All that follows is from The challenges of chronic pain and fatigue.
In this review, we explore the challenges of chronic pain and fatigue in clinical practice. Both pain and fatigue are common, troubling and frequently overlapping symptoms, and we describe both the clinical burden and the ‘clinical problem’. We explore commonly associated symptoms and possible pathological associations, including variant connective tissue (joint hypermobility), small fibre neuropathy, mast cell activation, dysregulated inflammatory and interoceptive processes, which may inform treatment targets. We suggest a multidisciplinary management approach.KEYWORDS: pain, fatigue, fibromyalgia, hypermobility,, rheumatology
Clinical burden of chronic pain and fatigue
Further understanding of pain and fatigue is clinically important as they are among the most frequent symptoms reported by patients.1 When these symptoms are ‘persistent’ or ‘unexplained’ they are associated with poorer quality of life and higher costs than other patient groups.2 They also pose a diagnostic conundrum and have a significant impact on healthcare utilisation costs and significant indirect costs.3,4
Fibromyalgia is characterised by chronic pain, fatigue and what are described as functional symptoms.5 Myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) is a complex, chronic condition characterised by symptom clusters that include pathological fatigue and malaise that is worse after exertion, cognitive dysfunction, immune dysfunction, unrefreshing sleep, pain, autonomic dysfunction, neuroendocrine and immune symptoms.6
Chronic pain affects between one-third and one-half of the population of the UK, whereby fibromyalgia has a reported prevalence of 5%.7 In a population-based sample of middle-aged individuals, fatigue was present in one out of five subjects.8
Assigning a diagnosis of ME/CFS in the clinical setting often takes years. Many physicians are uninformed or misinformed about the disease.9 It has been estimated that 84–91% of patients affected by ME/CFS are not diagnosed with the condition.10 Fibromyalgia and ME/CFS are not uncommon in UK and represent a significant burden to patients and society. Diagnostic delay is significant in both conditions and there are significant difficulties with nosology and nomenclature; presence of shared symptoms has led it to be questioned as to whether fibromyalgia and ME/CFS are manifestations of the same spectrum disorder or separate clinical entities.11–14 In our recent study of a mixed group of patients with a clinical diagnosis of fibromyalgia and/or ME/CFS, diagnostic overlap between the two conditions was ∼90%.15
The real clinical problem
Physicians of all sorts receive referrals asking for advice on the management of patients with chronic pain and fatigue. Most requests go to rheumatologists, but neurology services are also in the frame, and, in the context of fatigue in particular, advice from colleagues in endocrine, infectious diseases and even cardiology or haematology clinics may be sought, depending often on associated symptoms and comorbidities, clinician preference and availability of appointments. There are huge variations in referral practices across the UK
So, what is the evidence for an association between chronic pain and fatigue, hypermobility and autonomic dysfunction? What else should we be considering in this type of patient?