DIAGNOSIS OF FIBROMYALGIA IN HEALTH PRACTICE
Authors: Ullah Mahid 
Published: June 2024

Fibromyalgia is a chronic non inﬂammatory, non-autoimmune central aﬀerent processing disorder leading to a diﬀuse pain syndrome. It aﬀects individuals of diﬀerent age groups, sex and sociocultural background. It is estimated to aﬀect 2-5% of western population. The symptoms include widespread pain, fatigue, stiﬀness and sleep disturbance, cognitive problems and mood disorders (anxiety, depression or both) 1.
The etiology of Fibromyalgia (FM) is unknown; however several factors may contribute to development as well as severity of symptoms of FM. Genetic polymorphisms have been reported in serotonin transporter and receptors, as well as in dopamine, beta2 adrenergic and glutamate receptor genes. 2 Middle aged women and young are more aﬀected. Sleep abnormalities, autonomic dysregulation, and psychological variables like perfectionist personality, negative beliefs, low self-esteem, depression and anxiety are the contributory factors.3
Physical examination and pathological investigations reveal no evidence of articular, osseous or soft tissue inﬂammation or degeneration. Patients may have tender points both above and below the waist. The previously followed criteria, depending on presence of tender points, are no more followed.
In 2010, a new diagnostic criterion was adopted by American College of Rheumatology (ACR) 4. It has three points: -
1. Widespread pain index (WPI)>7 & a symptom severity (SS) score >5 or widespread pain index 3-6 & (SS) score >9.
2. Symptoms present for at least
3.No other disorder to explain

In diﬀerential diagnosis, many diseases need to be ruled out making the diagnosis of FM. These are systemic lupus erythematosis, systemic sclerosis, polymyositis, ankylosing spondylitis, osteomalacia, rheumatoid arthritis, polymyalgia rheumatic hypothyroidism, chronic hepatitis, HIV, hemo- chromatosis, celiac disease, myasthenia gravis, hyperthyroidism, myopathies, Sjogren`s, adrenal insufficiency, lymphoma and chronic fatigue syndrome.5
Although the exact pathophysiology of FM is unknown, most of the researchers believe that the pathophysiology of FM is due to the central sensitization within the CNS, manifesting as amplified pain perception. The specific abnormalities that have been observed in the aﬀerent pain procession areas of the CNS in FM patients, who exhibit the following symptoms: increased excitability of dorsal horn nuclei due to abnormal windup;

increased levels of substance P, nerve growth factor, glutamate and aspartate measured in CSF of patients with FM 6expanded receptive fields for central pain perception (central sensitization); MRI shows expanded fields in the insula, anterior cingulate cortex and somatosensory area.7
The abnormalities within the descending analgesia system are also observed i.e decreased levels of pain inhibitory neurotransmitters including nor epinephrine, serotonin, dopamine and suppression of normal activity of dopamine releasing neurons in limbic system.1
The management of FM is very challenging. It has many components i.e patient education, physical exercises, analgesia, treatment of associated condition like anxiety, depression, and mood disorders. Counseling about the disease and CBT are also helpful. Medication approved for the treatment of FM are:
Serotonin-noreprenphine reuptake inhibitors (SNRIs); Duloxetine
,venlaxafine, Milnacipran. Anticonvulsants; Pregabalin. Tri cyclic antidepressants: Amitriptyline, imipramine. Analgesia; Tramadol. Paracetamol and NSAIDS are not aﬀective for analgesia.8,9
The diagnosis of FM is quiet challenging in the developed world with good evaluation and referral system. In underdeveloped country with poor medical education and no referral system FM patients are the mostly go un-diagnosed and hence are under treated. It is high time to highlight the importance of diagnosis of FM by the general practitioner and other specialties doctors for proper management of these patients.
The disease impact of FM is not less than any other chronic inﬂammatory disease like Rheumatoid Arthritis. On an average the FM patients visit doctor 3-4 times more often than the general population (17 versus 4 visits/year). The frequent visits of patients with FM, is one of the factors of increasing burden on health system as well as having socio-economic impact on patients.