The concept of "fibromyalgia", which has become popular since the 1970s, thanks to a series of publications by Hugh Smyth and N. Moldofsky (1977), suggests this suffering as non-rheumatic, extraarticular, non-inflammatory diffuse involvement of the muscular system with the characteristic phenomena of pain, tension and muscle weakness.
A consequence of the absence of signs of an inflammatory nature of the disease was the rejection of the previously widespread term "fibrositis" and its replacement by a broader concept of "fibromyalgia".
Fibromyalgia refers to the frequent form of pathology. So, in general clinical practice, it is one of the three most frequent causes of primary treatment to doctors. Most doctors note an increase in the incidence of fibromyalgia in the last 5 years. So, by the end of 1994, there were 6 million patients registered for fibromyalgia of Americans, 4 million of whom were women. According to different authors, fibromyalgia found in 5% of cases - common practice among patients (Campbell, 1983) and about 2% - in the population (Wolfe, 1993). At the same time 80-90% of them are women, and the prevailing age is 25-45 years. The onset of the disease is usually in the second-third decade of life. However, debut cases are also observed in childhood. At the same time, out of 15 children with signs of fibromyalgia with the passage of time in 11 the disease passes without a trace.
Causes of fibromyalgia
The basis of the clinical description of patients with fibromyalgia is pain, which is the reason for going to the doctor. Soreness at the same time may be very diverse in nature: with a focus on joint pain (frequent complaints of swelling of one or more joints, distension, movement restriction), with a focus on the pain of the axial skeleton (usually in the neck and lower back), with an emphasis on muscle pain, generalized bursting pain, pain (peripheral extremities. The most vivid metaphor to describe patients with fibromyalgia is the "Princess and the Pea" because of the extremely heightened perception of any stimulus, including tactile. Often these people the pain can be caused when grooming, writing letters to wash laundry, etc..
The course of the disease is chronic. Fibromyalgia Symptoms last for years and decades, undergoing minor variations under the influence of certain factors. Long-term monitoring of patients with fibromyalgia in a prospective study showed that for 15 years the overall positive dynamics are subject to 50% described their symptoms earlier, with 75% of patients during this time continued reception of a particular therapy.
The existence of a large number of possible factors accompanying fibromyalgia, presupposed the allocation of fibromyalgia as primary and secondary (as a manifestation of some primary suffering).
Symptoms of fibromyalgia
The main symptoms of fibromyalgia: pain (100%), stiffness (77%) and fatigue (81.4%). The onset of fibromyalgia in most patients is gradual. About half of the patients reported a diffuse pain sensation in childhood in childhood. However, the debut of the disease is more often associated with emotional factors, stress, changes in the family, as well as other events: trauma, surgery, etc.
The most frequent symptoms of fibromyalgia are painful sensations, which are aggravated in a state of fatigue, tension, excessive physical activity, immobility and cooling. The pains are alleviated by the action of heat, massage, while observing the regime of motor activity, rest. Pain, as a rule, is bilateral and symmetrical. Characteristic in the morning hours of pain and stiffness in the head and neck. Complaints on cramps of calf muscles, paresthesia and sensation of raspiranija in the top and bottom extremities are widespread enough. Fatigue is one of the most frequent complaints. Often the patient wakes up more tired than before going to sleep.
The most characteristic for patients with fibromyalgia is that after palpation of trigger points, the pain is reproduced. Areas in places other than finding points are not more sensitive than in healthy people. Common areas of location of trigger points are: cervical points in the region of transverse processes of the 4th, 5th, 6th cervical vertebrae; On the border of the muscular abdomen of the right and left trapezius muscles; In the region of the second costal cartilage joint on each side; In the place of attachment of the supraspinatus at the medial edge of the scapula on each side; In the muscular abdomen of rhomboid, lifting the scapula or subacute muscles; 1-2 cm distal to the lateral epicondyle of the elbow in the region of the tendon of the common extensor; In the upper-lateral quadrant of the buttocks; In the lumbar interstitial ligaments on both sides of £ .4.5, SI of the lumbar vertebrae; The medial fat body is proximal to the joint line that crosses the collateral ligaments of the knee; Bone dots, especially the tip of the acromion or on a large spit.
Along with the most typical complaints of pain, fatigue and stiffness described, patients with fibromyalgia have a whole symptom complex of somatic, mental and other disorders, which leads to a sharp disadaptation of these patients.
Sleep disorders are one of the most frequent (74.6%) symptoms of fibromyalgia. The most typical complaints are the lack of satisfaction with sleep, noted by patients in the morning, which made it possible to characterize sleep in fibromyalgia as "non-restorative." Studies of the structure of night sleep in patients with fibromyalgia demonstrate a sharp reduction of 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, seems to be a reflection of the disturbance of the homeostatic circadian mechanisms of sleep regulation and can be related to the symptoms of the disease, manifested in wakefulness.
Headaches are also a common symptom of fibromyalgia and are generally found in 56% of patients: in 22% - migraine, in 34% - in tension headaches. At the same time, the intensity of the latter is large. The fact of correlation of the severity of headaches and intensity of the main manifestations of fibromyalgia is important.
Among patients with fibromyalgia, 30% note the presence of signs of the phenomenon of Raynaud. The degree of its manifestations can also be different - from mild paresthesia and cooling of the distal limbs, but the vast majority of patients show an extreme degree of its manifestations. In 6% of patients, carpal tunnel syndrome can be diagnosed.
Characteristic for patients with fibromyalgia are subjective sensations of bursting and tightening of the tissues, most often noted in the hands and in the knee area.
The presence of the main syndrome - "pain in the muscles" - makes it necessary to make some distinctions in the concepts of "fibromyalgia" and "myofascial syndrome". Along with many common features - the nature of pain, the limitation of the volume of movements, the prevalence prevalence among women, etc. - only for fibromyalgia is characterized by such diffuse prevalence, intensity and reproducibility of local pains, characterized by a pattern of psycho-vegetative disorders (high representations of sleep disorders, cardialgia, anxiety-depressive Disorders, irritable bowel syndrome, etc.). With myofascial syndromes, the listed phenomena are not found more often than in the population.
Unanimous is the recognition by most authors investigating fibromyalgia, the significant role of psycho-vegetative disorders in the symptom formation of fibromyalgia. They primarily include: migraine, tension headaches, sleep disorders, hyperventilation disorders, "panic attacks", cardialgia, syncopal conditions, etc. Along with this, most researchers note a high degree of representation of psychopathological phenomena in fibromyalgia. Personality disorders in general occur in 63.8%, depressive disorders - in 80% (compared with 12% in the population), anxious - in 63.8% (16%). Numerous studies confirm clinical observations that attest to the great role of psychiatric disorders in the origin and course of fibromyalgia.
The views on the nature of fibromyalgia are very ambiguous and have undergone a significant transformation from the consideration of the leading role of infectious factors, immune and endocrine mechanisms to the recognition of the key role of violations of the physiological mechanisms of modulation of pain and mental disorders (somatization of depression). Considering in aggregate all the existing concepts, it is possible to affirm with obvious probability only the following: fibromyalgia is a dysregulation of neurotransmitter functioning: serotonin, melatonin, norepinephrine, dopamine, substance P, which help to control pain, mood, sleep and immune system. This explains the undeniable clinical facts of high compatibility of clinical phenomena (pain, sleep disorders, migraine, depression, anxiety).
Diagnosis of fibromyalgia
The first attempts to establish diagnostic criteria for primary fibromyalgia were undertaken by H.Smyth (1972) and Wolfe. (1990). In the future, 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 most widely distributed. First, fibromyalgia is identified as a musculo-skeletal disease with spontaneous diffuse pain and simultaneously reproducible local pain from certain places, designated as trigger points (TT). Secondly, pain must 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 three last months. The study of trigger points is extremely important and requires certain knowledge of their exact location. If the patient has a symptomatic complex of fibromyalgia and there is not enough "positive" trigger points, in this case one can only talk about "possible fibromyalgia". Third, there should be a characteristic symptom-complex of vegetative, mental and somatic disorders, described below.
This syndrome is usually considered primary, but fibromyalgia can accompany many rheumatological diseases. In this case, the presence in the patient of another clinically outlined disease does not exclude the possibility of determining fibromyalgia in him. Another necessary condition for the diagnosis of primary fibromyalgia is the presence of normal laboratory results.
Treatment of fibromyalgia
Approaches to the treatment of fibromyalgia should be strictly individual. A qualified clinical evaluation of the main symptoms of fibromyalgia: mental disorders, the severity of the pain syndrome, the state of the trigger points is required. There are several areas of therapeutic treatment of fibromyalgia.
- Benzodiazepines as a whole have relative indications for fibromyalgia (except alprazolam), as they, along with some clinical effect, cause a reduction in the 4th stage of sleep and can resume the symptoms of fibromyalgia. Alprazolam is prescribed in a dose of 0.25-1.5 mg per night. It has special efficacy if it is combined with a high dose of ibuprofen (2,400 mg).
- Clonazepam (0.5-1 mg per night) is especially effective in nighttime cramps.
- Tricyclic antidepressants have significant efficacy in the treatment of fibromyalgia (amitriptyline 25-50 mg per night, Cyclobenarin 10-30 mg). With prolonged use, there is an improvement in sleep, a reduction in pain and muscle relaxation. The side effects of tricyclic antidepressants are well known, but in patients with fibromyalgia they are very rarely described.
- Serotonin boosting drugs are characterized by a fairly high efficacy in the treatment of fibromyalgia, especially in cases of high levels of depressive disorders. Preparations 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) may be effective in some patients. Paxil (5-20 mg) is the most potent in this group.
- Muscle relaxants: norflex (50-100 mg 2 times a day) has a central analgesic effect, flexeryl, etc. These drugs are more effective in treating fibromyalgia also in combination with tricyclic antidepressants.
- Non-steroidal anti-inflammatory drugs (relafen, voltaren, ibuprofen, etc.) can be effective in the treatment of fibromyalgia. Perhaps their use in the form of creams, ointments.
Physiotherapeutic treatment of fibromyalgia in the long course of the disease is ineffective. There are observations that indicate the beneficial effect on these patients of regular aerobic exercise.
Along with pharmacotherapy, the effectiveness of various modifications of psychotherapy is quite high.