Fibromyalgia: An Environmental Scan
Table of Contents
3.3.8 Co-Morbid/Co-Occurring Conditions
Misdiagnosis is always a pertinent point to remember in the area of fibromyalgia as there is no gold standard, thus ruling out other joint and muscle pathologies requires vigilance on the part of the clinician to make an accurate diagnosis (Perot 2008) (Nampiaparampil and Shmerling 2004). Myofascial pain syndrome, chronic fatigue syndrome, hypothyroidism and other less commonly occurring rheumatic disorders may either be present with fibromyalgia or responsible for presenting symptoms (Chakrabarty and Zoorob 2007). An individual’s presenting symptoms are characteristic of many other co-morbid conditions and are reported in a highly subjective manner, which in some instances makes it substantially difficult to differentiate between fibromyalgia and is a particular challenge to providing an accurate diagnosis.
A barrier to accurate diagnosing of fibromyalgia is the number of symptoms than can mimic other diseases. For example, individuals with iron deficiency exhibit pain, muscular aches and checking serum ferritin levels will differentiate from fibromyalgia, when serum iron levels increase general pain improves. Additionally, people with low Vitamin D levels (hypovitaminosis D) will also experience widespread pain. Again this is addressed through Vitamin D supplementation and addressing any absorption issues, which once completed will improve pain levels.
Furthermore, there numerous other chronic syndromes that may co-exist with fibromyalgia syndrome.
- Chronic fatigue syndrome
- Irritable bowel syndrome (IBS)
- Post-traumatic stress disorder
- Restless legs syndrome
- Rheumatoid arthritis
Chronic Fatigue Syndrome
The term chronic fatigue syndrome (CFS) is also used interchangeably with myalgic encephalomyelitis (ME). Researchers and clinicians either use the term interchangeably whereas others feel one syndrome is a sub-type of the other. The syndrome is characterized by extreme exhaustion of either gradual or rapid onset that has no alternative explanation and lasts for a minimum of 6 months. In other words, it cannot be attributed to physical exertion, any physical pathology or disease process and it not relieved through rest and/or sleep. Epidemiological estimates suggest the prevalence of CFS is between .2% and 2% in the general population. The most common age of onset is between 40 and 50 years; however, CFS has been noted in both children and teenagers. Women suffer from CFS more often than men at a rate of 2 to 3 times higher (Wyller 2007) . The exact cause of CFS remains unknown; however, recent research from the Whittemore Institute, examining the role of viruses in the precipitation of CFS holds promising information of not only explaining a cause for CFS but may lead to primary prevention protocols; however it is important to note that it is not yet empirically proven that XMRV causes CFS. The challenge for physicians is that many patients who meet the diagnostic criteria of CFS also meet the criteria set for fibromyalgia and vice versa. There is no diagnostic tool to differentiate the two syndromes. To further complicate matters, CFS symptoms also overlap with Lyme disease, infectious mononucleosis, hypothyroidism and Epstein – Barr virus (EBV).
At this time, there are no known diagnostics tests for CFS and treatment options include focusing on modifiable lifestyle factors such as diet, exercise and stress management along with some alternative or complementary therapies such as acupuncture and massage therapy. Additionally, some pharmacological agents such as antidepressants, anti-inflammatory medication and basic analgesics have shown some benefit to patients managing their CFS symptoms and improving their quality of life (van’t Leven et al. 2009).
Irritable Bowel Syndrome
Irritable Bowel Syndrome (IBS) affects between 10% and 20% of the population in the United States and Europe, more often females than males along and can affect all ages (Longstreth et al. 2006). IBS is classified as a chronic disorder where individuals suffer with mild to severe abdominal pain in conjunction with problems associated with bowel function. Other symptoms include constipation, diarrhea, nausea, vomiting and bloating. The exact cause of IBS is unknown but can be initiated by emotional characteristics, a bacterial or parasitic event, certain foods and in some cases inflammatory bowel disease (Kellow et al. 2006). IBS is treated by focusing on the predominated symptom and frequently involves both pharmacological agents such as tricyclic antidepressants and psychological treatments to manage both anxiety and depression, which may exacerbate symptoms. It is important to rule of differential diagnoses such as inflammatory bowel disease or celiac disease through a combination of laboratory testing and physical examination (R Spiller et al. 2007).
Systemic Lupus Erythematosus
Lastly, systemic lupus erythematosus (SLE) can also exist with fibromyalgia. SLE is the acronym given to systemic lupus erythematosus, an autoimmune disorder which presents as a skin rash or arthritis. The most commonly occurring symptoms are extreme fatigue, rash and musculoskeletal symptoms. SLE can be triggered by an infection. There are various types of lupus and SLE is the most the form people are familiar with among this group of autoimmune disorders. SLE manifests when the body’s own immune system attacks its own healthy cells as if they were a foreign invader, producing autoantibodies of which the most common is antinuclear antibody (ANA). The long term effects of SLE include damage to major organ systems such as the kidney, heart, lungs and brain. Although it is found among all populations in the world, there is a higher prevalence in those of Asian and African descent. SLE is more common among women and frequently occurs between ages of 15 to 45. (Bertsias et al. 2008). The symptomology of SLE can vary over time with periods of remission and commonly occurring symptoms are: skin rash, fever, joint problems, fatigue (most frequently occurring), cognitive difficulties, swollen glands, chest pain, seizures and depression. Despite the definitive cause of SLE remaining unknown, it is conceived of as multi-factorial in nature; SLE tends to run in families thus, either a genetic cause or predisposition is a common hypothesis.
There is no cure for SLE; however, in recent years, earlier diagnosis, pharmacological intervention and self-management have reduced the mortality and morbidity of this disorder notwithstanding the serious complications that can arise from SLE such as cardiac disease (R. Cervera 2006). Furthermore, the diagnostic investigation must consist of ruling out other diseases such as rheumatoid arthritis, systemic sclerosis, Lyme disease along with other infectious diseases such as CMV and infectious mononucleosis to highlight a few.
Most individuals with SLE are treated by a multidisciplinary team of health care professionals made up of a family physician, nurse, rheumatologist, social worker, dermatologist, nephrologists and neurologist. Various pharmacological agents employed to relieve the symptoms of SLE and the more common approaches include: NSAID’s, antirheumatic drugs, corticosteroids and immunosuppresants. New and emerging treatments for SLE are incorporating the use of antibodies (Vigna-Perez et al. 2006).