“I feel so tired, all the time. And the pain… sometimes I have pain in my leg that is so bad I can’t walk and just to touch it… it feels like someone has slammed into it with a hammer. I have trouble sleeping, I have trouble concentrating… and did I mention the tiredness? When I’m stressed the pain becomes worse, and it’s not only in my leg, sometimes it feels like I have it everywhere, but the leg is always the worst.” – Quoted from Ms X
You are probably wondering what has happened to Ms X. What is the cause of this pain?
Is the pain causing the fatigue and difficulty concentrating or is the fatigue making the pain worse?
Why is it worse when she is stressed?
And why is it widespread and not just to her leg?
So many questions and at times, especially for people suffering from fibromyalgia, so little answers.
Fibromyalgia is a musculoskeletal pain syndrome which has no identified cause and because of this, treatment also tends to be difficult. It is estimated to occur in 2-8% of the population and occurs in more women then men (Agency for Healthcare Research and Quality 2015; Clauw 2015).
You can probably guess the main debilitation symptom of this condition from Ms X’s statement is chronic and widespread pain. Fibromyalgia can also change the person’s ability to process pain and often leaves them with an increased sensitivity to pain and, like Ms X mentioned, the slightest touch can feel extremely painful, a condition otherwise known as allodynia (Agency for Healthcare Research and Quality 2015).
Not only is fibromyalgia associated with pain, but other symptoms include chronic fatigue, sleep disorders, and often people are also diagnosed with illnesses such as anxiety and depression (Agency for Healthcare Research and Quality 2015).
It has also been found that people with fibromyalgia are more likely to experience headaches, irritable bowel syndrome as well as other functional gastrointestinal tract disorders, further pain syndromes (including chronic back and neck pain), endometriosis, chronic fatigue and painful bladder syndrome.
Fibromyalgia is also commonly seen to coexist other chronic pain conditions such as rheumatoid arthritis, lupus and osteoarthritis, with between 10-30% of people with rheumatic disorders also meeting the criteria for fibromyalgia (Clauw 2015). So as you can imagine, fibromyalgia can often severely impact the quality of life and be a significant cause of disability for the individual.
Diagnosis and Treatment of Fibromyalgia
Fibromyalgia is diagnosed based on specific diagnostic criteria that states that symptoms must have been present for a minimum of three months and that there is no other disorder that can account for the symptoms present in the individual (Agency for Healthcare Research 2015).
The criteria also takes into account other symptoms associated with fibromyalgia such as fatigue, sleep problems and cognitive disturbances. It also recognises that symptoms will fluctuate over time (Guymer & Littleohn 2013).
Based on that diagnostic criteria, it can be very difficult to diagnose fibromyalgia and be an even more difficult time for the individual waiting for a diagnosis to tell them why they are feeling this way and what they can do about it.
Treatment of fibromyalgia is based around therapies that will improve both the symptoms and the level of functioning of the individual. So these therapies will generally be based on decreasing musculoskeletal pain, improving both physical and cognitive function, managing any co-morbidities such as depression, and increasing the level of independence for that person.
Treatment will often be a multimodal approach and incorporate strategies such as pharmacological management, exercise programs, patient education and cognitive behavioural therapies (Agency for Healthcare Research and Quality 2015).
Further Learning: Complete the ‘Pain’ Video Learning Activity
Pain Management Associated with Fibromyalgia
The pain experienced in fibromyalgia is often difficult to manage. This can be a result of its unknown cause and also because it is understood to be neuropathic in nature.
One of the main thoughts relating to pain and fibromyalgia is that there have been changes to the central nervous system, which has resulted in central sensitisation that causes the pain and also the increased sensitivity to pain (Clauw 2015; National Health Service 2016).
Unfortunately, there is no cure for fibromyalgia. Treatment focuses on symptom control and pain management.
Pharmacological pain management can include the use ofcentrally-acting antidepressants and anticonvulsants to help reduce the pain. However, these medicines can also cause a number of side effects for the individual including nausea, dry mouth, drowsiness, agitation, anxiety, weight gain and constipation. Tramadol may also be prescribed to the individual, which has been shown to help decrease pain in those with fibromyalgia, however there are limited studies completed in its treatment of fibromyalgia-related pain (Hauser et al. 2014; National Health Service 2016).
Strong opioids can also be prescribed, however they are generally not recommended for use in the treatment of fibromyalgia. This is also true of anti-inflammatory agents. Caution should be used with both of these types of medicines due to their risk of side effects and the lack of research undertaken into their effectiveness of treatment of fibromyalgia (Hauser et al. 2014).
In the case of use of strong opioids for treatment of fibromyalgia, they have a high risk of addiction and also the tendency for their effect to weaken over time. This can often result in opioid dose increases and then consequently increases in side effects of the opioid as well as further addiction (National Health Service 2016).
Muscle relaxant medications can also be used for any muscle stiffness or spasms associated with fibromyalgia. These medications can also help with the sleeping difficulties present in those with fibromyalgia and then further assist with other symptoms that may have been exacerbated due to fatigue (National Health Service 2016).
Individuals can also participate in non-pharmacological pain management techniques such as relaxation, exercise, hydrotherapy and cognitive behavioural therapy (National Health Service 2016).
Often treatment will involve a variety of these interventions and look at the holistic view of the patient to ensure they are cared for in all areas of health, as fibromyalgia will impact on all areas of their life.
The main focus of treatment is to control symptoms. Everyone with fibromyalgia will have different symptoms and different goals of treatment, therefore treatment will be individualised.
As nurses, we may find our role is to provide support to the individual, as well as to focus on pain management.
It is also important to remember that fibromyalgia isn’t just about pain management – there are many other symptoms the person will be experiencing, and all of these symptoms will be impacting on their quality of life.
- Agency for Healthcare Research and Quality 2015, Treatments for fibromyalgia in adult subgroups, viewed 9 March 2017, https://www.ncbi.nlm.nih.gov/books/NBK274474/pdf/Bookshelf_NBK274474.pdf
- Clauw, DJ 2015, ‘Fibromyalgia and related conditions’, Mayo Clinic Proceedings, vol. 90, no. 5, pp. 680-692, viewed 9 March 2017, http://www.mayoclinicproceedings.org/article/S0025-6196(15)00243-8/fulltext
- Guymer, E & Littlejohn, G 2013, ‘Fibromyalgia’, Australian Family Physician, vol. 42, no. 10, pp. 690-694, viewed 9 March 2017, http://www.racgp.org.au/afp/2013/october/fibromylagia/
- Hauser, W, Walitt, B, Fitzcharles, MA & Sommer, C 2014, ‘Review of pharmacological therapies in fibromyalgia syndrome’, Arthritis Research and Therapy, vol. 16, no. 201, viewed 9 March 2017, https://arthritis-research.biomedcentral.com/articles/10.1186/ar4441
- National Health Service 2016, Fibromyalgia, viewed 9 March 2017, http://www.nhs.uk/Conditions/Fibromyalgia/Pages/Causes.aspx