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Fibromyalgia

Fibromyalgia is a commonly encountered disorder in which there is widespread musculoskeletal pain, stiffness, paresthesia, easy fatigability and nonrestorative sleep (sleeping doesn't refresh the patient) along with multiple tender points which are widely and symmetrically distributed.

Fibromyalgia is seen mainly females with a ratio of 8:1 as compared to males. It is commoner in those above the age of 50 and in those with concomitant psychiatric illness (mainly depression).

Causes

The cause of fibromyalgia is not specifically known. However, many studies have enabled a better picture of how this disease happens.

Nonrestorative sleep: is a condition in which sleeping does not lead to refreshening of the patient (i.e. a tired person does not feel better after sleeping). Nonrestorartive sleeping  is manifested in almost all patients with fibromyalgia. Sleep studies have attributed this to a disturbance in stage 4 sleep (NREM - Non-rapid eye movement sleep). When stage 4 sleep is artificially disturbed during an experiment, all subjects started presenting with manifestations of fibromyalgia. This shows that a disturbance in phase 4 sleep represents one of the steps involved in the pathogenesis of this disease.

Other observations found were:

low levels of CSF (cerebro-spinal fluid) serotonin (a neurotransmitter). However, drugs that lower serotonin levels were not found to induce symptoms of fibromyalgia.

Low levels of growth hormone which leads to phase 4 sleep disturbance and may explain the occurrence of Raynaud's phenomenon in these individuals.

Decrease cortisol response to stress due to a disruption in the hypothalamic pituitary function is found in these patients.

High levels of substance P were also found in these patients.

Studies failed to show any abnormalities in muscle, tendons or joints.

Clinical suspicion

In patients without a concomitant illness and complaining of widespread pain, fibromyalgia is suspected. Pain may start in one area but usually spreads to become more widespread in nature.

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Diagnosis

The diagnosis is established clinically through the ACR criteria by the induction of tenderness in at least 11 of 18 points all over the body. If tender points add up to less than the 11 required for the diagnosis then the case is dubbed "probable fibromyalgia".

Some patients are tender all over and not just at the specific tender point sites. These patients are still more tender over the specific tender point sites, however. Sites where there is usually no tenderness and which can be used as controls are the dorsum of the third digit between the proximal interphalangeal and distal interphalangeal joints, the medial third of the clavicle, the medial malleolus, and the forehead. If tenderness at these sites is also present, the diagnosis of fibromyalgia should be questioned and possible psychiatric disorders investigated.

Results of joint and muscle examinations are normal in fibromyalgia patients, and there are no laboratory abnormalities.

Treatment

Patients should be informed that they have a condition that is not crippling, deforming, or degenerative, and that treatment is available. Salicylates or other NSAIDs only partially improve symptoms. Glucocorticoids have been of little benefit and should not be used in these patients. Opiate analgesics should be avoided. Local measures such as heat, massage, injection of tender sites with steroids or lidocaine, and acupuncture provide only temporary relief of symptoms. Other therapies that may help to varying degrees including biofeedback, behavioral modification, hypnotherapy, and stress management and relaxation response training. The use of tricyclics such as amitriptyline (10 to 50 mg) and doxepin (10 to 25 mg) or a pharmacologically similar drug, cyclobenzaprine (10 to 40 mg), 1 to 2 h before bedtime will give the patient restorative sleep (stage 4 sleep), resulting in clinical improvement.

Depression and anxiety along with life stresses are dealt with appropriately. . Patients may also benefit by regular aerobic exercises. Exercise should be of a low-impact type and begun at a low level. Eventually, the patient should be exercising 20 to 30 min 3 to 4 days a week. Regular stretching exercises are also very important.

Outcome and prognosis

In a community-based study reported after 2 years of treatment, 24% of patients were in remission, and 47% no longer fulfilled the ACR criteria for fibromyalgia.

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