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What is Fibromyalgia?
Fibromyalgia is a chronic syndrome that occurs predominantly in women and is marked by generalized pain, multiple defined tender points, fatigue, disturbed and nonrestorative sleep, and numerous other somatic complaints. Fibromyalgia is not a discrete disease; rather, it lies at the far end of a continuum of psychological distress and chronic pain in the general population. Fibromyalgia largely overlaps with other syndromes, such as chronic fatigue syndrome, irritable bowel syndrome, temporomandibular joint pain, and multiple other regional pain syndromes, all of which feature symptoms that remain unexplained after usual clinical and laboratory assessment and all of which are related to, but not fully dependent on, depression and anxiety. Fibromyalgia frequently coexists with diseases of structurally defined pathology, such as systemic lupus erythematosus (SLE) or rheumatoid arthritis.
Otherwise unexplained widespread pain occurs in about 10% of the general adult population in Western countries, with approximately half of those affected—mostly women—meeting American College of Rheumatology (ACR) classification criteria for fibromyalgia. It becomes more common after 60 years of age but occurs not infrequently in children. On a typical day, primary care physicians should expect to interact with several patients with fibromyalgia, many of whom will be seeking care for illness other than fibromyalgia. For example, more than 25% of patients with SLE exhibit painful tender points and other clinical and psychological features of fibromyalgia.
The cause of fibromyalgia is unknown. Despite extensive research, no structural pathology has been identified in muscles or other tissues. Although psychological factors associated with chronic distress appear to be important for the development of fibromyalgia in many patients, abundant evidence now indicates that pain in fibromyalgia reflects abnormal pain processing in the central nervous system (i.e., central sensitivity). Clinically, fibromyalgia syndrome is best viewed from a biopsychosocial perspective encompassing multiple variables that contribute to chronic pain and fatigue.
Fibromyalgia has been classified as one of a group of disorders that are variously termed symptom-based conditions, functional somatic syndromes, and affective spectrum disorders. Common somatic symptoms in these illnesses are chronic musculoskeletal or abdominal pain, persistent fatigue, disturbed sleep, and cognitive difficulty. Advances in the understanding of the psychophysiologic and neurophysiologic dysregulation in such illnesses is impelling researchers to develop a unifying reclassification of these illnesses as central sensitivity syndromes.
Clinical Symptoms of Fibromyalgia
Pain is the hallmark of fibromyalgia. The pain radiates diffusely from the axial skeleton and is localized to muscles and muscle-tendon junctions of the neck, shoulders, hips, and extremities. Fibromyalgia patients describe the pain with such terms as exhausting, miserable, or unbearable. Generalized hyperalgesia is a cardinal feature. Patients frequently complain that even gentle touch is unpleasant, a manifestation of allodynia.
Fibromyalgia patients also experience severe fatigue, insomnia, and low mood or depression. In fibromyalgia, fatigue occurring most times of the day on most days, together with subjective weakness and nonrestorative sleep, is almost universal. Cognitive complaints, such as difficulties with concentration and memory, may be prominent. Depression, anxiety disorders, and personality disorders contribute to ongoing psychological distress. Other complaints result from somatization, which can be defined as translating psychological distress into somatic symptoms (which are considered more socially acceptable) and seeking care for those symptoms.
Functional impairment is usually present, at least in patients with fibromyalgia who seek care. Patients report difficulty doing usual activities of daily living and lack of exercise—indeed, they actually fear and avoid exercise.
Regional pain syndromes, such as headache, temporomandibular joint disorder, or irritable bowel syndrome, are often present in fibromyalgia patients. It is essential that the physician not automatically attribute all such symptoms to fibromyalgia, however, because fibromyalgia frequently coexists with other disorders of defined structural pathology, such as SLE and rheumatoid arthritis. Optimum therapy requires recognition of both fibromyalgia and comorbid disease.
Tender Points may occur at nine bilateral locations:
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Front of the Body:
Low Cervical Region: (front neck area) at anterior aspect of the interspaces between the transverse processes of C5-C7.
Second Rib: (front chest area) at second costochondral junctions.
Lateral Epicondyle: (elbow area) 2 cm distal to the lateral epicondyle.
Knee: (knee area) at the medial fat pad proximal to the joint line.
Back of the Body:
Occiput: (back of the neck) at suboccipital muscle insertions.
Trapezius Muscle: (back shoulder area) at midpoint of the upper border.
Supraspinatus Muscle: (shoulder blade area) above the medial border of the scapular spine.
Gluteal: (rear end) at upper outer quadrant of the buttocks.
Greater Trochanter: (rear hip) posterior to the greater trochanteric prominence.
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