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(Myofascial Pain Syndrome; Fibrositis; Fibromyositis)
Fibromyalgia
is a common nonarticular disorder of unknown cause characterized
by achy pain, tenderness, and stiffness of muscles, areas of tendon
insertions, and adjacent soft tissues. Diagnosis is clinical. Treatment includes
exercise, local heat, and drugs for pain and sleep.
Any fibromuscular tissues may be involved, especially those of the occiput, neck, shoulders, thorax, low back, and thighs.
Localized soft-tissue pain and tenderness (ie, myofascial pain syndrome [see also Temporomandibular Disorders: Myofascial Pain Syndrome], is often related to overuse or microtrauma). In fibromyalgia, symptoms and signs are more generalized, and there is no specific histologic abnormality. It sometimes occurs in patients with systemic rheumatic disorders, which complicates the diagnosis. Fibromyalgia is common, occurring most often in women; it can occur even in children or adolescents. The cause is unknown, but disruption of stage 4 sleep may contribute, as can emotional stress. Fibromyalgia may be precipitated by a viral or other systemic infection (eg, Lyme disease).
Symptoms,
Signs, and Diagnosis
Stiffness and pain in fibromyalgia frequently begin gradually, diffusely, and with an achy quality. Symptoms can be exacerbated by environmental or emotional stress, poor sleep, trauma, exposure to dampness or cold, or by a physician who gives the patient the incorrect message that it is “all in the head.” Patients tend to be stressed, tense, anxious, fatigued, striving, and sometimes depressed. Many patients also have irritable bowel symptoms or tension headaches.
Fibromyalgia is suspected in patients with generalized pain and tenderness, especially disproportionate to the physical findings; with negative laboratory results despite widespread symptoms; or when fatigue is the predominant symptom. Tests should include ESR or C-reactive protein, CK, and probably screens for hypothyroidism and hepatitis C (which can cause similar symptoms). The diagnosis is supported by explicit tender points and other findings, which comprise diagnostic criteria (see Fig. 1: Bursitis, Tendinitis, and Fibromyalgia: Diagnosing fibromyalgia. ). Patients meeting some, but not all, criteria may still have fibromyalgia. Chronic fatigue syndrome (see Syndromes of Uncertain Origin: Chronic Fatigue Syndrome) can cause similar generalized myalgias. Polymyalgia rheumatica (see Vasculitis: Polymyalgia Rheumatica) can cause generalized myalgias, particularly in older adults but tends to affect proximal muscles selectively and produce a high ESR.
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Fig. 1
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Diagnosing fibromyalgia.
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For diagnosis, patients tend to have the following features: (1) Pain on palpation of at least 11 of the 18 tender points. Digital palpation should be performed with a force of about 4 kg. For a tender point to be considered positive, palpation must be painful. (2) A history of widespread pain for at least 3 mo. Pain is considered widespread when the patient has pain in the left and right side of the body, above and below the waist, and in the axial skeleton (cervical spine or anterior chest or thoracic spine or low back.)
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Prognosis
and Treatment
Fibromyalgia may remit spontaneously if stress decreases but can recur at frequent intervals or become chronic. Functional prognosis is usually favorable with a comprehensive, supportive program, although some degree of symptoms tends to persist.
Relief may be obtained from stretching exercises, aerobic exercises, sufficient sound sleep, local applications of heat, and gentle massage. Overall stress management is important.
The involved muscles should undergo daily gentle and prolonged stretches, lasting for about 30 sec and repeated about 5 times. Aerobic exercise (eg, fast walking, swimming, exercise bicycle) can improve symptoms.
Improving sleep is critical. Low-dose oral tricyclic antidepressants at bedtime (eg, amitriptyline 10 to 50 mg, trazodone 50 to 150 mg, doxepin 10 to 25 mg) or the pharmacologically similar cyclobenzaprine 10 to 40 mg may promote deeper sleep and decrease muscle pain. The lowest effective dose should be used. Drowsiness, dry mouth, and other adverse effects may make one or more of these drugs intolerable, particularly in older adults.
Nonopioid analgesics may help individual patients but have not generally been shown to be effective. Opioids should be avoided. Incapacitating areas of focal tenderness may rarely be injected with 0.5% bupivacaine or 1% lidocaine 1 to 5 mL, but this should not be a primary focus of therapy. Caution must be taken not to aggravate sleep problems with drugs that may cause insomnia. Anxiety or depression, if present, may require treatment.
Last full review/revision November 2005
Content last modified November 2005
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