The 20th Congress of RSCANP,

Băile Felix, 18-21.09.2019

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The 42st National Conference of Child and Adolescent Neurology and Psychiatry and Allied Professions with international participation


NEWS ABOUT FIBROMYALGIA

Autor: Constantin Lupu
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ABSTRACT:

Since 1992, fibromyalgia has been recognised by the WHO as a polymorphous pathology, a disease involving the muscles and the connective tissues, with a subacute or chronic evolution and having an anxious-depressive psychic component. Semiologically speaking, the polisymptomatology of fibromyalgia includes muscle pains, difficulties in movement: walking and physical activities, muscle cramps, insomnia and depression.

Etiopathogeny: The defining causes of this disease are unknown, but, in our opinion, we agree with the most accepted concept of evolution, from the acute state to chronic one, and the present material describes the results of the most important hypothesesand research.

Physio-pathologically, inflammatory mechanisms are involved, leading to the fiberization of certain muscle groups. This change is evidenced microscopically by the biopsy of long muscle fi bres. There are also neurological mechanisms that signal alterations of the sensory and pain transmission as well as a third complex of symptoms – the psychic ones: asthenia, cachexia, loss of psychomotor initiatives, insomnia and anxious-depressive states. The work is illustrated with the preferred locations of the painful areas. The treatments prescribed at present are:

— pharmaceutical ones: blocking the depression with tricyclic antidepressants, blocking the pain with analgesic drugs and nonsteroidal anti-inflammatory drugs;
— various physiotherapeutic and non-conventional methods.

At the same time, many affected people prefer meetings in small psychotherapeutic groups constituted by NGOs involved in the treatment of fibromyalgia and the fight against pain.The most specific are Fibromyalgia Associations, where patients may analyse their own situations and take favourable measures.

 


 

Among the chronic muscular painful syndromes,fibromyalgia has undergone multiple interpretations,and the present classifi cations have been arrived atthrough clinic systematization, targeted laboratoryexaminations as well as through other paraclinic electrophysiologicalexaminations such as: electromyography,muscular echography, including immunologic,genetic and electron-microsopic determinations.

We must point out that modern studies on thepainful pathology of connective tissues have led atfi rst to diagnoses such as chronic muscular fever ormuscular rheumatism, fi brositis and only recently fi -bromyalgia was the name given to a pathology whichexpresses itself by pains, but it has neither the biologiccharacteristics of rheumatism nor any other identifi -cation by a test specifi c to fi bromyalgia (FM). Th us,the FM diagnosis is based on clinic symptomatologyassociated with depressive symptoms.

Clinics aspects of fi bromyalgia

The primary symptom is the muscular suff erencewhere the acute pains are characteristic especially in theinitial periods: muscular pains in viral febrile states aswell as acute states in chronic fi bromyalgia, on a backgroundof subacute or chronic myalgias. Acute painbursts are attributed to certain physical factors (cold,heat, humidity) or to the meteosesitivity of the aff ectedmuscular areas. The myalgia symptoms are accompaniedby weakened muscular force, motility reductionand slowing down, spreading of pain to neighbouringmuscle groups. Sometimes it is also accompanied byspasticity with rigidity, muscular cramps, sensations ofimmobilization, diffi culties in initiating and sustainingphysical movements and fright of becoming immobile.The patients prefer warmth and need frequent rest withmuscle relaxation.

The childhood acute febrile myalgia episodes occuras precursors of chronic FMs. It is possible thatwe are in the already known pathogenic situation ofviral or prionic infections with retrovirus type agentsthat get included in the muscular fi bres and manifestthemselves in favourable environments after latencyperiods of some years.

Synthesising the possible aetio-pathogenic causesof FM, I made use of W. Muller’s data (1987) adaptedto the present knowledge (Table 1).

Table 1. Aetio – pathogenesis in fibromyalgia. After W. Muller

Although the FM aetio – pathogenesis is still unclear, according to this table, two big aetiological categories are analysed: the infectious and the inflammatory. This definition is also oriented for the differential diagnoses of FM. Depending on localization and lesional aspects this guide evokes the FM association possibilities with the neighbouring anatomical forms (Table 2).

The inflammatory (dysmetabolic) processes, as well as the inflammatory ones, are associated with the deficiencies of the neuromuscular plaque and of the receptors in the muscle and tendon fasciae which signal the pain and induce the muscular contraction.When the chemistry of these networks and terminations is perturbed, perpetuation and maintenance reflexes install themselves, which disrupts the vascular network from the muscles, too. The chronic hypoxia establishes itself, disturbing the supply and exchanges of the muscular glycogen by lowering the level.

Table 2. Fibromyalgy comorbidities. After R. Seidel

 

All the authors support the importance of thepsychic pathology in the development of the myalgic pathology. The American definition of FM: “it ischaracterised by diffused pains in the skeletal muscles,associated with multiple sensitivities of the connectivetissues and with depressive moods; it manifests itselfby morning rigidity, muscular fatigue, migraine, cervical pains and rachialgias, sleep disorders, anxiety, sadness, sometimes with suicidal ideas.” These depressivemoods enter the scene ab initio and amplify themselvesin evolution, being fed by myalgias, reduced motility,invoking the differences between the anterior motorabilities and the present deficit which amplifies in orthostasis and especially during and after physic activities. It affects especially the feminine sex.

The national and international societies that study the pain have obtained the official recognition of FM in the WHO nomenclature since 1992.The evolution of this pathology from acute to chronic has been included in the definition, and the major argument was the statistic one, by which FM is signalled in over 2030% of the population over 30-40 years old.

The present criteria established by The American College of Rheumatology for the positive diagnosis of FM are:
— The presence of the pain acutely installed or slowly progressing to muscular groups or masses (fi g. 1);
— Chronic evolution with the persistence of these physical pains;
— The presence of depressive disorders which intensify along the way;
— Exclusion of other neurological diagnoses;
— Basic paraclinical balance for the differential diagnosis with other allergies or recognition of certain comorbidities, because we still do not have a specific test for FM. The current tests are performed which allow to defi ne the patient’s bio-clinical state. Thus, the negative laboratory tests contribute to sustaining the fibromyalgia diagnosis.

Research in the structural pathology of FM has been done and continues to be done. In the evolution stages of the disease, especially in aged people,the inflammation of the muscular filaments could be detected and inflammatory dilacerations among myofibrils. In later evolution stages, the disorder in the sarcolemma and in the contractile structures appears,together with necroses of the muscle tissue with intracellular glycogen deposits. These microscopic aspects could be the basis for muscle fibrosis which is clinically expressed by myalgias and motor deficits.

Figure 1. Preferred locations of fibromyalgia. After R. Seidel

DIFFERENTIAL DIAGNOSIS

We shall take into consideration that FM is a chronic disease. Myopathy and infectious or inflammatory (viral, bacterial, helmintic, caused by protozoan parasites) myositis are excluded, as well as poly-myositis, dermatomyositis, gout, medicine induced myositis, periarthritis, and with muscular fever following an excessive effort.

THERAPEUTIC RELATIONSHIPS IN FM

First of all we must point out the importance of antiviral, ant-inflammatory and anti-fever treatments in children with myalgia infectious diseases.

Being a syndrome which manifests itself through pains, with the same location most of the time, the local therapy has become usual under diff erent aspects.Physio-therapeutic measures are warm relaxing baths,cures in rest homes in heath resorts with thermal waters accompanied by kinesiotherapy and sedative-relaxing procedures, including herbal baths.

Muscle relaxing massages are recommended as well as passive and active mobilizations in water.These treatments are parallel with local applications of therapeutic mud and warm paraffi n or bee wax, all of them at medium temperatures avoiding overheated or hot procedures; mineral water baths at 300 – 320C are practiced too. There are also sets of antiphlogistic and antalgique ointments which are tolerated in fi brositis or anti-inflammatory and antalgique ointments with herb extracts: Heleborus (Boicil), combined preparations (mint with cinnamon, etc.)

Revulsive medicines or different alcoholic solutions are not recommended.

The range of oral treatments is very extended, each practicing doctor having their own formulas. Nonsteroidal anti-inflammatory drugs are preferred lately,which have become usual in treating pains in soft tissues, joints, fever and in fibromyalgia: Diclofenac,Ketoprofen, Nimesulid, etc. But, in case of intolerance, we appeal again to classical salicylate preparations which have good effects.

Exercise, walking, swimming, and gymnastics,short runs are recommended, knowing that overstraining doubles the pains by loading the muscles with catabolits (lactic acid) which produce muscle fever. In FM, there is a classic pharmacologic triade made up of antalgique – antiphlogistic treatments associated with muscle relaxing preparations and accompanied by tricyclic antidepressives that proved necessary and efficacious in adopting a complete therapeutic conduit.

The doctor will establish the preponderance of one or of another pharmacological group according to the predominance of the patient’s symptomatology.In cases of somatogenic depression (“masked” depression) the effect of tricylic antidepressives is effi cacious with very good resolution of myalgic pains and recovery of the negative psychic states. I have used amitriptilina, the best recommended in the series of tricylic antidepressives.

The corticosteroids may be used only in local applications.

Acupuncture, pressopuncture or other non-aggressive, non-conventional therapies could be used, too.

Occasionally, self-medication treatment practiced by patients is possible when it is applied for a short period, but the doctor’s recommendation is essential.

Patients use various common analgesics such as paracetamol, metamizol (algocalmin, analgin, novalgin), derivates of pirazolidină (fenilbutazonă, ibuprofen, naproxen), diclofenac, derivates of preparations from salicylates, up to strong analgesics like fl upirtin,trancopal, tilidina (valoron), piroxicam and associates:lornoxicam and meloxicam or tramadol.

FM has oscillating clinic manifestations, being meteo-sensitive, sometimes accompanied by trailing myalgies which immobilise the patient, especially in senior individuals with pains in the lower limbs: the heavy feet of the older people.These situations amplify the negative and depressive psychic states which is why one should not omit the above mentioned anti-depressive treatments.

Chronic patients with FM benefit from various socio-therapies, as, for instance, organisation of meetings, games, performances, trips which detach them from their myalgic suff erance.

 

CONCLUSIONS

Fibromyalgia, a modern term continuing the classical concept of muscular rheumatism, is an ordinary and frequent pathology, especially in persons with ages over 30. I have presented a rough guide in this pathology and some therapeutic aspects for the information of the specialist physician and for the practitioner who very frequently meet muscular suff ering and pains in their patients.

BIBLIOGRAPHY

  1. Asociația de Alegeziologie din România-Centrul de Studiu și Terapia Durerii: Iași-Zilele Medicamentului-17 mai 2008.
  2. Bennet R.M.: The fi brositis /fibromyalgia syndrome. Curent issues and perspectives, Am. J. Med. 1986-81:1.
  3. Campbell S.M. and al: Clincal Characteristic of fi brositis. Arthritis Rheum. 1983-26:817.
  4. Lupu C.: Fibromialgia, interpretări de diagnostic și tratament. Rev. N.Psi. a Copilului și Adolesc. Din România, 2010. Vol.13, Nr. 3 (74-75).
  5. Muller W.: Neuropathologie der Musculare Schmerzen. Bonn.1987.
  6. Seidel R., Schwen A.: Neve orientirung in fi bromiositis. Frankfurt, 1996.
  7. Thom H.: Wirbelsaulen Syndrome. Winthrop, Nurnberg, 2001.
  8. Walton J.N.: The idiopatic infl amatory myopathies. J. of Neurology, 54:285,1991.
  9. Weatherall D.J., and al: Tratat de Neurologie, Edit. Tehnică, Buc. 2000.

 

Correspondence to:
Constantin Lupu Hipocrate Infantile Neuropsychiatry Cabinet Dr. I. Nemoianu Str. nr. 9, 300100 Timiºoara