Fibromyalgia is a chronic pain syndrome resulting from a genetically determined phenomenon of central sensitization. It is manifested by diffuse pain in the musculoskeletal structures, combined with fatigue, sleep disorder, depression. It is diagnosed according to clinical criteria with laboratory and instrumental exclusion of rheumatic pathology, organic causes of pain. Treatment is carried out using a combination of non-drug (exercise therapy, psychotherapy) and medication (antidepressants, GABA derivatives, local anesthetics) methods.
ICD 10
M79.7 Fibromyalgia
General information
Fibromyalgia has long been known in medical practice, it is observed in 4% of the population, it is prevalent mainly in middle-aged women (35-55 years). Due to the lack of an organic substrate, the disease was attributed for a long time to disorders of the mental sphere, diagnosed as hypochondria, hysteria, psychogenic rheumatism.
The term “fibromyalgia” was introduced in the 70s of the twentieth century. In 1990, the American College of Rheumatology first published diagnostic criteria for the disease. At the beginning of the XXI century, evidence was obtained that fibromyalgia is not accompanied by inflammatory changes in peripheral tissues, therefore, it is not a rheumatic pathology. The detection of violations of the central mechanisms of pain perception in patients finally secured the curation of the disease for specialists in the field of clinical neurology.
Causes
Recent studies have proved the hereditary nature of the pathology. The localization of the genetic defect has not yet been established. It is known that the probability of developing the disease in persons whose relatives have been diagnosed with fibromyalgia is 8 times higher than the population average. Studies of twins demonstrate that 50% of the risk of pathology is caused genetically, and 50% is associated with the influence of external factors acting as provoking triggers. The most likely etiofactors, under the influence of which genetically determined fibromyalgia occurs, are:
- Peripheral pain syndromes. They are associated with damage to peripheral nerve trunks as a result of trauma (nerve damage), compression (carpal tunnel syndrome), inflammation (neuritis, sciatic nerve neuropathy), dysmetabolic processes (diabetic neuropathy).
- Infectious diseases: borreliosis, herpetic infection, infectious mononucleosis, Ku fever.
- Distress — mental stress accompanied by negative emotions. The negative perception of life events is due to the presence of suspiciousness in the patient, a tendency to catastrophize events, excessive alertness, fixation on their own feelings. Similar character traits are noted in almost all patients.
- Physical injury (bruise, fracture, burns). Acts as a stressful factor, associated with severe pain.
- Hormonal imbalance. Fibromyalgia is most often observed in hypothyroidism.
- Pharmaceuticals and the introduction of vaccines. Negatively affect the neurotransmitter processes involved in the formation of pain perception.
Pathogenesis
Chronic pain syndrome, which is accompanied by fibromyalgia, is caused by central sensitization — constant hyperexcitation of sensitive neurons of the posterior horns of the spinal cord. Increased arousal is formed both under the influence of pain impulses coming from the periphery (injuries, peripheral syndromes), and as a result of neurometabolic shifts against the background of distress, infection, hormonal disorders.
The leading role in pathogenesis belongs to serotonin and noradrenergic neurotransmitter systems. It was found that the concentration of serotonin, L-tryptophan, norepinephrine in the blood was reduced in patients, and the level of 5-hydroxyindole, the basic metabolite of serotonin, was reduced in the cerebrospinal fluid. Since serotonin is considered responsible for good mood, the drop in its level explains the tendency of patients with fibromyalgia to depressive and anxiety states.
Symptoms
The leading symptom complex of the disease is constant diffuse pain throughout the body. Patients characterize pain syndrome as “a feeling that it hurts everywhere”, “a constant feeling that they have a cold”, “burning all over the body”. The pain is accompanied by sensory phenomena: tingling, numbness, “running goosebumps”, especially pronounced in the extremities. Sometimes fibromyalgia occurs with periodic arthralgias.
It is characterized by increased fatigue, maximally manifested in the morning, less pronounced in the afternoon and somewhat increasing in the evening. Even a slight increase in physical activity, as well as a prolonged absence of activity, can increase the pain syndrome and the feeling of fatigue. Sleep disorders are represented by difficulties falling asleep, frequent night awakenings, lack of vigor after a sufficient period of sleep. A typical symptom is a feeling of exhaustion, fatigue after sleep. The feeling of lack of sleep is present even after a period of sleep lasting 9-10 hours, accompanied by morning stiffness in the body.
In 30-60% of cases fibromyalgia is combined with mental disorders. Generalized anxiety and depression are the most typical. Many patients have mild cognitive impairments: memory impairment, decreased ability to concentrate, inattention. Patients often describe them as a “fog in the head” that prevents them from concentrating.
The characteristic symptoms of fibromyalgia in most cases are combined with other problems: migraine headaches, restless legs syndrome, gastrointestinal dyskinesia, urination disorders. Chronic pain, disturbed sleep negatively affect the patient’s ability to work, complicate his daily life, reduce its quality.
Diagnostics
Fibromyalgia is diagnosed mainly according to clinical data after the exclusion of the organic genesis of pain. The comprehensive examination includes:
- A patient survey. Allows you to determine the main complaints, their nature, the prescription of the disease, concomitant pathology. The FiRST questionnaire is used as a diagnostic screening, the sensitivity of which is at the level of 90.5%, the specificity is 85.7%. The questionnaire contains 6 items, a positive answer to 5 questions indicates the presence of fibromyalgia.
- Assessment of neurological status. The status corresponds to the norm. The asthenization of the patient is noted, and in the study of cognitive functions — difficulty in concentrating attention.
- Investigation of trigger points. There are 9 pairs of points, the soreness of which is accompanied by fibromyalgia. Diagnostic palpation should be carried out with a certain uniform pressure force, combined with comparative palpation of other areas.
- Laboratory tests. The absence of inflammatory changes in the general blood test, increased markers of autoimmune pathology (C-reactive protein, RF, antinuclear antibodies, ASL-O) makes it possible to exclude the rheumatic nature of the disease. There is a decrease in the concentration of L-tryptophan, serotonin in the blood serum.
- Tomography. Computed tomography, MRI of the brain do not reveal morphological changes, exclude intracranial hypertension, cerebral tumors, slow CNS infections, degenerative processes.
Differential diagnosis
Differential diagnosis is carried out with myositis, dermatomyositis, hypercalcemia, neurasthenia, hysterical neurosis, somatoform disorders, oncological processes. When making a diagnosis of fibromyalgia, doctors can focus on the following diagnostic criteria:
- Pain in the four quadrants of the body with the presence in the chest and/or spine, lasting at least 3 months.
- On palpation, pain occurs at 11 of the 18 trigger points.
- The presence of increased fatigue.
- Characteristic sleep disorders.
- Difficulties when necessary to focus attention.
- Morning stiffness.
- Depressive, anxious mood background.
- The impact of the disease on the quality of life.
Treatment
Therapy is carried out by a neurologist or an algologist, requires an integrated approach, a combination of several techniques. Among the methods of treatment used, non-drug and medicinal are distinguished.
Non-drug methods:
- Cognitive behavioral psychotherapy. It allows the patient to develop a positive outlook on life, reduce anxiety, and raise the mood background.
- Physical therapy. It is proved that moderate physical activity helps to reduce pain, regression of symptoms of the disease for a period of up to a year or longer.
- Other techniques: BOS therapy, acupuncture, hydrotherapy, hypnotherapy. They showed average effectiveness in relieving pain syndrome. They can be used as an addition to basic therapy.
Pharmacotherapy:
- Antidepressants. Effective against fibromyalgia and concomitant depression, improve sleep. Amitriptyline, serotonin and norepinephrine uptake inhibitors (venlafaxine, duloxetine) have proven effectiveness.
- Anticonvulsants that are derivatives of GABA (pregabalin). Against the background of treatment, there is a significant decrease in pain symptoms, sleep is normalized, and the overall activity of the patient increases.
- Central analgesics (tramadol). They are used to relieve acute pain. The analgesic effect of tramadol potentiates its reception together with paracetamol. Side effects are pronounced (dizziness, weakness, nausea), a long course of treatment is addictive.
- Local anesthetics (lidocaine). They are used as part of course treatment in the form of infusions. When injected locally into trigger points, they have a local and general analgesic effect.
Prognosis and prevention
Fibromyalgia is a chronic pathology. Regular comprehensive treatment can reduce pain by 30-50%, normalize sleep, reduce anxiety and depression, improve the efficiency and quality of life of patients. The best prevention of the disease is a positive attitude to life, a benevolent view of events, caring for others as opposed to excessive concentration on inner feelings. People who have developed such an attitude to life are protected from the likelihood of disease, even if there is a genetic predisposition.