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Fibromyalgia

Fibromyalgia is a syndrome characterized by widespread musculoskeletal pain and chronic fatigue, usually associated with other symptoms (postexertional fatigue, sleep disturbance, headaches, cold intolerance, dizziness, paresthesias, siccus, chest pain, jaw pain). The primary manifestation of fibromialgia is diffuse, chronic aching and stiffness, usually axial in location, although the extremities may be involved. Pain varies in severity over time, with exacerbation commonly triggered by uncustomary exertion, injury, impaired sleep, and undue stress, as well as environmental factors such as humidity. Patients often complain of morning stiffness that may mimic that of rheumatoid arthritis, and they may have difficulty distinguishing between joint.

They may report a sense of swelling, although this is not observed on examination. Numbness, tingling, and burning in diffuse locations also may be described. Fibromyalgia may be associated with other enigmatic syndromes (irritable bowel syndrome, interstitial cystitis, irritable bladder, female urethral syndrome, premenstrual syndrome, tension headaches.

Fibromyalgia may occur in the absence of coexistent illness or in association with chronic diseases such as rheumatoid arthritis, osteoarthritis, Lyme disease, or sleep apnea. Fatigue is a major complaint of most fibromyalgia patients.

Fibromyalgia and chronic fatigue syndrome patients are similar clinically. Both conditions occur much more commonly in women than men, and in both conditions prominent symptoms include fatigue, myalgias, and sleep disturbance. However, in patients with chronic fatigue syndrome, symptoms often are reported to have begun after an acute influenza-like, mononucleosis-type illness, with subsequent abrupt onset of fatigue and associated typical complaints. Symptoms seen commonly in chronic fatigue syndrome patients but not fibromyalgia patients include pharyngitis, lymphodynia.

In addition, fibromyalgia prevalence increases with advancing age, whereas chronic fatigue syndrome most commonly occurs in young adulthood. Patients with fibromyalgia exhibit pain on digital palpation at specified tender point sites, a phenomenon not intrinsic to, but occasionally seen in, patients with chronic fatigue syndrome.

On the basis of validated diagnostic classification criteria, fibromyalgia has emerged in epidemiologic studies as the most common cause of musculoskeletal pain in women between the ages of 20 and 55 years, increasing in frequency with advancing age. There is a strong female predominance (>75%). Fibromyalgia affects up to 15% of rheumatology patients and 5% of general medical patients.

Etiology

The pathophysiology and etiology of fibromyalgia are not understood. Biopsies of sites of muscle tenderness in patients with fibromyalgia have failed to reveal any abnormalities, including specifically inflammatory changes, which has led to abandonment of the old term "fibrositis." The relationship of fibromyalgia to autoimmune abnormalities.

Psychologic distress and dysfunction are common in patients with fibromyalgia, but it generally is believed that these problems are secondary to suffering from the condition, not the primary cause of fibromyalgia.

Diagnostic Criteria

Fibromyalgia is a clinical diagnosis. It is strongly suggested by a patient's history of chronic generalized pain with associated features including 1) sleep disturbance, 2) fatigue, 3) headaches, 4) mood disturbance and cognitive difficulty, and 5) complaints suggestive of other syndromes including irritable bowel syndrome, female urethral syndrome, premenstrual syndrome, Raynaud's phenomenon, and restless leg syndrome.

Treatment

Fibromyalgia is a chronic, persistent condition, and sustained remission of all symptoms is unusual. Treatment goals are to reduce pain, inflexibility, fatigue, and dysfunction and to enhance productivity and wellness. Management requires time, patience.

Psychologic evaluation and intervention can help with managing primary or secondary psychosocial issues. Therapy may include physical therapy, exercise or stretching instruction, occupational therapy, and social service and psychological intervention, including goal setting, lifestyle modification, and stress reduction programs. Regular, low-impact aerobic exercises such as walking, stationary bicycling, and water (pool) exercising.

Pharmacotherapy may be helpful in ameliorating pain and sleep disturbances. Sleep derangement may be improved with prebedtime administration of low doses of amitriptyline for early awakening problems or bedtime administration of trazodone for prolonged sleep latency. Other agents such as clonazepam or newer serotonin reuptake inhibitors given at bedtime also may be useful.

Most patients with fibromyalgia experience only partial relief of musculoskeletal pain with non-steroidal antiinflammatory agents. Corticosteroids are not indicated. Occasionally, mild prescription analgesics may be indicated, such as acetaminophen with codeine or propoxyphene, although these should be administered with caution on a chronic basis. Injection of tender points with lidocaine-type agents may be indicated in instances where there is a major focus.