Fibromyalgia and chronic fatigue syndrome. Fibromyalgia symptoms, examination, treatment

Causes

The process of studying the causes of fibromyalgia is still ongoing. Some researchers are studying hormonal and biochemical disturbances that may affect receptor sensitivity. Other experts believe that fibromyalgia, with its characteristic deep muscle pain, is related to stress, illness or injury. Still others believe that there are hereditary reasons. But due to the fact that there is no clear explanation for the causes of this syndrome, all researchers agree that fibromyalgia occurs due to a combination of several factors, and not just one (physical and emotional stress). Recently, studies have appeared on the role of neurotransmitters such as serotonin (low levels in the brain reduce the threshold of pain sensitivity). A decrease in the threshold of pain sensitivity may also be due to the ineffectiveness of neuropeptides such as endorphins and, as a result, an increase in substance P, which enhances pain impulses. Perhaps because women have 7 times less serotonin in their brains than men, fibromyalgia is much more common in women than in men. It is also possible that hormonal factors play a role in women, especially during menopause.

Stress, as well as insufficient sleep, can lead to decreased serotonin levels, which leads to increased sensitivity to pain.

Genetic determination may have a role in the development of fibromyalgia, as pain sensitivity is determined by certain genes. But so far these genes have not been isolated or identified.

Treatment of fibromyalgia and chronic fatigue syndrome

The pain associated with fibromyalgia can almost always be relieved. Sometimes this can be troublesome, the process of selecting a treatment regimen may require more time, but treatment of fibromyalgia is real. In most cases, pain with fibromyalgia begins to subside after 2-4 weeks if 3 issues are resolved: a full night's sleep with the phases of slow-wave sleep and REM sleep represented, treatment of inflammatory triggers (autoimmune processes and infections - these are usually visible in test results), recovery normal functioning of the immune system. Why exactly 2-4 weeks? This is due to the lifespan of certain immune system cells, antibodies and other factors that support inflammation.

Prognosis for treatment of fibromyalgia. In most cases, after three or four months, you can gradually reduce your medication dosage. As physiological regulation is restored, the need for treatment gradually decreases, until all medications are completely withdrawn. Difficulties in treatment are possible if some factor continues to act on the body, again triggering fibromyalgia. For example, relapses of fibromyalgia are observed against the background of chronic viral hepatitis, when it is not possible to completely destroy the virus, in the case of “major” psychiatric pathology (schizophrenia, endogenous depression), but in these cases clinical improvement is possible, although it requires a little more effort.

Risk factors

Possible risk factors for developing fibromyalgia include:

• gender factor (women are usually affected)
• genetic predisposition
• menopause (decrease in estrogen levels)
• poor physical fitness
• history of surgery
• damage to the brain or spinal cord (accidents, illnesses, emotional stress).

Thus, there is no single theory of both the occurrence of fibromyalgia and the causes that provoke this condition.

Regardless of the cause, constant pain, tender spots, and insomnia lead to an increased feeling of fatigue and decreased energy, which in turn, over time, begins to affect performance. Therefore, as soon as the doctor makes such a possible diagnosis, it is necessary to begin treatment, which will quickly eliminate symptoms and improve the quality of life.

Description

The prevalence of fibromyalgia in the population is from 1% to 8%; women are mainly affected by this syndrome. Fibromyalgia can be idiopathic, when it is not combined with another pathology, and secondary, if it is diagnosed together with any clinical pathology (most often, a chronic disease). Since 1984, the term central sensitivity syndrome has been proposed as a pathological concept that includes various processes with similar characteristics, including fibromyalgia, chronic fatigue syndrome and others.

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Symptoms

Common symptoms of fibromyalgia may include:

• Pain
• Anxiety
• Impaired concentration and memory
• Depression
• Fatigue
• Headache
• Irritable bowel syndrome
• Morning stiffness
• Painful periods
• Sleep disorders
• numbness and tingling in the arms and legs
• painful (tender) points
• dysuric phenomena (painful or frequent urination

Pain is the most common symptom of fibromyalgia and affects more than 97% of fibromyalgia patients. And pain, as a rule, is the main symptom that forces a person to seek medical help.

Unlike joint pain caused by osteoarthritis, fibromyalgia pain is felt throughout the body. The pain can be deep, sharp, dull, throbbing and felt in the muscles, tendons and ligaments around the joints. The pain may come and go in some patients and appear in different parts of the body. The pain may be felt as muscle fatigue, similar to that which occurs after physical activity, and fibrillation of muscle groups is sometimes possible. Pain and stiffness may occur in the neck, shoulders, back, and hips, and this pain makes it difficult to sleep or exercise. In the skin there are about 20 types of different receptors (including pain ones), impulses from which enter the brain and are analyzed. With fibromyalagia, a peculiar failure occurs in the analysis of these impulses in the brain (similar to a computer “Glitch”). The brain begins to perceive minor impulses as strong and small stimulation causes inadequate pain.

Pain from fibromyalgia can be either acute or chronic. The pain can be acute but usually disappears within one to two weeks. The pain is similar to that which occurs with muscle spasm due to excess load, and also gradually disappears on its own. Often, in such cases, the diagnosis of fibromyalgia is not considered. More often, the pain associated with fibromyalgia is chronic and localized in parts of the body that were in no way associated with excessive physical activity.

Painful (tender) points. In patients with fibromyalgia, along with deep muscle soreness, there are points or areas of tenderness characteristic of this disease in certain parts of the body. And if normally a person feels only pressure on soft tissue when pressing in these areas, then with fibromyalgia, when pressing on these points, severe painful sensations occur. These zones are often located not deep in the tissues where pain is felt, but superficially, under the skin. Painful points are located around the joints, and not in the area of ​​the joint itself. Painful points are usually small in area (1-2 sq. cm) and are scattered over the neck, back, chest, elbows, hips, buttocks and knees. The reason for the presence of such pain points (tender points) is not known. But their presence in a certain amount, as a rule, allows the doctor to suggest a diagnosis of fibromyalgia. There is even a special algesimeter device that allows you to influence points with a certain pressure and compare the sensitivity of these points with other parts of the body. There are 18 main tender points characteristic of fibromyalgia. To make a diagnosis of fibromyalgia, tenderness in 11 of these 18 points must be present. In addition, to diagnose fibromyalgia, widespread pain must be present for three months.

A number of factors can increase the symptoms of fibromyalgia.

They include:

• Anxiety
• Changes in the weather
• Depression
• Fatigue
• Hormonal fluctuations such as PMS
• Infections
• Lack of sleep or restless sleep
• Period of emotional stress
• Physical exhaustion
• Sedentary lifestyle

Fatigue, after pain, is the most common patient complaint. Patients with fibromyalgia feel tired even after a long period of rest, and the condition is somewhat reminiscent of the flu or after a long day of work or a sleepless night. The following sensations are typical for fibromyalgia:

• Fatigue in the morning
• Fatigue after light activity (such as grocery shopping or cooking dinner)
• Feeling too tired to do any household chores
• Tired to exercise or have sex
• Severe fatigue after physical activity.

But unlike normal fatigue, the feelings of tiredness, weakness and exhaustion that come with fibromyalgia can often lead to social isolation, and even depression. Patients with fibromyalgia do not feel energized, even after a long sleep, and, as a rule, their sleep is not deep, and patients experience a feeling of drowsiness during the day. Experts say there are many similarities between fibromyalgia and chronic fatigue syndrome, especially in the feeling of fatigue. In patients with fibromyalgia, the feeling of fatigue is combined with impaired concentration and poor memory (feeling of brain fatigue).

Additional symptoms of fibromyalgia include:

• abdominal pain
• anxiety and depression,
• chronic headaches
• dry mouth, nose and eyes
• increased sensitivity to cold and/or heat
• inability to concentrate
• urinary incontinence
• irritable bowel syndrome
• numbness or tingling in the fingers and toes
• painful menstrual pain
• painful tender points
• poor circulation in the arms and legs (Raynaud's syndrome)
• restless legs syndrome
• stiffness

Fibromyalgia can cause symptoms similar to those experienced by patients with osteoarthritis, bursitis, and tendinitis. But unlike the localized pain of bursitis or tendinitis, the feelings of pain and stiffness in fibromyalgia are widespread.

Sleep disturbances are a fairly common symptom in most patients with fibromyalgia. Patients with fibromyalgia generally do not have difficulty falling asleep, but sleep is light and easily disturbed. Therefore, many patients feel tired in the morning and lack of rest. These sleep disturbances can contribute to a constant feeling of tiredness. During sleep, patients with fibromyalgia experience bursts of brain activity that are characteristic of the waking state, and studies have shown that deep sleep is disrupted and shortened in patients. Therefore, the brain cannot recover fully.

Stiffness in the morning is observed in 75% of patients with fibromyalgia. Stiffness may occur in the muscles and joints of the arms, legs, and back. As a rule, the duration of such morning stiffness does not exceed a few minutes, but can sometimes last up to 15-20 minutes. Morning stiffness resembles that of systemic rheumatological diseases such as rheumatoid arthritis.

Depression is a key symptom for many fibromyalgia patients. About one in four patients with fibromyalgia have current depression. Constant stress from chronic pain and fatigue can stimulate the development of depression. In addition, chronic pain can cause the patient to become less active and become withdrawn. The patient's ability to concentrate is impaired and memory is impaired. Anxiety and depression are as much a part of fibromyalgia as pain.

Neurological symptoms such as numbness, tingling and burning are common in patients with fibromyalgia. Although the cause of these sensations is unclear, numbness or tingling in the arms, hands, or feet is experienced by more than half of fibromyalgia patients. The sensations are especially unpleasant when they appear in the morning, along with stiffness. Such sensations are called paresthesia and, although they cause discomfort to the patient, they do not greatly affect the ability to function, especially since these sensations are short and irregular

Chronic headaches, such as recurrent migraines or tension headaches, occur in about 70% of patients with fibromyalgia. Headaches can be a result of pain in the neck and upper back. They are often caused by spasm of the neck muscles or due to tender points in the neck. But headaches can also be a sign of other diseases, and therefore the doctor needs to clearly differentiate the genesis of the pain.

Constipation, diarrhea, frequent abdominal pain, gas, and nausea occur in approximately 40% to 70% of patients with fibromyalgia.

Frequent, painful urination and incontinence can occur in up to 25% of fibromyalgia patients. Since these symptoms can also be caused by other diseases of the bladder and kidneys, such as infection, it is also necessary to exclude such a genesis of the symptoms. Unusually painful menstrual cramps may also occur (in 30-40% of patients).

Restless legs syndrome causes discomfort in the legs, especially in the knees and feet. This especially worries patients at night. The feeling can be uncomfortable and is most often described as having to move your legs to try to get into a comfortable position.

Restless legs syndrome often disrupts sleep as a person struggles to find a comfortable position to rest. Like other symptoms, restless legs syndrome can occur alone or along with other conditions.

Electromyography of nerves and muscles in fibromyalgia / ENMG in fibromyalgia

Our clinic can offer you specialists who are well acquainted with the topic of fibromyalgia and ENMG diagnostics using modern equipment. The main tasks of electromyography in fibromyalgia:

1. Rule out poliomyositis of an autoimmune nature, myopathy, amyotrophic lateral sclerosis;
2. Differential diagnosis of fibromyalgia and radicular pain caused by compression of the spinal cord roots;
3. Diagnosis of polytunnel syndrome, which often accompanies fibromyalgia (pinching of the nerves of the arms and legs by thickened entheses).

How to Prepare for Electromyography for Fibromyalgia

1. Before the examination, you should not treat the skin in the examination area (arms and legs) with greasy creams.
2. We recommend that you do not take tranquilizers and centrally acting painkillers the day before and on the day of the study (this must be agreed with your doctor).
3. If possible, take with you the results of previously performed studies, including tests, images, consultation data, this may be useful for choosing the most appropriate ENMG technique.
4. Come to us 15-20 minutes before the test to calmly fill out your medical card.

Diagnostics

Due to the availability of a multifaceted treatment approach that includes both medications and lifestyle changes, the prognosis for patients with fibromyalgia is better than ever before. But first, the doctor must make an accurate diagnosis of fibromyalgia. Unfortunately, the diagnosis of fibromyalgia is often not made immediately. Despite the presence of characteristic symptoms, such as prolonged muscle pain, sleep disturbances, fatigue, anxiety, depression, other diagnoses are still made, for example chronic fatigue syndrome, arthritis, etc. On average, it usually takes about 5 years for fibromyalgia to be diagnosed. This is partly due to the fact that there are no specific research methods that would clearly confirm the diagnosis of fibromyalgia (neither laboratory tests nor imaging methods allow this to be done). Therefore, in the past, millions of patients were diagnosed with rheumatoid arthritis, chronic myofascial pain or chronic fatigue syndrome. Most laboratory tests are not very helpful in diagnosing fibromyalgia. From laboratory tests, tests are important that help exclude the presence of other diseases (general blood tests, urine tests, blood for rheumatic tests, blood biochemistry, blood for hormones, blood for the presence of antibodies to nuclei). These tests can help rule out diseases such as rheumatoid arthritis or systemic lupus erythematosus. For example, rheumatoid factor is positive in 80%. cases of patients with rheumatoid arthritis. The presence of antinuclear antibodies is usually evidence of SLE.

In fibromyalgia, radiography of painful areas does not reveal abnormalities. If there is a disease such as arthritis, then x-rays will determine the presence of an inflammatory process in the joint. So, any changes on the x-ray are not due to fibromyalgia.

The main diagnostic criteria for fibromyalgia are as follows:

• Have you had widespread pain in all four quadrants of the body for at least three months?
• Is there tenderness in at least 11 of 18 specific tender points when pressed?

In addition, the doctor needs to evaluate 6 more indicators:

• check the spread of pain
• evaluate tender points
• find out if you are tired
• identify sleep disorders
• assess your stress level
• take a depression test...

The criteria helped create an objective way to identify patients with fibromyalgia. But two criteria turned out to be insufficient and too narrow.

For example, these diagnostic criteria do not include patients with widespread pain, who have 10 or fewer painful points. And it turns out that such patients should not be diagnosed with fibromyalgia. In addition, men are 10 times less likely than women to develop tender spots. Thus, some patients with fibromyalgia symptoms other than tender spots will not be properly diagnosed.

Using tender points as a criterion for fibromyalgia can also create another dilemma. With treatment, the number of pain points in many people decreases. So a reasonable question arises: If the patient no longer has 11 or more tender points, does the diagnosis of fibromyalgia remain? Another problem is that performing a tender spot test requires a certain technique and pressure, and not all doctors always perform this test in the same way. The development of clearer criteria that are not tied to painful points continues. In addition, studies are being conducted on the possibility of using objective research methods that would allow a more accurate diagnosis of fibromyalgia.

How to diagnose fibromyalgia and CFS and find the cause of the disease in your case

With fibromyalgia, it is important to find the cause and provoking infections, as well as to exclude major rheumatic diseases, blood diseases, hereditary pathologies, multiple sclerosis, amyotrophic lateral sclerosis.

Typically the diagnostic plan is as follows:

• Laboratory diagnostics for fibromyalgia (state of the immune system, infections, markers of muscle damage);
• Ultrasound of entheses to diagnose current/past inflammation;
• Electroneuromyography according to the “fibromyalgic” program to assess the condition of muscles and peripheral nerves;
• Polysomnography to diagnose the causes of night sleep disorganization;
• Examination by a neurologist – immunologist or rheumatologist.

Usually these studies are sufficient to make a diagnosis and begin treatment.

The question of diagnosing fibromyalgia is posed as follows:

1. Determine the presence of fibromyalgia
2. Find its cause and, accordingly, the path to treatment.

The range of possible causes of fibromyalgia is, in various combinations, a deficiency of the slow-wave sleep and REM sleep phases with a “breakdown” of the immune function against this background, infection (borrelia, brucella, herpes type 6, etc.), hereditary predisposition, endocrine disorders (high the level of the hormone prolactin, for example), inflammatory processes of an autoimmune nature, etc. All these processes are accessible to diagnosis, understanding and treatment. Read more about laboratory testing for fibromyalgia below.

A full medical examination usually takes about 1 hour, because... You need to understand the overall health picture and evaluate the criteria for fibromyalgia. We recommend that you take all available research results and images to your doctor’s appointment. If you have experience, diagnosis here usually does not present any particular difficulties. If the situation requires it, we will also conduct some instrumental research, including:

• Ultrasound examination of entheses in fibromyalgia - it shows the criteria for the activity and duration of the fibromyalgic process;
• Electroneuromyography to exclude “major” autoimmune myositis, hereditary myopathy, polyneuritis and other conditions with similar symptoms.

Find the causes of fibromyalgia and treatment path

There is no single treatment regimen for fibromyalgia that suits everyone. There are principles by which you can build a working treatment regimen in each case. And this treatment regimen is based on research results. The examination plan may include:

• The main thing is a laboratory examination to search for infections involved in the pathogenesis of fibromyalgia, assessing the state of immunity;
• If indicated, rheumatological examination, lung examination (one of the possible findings is sarcoidosis);
• Diagnosis of sleep disorders (EEG during sleep, polysomnography), if sleep cannot be restored using conventional methods.

Treatment methods

Drug treatment

Antidepressants are recommended as initial medications for treating symptoms of fatigue. These drugs affect symptoms such as pain, fatigue, and depressed mood. The best known tricyclic antidepressants, such as amitriptyline, provide effective symptom relief. But these drugs cannot completely eliminate the pain syndrome. Anticonvulsant medications, such as Lyrica, have been shown to be quite effective in some patients. But this drug can cause side effects such as drowsiness, dizziness, swelling, and weight gain. Other drugs in this group are also used.

In recent years, antidepressants from the class of drugs known as serotonin and norepinephrine reuptake inhibitors, such as Cymbalta or Savella, have become quite widely used. Drugs from this group help reduce pain and improve overall well-being in patients with fibromyalgia. Side effects of these drugs may include nausea, dizziness, and insomnia.

Medicines that increase sleep duration may help treat fibromyalgia symptoms. It is possible to use low doses of a drug such as amitriptyline. Anti-inflammatory drugs - including ibuprofen and naproxen - do not have much therapeutic effect, since there is no inflammation in fibromyalgia. In addition, drugs from the NSAID group have a number of side effects such as stomach irritation, bleeding, and increased blood pressure. It is possible to use drugs such as paracetamol, because the irritant effect on the stomach is not very great, and it potentiates the effect of other drugs used to treat fibromyalgia. Muscle relaxants (mydocalm, sirdalud) can reduce muscle spasms and improve sleep, especially if used in the evening.

Steroids are usually used in cases where there are concomitant rheumatological diseases.

It is also possible to inject steroids into tender points, but the effectiveness of this method is quite controversial.

The introduction of Botox into tender points has become widespread recently, and studies have shown the fairly high effectiveness of this treatment method. Non-drug treatment methods:

• Acupuncture. Research has shown that the use of acupuncture changes brain metabolism and increases tolerance to the perception of pain.
• Manual therapy helps reduce muscle pain and increase range of motion in the spine.
• Massage, both classical and acupressure, can stimulate blood circulation and reduce muscle spasms.
• Biofeedback . This treatment method allows the patient to learn to control their sensations and reduce chronic pain.

Fibromyalgia pain points and local pain syndromes

Typical pain points for fibromyalgia are where the muscles intertwine with the bones, i.e. enthesis. In fibromyalgia, the immune system attacks the enthesis, causing inflammation and pain. The picture of inflammation can be seen with MRI and ultrasound of the entheses, although structural changes in the entheses are not very noticeable due to their anatomical structure.

Local pain syndrome is a form of fibromyalgia in which pain is more severe in one region of the body. At the same time, other typical pain points are also active.

Fibromyalgia: typical pain points

Typical local pain syndromes in fibromyalgia:

1. Headache;
2. Atypical facial pain;
3. Chronic pelvic pain (including tendinitis of the lumbar muscles, trochanteritis);
4. Coccygeal pain – coccydynia;
5. Humeral periarthritis of non-traumatic nature.

Practice shows that successful treatment of fibromyalgia and local pain syndromes is possible if 3 issues are resolved: a full night’s sleep is restored with the phases of slow-wave sleep and REM sleep present, infections that trigger inflammation are treated (they are usually visible in test results), normal work is restored immunity. Read more about treatment below on this page.

Bibliography:

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Dissection of the filum terminale using the Filum Sistem method

Advantages

1. The tension on the spinal cord caused by a too short or tight filum terminale is eliminated.
2. Using the minimally invasive surgical technique of the Chiari Institute of Barcelona, ​​the surgical time is 45 minutes. Stay in the hospital for about a day. The post-operative period is short and without serious restrictions. No admission to the intensive care unit. No blood transfusion.

3. Its use reduces the risk of mortality to zero. No serious complications.

4. Improves symptoms and stops the development of pathologies associated with filum terminale disease.