Introduction
Fibromyalgia
is a syndrome of chronic, diffuse musculoskeletal pain with associated
widespread, discrete tender points. Although fibromyalgia may be
confused with myofascial pain syndrome, considerable differences exist.
Myofascial pain is often discrete in nature, whereas fibromyalgia is
widespread. Myofascial Pain Syndrome is characterized by trigger points
with distinctive referral pain patterns, which are often not seen with
fibromyalgia. Myofascial Pain Syndrome most frequently arises from
trauma or repetitive-type injuries, in contrast to fibromyalgia which
has no history of trauma or inciting event. Fibromyalgia patients may
have associated fatigue, non-restorative sleep and widespread
stiffness.
Most studies of patients with fibromyalgia have not
shown any discrete pathology in muscle tissue. Some studies have
demonstrated decreased muscle blood flow and oxygenation in
fibromyalgia patients, probably caused by deficiencies in the
microcirculation.
Some authors contend that fibromyalgia is
primarily psychologic in origin. The symptoms of fibro-myalgia reflect
problems in coping with environmental stresses, which secondarily
produce sleep disturbance, fatigue, a low level of physical activity
and poor physical fitness. This makes the patient susceptible to muscle
pain and tenderness, which produces a vicious cycle. Most practitioners
who deal with fibromyalgia patients do not appear ready to place this
condition into the category of somatoform disorders.
Clinical Presentation
Fibromyalgia
is diagnosed by clinical signs and symptoms. No laboratory tests or
radiologic exams are specific for the disorder. The most widely used
criteria for the diagnosis of fibromyalgia were developed by The
American College of Rheumatology in 1990. These criteria include
widespread, chronic pain and the presence of 11 of 18 standardized
tender points on physical examination.
The typical
fibromyalgic patient has multiple somatic complaints. Pain is often
migratory in nature. Fatigue and sleep disturbances should be
considered hallmarks of fibromyalgia. A thorough history, physical
examination, appropriate laboratory testing and radiologic examination
should be performed to rule out other organic causes prior to the
diagnosis of fibromyalgia.
Treatment
Physical
Therapy: This is an essential component of the treatment of any patient
with fibromyalgia. Physical therapy (PT) is often rejected by the
patient with this disorder. Patients need to understand that PT may
flare their pain initially, but it is essential to prevent the patient
from becoming further deconditioned. While strengthening and
conditioning are the most important components of PT, other modalities
such as massage, ultrasound and electrical stimulation of muscles may
offer benefits.
Medical Psychology: Patients with fibromyalgia
often lack understanding of the disease process and have nonexistent
coping strategies. Many patients do not understand the role that
depression, anxiety, sleep disturbances, secondary weight gain and a
dysfunctional home environment may play in the perpetuation of
symptoms.
Medical Management: The management of this disorder
has frustrated many physicians. Rarely can a "cure" be achieved.
Therefore, control of symptoms often becomes a major strategy with
these patients. Trigger point injections typically are ineffective for
several reasons. Most of these patients exhibit "tender points" not
true trigger points. Additionally, the diffuse and widespread nature of
the condition does not lend itself to injection therapy.
Nonsteroidal
anti-inflammatory drugs (NSAIDs) may be useful in this population,
although the exact inflammatory nature of fibromyalgia has not been
established. Care should be exercised when prescribing NSAIDs due to
the multiple side effects that have been reported, including GI
irritation and renal toxicity.
Muscle relaxants may be
beneficial. These medications have a central site of action and may
demonstrate significant sedation as a side effect. Flexeril
(cyclobenzaprine) has been shown in several studies to cause a
significant improvement in symptoms.
Antidepressant drugs have
been a mainstay of therapy for this disorder. Multiple antidepressants
are available, but Elavil seems to be the drug with the highest rate of
success. Fibromyalgia patients typically respond to lower doses than
those required for the anti-depressant effect, suggesting a different
mechanism. Due to the sometimes significant sedation seen with some of
the drugs, the time of dosing is usually bedtime. All patients with
fibromyalgia should undergo a trial of several of these medications.
Tramadol
is a medication that shows promise in fibromyalgia. It has analgesic
effect at the opioid receptor and also acts at the serotonin receptor.
This combination of effects may be particularly useful in the
fibromyalgic patient. Abuse of tramadol has been very low, allowing
this drug to be introduced as a non-scheduled medication.
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