Fibromyalgia - muscle pain in the back without trigger zones

The syndrome of fibromyalgia is characterized by widespread musculoskeletal pain and increased soreness in a multitude of sites called "sensitive points". Recently, it is divided into a separate clinical nosology, and can be accurately diagnosed on the basis of characteristic features.

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

Symptoms	Frequency of occurrence (averaged%)
Musculoskeletal:
Pain in many places	100
Feelings of stiffness	78
"Soreness everywhere"	64
Feeling of soft tissue edema	47
Not muscular-skeletal:
Mostly 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-Determined Depression	34
Dry symptoms	15
The Reynaud phenomenon	13
Female urethral syndrome	12

Pain is described by patients as 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 amount complains of morning fatigue, which indicates a low quality of sleep. Despite the presence of a feeling of swelling and numbness, there are no objective signs of this.

Symptoms are often aggravated by fatigue, trauma, physical exertion, cold and wet weather, lack of sleep and mental overwork. At the same time, regular exercise, warm and dry weather, full sleep, daily walks and mental relaxation improve the condition of many patients.

At an objective inspection the visible swelling of a joint or neurologic symptomatology is not revealed. But at a palpation joints can be sensitive, and movements in them are moderately limited because of a pain. The most characteristic symptom of fibromyalgia is the presence of sensitive points of a certain localization.

The palpation of the sensitive points is carried out with an effort of about 4 kg. Optimum for this purpose use a strain gage. In the absence of such, the effect is with the force necessary to make the nail white (as when pressing on a hard surface). Palpation is carried out with the tip of one of the first three fingers, at the investigator's discretion. At first, the soft impact (the press) is on the back surface of the forearm (so that the patient feels only pressure), then intensively affects the projection of the lateral epicondyle of the humerus until the pain appears so that the patient can differentiate the pressure and pain. The criterion for the detection of a sensitive point is the moderate or severe pain experienced by the patient at the place of palpation. Although the diagnosis can be limited to palpation of 18 points, it should be remembered that a patient with fibromyalgia may be sensitive to the press in many other areas, including articular and periarticular tissues. A small number of patients may have soreness everywhere, even at a touch.

The criteria of the American College of Rheumatology for diagnosis of fibromyalgia are based on the presence of widespread pain and the presence of 11 sensitive points from 18 subjects.

Criteria for the American College of Rheumatology for diagnosis of fibromyalgia

Symptoms	Explanations
Anamnestically detectable widespread pain	Widespread is considered pain, present in the left and right halves of the trunk, pain above and below the waist. In addition, axial pain (cervical spine or the front of the chest or thoracic spine or pain in the lower back).
Pain in at least 11 of 18 sensory points in finger palpation	Pain with finger palpation should be present in at least 11 of the following 18 sensory points: Nape: in the places of attachment of the suboccipital muscles on each side Lower-cervical region: on the front side of the intertransverse spaces 5, 6, 7 cervical vertebrae on each side Trapezius: in the middle of the upper border on each side Muscular muscle: at the point of attachment, above the scapular awn, at the medial edge on each side The second rib: in the region of the second costal cartilage joint, immediately lateral to this transition on the upper surface on each side Lateral epicondyle of shoulder: 2 cm distal to epicondyle on each side Buttock: in the upper-outer quadrant in the anterior muscular fold on each side Big spit: behind the spear on each side Knee: in the area of the medial fat pad, proximal to the joint line on each side

Widespread pain should be present for at least 3 months. Palpable palpation should be performed with a moderate strength of about 4 kg. For a sensitive point to be considered "positive", the patient should consider that the palpation was painful. The sensory point should not be considered painful.

Simultaneous presence of other rheumatological diseases with fibromyalgia is often found and does not exclude it. Fibromyalgia is not secondary to these diseases, since satisfactory treatment of a concomitant disease (such as rheumatoid arthritis or hypothyroidism) slightly alters the symptoms or the available number of sensitive fibromyalgia points. Some patients may not have 11 sensitive points or widespread pain as a defining criterion, but other characteristic signs of fibromyalgia may be present. These patients should be treated as suffering from fibromyalgia.

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

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

Differential diagnosis of fibromyalgia

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

[1], [2], [3], [4], [5], [6], [7]

Tactics of management of patients with fibromyalgia

Patients with fibromyalgia are multimodal. The most important aspects are a positive and sympathetic attitude that begins with the very first contact with the patient as soon as he enters the examination room; strong confidence in the diagnosis; and educating the patient. The patient's education includes an accessible explanation of currently known physiological mechanisms, discussion of aggravating factors (for example, insomnia, lack of physical activity, anxiety, mental stress, labor factors and regular use of the limb in monotonous work), assurance that the disease is not inflammatory and non-malignant in nature . Experience shows that the use of such a term as an "easy form of the disease" often outrages a patient who feels a strong ailment and constant pain. It is necessary to demonstrate an understanding position.

It is important to keep in mind psychological factors, especially for patients with obsessional neurosis, in a state of chronic stress or depression. Only a small proportion of patients need a psychiatrist consultation. The most effective was the multidisciplinary approach, which includes cognitive behavioral therapy, physiotherapy, physical fitness exercises for all patients with various symptoms, regardless of their psychological state.

Proved a positive undoubted effect of regular physical activity (fitness program). It should be remembered that patients with severe pain or fatigue need a slow start with a few minutes and a gradual increase in training time. Walking in the open air and, for some patients, swimming is a more appropriate form of exercise. A study of 24 patients with fibromyalgia and 48 controls showed that fibromyalgia is a risk factor for the development of osteoporosis.

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

Non-pharmacological forms, including BOS, hypnotherapy and electro-acupuncture, are also effective in fibromyalgia.

Pregabalin is recommended by the FDA as a drug for the treatment of fibromyalgia. The recommendations are based on the results of a controlled double-blind study of 1800 patients taking pregabalin at a dose of 300-450 mg per day. Studies have shown a reduction in pain after taking pregabalin, however, the mechanism of this effect is unknown.

Medicines for treating SPS (Podell RN, 2007)

Class / preparation	Level of Evidence
Tricyclic antidepressants Amntiriptyline Cyclobenzapril	A A
Antagonists of serotonin receptors 3 subtypes (5HTZ) Tropisetron Odanzerethon	A AT
NMDA receptor antagonists Ketamine (for intravenous administration) Dextromethorphan	A FROM
Analogues of growth hormone Growth Hormone Injection Pyridostigmine	AT AT
Norepinephrine / serotonin reuptake inhibitors Duloxetine Milnacipran Venflaxin	AT AT FROM
Anticonvulsants / GABA agonists Pregabalin Gabapentin Sodium hydroxybutyrate	AT FROM AT
Opioids Tramadol Narcotic Analgesics	AT FROM
Anesthetics Lidocaine (intravenous)	AT
Serotonin reuptake inhibitors	AT
Nonsteroidal anti-inflammatory drugs and COX-2 inhibitors	FROM
Dopamine agonists Pramipexole Bupropion	AT FROM
Acetaminophen / Tylenol	FROM
Drugs for the treatment of spasticity Tizanidine Baclofen	FROM FROM

Local injection of sensitive 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 is injected slowly with a 27 gauge needle. The patient is asked not to load injected sites for 24-48 hours. They are also advised to apply ice for several hours to avoid post-injection inflammation.

The curation of patients with fibromyalgia is a laborious 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 the drugs, combining them with non-medicamentous methods in order to develop a patient-specific therapy regimen for the disease.

Skin Trigger Zones

Cutaneous trigger zones have been known for a long time and have been used for segmental diagnosis and treatment in acupuncture. In the area of skin trigger zones, there are changes in the morphological, electrical and mechanical characteristics of the skin. Empirically, methods of mechanotherapy (massage, pressurization), temperature effects, acupuncture, destructive methods (dissection) were effective for eliminating skin trigger zones. Modern manual medicine assigns a significant place to the diagnosis and treatment of skin trigger zones, putting at the forefront the methods of mechanotherapy (rolling, bending, stretching).

The results of our studies showed that skin trigger zones may have signs of primary and secondary hyperalgesia. Changes that occur in skin trigger zones cause dysfunction of the mechanoreceptor apparatus, namely Pacini's bodies. This is probably due to morphological changes that can be determined visually in the clinic (change in turgor, mottle). With primary hyperalgesia, there are more pronounced functional disorders of the mechanoreceptor apparatus.

Treatment of skin trigger zones is possible with manual medicine techniques, called the "stretching" and "stretching" technique. They are well described by A.Kobesova and K.Lewit (2000). The doctor stretches the skin trigger regions to the first resistance threshold and keeps it with this effort, waiting for the tissue to relax. The technique is highly effective, but it takes considerable time to up to 10 minutes per skin trigger zone and repeated sessions.

The J.Trawell, D.Simons method of refrigeration with a cold agent also helps to reduce the skin trigger zones, but is time-consuming, because After irrigation, the coolant should be applied with a hot moist compress, as well as 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. Another great AV Vishnevsky wrote about the positive effect of local anesthetics (novocaine). At present, the polymodality of the positive effect of local anesthetics is confirmed.

Methods of manual treatment for time costs per patient should be considered highly cost-effective. An alternative can be the use of local anesthetics in the form of a gel, ointment.