Fibromyalgia: Diagnosis and Treatment

Fibromyalgia is a disease characterized by chronic diffuse musculoskeletal pain in various parts body, stiffness of movements, fatigue and weakness, depressive disorders, sleep disorders. In recent years, interest in this neurological disease has increased due to an increase in the incidence rate by approximately 5%. In the absence of treatment, fibromyalgia significantly reduces the patient's ability to work and the quality of his life, leading to a deterioration in adaptability to external conditions, especially in society.

This disease has a characteristic feature: objective research methods (blood tests, urine, X-ray images, computed tomography, etc.) do not reveal any pathological changes. This aspect makes the diagnosis of this disease very difficult. But, nevertheless, an experienced doctor when comparing all manifestations may suspect a diagnosis of "fibromyalgia". To let the process go by itself is by no means possible, patients should trust the doctor and the treatment prescribed for them for this pathology.

Diagnostics

The diagnosis of "fibromyalgia" is made on the basis of the patient's thorough questioning and examination. Additional research methods are prescribed to exclude all other possible diseases that can give chronic pain.

For a long time in medicine, there were no clear criteria for diagnosing fibromyalgia. One can not reliably state that they have been determined even now, but there is still a scale of criteria for the possible presence of fibromyalgia. This scale was developed in 1990. the College of American Rheumatologists. It is not intended for full-fledged use in the clinic, mostly within the framework of research, but more precise diagnostic criteria have not yet been developed.

At the moment the disease is diagnosed on the basis of some factors. We list them.

1. Information on diffuse pain: the presence of pain in four quadrants of the body (division occurs along the median axis of the body and at the level of the belt), i.e., left and right, in the upper and lower half of the body. An obligatory criterion is the presence of pain in either one of the spine (cervical, thoracic, lumbar), or in front of the chest.
2. Duration of pain - at least 3 months.
3. The presence of specific points on the body (paired), characterized by increased sensitivity (soreness). Soreness is determined by pressing with a certain force (4 kg / cm). This force of pressure is comparable to the pressure that is necessary in order to compress the nail plates when pressed. To more accurately conduct the palpation of such points, it is necessary to press on other parts of the body, where the potential sensitivity is not disturbed, with the same effort. This is a rather subjective procedure that requires a certain skill. Therefore, it is more intended for research purposes. In total, 18 such points on the body (respectively, 9 pairs) were studied. If the increased morbidity is determined in 11 points out of 18, this is already considered a criterion for the presence of fibromyalgia. To such points carry: symmetrical sites in the occipital muscles on the left and on the right; the lower part of the neck in front at the level of C5-C7 on the left and on the right; In the middle of the upper boundary of the trapezoidal muscles on both sides; the upper point of the inner edge of the scapula; in places of transition of the second ribs to the cartilage near the sternum (somewhat away from the joint); a point 2 cm below external epicondyle of humerus; the outer quarter of the buttocks; points of projection of a large trochanter (posterior to the acetabulum); the internal surface of the knee joint.
4. Decrease in tolerance to the load: increased fatigue, general weakness, lethargy, intolerance even small ("Habitual") physical activity, difficulty in performing movements (rigid, naughty muscles).
5. Stiffness in the joints: can have a significant range (from minimal, almost not noticeable for the patient's limitations, to severe stiffness, impeding movement). Stiffness is reversible, not progressive.
6. Lack of motivation and commitment, loss of "taste for life": such patients can not and do not want to plan in their lives, do not strive to achieve the goal.
7. Activities in everyday life: everyday household chores are performed in a smaller volume, with difficulties, for a longer period of time.
8. Hypersensitivity, touch.
9. Sleep disorders: sleep is very shallow, with frequent awakenings, not giving a sense of rest.
10. Violations in the psychological sphere: decreased attention, memory impairment, decreased speed of thought processes. To the same category include depressive disorders with a sense of frustration, unreasonable anxiety and apathy.

There is a special questionnaire (not yet widely used in Russia) for screening for the identification of "potential" patients with fibromyalgia. After answering simple 6 questions (relating to pain syndrome), the questionnaire reveals the category of people who need a more thorough examination for fibromyalgia.

An important role in diagnosis is played by the refutation of another diagnosis. T. e. when the patient is treated with symptoms similar to fibromyalgia, the primary task for the doctor is to exclude other (sometimes heavier) diseases. That is why the patient is assigned a range of additional examination methods. Among them, one can note a general blood test (search for inflammatory changes), urine, biochemical blood tests and the search for "rheumatic" changes in blood, an immunogram, a radiography of various departments of a backbone, an electroneuromyography, research of function of a thyroid gland. The list of necessary examinations is individual and depends on the state of health of the patient. The absence of pathological changes in additional methods of investigation becomes another criterion for the diagnosis of fibromyalgia.

Treatment

Fibromyalgia is well amenable to complex treatment with the use of medicines and non-medicinal methods of influence.

Medication

Among groups of drugs use:

• antidepressants;
• antiepileptic drugs (anticonvulsants);
• non-steroidal anti-inflammatory drugs;
• analgesics (narcotic and non-narcotic);
• muscle relaxants.

The basis for the use of all these groups of drugs is the idea of ​​a mechanism for the development of pain in fibromyalgia.

Among antidepressants more often apply:

• selective serotonin reuptake inhibitors:Fluoxetine (Prozac) for 20-80 mg per day, Paroxetine (paxil) for 5-20 mg in the morning, Sertralin (zoloft, saliflift) 50-100 mg in the morning or in the evening, Fluvoxamine (feravin) 50-200 mg per day;
• selective serotonin and noradrenaline reuptake inhibitors: Milnacipran 100-200 mg per day, Duloxetine 60-120 mg per day;
• tricyclic and four-cycle antidepressants: Amitriptyline 10-50 mg per day, Ludomil 50-150 mg per day, Mianserin (lerivone) 30-80 mg per day.

All these drugs are recommended to take at least a month, the effect is already in the first week of use.

Among anticonvulsants use:

• Gabapentin (gabagamma, tebanthine) 300 mg with titration of the dose increasing until it reaches clinically effective, followed by a decrease in dosage;
• Pregabalin (lyric) is a very effective drug. It is necessary to take 150-450 mg per day. Affects most of the symptoms of fibromyalgia.

Nonsteroidal anti-inflammatory drugs are applied inside and locally in the form of ointments, gels and patches. They help to reduce the pain syndrome. This group of drugs is quite extensively represented in the pharmaceutical market: diclofenac (Voltaren, Almiral, Naklofen), meloxicam (Movalis), Revmoxicam,ibuprofen (Nurofen, Imet), indomethacin (Metindol), sulindac (Clinoril). Medicinal forms of these substances in the form of patches (Diclofenac-plaster, Voltaren-plaster, Olfen and others) allow the use of the active substance only locally, avoiding systemic side effects, not dirty clothes and lengthening the interval between doses (patch paste for 12 hours). From "local" drugs it is possible to use ointments containing capsaicin. They have a "distracting" analgesic effect.

Among narcotic analgesics, the use of Tramadol is possible, however, after the appearance of selective inhibitors re-seizure of serotonin and anticonvulsants, this drug is used as rarely as possible.

A good effect is the local application of lidocaine solution. As it turned out during the use, single or course injections in painful points have not only a local anesthetic effect, but also a general, that is, The pains disappear not only at the injection site. The total dose of lidocaine is 5-7 mg / kg.

The muscle relaxants are shown to patients with rigidity and muscle tension. The most justified application of Baclofen 15-30 mg at a time and Sirdalud (tizanidine) 2-4 mg 2-3 r / d.

Among the methods of treatment, occupying an intermediate position between directly medicamentous and "folk" methods, it should be noted herbal medicine. Most doctors do not deny the positive effect of using this group of medicines. They include:

• tincture of Chinese magnolia vine: take 5-10 drops a long time in the morning, washing down with water;
• tincture of ginseng: 10-30 drops in the morning for half a cup of water;
• tincture of aralia: 30-40 drops in the morning in ¼ cup of water;
• tincture of St. John's wort: 40-50 drops 3 times a day.

In complex treatment, the use of multivitamins is possible, in connection with their antioxidant and restorative action. It is acceptable to use the courses of vitamin E, vitamin C, complexes of vitamins of group B (milgamma, neurorubin, etc.).

Non-drug therapies

To this group of therapeutic influences can be attributed the rationalization of the way of life. It is necessary, if possible, to reduce the number of stressful situations, observe the regime of work and rest, normalize food (more eat fruits and vegetables, reduce the number of foods containing animal fats, do not drink beverages, energy and coffee). Important organization of retirement. It is desirable to live in a warm and mild climate.

From psychotherapeutic influences the high efficiency of cognitive behavioral therapy has been proved (for its realization competent psychotherapist), as a result of which the patient changes his idea of ​​pain and learns to correctly prioritize. The course usually consists of 6-20 sessions. Positive action was noted in autogenous training.

Acupuncture contributes to the normalization of the processes of production of serotonin, substance P, noradrenaline. Not only the analgesic effect of the procedures was noted, but also psycho-relaxing, reducing the level of stress.

General massage is shown as a general restorative, to improve the processes of blood supply to the muscles and joints, to remove stiffness. Acupressure is also effective in fibromyalgia.

Physiotherapy exercises a positive effect on neurohumoral processes in the body, stimulating the production of endorphins, normalizing the level of serotonin, thereby providing an analgesic effect. Previously, it was believed that exercise therapy can aggravate the symptoms of fibromyalgia, to date, the positive effect of moderate exercise in physical education has been proven. The load should be selected individually and gradually grow to the level optimal for a particular patient. A very good effect is observed in various types of gymnastics aimed at increasing the extensibility of tissues and increasing flexibility (yoga, pilates). Of other types of physical activity should be noted swimming, exercise bikes, treadmills.

Another non-pharmacological treatment for fibromyalgia is cryotherapy. This method is based on the use of liquid nitrogen for local cooling of tissues. When it is used, an analgesic effect is achieved, an improvement in the blood supply of tissues, and the normalization of sleep.

In the course of the research, it was shown that curative physical exercises and cognitive behavioral therapy have the greatest effect among non-pharmacological methods of treating fibromyalgia. However, this fact does not in any way diminish the importance of other ways of influencing the disease.

Fibromyalgia is not a fully studied disease. It is believed that this is a lifelong disease, control of which is achieved through joint efforts of the doctor and the patient. A single therapeutic strategy has not been developed to date, but scientists all over the world are working to create a program for treating this disease.