The patient, 64, was submitted to consultation with diffuse muscle pain and fatigue. The pain worsened to the touch or pressure, decreased with rest and local heat and limited ability to perform physical exercise. The patient was diagnosed with fibromyalgia and was then treated with different drugs in general, it caused adverse effects. Currently being treated with acupuncture and pregabalin, hydrocodone, paracetamol and cyclobenzaprine. In recent years, the patient had loss of energy, weight gain, headaches, insomnia and depression, accompanied by an even greater physical dysfunction. The patient had also hypertension and Graves’ disease and received amlodipine, cyclobenzaprine, hidroxiclorotiazida, hydrocodone and paracetamol, levothyroxine, pregabalin and aspirin, among other drugs. Physical limitations prevented him from continuing their work as a nurse. On physical examination, the patient presented afebrile with normal vital signs. Palpation revealed different areas of sensitivity. The remainder of the physical examination was normal, as the results of laboratory tests.
As regards the patient, most people do not understand fibromyalgia because no visible manifestations of disease. The pain is deep and widespread. Since it is not possible to predict the physical condition of each day, it is necessary to adapt the activity to pain and apply a consistent therapeutic strategy. In addition, medication affects the daily performance. For the patient, acupuncture was helpful for pain relief and helped to reduce the use of other medications. The hardest part was to receive diagnosis and, subsequently, the appropriate treatment to achieve a normal performance.
a search for studies on fibromyalgia in the databases Medline and Cochrane Central Registry of Controlled Trials was performed. In general, therapeutic recommendations included in this review were developed by the Canadian Pain Society.
► Epidemiology and pathophysiology of fibromyalgia
Fibromyalgia is the most common rheumatic disease after osteoarthritis. Most patients with fibromyalgia are women. As already described, it is characterized by the presence of chronic, widespread pain in different sensitivities. However, at present not diagnosed fibromyalgia by tender point count, but takes into account the main symptoms of the disease. This decreased the difference in prevalence between males and females, and resulted in a 1: 2 ratio, similar to that found in the presence of other disorders chronic pain.
Fibromyalgia can be seen in people of all ages, cultures, ethnic groups and socioeconomic levels. Often a history of pain in a body region, according to a phenotype of predisposition for pain is observed. In addition, relatives of patients with fibromyalgia may have a history of chronic pain, which would be associated with a genetic predisposition.
As for the factors that can trigger fibromyalgia highlights stressful situations such as acute pain, infection, trauma and stress. It is estimated that up to 30% of patients with rheumatic diseases such as rheumatoid arthritis, osteoarthritis and lupus meet the criteria for diagnosing fibromyalgia.
Studies using neuroimaging allowed the observation that patients with fibromyalgia present activation of pain processing pathways to touch, pressure or mild heat applied to sensitive areas. Psychological, behavioral and social factors contribute to the pathophysiology of the disease, which complicates treatment.
This could be due to the existence of triggers and neurological common factors between fibromyalgia and psychiatric disorders such as depression or anxiety. Factors potentially modifiable risk of fibromyalgia lack of sleep, obesity, sedentary lifestyle and work or general dissatisfaction are included. Cognitive behavioral therapy is a tool that can be used to handle the psychological component of fibromyalgia, although its application in clinical practice is uncommon.
► Diagnosis of fibromyalgia patient
The diagnostic criteria for fibromyalgia developed in 1990 by the American College of Rheumatology were created primarily for application in the field of research. At present it is known that many patients with fibromyalgia do not have at least 11 tender points as enunciated these criteria.
2001 alternative criteria including evaluation of the location of the pain, the presence and severity of fatigue, sleep disorders, the mnemonic difficulties, headaches, irritable bowel and mood disorder were proposed. This assessment does not require the analysis of the number of tender points. One advantage of the new criteria for the diagnosis of fibromyalgia is the conceptualization of the main symptoms of pain in a continuum.
In clinical practice, a patient with multifocal pain not associated with inflammation mechanisms may suffer injury or fibromyalgia. Musculoskeletal pain or may be present as chronic headaches, sensory hypersensitivity or visceral pain, among other pictures. Laboratory tests are not useful for the diagnosis of fibromyalgia.
► Treatment of patients with fibromyalgia
The best studied non-pharmacological approach for patients with fibromyalgia is education, cognitive behavioral therapy and exercise
Treatment of patients with fibromyalgia should be comprehensive, pharmacological and non-pharmacological, and include the individual actively. Both diagnosis and treatment can be carried out at the primary care level. The treatment team should include professionals with experience in patient education and cognitive behavioral therapy.
Coincidentally, the Canadian National Fibromyalgia Guideline Advisory Panel and others recommend that patients with fibromyalgia are educated about their clinical picture, about the importance of getting involved in the treatment, lower stress levels, sleep well, and exercise. While drug therapy may be helpful in relieving some symptoms, patients generally do not achieve a significant improvement if they fail to non-pharmacological strategies.
The pharmacological approach is based on decreased activity of neurotransmitters that facilitate the pain such as glutamate, and increased neurotransmitter activity inhibiting it as serotonin, norepinephrine and gamma aminobutyric acid (GABA). Amitriptyline, cyclobenzaprine, pregabalin, gabapentin, duloxetine and milnacipran are some drugs may be effective in patients with fibromyalgia.
There are also drugs with an efficiency less proven as selective reuptake inhibitors (SSRIs) in high doses, low doses of naltrexone and cannabinoids. However, the drugs used for treating patients with peripheral pain such as nonsteroidal anti-inflammatories, opioids and corticosteroids not be usefully employed in the presence of fibromyalgia.
The best studied non-pharmacological approach for patients with fibromyalgia is education, cognitive behavioral therapy and exercise. In general, the response to such treatments is higher compared to the response to drug treatment. As found, the improvement provided by the non-pharmacological approach may be durable, although there are limitations regarding access and treatment compliance.
Complementary or alternative therapies may be useful, but not have enough studies about it. Your application may not always be adequate to generate a patient harm. While fibromyalgia is not considered a disease of peripheral cause, treatment of peripheral pain generators it could be useful. Anyway, the real consequences of this approach are not yet clear. Neuroestimuladoras therapies can be beneficial in patients with musculoskeletal pain. At present there are new therapies for central stimulation that could be beneficial for people with fibromyalgia.
► Therapeutic recommendations for patient described
The patient described in this study did not require referral to a specialist. Once the diagnosis is made, the patient should be educated about the nature of the symptoms and the limited effectiveness of drug treatment. It must also emphasized the importance of behavioral approach including standardization of sleep and exercise, as these strategies are generally more useful than pharmacotherapy. The pharmacological approach to the patient includes limiting dose cyclobenzaprine optimizing dose pregabalin and the addition of an inhibitor of serotonin and noradrenaline reuptake (NSRI).
At present it has a higher level of understanding, both fibromyalgia and other pain disorders. Fibromyalgia is a disease that includes symptomatic constellation characterized by the central amplification of pain and accompanied by fatigue and memory disorders, sleep and mood. Patients with this clinical picture can be effectively treated.