Fibromyalgia: a real disability

Simon Hayhoe
GM,

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Introduction
Definition
Pathophysiology
Treatment
Pharmacological Non – pharmacological treatment
Diagnosis
Conclusion

Introduction
Fibromyalgia is part of the spectrum of central sensitivity syndromes and has symptoms that include generalized muscle pain, disordered and unsatisfactory sleep, fatigue and confused thinking, along with a variety of intrusive comorbidities that combine to make life difficult for both the patient and the patient. of the doctor.

Symptoms, while unpleasant, seem nonspecific initially and therefore it is often a year before presentation to a GP. Then it takes on average another two more years with multiple investigations and consultations involving multiple physicians before a fibromyalgia diagnosis is agreed upon. 3 There is evidence that physical or mental trauma or infection can act as a trigger, but there is also a family relationship with genetic susceptibility through genetic polymorphisms involved in the serotonin and dopamine pathways. 4-6

Population surveys in various countries have found similar levels of fibromyalgia-equivalent self-reported symptoms that vary primarily by estimation method. They provide an overall prevalence of 3-8% in women and 1-5% in men, but if restricted to a disease formally diagnosed as fibromyalgia, the rates are only 2% in women and 0.2% in men. However, there is a clear relationship between age and peak prevalence in people aged 50 to 70 years, and 10% of European women report fibromyalgia symptoms at age 80. 7.8

Definition
An early description (17th century) of a fibromyalgia-like disease was called muscular rheumatism. 9 Since then it has gone by various names, including psychogenic rheumatism and fibrositis, and it seems very similar to the popular Victorian disease of neurasthenia. Possible high-profile patients include Darwin and Florence Nightingale; in fact, International Fibromyalgia Awareness Day is on your birthday (May 12). However, it was not until 1990 that the American College of Rheumatology specified formal criteria for the diagnosis of fibromyalgia as: generalized pain for at least three months, above and below the waist, affecting both sides of the body and includes the axial skeleton; more tenderness in 11 or more than 18 specific sites (bilateral). They also stated that having another disorder still allows for the additional diagnosis of fibromyalgia. 10

In formulating these criteria, Wolfe et al reported that, unsurprisingly, many patients (65%) have “pain all over the place”, but also 76% complain of stiffness, particularly in the morning and even after exercise. mild, and also paresthesia (58%). However, the main complaint other than pain is fatigue (85%) associated with disturbed and non-restorative sleep (75%). In addition, he complains of a variety of comorbidities: headache (51%), irritable bowel syndrome (35%), anxiety (51%), depression, temporomandibular joint disorder, and restless legs syndrome. 10 These symptoms and comorbidities were not included in the 1990 criteria, although doctors often made the diagnosis of generalized pain in conjunction with fatigue,

As a result, 20 years after the original, the American College published revised criteria that rate fatigue, restful sleep, and cognitive impairment, as well as the number of painful areas. 11 Additionally, there is a score for the number of comorbidity symptoms (out of 40 commonly found). A checklist can be downloaded from the Fibromyalgia Network. 12 This provides a much more effective overview of the spectrum of “fibromyalgia” 13 but emphasizes the overlap of symptoms with chronic fatigue syndrome, post-viral syndrome, myalgic encephalomyelitis, post-traumatic stress disorder and related conditions, such as myofascial pain syndrome and irritable bowel syndrome. In fact, Yunus has proposed that all of this be considered as part of a spectrum of “Central Sensitivity Syndromes” in which there is brain sensitization with neuroendocrine dysfunction, resulting in reports of multiple symptoms. 14 There also appears to be a spectrum within fibromyalgia itself: up to five subgroups have been described, 15,16 and each may respond differently to medical treatment.

Because central sensitization can occur after a variety of physical and mental stresses, the diagnosis of fibromyalgia can be made in addition to another condition, most often rheumatoid or osteoarthritis, lupus, or another rheumatoid disease, but the American National Health Survey of 2012 found that 23% of fibromyalgia patients had diabetes, 30% had asthma, 56% had migraines, and 62% had depression. 17 In addition, 39% smoke, 47% are obese, and 54% have hypertension with 16% other heart conditions, so it is not surprising that fibromyalgia is a predictor of myocardial infarction and stroke. 18.19

Pathophysiology
Fibromyalgia patients show hyperalgesia, allodynia, and expansion of cortical receptive fields, whereby painful stimuli are felt more intensely, non-painful stimuli such as touch and mild pressure are felt as pain, and stimuli outside of an area sensitive can also be felt as pain. . FMRI research has shown that fibromyalgia patients feel pain at a 50% lower stimulus level compared to normal subjects, and that connections between areas of the brain involved in pain perception increase and those related to emotion, thought and memory. This results in a mental focus on the pain, with catastrophic thinking improving mild pain to become intolerable. Also, It gives rise to the forgetfulness and confused thinking (unknowing) of which fibromyalgia complains, which has been called “fibrofog”. 22

M-opioid receptors in areas of the brain key to pain and emotion regulation appear to be off, despite an increase in endorphin levels. 23 Furthermore, serum levels of the neurotransmitters serotonin and norepinephrine are reduced in fibromyalgia. These are involved in the perception of pain through the descending inhibitory pathway, and also in sleep, fatigue, cognition, and mood. Substance P levels, on the other hand, rise. This improves the transmission of pain, stress and anxiety. 6 So, in total, these neurotransmitter changes, along with central neurological changes, conspire to promote symptoms of generalized pain, anxiety, poor sleep, fatigue, and fuzzy thinking.

Sleep disruption experiments can reproduce these fibromyalgic symptoms, 24 and patients show an EEG pattern similar to that of deep sleep deprived subjects with type a waves of excitation that intrude on normal d waves of deep sleep. 25 Additionally, sleep disorders cause an increase in pro-inflammatory cytokines that increase pain and further disrupt sleep. 26

Drug treatment
The main drug treatment, therefore, aims to increase the levels of serotonin and norepinephrine. The most popular medication for fibromyalgia is amitriptyline, which inhibits the transporters of serotonin and norepinephrine. 27 It also has an affinity for histamine, cholinergic, and other adrenergic receptors, thus initially having the side effects of heavy sedation, dry mouth, and constipation, however these generally disappear after a couple of weeks and a low dose 10-25 mg at night. lessens the problem while helping you sleep. Modern antidepressant drugs that increase serotonin, although more expensive, appear to have fewer side effects for fibromyalgia patients. 28 Duloxetine, A serotonin norepinephrine reuptake inhibitor (SNRI), it has been specifically approved by the United States Food and Drug Administration for use in fibromyalgia. Pregabalin, another approved drug, is an antiepileptic that works by decreasing the entry of calcium ions into nerve endings, thereby reducing the release of glutamate and substance P. It is used to treat neuropathic pain and also acts as an anxiolytic and stabilizer of the mood with the added benefit of reducing the symptoms of a common fibromyalgia comorbidity: restless leg syndrome. 29,30 It is doubly effective when taken in combination with an SNRI if the patient can tolerate both. 31 It has been specifically approved by the US Food and Drug Administration for use in fibromyalgia. Pregabalin, another approved drug, is an antiepileptic that works by decreasing the entry of calcium ions into nerve endings, thereby reducing the release of glutamate and substance P. It is used to treat neuropathic pain and also acts as an anxiolytic and stabilizer of the mood with the added benefit of reducing the symptoms of a common fibromyalgia comorbidity: restless leg syndrome. 29,30 It is doubly effective when taken in combination with an SNRI if the patient can tolerate both. 31 It has been specifically approved by the US Food and Drug Administration for use in fibromyalgia. Pregabalin, another approved drug, is an antiepileptic that works by decreasing the entry of calcium ions into nerve endings, thereby reducing the release of glutamate and substance P. It is used to treat neuropathic pain and also acts as an anxiolytic and stabilizer of the mood with the added benefit of reducing the symptoms of a common fibromyalgia comorbidity: restless leg syndrome. 29,30 It is doubly effective when taken in combination with an SNRI if the patient can tolerate both. 31 is an antiepileptic that works by decreasing the entry of calcium ions into nerve endings, thus reducing the release of glutamate and substance P. It is used to treat neuropathic pain and also acts as an anxiolytic and mood stabilizer with the added benefit that Reduces the symptoms of a common comorbidity of fibromyalgia: restless legs syndrome. 29,30 It is doubly effective when taken in combination with an SNRI if the patient can tolerate both. 31 is an antiepileptic that works by decreasing the entry of calcium ions into nerve endings, thus reducing the release of glutamate and substance P. It is used to treat neuropathic pain and also acts as an anxiolytic and mood stabilizer with the added benefit that Reduces the symptoms of a common comorbidity of fibromyalgia: restless legs syndrome. 29,30 It is doubly effective when taken in combination with an SNRI if the patient can tolerate both. 31 30 It is doubly effective when taken in combination with an SNRI if the patient can tolerate both. 31 30 It is doubly effective when taken in combination with an SNRI if the patient can tolerate both. 31

Because inflammation is not a major feature of fibromyalgia, steroids are not suitable and nonsteroids are generally not beneficial unless there is comorbid arthritic or rheumatoid disease. Strong opioids are rarely helpful due to the unavailability of m-opioid receptors. They are not appropriate for chronic fibromyalgia pain, while reducing mobility and worsening fatigue. However, some patients find buprenorphine patches helpful, as this has some antihyperalgesic effect. Recent and intriguing work has shown that the opioid antagonist naltrexone has significant analgesic effects in fibromyalgia. 32 At a low dose of 3-5 mg, It appears to antagonize the immune cell (microglial) receptor in the central nervous system, which reduces the production of pro-inflammatory cytokines, reverses hyperalgesia, and improves the so-called “disease behavior” attributed to microglial activation. This could prove to be an effective future treatment, but major trials are needed. The only true pain reliever generally helpful in fibromyalgia is tramadol (often combined with acetaminophen) which, in addition to being a weak opioid, has SNRI action. 33 However, beware of serotonin toxicity in patients also taking other serotonin-increasing medications. it reverses hyperalgesia and improves the so-called “disease behavior” attributed to the activation of microglia. This could prove to be an effective future treatment, but major trials are needed. The only true pain reliever generally helpful in fibromyalgia is tramadol (often combined with acetaminophen) which, in addition to being a weak opioid, has SNRI action. 33 However, beware of serotonin toxicity in patients also taking other serotonin-increasing medications. it reverses hyperalgesia and improves the so-called “disease behavior” attributed to the activation of microglia. This could prove to be an effective future treatment, but major trials are needed. The only true pain reliever generally helpful in fibromyalgia is tramadol (often combined with acetaminophen) which, in addition to being a weak opioid, has SNRI action. 33 However, beware of serotonin toxicity in patients also taking other serotonin-increasing medications.

Despite the availability of seemingly powerful drugs, a benefit can only be claimed for half of those who can take them, 31 and even then success is only partial and almost never a cure. A major problem is that some fibromyalgia patients suffer from the comorbidity of “multiple chemical sensitivity” and many are hypersensitive to most medications, so excessive side effects prevent them from taking any of the more helpful medications, or mean reducing dosing at a level that offers minimal benefit. Non-pharmacological and complementary therapies therefore offer an uncomplicated perspective of helping to modify frustratingly intrusive symptoms and should be considered as the mainstay of treatment, certainly in the elderly (Box 1). 34.35

Non-pharmacological treatment
A particularly frustrating feature of fibromyalgia, in common with chronic fatigue syndrome, is that after mild exercise, such as grocery shopping or light gardening, the patient may feel racked with pain and remain in bed for the duration. next days. However, gradual exercise is a vital element in rehabilitation. To be acceptable, this requires trust in the physician and effective education about the condition, so that it is understood that post-exercise disorders have no long-term effects and become less intense if exercise has been carefully graded and, if it is possible, taken in conjunction with hydrotherapy or at least a warm bath for post-exercise relaxation.

Of the working-age patients, 56% report that they are unable to work due to their fibromyalgia (71% for men). This substantially reduces social contact and results in isolation, particularly since a high proportion (49%) are not married, divorced or separated, allowing them to focus more on their disability. 17 Distraction from work and social contact has been shown to be beneficial in reducing pain and enhancing rehabilitation through increased self-confidence. Therefore, it is important to encourage patients to socialize and seek employment, even if they only help out in a charity – employers today are legally required to take disability into account.

Among complementary therapies, acupuncture has the best clinical evidence. In fact, about 20% of fibromyalgia patients have tried acupuncture within two years of diagnosis. 37,38 It has been found to increase the synthesis and release of serotonin and norepinephrine, and mild acupuncture can improve oxytocin levels, with consequent calming effects. 39-41 Therefore, it appears to be in a good position to offer benefits to fibromyalgia sufferers, particularly as it appears to have synergistic action with the more common fibromyalgia drug treatment, amitriptyline, 42 and has been shown to be effective for several of common comorbidities such as headaches, restless legs syndrome, and irritable bowel syndrome.

Most fibromyalgia patients have more than one comorbidity, some several, so making improvements in these, by any means, can substantially improve quality of life. Also, since sleep disturbance is a major factor in fibromyalgia, attention to standard sleep hygiene can pay dividends, and melatonin may be helpful for some patients. But, in general, the recommendation is that a combination of physical, psychological and pharmacological therapies offers the best opportunity for significant improvement, both for fibromyalgic symptoms and for quality of life. 43 However, for the greatest benefit, treatment should be started as soon as possible, before central sensitization has become firmly established.

BOX 1: APPROPRIATE TREATMENTS FOR FIBROMYALGIA

           Educación como estándar para todos los tratamientos.

Physical and psychological

Level of evidence

Cognitive behavioral therapy (CBT)

Alto

Gradual exercise / walking

Alto

Hydrotherapy / Balneotherapy / Swimming

Moderate

Acupuncture / Electroacupuncture

Moderate

Combine some or all of the above and add drug therapy if needed

Drug therapy

Amitriptyline 10-25mg at night

Alto

Replace with duloxetine (SNRI)

Alto

Add pregabalin (or gabapentin)

Alto

Tramadol (or Tramacet) for analgesia if needed

Moderate

Diagnosis
Since fibromyalgia symptoms, particularly in the elderly, can be found as an accompaniment to another illness, they should be sought if a patient complains of pain and exhaustion beyond what was expected after treatment of his original problem. However, other causes of myalgic pain should be considered before diagnosing fibromyalgia, either alone or in addition.

Polymyalgia rheumatica has similar symptoms but a more dramatic presentation and increased muscle stiffness. It is easily treatable and should not be missed. Other rheumatic diseases can be associated with fibromyalgia, particularly rheumatoid arthritis, systemic lupus erythematosus, and polymyositis. Fibromyalgia-like symptoms can also be caused by some infections such as hepatitis, infectious mononucleosis, and Lyme disease. All can be identified or excluded with simple investigations such as ESR, complete blood count, liver function tests, and possibly tests for C-reactive protein, rheumatoid factor, or antibodies. A subset of fibromyalgia patients have mild hypothyroidism, so thyroid function tests and subsequent treatment can make a difference in fatigue symptoms. In addition to this, be aware of drug-induced myalgias, particularly statins, ACE inhibitors, and cocaine. Once the above is eliminated, it is important to accept the fibromyalgia diagnosis, stop more, more intrusive, investigate and institute a treatment regimen as soon as possible.34,44

Due to the early psychological influence of fibromyalgia and its subjective diagnosis and evaluation without supporting evidence from blood tests or imaging, there have been questions about its status as a real disease. Illness or disorder may be more appropriate terms, although there is no doubt that it is a disability. 14 Furthermore, the very name fibromyalgia seems to give some patients permission to retire from active life and live on disability pay, a course that cognitive behavioral training can be used to try to avoid, but one consequence is that some physicians are reluctant to make the diagnosis.

Certainly, causal attribution and diagnosis label can influence recovery, 45,46 and “fibromyalgia” has negative connotations, but there is evidence that after diagnosis there is a reduction in the previous high level of health care costs and that patients with late diagnosis report their pain and other symptoms are more severe and their satisfaction with treatment is lower. Therefore, an early diagnosis with the initiation of therapy is important, although if it is considered that a patient would not respond well to the term fibromyalgia, then the diagnosis could reasonably be given as “muscular rheumatism” or “central sensitivity syndrome” and, if appropriate, then improve fibromyalgia.

The symptoms of fibromyalgia are very sensitive to stress and external elements such as the weather (usually improves in the summer), family problems or legal problems. Therefore, levels of disability fluctuate, sometimes quite a lot, making treatment interpretation difficult. However, a useful aid in response assessment is the validated, yet self-rated, Fibromyalgia Impact Questionnaire, which provides a comprehensive assessment, both psychological and physical, and provides a reasonable overview of quality of life and ability to respond. coping. 47 Versions of this questionnaire are available for download from Arthritis Research. 48

Conclusion
Fibromyalgia is an unsatisfactory disorder to treat. Due to their disabling symptoms, patients are unreliable to keep appointments; they are often unable to take medications, and when they do, they only partially respond to them. Some of the most effective treatments are non-drug: graded exercise, hydrotherapy, and cognitive behavioral therapy, but these are difficult to maintain. Despite this, patients are generally very grateful for an understanding physician who understands and believes in their distress, even if there is little apparent change in their symptoms.

Conflict of interest: none declared

Dr. Simon Hayhoe

Formerly with the Department of Pain Management, University Hospital, Colchester

simonhayhoe@doctors.orguk

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