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    Fibromyalgia: Lars Grimm, MD, MHS May 15, 2014

    Fibromyalgia is a common and chronic disorder of unknown etiology characterized by widespread pain, abnormal pain processing, sleep disturbance, fatigue and, often, psychological distress, as well as other symptoms. Although fibromyalgia is often grouped with arthritis-related conditions, there is no inflammation or damage to the joints, muscles, or other tissues. Sources: (1) Centers for Disease Control and Prevention (CDC). Arthritis types: fibromyalgia. Available at: http://www.cdc.gov/arthritis/basics/fibromyalgia.htm. Accessed May 5, 2014; (2) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Fibromyalgia: questions and answers about fibromyalgia. Available at: http://www.niams.nih.gov/health_Info/Fi … ault.asp#k. Accessed May 5, 2014.

    There are limited data about the exact prevalence of fibromyalgia in the United States. The estimated prevalence is 2%, affecting roughly 5 million adults (age ?18 y), with women having a higher prevalence (3.4%) and incidence (80-90%) of this condition than men (0.5% and 10-20%, respectively). Fibromyalgia leads to approximately 5.5 million ambulatory care visits per year, at an average total annual cost (direct and indirect) of $5,945 per person. Direct medical costs among these patients primarily include office and emergency department visits, procedures and laboratory tests, and hospitalizations.

    The pain associated with fibromyalgia is typically described as radiating diffusely from the axial skeleton over large areas of the body, predominantly involving the muscles and joints. Patients also present with various additional complaints: Fatigue and poor sleep are nearly universal, and most patients with fibromyalgia also meet the classification for chronic fatigue syndrome. Cognitive problems, known as “fibro fog,” produce impairments in memory and thinking.

    There is a significant amount of overlap among chronic pain disorders, central sensitivity syndromes (eg, chronic fatigue syndrome, irritable bowel syndrome, posttraumatic stress disorder), and anxiety disorders. Many patients with fibromyalgia also suffer with concomitant systemic inflammatory illnesses (eg, rheumatoid arthritis, chronic hepatitis C, systemic lupus erythematosus). The diagnosis applied to a given patient is often the result of the type of specialist first seen by the patient. Patients with fibromyalgia typically suffer for many years—often exposed to unnecessary, expensive, and/or invasive procedures or medications—before being properly diagnosed. In fibromyalgia, however, patients have abnormal pain perception, which can be elicited by the application of pressure at 18 “tender points” (9 pairs) on the body, as designated by the American College of Rheumatology (ACR).

    The etiology of fibromyalgia is multifactorial and not completely understood, but a biopsychosocial model provides a useful framework for organization. A number of biological variables have been identified, including genetics, female sex, age, poor sleep, trauma, deconditioning, autonomic dysregulation, chronic infection, abnormal nociceptive processing, and stress. Identifiable psychological variables include hypervigilance, feelings of helplessness, poor coping strategies, depression, anxiety, certain personality traits and styles (ie, neuroticism, perfectionistic/compulsive), and excessive pain behaviors. Environmental and sociocultural variables associated with fibromyalgia include family support, job satisfaction, childhood abuse, and family members or friends with chronic pain.

    The pathophysiologic sequence of events that leads to the development of fibromyalgia is not well elucidated; however, a number of discrete cellular and biochemical abnormalities have been identified. The volume of abnormalities discovered in patients with fibromyalgia is enough to substantiate the claim that it is not a subjective pain condition. When viewed collectively, these abnormalities suggest that fibromyalgia is a disorder of central sensitization or abnormal central processing of nociceptive pain input.

    The 2010 ACR criteria are used to diagnose fibromyalgia. Patients must also undergo a thorough clinical and laboratory evaluation to identify alternative or coexisting diagnoses for chronic pain. Although no diagnostic laboratory tests currently exist for fibromyalgia, appropriate initial studies include a workup to rule out hypothyroidism (thyroid-stimulating hormone [TSH]), inflammatory myopathies (creatine phosphokinase [CPK]), polymyalgia rheumatica (erythrocyte sedimentation rate [ESR]), lupus (antinuclear antibody [ANA]), and chronic infections (complete blood count with differential). Depending on the constellation of presenting symptoms, sleep studies and joint fluid analysis may be helpful. The use of a dolorimeter can provide reproducible pressure measurements in the evaluation of fibromyalgia tender points. .

    Treatment for fibromyalgia is multifactorial and involves a multidisciplinary approach: psychological and behavioral therapy, physical therapy, and pharmacotherapy. Achieving a satisfactory clinical response is difficult, but combination therapy has proven to be more effective than monotherapy alone. Psychological and behavioral therapy includes aggressive depression treatment, cognitive-behavioral therapy, operant-behavioral therapy, relaxation training, sleep hygiene, coping skills, and distraction strategies. Sources: (1) CDC; (2) NIAMS; (3) PubMed Health. A.D.A.M. Medical Encyclopedia: fibromyalgia. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001463/. Accessed May 6, 2014.

    Exercise has been proven to provide both subjective and objective improvements in pain and overall sense of well-being. Deconditioning is a major contributing factor to pain. Graded aerobic activity with aerobics (shown), aquatherapy, or stationary bicycles can be transitioned to more rigorous endurance and strength training. Heat and massage provide symptomatic relief for many forms of chronic pain, including fibromyalgia. Trigger point injections, acupuncture, chiropractic manipulations, and myofascial release are not current evidence-based approaches to therapy. All therapeutic approaches should emphasize self-sufficiency in pain control, rather than reliance on others for symptomatic relief.

    See also: http://www.tnmgc.com/discus/viewtopic.php?f=8&t=355 posted on 16th April.

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