fibromyalgia may include the use of the FDA-approved antidepressants amitriptyline (Elavil), nor- triptyline (Pamelor), and venlafaxine (Effexor), and two antidepressants approved specifically for fibromyalgia, duloxetine (Cymbalta) and milnacipran (Savella). Another type of antidepressant, selective serotonin reuptake inhibi- tors (SSRIs), also used for fibromyalgia are fluoxetine (Prozac) and paroxetine (Paxil). The muscle relaxant cyclobenzaprine (Flexeril) may also be prescribed.

Anti-seizure medications, namely pregabalin (Lyrica) and gabapentin (Neurontin), which were originally devel- oped to treat seizures and nerve pain associated with diabetes, are also approved for treating fibromyalgia pain. However, these drugs are used with caution because of potentially serious side effects such as weight gain, blurred vision, swelling of tissue, sleepiness, and dizziness. In addition, pregabalin may not provide long-lasting benefits.

Alternative and complementary therapies

In addition to conventional medical care, certain alternative and complementary therapies can help improve day-to-day functioning of fibromyalgia patients and

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contribute to symptom relief. Massage therapy stimulates muscle tissue to improve circulation, flexibility, and immune system function as well as releasing muscle tension. A family member can sometimes be instructed in specific massage techniques to manage flare-ups of symptoms.

Chiropractic addresses pain, regardless of location, as stemming from poor spinal alignment and the primary treatment involves realigning the spine to relieve pain elsewhere.

Homeopathic medicine, Chinese traditional medicine (TCM), and Western botanical medicine recommend various topical and oral medicines and herbal formulas to relieve pain and inflammation. Capsaicin, which is derived from hot chili peppers, actually reduces levels of substance P and, used topically, capsaicin cream or gel applied to muscle tissue may relieve pain directly.

Acupuncture is a 5,000-year-old therapy in which fine, ultra-sharp needles are inserted into the body at precise points along energy channels known as meridians. It activates the flow of energy in the body, which improves blood flow, releases muscle tension, and resolves energy blockages that may be causing pain. In turn, the increased flow of energy passing through the meridians stimulates the body’s self-healing abilities.

Yoga and tai chi are ancient practices that involve the integration of mind and body. Both practices are forms of movement therapy that work with all muscle groups in the body. Practicing the movements helps to increase body awareness and focuses attention on healing. Besides providing gentle exercise, these practices are reported to help relieve pain, promote flexibility, and help patients relax.

Clinical trials

As of 2017, clinical trials of experimental fibromyal- gia treatments were being conducted by the National Institute for Arthritis and Musculoskeletal and Skin Diseases (NIAMS). In addition, researchers around the world were conducting independent studies to better understand the biological mechanism behind fibromyal- gia. Clinical trials in major cities in the United States were testing the safety and effectiveness of an experimental drug labeled DS-5565 in patients with fibromyalgia compared to effectiveness of the anti-seizure medication pregabalin (Lyrica). A drug already approved for treating narcolepsy (sodium oxybate) was being evaluated for its effectiveness in treating the widespread pain and tender- ness seen in fibromyalgia.

Prognosis

Fibromyalgia has no cure but can be managed in most patients through symptom relief. Effective management of

symptoms through a variety of treatment options may allow patients to return to a higher level of function at work, play, and home. The patient may enjoy periods of complete remission, but recurrence is common. One study found that fibromyalgia patients average 10 outpatient visits to their doctor every year and are hospitalized once every three years. The disease has no major complications and does not damage either joints or body organs. Patients have a higher rate of accidental injuries and suicide than the general public, but the death rate is the same as in the general population. Nevertheless, the CDC reports that about 23 Americans each year have fibromyalgia listed on their death certificates as the underlying cause of death.

Healthcare team roles

Primary care physicians and family practice practi- tioners are often the first to see patients with symptoms of fibromyalgia. Referral to a rheumatologist is usually the next step so that the disease can be differentiated from other connective tissue diseases with similar symptoms.

KEY TERMS

Acupuncture—A form of complementary medicine in which superfine needles are inserted into the skin at specific acupoints on the body to release energy, relieve pain, and support organ function.

Chiropractic—A form of complementary medicine that treats disorders of the spine that affect joints and muscle function; chiropractic treatment focuses on adjusting the spine, which corrects other joint problems.

Fibro fog—A coined term that describes the memory loss and difficulty concentrating charac- teristic of fibromyalgia.

Pressure points—Specific locations on the body where people with fibromyalgia feel pain even with light pressure (not to be confused with acupoints used in acupuncture or acupressure, although some may correspond).

Rheumatology—The branch of medicine that deals with disorders of the muscles, joints, and connec- tive tissue.

Substance P—A biochemical in the central nervous system that transmits pain signals back and forth between nerves of the brain and those in the rest of the body.

Syndrome—A collection of signs and symptoms that occur together and characterize a specific condition or disease.

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Depending on the severity of pain, physical medicine specialists, pain management specialists, psychologists, psychiatrists, and other medical specialists may provide evaluation and treatment. Physical therapists, acupunctur- ists, massage therapists, and movement therapists may become involved in symptom management. Nursing parameters include pain management, improved sleep management, introduction of relaxation techniques (includ- ing massage and biofeedback if needed), and monitoring alternative treatments and medication. A nutritionist can provide recommendations for an anti-inflammatory diet to help reduce inflammation that contributes to pain. Coordination between members of the care team will usually increase patient compliance and may boost patients’ perception of their level of function.

Because of the anxiety and emotional distress experienced by fibromyalgia patients during diagnosis and treatment and, in some patients, the cumulative effects of previous stress or trauma, fibromyalgia patients often benefit from psychological counseling and stress reduc- tion. Nurses, nurse practitioners and physician’s assistants can assess patients’ emotional state and make appropriate recommendations. Mental health consultation may be necessary, and the importance of a support group for fibromyalgia patients should be emphasized.

Since diagnosing and treating fibromyalgia can be stressful and frustrating for patients, patient education provided by the healthcare team is imperative so that patients have a clear understanding of their role in the recovery process and successful management of this condition. Patients need both physical and emotional support as they endure a period of trial and error to pinpoint which agents and activities work best for individual patients. Care providers may urge patience while patients wait for diagnosis and treatment and may provide reassurance that the team is working to find a treatment regimen that will relieve symptoms.

Chronic pain may make it more difficult to communi- cate with fibromyalgia patients in a manner that promotes optimal care. Constant awareness of the treatment goals (to control pain and increase level of function) is needed by all members of the care team so they can provide positive reinforcement of patient compliance and monitoring of patient milestones.

Prevention

Since the underlying cause of fibromyalgia is not known, no specific means of prevention was known as of 2017. However, adequate sleep and nutrition, stress management, safe levels of exercise, and annual check- ups are important in reducing the risk of developing autoimmune fibromyalgia.

See also Accupuncture; Autoimmune disorders; Pain; Rheumatoid arthritis.

Resources

BOOKS Liptan, Ginevra. The FibroManual: A Complete Fibromyalgia

Treatment Guide for You and Your Doctor. New York: Ballantine Books, 2016.

PERIODICALS Wolfe, F., D. J. Clauw, M. A. Fitzcharles, et al. “2016 Revision

to the 2010/2011 Fibromyalgia Diagnosic Criteria.” Seminars in Arthritis and Rheumatism. 46 (December 2016): 319–29.

Yuan, H., and S. D. Silberstein, “Vagus Nerve and Vagus Nerve Stimulation, A Comprehensive Review: Part I.” Headache 56 (January 2016): 71–78.

Zemel, L., and P. R. Blier. “Juvenile Fibromyalgia: A Primary Pain, or Pain Processing, Disorder.” Seminars in Pediatric Neurology 23 (August 2016): 231–41.

Zhu, C. E., B. Yu, W. Zhang, et al. “Effectiveness and Safety of Transcranial Direct Current Stimulation in Fibromyalgia: A Systematic Review and Meta-Analysis.” Journal of Rehabilitative Medicine. Published electronically Decem- ber 2016. doi: 10.2340/16501977-2179.

WEBSITES American College of Rheumatology. “Fibromyalgia.” http://

www.rheumatology.org/practice/clinical/patients/diseases _and_conditions/fibromyalgia.asp (accessed January 18, 2017).

Mayo Clinic staff. “Fibromyalgia.” MayoCLinic.org. http:// www.mayoclinic.org/diseases-conditions/fibromyalgia /basics/definition/con-20019243mayoclinic.com/health /fibromyalgia/DS00079 (accessed January 18, 2017).

Medscape. “Fibromyalgia.” http://emedicine.medscape.com /article/329838-overview (accessed January 18, 2017).

National Fibromyalgia Association. “About Fibromyalgia.” http://www.fmaware.org/about-fibromyalgia (accessed January 19, 2017).

QUESTIONS TO ASK YOUR PROVIDER

• Why do my symptoms suggest fibromyalgia?

• How can a diagnosis of fibromyalgia be con- firmed?

• Have you ever treated a patient with fibromyal- gia? If so, what treatments did you recommend?

• Do you recommend that I take any of the drugs approved by the FDA to treat fibromyalgia?

• What can I do at home and in my daily life that may help relieve my symptoms?

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National Institute of Arthritis, Musculoskeletal and Skin Diseases. “Questions and Answers about Fibromyalgia.” http://www.niams.nih.gov/Health_Info/Fibromyalgia /default.asp (accessed January 18, 2017).

ORGANIZATIONS American College of Rheumatology , 2200 Lake Boulevard NE,

Atlanta, GA 30319, (404) 633-3777, Fax: (404) 633-1870, acr@rheumatology.org, http://www.rheumatology.org/.

National Fibromyalgia Association, 3857 Birch Street, Suite 312, Newport Beach, CA 92660, (301) 495-4484, Fax: (301) 718-6366, (877) 226-4267, nfa@fmaware.org, http:// www.fmaware.org.

National Institute of Arthritis, Musculoskeletal, and Skin Diseases, 1 AMS Circle, Bethesda, MD 20892-3675, (301) 495-4484, Fax: (301) 718-6366, (877) 226-4267, NIAM- Sinfo@mail.nih.gov, http://www.niams.nih.gov/default .asp.

Michele R. Webb Revised by L. Lee Culvert

Fibrosarcoma see Sarcomas

Filling materials see Restorative dental materials

Filmless imaging see Computed radiography

Fine motor skills Definition

Fine motor skills encompass the abilities required to control the smaller muscles of the body for writing, playing an instrument, artistic expression, and craft work. The muscles required to perform fine motor skills are generally found in the hands, feet, and head.

Description

Fine motor skill involves deliberate and controlled movements requiring both muscle development and maturation of the central nervous system. Although newborn infants can move their hands and arms, these motions are reflexes that a baby cannot consciously start or stop. The development of fine motor skills is crucial to an infant’s ability to experience and learn about the world and thus plays a central role in the development of intelligence. Like gross motor skills, fine motor skills develop in an orderly progression, but at an uneven pace characterized by both rapid spurts and, at times, frustrating but harmless delays. In most cases, difficulty with acquiring certain fine motor skills is temporary and does not indicate a serious problem. However, medical help should be sought for children who are significantly behind

their peers in multiple aspects of fine motor development; or if they regress, losing previously acquired skills.

Function

Fine motor skills develop over a long period of time, primarily during childhood. However, athletes, musicians, jewelry makers, physicians, machinists, and others who engage in activities requiring high degrees of manual dexterity and control may spend decades improving their level of muscle coordination and fine motor skills.

Infancy

The hands of newborn infants are closed most of the time and, like the rest of their bodies, are not well controlled. If its palm is touched, an infant will make a very tight fist, but this is an unconscious action called the Darwinian reflex, and it disappears within two to three months. Similarly, an infant will grasp at an object placed in the hand, but without any conscious awareness of the act. At some point, hand muscles will relax, and an infant will drop an object, equally unaware that it has fallen. Babies may begin flailing at objects that interest them by two weeks of age but cannot grasp them. By eight weeks, they begin to discover and play with their hands, at first solely by touch, and then, at about three months, by sight as well. At this age, however, the deliberate grasp remains largely undeveloped.

Hand-eye coordination begins to develop between the ages of two and four months, inaugurating a period of trial-and-error practice at sighting objects and grabbing at them. At four or five months, most infants can grasp an object that is within reach, looking only at the object and not at their hands. Referred to as “top-level reaching,” this achievement is considered an important milestone in fine

Small newborn baby sitting on the floor playing a plastic toy pyramid, learning to develop fine motor skills. (seirceil/ Shutterstock.com)

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