Fibromyalgia is a complex multi faceted disorder. It is poorly understood not only by the common people but sadly a vast majority of the medical fraternity are also are pretty oblivious to it’s course, diagnosis and management. Fibromyalgia ,if left untreated for a long time can have a  considerably debilitating  effect on the quality of one’s life. It was only in 1990 that the American College of Rheumatology defined Fibromyalgia and published their research which has now become the cornerstone in diagnosing Fibromyalgia.[1]

The quartet of Unexplained pain, easy fatiguability, frequent mood disturbances and loss of function are the major components in FM. There are four main components in FM: Pain, fatigue, mood, and function. The incidence of FM is seven times more in women than men. [2] Incidence has been seen to be more in women of the childbearing age. More often than not fibromyalgia presents in association with other somatic disturbances like chronic fatigue syndrome, temperomandibular joint dysfunction, Irritable Bowel Syndrome .[3]

As of today, a patient centric  multidisciplinary approach to tackle fibromyalgia has been the most widely accepted methodology by clinicians all over.

ETIOPATHOGENESIS

Throughout the first half of the 20th century FM  was widely referred to as fibrositis. The term fibromyalgia came into existence and gained popularity owing to the concomitant pain symptoms seen in people suffering with FM.[4]

A lot of theories attempting to explain the etiology of FM have sprung up. While some of them have been thwarted by research, some of them have enjoyed partial acceptance in the medical fraternity.

• Damage to soft tissues including muscles was  thought to be a main causative factor  but absence of damage seen in muscle biopsies strongly refuted this theory.[5]
• It has been considered that there might be disturbances in the serotonin and epinephrine pathways with may prevent the relative muting  of afferent pain. This results in a stronger perception of pain
• Increase in the concentration of Substance P was considered to increase the peripheral sensitivity to pain in patients suffering with FM but future studies failed to show a correlation between the level of Substance P and the degree of pain present.[6]
• Autoimmune causes have been considered owing to the elevated levels of cytokines such as Interleukin- 2 but what is unclear is  whether FM brings about increased levels of cytokine or increased levels of cytokines play a causative role in FM.[7]
• Studies on sleep patterns of patients with FM have shown increased alpha activity and reduced delta activity on Sleep Electroencephalogram indicating sleep disturbances might find a place in the complex etiology of FM.[8]
• Impairment of the hypothalamic- pituitary axis has also been considered ads a cause of FM.
• Trauma, infection or surgery may precipitate some of the biological changes leading to the onset of symptoms.

CLINICAL PRESENTATION

FM is characterised by widespread pain present all throughout. Bilateral involvement of body parts is seen. Pain also occurs in the axial structures like the cervical spine, thoracic spine, lumbar spine or the chest wall. The following 18 musculoskeletal structures have been identifies as the commonest trigger or tender points in FM. A patient exhibiting tenderness palpation  in 11 out these 18 points may strongly favour the diagnosis of fibromyalgia.

1. Occiput or suboccipital muscle insertions
2. Low cervical or anterior aspects of the intertransverse spaces at C5–C7
3. Trapezius or midpoint of the upper border
4. Supraspinatus or origins above the scapula spine near the medial border
5. Second rib or upper lateral to the second costochondral junction
6. Lateral epicondyle or at 2cm distal to the epicondyles
7. Gluteal or in upper, outer quadrants of buttocks in anterior fold of muscle
8. Greater trochanter or posterior to the trochanteric prominence
9. Knee or at the medial fat pad proximal to the joint line.

(Image of these tender points to be added)

Other than tender points the other features of Fibromyalgia are as follows-

• Fatigue
• Insomnia
• Joint pain
• Jaw Pain (unexplained)
• Headaches
• Restless legs
• Associated tingling and numbness
• Impaired Memory and Concentration
• Nervousness
• Anxiety
• Depression

A lot of patients with FM showed coexisting depression and anxiety disorders such as

Dysthymia, panic disorder and phobias to name a few.

Diagnosis

The Fibromyalgia Impact Questionnaire is a questionnaire for the patient comprising of 20 questions. This helps to quantify the impact of Fibromyalgia on the patient. Scoring ranges from 0-100 with majority of the FM patients scoring over 50.[9,10]

Box 1

Fibromyalgia survey questionnaire

1.Using the following scale, indicate for each item the level of severity over the past week by checking the appropriate box.

0: No problem

1: Slight or mild problems; generally mild or intermittent

2: Moderate; considerable problems; often present and/or at a moderate level

3: Severe; continuous, life-disturbing problems

Fatigue                 □ 0 □ 1 □ 2 □ 3

Trouble thinking or remembering             □ 0 □ 1 □ 2 □ 3

Waking up tired (unrefreshed)                  □ 0 □ 1 □ 2 □ 3

2.During the past 6 months have you had any of the following symptoms?

Pain or cramps in lower abdomen                            □ Yes □ No

Depression                         □ Yes □ No

Headache                            □ Yes □ No

3. Joint/body pain

Please indicate below if you have had pain or tenderness over the past 7 days in each of the areas listed below. Please make an X in the box if you have had pain or tenderness. Be sure to mark both right side and left side separately.

□ Shoulder, left                □ Upper leg, left               □ Lower back

□ Shoulder, right              □ Upper leg, right            □ Upper back

□ Hip, left            □ Lower leg, left               □ Neck

□ Hip, right                          □ Lower leg, right

Along with this questionnaire, Other chronic conditions such as thyroid disorders and temperomandinular dysfunction must be ruled out

TREATMENT

Non Pharmacological Treatment- Living with Fibromyalgia is a big challenge when compared to some of the other chronic conditions.

Clinicians need to excercise a lot of patience with these patients. One of the key elements to non-pharmacological approach is to encourage the patients to become SELF MANAGERS through counselling and training. Patient education is focussed on improving pain, sleep, fatigue and function. Out of the non- pharmacological approaches excercise and psychoeducational approaches have shown be highly beneficial in curbing the symptoms of FM. High intensity aerobic excercises

And Aquatherapy are very helpful in some patients.[11,12]] Other tools which might have a positive impact on the quality of life are meditation, stress management and relaxation techniques.

Pharmacological Intervention

Antidepressants- Tricyclic Antidepressants in low doses of 25-50mg/d have been found to be effective for bringing about improvement of fatigue, sleep, pain and depressive symptoms of fibromyalgia.[13]. Amitryptyline has found itself as the first line drug in the management of fibromyalgia in many practices. It has to be carefully monitored as patients on it will have a tendency towards weight gain and developing tolerance. Serotonin Noradrenaline Reuptake Inhibitors are also used in treating FM as levels of serotonin and noradrenaline has been found to be lower in certain subgroups.

Duloxetine at 60mg dosage has been tried but with only marginal effects on patients with FM.Milnacipran  which inhibits the reuptake of serotonin and noradrenaline (norepinephrine), has found itself approved in Australia for the treatment of FM. It is generally administered with a dosage of 100 mg which is given daily in divided doses.

Antiepileptic drugs

The neurotransmitters Substance P and glutamate are found in increased levels in patients suffering with Fibromyalgia. These constitute the targets of pregabalin and gabapentin, which help in promoting sleep, alleviating anxiety and modulate pain.

Other drugs that are commonly used in the management of fibromyalgia are

Tramadol[14], Pramipexole[15] and Memantine[16]. There is weak supporting evidence for use of anti inflammatory medications and hardly any so for paracetamol. Opioid induced hyperalgesia and poor clinical response have put drugs like codeine, fentanyl and oxycodone as contraindications.

Intravenous Infusions

Myer’s Cocktail, named after John Myers MD is a well-known form of infusion treatment in the medical circles attending to FM. It’s constituents are as follows

• 5 milliliters (mL) magnesium chloride hexahydrate
• 3 mL calcium gluconate
• 1 mL hydroxocobalamin
• 1 mL pyridoxine hydrochloride
• 1 mL dexpanthenol
• 1 mL B-complex (thiamine, riboflavin, niacinamide) vitamins
• 5 mL vitamin C

Think a cocktail might help you better manage your fibromyalgia symptoms?

We’re not talking about a fruity drink with a cherry and an umbrella. Many people who are living with fibromyalgia swear by the Myers cocktail, an intensive vitamin and mineral dose delivered once a week intravenously. Both patients and practitioners report that this infusion – named for John Myers, MD, the Baltimore doctor who first experimented with a vitamin and mineral mix of magnesium, calcium, B vitamins, and vitamin C – helps ease fibromyalgia pain and other symptoms, such as profound fatigue.

According to fibromyalgia researcher David Katz, MD, founding director of the Prevention Research Center at Yale University in Derby, Conn, about 12,000 people across the United States are treated with the Myers cocktail, and about four out of five say the treatment helps ease fibromyalgia symptoms. The treatment is considered to be a form of complementary and alternative medicine (CAM), not traditional treatment, which includes prescribed medications. However, people often are willing to try novel approaches because living with fibromyalgia is often challenging and fibromyalgia symptoms can be so persistent.

Myers Cocktail 101

The Myers cocktail contains a variety of nutrients:

• 5 milliliters (mL) magnesium chloride hexahydrate
• 3 mL calcium gluconate
• 1 mL hydroxocobalamin
• 1 mL pyridoxine hydrochloride
• 1 mL dexpanthenol
• 1 mL B-complex (thiamine, riboflavin, niacinamide) vitamins
• 5 mL vitamin C

Proposed Mechanism of action

Though the exact mechanism of action remains unclear, groups of patients receiving Myer’s Cocktails have experienced reduction in pain and fatigue.

B Vitamins are essential for maintaining the health of nerve cells and hence probably stabilisation of the nerve cells by the influx of B Vitamins maybe helpful in reducing the pain. The fatigue of FM has been compared to the fatigue experienced after rigorous excercise, which can build up lactic acid in the oxygen deprived muscles. The Magnesium and Calcium help in dilating the blood vessels so that they can carry more oxygen and help muscles relax.

Lidocaine Infusions- Lidocaine infusions are becoming pretty popular amongst some patients and practitioners alike. Some patients have reported a significant reduction of the symptoms of FM.

Ketamine Infusions

Ketamine works by blocking the NMDA receptors. In doing so, it can reboot the pain receptors which have been altered in patients of FM. In the long term ketamine may also help in decreasing  Neuro inflammation which might play a role in neuropathic pain.

MULTIDISCIPLINARY APPROACH involving pain physicians, physical therapist, clinical nutritionist, clinical pyschologist  and pharmacological  as well as non pharmacological interventions for the cornerstone in management of this complex yet highly debilitating Entity.

References:-

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