[Fibromyalgia--a new name for a syndrome with diffuse muscular disorders]

This new name for an old and common disease has introduced fresh criteria and initiated clinical and basic research. The present clinical knowledge of the diagnosis and treatment is reviewed. Morphological and biochemical findings in the muscle of fibromyalgia patients have shown an unevenly distributed reduction of the oxygen tension. Hypoxia in the muscle sensitizes nociceptors, resulting in hyperalgesia with a diffuse distribution of pain symptoms. These are difficult for the individual to localize and are often combined with muscle stiffness and increased fatigability. These symptoms correspond to complaints received from fibromyalgia patients.

Evaluation and differential diagnosis of fibromyalgia. Approach to diagnosis and management

The combination of widespread musculoskeletal pain, high tender point count, and nonrestorative sleep are sufficient criteria for the diagnosis of fibromyalgia. The condition is primary in the absence of underlying disease and is considered concomitant or secondary when closely associated with another organic disease. Despite more simplified diagnostic criteria, the work-up for fibromyalgia must always be directed toward excluding the underlying causes. In addition to general and rheumatic history and physical examination and selected laboratory studies, careful attention to defining any existing sleep and mood disturbances is important in designing a management program. Although 46 medical conditions have been associated with fibromyalgia, a practical differential diagnostic list included polymyalgia rheumatica, myofascial pain, connective tissue disease, endocrine myopathies, psychoneuroses, and other chronic fatigue syndromes.

Nonmedicinal treatments in primary fibromyalgia

To date, few nonmedicinal treatments for primary fibromyalgia have been studied using acceptable scientific standards. This has led to rather arbitrary use of disparate treatment modalities, often in a haphazard sequence. Because primary fibromyalgia syndrome is a chronic painful condition, rationale for treatment should be based on present concepts of pain perception supported by studies in the basic sciences. Recent clinical studies in the treatment of primary fibromyalgia syndrome conforming to the scientific method have been discussed in light of what is presently known about pain transmission and perception.

Treatment of fibromyalgia syndrome

The therapeutic role of medications in fibromyalgia is reviewed. The tricyclics, amitriptyline and cyclobenzaprine, have been the most extensively evaluated, and in controlled studies have proven to be more effective than placebo or NSAIDs. Their mode of action is not known, but their effect may relate to a number of potential mechanisms. However, neither the tricyclics nor any other medication has provided long-term, clinically meaningful improvement in the majority of patients.

Fibrositis

Fibrositis is a common clinical syndrome characterized by diffuse musculoskeletal pain and multiple tender points on physical examination. The symptoms wax and wane but do not produce severe disability. Although no single treatment is curative, a comprehensive program of patient education, drug therapy and appropriate physical activity is beneficial in many patients.

Fibromyalgia in the elderly: differential diagnosis and treatment

Fibromyalgia in the elderly often occurs in the presence of other musculoskeletal disorders where it is often unsuspected. The clue to the diagnosis of concomitant fibromyalgia lies in the widespread distribution of the pain and in its severity. All patients with this disorder have multiple, symmetrically distributed "tender points," a physical sign which is specific for fibromyalgia. Treatment includes, first, explanation. Aerobic exercise may be helpful in many patients, and administration of tricyclic compounds in very low doses is often effective in treating the associated sleep disorder and in reducing overall disease severity.

Diagnosis, etiology, and management of fibromyalgia syndrome: an update

Recent controlled studies suggest a physiologic basis for FMS, which should be diagnosed by its own characteristic features and not by exclusion of other conditions alone. Diffuse musculoskeletal aching, accompanied by multiple TPs in the absence of an underlying arthritic or systemic condition, are the key features for diagnosis. Based on our controlled study, guidelines for diagnosis are provided in Table 5. Successful management of an FMS patient is often challenging, but frequently gratifying if approached with a positive and caring attitude. The most important aspects of management are a firm diagnosis, reassurance regarding the benign nature of the condition, help in changing patient behavior in order to accept pain and increase functional activities and exercise tolerance, and the use of tricyclic agents. Overall, management of fibromyalgia is an art that requires the combined ingredients of patience, understanding, and firmness in helping patients to assume responsibility for their pain management through behavior modifications.

Fibrositis (fibromyalgia). A common non-entity?

The literature on fibrositis (fibromyalgia), which originated in the early years of the last century in the UK and proliferated there in the first half of this century, has since diminished there in the last 30 years or so, but has increased in Canada and the US. Criteria suggested for diagnosis have created a syndrome with no diagnostic tests, serological or radiological signs, and no truly objective physical signs, but with predictable tender spots on pressure. The syndrome is largely, but not completely, confined to females, mostly of middle age; the symptoms include widespread aching of more than 3 months' duration, disturbed sleep, morning fatigue and stiffness, a failure to respond satisfactorily to any one form of therapy and a tendency to persist over long periods, but without permanent tissue changes. Features of psychological disturbance are present in many patients but not in all or even the majority. Definition of the condition as a disorder of pain modulation - a pain amplification syndrome - would seem to fit the facts best. Most would agree that an abnormal response to stress is an important factor in the appearance of the syndrome, as other stress related disorders, such as the irritable bowel syndrome and tension headaches, may coexist. Response to therapy, whether physical or pharmacological, is on the whole unsatisfactory. This type of patient has been well recognised in hospital clinic and general practice for many years.(ABSTRACT TRUNCATED AT 250 WORDS)

[Generalized tendomyopathy: psychological profile of a patient group in the course of integrated treatment]

27 patients suffering from fibrositis were studied using a series of psychological tests in the course of an integrated group treatment program. In addition, their behaviour in the treatment program was observed and information about their behaviour in interpersonal conflicts was gathered. The results confirmed earlier observations that these patients show similar patterns in a projective test (Rosenzweig Picture Frustration Test) as patients with other rheumatic or other psychosomatic affections. The observations in the group sessions gave further support to these findings. However, in their self-evaluation with a personality inventory (Freiburger Persönlichkeits-Inventar), these people described themselves as more disturbed than the other kinds of patients mentioned. But this disturbance seems to be rather the consequence than the cause of this chronic illness of unclear origin. These signs of emotional disturbance were more distinct in those patients who had been suffering for longer from their illness and showed a poorer response to our treatment program.

Management of fibromyalgia, a distinct rheumatologic syndrome

The pathophysiology and management of fibromyalgia, a unique nonarticular rheumatologic syndrome characterized by diffuse musculoskeletal aches and pains, stiffness, discrete tender points at typical soft-tissue sites, and a characteristic sleep disturbance, are reviewed. The prevalence and incidence of fibromyalgia are not known, but it is one of the most common conditions seen by rheumatologists (after degenerative joint disease and rheumatoid arthritis). It was previously thought to involve inflammation of fibrous intermuscular septa and is sometimes referred to in the literature as fibrositis. It is not primarily psychogenic, but psychological factors may contribute. The tender points are the key to diagnosis. Fibromyalgia may be classed as primary (when no underlying disease is present) or secondary (when an associated condition exists). The pathophysiology of fibromyalgia is unknown but appears to involve complex interactions of central neurotransmitters with a relationship to pain perception, mood, and sleep. Treatment is empiric; nondrug treatment involving education, relaxation, and increased physical activity is essential. Few controlled trials of drug therapy have been conducted. Analgesics, anti-inflammatory drugs, phenothiazines, tricyclic antidepressants, and the tricyclic muscle relaxant cyclobenzaprine have been used; low doses of amitriptyline or cyclobenzaprine provide increased control of pain and mood.(ABSTRACT TRUNCATED AT 250 WORDS)

EMG-biofeedback training in fibromyalgia syndrome

Fifteen patients with fibromyalgia syndrome were given EMG-BFB (biofeedback) training sessions because of persistent aches after one year of monthly courses of NSAID. A long-lasting clinical benefit was observed in 56%. The improvement was found in those without overt psychopathological disturbances. In fact, a subgroup of clinically depressed patients responded poorly. Our findings were confirmed in a controlled study. Six patients were allocated into "true EMG-BFB" and 6 into "false EMG-BFB" treatment in a blinded fashion. The rheumatological assessment revealed a significant improvement in most of the variables only in the "true EMG-BFB" group.

Fibromyalgia syndrome. An emerging but controversial condition

The clinical manifestations, laboratory findings, and treatment results of 118 patients with fibromyalgia followed up by one investigator were compared with those of other recent reports. The history of this syndrome and recent efforts to establish diagnostic criteria and to understand underlying pathophysiologic mechanisms were studied. A practical, noninvasive office-based evaluation and conservative treatment approach were developed, determined by an understanding of the natural history of this common but controversial disorder.

Fibromyalgia. 2. Management guidelines and research findings

Treatment of fibromyalgia includes various forms of therapy--physical, behavioral, psychological, and pharmacologic. No drug therapy has proved uniformly successful, but some drugs provide temporary relief from pain. After an initial therapy program has been established, patients can assume the major responsibility for management. Research studies aimed at defining the cause of fibromyalgia have linked it to sleep disorders, neurogenic mediators, immune mechanisms, muscle disease, and psychological disturbances.

Secondary fibrositis

Fibrositis is considered primary when there is no associated underlying disorder, and secondary when it occurs in patients with underlying rheumatic or other organic disease. Since fibrositis has become better defined, the list of underlying disorders has grown, and its identification requires careful diagnostic study. The differentiation of primary and secondary fibrositis has therapeutic implications. Secondary fibrositis should respond to treatment of the underlying disorder, whereas the primary syndrome may require additional management directed to the musculoskeletal pain and sleep and emotional disturbances commonly recognized as major manifestations of this syndrome.

Socioeconomic impact of fibrositis. A study of 81 patients with primary fibrositis

Demographics and health service utilization were studied for 81 patients with fibrositis during 1985. Patients reported high levels of pain, mild disability, and moderate impairment of global health. Work disability was limited and only 6.3 percent described themselves as disabled. Employed patients were able to work full work weeks. Utilization of outpatient medical services was increased compared with that of control subjects and national averages during the study year, but was consistent with other rheumatic disorders such as osteoarthritis and low back pain. Medication usage was limited and seemed appropriate. Very high hospitalization rates were noted prior to diagnosis of fibrositis, both for musculoskeletal and non-musculoskeletal hospitalizations, but these rates dropped during the post-diagnosis study year.

Current issues concerning management of the fibrositis/fibromyalgia syndrome

The fibrositis/fibromyalgia syndrome is one of the commonest forms of musculoskeletal pain seen in clinical practice. It is diagnosed on the basis of widespread pain accompanied by the physical finding of multiple tender points in remarkably reproducible locations. Accompanying the pain are two symptoms commonly associated with the "systemic" rheumatic disorders, namely morning stiffness and easy fatigability. Unlike the classical rheumatic diseases, however, fibrositis is not responsive to anti-inflammatory medications, including corticosteroids. Current therapeutic strategies, which are only partly successful, are aimed at modifying those factors that seemingly influence the severity and course of the condition; such afferent features include sleep disturbance, overuse syndromes, mechanical stress, psychic stress, and other causes of chronic pain. Major unresolved issues center around the assessment of functional disability in fibrositis and the apparent relationship to trauma in some patients. Until more is known about the underlying pathogenesis of this common condition, significant progress will be thwarted.

Fibromyalgia and menopause. Examination of the relationship

Women predominate at all ages among patients diagnosed as having primary fibromyalgia. Of 100 patients reviewed, the average age at onset of fibromyalgia was 46. Of 65 patients in whom menopause occurred before diagnosis of fibromyalgia, the average age at menopause was 42, and most of these women had menopause related to surgery and insufficient estrogen therapy. Estrogen deficit is, thus, a prominent promoting factor in the majority of fibromyalgia patients and is likely to have an effect on sleep, mood, and anxiety state. These emotional responses may subsequently be somatized as pain. Therefore, estrogen therapy should be added to the treatment armamentarium for fibromyalgia in selected patients.

"Fibrositis" syndrome

There appears to be as yet undefined but significant and possibly multifactorial elements of personality, stress, or depression in the manifestations and possibly the pathogenesis of FS. If these factors, perhaps amplified by the neurophysiologic effects of disturbed sleep, produce a neurochemical disturbance in CNS function, and if this perturbation includes a reduction or impairment of function involving the pain-modulation pathways, then a simple and perhaps compelling explanation for the experience of pain in FS becomes apparent. Reduced midbrain/brainstem inhibition of ascending nociceptive impulses would clearly explain the finding of tender points in normal-appearing areas of the body, as well as the lack of segmental distribution of discomfort in FS. Local anesthetics, injected peripherally into tender points, would be expected, as is the case, to block pain and tenderness in the local area for the duration of action of the agent used. Analgesics with peripheral activity, such as aspirin and NSAIDs, are relatively ineffective in treating FS, and would be predictably so in a disorder involving reduced central pain inhibition as opposed to increased peripheral nociceptive input. It would not be surprising to find that centrally acting agents, particularly those producing enhancement of serotonergic neurons such as amitriptyline, would provide substantial or total pain relief as well as improvement in mood in a significant number of patients. Most importantly, this concept would highlight the real pain experienced by these patients and the obligation of involved physicians to appropriately diagnose and treat this common pain syndrome. Avoiding excessive conjecture, it is then permissible at the present time to conclude that: FS is a characteristic, clinically common pain syndrome in which aspects of the pain itself appear to be of physiologic origin. Although stress or inherent personality traits may play a role in FS, the relative uniformity in symptomatology virtually excludes conversion hysteria as a major factor in this disorder. The lack of evidence for a disturbance in muscle, fascia, and other soft tissues in FS, the lack of adequate response to NSAIDs, and the frequent response to TCAs suggest that specific dysfunction of the CNS may play a major role in the symptomatology of this entity. Impaired function of the pain-modulation system, located anatomically in the midbrain and brainstem, provides a plausible explanation for the pain and finding of tender points in FS, as well as a potentially rational basis for therapy.

[Soft-tissue rheumatism--diagnosis and therapeutic concept]

The term fibrositis or soft tissue rheumatism, provides a label to describe a symptom-complex which is common in practice, but the name is suggesting a defined entity that has not been demonstrated. The complaints known as soft tissue rheumatism can be defined as painful states which arise in the muscle and fibrous structures of the body. The patients complain of pain and stiffness in the neck-shoulder girdle and extremities which are worse with work or stress, better with rest or diversion. Physical examination is normal, as are those of x-rays, laboratory tests and biopsies. Numerous forms of therapy, physical and pharmacological, have been employed. Several theories of causative factors are discussed in this paper. Therapy and diagnosis are compared with many theories.

[Physical therapy and rheumatism of soft tissues]

Soft tissue rheumatism (extraarticular rheumatism) is a group of common disorders found separately as independent disorders or as a symptom of systemic joint or spine diseases. The most frequent soft tissue rheumatisms are tendinopathies, rheumatism of muscles with myofascial pains, fibrositis of subcutaneous tissue and, finally, bursitis and inflammations of tendon sheaths. The commonest therapeutic procedures are non-steroidal anatirheumatic drugs, local infiltrations of corticosteroids, and physiotherapy. In the acute stages cold packs are the best physical measure against subjective pain. In subacute and chronic cases the pain in subcutaneous tissues can be lessened by connective tissue massage and underwater jet massage, muscle pain by heat and active exercises, and tendinopathies by ultrasonics and electrotherapy but very seldom by heat. In chronic bursitis and tendovaginitis, iontophoresis with potassium iodine may be helpful. Reflex pains in muscles are due to lesions of the spine and should therefore be treated by spine extension and manipulations. Every pain in soft tissue has one source in the anatomic lesion of the tissue and the second in psychogenic disorders. The latter must be sought when soft tissue pains are found all over the body on the lines of a generalized fibrositis syndrome.

Primary fibromyalgia

Primary fibromyalgia is a common but often unrecognized rheumatic condition. The typical patient is a young woman who complains of diffuse aches, pains and stiffness in joints and muscles. The symptoms are affected by weather and activities. Patients sleep poorly, feel tired and are often anxious. Physical examination reveals multiple tender points without evidence of arthritis or muscle weakness. Laboratory findings are normal. Management requires a program of patient education and reassurance, analgesics, physical therapy, restful sleep and occasional injection of tender areas with lidocaine. Psychoactive drugs are frequently useful.

Fibrositic myofascial pain in intermittent claudication. Effect of anesthetic block of trigger points on exercise tolerance

The blocking of trigger points in the calf by the local injection of an anesthetic agent was performed in 15 patients with intermittent claudication. Reactive and exercise hyperemia, work load and duration of exercise were recorded before and after infiltration of the trigger points. Reactive hyperemia does not change, but the exercise tolerance of the leg significantly improves after local blocking of the trigger areas and the exercise hyperemia increases because of the higher work load. The pain pattern of intermittent claudication can be activated by the summation of abnormal input from muscles, due to contraction in the presence of anoxia, with activity from trigger points. Local infiltration of trigger areas blocks theirir activity. The vicious cycle of pain is interrupted and the exercise tolerance of the leg is increased, without improving blood circulation.

Diagnosis and management of fibrositis syndrome and psychogenic rheumatism

Diffuse aching and stiffness may be caused by a fibrositis syndrome or by psychogenic rheumatism. If fibrositis is present, a careful search for underlying disease is made, and appropriate therapy started depending upon the results of all diagnostic studies.