Fibromyalgia ✅

🌸 Fibromyalgia is a chronic primary pain syndrome (nociplastic pain) characterised by widespread musculoskeletal pain, fatigue, sleep disturbance, and cognitive/emotional symptoms. It is a diagnosis of exclusion based on symptom criteria (no specific lab/test), often overlapping with other chronic pain, rheumatological, or functional disorders. Central sensitisation and altered pain processing are key mechanisms (NICE NG193 classifies it as chronic primary pain).

📖 About

• Prevalence: 2–8% in general population; predominantly affects women (ratio ~7–9:1), peak onset 30–60 years.
• Frequently coexists with other conditions (e.g., osteoarthritis, RA, SLE, Sjögren’s, IBS, migraine, chronic fatigue syndrome/ME, depression/anxiety).
• Pathophysiology: central amplification of pain signals, disrupted sleep architecture (reduced stage 3/4 deep sleep), heightened stress response, small-fibre neuropathy in some cases.
• Often misdiagnosed as inflammatory arthritis, somatisation, or depression; no evidence of ongoing inflammation or tissue damage.

🩺 Clinical Features

• Widespread pain: bilateral, above/below waist, axial involvement; often described as aching, burning, stiffness; fluctuates but persistent ≥3 months.
• Fatigue: disproportionate, non-restorative sleep, worsens with activity (physical/mental).
• Sleep disturbance: insomnia, frequent waking, unrefreshing sleep.
• Cognitive symptoms: “fibro fog” (poor concentration, memory issues, word-finding difficulty).
• Other common: mood disorders (anxiety/depression), IBS, tension headaches/migraine, paraesthesia (non-dermatomal), Raynaud’s-like symptoms, jaw pain (TMJ), multiple chemical sensitivities.
• Historical exam finding: Multiple tender points (≥11/18 on 1990 ACR criteria) — still taught but **not required** for modern diagnosis (low specificity; many healthy people have tenderness).
• Symptoms often worsened by stress, poor sleep, weather changes, overexertion.

🔬 Investigations

All tests are normal in pure fibromyalgia; used only to exclude mimics (NG193: do not routinely investigate beyond basic screen if history/exam consistent).

• Basic bloods: FBC, ESR/CRP (rule out inflammation), CK (myopathy), TFTs (hypothyroidism), vitamin D if indicated.
• Other as needed: ANA/ENA if rheumatological overlap suspected; serology (e.g., Hep C, Lyme in endemic areas/risk factors); sleep study if prominent sleep apnoea.
• No role for routine imaging, muscle biopsy, or specialised pain tests unless red flags (e.g., weight loss, fever, focal neurology → consider PMR, malignancy, neuropathy).

💊 Management (NICE NG193 Compliant – Non-Pharmacological First-Line)

• Education & self-management: Explain chronic primary pain nature (no damage/deformity), central sensitisation, realistic expectations; patient information resources (e.g., Versus Arthritis, NHS pages).
• Exercise: Graded aerobic (walking, swimming, cycling) + strengthening/stretching; supervised programmes improve pain, function, mood (strong evidence; start low, build gradually).
• Psychological therapies: CBT (for pain coping, sleep, mood); acceptance & commitment therapy (ACT), mindfulness-based stress reduction (MBSR); group or individual (NG193 recommends psychological therapies).
• Sleep hygiene: Consistent routine, avoid caffeine/screens, address pain interrupting sleep.
• Other non-drug: Acupuncture (NG193: consider if patient wishes, short-term benefit possible); hydrotherapy, yoga, tai chi (supportive evidence).
• Pharmacological (adjunctive only; shared decision-making; review regularly; stop if no benefit):
  • First-choice: Duloxetine (SNRI; best evidence for pain/fatigue/mood) or amitriptyline (low-dose TCA at night for sleep/pain).
  • Alternatives: Pregabalin or gabapentin (if widespread pain dominant; monitor for side effects).
  • Avoid routinely: Opioids (harm > benefit; NG193 strong recommendation against), paracetamol, NSAIDs, benzodiazepines, corticosteroids, tramadol (unless exceptional circumstances).
• Multidisciplinary approach: GP, rheumatology/pain clinic, physiotherapy, psychology, occupational therapy; refer if complex/comorbid.

📌 Key Teaching Pearls

• Diagnose using 2016 ACR criteria (WPI ≥7 + SSS ≥5 OR WPI 4–6 + SSS ≥9; symptoms ≥3 months; generalised pain in ≥4/5 regions; no other disorder explains fully).
• It is a central nociplastic pain disorder (not inflammatory or structural); normal labs/inflammation markers expected.
• Multimodal, patient-centred management works best; exercise + psychological support have strongest evidence (NG193).
• Always exclude red-flag mimics: PMR (older patients, high ESR), hypothyroidism, inflammatory arthritis (raised CRP/ESR), malignancy, neuropathy.
• Prognosis: Chronic but non-progressive; many improve with lifestyle/therapy; focus on function/quality of life over cure.

📅 Revision Note

• Last updated: March 2026 (aligned with NICE NG193 2021; no major updates noted 2025–2026; 2016 ACR criteria remain standard).

📚 References (Current as of March 2026)

• NICE NG193 – Chronic pain (primary and secondary) in over 16s (2021; current)
• American College of Rheumatology – Fibromyalgia (updated 2025)
• 2016 ACR Revisions to Fibromyalgia Diagnostic Criteria (Arthritis Care Res 2016).
• EULAR revised recommendations (2017; still referenced; no major update noted).