The Pathophysiology, Diagnosis and Treatment of Fibromyalgia

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Diagnostic Criteria

The criteria for the ACR classification of FM include widespread pain of at least 3 months duration and pain on palpation of 11 or more of 18 specific tender point sites on the body (Box 1).2 To assess the tender points, pressure is applied with the dominant thumb pad perpendicularly to each site and the force increased by approximately 1 kg per second until 4 kg of pressure is achieved, which usually leads to whitening of the thumb nail bed.

Although the ACR classification criteria are the

Epidemiology

FM is common in the United States, with an estimated prevalence of 2% in the adult (18 years of age or older) general population. FM affects women disproportionately, with a prevalence of 3.4% in women compared with 0.5% in men.22 The community prevalence of FM in Europe, South Africa, and Canada varies from 0.7% to 4.5%, with a greater prevalence in women compared with men.23, 24, 25, 26, 27, 28, 29 It is unclear why there are international differences in the community prevalence of FM, but

Psychiatric Comorbidity

In clinic and community groups, FM was strongly associated with multiple somatic complaints, depressive and anxiety symptoms as well as a personal and family history of depression and subsequent antidepressant treatment.22 Depressive and anxiety symptoms are common and frequently severe, even among community cases of FM.37 Consistent with previous controlled studies of psychiatric comorbidity in FM,38, 39 a recent study reported a high lifetime prevalence of mood and anxiety disorders in

Course of FM

In one of the longest follow-up studies of rheumatology outpatients with FM, all 29 patients, who were surveyed by telephone 10 years after the original evaluation, had persistence of some FM symptoms, with moderate to severe pain or stiffness in 16 (55%), moderate to severe sleep difficulties in 14 (48%), and moderate to severe fatigue in 17 (59%). However, despite persistent symptoms, 19 (66%) of 29 felt better overall than when first diagnosed with FM. The only baseline variables that

Genetic Factors

The cause of FM is unknown, although genetic and environmental factors probably contribute to the liability to FM. Early small, uncontrolled family studies provided evidence for familial aggregation of FM.71, 72, 73 A recent, large, controlled study confirmed that FM aggregates strongly in families. In this study, the OR measuring the odds of FM in a first-degree relative of a patient with FM versus the odds of FM in a relative of a patient with the control condition, rheumatoid arthritis, was

Treatment of FM

Because the clinical presentation of FM is heterogeneous, the treatment should be individualized for each patient, depending on the severity of the patient's pain, the presence of other symptoms or comorbidities, and the degree of functional impairment. The management of FM includes the identification and treatment of all symptoms or disorders that commonly occur in patients with FM, such as pain, fatigue, sleep disturbances, cognitive impairment, stiffness, and mood or anxiety disorders. The

Summary and recommendations for treatment of FM

Because the clinical presentation of FM is heterogeneous, treatment recommendations must be individualized for each patient. The rapid growth of trials in FM in recent years has resulted in new evidence-based approaches to pharmacological treatment.215 Recent evidence suggests that comorbidity and the presence and severity of symptom domains are important when selecting initial medication treatments for FM. Until recently, a trial of tricyclic antidepressants or cyclobenzaprine was the

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