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Chronic widespread pain in the spectrum of rheumatological diseases

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Chronic pain is very common in all European countries, with musculoskeletal problems predominating. About 1% of the adult population develops a syndrome of chronic muscle pain, fibromyalgia (FMS), characterized by multiple tender points, back or neck pain, and a number of associated problems from other organs, including a high frequency of fatigue. Evidence points to central sensitization as an important neurophysiological aberration in the development of FMS. Importantly, these neurological changes may result from inadequately treated chronic focal pain problems such as osteoarthritis or myofascial pain. It is important for health professionals to be aware of this syndrome and to diagnose the patients to avoid a steady increase in diagnostic tests. On the other hand, patients with chronic widespread pain have an increased risk of developing malignancies, and new or changed symptoms should be diagnosed even in FMS. In rheumatology practice it is especially important to be aware of the existence of FMS in association with immune inflammatory diseases, most commonly lupus and rheumatoid arthritis. Differential diagnoses are other causes of chronic pain, e.g. thyroid disease. The costs of this syndrome are substantial due to loss of working capability and direct expenses of medication and health-system usage. Fibromyalgia patients need recognition of their pain syndrome if they are to comply with treatment. Lack of empathy and understanding by healthcare professionals often leads to patient frustration and inappropriate illness behavior, often associated with some exaggeration of symptoms in an effort to gain some legitimacy for their problem. FMS is multifaceted, and treatment consists of both medical interventions, with emphasis on agents acting on the central nervous system, and physical exercises.

Section snippets

Chronic widespread pain, what is the evidence?

Chronic pain is very common in all European countries1, and problems with musculoskeletal pain are particularly prominent.2 Pain leads to disability for the individual3, and for society the disease has significant economic implications.4, 5 In the muscles the most prominent pain syndrome is rather localized and generally referred to as myofascial pain, which may occur in most of the population given the right circumstances (see Chapter 3). The muscles, whether healthy or painful, have the

Importance for the Rheumatologist

For the rheumatologist, chronic widespread pain has always been relevant as it occurs in a significant percentage of the patients in their clinic. It is quite evident that musculoskeletal specialists have reacted very differently with regard to diagnostic and therapeutic strategies for patients with chronic pain syndromes. There are geographic and cultural variations in the attitude to chronic widespread pain, and in some countries only about one in four rheumatologists ‘believe’ in the

Importance for the patient

FM patients and physicians often have discordant views upon several matters which may impact on physician–patient collaboration during office visits.20 Persuading a skeptical physician about the validity of a pain complaint may be quite hard work.21 If the patient succeeds in adequately describing the problem, the chances of obtaining successful management is enhanced, as the attitude of healthcare professionals can positively add to treatment results. Conversely, denial on the part of the

Characteristics of FMS

The core diagnostic feature of FMS is a reduced threshold for pain in the muscles, generally identified by an increased sensitivity to pressure, with hyperalgesia and sometimes allodynia. Usually this feature is tested clinically with a pressure of about 4 kg/cm2 applied by the examiner's fingertip.23 The test is somewhat biased by examiner expectations, but is reasonably reproducible in daily clinical practice.24 For research purpose, a more elaborate instrument (such as an algometer) may be

Prevalence of FMS

Epidemiological data indicate that FM is fairly prevalent in all age groups in all cultures; the typical prevalence varies from about 1% to 10% (see Chapter 2).

FMS, like most descriptive syndromes, cannot be regarded as a truly discrete entity; rather it is best envisaged as being at one extreme of a continuous spectrum of pain intensity and distribution. Many adults have been observed to have three to six tender points without significant pain complaints50, and it is now evident that the

Classification of FMS

For research purposes, it has been of huge importance to have definite criteria for these patients.

In 1990 the American College of Rheumatology (ACR) published classification criteria for FMS.23 These are the most commonly used classification criteria in clinical and therapeutic research. They stipulate that an individual must have both chronic widespread pain for at least 3 months involving at least three quadrants of the body as well as the axial skeleton, and the presence of 11 or more of 18

Differential diagnosis

The case history of any patient with a complaint of musculoskeletal pain must include questioning about symptoms from other parts of the body, if possible supplemented by a pain drawing. Even chronic widespread pain has fluctuations, and this is especially the case in different areas, of which some will be the main problem at a given time.

The objective examination will as a matter of course include a palpatory evaluation of muscles, in this case including the well-defined 18 points of the ACR

Conclusion, treatment strategy

The 1990 ACR classification criteria for fibromyalgia were developed as a result of a large blinded multicenter study in North America which included patients with presumed fibromyalgia as well as patients with other chronic pain conditions.23 It is now apparent that these classification criteria, developed for epidemiological studies, while showing high diagnostic specificity, are sometimes lacking in sensitivity in the clinical setting. As such there are now renewed efforts to develop

Acknowledgements

This work was supported by the Oak Foundation. The authors are indebted to Rob Bannett for helpful comments on the manuscript.

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