Fibromyalgia - muscle pain in the back without trigger zones

Fibromyalgia syndrome is characterized by widespread musculoskeletal pain and increased tenderness in multiple areas called "tender points." It has recently been identified as a distinct clinical entity and can be accurately diagnosed based on its characteristic features.

The prevalence of fibromyalgia syndrome, according to KP White et al. (1999), is 3.3% (4.9% of the female population and 1.6% of the male population). Most patients are women (85 - 90%) aged 40 to 60 years. According to the FDA, in the United States of America, fibromyalgia syndrome affects 3 to 6 million people. Among the symptoms, in addition to widespread pain and a feeling of stiffness, the following are noted:

Symptoms	Frequency of occurrence (average %)
Musculoskeletal:
Pain in many places	100
Feeling of stiffness	78
"Sickness is everywhere"	64
Feeling of swelling of soft tissues	47
Non-musculoskeletal:
Mainly daytime fatigue	86
Morning fatigue	78
Sleep disorders (insomnia)	65
Paresthesia	54
Associated symptoms:
Self-defined anxiety	62
Headache	53
Dysmenorrhea	43
Irritable bowel syndrome	40
Restless Legs Syndrome	31
Self-defined depression	34
Dry symptoms	15
Raynaud's phenomenon	13
Female urethral syndrome	12

The pain is described by patients as being present "everywhere", including all limbs, the spine and chest wall. Increased fatigue during the day is often the leading symptom in almost 90% of patients, the same number complain of morning fatigue, which indicates poor sleep quality. Although there is a feeling of swelling and numbness, there are no objective signs of this.

Symptoms are often aggravated by fatigue, injury, physical exertion, cold and damp weather, lack of sleep, and mental fatigue. However, regular exercise, warm and dry weather, adequate sleep, daily walks, and mental relaxation improve the condition of many patients.

An objective examination does not reveal visible swelling of the joint or neurological symptoms. However, the joints may be sensitive to palpation, and movements in them are moderately limited due to pain. The most characteristic symptom of fibromyalgia is the presence of sensitive points of a certain localization.

Palpation of sensitive points is performed with a force of about 4 kg. It is optimal to use a tensalgimeter for this purpose. If one is not available, the impact is exerted with the force necessary to make the nail turn white (as when pressing on a hard surface). Palpation is performed with the tip of one of the first three fingers, at the discretion of the examiner. First, a soft impact (pressure) is exerted on the back of the forearm (so that the patient feels only pressure), then an intense impact is produced in the projection of the lateral epicondyle of the humerus until pain occurs so that the patient can differentiate pressure and pain. The criterion for detecting a sensitive point is moderate or severe pain experienced by the patient at the palpation site. Although palpation of 18 points can be limited to making a diagnosis, it should be remembered that a patient with fibromyalgia may be sensitive to pressure in many other areas, including articular and periarticular tissues. A small number of patients may have pain throughout, even to the touch.

The American College of Rheumatology criteria for diagnosing fibromyalgia are based on the presence of widespread pain and the presence of 11 tender points out of 18 tested.

American College of Rheumatology criteria for the diagnosis of fibromyalgia

Symptoms	Explanations
History of widespread pain	Pain in the left and right halves of the body, pain above and below the waist is considered to be widespread. Also, axial pain (cervical spine or anterior chest or thoracic spine or low back pain).
Pain in at least 11 of 18 tender points on digital palpation	Pain on digital palpation should be present in at least 11 of the following 18 tender points: Occipital: at the attachment points of the suboccipital muscles on each side Lower cervical region: on the anterior side of the intertransverse spaces 5, 6, 7 cervical vertebrae on each side Trapezius muscle: in the middle of the upper border on each side Supraspinatus muscle: at its insertion, above the scapular spine at the medial border on each side Second rib: in the region of the second costochondral junction, immediately lateral to this junction on the superior surface on each side Lateral epicondyle of the humerus: 2 cm distal to the epicondyle on each side Buttock: in the upper outer quadrant in the anterior muscle fold on each side Greater trochanter: behind the trochanteric protrusion on each side Knee: in the area of the medial fat pad, proximal to the joint line on each side

Widespread pain must be present for at least 3 months. Digital palpation should be performed with moderate force of approximately 4 kg. For a tender point to be considered “positive,” the patient must consider the palpation to be painful. The tender point should not be considered painful.

The co-existence of other rheumatologic diseases with fibromyalgia is not uncommon and does not exclude it. Fibromyalgia is not secondary to these diseases, as satisfactory treatment of the co-existing disease (such as rheumatoid arthritis or hypothyroidism) does not significantly alter the symptoms or the number of tender points present in fibromyalgia. Some patients may not have 11 tender points or widespread pain as a defining criterion, but may have other characteristic features of fibromyalgia. These patients should be treated as having fibromyalgia.

The absence of muscle pathology and evidence of global hyperalgesia in fibromyalgia are explained by pathology of central nociceptive structures, including abnormal processing of sensory information.

It is not difficult to diagnose fibromyalgia using the American College of Rheumatology criteria. It is important to remember that similar symptoms can occur in other diseases.

Differential diagnosis of fibromyalgia

Disease groups	Examples
Autoimmune/inflammatory diseases	Temporal arteritis, polymyositis, rheumatoid arthritis, systemic lupus erythematosus, dry syndrome, polymyalgia rheumatica
Diseases of the musculoskeletal system	Herniated disc, Arnold-Chiari syndrome, spinal stenosis, postural disorders, lower limb asymmetry, osteoarthritis, myogenic pain syndrome
Psychiatric illnesses	Situational stress, anxiety, depression. post-traumatic stress disorder
: Infectious diseases	Lyme disease, hepatitis C
Medicinal causes	Statins
Endocrine diseases	Hypothyroidism, hypoadrenal syndrome, hypopituitarism, vitamin D deficiency, hyperparathyroidism, mitochondrial diseases
Diseases of the nervous system	Multiple sclerosis, polyneuropathy
Sleep disorders	Non-restorative sleep, specific sleep disorders including periodic limb movements, sleep apnea, narcolepsy

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Tactics for managing patients with fibromyalgia

The management of patients with fibromyalgia is multimodal. The most important aspects are a positive and sympathetic attitude, which begins with the very first contact with the patient as he or she enters the examination room; firm confidence in the diagnosis; and patient education. Patient education includes an understandable explanation of the currently known physiological mechanisms, discussion of aggravating factors (e.g., insomnia, lack of physical activity, anxiety, mental stress, work factors, and regular use of the limb in monotonous work), and reassurance that the disease is not inflammatory or malignant. Experience has shown that the use of such a term as "mild disease" often offends the patient, who feels severe discomfort and constant pain. An understanding attitude should be demonstrated.

It is important to keep in mind psychological factors, especially for patients with obsessive-compulsive disorder, chronic stress or depression. Only a small proportion of patients need to consult a psychiatrist. The most effective has been a multidisciplinary approach, which includes cognitive behavioral therapy, physiotherapy, physical fitness exercises for all patients with various symptoms, regardless of their psychological state.

The positive and undeniable effect of regular physical activity (fitness program) has been proven. It should be remembered that patients with severe pain or fatigue need to start slowly with a few minutes and gradually increase the training time. Walking in the fresh air and, for some patients, swimming are more suitable forms of physical activity. A study of 24 patients with fibromyalgia and 48 controls showed that fibromyalgia is a risk factor for osteoporosis.

For patients with fibromyalgia, normalization of sleep is important, which is achieved by eliminating alcohol and caffeine-containing products before bedtime, using tricyclic antidepressants. Zolpidem at a dose of 5-10 mg before bedtime has a beneficial effect on sleep. Clonazepam at a dose of 0.5 mg in the evening or before bedtime is most appropriate for restless legs syndrome.

Non-pharmacological modalities, including biofeedback, hypnotherapy, and electroacupuncture, are also effective for fibromyalgia.

Pregabalin is approved by the FDA for the treatment of fibromyalgia. The recommendation is based on the results of a controlled, double-blind study of 1,800 patients taking pregabalin at a dose of 300-450 mg per day. The studies showed a reduction in pain after taking pregabalin, but the mechanism for this effect is unknown.

Medicines for the treatment of SFM (Podell RN, 2007)

Class/drug	Level of evidence
Tricyclic antidepressants Amnitriptine Cyclobenzapril	A A
Serotonin receptor antagonists subtype 3 (5HT3) Tropisetron Odanseterone	A IN
NMDA receptor antagonists Ketamine (for intravenous administration) Dextromethorphan	A WITH
Growth hormone analogues Injectable growth hormone Pyridostigmine	IN IN
Norepinephrine/serotonin reuptake inhibitors Duloxetine Milnacipran Venflaxin	IN IN WITH
Anticonvulsants/GABA agonists Pregabalin Gabapentin Sodium oxybutyrate	IN WITH IN
Opioids Tramadol Narcotic analgesics	IN WITH
Anesthetics Lidocaine (intravenous)	IN
Serotonin reuptake inhibitors	IN
Nonsteroidal anti-inflammatory drugs and COX-2 inhibitors	WITH
Dopamine agonists Pramipexole Bupropion	IN WITH
Acetaminophen/Tylenol	WITH
Drugs for the treatment of spasticity Tizanidine Baclofen	WITH WITH

Local injection of tender points with 1% lidocaine about 0.75 ml or a mixture of 1% lidocaine (0.05 ml) and triamcinolone diacetate (0J25 ml) is often effective as an adjunctive therapy. A limited number (1 to 4) of the most symptomatic sites are injected slowly with a 27-gauge needle. The patient is asked not to put any weight on the injected sites for 24-48 hours. They are also advised to apply ice for several hours to avoid post-injection inflammation.

Treatment of patients with fibromyalgia is a labor-intensive art and requires an individual approach. During the entire course of therapy, if the effect is unsatisfactory, it is advisable to vary the doses of drugs, their combinations with non-drug methods in order to develop an individual treatment regimen for each patient.

Skin trigger points

Skin trigger zones have been known for a long time and have been used for segmental diagnostics and treatment in acupuncture. In the area of skin trigger zones, changes in the morphological, electrical and mechanical characteristics of the skin occur. Empirically, mechanotherapy methods (massage, pressure), temperature effects, acupuncture, destructive methods (dissection) have been determined as effective for eliminating skin trigger zones. Modern manual medicine devotes significant space to diagnostics and treatment of skin trigger zones, putting mechanotherapy methods (rolling, bending, stretching) at the forefront.

The results of our studies showed that cutaneous trigger zones may have signs of primary and secondary hyperalgesia. Changes occurring in cutaneous trigger zones cause dysfunction of the mechanoreception apparatus, namely, Pacinian corpuscles. This is probably explained by morphological changes that can be determined visually in the clinic (change in turgor, mottling). In primary hyperalgesia, there are more pronounced functional disorders of the mechanoreception apparatus.

Treatment of skin trigger zones is possible by manual medicine methods called "stretching" and "stretching" methods. They are well described by A. Kobesova and K. Levit (2000). The doctor stretches the skin trigger zones to the first threshold of resistance and holds it with this force, waiting for tissue relaxation. The method is highly effective, but requires a significant investment of time up to 10 minutes per skin trigger zone and repeated sessions.

The method of irrigation with a cooling agent proposed by J.Trawell, D.Simons also helps to reduce skin trigger zones, but it is labor-intensive, since after irrigation with a cooling agent it is necessary to apply a hot wet compress, as well as conduct repeated treatment sessions.

High efficiency of treatment of skin trigger zones with minimal time expenditure can be achieved by using a transdermal therapeutic system with 5% lidocaine gel. The great A.V. Vishnevsky wrote about the positive effect of local anesthetics (novocaine). Currently, the polymodality of the positive effect of local anesthetics is confirmed.

Manual treatment methods should be considered highly expensive in terms of time spent per patient. An alternative may be the use of local anesthetics in the form of gel or ointment.