Fibromyalgia, pain-sensitive

Fibromyalgia

What is fibromyalgia?

Fibromyalgia is one of the most common causes of pain and, in recent years, has gained increasing importance, to become a public health problem of the first order. In Spain, more than a million people are affected by fibromyalgia and chronic fatigue, although the figures are not accurate because they are diseases in which the diagnosis is difficult or is delayed relative to the appearance of the first symptoms.
is a chronic condition characterized by widespread musculoskeletal pain and reduced pain threshold, with increased tenderness to pressure at certain points of the body. This pain occurs mainly in muscle areas, with no apparent damage, and the patient has high sensitivity to any physical contact or temperature change.
Fibromyalgia is often associated with other health problems such as poor quality of sleep, morning stiffness, fatigue, depression and anxiety, headache, irregular bowel habits, diffuse abdominal pain, muscle cramps and feel bloated opinion.
Fibromyalgia rheumatologic disease is the third most commonly diagnosed after the osteoarthritis and rheumatoid arthritis. It is more common in women, so that is diagnosed in a male for every eight women. The mean age at which diagnosis predominates is around 40-49 years, although the first symptoms may appear between 20 and 40 years.
disease can be associated with other chronic pathologies such as rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis and Sjögren's syndrome.
In 1992 the World Health Organization (WHO) has recognized fibromyalgia as a rheumatic disease.

Causes of fibromyalgia

Both the causes that trigger fibromyalgia , as the form of this disease occurs, are unknown at the moment.
But there is some evidence on the mechanisms that can lead to a picture of fibromyalgia:

• Imbalance of neurotransmitters in the nervous system (substances produced by neurons in the brain). There is a change in the regulatory mechanisms of pain, the autonomic nervous system (nervous system of the body) and mood.
• Altered levels of certain substances neurochemical processes involved in producing increased susceptibility to pain: serotonin, tryptophan, substance P, glutamic acid.
• Alterations in the arrival of blood flow to certain brain structures (it was found by imaging studies).
• Certain genetic basis or genetic predisposition. Fibromyalgia occurs in 28% of children of affected patients, and there is influence in relatives of affected patients (8.5% more frequent with affected relatives).
• Triggers and precipitating factors: chronic infections, viral infections, inflammatory processes, or muscular disorders. Recently we have discovered a retrovirus (type of virus, XMRV), which is believed may be involved in fibromyalgia.
• Affective spectrum; very often associated with fibromyalgia depressive symptoms, but may be specified if fibromyalgia appears first and thereafter, depression, or vice versa.

Overall there is an over-stimulation of all body systems, but the final answer to pain is not adequate. Known data on fibromyalgia suggest that disease symptoms are probably caused by a central disturbance (in the brain) of the sensitivity to pain, rather than by a dysfunction in the peripheral tissues of the body. These imbalances cause the patient to experience severe pain in the tissues, with no apparent damage on them.
Though psychological factors have a great influence on the symptoms of fibromyalgia and associated problems, is not considered appropriate inclusion in the group of common mental disorders.
has been shown that the disease is triggered when a person with this predisposition receives any impact as an accident, trauma, surgery, exposure to toxic substances, viral infections, etc. .

Symptoms of Fibromyalgia

Pain is the predominant symptom in fibromyalgia: chronic, widespread, affecting large muscle areas: around the spine, at the origin of the limbs, in the cervical region, shoulders, arms, lower back, hips and thighs, and so on.
The patient defines pain as continuous, with fluctuations over time, worse in the morning and improves during the day partly to deteriorate again in the afternoon and evening. Pain also worsens if the patient remains in the same position, with physical loads, emotional arousal and climate change. Is characteristic pain intensity, which by patients as intense and unbearable is defined.
Another typical symptom of fibromyalgia is the physical and mental exhaustion . Fatigue is present in over 70% of patients; may appear as crisis depletion of one or two days, or more often, continuously.
The third symptom is often sleep disturbance , which correlates with the intensity of the syndrome.
Moreover, there are other possible symptoms the fluctuating fibromyalgia , which can be combined with the above:  

• Muscle stiffness and spasms in various muscle groups.
• Headaches.
• Intestino irritable.
• Cold extremities, increased sweating, palpitations.
• Intolerance to drugs and chemicals.
• Dry mouth and eyes.
• Pain in the jaw.
• Problems with concentration and memory; affective symptoms such as anxiety or mood disorder.
• Dizziness and unsteadiness.

Degrees of impairment in fibromyalgia

It is important to assess the degree of impairment in fibromyalgia, as there are different degrees of functional assessment in Spain ranked:

• Grade I - mild vital involvement: clinical assessment scales with scores below 50% without interfering with the operation or work.
• Grade II - moderate vital apportionment score between 50% and 75%, and interference with the functioning and work (partial loss of activity).
• Grade III - Severe vital involvement: clinical assessment scales above 75% and marked interference with the functioning and work; inability to perform the job, or situation of temporary sick leave.

Diagnosis of fibromyalgia

The diagnosis of fibromyalgia is clinical, ie, based on the symptoms presented by the patient. Still no specific diagnostic tests to confirm fibromyalgia, or laboratory tests, or imaging or biological tests are known. These explorations are intended to rule out the possible existence of other medical conditions with similar symptoms.
should be developed a detailed medical history based on the symptoms reported by the patient and performing a good physical examination. Blood tests and imaging tests may be performed, in order to rule out other causes of illness that may confound the diagnosis: depression, lupus, infections, thyroid problems, or other rheumatologic or orthopedic diseases. It is also possible that these pathologies can coexist with fibromyalgia.
All this complicates the diagnosis of this disease, in fact it is estimated that 75% of patients are not diagnosed.
There are diagnostic criteria for fibromyalgia developed by the American College of Rheumatology in 1990 (ARC 1990 criteria) for the diagnosis of fibromyalgia :

• Continuous and widespread musculoskeletal pain , more than three months' duration, affecting at least three of the four body quadrants.
• Pain and tenderness in the so-called 'trigger points' : 18 tender points, of which at least 11 must be positive. These trigger points are located at the level of the occipital region, lower cervical region of the trapezius and supraspinatus (side and back of the neck), second intercostal space (anterior portion of the thoracic region), elbow, buttock, hip and knee muscles.

The ACR criteria have been useful in that they have allowed to better define and detect fibromyalgia patients affected by this disease, but are being revised because, in addition to chronic, widespread musculoskeletal pain, other symptoms should be assessed accompanying the disease (neurological manifestations, cognitive, psychological, endocrine, etc.) and to help identify the patient with fibromyalgia.
Additional criteria for the diagnosis of fibromyalgia propose the most recent need for pain sensitive only five points, but include the absence of other diseases such as mandatory criteria, as well as the presence of three minor criteria of the following:

• Changes of symptoms by physical activity.
• Alterations of symptoms by weather factors.
• Worsening of symptoms with stress.
• Not sleep.
• General fatigue.
• Headaches.
• Colon irritable.
• Burning sensation.
• Paresthesia.
• Anxiety.

It should be in the differential diagnosis, ie, we must rule out other diseases as a cause of symptoms, before concluding in the diagnosis of fibromyalgia. Among the diseases to consider are:

• Diseases with widespread pain and fatigue.
• Inflammatory joint diseases.
• Autoimmune diseases.
• Neurodegenerative diseases.
• Endocrine diseases.

Treating Fibromyalgia

Treatment to cure fibromyalgia is unknown. In fact, it is believed that the more medications taken by the patient with this disease, the worse the prognosis. This is because many drugs contain chemical compounds that worsen the health of a high percentage of patients with fibromyalgia, because they exhibit certain chemical sensitivity, being more susceptible to adverse reactions.
In the treatment of fibromyalgia agents and measures are used not Pharmacological:

Pharmacological treatment for fibromyalgia

Its aim is:

• Relieve pain.
• Improve the quality of sleep.
• Eliminate fatigue and associated problems.
• Maintaining and restoring emotional balance.

Medications for Fibromyalgia

At the moment there exists no authorized in Europe by the European Medicines Agency indicated in the treatment of fibromyalgia drug. Then the most commonly used for the relief of symptoms of fibromyalgia agents are associated:

• Analgesics: tramadol, acetaminophen, or the combination of both drugs.
• Anti-inflammatories: In studies of treatment outcome research with these drugs has not been shown effective in treating the symptoms of fibromyalgia. Is not recommended, therefore, their use systematically.
• Benzodiazepines (muscle relaxants, anxiolytics) should be used with caution because of the risk of dependence, nor have demonstrated effectiveness.
• Other muscle relaxants such as cyclobenzaprine have obtained good results for symptomatic management for antidepressants similar to real effect.
• Anticonvulsants: gabapentin and pregabalin. In clinical trials have demonstrated decreased pain and fatigue, and improved sleep and quality of life.
• Antidepressants: amitriptyline could be considered as first-line drug for the treatment of fibromyalgia, especially if the patient has difficulty falling or mood disorders. Other antidepressants: fluoxetine, paroxetine, duloxetine and venlafaxine.
• Other drugs such as steroids, opioids (major analgesics), melatonin, have not demonstrated efficacy, and also have numerous side effects

Non-pharmacological treatment for fibromyalgia

It aims to improve functional ability and quality of life for people with fibromyalgia. Its pillars are:

• Patient education.
• Performing an exercise program and proper stretching.
• Cognitive Behavioral Therapy.

In most cases it will be advisable to use a multi-pronged strategy, combining different therapeutic possibilities, emphasizing the council maintain activity, as patients always have to stay active.
should be stressed the need to provide basic information to patients on this condition and the best way to manage therapeutic options. Where deemed necessary, patients must be motivated to undertake self-help programs.

• Physical activity (exercise): the completion of a supervised exercise program, may have beneficial effects on the physical ability of the patient and fibromyalgia symptoms in the short term. Must be personalized with a physical activity 2-3 times per week, of gradual onset, and avoiding exercises that cause pain to force a particular area. The most suitable physical activity is aerobic, such as gymnastics, dance, swimming and water aerobics. Aerobic exercise helps improve performance and sometimes helps decrease the pain threshold.
• Psychological therapy. Cognitive-behavioral therapy is based on the idea that perceptions that an individual has about himself and his environment affect their emotions and their behavior. We must assess the aspects that characterize the disease: knowledge of it, involvement in daily life and ability to cope.

The goal of therapy is to change the idea that a person has about their pain to adopt a more positive attitude against the disease. There are very consistent evidence on treatment outcomes, both psychological and behavioral, in fibromyalgia. Reduces the intensity of pain and fatigue, and improve mood and functional ability.
Cognitive behavioral therapy is done in weekly sessions of approximately two hours, in groups, and raising a number of useful strategies to address various aspects disease, with a practical approach to the usual means.

Other alternative treatments for fibromyalgia

• Hypnotherapy and relaxation from meditation has not been demonstrated to improve pain and functional capacity.
• The tender point injection, transcutaneous nerve stimulation and laser treatment have not demonstrated efficacy.
• Acupuncture also has shown favorable results.

Conclusions about treatment of fibromyalgia

Regarding the treatment of fibromyalgia will have to consider several points:

• Treatment of fibromyalgia requires a multidisciplinary approach, ie precisely the collaboration of several specialists: family physicians, rheumatologists, physiotherapists and psychologists.
• In some Spanish Communities are specific to the treatment of fibromyalgia units, such as Catalonia and the Basque Country.
• The ultimate goal of treatment is to improve the care of patients with fibromyalgia: early diagnosis with early onset and therapeutic avoiding unnecessary diagnostic testing and promote access to the health system from treatments of psychotherapy and physical activities.
• Overall, the combination of pharmacotherapy with an exercise program is associated with better results than exercise alone.

Forecast fibromyalgia

There is no cure for fibromyalgia yet, so it must be considered as a chronic disease, and keep in mind that the quality of life of the sick person is affected in several of its facets: labor, economic, social and family .
Most patients continue to experience pain and fatigue. Two thirds of patients say they can maintain their ability to work and recognize that fibromyalgia interferes little with his life, and another 30% do not feel qualified to work. In Spain, a study of the Spanish Society of Rheumatology, fibromyalgia is a musculoskeletal disease that produces lower occupational disability. Still, only a small percentage of affected people receiving benefits.
Comparing patients with fibromyalgia with other groups of people with chronic pain, they have a greater sense of incapacity and disability.
A number of psychological factors associated with a better prognosis: feeling pain control, self-perception of being functionally capable not interpret pain as a sign of damage, physical exercise, and perform routine tasks systematically.

Recommendations for Fibromyalgia

A major difficulty to be overcome fibromyalgia patients is the profound ignorance of the syndrome by society. In general, fibromyalgia is only a reality for the circle of family and close friends of patients, other professionals in contact with patients. There is, therefore, an underestimation of the potential incapacitation of fibromyalgia, which means added to the patient in their struggle to overcome the difficulties that this condition introduces basic aspects of daily life obstacle.
Consider several points for approach to social problems associated with this disease:

• The patient with fibromyalgia should be informed from the beginning about your symptoms and prognosis , desdramatizando the course of the disease with the contribution of positive expectations, and fostering collaboration with patient therapies confidence in a likely improvement.
• Be fundamental improvement in the training of professionals involved in dealing with fibromyalgia to ensure an adequate response to the needs of the patient.
• A basic question to be considered is the social work approach, since the possibility of developing a business, activity compatible with the evolution of fibromyalgia, it is helpful for the patient. It would be necessary to promote, therefore, close coordination between the health services, occupational health services and human resources departments of companies, in order to facilitate maximum employment integration of those affected by fibromyalgia.
• In the case of incompetent patients as a result of this disease, you should get the development of protocols, such inability to evaluate and qualify patients within any of the degrees of disability recognized in the regulations of the Social Security or disability .
• Because of the prevalence of fibromyalgia and its important individual, family and social impact, it would be advisable to intensify clinical research on this disease.

The basic points to improve the quality of life despite the diagnosis of fibromyalgia could be:

• Understand clearly the meaning of this condition.
• Follow appropriate drug therapy, and psychological, if applicable.
• Reduce stressors, improving lifestyle with healthy habits and avoiding toxic.
• Perform aerobic exercise.

Article contributed for educational purposes