Фіброміалгія

Current evidence suggests fibromyalgia may be a centrally mediated disorder of pain sensitivity. The cause is unknown, but disruption of stage 4 sleep may contribute, as can emotional stress. Fibromyalgia may temporally follow a viral or other systemic infection (eg, Lyme disease or perhaps COVID-19 infection [1]) or a traumatic event, but additional or prolonged antiviral or antibiotic therapy is not indicated because it has not been demonstrated to be effective.

Stiffness and pain frequently begin gradually and diffusely and have an achy quality. Pain is widespread and may worsen with fatigue, muscle strain, or overuse.

Patients typically have a variety of somatic symptoms. Fatigue is common, as are cognitive disturbances such as difficulty concentrating and a general feeling of mental cloudiness. Many patients also have symptoms of irritable bowel syndrome, interstitial cystitis, or migraine or tension headaches. Paresthesias may be present, typically bilaterally and often migratory.

Symptoms can be exacerbated by concomitant disorders such musculoskeletal pain in patients with an inflammatory arthritis (eg, rheumatoid arthritis) or sleep disturbances in patients with obstructive sleep apnea or depression.

Patients may be stressed, tense, anxious, fatigued, ambitious, and sometimes depressed. Patients are not uncommonly high-achieving perfectionists.

Physical examination is unremarkable except that specific, discrete areas of muscle (tender points) are variably tender when palpated. The tender areas are not swollen, red, or warm; such findings should suggest an alternative diagnosis.

• Clinical criteria

• Usually testing and a detailed physical examination to exclude other disorders

Fibromyalgia is suspected in patients with the following:

• Generalized pain and tenderness, especially if disproportionate to physical findings

• Negative laboratory results despite widespread symptoms

• Fatigue as a predominant symptom

The diagnosis of fibromyalgia should be considered in people who have had widespread pain for at least 3 months, particularly when accompanied by various somatic symptoms. Pain is considered widespread when patients have pain in the left and right side of the body, above and below the waist, and in the axial skeleton (cervical spine, anterior chest or thoracic spine, or low back).

The diagnosis is based on clinical criteria from the American College of Rheumatology (1), which include a combination of joint and usually non-joint pain (sometimes including widespread body-wide pain) and the presence of various other cognitive and somatic symptoms, such as those listed above, which are graded in severity. Previous criteria relied on the presence of tenderness at some of 18 specified tender points. This criterion was eliminated because of difficulty in evaluating tenderness consistently, the tender points may fluctuate in intensity, and it was thought advantageous to have criteria that are entirely symptom-based. However, tenderness is quite common, and some specialists continue to assess it systematically.

Tests for other causes of patient symptoms should include erythrocyte sedimentation rate (ESR) or C-reactive protein, creatine kinase (CK), and probably tests for hypothyroidism and hepatitis C (which can cause fatigue and generalized myalgias). Fibromyalgia does not typically cause abnormalities in these tests. Other tests (eg, serologic testing for rheumatic disorders) should be done only if indicated by findings on history, physical examination, and/or routine laboratory tests.

To avoid potential pitfalls, clinicians should consider the following:

• Fibromyalgia is often overlooked in men, children, and adolescents.

• Systemic exertional intolerance disease (SEID) (formerly chronic fatigue syndrome or myalgic encephalomyelitis) can cause similar generalized myalgias and fatigue, and laboratory test results are typically normal.

• Polymyalgia rheumatica causes more focal pain around the shoulders and hip girdle, particularly in older adults; it is more symptomatic in the morning and is usually accompanied by high ESR and C-reactive protein levels.

• In patients with systemic rheumatic diseases, diagnosing coexistent fibromyalgia may be more difficult, but it is quite common. For example, fibromyalgia may be misinterpreted as an exacerbation of rheumatoid arthritis, ankylosing spondylitis, or systemic lupus erythematosus.

• Stretching and aerobic exercise, local heat, and massage

• Stress management

• Medications such as tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, GABA-ergic agents, or cyclobenzaprine

• Nonopioid analgesics

Stretching exercises, aerobic exercises, sufficient sound sleep, local applications of heat, and gentle massage may provide relief. Overall stress management (eg, deep breathing exercises, meditation, psychologic support, counseling if necessary) is important.

Exercises to gently stretch the affected muscles should be done daily; stretches should be held for about 30 seconds and repeated about 5 times. Aerobic exercise (eg, fast walking, swimming, exercise bicycling) can lessen symptoms.

Improving sleep is critical. Patients should be screened for sleep disorders (eg, obstructive sleep apnea) and other factors that may interfere with sleep. Good sleep hygiene should also be emphasized.

Pharmacologic therapies for fibromyalgia (eg. amitriptyline, duloxetine, milnacipran, and pregabalin) could be used as adjuncts to exercise to improve sleep and manage stress; they may modestly reduce pain. Sedating medication,s such as low-dose oral tricyclic antidepressants (eg, amitriptyline 10 to 50 mg) or the pharmacologically similar cyclobenzaprine), are taken at bedtime and may promote deeper sleep and decrease muscle pain. The lowest effective dose should be used. A serotonin-norepinephrine reuptake inhibitor (eg, duloxetine) is a reasonable alternative, particularly for patients with severe fatigue and depression. Pregabalin and gabapentin may also be particularly useful for patients with more severe sleep problems. Drowsiness, dry mouth, and other adverse effects may make some or all of these medications intolerable, particularly for older patients.

Nonopioid analgesics (eg, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) may help some patients. Opioids should be avoided.

Occasional injections of 0.5% bupivacaine or 1% lidocaine 1 to 5 mL may relieve incapacitating areas of focal tenderness, but such injections should not be relied on as primary treatment because evidence does not support their regular use, and does not address the widespread pain caused by fibromyalgia.

Medications taken by the patient should be reviewed to identify those that may aggravate sleep problems. Such medications should be avoided. Anxiety, depression, and especially bipolar disorder, if present, should be addressed.

Evidence also supports use of capsaicin, biofeedback, massage, hypnotherapy, chiropractic interventions, and other complementary and alternative therapies that are a part of the European Alliance of Associations for Rheumatology (EULAR) recommendations for management of fibromyalgia (1). Although randomized trials and systematic reviews have evaluated some of these therapies against controls, the overall effects of these therapies are small.

Fibromyalgia tends to be chronic but may improve spontaneously if stress decreases. It can also recur at frequent intervals. Functional prognosis is usually favorable for patients being treated with a comprehensive, supportive program, but symptoms tend to persist to some degree. Prognosis may be worse if there is a superimposed mood disorder that is not addressed.