Advanced Practice Rheum: Fibromyalgia Save

Know-it-now:

• Fibromyalgia is 5 times more prevalent than RA; and 15-20 times more prevalent than lupus.
• Presentation is rarely textbook: patients present with chronic, focal MSK complaints, rather than classic widespread pain. , and may carry multiple prior diagnoses across specialties.
• FM frequently co-exists with other conditions and is strongly linked to poor sleep, chronic pain, and depression/anxiety.
• Treatment is multimodal and hinges on sleep improvement, stretching or pool exercise and non-opioid analgesics.

(Companion slide deck available) Fibromyalgia (FM) is a common yet frequently misdiagnosed condition characterized by a triad of widespread pain, multiple tender points, and sleep disturbance, affecting an estimated 5–7 million Americans with a female-to-male ratio of up to 5:1. FM is one of the most commonly missed musculoskeletal diagnoses – it is 5 times more prevalent than RA; and 15-20 times more prevalent than lupus.  Patients rarely present with classic widespread pain complaints; instead, they present with focal musculoskeletal symptoms, a globally positive review of systems, and normal laboratory findings. As one of the most common rheumatologic conditions, high suspicion and clinical recognition are essential to diagnosis. FM commonly co-occurs with other conditions including RA, lupus, Sjögren's syndrome, and psoriatic arthritis, and shares strong associations with depression, anxiety, irritable bowel syndrome, tension headache, and other centrally mediated pain disorders. Diagnosis remains clinical, best guided by the 1990 ACR criteria (widespread pain >3 months, axial involvement, and ≥11/18 tender points).  Routine laboratory workup (ANA, rheumatoid factor, ESR and CRP) is generally not indicated unless history and physical strongly suggest an alternative etiology. Treatment is multimodal: patient education, simple analgesics (avoiding opioids), sleep optimization, and a structured program of stretching and aquatic exercise as the foundation of care. Cognitive behavioral therapy and mindfulness approaches are effective, recommended, but are under-utilized.  FM may represent up to 20% of a rheumatology practice's patient volume, an accurate diagnosis, effective education and treatment algorithm are necessary before referral or comanagement by primary care, neurology, sleep medicine, or psychiatry.

Watch the full Advanced Practice Rheum video series, featuring Dr. Jack Cush. Topics include difficult-to-treat RA; methotrexate; evaluation of rheumatic complaints; steroids; antinuclear autoantibodies (ANA); Still's disease; lupus; and more.