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By Nathan Wei
Fibromyalgia is a multisystem disease characterized by various and diffuse symptoms including sleep disturbance, fatigue, headache, dizziness, reduction in short term memory, hypersensitivity to environmental stimuli, morning stiffness, irritable bowel and irritable bladder, numbness and tingling, premenstrual syndrome, restless leg syndrome, temporomandibular joint pain, noncardiac chest pain, Raynaud’s phenomenon, sicca syndrome, and anxiety.
Prevalence in the United States is 3.4% in women and 0.5% in men, with increasing prevalence to age 80 years and women being affected 10 times more frequently than men and familial clustering suggesting a genetic etiology.
It is chronic and, because the symptoms do not follow strict anatomic pathways, is often misdiagnosed and poorly treated.
Functional MRI studies have demonstrated that the brains of patients with fibromyalgia react differently to pain stimuli than the brains of patients without fibromyalgia. Thus, the problem appears to be that the brains of fibromyalgia patients have different functional, electrical, and chemical differences than the brains of people without the disorder. In other words, patients with fibromyalgia handle brain inputs and outputs of different stimuli in an abnormal fashion.
Triggers for symptoms include emotional stress, illness, surgery, and trauma.
Criteria for diagnosis of fibromyalgia were formulated by the American College of Rheumatology (ACR) in 1990. ACR criteria include 2 components: widespread pain above and below the waist including the axial skeleton and presence of 11 tender points among 18 specified points.
A careful history, physical examination, and laboratory testing are helpful in defining the diagnosis.
The Fibromyalgia Impact Questionnaire is a self-administered instrument that is useful in assessing functional abilities in daily life and outcomes of treatment.
Conditions that should be considered in the differential diagnosis of fibromyalgia include chronic fatigue syndrome, Lyme disease, rheumatoid arthritis, systemic lupus erythematosus, Sjogren’s disease, polymyalgia rheumatica, and hypothyroidism. Furthermore, these conditions may also be present in patients with fibromyalgia, which renders the diagnosis more difficult.
In recent years, recognition, understanding, and diagnosis of fibromyalgia have improved. It appears from multiple well controlled studies that a multidimensional approach is probably the most effective approach.
Specific treatment recommendations are:
— Patient education
— Cognitive behavioral therapy
— Non impact aerobic exercise
— Physical therapy may be beneficial for some patients.
— Drugs including tricyclic medications, selective serotonin reuptake inhibitors, selective serotonin and nor-epinephrine uptake inhibitors may alleviate pain and improve sleep quality and global well-being in patients with fibromyalgia.
— Cyclobenzaprine (Flexeril) at bedtime, may decrease pain and improve sleep quality in patients with fibromyalgia.
— GABA pathway drugs such as gabapentin (Neurontin) and pregabalin (Lyrica) are helpful for reducing pain.
— Nonnarcotic analgesics and mu antagonists such as tramadol (Ultram) may help with pain.
— Modafinil (Provigil) can help with fatigue. Low grade amphetamines such as phentermine can also help with fatigue but may aggravate hypertension.
Nonpharmacologic therapies with moderate evidence of effectiveness in fibromyalgia are balneotherapy, biofeedback, hypnotherapy, and strength training.
Evidence to support the use of chiropractic therapy, electrotherapy, manual and massage therapy, or ultrasound, in patients with fibromyalgia is weak, but worth trying in selected individuals.
Acupuncture has been used successfully. Serum levels of substance P and serotonin have been found to be significantly elevated after acupuncture treatment, suggesting possible mechanisms in pain relief. Although their effectiveness has not been proven by controlled trials, other treatment modalities employed include chiropractic therapy, yoga, Tai Chi, massage therapy, magnetic therapy, and tender-point injections.
Opioids (narcotics), as a rule, are not indicated in the management of fibromyalgia.
Conclusion: Fibromyalgia is a real disease manifested by abnormal sensory processing of environmental stimuli. It is quite clear that a multi-faceted approach to the management of this disorder is required for optimal response. The primary components should consist of patient education, cognitive behavioral therapy, non impact aerobic exercise, and individualized medications. The addition of alternative/complementary therapies should also be considered.
About the Author: Nathan Wei, MD FACP FACR is a Rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info:
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