Fibromyalgia

The concept of "fibromyalgia", which became popular in the 1970s thanks to a series of publications by Hugh Smyth and H. Moldofsky (1977), suggests considering this disorder as a non-rheumatic, extra-articular, non-inflammatory diffuse involvement of the muscular system with characteristic phenomena of pain, tension and muscle weakness.

The absence of signs of an inflammatory nature of the disease resulted in the abandonment of the previously widespread term “fibrositis” and its replacement with the broader term “fibromyalgia”.

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Epidemiology

Fibromyalgia is a common form of pathology. Thus, in general rheumatological practice, it is one of the three most common reasons for primary visits to doctors. Most doctors note an increase in the incidence of fibromyalgia in the last 5 years. Thus, by the end of 1994, 6 million Americans were registered with fibromyalgia, and 4 million of them were women. According to various authors, fibromyalgia occurs in 5% of cases among general practitioners (Campbell, 1983) and approximately 2% in the population (Wolfe, 1993). At the same time, 80-90% of them are women, and the predominant age is 25-45 years. The onset of the disease is usually in the second or third decade of life. However, cases of debut in childhood are also noted. At the same time, out of 15 children with signs of fibromyalgia, over time, the disease passes without a trace in 11.

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Causes fibromyalgia

The basis of the clinical description of patients with fibromyalgia is pain, which is the reason for visiting a doctor. Painful sensations can be of a very diverse nature: with an emphasis on joint pain (complaints of swelling of one or more joints, distension, limitation of movement are common), with an emphasis on pain in the axial skeleton (usually in the neck and lower back), with an emphasis on muscle pain, generalized aching pain, pain in the peripheral parts of the limbs. The most vivid metaphor for describing patients with fibromyalgia is the "princess and the pea" due to the extremely heightened perception of any irritant, including tactile ones. Often, these people can experience pain when combing their hair, writing a letter, washing clothes, etc.

The course of the disease is chronic and inpatient. Symptoms of fibromyalgia last for years and decades, subject to minor fluctuations under the influence of certain factors. Long-term observation of fibromyalgia patients in one prospective study showed that over 15 years, about 50% of the symptoms described in them earlier were subject to positive dynamics, while 75% of patients continued to take one or another therapy during this time.

The existence of a large number of possible factors associated with fibromyalgia has suggested that fibromyalgia may be classified as either primary or secondary (as a manifestation of some primary disorder).

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Symptoms fibromyalgia

The main symptoms of fibromyalgia are pain (100%), stiffness (77%) and fatigue (81.4%). The onset of fibromyalgia in most patients is gradual. About half of the patients noted diffuse pain in the past in childhood. However, the onset of the disease is often associated with emotional factors, stress, changes in the family, as well as other events: trauma, surgery, etc.

The most common symptoms of fibromyalgia are pain, which is exacerbated by fatigue, tension, excessive physical activity, immobility and cold. Pain is relieved by heat, massage, physical activity and rest. Pain is usually bilateral and symmetrical. Pain and stiffness in the head and neck are typical in the morning. Complaints of cramps in the calf muscles, paresthesia and a feeling of distension 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.

The most characteristic feature of patients with fibromyalgia is that pain is reproduced after palpation of trigger points. Areas other than the locations of the points are not more sensitive than in healthy people. Common areas of trigger points are: cervical points in the area of the transverse processes of the 4th, 5th, 6th cervical vertebrae; on the border of the muscle belly of the right and left trapezius muscles; in the area of the second costochondral junction on each side; at the attachment of the supraspinatus muscle at the medial border of the scapula on each side; in the muscle belly of the rhomboid, levator scapulae, or infraspinatus muscles; 1-2 cm distal to the lateral epicondyle of the elbow in the area of the common extensor tendon; in the upper lateral quadrant of the buttocks; in the lumbar interspinous ligaments on both sides of the £.4.5, SI lumbar vertebrae; medial fat pad proximal to the articular line crossing the collateral ligaments of the knee; bony points, especially the apex of the acromion or on the greater trochanter.

Along with the most characteristic complaints described of pain, fatigue and stiffness, patients with fibromyalgia experience a whole symptom complex of somatic, mental and other disorders, which generally leads to a sharp maladaptation of these patients.

Sleep disturbances are one of the most common (74.6%) symptoms of fibromyalgia. The most typical complaints are about the lack of satisfaction with sleep, noted by patients in the morning, which allowed us to characterize sleep in fibromyalgia as "non-restorative". Studies of the structure of night sleep in patients with fibromyalgia demonstrate a sharp reduction in deep sleep phases and the inclusion of alpha activity in 5-sleep, which is defined as alpha-sigma sleep due to microarousal complexes. At the same time, frequency analysis of the EEG during sleep shows the dominance of high-frequency components and a decrease in the power of low-frequency oscillations in the overall EEG spectrum. This, in general, apparently, reflects a violation of homeostatic circadian mechanisms of sleep regulation and may be related to the symptoms of the disease that manifest themselves in wakefulness.

Headaches are also a common symptom of fibromyalgia and are generally found in 56% of patients: 22% have migraine headaches, 34% have tension headaches. The intensity of the latter varies greatly. The fact that the severity of headaches and the intensity of the main manifestations of fibromyalgia are related is important.

Among patients with fibromyalgia, 30% report signs of Raynaud's phenomenon. The degree of its manifestations can also vary - from mild paresthesia and coldness of the distal parts of the extremities, but the vast majority of patients experience extreme degrees of its manifestations. In 6% of patients, carpal tunnel syndrome can be diagnosed.

Characteristic for patients with fibromyalgia are subjective sensations of distension and tissue compaction, most often noted in the hands and knee area.

The presence of the main syndrome - "muscle pain" - makes it necessary to make some distinctions in the concepts of "fibromyalgia" and "myofascial syndrome". Along with many common features - the nature of pain, limitation of range of motion, predominant prevalence among women, etc. - only fibromyalgia is characterized by such a diffuse prevalence, intensity and reproducibility of local pain, a pattern of psychovegetative disorders is characteristic (high prevalence of sleep disorders, cardialgia, anxiety-depressive disorders, irritable bowel syndrome, etc.). In myofascial syndromes, the listed phenomena are encountered no more often than in the population.

The majority of authors studying fibromyalgia unanimously acknowledge the significant role of psychovegetative disorders in the symptom formation of fibromyalgia. These primarily include: migraine, tension headaches, sleep disorders, hyperventilation disorders, "panic attacks", cardialgia, syncope, etc. Along with this, most researchers note the high representation of psychopathological phenomena in fibromyalgia. Personality disorders are generally found in 63.8%, depressive disorders - in 80% (compared to 12% in the population), anxiety - in 63.8% (16%). Numerous studies confirm clinical observations indicating the large role of mental disorders in the origin and course of fibromyalgia.

Views on the nature of fibromyalgia are quite ambiguous and have undergone a significant transformation from considering the leading role of infectious factors, immune and endocrine mechanisms to recognizing the key role of disturbances in the physiological mechanisms of pain modulation and mental disorders (somatization of depression). Considering all existing concepts in total, we can only state with obvious probability the following: fibromyalgia is a dysregulation of neurotransmitter functioning: serotonin, melatonin, norepinephrine, dopamine, substance P, which help control pain, mood, sleep and the immune system. This explains the undeniable clinical facts of the high compatibility of clinical phenomena (pain, sleep disorders, migraine, depression, anxiety).

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Diagnostics fibromyalgia

The first attempts to establish diagnostic criteria for primary fibromyalgia were made by H. Smyth (1972) and Wolfe. (1990). Later, all these preliminary data were reflected in a more generalized form in the diagnostic criteria of the American College of Rheumatology (1990), which are now the most widely used. Firstly, fibromyalgia is identified as a musculoskeletal disease with spontaneous diffuse pain and simultaneously reproducible local pain from certain places designated as trigger points (TP). Secondly, the pain should be reproduced by palpation of at least 11 of the 18 described characteristic trigger points. The duration of the described symptoms should be at least the last three months. The study of trigger points is extremely important and requires certain knowledge of their exact location. If the patient has a fibromyalgia symptom complex and there are not enough "positive" trigger points, then we can only talk about "possible fibromyalgia". Thirdly, there must be a characteristic symptom complex of vegetative, mental and somatic disorders, described below.

This syndrome is considered primary, but fibromyalgia can also accompany many rheumatological diseases. In this case, the presence of another clinically defined disease in the patient does not exclude the possibility of determining fibromyalgia in him. Another necessary condition for diagnosing primary fibromyalgia is the presence of normal laboratory test results.

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Treatment fibromyalgia

Approaches to fibromyalgia treatment should be strictly individual. A qualified clinical assessment of the main symptoms of fibromyalgia is required: mental disorders, severity of pain syndrome, condition of trigger points. There are several directions of therapeutic treatment of fibromyalgia.

1. Benzodiazepines in general have relative indications for fibromyalgia (except alprazolam), since they, along with some clinical effect, cause reduction of stage 4 sleep and can renew fibromyalgia symptoms. Alprazolam is prescribed in a dose of 0.25-1.5 mg at night. It is especially effective if combined with a high dose of ibuprofen (2400 mg). Clonazepam (0.5-1 mg at night) is especially effective for night cramps.
2. Tricyclic antidepressants are highly effective in the treatment of fibromyalgia (amitriptyline 25-50 mg at night, cyclobenaraine 10-30 mg). With prolonged use, improved sleep, decreased pain, and muscle relaxation are observed. The side effects of tricyclic antidepressants are well known, but they have been described extremely rarely in patients with fibromyalgia.
3. Serotonin-enhancing drugs are characterized by a fairly high efficiency in the treatment of fibromyalgia, especially in cases of high levels of depressive disorders. Drugs of this group (Prozac 20 mg in the morning) can, however, cause insomnia, so it is recommended to combine it with tricyclic antidepressants. Sertraline (50-200 mg) can be effective in some patients. Paxil (5-20 mg) is the most potential in this group.
4. Muscle relaxants: Norflex (50-100 mg 2 times a day) has a central analgesic effect, Flexeril, etc. These drugs are more effective in the treatment of fibromyalgia also in combination with tricyclic antidepressants.
5. Nonsteroidal anti-inflammatory drugs (Relaphen, Voltaren, Ibuprofen, etc.) can be effective in the treatment of fibromyalgia. They can be used in the form of creams and ointments.

Physiotherapeutic treatment of fibromyalgia in the long-term course of the disease is ineffective. There are observations indicating the beneficial effect of regular aerobic exercise on these patients.

Along with pharmacotherapy, a fairly high efficiency of various modifications of psychotherapy is noted.