FIBROMYALGIA Daily aches and Pains
Dr. Samir Elbadawy
Professor of Rheumatology & Immunology Cairo University
It was in 1842 that Balfour ( England) reported the association between tender points & rheumatism.
It was not until 1972, smythe was the first to describe the entity currently known as fibromyalgia.
In 1975, Moldofsky et al. stated the association between slow, paradoxical sleeping disorders and fibrositis. It was not until 1976 that Hench introduced the term "Fibromyalgia" .
Literally, fibromyalgia is a painful affliction of the muscle tissues.
It was a common form of chronic non-joint rheumatic pain which manifests itself by generalized pain and stiffness of the muscles and other soft tissues, as well as the presence of painful tender points sensitive to pressure in various characteristic areas.
The most common onset seems to be progressive and manifests itself in adults around the age of thirty.
Clinical picture :
1- Pain :
The complaint is essentially painful.
It consists of diffuse pain, or predominantly localized, but always persistent and resistant to treatment.
In its diffuse form, the pain affects the axial part of the body ( cervico - scapular and lumbar- gluteal regions) and peripheral articulations, often appearing to be the onset on inflammatory rheumatism, since there is often morning stiffness and a subjective impression of joint swelling.
Muscular fatigue is common and is accompanied by a sensation of " knotted muscles " .
Sensations of swelling, paresthesia or vasomotor disorders in the extremities are frequently reported.
2- Sleeping disorders:
Exists in almost all patients, but are only spontaneously reported in 25 % of cases. Sleep is described as being light, broken and non-restorative, with difficulty in waking.
Also frequent, recrudescent in the morning, but persistent throughout the day, making any activity difficult.
Common and more or less marked .
Frequent such as chronic colitis or irritable Bowel syndrome .
One third of the subjects suffering from irritable bowel syndrome fit the criteria of fibromyalgia. Inversely, a third of fibromyalgia patients describe the symptoms of irritable bowel syndrome.
6- Vasomotor disorders:
Are common: acrocyanosis resembling Ranayd's syndrome, acroparesthesia or Carpal tunnel syndrome, reticular livedo of the inferior members & blood pressure instability.
7- Cognitive disorders:
Fixation memory disorders and for some patients, the speed of treating information have been noted in many patients.
8- Restless Legs syndrome:
This occurs especially nocturnal being reported in 31% to 41% of patients complaining of cramps.
American college of Rheumatology Fibromyalgia Classification
1 Generalized pain:
Pain in 11 of the following 18 tender point sites on digital palplation:
= Occiput: bilateral, at the suboccipital muscle insertions.
= Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7 = Trapezius: bilateral, at the midpoint of upper border.
= Supraspinatus: bilateral, at origins, above the scapula spine near the medial border.
= Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces.
= Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.
Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
= Greater trochanter: bilateral, posterior to the trochjanteric prominence.
= Knee: bilateral, at the fat pad proximal to the joint line.
The clinical characteristics of Fibromyalgia include diffuse pain, with a lowered pain threshold with, as its principal manifestation, tender points, severe fatigue, musculoskeletal stiffness and sleep disorders, they are associated with an array of disorders which incorporate, among other things, paresthesia, headaches, anxiety, symptoms of depression and irritable colon .
Types of Fibromyalgia:
1- Primary Fibromyalgia:
The diagnosis of primary Fibromyalgia implies the presence of the clinical characteristics of Fibromyalgia with no recognizable cause .
2- Secondary Fibromyalgia:
The diagnosis of secondary Fibromyalgia is established when these characteristics appeared as being secondary to a known cause or disease, or that they were so intrinsically connected to other nosological entities that the manifestations of both seemed to be mutually mixed up and or when the treatment of the basic disease led to an improvement in the Fibromyalgia.
It was found that patients suffering from Rheumatoid Arthritis, Systemic Lupus Eryhtematosus as well as other chronic rheumatic diseases, Fibromyalgia can be seen in 20% to 35% of such cases.
Diagnosis of Fibromyalgia:
There are no clinical, lab., radiological or other examinations exist that can confirm or exclude the presence of Fibromyalgia.
Sedimentation rate, muscular enzymes, anti-nuclear antibodies, rheumatoid factors and thyroid hormones are not more frequently higher or positive than in normal control subjects whose sex and age have been determined by randomization.
The lack of objective signs and the absence of specific complementary diagnostic examinations make the subjective complaints of the patients fundamental for diagnosis.
1- Non-Pharmacological Treatments:
Regular physiotherapy can be of value as a line of treatment of Fibromyalgia:
It is valuable when used for relaxation as an analgesic.
= Other modalities:
Manual therapy, electrotherapy, the application of mud, infrared, ultrasound all have an analgesic effect. As with massage, its primary use is to prepare the patient for active physiotherapy.
b- Active physiotherapy:
= Aerobic exercise:
Physical exercise improves the subject's general physical condition, cardiorespiratory function and self confidence.
Aerobic exercise such as walking, cycling and dancing has a positive effect on Fibromyalgia patients as well as hydrotherapy are all beneficial to the patients.
In practice , stretching is a very useful means of reducing muscular spasms.
Thermal hydrophy siotherapy offers a number of advantages: the hot water relieves pain and muscular spasm, reduces joint strains and enables the patients to perform exercises that they would be unable to do out of the water
2- Pharmacological Treatment:
The possible impact of treatment aims at improving the following:
= Sleep disorders.
= Mood disorders.
= Associated symptoms.
a- Analgesics and anti-inflammatory drugs:
The benefits of Non-steroidal anti-inflammatory drugs seem limited, however, analgesics such as tramadol alone or in combination with acetaminophen seem to be helpful.
Tramadol is a central-acting analgesic that inhibits the reuptake of serotonin and noradrenaline while having an agonist action on the mu opioid receptors.
Pure morphinics are poorly tolerated and ineffective and have no place in the treatment of Fibromyalgia.
Are some of the most commonly used drugs in the treatment of fibromyalgia, however they most meet the following four requirements if prescribed over the long term:
1- It must not have any excessive undesirable effects so patients comply with the intake of the drug.
2- It must not lead to dependenc as a result of the "addictive appetite " frequently found in this type of patient 3- It must respect the sleep structure especially deep sleep which must be corrected in fibromyalgia patients.
4- It must be able to be prescribed in an effective dose, for a sufficient period of time.
In addition to inhibiting the reuptake of serotonin and noradrenaline, tricyclics act on glutamatergic neurotransmission via the histamine, acetylcholine, and N-methyl-d-aspartate (NMDA) pathways. They are effective in treating sleep, psain and asthenia.
The most frequently drug used is amitriptyline. The initial dose is 10 mg. at night when going to sleep, which can gradually be increased up to a maximum of 50 mg.
- Selective serotonin reuptake inhibitors:
These antidepressants have proven their efficacy in treating fibromyalgia patients and are better tolerated than tricyclic antidepressants. They inhibit the reuptake of serotonin without having any significant adrenergic activity.
They are recently introduced in the treatment of fibromyalgia patients. They act by blocking calcium and or sodium channels by increasing the the neurotransmission inhibitor.
They can be used in doses starting with 150 mg, 300 mg up to 450 mg daily. Many patients did show improvement in pain, positive effect on fatigue and the quality of sleep. Apart from drowsiness, tolerance seems relatively good