Monday, July 20, 2009

Fibromyalgia




Introduction:


Fibromyalgia syndrome includes symptoms of widespread, chronic musculoskeletal aching and stiffness and soft tissue tender points. It is frequently accompanied by fatigue and sleep disturbance (1). The impact of the disease is considerable both for those directly affected (restriction in activities of daily living and in ability to take part in family, professional, and social life) and for society as a whole (direct and indirect costs) (4). Fibromyalgia requires a comprehensive treatment care (2).

Definition:

Fibromyalgia is a fairly common syndrome characterized by chronic, widespread musculoskeletal pain, multiple "tender points", fatigue, sleep disturbance, stiffness and other symptoms such as headache, dizziness, trouble with concentration, irritable bowel syndrome, urinary urgency, depression (2). The disease usually has a chronic course (3).

Epidemiology:

Fibromyalgia is a common chronic pain syndrome affecting particularly middle aged women as it occurs at a mean age of 49 years (1, 4). However, according to Polańska (2) fibromyalgia may occur at any age, even in childhood. The prevalence is about 3.5% for women and 0.5% for men (3).

Signs & symptoms:

The cause of fibromyalgia is unknown. It is difficult to diagnose because many of the symptoms are similar to symptoms of other disorders (2). However, the symptomatology is characterized by diffuse widespread myofascial pain and tenderness on palpation at multiple "tender points" (3). The characteristic symptoms of fibromyalgia are chronic widespread musculoskeletal pain in various parts of the body and abnormal tenderness at 18 specified tender points (4).

Additional symptoms are various vegetative and functional disorders, nonrestorative sleep, depression and anxiety. It also includes stiffness, sleep disorders, fatigue, and problems with concentration (3, 4).

Pathology:

Etiology and pathogenesis of fibromyalgia still remain unclear. Current pathogenetic theories conceptualize a combination of biological and psychic, social and mental factors (4). However researchers points to an abnormality of the central pain-processing mechanisms is highly relevant for the pathogenesis (3).
The pain and fatigue reported by individuals with fibromyalgia results in a relative sedentary lifestyle, hence also a decrease in the fitness level of skeletal muscles (6).

Lab. Investigations:

There are no laboratory tests that can confirm a diagnosis of fibromyalgia. Laboratory examinations and imaging only provide nonconclusive results (2, 4).

DD:

Average time from onset to diagnosis is 5-8 years (2). Diagnosis is based on the characteristic clinical presentation, the presence of multiple tender points and the exclusion of certain disorders with similar symptoms (4). But differential diagnosis must include myofascial pain syndrome and chronic fatigue syndrome (1).

Treatments :

Fibromyalgia is a multifactorial problem and no universal treatment guidelines apply to all cases (1). As we know upto yet, fibromyalgia is a chronic widespread unexplained musculoskeletal pain syndrome with decreased pain threshold (6). In addition to early diagnosis and intensive patient education, pharmacotherapy, exercise therapy, behavior therapy, and multidisciplinary treatment are particularly important for the management of fibromyalgia (3).

Because the etiology of fibromyalgia is unknown and the pathogenesis is unidentified, treatment is largely symptomatic and not standardized (6). Pharmacologic therapy may include common pain medications & tricyclic antidepressants (1).

However, patient education, reassurance and an exercise program can each play an important role in relieving the symptoms associated with this common musculoskeletal syndrome (1). However, combination of medication and physical therapies only accomplish some temporary symptomatic relief (30-50%) (4).

Impact of exercises on fibromyalgia pain:

Kurtze (6) reviewed the effect of exercise in fibromyalgia from the Cochrane Controlled Trials Register. He selected 17 studies of exercise interventions on cardiorespiratory endurance, muscle strength and/or flexibility. The group exercises varied from 1-3 times per week, sessions from 25 minutes to 90 minutes; the duration of the programmes from 6 weeks to 6 month.

However, low-intensity aerobic exercise regimens were found to be one of the few effective treatments. Most of the programmes were low-intensity dynamic endurance training with a working rate at 50-70 % of maximal heart rate in relation to age.

Analysis of these studies shows inconsistent of these above said interventions (i.e. cardiorespiratory endurance, muscle strength and/or flexibility). These studies also reveal subjective pain levels fail to show significant improvement, although improvements are seen on other parameters such as improvement in the number of tender points, in total myalgic scores and reduced tender point tenderness, improved aerobic capacity, physical function, subjective well-being and self-efficacy.

Hence Fürst’s (4) conclusion on rehabilitation of fibromyalgia sounds apt. According to him psychosomatic rehabilitation should not focus on reduction of pain, but rather on physical reconditioning and development of an active coping style. Hence in these context psychological interventions, education and psychotherapy are essential (4).

Multidimensional rehabilitation (5):

Multidimensional rehabilitation: According to Wigers & colleagues multidimensional rehabilitation is an effective intervention for patients with widespread chronic pain. They studied 200 patients with chronic myofascial pain and/or fibromyalgia who participated in a 4-week multidimensional rehabilitation programme. Work capacity, a tender point count and whether patients met the diagnostic criteria for fibromyalgia were assessed at baseline and at discharge.

The programme included:

1. Education and pain management in a cognitive setting,
2. Various forms of aerobic exercises,
3. Myofascial pain treatment,
4. Relaxation and
5. Medication as needed.

Wigers & colleagues found:

1. Significant improvements were seen in all variables throughout the follow-up period.
2. 30% of the fibromyalgia patients no longer met the diagnostic criteria at discharge.
3. There was a significant increase in quality of life over time.
4. After one year, more patients had returned to work than not. And fewer people took sick leaves.
5. The majority did exercise training on a regular basis.
Measurements in this study: The patients filled in questionnaires on arrival, at follow-up after six and 12-months and at discharge.

They completed:

1. VAS- visual analogue scales ( for pain, fatigue, sleep problems, depression)
2. Nottingham Health Profile
3. Fibromyalgia Impact Questionnaire

The following ware also assessed:

1. Global subjective improvement
2. Physical activity level,
3. Changes in quality of life and
4. Occupational workload.

References:

1. Reiffenberger DH et al; Am Fam Physician. 1996 Apr;53(5):1698-712.
2. Polańska B; Pol Merkur Lekarski. 2004 Jan;16(91):93-6.
3. Jäckel WH et al; Z Rheumatol. 2007 Nov;66(7):579-90.
4. Fürst G; Wien Med Wochenschr. 2007 Jan;157(1-2):27-33.
5. Wigers SH et al; Tidsskr Nor Laegeforen. 2007 Mar 1;127(5):604-8.
6. Kurtze N; Tidsskr Nor Laegeforen. 2004 Oct 7;124(19):2475-8.


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