FIBROMYALGIA AND CHRONIC FATIGUE SYNDROME
FIBROMYALGIA AND CHRONIC FATIGUE SYNDROME
August 18, 2020
Fibromyalgia and Chronic Fatigue Syndrome are two chronic illnesses that present with extreme amounts of fatigue. The conditions are closely related to both terminologies often exchanged in the medical world. In fact, The Arthritis Foundation has estimated that up to 70% of people with Fibromyalgia also satisfy the criteria for Chronic Fatigue Syndrome.
However, despite the overwhelming similarities of Fibromyalgia and Chronic Fatigue Syndrome, the earlier has been thought to be more of a muscular disorder, during the later a viral illness. The good news is that several studies have been carried out, leading to the discovery of effective treatment and management modalities for these conditions.
FIBROMYALGIA.
INTRODUCTION TO FIBROMYALGIA.
Fibromyalgia is a common chronic inflammatory disorder characterized by widespread musculoskeletal pain, aching, and tenderness. It is closely associated with Chronic Fatigue Syndrome and typically affects young to middle-aged women, however it could affect patients of any age and sex.
EPIDEMIOLOGY.
The disease has no racial predilection and it has been reported around the world. It affects women more than men. Fibromyalgia is the second most common disease that rheumatologists face. It is seen in as many as 15% of their patients. International prevalence rates and widespread epidemiology have been documented.
PATHOPHYSIOLOGY.
The pathophysiology of Fibromyalgia is not fully understood. However, it is thought to originate from central pain processing. Further research reveals altered connectivity in the pain signaling system of the brain, as described by Clauw. Complex neurobiological changes cause a reduced threshold to pain. These changes are cut across biochemical, immunoregulatory, and metabolic abnormalities. Thus, Fibromyalgia is not merely a subjective condition.
At the cellular level, important elements such as proinflammatory cytokines, growth hormone abnormalities, HPA axis, and other neuroendocrine axes are implicated. Some of these abnormalities include the following:
‣ Excess pronociceptive neurotransmitters such as Substance P and glutamate in the insula.
‣ Decreased levels of serotonin and norepinephrine at the antinociceptive pathways.
‣ Dopamine dysregulation
‣ Altered endogenous opioid activity
‣ Single-nucleotide polymorphism (SNP) haplotypes
These cellular changes, alongside a concurrent lack of sleep, effectively form the clinical picture seen in Fibromyalgia.
CLINICAL MANIFESTATION.
Fibromyalgia consists of the following signs and symptoms:
‣ Persistent widespread pain on both body sides, including the axial spine greater than three months.
‣ Stiffness
‣ Paraesthesia
‣ Sleep disturbances
‣ Cognitive difficulties
‣ Easy fatigability
‣ Multiple unexplained symptoms
DIAGNOSIS.
The diagnosis is mainly clinically. It is a diagnosis of exclusion. However, there has been a study concerning its diagnostic criteria. Clinical assessment should involve an evaluation for the following:
‣ Hypothyroidism
‣ Rheumatoid arthritis
‣ Polymyalgia rheumatica
‣ Systemic lupus erythematosus
‣ Inflammatory or autoimmune disorders
Laboratory and radiological investigations should follow the evaluation.
MANAGEMENT.
Fibromyalgia and Chronic Fatigue Syndrome do not have an exact cure. However, they can be managed with great results through different modalities.
Non-Pharmacotherapy:
‣ Diet (adequate nutrition, healthy weight, and vitamin supplementation)
‣ Stress management
‣ Aerobic exercise
‣ Education on sleep hygiene
‣ Psychotherapy and cognitive behavioral therapy
Pharmacotherapy:
‣ Analgesics (e.g., tramadol)
‣ Antidepressants (duloxetine, milnacipran, amitriptyline)
‣ Anxiolytics (e.g., temazepam)
‣ Anticonvulsants (pregabalin, gabapentin)
‣ Alpha 2 agonists (e.g., clonidine)
These drugs have all shown benefits for those with Fibromyalgia.
PROGNOSIS.
Fibromyalgia is a chronic relapsing condition and it needs a long-term follow-up. Fibromyalgia and Chronic Fatigue Syndrome coexisting increase the likelihood of developing metabolic syndrome.
The goal of treatment should be to improve the quality of life and limit disability. Note that it is not life-threatening or even progressive. With optimum care and support, the prognosis is good, and one can lead a normal life. The Journal of the American Osteopathic Association discusses extensively on Fibromyalgia and often releases clinical updates.
CHRONIC FATIGUE SYNDROME.
INTRODUCTION TO CHRONIC FATIGUE SYNDROME.
Chronic Fatigue Syndrome (CFS) is a disorder that is characterized by unexplainable profound fatigue that gets worse on exertion. Most of the time, cognitive dysfunction accompanies fatigue. Before now, CFS was often referred to as Myalgic Encephalomyelitis (ME). However, it was later discovered to be erroneous. It was consequently renamed to Systemic Exertion Intolerance Disease (SEID).
EPIDEMIOLOGY.
Fibromyalgia and Chronic Fatigue Syndrome both affect females more than males. However, it is four times more in CFS. The true prevalence is unknown because up to 91% of people with the condition have not even been diagnosed. Most CFS patients are middle-aged, with the mean age being 33 years old. However, the incidence of extremes of ages has been documented.
PATHOPHYSIOLOGY.
The exact cause of CFS is not known. It is often considered a diagnosis of exclusion. However, some pain receptors might reflect the influence or association of non-organic amplifying factors. Nevertheless, it is a biological illness.
At the cellular level, numerous mechanisms have been implicated and include the following:
‣ Abnormalities in immune system function
‣ Hormonal dysregulation
‣ Metabolic responses to oxidative stress
‣ Defective natural killer cells and T-cell function
‣ Elevated cytokines
‣ Presence of autoantibodies such as Rheumatoid factor, anti-gliadin, antithyroid antibody, cold agglutinins, and anti-smooth muscle antibodies
Environmental factors and the presence of several viruses have also been associated with the disease.
CLINICAL MANIFESTATION.
Short-term memory loss and verbal dyslexia are not uncommon in CFS patients. However, five main symptoms usually grab the headlines:
‣ Profound fatigue that affects daily activities significantly
‣ Unrefreshing sleep
‣ Worsening of symptoms on exertion (this could be physical, cognitive, or emotional)
‣ Orthostatic intolerance
‣ Cognitive impairment
DIAGNOSIS.
The diagnosis is clinical. However, baseline investigations, imaging studies, and other laboratory investigations must be carried out to rule out any traceable cause of the fatigue.
MANAGEMENT.
Treatment is mostly supportive and focuses on symptomatic relief. The outcome might vary with treatment, with some patients improving and making a full recovery while others get worse and do not get any better.
Pharmacotherapy:
Drugs are taken based on the symptoms that appear. For instance, a patient might take an antidepressant like amitriptyline if there are signs of depression.
Other classes or groups of drugs for CFS include anxiolytics and pain killers. The FDA has not approved any medication made for treating CFS. However, extensive reviews and researches are carried out daily.
Non-Pharmacotherapy: Mostly involves lifestyle modifications and includes the following:
‣ Adequate diets and supplements
‣ Exercise therapy
‣ Sleep, rest, and relaxation
‣ Workplace modifications
‣ Cognitive behavioral therapy and psychotherapy.
Several surveys and guidelines have shown improvement of symptoms with consistent use of non-pharmacological options. However, whatever treatment you opt for, you should not attempt it without having the necessary guidance.
There have been reports of symptoms getting worse without the right support. More so, you should always contact your physician before you commence treatment or management.
PROGNOSIS.
Chronic Fatigue Syndrome has no cure. Moreover, symptoms could persist, and relapse is common—the shorter the duration of the illness, the better the prognosis. Depression, anxiety, and other comorbid conditions also affect the clinical picture and outcome. Overall, the prognosis is good with great management and support, and the mortality is low.
RELAPSE.
Do not be discouraged if you notice that your symptoms are getting worse. Relapses are common to Fibromyalgia and Chronic Fatigue Syndrome. They might come after an unplanned activity, infection, or no clear cause.
It is important to take a break at this point, learn relaxation techniques, focus on recovery, and be optimistic about getting back on track. Remember that an important complication of these conditions is depression alongside anxiety. Therefore, it is important to maintain a positive attitude.
DIFFERENCES: Fibromyalgia and Chronic Fatigue Syndrome.
The two most common symptoms of Fibromyalgia and Chronic Fatigue Syndrome are pain and fatigue. However, there are prominent differences between the two conditions. The table below highlights some of the differences.
| DIFFERENCES | FIBROMYALGIA | CHRONIC FATIGUE SYNDROM |
|---|---|---|
| AETIOLOGY | Symptoms often follow some form of trauma; this could be physical or emotional | More likely to be from viral causes such as mononucleosis or influenza |
| PAIN REGIONS | Patients often point to specific and notable pain regions | Patients here do not have any pain sites predilection |
| INFLAMMATION | No evidence of inflammatory responses | Complaints include fever, swollen glands, etc. |
| SLEEP | Disrupted REM sleep | Disrupted sleep pattern generally |
SIMILARITIES: Fibromyalgia and Chronic Fatigue Syndrome.
These two disorders share a lot of similarities in their clinical picture, including the following:
‣ Primarily affect middle-aged people
‣ Affect women more than men
‣ Similar symptoms and treatments
‣ Chronic relapsing disorders
These similarities reflect the close relationship between the two diseases.
CONCLUSION.
Fibromyalgia and Chronic Fatigue Syndrome chronic pain syndromes that are strongly associated with depression. While these conditions share many similarities, it is important to distinguish them for academic, medical, and many other reasons. These debilitating disorders are followed by poor sleep patterns and severe fatigue.
More so, they share cultural and religious significance in some communities. One should never underestimate the severity of the pain or even make it subjective. A detailed clinical history, examination, and investigations are needed to differentiate them from other rheumatic disorders.
As we delve into further research, patients can rest assured knowing that the prognosis of both conditions are good, and with adequate management and support, they can live normal lives. This is the time to remain optimistic for a brighter future!
REFERENCES
Harrison’s Manual of Medicine
Hutchison’s Clinical Methods