Pharmacophore an International Research Journal
FIBROMYALGIA MANAGEMENT APPROACH: A BRIEF REVIEW FOR FAMILY PHYSICIANS
Mahmoud Salah Aldin Andijani1, Musaab Abdullah Badawood2, Shahad Abdullah Badawood3, Zahraa Mohammed Al-Khwaildy4, Afrah Farhan Alanazi5*, Mohammad Faisal Allaf1, Yasser Owaidh Alsahli6, Alaa Mohammed Alahmadi7, Majed Abdulaziz Saeed Almajdui8, Mohammad Ahmad Alshehri3, Mayssan Hussein Almalki9
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ABSTRACT
Background: Fibromyalgia syndrome is a complex chronic musculoskeletal pain disorder that is believed to exist since the 16th century expressing functional and psychosomatic symptoms. The etiology of fibromyalgia is unknown so causes that have been proposed that suggest fibromyalgia were numerous. This might confuse clinicians sometimes on promoting the existence of fibromyalgia as the disease seems to be confusing by a complex set of clinical manifestations that diverse the definition of the disease. There have been several classifications and screening criteria to develop expert diagnostic abilities for clinicians over the years. However, many health interprofessional teams, particularly primary health care providers reported a lack of training and confidence in the recent criteria and unclear diagnostic options. Supporting the fact that fibromyalgia displays a form of chronic pain that might be misdiagnosed and very difficult to identify. Objective: To assist family medicine physicians’ clinical approach towards fibromyalgia. Methodology: PubMed database was used for article selection, papers were obtained and reviewed. Conclusion: Fibromyalgia is often complex and requires multidisciplinary management as the disease might be profound with multidimensional disability. Family medicine physicians must develop the necessary clinical skills to achieve meaningful supportive management for the patient. There have been ongoing researches on developing a new diagnostic framework to improve clinicians’ diagnostic outcomes.
Keywords: Fibromyalgia, Pathogenesis, Diagnosis, Criteria, Management
Introduction
Fibromyalgia syndrome is a complex chronic musculoskeletal pain disorder that is believed to exist since the 16th century expressing functional and psychosomatic symptoms. [1, 2] This condition is a form of a widespread disorder with unexplained pathogenesis and is often described as a chronic overlapping pain condition related to strong alterations in the nervous system. [3] Therefore, the aetiopathogenesis of fibromyalgia is unknown and not yet has been discovered and its postulated to be linked to numerous exogenous and physical factors. [4] Physicians might sometimes question the existence of fibromyalgia as the disease seems to be confusing by a complex set of clinical manifestations that diverse the definition of the disease. [5] Therefore, there have been several classifications and screening criteria to develop expert diagnostic abilities for clinicians over the years. However, many health interprofessional teams, particularly primary health care providers reported a lack of training and confidence in the recent criteria and unclear diagnostic options [6-9]. Therefore, there has to be an advanced criterion that clarifies the current understanding of fibromyalgia and can be recognized by clinicians and researchers. [10] This review will explore the most recent findings in the epidemiology, diagnosis and management of fibromyalgia to assist family medicine physician approach towards fibromyalgia.
Methodology
PubMed database was used for article selection, and the following keys were used in the mesh ((“Fibromyalgia"[Mesh] AND “Pathogenesis” Mesh] AND “Criteria"[Mesh] AND “Diagnosis"[Mesh] AND “Management"[Mesh])). In regards to the inclusion criteria, the articles were selected based on the inclusion of one of the following endpoints; Fibromyalgia evaluation, presentation, classification criteria, and management. Exclusion criteria were all other articles that did not have one of these topics as their primary endpoint.
Review
Fibromyalgia is estimated globally to be around 0.2% up to 6.6% according to studies by numerous countries from around the globe. It commonly affects women particularly after 50 years of age. [11, 12] Fibromyalgia prevalence in the general population on female to male ratio is about (7:1). The mean rate of fibromyalgia globally was the lowest in Asia of 1.7%, 2.5% in Europe and the highest rates of fibromyalgia were found to be 3.1% in America. [13]
Aetiopathogensis
The etiology of fibromyalgia is unknown and not yet has been discovered. [4] The causes that have been proposed that suggest fibromyalgia were numerous. However, suggested psychosocial and environmental factors were found to significantly relate to fibromyalgia with psychiatric disorders notably in female victims of domestic violence. [4, 14] It has been postulated that immunity plays a vital role in the pathogenesis of fibromyalgia, as a part of an auto-immunity reaction linked to vaccinations, infections (Human papillomavirus), traumas, mineral oil injections, and silicone breast implants. [4, 15] Oxidative stress phenomenon in recent studies is linked to fibromyalgia causing major hemostatic alterations on the cellular base. [4, 16]
Diagnosis
Presentation
Fibromyalgia patients are frequently presented with chronic rheumatic diseases that are associated with widespread chronic painful muscles, tendons, joints, ligaments, and bones that persist for nearly 3 months or more. Complex forms of fibromyalgia are often granted in over 100 rheumatological diseases that identify fibromyalgia and are portrayed in inflammatory disorders (gout), biomechanical and biochemical disorders (osteoarthritis), and lastly, autoimmune dysfunctional disorders (rheumatoid arthritis and systemic lupus diseases). [4, 17] The fact that fibromyalgia displays a form of chronic pain that might be misdiagnosed and very difficult to identify, but also demands guidelines and significant classification criteria. [4, 18]
The American College of Rheumatology published and updated the fibromyalgia syndrome (ACR FMS) diagnostic criteria since 1990 this criterion could help with the diagnosis for many health interprofessional teams. The 1990 version of the ACR FMS criteria were not intended to adjust and aid in clinical practice but rather helped with clinical research. Chronic pain was the core symptom in the 1990 version. The 2010/2011 version defined other associated symptoms with generalized chronic symptoms with a specificity of 91.8% and a sensitivity of 96.6%. In the 2016 criteria, the definition of fibromyalgia was distinguished in 5 different spatial distribution of pain regions with a score of 4 out of 5 regions to confirm the diagnosis, but still has a considerable risk of misdiagnosis. [10] The table below clarifies the 2016 version of Fibromyalgia syndrome diagnostic criteria (Table 1). [19]
Table 1: Fibromyalgia syndrome criteria (2016): [19]
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Fibromyalgia syndrome diagnostic criteria |
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Recent international working researches proposals of the current 2016 criteria limitations for suggesting new perspectives of Fibromyalgia diagnosis. The new diagnostic proposal dimensional criteria of ACTTION-APS Pain Taxonomy (AAPT) and includes 5 dimensions. However, the AAPT criteria proposal is still under the study of the criteria diagnostic accuracy and is not yet valid for use. (Table 2). [2]
Table 2: Dimensions of AAPT Diagnostic Criteria for fibromyalgia proposal [2]
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Dimensions of AAPT Diagnostic Criteria for fibromyalgia |
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Management
There are different effective treatment protocols in primary health care for managing patients with fibromyalgia as the disease has no definite cure. The protocol supports a delicate framework of pharmacological and non-pharmacological therapies. A majority of cases of fibromyalgia syndrome are diagnosed firstly in the primary care unit, a family medicine physician needs to improve his knowledge about the current guidelines, necessary diagnostic criteria regarding the disease to develop diagnostic accuracy and avoid delayed treatment. [18]
Family medicine physicians are also exposed to provide a trustworthy therapeutic relationship and ongoing support in helping and educating the patient about fibromyalgia and the recommended medical and non-medical interventions to encourage the patient’s symptomatic improvements. [18] Pharmacological approach in fibromyalgia has an only supportive role in providing symptoms relieving effects such as pain the aggravating disorders that has a greater influence on pain (Table 3). Drugs should highly be monitored cautiously during treatment and should be stopped if it appears to have no appreciable effects. [20]
Table 3: Disorders that aggravate pain in fibromyalgia: [20]
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Disorders that aggravate pain in fibromyalgia |
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Chronic peripheral pain generators (Arthritis, myofascial triggers, and tendinopathies) |
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Sleeping disturbances (restless legs, obstructive sleep apnea, and limb movement disorder) |
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Cigarette smoke |
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Morbid obesity (painful meta-inflammation effects) |
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Statin myopathy |
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Depressive disorders |
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Psychosocial stressors |
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Opioid-induced hyperalgesia |
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Catastrophizing cognitive style |
In general, the treatment strategies of fibromyalgia entail an overall multidisciplinary approach that is experienced in lifestyle modifications, pharmacologic measures, and other complementary approaches. [1]
Conclusion
The approach of fibromyalgia is often complex and requires multidisciplinary management as the disease might be profound with multidimensional disability. Fibromyalgia diagnosis is fundamentally based on the exclusion of symptoms to avoid any possibility of misdiagnosis with diseases. There have been ongoing researches on developing a new diagnostic framework to improve clinicians’ diagnostic outcomes. On the other hand, family medicine physicians must develop the necessary clinical skills to achieve meaningful supportive management for the patient.
References
