Fibromyalgia (FM) is a widespread pain disorder often encountered within a chiropractic practice because we commonly manage musculoskeletal disorders, but the nature of the condition can make an accurate and timely diagnosis problematic. Often the presenting patient's symptoms are reported simply as non-traumatic pain or a vague complaint of, "I hurt all over." They may even suffer from a host of other maladies.
Advances in the understanding of this clinical entity have improved the recognition and diagnosis of FM. Common presenting symptoms include widespread chronic pain on both sides of the body, upper, lower and spinal; duration of greater than three months; and sleep disturbance. The following FM case presentation is complex and includes a myriad of other clinical differentials.
Case History
A 30-year-old female reports pins and needles in the hands and feet; right hip and groin burning. Patient has secondary complaints of right and left shoulder pain, jaw pain, bilateral knee pain and bilateral neck pain of six months' duration. Referral is from her primary care medical provider for chronic pain syndrome. Patient denies improvement with multiple pharmacotherapeutics.
History of the illness includes acute pyelonephritis; the patient was treated with volume infusion for dehydration. Significant history also includes heavy and irregular menses flow of one year's duration.
Examination reveals slumped posture; pain augmented on lifting the neck up. Right abdominal oblique paraspinous pain detected; positive pain production with light percussion over right kidney. The patient is right-handed. Maxilla sinuses are painful to touch and she is afebrile. Vibratory sense loss. No record review preformed.
Diagnostic Impression
Possible fibromyalgia due to triad symptoms. Differential diagnoses: hand and foot pain – screen as secondary to possible pernicious anemia; heavy menses history with positive loss in vibratory sense; myalgias; groin pain right-sided secondary to resolving kidney infection, jaw pain secondary to sinus disorder.
Treatment Plan
Education: The patient was counseled on diet, hydration, exercise, and the effects of anemia and irregular menses. Screening: kidney function, anemia, autoimmune disorder, and PCP to monitor kidney dysfunction and regular hydration. Referral to PCP to request consultation with a women's health specialist.
Discussion
Fibromyalgia is classified as a rheumatic autoimmune disorder. The diagnosis of fibromyalgia requires that a patient experience widespread pain in all four quadrants of the body for at least three months' duration, along with tenderness at 11 or more of 18 specific "tender point" sites.
Ninety percent of fibromyalgia patients have jaw and facial tenderness that can produce TMJ joint dysfunction syndrome (TMJDS). Other commonly noted symptoms include disturbed sleep patterns; fatigue; morning stiffness; depression; recurrent headaches; tender lymph nodes; bowel or bladder disturbances; sensitivity to heat or cold; anxiety; gastrointestinal disturbances; dizziness; occasional tachycardia; and environmental allergies.
On review of symptoms, this patient reported 4-6 hours of sleep per night due to right-sided groin / hip pain. She remarked that she usually doesn't sleep well anyway, but that currently, the pain prevented her from resting.
Fibromyalgia is thought to be triggered by infections, physical trauma or other illnesses, such as lupus, rheumatoid arthritis or leaky gut syndrome. This patient reports a kidney infection and states that her lupus and ANA (autoimmune) testing is positive. I have not reviewed these records.
With regards to leaky gut syndrome, epidemiological studies have shown that patients with functional gastrointestinal disorders, such as irritable bowel syndrome, frequently suffer from fibromyalgia.
While treatment for fibromyalgia (under the umbrella descriptor of chronic pain syndrome) can involve a combination of medications, it has been shown that a low-impact exercise program to improve muscle tension and reduce the impact of stress is beneficial. The Department of Psychology at the University of Missouri, in a meta-analysis study, recently reported: "The optimal intervention for FMS would include no pharmacological treatments, specifically exercise and cognitive-behavioral therapy, in addition to appropriate medication management as needed for sleep and pain symptoms."1
There is "gold-level" evidence that supervised aerobic exercise training has beneficial effects on physical capacity and FM symptoms.2 Strength training may also have benefits on some FM symptoms.
A number of dietary modifications and nutritional supplements have been shown to be effective. In one controlled study, women with fibromyalgia were put on a vegetarian diet consisting of only raw food (primarily fruits, vegetables, nuts, seeds, legumes and cereals such as rolled oats). During the three-month trial, women following the therapeutic diet experienced a significant reduction in body weight; pain; morning stiffness; use of painkillers; depression; and the number of sore fibromyalgia points, compared with those who continued to follow their regular diets. This suggests that prostaglandin synthesis may be a contributing factor in fibromyalgia, as a high-animal-fat diet encourages the production of prostaglandin series-2, which is known to promote pain.
The physical examination of a patient with suspected FM should focus on identifying associated or comorbid disorders as warranted by symptoms, signs and the medical history, because these may require separate management.3
References
- Rossy LA, et al. A meta-analysis of fibromyalgia treatment interventions. Ann Behav Med, 1999 Spring;21(2):180-91.
- Busch AJ, Barber KAR, Overend TJ, Peloso PMJ, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane Data System Rev, 2007, Issue 4. Art. No.: CD003786. DOI: 10.1002/14651858.CD003786.pub2
- Lesley M. Arnold, MD, Daniel J. Clauw, MD, Bill H. Improving the recognition and diagnosis of fibromyalgia. Mayo Clin Proc, 2011 May;86(5):457-464.
