A PRACTICAL APPROACH TO FIBROMYALGIA – part 1

fibromyalgia

Fibromyalgia is the name given to a collection of symptoms with no clear physiologic cause. The constellation of symptoms are clearly recognizable as a distinct pathologic entity. The diagnosis is made through clinical observations made by the examiner. Differential diagnosis must include other somatic syndromes as well as disease entities like hepatitis, hypothyroidism, diabetes mellitus, electrolyte imbalance, multiple sclerosis, and cancer. Diagnostic criteria are given as guidelines for the diagnosis, not as absolute requirements. Treatment of this condition remains individualized and relies heavily on having a therapeutic relationship with a provider. Treatment of this syndrome needs to be looked at as an ongoing process. Goal oriented treatment aimed at maintaining specific functions can be directed at helping a patient get restorative sleep, alleviating the somatic pains that ail the patient, keeping a person productive, regulating schedules or through goal oriented agreements made with the patient. Since this syndrome is chronic and may effect all areas of a persons functioning the family and social support system of the person being treated need to be evaluated. Patients often seek alternative medical treatments for this problem including diet therapy, acupuncture, and herbal therapy. Treatment must involve more than just the symptoms presented and the patient can only be treated successfully if they are willing to work at changing their own perceptions, and ways of relating to stressors in their world. Omnicef 125 5 mg/ML

INTRODUCTION
The fibromyalgia syndrome is seen amongst all socioeconomic classes in most countries, most ethnic groups, and in all types of climates. It is a common condition frequently seen in primary care settings. An estimated 6 million Americans have fibromyalgia, and between two and six percent of people presenting to a primary care physician’s office will have the illness. Making an accurate diagnosis ofis important, patients are often relieved that there is a diagnosis which reduces anxiety and tension. Once diagnosed, consultations and laboratory tests can be used in a more judicial manner.

Patients with fibromyalgia are high utilizers of health care resources. Studies have shown patients with fibromyalgia see their primary care provider anywhere from 10 to 22 times a year and have additional visits to alternative medicine providers. Fibromyalgia patients’ average one inpatient admission every three years, Prescriptions are written for patients with fibromyalgia at the rate of 2.7 every six months.
Fibromyalgia is a noninflammatory pain syndrome of unknown etiology. There is no long-term target organ damage in fibromyalgia. Women are mostly effected but men do get the condition, and it is more common in young to middle age people.

Patients with fibromyalgia have a heightened somatosensory ability. Which is characterized by a sensitivity and hyperawareness to touch, sounds/lights, vibration and smell. Such sensations are often no more than minor in most individuals, but become “danger signals” in fibromyalgia patients that need immediate attention. If the body does not feel that an adequate response has been made to these stimuli, anxiety occurs and a fixation on the area of disturbance results. generic Imitrex online

HISTORY OF FIBROMYALGIA
Muscular pain that limits activity, but have no observable cause has been noted in the medical literature since 1736, when Guillaume de Baillou published Liber de Rheumatismo describing a case that is currently accepted to be consistent with fibromyalgia. The term fibrositis was officially coined in 1904 but not accepted by the medical community as a condition worthy of their attention or medical treatment. The term fibrositis was first used in the medical literature in 1976 and accepted by the medical community in 1981. It wasn’t until 1986 that the American College of Rheumatology established a committee of physicians to determine diagnostic criteria for the syndrome. In 1990, the concept of inflammation as the cause of the pain was deleted as there was no support, and the name of the syndrome was¬†changed to fibromyalgia with tender points located in specific areas (see Table 1). buy Celebrex 200 mg

Table 1. Fibromyalgia Synonyms
Fibrositis
Myofascial Pain Syndrome
Neuromyasthenia
Neurashenia
Psychalgia
Muscular Rheumatism
Myofasciitis
Myodysneuria
Chronic Rheumatism
Pressure Point Syndrome

SYMPTOMS
The most common complaint in people with fibromyalgia is that they “feel bad”. One third to one half of patients with fibromyalgia relate the onset of the condition to a traumatic experience often can recount the day and time the condition started. Chronic widespread pain not associated with inflammation is considered the hallmark of the disease. Chronic fatigue, cold fingers and feet, impaired memory, frequency and awareness of urination, depression (stipulated as reactive and not clinical), sleep and balance disturbance, muscle twitching, muscles aches, pain, dry mouth, headache and sore throat are all common symptoms associated with fibromyalgia. Symptoms occur daily, but vary in severity. Patients are never symptom free, but at times may reach functional levels in which time they typically see no need for treatment. Symptoms of the condition and the body awareness eventually become a large part of the person’s life. Desires to get better and full awareness of the abnormalities differentiate this entity from depression. A search for normalcy and a focus on the symptoms often aggravate intrafamily relationships and get the affected individual labeled as an “emotional vacuum cleaner” and worsen otherwise minor family issues. buy Atomoxetine online

PRECEDING AND COMORBID CONDITIONS
Before the onset of Fibromyalgia a majority of patients reported symptoms of constant gas, bloated feelings, constipation, premenstrual dysphoric disorder or endometriosis, and a large majority reported a history of recurrent childhood ear nose and throat infections. It has long been noted that people with somatic syndromes such as irritable bowel disease, temporomandibular joint dysfunction, interstitial cystitis, multiple chemical sensitivities, and chronic fatigue syndrome have overlapping symptom complexes and the diagnosis they get largely depends on the physician who sees them first. Compared to patients with other rheumatologic problems people with fibromyalgia tend to have more lifetime surgical interventions, 66% of people with fibromyalgia suffer from allergic rhinitis There may be a relationship between fibromyalgia and hyperventilation syndrome hypoglycemia and hypotension. Although treatment of fibromyalgia may alleviate the symptoms of these comorbid conditions, oftentimes these conditions demand attention and treatment separate from fibromyalgia.

DIAGNOSING FIBROMYALGIA
It is difficult to diagnose a problem that has mostly subjective findings and few objective ones. Fibromyalgia is a diagnosis of exclusion. It takes an average of 5 years for the diagnosis to be made in a person because of the need to exclude so many other diagnoses. The two criteria that need to be met for the diagnosis of fibromyalgia to be made include pain on the left and right side of the body, both above and below the diaphragm. The pain must also be present for a minimum of three months. This ensures that the somatic syndrome is a whole body syndrome and can be called fibromyalgia and does not need to be relegated into one of the subspecialty somatic syndromes like migraine headache, irritable bowel, interstitial cystitis, chronic fatigue syndrome or one of the others. There should also be areas of tenderness checked in 18 areas of the body. Presence of tenderness with application of 4kg/pressure at eleven of these points confirms the diagnosis. These criteria were set up for research purposes and people who only have 6 areas of tenderness have also been shown to have fibromyalgia. buy omnicef antibiotics

HISTORY AND PHYSICAL EXAMINATION
The patient most likely to be diagnosed as having fibromyalgia is a women between 25-50 years of age. Almost all patients with fibromyalgia will have some pain in the head and neck area. The pain is described as tingling, aching, soreness, flowing, and diffuse. Since the disease takes so long to diagnose, most patients suffer from chronic pain syndrome by the time their symptoms are taken seriously and they have trouble localizing the pain to discrete areas. Another common theme in these patients is fatigue. The fatigue is severe, sometimes preventing any movement at all. Sleep in non-restful and not restorative. People wake up feeling like they need eight more hours of sleep. Another frequent complaint is swelling of the hands that is not obvious to the examiner, but the patient is clearly able to discern a difference, regardless of whether the swelling effects the ability to wear jewelry, clothing, and can be shown to not effect the shape and size of the fingers. Forgetfulness and an inability to concentrate and think or plan for long term events is also a hallmark of this condition. This last symptom is called fibrofog by the afflicted and is one of the most bothersome symptoms. generic Levofloxacin online

On physical examination exclusion of other conditions is the priority. Besides severe tenderness of the skin and muscle tissue there are few objective findings. Bowel sounds are almost always increased, and there may be mild diffuse abdominal tenderness in varying locations and these sites change during the course of the examination.

TENDER POINTS AND TRIGGER POINTS
Patients can generally feel and find tender points on their own, and fibromyalgia patients are no exception. Tender points are area of tenderness that can be found in the muscle, muscle tendon junction, bursa or fat pad. Trigger points are areas of muscle that are painful to palpation and usually not noted by the patient until pointed out by the practitioner. Trigger points feel like taut bands of tissue. Both may exist together in patients with fibromyalgia, but it is the tender points that are diagnostic. canadian pharmacy Skelaxin

DIFFERENTIAL DIAGNOSIS
Fibromyalgia is often self diagnosed with the aid of the internet or friends. Finding a treatable condition in a person who claims to have fibromyalgia can be a tremendous benefit to a patient. Hepatitis, hypothyroidism, hyperparathyroidism, diabetes, hypokalemia, hyponatremia have all been found in people who claim to have self diagnosed fibromyalgia. Sleep apnea can be found even in thin women who are not considered to have the typical body build to have sleep disturbances. Malignancy also needs to be considered and evaluated for before a physician can be comfortable that the person has fibromyalgia. canadian pharmacy Soma

Workup includes a laboratory analysis of a complete blood count, TSH, Hepatitis panel, ESR, chemistry profile, creatinin kinase and a urineanalysis. If rheumatologic disorders like SLE, PMR, RA and polymyositis need to be considered then an ANA and RF should also be done. Sleep studies are also a useful test, but must be done by a sleep center that evaluates for fibromyalgia, and not just pulmonary problems that arise from sleep disturbances.
Muscle biopsies, EMG’s, MRI’s may be needed to address other issues, but are not useful in all patients suspected of having fibromyalgia.

to be continued….

Category: Diseases

Tags: acupuncture, alternative medicine, chronic fatigue syndrome, elimination diet, Fibromyalgia, fibrositis, hyperventilation syndrome, hypoglycemia, irritable bowel syndrome, magnetic therapy, rheumatism, somatic dysfunction, somatic syndrome, SSRI, tender points/trigger points, tricyclic antidepressants

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