- 1 Definition
- 2 Disease Cause
- 3 Occurrence
- 4 Symptoms
- 5 Examinations
- 6 Similar conditions, differential diagnoses
- 7 Treatment
- 8 Prognosis
- 9 Key words for medical examinations, referral to a specialist and journal writing for fibromyalgia
- 10 Your rights
- 11 Guidelines
- 12 Literature
Fibromyalgia is a common cause of chronic, widespread (generalized) pain in muscles, tendons and joints, mostly among adult women. The pain often causes a number of additional complaints that affect night sleep, concentration difficulties and exhaustion (fatigue), as well as depression (Reference: Wolfe F, 2015). The pain threshold is lowered so that small loads trigger great pain (Desmeules JA, 2003). Rheumatic inflammation is not present and the disease is not a systemic connective tissue disease or a vasculitis. Fibromyalgia is defined as a pain condition and is included among disease states without medically explained physical causes (MUPS). The condition is therefore often described as "the invisible disease". Most are examined and diagnosed by a general practitioner.
The cause of the disease is unknown, but the pain is made worse by general tension and stress. Other chronic rheumatic diseases are also predisposing. Certain results may indicate that the brain is affected (Reference: Albrecht DS, 2018), while others emphasize stresses and psychological aspects (Reference: Furness PJ, 2018). In research projects, immune substances related to pain can be detected, but it is uncertain whether these are part of the cause of the disease or a result of the pain. Fibromyalgia often also occurs among close relatives (mothers, sisters, daughters), so that a genetic link is also possible (D'Agnelli S, 2018).
About 2-3% of the population have the disease defined by Wolfe 1990 criteria (see below). Most are women in the 20-49 age group, where approximately 8-10% have fibromyalgia (Reference: Forseth KO, 1992).
Chronic pain and stiffness in muscles, joints, neck, back and tendon attachments characterize the condition (Björkegren K, 2009). The symptoms develop gradually, usually over several years. Many notice worsening after physical activity and in cold and bad weather, while the southern climate is soothing. Migraine-like headaches are often present (de Tommaso M, 2011). Pain in the teeth, jaw and face is also common. Someone tells about "growing pains" as a child. Neck and headache, stiffness, especially after physical activity, frostbite, feeling of fever, vVarying numbness in hands and feet, feeling of swelling, eye irritation, discomfort from light and sounds, sensation of foreign body in throat, alternating stools, flatulence. Many have Irritable bowel syndrome (IBS). Reduced sleep and exhaustion affects the vast majority of people and causes concentration difficulties.
Medical history charts symptoms (see above) and their duration. The symptoms alone can lead to strong suspicion of the diagnosis, although supplementary examinations to rule out similar conditions (differential diagnoses) are also applicable.
Clinical examination. A medical examination reveals areas in the muscles and tendons ("tender points") that are noticeably painful even with fairly light pressure. Tender points are found on both arms and legs and are often quite similar on both sides of the body (symmetric distribution). The muscle strength itself is not affected, but the pain often reduces the ability to work hard. To rule out other diseases with similar symptoms, the joints, tendons, nervous system and other organs can be examined. The muscle weakness that may be present is usually pain-related. Some have changing skin temperature and varying red-blue discoloration, most often on the hands and feet. The reason may be that pain affects nerves which in turn cause blood vessels to constrict (Esen E, 2017).
Blood and urine tests. There are no special tests and one expects that all samples are normal. To rule out other conditions / differential diagnoses (see below), inflammation tests such as CRP and SR can be measured. For cell counts, liver, kidney and metabolism tests, normal results are also expected and the salts (electrolytes) are inconspicuous. "Rheuma tests" (antibody tests) such as ANA, ANCA and anti-CCP, as well as urine, do not turn out either.
Imaging shows no special findings. X-rays, ultrasound, CT or MRI examinations are usually not necessary. These are done if other investigations (see above) indicate a need for further clarification.
Tissue samples (biopsy) of painful areas have not revealed special changes in the tissue (Quinter JL, 2015). Tissue samples are therefore not part of a routine investigation.
Usually, the general practitioner/general practitioner performs the medical examinations and makes the diagnosis.
A common way of diagnosing is to use criteria, although these are actually developed for research (classification criteria). It is still common to diagnose fibromyalgia on the basis of criteria from 1990 (Reference: Wolfe F, 1990):
- Daily, significant pain in both arms, both legs and in the neck or back, provided that these have lasted for more than 3 months (chronic generalized rheumatic pain).
- In addition, the examination requires clear pain in at least 11 out of 18 defined points at a certain pressure ("tenderpoints").
It is assumed that no other causes of the pain are detected (differential diagnoses).
With the newer (2016) criteria can the diagnosis be made using a questionnaire (Fibromyalgia Criteria Patient Version (2019) NEL.pdf) (references: Wolfe F, 2016; Fors EA, 2020). It is recommended that you review the form with your GP. Certain patients are also referred to a rheumatologist if the examination shows that it is difficult to rule out another rheumatic disease. It has been shown that these newer criteria do not necessarily identify the same patients as in earlier criteria (Perrot S, 2017).
Similar conditions, differential diagnoses
A doctor experienced in fibromyalgia will usually make the correct diagnosis without uncertainty. In special cases, however, the diagnosis can be difficult. Listed below are some more or less rare conditions that can be misinterpreted as fibromyalgia. Sometimes there is also a combination with fibromyalgia.
- Carnitine-palmitoyltransferase II deficiency is a very rare, genetic, serious muscle disease with results in blood tests.
- Complex regional pain syndrome (CRPS) is usually unilateral, often where a previous injury has occurred.
- Depression can cause similar symptoms, intensify the pain, but also be a consequence of long-term pain.
- Electrolyte deficiency such as hypokalemia, hypocalcemia, hypomagnesemia
- Glycogen storage disease type II, Adult acid maltase deficiency (Pompes disease) or type V: McArdle's disease / phosphorylase deficiency: Pain/cramps after activity. Special tests.
- Hyperparathyreosis. High levels of parathyroid hormone (PTH) and calcium in blood tests
- High metabolism (hyperthyroidism). Low TSH and High f-T4 in blood tests.
- Chronic Fatigue Syndrome (CFS), ME. Fatigue, increased sleep, little pain
- Localized muscle pain does not cause as widespread symptoms
- Muscular Dystrophy (Hereditary progressive muscle diseases)
- Polymyositis is characterized by muscle weakness, often without pain and CK in the blood test is high.
- Polymyalgia rheumatica occurs within hours to a few days in people over 50 (most often in their 70s) and almost 100% have a high blood-lowering reaction (SR) and CRP in the blood.
- Polyneuropathy (constant symptoms, pathological neurography)
- Low metabolism. High TSH and low f-T4 in blood test
- Vitamin B12 deficiency detected by low B 12 in a blood test, macrocytosis (high MCV)
- Parkinsonism causes gradually increasing stiffness, but little pain
- Sjøgren's syndrome: reduced tear and saliva production, SSA antibody
- Stiff person syndrome is a serious nerve disease that causes abnormal, uncontrolled movements.
It is important to be well informed about the basis for the diagnosis, so that the symptoms are recognized and related to the condition. One can learn coping techniques against stress, tension, anxiety and pain, as well as measures to improve night's sleep. Physiotherapists can provide training, in some cases psychomotor physiotherapy or a psychologist can also be of help. Physical activity or light training that is individually adapted helps many people in the long run. Some benefit from exercises in warm water and relaxation exercises. Training institutions have programs for chronic pain, and a stay for information and the initiation of continuous measures can be useful. Most people with fibromyalgia feel less pain and stiffness in warm climates. Research supports that rehabilitation in warm climates helps (Clarke-Jenssen AC, 2014), but public support schemes for this do not exist for this diagnosis.
Unfortunately, no drugs are particularly effective. Long-term side effects often exceed any effect. Several types of medication have been tried. Sarotex (aminotryptiline) 10-25 mg taken one hour before bed can improve sleep and pain in some people and is not addictive. However, many people experience a "hang-over" at the start with increased fatigue the next morning. These side effects usually go away within a few weeks (Forseth KO, 2006; Macfarlane GJ, 2016).
No diet has been shown to affect the pain or the course of the disease. Nevertheless, dietary changes can be useful for those who struggle with stomach symptoms or sleep difficulties. About 40% with fibromyalgia also have symptoms of "Irritable bowel”. These are gas pains, alternating liquid and hard stools, normal bowels on examination, without any specific bowel disease being detected on examination. Raw onions, broccoli, beans and broccoli are good sources of nutrition, but can contribute to unfavorable gas in the stomach and intestines. Lightly cooked vegetables may be preferred. Some have in addition lactose intolerance and experience intestinal problems with loose, frequent stools, stomach cramps, bloating from dairy products. If one avoids dairy products, calcium should be taken via chewable tablets such as Calcigran Forte) or capsules (Kalcipos vitamin D and more). Guten Sensitivity is quite common in the population and the symptoms overlap with fibromyalgia. Try with Gluten free diet can be done for a limited time (reference: Rossi A, 2015). Reduced sleep and affected sleep quality are common. Coffee, tea and chocolate can exacerbate sleep problems, especially when consumed in the evening. Alcohol is unfavorable for the quality of sleep.
In general, it is important to find a diet that works well for the individual. Pain often leads to reduced physical activity. Some gain weight. A mismatch between nutritional intake and physical activity easily occurs. The diet should consist of a lot of polyunsaturated fat via fish, vegetables, fruit and grain products. If a deficiency of vitamins, iron and salts is suspected, a medical examination should be carried out and appropriate tests carried out. General information about diet in rheumatic disease is described in a separate chapter.
Most people will be plagued with pain for many years. The intensity varies. After 16 years of illness, two out of three people with fibromyalgia report that they are better than at the time of diagnosis. It has not been proven that fibromyalgia develops and damages joints, muscles or internal organs, and there is no evidence of increased mortality (Reference: Wolfe F, 2011).
Key words for medical examinations, referral to a specialist and journal writing for fibromyalgia
- Bhargava J, 2022
- Macfairlane GJ, 2016 (EULAR Recommendations for Management of Fibromyalgia)
- Häuser W, 2017
- Claw J, 2014
- Furness PJ, 2018
- Wikipedia Norwegian
- Wikipedia English
- Grans Compendium in Rheumatology
- Great Norwegian encyclopedia