Fibromyalgia

I. Background

• Fibromyalgia is a disorder of unknown etiology characterized by widespread pain, abnormal pain processing, sleep disturbance, fatigue and often psychological distress. People with fibromyalgia may also have other symptoms; such as, (26)
  • Morning stiffness
  • Tingling or numbness in hands and feet
  • Headaches, including migraines
  • Irritable bowel syndrome
  • Sleep disturbances
  • Cognitive problems with thinking and memory (sometimes called "fibro fog")
  • Problems with thinking and memory (sometimes called "fibro fog")
  • Painful menstrual periods and other pain syndromes
    
• The American College of Rheumatology (ACR) 2010 criteria is used for clinical diagnosis and severity classification. Diagnosis is based on:

• Fibromyalgia often co-occurs (up to 25-65%) with other rheumatic conditions such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and ankylosing spondylitis (AS).

NOTE: for the following sections using data based on ICD9-CM codes, there is no specific single code for fibromyalgia. According to coding rules, fibromyalgia is coded to 729.1 which is labeled “Myositis and Myalgia, unspecified” and can include other conditions. Thus, numbers based on ICDM9-CM code 729.1 for mortality, ambulatory care and hospitalizations may be overestimates.

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II. Prevalence

• The prevalence of fibromyalgia is about 2%, affecting an estimated 5.0 million adults in 2005. Prevalence was much higher among women than men (3.4% versus 0.5%). (1)
  
• Most people with fibromyalgia are women (Female: Male ratio 7:1). However, men and children also can have the disorder.
  
• Most people are diagnosed during middle age and prevalence increases with age.
  
  

• Working age women with fibromyalgia hospitalized for occupational musculoskeletal disorders were almost 10 times less likely to return to work and 4 times less like to retain work at 1-year post hospitalization. (2)
  
  

• Working adults with fibromyalgia average almost 17 days of missed work per year compared to 6 days for persons without fibromyalgia. (3) Fibromyalgia has been associated with lower levels of health-related quality-of-life and more work productively loss. (27)

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III. Incidence

• No incidence data found.

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IV. Mortality

• ~23 deaths per year from 1979–1998. [Unpublished CDC data]
  • Crude numbers of deaths coded as underlying cause-of-death as 729.1 rose from 8 in 1979 to a high of 45 in 1997.
  • In 1998,”Myositis and Myalgia, Unspecified” accounted for only 0.45% (42/9367) of all deaths attributed to arthritis and other rheumatic conditions.

• Mortality among adults with fibromyalgia is similar to the general population, although death rates from suicide and injuries are higher among fibromyalgia patients. (4)

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V. Hospitalizations

• In 1997, ~7,440 hospitalizations listed ICD9-CM code 729.1 as the principal diagnosis. (5)
  
• People with fibromyalgia have approximately 1 hospitalization every 3 years. (6)
  
• Women have higher hospitalization rates than men at all ages. Persons hospitalized with primary cardiovascular conditions more had a high prevalence of reporting fibromyalgia as a secondary condition. (25)

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VI. Ambulatory Care

• 5.5 million ambulatory care visits on average per year. (7)
  
• Medical and psychiatric co-morbidity are stronger determinants of high physician use than functional co-morbidity among patients with fibromyalgia. (8)

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VII. Costs

• Average yearly direct medical costs/person range from $3400 to $3600. (9)
  
• Total annual costs (direct and indirect)/person = $5,945. (6)
  
• Office and emergency room visits, procedures and tests, and hospitalizations are the largest components of direct medical costs among patients with fibromyalgia. (9)

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VIII. Impact on health-related quality of life (HRQOL)

• Fibromyalgia patients scored lowest on 7 of 8 subscales (except role-emotional) of the SF-36 compared to patients with other chronic diseases. (10,11)
  
• Fibromyalgia patients scoring their perceived "present quality of life" averaged a score of 4.8 (1 = low to 10 = highest). (12)
  
• Standard, generic HRQOL instruments may not be sensitive enough to capture quality-of-life issues for many people with fibromyalgia.
  
• Adults with fibromyalgia are 3.4 times more likely to have major depression than peers without fibromyalgia. (13)

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IX. Unique characteristics

• Causes and/or risk factors for fibromyalgia are unknown, but some things have been loosely associated with disease onset:
  • Stressful or traumatic events, such as car accidents, post traumatic stress disorder (PTSD) (14)
  • Repetitive injuries (14)
  • Illness (e.g. viral infections) (14)
  • Certain diseases (i.e., SLE, RA, chronic fatigue syndrome) (14)
  • Genetic predisposition (14, 15)
  • Obesity (16)

• People with fibromyalgia react strongly (abnormal pain perception processing) to things that other people would not find painful.
  
• Multidisciplinary treatment is recommended, including screening and treatment for depression. (17) Scientific evidence for effective therapies include:
  • Pharmacotherapy (17, 18)
  • Aerobic exercise and muscle strengthening exercise (19-23)
  • Aerobic exercise may be most beneficial but more studies are needed examining resistance exercise
  • Aerobic exercise has been shown to improve global well-being and reduce tender point counts in fibromyalgia (19,20,23)
  • Education and relaxation therapy in a primary care setting has also shown improvements in physical impairment, days not feeling well, general and morning fatigue, stiffness, anxiety and depression. (24)
  • Cognitive behavioral therapy (28)

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X. References

1. Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum 2008;58(1):26–35.
2. Howard KJ, Mayer TG, Neblett R, Perez Y, Cohen H, Gatchel RJ. Fibromyalgia syndrome in chronic disabling occupational musculoskeletal disorders: revalence,risk factors, and posttreatment outcomes. J Occup Environ Med. 2010;Dec;52(12):1186-91.
3. Kleinman N, Harnett J, Melkonian A, Lynch W, Kaplan-Machlis B, Silverman SL. Burden of fibromyalgia and comparisons with osteoarthritis in the workforce. J Occup Environ Med. 2009 Dec;51(12):1384-93.
4. Wolfe F, Hassett AL, Walitt B, Michaud K. Mortality in fibromyalgia: a study of 8,186 patients over thirty-five years. Arthritis Care Res (Hoboken). 2011; Jan;63(1):94-101.
5. Lethbridge-Cejku M, Helmick CG, Popovic JR. Hospitalizations for arthritis and other rheumatic conditions: Data from the 1976 National Hospital Discharge Survey. Medi Care 2003;41(12):1367–13673.
6. Wolfe F, Anderson J, Harkness D, et al. A prospective, longitudinal, multicenter study of service utilization and costs in fibromyalgia. Arthritis Rheum 1997;40(9):1553–1555.
7. Sacks JJ , Luo YH, Helmick CG. Prevalence of specific types of arthritis and other rheumatic conditions in the ambulatory health care system in the United States, 2001-2005. Arth Care Res, 2010;62(4):460-4.
8. Bernatsy S, Dobkin PL, DeCivita M, Penrod JR. Co-morbidity and physician use in fibromyalgia. Swiss Med Wkly 2005;135(5-6):76–81.
9. Sanchez RJ, Uribe C, Li H, Alvir J, Deminski M, Chandran A, Palacio A. Longitudinal evaluation of health care utilization and costs during the first three years after a new diagnosis of fibromyalgia. Curr Med Res Opin. 2011; 27(3):663-71.
10. Picavet HSJ, Hoeymans N. Health related quality of life in multiple musculoskeletal diseases: SF-36 and EQ-5D in the DMC3 study. Ann Rheum Dis 2004;63:723–729.
11. Schlenk EA, Aelen JA, Dunbar-Jacob J, et al. Health-related quality of life in chronic disorders: A comparison across studies using the MOS SF-36. Qual Life Res 1998;7(1):57–65.
12. Bernard Al, Prince A, Edsall P. Quality of life issues for fibromyalgia patients. Arthritis Care Res 2000;13(1):42–50.
13. Patten SB, Beck CA, Kassam A, Williams JV, Barbui C, Metz LM. Long-term medical conditions and major depression: strength of association for specific conditions in the general population. Can J Psychiatry 2005;50(4):195–202.
14. Neumann L, Buskila D. Epidemiology of fibromyalgia. Curr Pain Headache Rep 2003;7(5):362–368.
15. Arnold LM, Hudson JI, Hess EV, Ware AE, Fritz DA, Auchenbach MB, Starck LO, Keck PE. Family study of fibromyalgia. Arthritis Rheum 2004;50(3):944-952.
16. Mork PJ, Vasseljen O, Nilsen TI. Association between physical exercise, body mass index, and risk of fibromyalgia: longitudinal data from the Norwegian Nord-Trøndelag Health Study. Arthritis Care Res (Hoboken). 2010; May;62(5):611-7.
17. Rossy LA, Buckelew SP, Dorr N, Hagglund KJ, Thayer JF, McIntosh MJ, Hewett JE, Johnson JC. A meta-analysis of fibromyalgia treatment interventions. Ann Behav Med 1999;21(2):180–191.
18. Traynor LM, Thiessen CN, Traynor AP. Pharmacotherapy of fibromyalgia. Am J Health Syst Pharm. 2011;68(14):1307-19.
19. Kelley GA, Kelley KS, Hootman JM, Jones DL. Exercise and global well-being in community-dwelling adults with fibromyalgia: a systematic review with meta-analysis. BMC Public Health. 2010; 10:198.
20. Kelley GA, Kelley KS. Exercise improves global well-being in adults with fibromyalgia: Confirmation of previous meta-analytic results using a recently developed and novel varying coefficient model. Clin Exp Rheuatol, 2011;29(6 suppl 69):S60-2.
21. Kayo AH, Peccin MS, Sanches CM, Trevisani VF. Effectiveness of physical activity in reducing pain in patients with fibromyalgia: A blinded randomized clinical trial. Rheumatol Int, 2012;32(8):2285-92.
22. Sanudo B, Galiano D, Carrasco L, de Hoyo M, McVeigh JG. Effects of a prolonged exercise program on key health outcomes in women with fibromyalgia: a randomized controlled trial. J Rehabil Med 2011;43(60):521-6.
23. Kelley GA, Kelley KS, Jones DL. Efficacy and effectiveness of exercise on tender points in adults with fibromyalgia: a meta-analysis of randomized controlled trials. Arthritis 2011;2011:125485.
24. Luciano JV, Martinez N, Penarrubia-Maria MT, Fernandez-Vergel R, Garcia-Campayo J, Verduras C, Blanco ME, Jimenez M, Ruiz JM, Lopez del Hoyo Y, Serrano-Blanco A, FibroQol Study Group. Effectiveness of a psychoeducational treatment program implemented in general practice for fibromyalgia patients: A randomized controlled trial. Clin J Pain 2011;27(5):383-391.
25. Fibromyalgia: prevalence, course, and co-morbidities in hospitalized patients in the United States, 1999-2007. Clin Exp Rheumoatol 2011;(6 suppl 69):S79-6-87.
26. SmithHS, Harris R, Clauw D. Fibromyalgia: an afferent processing disorder leading to a complex pain generalized syndrome. Pain Physician 2011;14(2):E217-45.
27. McDonald M, DiBonaventura M, Ullman S. Musculoskeletal pain in the workforce: the effects of back, arthritis, and fibromylagia pain on quality of life and work productivity. J Occup Environ Med 2011;53(7):765-770.
28. Nüesch E, Häuser W, Bernardy K, Barth J, Jüni P. Comparative efficacy of pharmacological and non-pharmacological interventions in fibromyalgia syndrome: network meta-analysis. Ann Rheum Dis 2012, Epub ahead of print

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XI. Resources

• American College of Rheumatology
• CDC Recommended Intervention Programs
• ClinicalTrials.gov
• National Fibromyalgia Association
• National Institute of Arthritis and Musculoskeletal and Skin Diseases
• National Institute of Arthritis and Musculoskeletal and Skin Diseases – Español
• National Library of Medicine—MedlinePlus

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