|
| A) | 40 to 49 years of age | ||
| B) | 50 to 59 years of age | ||
| C) | 60 to 69 years of age | ||
| D) | 70 to 79 years of age |
As with autoimmune diseases, the prevalence of fibromyalgia is higher among women than men, although data are conflicting. A female-to-male ratio of 6:1 to 9:1 has been reported in some studies [5,12,16]. However, estimates that use newer, symptom-based diagnostic criteria show a female-to-male ratio of 2:1 [13,14].
| A) | double. | ||
| B) | three times higher. | ||
| C) | eight times higher. | ||
| D) | 100 times higher. |
Genetics is thought to be a factor in the susceptibility of fibromyalgia. Family clustering has been reported, and the risk for fibromyalgia is eight times higher for first-degree relatives of individuals with the syndrome [25]. Abnormalities in the serotonin transporter gene and the catecholamine-O-methyltransferase gene have been identified[5,9,26]. These abnormalities affect the metabolism or transport of serotonin and norepinephrine, which decrease the sensitivity of pain-processing systems through the descending central nervous system pain pathways [5].
| A) | Sleeping problems | ||
| B) | Emotional distress | ||
| C) | Strenuous activity | ||
| D) | Changes in the weather |
Psychiatric conditions have long been associated with fibromyalgia, and research suggests that such conditions may precede fibromyalgia and act as a trigger for the disease [6,8]. In one study, when individuals were asked what they perceived to be a trigger for fibromyalgia, 73% attributed the development of the disease to emotional trauma or chronic stress; 24% noted emotional/physical abuse as an adult or child as a perceived trigger [27].
| A) | stiffness, paresthesias, and anxiety. | ||
| B) | stiffness, fatigue, and sleep abnormalities. | ||
| C) | balance problems, headaches, and dry mouth. | ||
| D) | depression, fatigue, and cognitive dysfunction. |
There is a wide range of symptoms and comorbidities associated with fibromyalgia, and they occur in a variety of combinations and differ in terms of severity. After the three primary manifestations (fatigue, stiffness, and sleep abnormalities), the most common symptoms are headaches (usually migraine), dry mouth, low back pain, and paresthesias (Table 1) [1,3,27,31,32,33,34]. In an online survey conducted by the National Fibromyalgia Association (NFA), 19 symptoms, affecting virtually all body systems, were noted by at least 25% of the respondents [27]. Nearly all individuals with fibromyalgia are polysymptomatic [27].
| A) | Self-report | ||
| B) | Visual analog scale | ||
| C) | Brief Pain Inventory | ||
| D) | Short Form–McGill Pain Questionnaire |
Most individuals with fibromyalgia describe pain as arising from muscles and joints and also have tender skin [3]. Pain is typically axial in distribution, and pain/stiffness usually occurs in the morning and evening [3]. Patients may note a feeling of swelling in the soft tissues, primarily around the joints, but there is no objective evidence of swelling [3,28]. The American Pain Society recommends using self-reports as the primary source for pain assessment, focusing on such details as [4]:
Type and quality of pain
Source
Location
Duration
Time course
Pain affect
Effects on quality of life
| A) | Hair loss | ||
| B) | Mental slowing | ||
| C) | Profound fatigue | ||
| D) | Muscle weakness |
DIFFERENTIAL DIAGNOSIS OF FIBROMYALGIA
| Diagnoses to Consider | Shared Manifestations | Distinguishing Features |
|---|---|---|
| Myofascial pain syndrome | Painful, tender areas in the muscles, commonly affecting the axial muscles | Pain arising from trigger points in individual muscles during examination |
| Chronic fatigue syndrome | Chronic pain and fatigue | Low-grade fever, enlargement of lymph glands, continuous subclinical inflammatory process, and acute onset of illness |
| Rheumatoid arthritis | Joint pain/stiffness | Involvement of hands and feet, positive rheumatoid factor (in 80% to 90% of cases), radiographic evidence of joint erosion |
| Systemic lupus erythematosus | Involvement of multiple systems, joint pain | Malar rash, positive antinuclear antibody test |
| Hypothyroidism | Profound fatigue, muscle weakness, mental slowing | Weight gain, hair loss, increased TSH level |
| Polymyalgia rheumatica | Pain/stiffness in sacrohumeral and pelvic girdle | Increased ESR (in 80% to 90% of cases), age older than 65 years, treatment with glucocorticoids resolves symptoms |
| Spondyloarthropathy | Pain in neck, mid-thoracic, anterior chest wall, or lumbar regions | Pain localized to specific spinal areas, radiographic evidence of sacroiliitis, or radiographic changes in vertebral bodies |
| Polyarticular osteoarthritis | Pain in multiple joints | Radiographic evidence of joint degeneration |
| Polymyositis or other myopathies | Muscle weakness | Proximal, symmetrical muscles affected, increased serum levels of muscle enzymes, abnormal findings on EMG testing and on evaluation of biopsy samples |
| Neuropathic pain syndromes | Tingling, numbness | Burning, shooting pain |
| EMG = electromyography; ESR = erythrocyte sedimentation rate; TSH = thyroid-stimulating hormone. | ||
| A) | Duloxetine is better than amitriptyline in reducing pain. | ||
| B) | Duloxetine is better than milnacipran in reducing fatigue. | ||
| C) | Milnacipran is better tolerated than amitriptyline or duloxetine. | ||
| D) | Amitriptyline is better than milnacipran in reducing sleep disturbances. |
A systematic review to compare the effectiveness of the three antidepressants demonstrated several differences [81]:
Amitriptyline was superior to both duloxetine and milnacipran in reducing pain, sleep disturbances, fatigue, and limitations of health-related quality of life.
Duloxetine was superior to milnacipran in reducing pain, sleep disturbances, and limitations of health-related quality of life.
Milnacipran was superior to duloxetine in reducing fatigue.
No differences in tolerability were found among the three drugs.
| A) | The long-term safety and efficacy of pregabalin is unknown. | ||
| B) | Pregabalin and gabapentin are both approved by the FDA for the treatment of fibromyalgia. | ||
| C) | Gabapentin is associated with a higher rate of adverse events than pregabalin. | ||
| D) | Pregabalin has improved pain and fatigue but not other fibromyalgia symptoms. |
The third FDA-approved drug for the treatment of fibromyalgia is pregabalin, an anticonvulsant agent. Several studies have shown pregabalin to significantly improve pain, patient global assessment, fatigue, and health-related quality of life, as well as sleep disturbances [41,72,82]. The effect of the drug has lasted for as long as six months [41]. The drug was well tolerated, with the common side effects being dizziness and sedation, which tended to resolve with time of treatment [41].
Anticonvulsants have been evaluated in several trials, and the American Pain Society found level II evidence for this class of drug, whereas the later EULAR guidelines note level I evidence for pregabalin specifically [4,46,49]. Another anticonvulsant drug, gabapentin, has also demonstrated efficacy with respect to pain, patient global assessment, function, and sleep [41,70,72]. Gabapentin has not been approved by the FDA to treat fibromyalgia, and the drug is not specifically noted in treatment guidelines [4,46]. Approximately one-third of the respondents in the NFA survey said they had "ever used" gabapentin, and 46% who had used it considered the drug helpful [27]. The side effect profile of gabapentin is similar to that of pregabalin, but the pharmacokinetic and pharmacodynamic profile is not as favorable [41]. An overview of systematic reviews of anticonvulsants showed that both drugs had a modest effect on pain reduction, and it was not possible to conclude if one drug was better than the other [72]. The long-term safety and efficacy of both drugs is also unknown, and many patients are expected to discontinue therapy due to a high incidence of adverse effects. The overview found no evidence of clinical benefit with any other anticonvulsant, including carbamazepine [72].
| A) | pain. | ||
| B) | fatigue. | ||
| C) | stiffness. | ||
| D) | sleep disturbances. |
Strong evidence has also been documented for cyclobenzaprine, which has both muscle relaxant and tricyclic antidepressant properties [26,58,83]. A systematic review of five randomized controlled trials showed that individuals treated with cyclobenzaprine for fibromyalgia were three times as likely to report overall improvement and to note reductions in symptoms, especially sleep disturbances, than controls [83]. Among the NFA survey respondents, 64% had ever used cyclobenzaprine and 58% of these patients considered the drug to be helpful [27].
| A) | Bed rest | ||
| B) | Exercise | ||
| C) | Patient education | ||
| D) | Cognitive-behavioral therapy |
The authors of one review of nonpharmacologic treatment suggest that clinicians use the acronym ExPRESS to follow principles of nonpharmacologic pain management [47]:
Ex: Exercise
P: Psychiatric (i.e., addressing psychiatric comorbidities to help improve pain and disability)
R: Regain function (helping patients pace activities to avoid doing too much on days they feel well)
E: Education (referral to reliable resources)
S: Sleep hygiene
S: Stress management (such as cognitive-behavioral therapy and relaxation techniques)