Fibromyalgia and Chronic Pain

Fibromyalgia and Chronic Pain

Chief Complaint

Chief complaint: Chronic widespread body pain and severe fatigue for 18 months.

History of Present Illness

• Insidious onset 18 months ago following a viral URI; progressive worsening over the past 6 months.
• Diffuse, bilateral aching and burning pain affecting the neck, shoulders, lower back, hips, and thighs; baseline severity 6/10, flares to 8/10.
• Profound daily fatigue, non-restorative sleep with frequent awakenings, and daily cognitive difficulties ("fibro fog" with impaired short-term memory and concentration).
• Aggravated by cold/damp weather, prolonged sitting, poor sleep, and emotional stress; mildly relieved by warm baths, heating pads, and gentle stretching.
• OTC paracetamol and ibuprofen provided minimal relief; massage therapy offered temporary benefit; trial of cyclobenzaprine 5 mg PO QHS discontinued due to daytime somnolence.

Past Medical History

• Irritable bowel syndrome (IBS-M), episodic migraine without aura.
• Chronic mechanical low back pain, temporomandibular joint dysfunction (TMJD).
• Generalized anxiety disorder (GAD) and mild depressive episodes.

Medications

• Paracetamol (acetaminophen, Tylenol®) 1,000 mg PO TID PRN, ibuprofen (Advil®) 400 mg PO BID PRN.
• Escitalopram (Cipralex®) 10 mg PO daily, sumatriptan (Imitrex®) 50 mg PO PRN for migraines.

Social History

• Elementary school teacher; currently working reduced hours (0.6 FTE) due to pain and exhaustion.
• Struggles with household chores, grocery shopping, and prolonged standing; reduced social engagement.
• High work-related stress; copes via mindfulness apps, reading, and support from spouse.

Family History

• Mother has fibromyalgia and hypothyroidism; maternal aunt has rheumatoid arthritis.

Review of Systems

• Diffuse myalgias and arthralgias without joint swelling or erythema; morning stiffness lasting 45 minutes.
• Subjective bilateral hand tingling (non-dermatomal); frequent tension-type headaches; no focal weakness.
• Low mood secondary to chronic pain, persistent worry about job security; no suicidal ideation.
• Alternating constipation and non-bloody diarrhea, intermittent abdominal bloating.
• Difficulty falling asleep (sleep latency > 60 minutes), awakens 3–4 times nightly, wakes feeling unrefreshed.

Physical Examination

• Alert, oriented, cooperative; appears fatigued; shifts position frequently in chair due to discomfort.
• BP 118/74 mmHg, HR 76 bpm, RR 14/min, Temp 36.7 °C, SpO2 99% on RA, BMI 24.2 kg/m².
• No joint effusions, synovitis, or deformities observed.
  • Positive tenderness at 14/18 classic tender points (bilateral occiput, trapezius, supraspinatus, gluteal, greater trochanter, lateral epicondyle, and medial fat pad of knee); widespread allodynia to light palpation.
  • Full active and passive ROM in all cervical, lumbar, and peripheral joints, though pain-limited at end ranges of cervical and lumbar spine.
  • 5/5 strength bilaterally in upper and lower extremities; give-way weakness noted secondary to pain.
• CN II–XII intact; sensation intact to light touch and pinprick throughout; DTRs 2+ and symmetric; gait normal.
• Mood is frustrated and anxious; affect is constricted but appropriate to situation.

Diagnostic Criteria for Fibromyalgia

• WPI score: 13/19.
• SS scale score: 9/12 (Fatigue: 3, Waking unrefreshed: 3, Cognitive symptoms: 2, Somatic symptoms: 1).

Investigations

• Results from 10/03/2025: CBC normal (Hb 134 g/L, WBC 6.2 x 10^9/L), ESR 8 mm/hr, CRP 1.2 mg/L, TSH 2.1 mIU/L, ferritin 58 ug/L, vitamin D (25-OH) 78 nmol/L, ANA negative, RF negative, CK 85 U/L.
• Cervical and lumbar spine X-rays (12/01/2025): Mild multilevel degenerative disc disease at C5–C6 and L4–L5; no acute pathology or spondyloarthropathy.

Assessment

• Fibromyalgia (meets ACR diagnostic criteria with WPI ≥ 7 and SS ≥ 5, symptoms > 3 months, other disorders excluded).
• Generalized anxiety disorder, irritable bowel syndrome, chronic migraine, and sleep maintenance insomnia.

Treatment Plan

• Initiate targeted pharmacotherapy for central sensitization and neuropathic pain modulation; advise tapering off ineffective OTC NSAIDs.
  • Start pregabalin (Lyrica®) 25 mg PO QHS for 1 week, then titrate to 50 mg PO QHS as tolerated.
  • Cross-taper escitalopram to duloxetine (Cymbalta®) 30 mg PO daily for 2 weeks, then increase to 60 mg PO daily to address both chronic pain and GAD.
  • Trial melatonin 3 mg PO QHS alongside strict sleep hygiene; pregabalin expected to concurrently aid sleep architecture.
• Multimodal non-pharmacological management emphasized as core therapy.
  • Refer to community physiotherapy for gentle myofascial release, pacing education, and posture mechanics.
  • Recommend low-impact graded aerobic exercise: warm-water aquafit or walking 15 minutes 3x/week, increasing duration by 10% every 2 weeks.
  • Refer to provincial virtual CBT for chronic pain and insomnia (CBT-I) programme.
  • Encourage daily 15-minute mindfulness meditation, progressive muscle relaxation, and activity pacing (avoiding "boom-bust" cycles).
• Discussed pathophysiology of central sensitization; reassured patient that pain is real but not indicative of progressive tissue or joint damage; provided Arthritis Society Canada fibromyalgia educational resources.
• Refer to multidisciplinary Chronic Pain Management Clinic for comprehensive group education and occupational therapy assessment.

Follow-up

• Return to clinic in 4 weeks (scheduled for 22/04/2025 at 10:30).
• Assess tolerability and efficacy of duloxetine and pregabalin titration, review sleep diary, and evaluate progress with graded exercise programme.