Recent Fibromyalgia Article - a critique

Recent Paper


A clinical review paper in BMJ 2004 page 348 published on 24 February 2014 by Professor Anisur Rahman, rheumatologist at UCL, London, gives an overview of fibromyalgia.


It explained that the diagnosis of fibromyalgia has long been controversial with some experts questioning whether it exists as a separate entity.  The causes of fibromyalgia are incompletely understood and optimal management compromised by the limited evidence base for the available treatments.  The article reviews current thinking about what fibromyalgia is, whether it is a useful diagnosis to make and which drugs and non-drug treatments can be used to treat it.


Professor Rahman states that in general medical practice fibromyalgia is diagnosed in patients with chronic widespread pain and multiple muscular tender points on examination or associated symptoms of fatigue, unrefreshing sleep or a cognitive dysfunction.  Many patients have both tender points and associated symptoms.


He refers to the 1990 American College of Rheumatology (ACR) criteria which says that fibromyalgia could be diagnosed in a patient with chronic widespread pain if at least 11 of 18 specific sites on the body surface were tender to digital palpation.


I would stress that this diagnosis was only ever intended for research purposes and it is not correct to say that a person would have to have 11 out of 18 tender points for the individual to be diagnosed in a clinical setting.


The paper goes on to suggest that the ACR alternative criteria produced in 2010 may be more useful.  This widespread pain index assesses the severity of fatigue and unrefreshing sleep and cognitive symptoms together with pain.  The single questionnaire can be completed by self-report.  This therefore does away with the need for clinical examination.





Recent surveys seem to indicate that the prevalence is remarkably high.  In Germany, population prevalence for fibromyalgia is 2.1%, in Minnesota USA it is 6.4%.


Generally speaking, it appears to affect women more than men and prevalence rises steadily with age with a maximum prevalence of the over 60s.  It is not restricted to developed countries.



Causes of Fibromyalgia


Causes are not known.  However, it is considered that in fibromyalgia sufferers the pain processing mechanisms in the central nervous system are dysfunctional.


An experimental model of pain carried out in 2005 by Gaffaux indicated that the pain inhibition pathways did not operate as effectively in the fibromyalgia group.  It has been argued that this defective inhibition arises from an altered balance between excitatory (sectors glutamate, aspartate and substance P) and inhibitory (neuro transmitters in the spinal cord).  Cerebro-spinal fluid samples from patients with fibromyalgia were reported to contain higher concentrations of substance P.  There would also appear to be a genetic component.


Diagnosis of Fibromyalgia


Some specialists have argued that the diagnosis of fibromyalgia is unhelpful because it over medicalises this complex of distressing medically unexplained symptoms.  The authors of the paper in the BMJ considered that many patients find the diagnosis helpful especially when combined with a common-sense explanation of the link between poor sleep, tiredness and pain. 


Having spoken to many hundreds of fibromyalgia sufferers, some of whom have not been diagnosed at that point, my view is that almost all patients treat the diagnosis of fibromyalgia with relief.  They are reassured to know that there is a clinical diagnosis rather than being told 'it’s all in your mind', 'pull yourself together', or 'there’s nothing wrong with you'.


The article points out that there is no test for fibromyalgia in that there is no scan or blood test that can show it.  Diagnosis is made purely on a clinical basis.  It is not a diagnosive exclusion and can occur together with other diseases. 


I have come across numerous cases where a claimant has fibromyalgia in association with other problems such as CRPS or osteoarthritis.  It is also important to remember that fibromyalgia can develop in a patient who already has another diagnosis.  I have had cases where there has been fibromyalgia secondary to ankylosing spondylarthropathy and rheumatoid arthritis.


The treatment suggested in the article is exercise, psychological therapy by way of CBT, anti-depressants and also the use of Tramadol combined with Paracetamol.  Some anti-convulsant drugs such as Pregabalin or Gabapentin have been effective in the treatment of fibromyalgia.  However, the authors of a network meta-analysis concluded that the benefits of drug treatments were of questionable clinical value and there was only limited evidence for non-drug treatments.


The conclusion of the article is that fibromyalgia is a very real disease which can cause considerable distress and disability with limited treatment options.

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