Fibromyalgia

Fibromyalgia is a complex disorder characterized by diffuse musculoskeletal pain, the presence of specific painful points, insomnia, depression, a feeling of fatigue and stiffness. This disease is difficult to diagnose due to pain throughout the body. Statistically, the disease affects about 4% of the population. Such patients do not live their usual life, since its quality is significantly reduced. These are mostly middle-aged women.

If you don't know what fibromyalgia is or how to treat it, but the symptoms you are experiencing are similar to those described in this article, contact the CELT Pain Clinic. Treatment of fibromyalgia in Moscow is one of our areas of activity, and in it we have achieved significant success.

Causes

The reasons why fibromyalgia occurs are currently not clearly established. Previously, this disease was classified as inflammatory or psychiatric, but modern research has revealed that there is no reason to say this: inflammatory processes have not been detected in fibromyalgia, and depressive states can appear as a result of it.

Modern research has revealed increased levels of neurotransmitter and nerve growth factor in the cerebrospinal fluid of patients who suffer from this disease. In addition, there are prerequisites to assume that they have hypersensitivity of the central nervous system and impaired pain perception.

At CELT you can get advice from a specialist algologist.

Fibromyalgia is a disease that comes to the attention of not only rheumatologists, neurologists, pain specialists, but also general practitioners.
Fibromyalgia is a fairly common disease, affecting about 20 million people worldwide (about 4% of the population), mostly middle-aged women. However, despite its prevalence, the diagnosis of fibromyalgia in the world, particularly in Russia, is extremely rare. This is due to unusual manifestations of the disease, insufficient awareness of doctors and the lack of clear diagnostic criteria. Fibromyalgia is understood as a syndrome of non-articular widespread symmetrical musculoskeletal pain, which is chronic in nature and accompanied by depression, sleep disturbances and the presence of specific tender points. In neurological practice, this is also a fairly common pathology. Nevertheless, there is a paradoxical situation in which the actual diagnosis of fibromyalgia, even syndromic, is, in principle, absent in the daily practice of medical specialists. The reason for this, on the one hand, most likely lies in the variety of clinical manifestations of fibromyalgia. Neurologists most often evaluate such patients in accordance with the leading comorbid manifestations (“panic attacks”, tension headaches, widespread osteochondrosis, myofascial syndrome, osteoarthritis, etc.). On the other hand, the reason lies in the underestimation of the significance of mental disorders and stress for these patients and the lack of generally established ideas and views on this symptom complex as a single suffering. Undoubtedly, such patients are also encountered in the practice of psychiatrists, who, however, do not diagnose patients with FM, since they do not subject the patient’s somatic state to a detailed analysis and do not examine their sensitive points.

Story

Although the term “fibromyalgia” was coined relatively recently, this condition has long been described in the scientific literature. In 1904, William Gowers coined the term fibrositis. The modern concept of fibromyalgia was created by Smythe and Moldofsky in the mid-1970s. They coined a new term, fibromyalgia. The authors identified the presence of local hypersensitivity, so-called “tender points,” as a characteristic symptom of fibromyalgia. They also found that patients with fibromyalgia often experience sleep disturbances. The next stage in fibromyalgia research was the development of the American College of Rheumatology (ACR) diagnostic criteria for fibromyalgia, which were published in 1990. Significant progress in the study of fibromyalgia has been made after researchers concluded that the condition is not caused by damage or inflammation of peripheral tissues. Therefore, all efforts were aimed at studying the central mechanisms of pathogenesis.

Etiology and pathogenesis

One of the most important mechanisms for the formation of chronic pain in fibromyalgia is the phenomenon of central sensitization (CS). It is characterized by the fact that after prolonged peripheral nociceptive stimulation, a certain level of excitation remains in the central sensory neurons of the dorsal horn, which maintains pain even in the absence of further peripheral pathology. However, numerous studies have demonstrated that CS can develop in the presence of disorders in the central nervous system without peripheral damage. Fibromyalgia is such an example. Often, patients with fibromyalgia who do not show peripheral changes are considered by doctors as malingerers or patients with hysteria. Some doctors, in situations where they cannot find an organic cause of pain, prefer to use diagnostic labels such as psychosomatic and somatoform disorders. However, today it has been convincingly shown that central sesitization, as well as impaired descending (noradrenergic and serotonergic) inhibitory control of pain, occur in fibromyalgia not as a result of peripheral changes in muscles, fascia, ligaments or connective tissue, but as a result of neurodynamic disorders in the central nervous system in individuals with a genetic predisposition under the influence of a large number of stressful (physical and mental) events. Research into fibromyalgia over the past two decades has shown that the pain threshold depends on the degree of distress. Many psychological factors, such as hypervigilance, suspiciousness, catastrophizing, and external locus of pain control, may play an important role in the severity of fibromyalgia symptoms. Special studies have shown that patients with fibromyalgia have reduced serotonergic and noradrenergic activity. It has also been found that patients with fibromyalgia have decreased levels of serum serotonin and its precursor L-tryptophan. This evidence is supported by the fact that drugs that simultaneously increase serotonin and norepinephrine levels (tricyclic antidepressants, duloxetine, milnacipram and tramadol) are effective in treating fibromyalgia.

The main symptoms of fibromyalgia are pain (100%), stiffness (77%) and fatigue (81.4%). The onset of fibromyalgia in most patients is gradual. The onset of the disease is often associated with emotional factors, stress, changes in the family, injuries, surgical interventions, etc. The most common symptoms of fibromyalgia are pain, which worsens in a state of fatigue, tension, excessive physical activity, immobility and cold. The pain is usually bilateral and symmetrical. Pain and stiffness in the head and neck area are typical in the morning. Complaints of calf muscle cramps, paresthesia and sensations of fullness in the upper and lower extremities are quite common. Fatigue is one of the most common complaints. Often the patient wakes up more tired than before going to bed.

American College of Rheumatology criteria for fibromyalgia (N. Smyth, M. Yunus, 1990):

The presence of generalized symmetrical pain (spreading to the right and left, upper and lower halves of the body, or axial), lasting for at least the last 3 months.
Pain on palpation of at least 11 out of 18 (9 pairs) specific tender points.

The following points are used:

occipital region - place of attachment of m. suboccipitalis;
neck region - anterior sections of the space between the transverse processes CV - CVII;
trapezius muscle - middle of the upper edge;
supraspinatus muscle at its insertion;
the zone of articulation of the second rib with the sternum along its upper edge;
a point located 2 cm distal to the lateral epicondyle of the humerus;
in the gluteal region - the upper outer quadrant of the buttock along the anterior edge of the muscle;
greater trochanter of the femur;
in the area of the knee joint there is a medial fat pad.

The pressure applied at these points should be 4 kg/cm, the pressure at which the examiner's nail beds turn white. When palpating 18 painful points, it is recommended to apply even pressure on paired points and, with the same force, palpate other areas of the body to compare sensitivity. Patients with fibromyalgia experience increased sensitivity in tender spots compared to other areas of the body. Painful points reflect areas of increased sensitivity to painful stimuli, and are not a consequence of local inflammation or tissue damage. In addition, it is necessary to determine pain sensitivity at control points (in the frontal, above the head of the fibula).

The presence of a positive reaction in more than 11 of 18 painful points was determined by the diagnostic criterion based on the analysis of statistical data from large populations of patients. However, not all patients with fibromyalgia will have increased sensitivity in more than 11 points. Once again, we note that the ACR criteria for fibromyalgia are intended for research purposes and not for making diagnoses for specific patients. However, examination of tender points is considered an important part of studying the functioning of the musculoskeletal system in patients with generalized pain syndrome. Palpation of soft tissues and joints allows you to identify areas of increased sensitivity. This examination allows you to exclude synovitis or myositis and is very important in the diagnosis of fibromyalgia. Along with the described most characteristic complaints of pain, fatigue and stiffness, patients with fibromyalgia have a whole symptom complex of psychovegetative, psychosomatic and various algic disorders, which occur in FM several times more often than in the population. The high association with FM allows us to consider them as comorbid. The most common among them are the following: “panic attacks”, hyperventilation syndrome, tension headaches, migraines, lipothymic conditions, irritable bowel syndrome, cardialgia, abdominalgia, Raynaud’s syndrome. It should be emphasized that in one patient, as a rule, one can detect a whole symptom complex of the mentioned disorders, the dominance of which in the clinical picture often makes it difficult to identify “fibromyalgic phenomena proper,” which is reflected in the interpretation of these patients and, as a consequence, in the leading diagnosis (tension headaches). , chronic myofascial syndrome, etc.). Recently, the FiRST (Fibromyalgia Rapid Screening Tool) questionnaire has been proposed to screen for fibromyalgia (Table 3). The advantages of the questionnaire are its brevity and ease of completion. It should be emphasized its high sensitivity (90.5%) and specificity (85.7%). It is important to note that the questionnaire is intended for screening and a diagnosis cannot be made using it alone. Patients who score 5 or more on the FiRST questionnaire should be carefully evaluated to make a definitive diagnosis of fibromyalgia.

FiRST questionnaire for screening for fibromyalgia

Yes	No
I have pain all over my body
Pain combined with a constant feeling of exhaustion
The pain is like a burning sensation, electric shock, or cramping
The pain is combined with other unusual sensations throughout the body such as pins and needles, tingling, and numbness.
The pain is combined with other disorders (problems with digestion, urination, headaches, sleep disorders, depression)
The pain greatly affects my life, especially my sleep and ability to concentrate, I’m kind of slow

Fibromyalgia Treatment

The presence of pronounced psychological disorders dictates the need to include antidepressants in the treatment of fibromyalgia. The most commonly used are amitriptyline and melipramine at a dose of 10-25 mg 1 time per night. The course of treatment is 4-6 weeks. Fluoxetine is prescribed 20 mg 1 time in the morning. Non-steroidal anti-inflammatory drugs have found widespread use in the treatment of fibromyalgia. Long-term oral administration of non-steroidal anti-inflammatory drugs is undesirable due to possible side effects. Recently, preference has been given to local therapy in the form of ointments, gels, as well as local injections in combination with painkillers, in particular lidocaine. In a recent RCT of patients with fibromyalgia, lidocaine 50 mg was injected into a painful point in the trapezius muscle. As a result, not only a local reduction in pain at the injection site was noticed, but also a general analgesic effect. This study demonstrated the important role of peripheral tissues in the development of hyperalgesia in fibromyalgia and demonstrated the clinical utility of local anesthetic injections for the management of pain in fibromyalgia. It is considered appropriate to include so-called local muscle relaxants: baclofen at a dose of 15-30 mg per day or dantrolene at a dose of 25-75 mg per day help reduce muscle tone and have an analgesic effect. There are reports of the effectiveness of antioxidants (ascorbic acid, alpha-tocopherol) in the treatment of fibromyalgia. Among non-drug treatments, various physiotherapeutic procedures are widely used, in particular massage, balneotherapy, and cryotherapy. In recent years, much attention has been paid to physical exercise, namely aerobics, as an effective way to eliminate chronic muscle pain and fatigue. Importance is also attached to methods of psychological rehabilitation of patients with fibromyalgia - psychotherapy and autogenic training.

Symptoms of fibromyalgia

Manifestations of fibromyalgia include the following:

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More details

widespread pain throughout the body, often symmetrical;
sleep disturbances, lack of feeling of freshness after recovery;
feeling of stiffness in the morning;
changes in body temperature;
the occurrence of cramps and spasms;
difficulties with concentration and memory;
mental disorders, sudden changes in mood.

Diagnostics

To prescribe the correct treatment and eliminate the consequences of the disease, the following diagnostic examinations are prescribed:

interviewing the patient to identify complaints;
characterization of neurological status with determination of cognitive function values;
study of trigger points;
laboratory examinations to exclude diseases of a rheumatic nature;
CT and MRI to exclude tumors, degenerative changes and other problems.

When making a diagnosis, we focus on several groups of parameters:

pain lasting more than 90 days, observed in 4 quadrants of the body;
palpation pain in 11 trigger points;
excessive fatigue;
sleep problems;
difficulty concentrating;
manifestation of stiffness in the morning;
depression and anxiety;
change in quality of life.

Diagnosis of fibromyalgia

If you don’t know which doctor to contact for fibromyalgia, come to the CELT Pain Clinic. We employ algologists who have extensive experience in treating various pain syndromes, including this disease. They will make a diagnosis and propose a treatment plan. If necessary, specialists from related specialties will be involved - neurologists and rheumatologists, immunologists, as well as psychotherapists and psychiatrists.

Unfortunately, to date, no special diagnostic methods have been developed that allow one to immediately diagnose fibromyalgia. Therefore, our specialists conduct a series of studies that allow us to exclude other diseases that are characterized by similar symptoms. For this purpose, laboratory tests are carried out, direction to determine:

glucose level;
red blood cell level;
rheumatoid factor;
erythrocyte sedimentation rate;
prolactin and calcium levels.