Fibromyalgia

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Fibromyalgia (FM) is a common musculoskeletal syndrome characterized by generalized pain, fatigue, and a number of associated symptoms. The condition has formerly been called fibrositis and psychogenic rheumatism. The condition is confusing in that there is considerable overlap between FM symptoms and those of other conditions such as myofascial pain syndrome, temporomandibular joint syndrome, and chronic fatigue syndrome.

Diagnostic Criteria

The diagnosis of FM has been standardized through the use of specific accepted diagnostic criteria (Table 6.1, Fig. 6.1).

Epidemiology

At any given time, approximately 3% to 6% of the general population meet the criteria for diagnosis of FM.1 Studies also show that women more commonly meet the diagnostic criteria.2 The condition most commonly begins during the thirties or forties, although it may occur at any age. There is a familial aggregation of

Table 6.1. 1990 American College of Rheumatology Diagnostic Criteria for Fibromyalgia

1. History of widespread pain of at least 3 months' duration. This pain must be present in the axial skeleton as well as all four quadrants of the body.

2. Pain must be present in at least 11 of 18 of the following paired tender points on digital palpation.

a. Occiput: at the suboccipital muscle insertions b. Cervical: at the anterior aspects of the intertransverse spaces at C5-C7

c. Trapezius: at the midpoint of the upper border d. Supraspinatus: at the origins above the scapular spine near the medial border e. Second rib: at the second costochondral junctions f. Lateral epicondyle: 2 cm distal to the epicondyles g. Gluteal: in upper outer quadrants of buttocks in anterior fold of muscle h. Greater trochanter: posterior to trochanteric prominences i. Knees: at the medial fat pad proximal to the joint line

These points should be palpated with approximately 4 kg of pressure. For the tender point to be considered painful, the patient must state that it is painful and not merely tender.

Source: Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. 1990;33:160-72, with permission.

Tens Unit Placement Neck Pain
Fig. 6.1. Bilateral tender point locations in fibromyalgia are remarkably constant from patient to patient.

fibromyalgia, suggesting that there is a genetic predisposition to the condition.3

Clinical Features

Widespread pain and tenderness are the cardinal features of FM. Stiffness after being in one position for a prolonged period, including morning stiffness, is common. Frequently weather changes, emotional stress, unaccustomed physical activity, and menses worsen the symptoms. Although patients often report a sensation of swelling, there is usually no objective evidence of this on examination. People with FM may be more sensitive to pain throughout the body, not just in the areas of tender points. For example, it is common to see increased visceral pain in patients with FM, so associated syndromes and symptoms, such as irritable bowel syndrome, dysmenorrhea, mitral valve prolapse, interstitial cystitis, and migraine headaches are more common.1 One must also be aware that tender points are common sites for pain even in the general population, who have an average of 3.7 positive tender points.4 Pain perception is also influenced by a number of other factors including aerobic fitness, quality of sleep, and depression.5 Thus a condition based on pain sensation may encompass a number of other conditions.

Most patients with FM complain of fatigue (see Reference 33, Chapter 55), and many have poor-quality sleep (see Reference 33, Chapter 56). The relation between FM and sleep disturbance is not as clear as once thought.1 Improvement in FM symptoms with pharmacological treatment does not necessarily correlate with an improvement in sleep.6 FM patients also have a higher incidence of migraine and tension headaches than the general population1 (see Reference 33, Chapter 63). Approximately 84% of people with FM complain of numbness or tingling somewhere in the body.7 Echocardiography evidence of mitral valve prolapse is seen in up to 75% of FM patients.8 Patients with FM have a higher incidence of depression, and controversy remains as to whether FM symptoms are a manifestation of a psychosomatic syndrome, or, conversely, depression results from chronic pain (see Reference 33, Chapters 32 and 61).

Differential Diagnosis

Early rheumatoid arthritis (and other rheumatic conditions), polymyalgia rheumatica, and hypothyroidism are included in the differential diagnosis and can generally be excluded with an appropriate history and laboratory analysis. Infections, especially human immunodeficiency virus (HIV), hepatitis, and subacute bacterial endocarditis, can also present similarly to FM. Neoplastic conditions and endocrine problems may cause similar clinical presentations.

Diagnosis

Fibromyalgia can usually be reliably diagnosed by a typical history, physical examination consistent with the appropriate number of tender points, and appropriate laboratory studies. The laboratory evaluation, which should include a thyroid-stimulating hormone (TSH) assay, erythrocyte sedimentation rate (ESR), and an antinuclear antibody (ANA) test, helps to rule out other conditions but does not rule in FM.

Management

Patient Education. Important to the management of this condition is a thorough explanation of the condition. Patients have often seen many physicians while trying to "find a cure." It is often therapeutic for patients to find a physician who can provide them with a diagnosis. The Arthritis Foundation (1314 Spring Street NW, Atlanta, GA 30309) can provide additional information.

Behavior Modification. Modifying behavior often involves emphasis on activities that help to lessen symptoms. Patients often must be reminded that caffeine, especially near bedtime, may worsen an already poor sleep pattern. Helping patients to reframe their situation into one with less victimization, along with other cognitive therapy interventions, can also be useful. Directing the patient toward self-management of symptoms through relaxation training, meditation, or electromyographic (EMG) biofeedback can help control symptoms while shifting the locus of control back to the patient.

Medication. Amitriptyline (Elavil and others) and cyclobenzaprine (Flexeril) have been studied and found to be helpful for FM. They are both tricyclic compounds, although cyclobenzaprine does not have anti-depressant activities. Although it is generally acknowledged that these medicines are helpful, the mechanism of action is not clear. Low doses are recommended to start, and the doses can be slowly increased. The goal of therapy is to improve sleep and lessen symptoms but not cause a "hangover." The drugs are sometimes not well tolerated, usually due to anticholinergic side effects or vivid dreams. Zolpidem (Ambien) may be a reasonable alternative.1 If one is not able to control symptoms with the above medicines, the selective serotonin reuptake inhibitors offer another potential option. The nonsteroidal anti-inflammatory drugs (NSAIDs) are not usually highly effective in treating this condition.

Exercise. Because it is rare for patients to have lasting improvements without exercise,1 this modality should be emphasized in all cases.

Often these patients are deconditioned, and one must start at a low work load to avoid flaring symptoms. Water exercise classes, especially in heated pools, tend to be effective. Other exercises to consider include walking, riding stationary bicycles, and engaging in low-impact aerobics. Exercise programs that incorporate elements of muscle stretching, muscular endurance, and aerobic fitness tend to be most effective. Regardless of the specific exercise program, it must be approached slowly and consistently to produce optimal results.

Prognosis

Generally, FM patients have chronic symptoms, but their resulting disability is a function of their willingness to accept responsibility for managing these symptoms. A sense of helplessness is a strong negative predictor of outcome in FM patients.9 Only about 5% of FM patients have a complete remission.10 Patients may need to be guided away from costly and untested treatments. Patients should be counseled vocationally into returning to nonphysically demanding work. As with many other chronic conditions, the empathetic, optimistic physician's guidance and support can be therapeutic and help to empower FM patients to cope effectively with their conditions.

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