Chronic widespread pain

Chronic widespread pain is a very common reason for consultation. If it is limited to patients with fibromyalgia, their prevalence is 2-5% of the general population.

The physician’s approach is first to formally rule out any organic pathology may be by joint pain and / or muscle and / or diffuse bone as early forms of inflammatory rheumatism, metabolic muscle diseases, inflammatory or iatrogenic , some chronic infections, certain endocrine or bone disease (deficiency or neoplastic).

This first step, not always simple, crossed, we then turned to the “diffuse idiopathic polyalgic syndrome” now called fibromyalgia, and whose diagnosis is based on criteria formalized by the American College of Rheumatology.

This diagnostic approach is primarily clinical, helped by some diagnostic tests to perform consistently in first intention.

In the presence of such patients are two pitfalls to avoid: uselessly multiply these paraclinical explorations and of course ignore a curable organic disease.

EXAMINATION AND CLINICAL EXAM:

Examination:

The precise examination:

– Seniority pain, their start modes: sudden or progressive, localized or diffuse readily;

– Their locations: muscle, joint, tendon or bone, axial and / or devices, or not achieving the distal joints;

– Their schedules and circumstances of occurrence: permanent or only effort, insomniants their nature, the presence of morning stiffness, articular inflammation, etc. ;

– The existence of a muscular challenge cit;

– Associated manifestations: chronic fatigue, irritable bowel syndrome, cystalgia, headache, etc. ;

– Medication, including lipid-lowering.

Physical examination:

Complete, comprehensive review looks first to joints and muscles:

– Looking for arthrosynovite objective signs of a spinal stiffness pain sacroiliac, etc. ;

– Looking for a cit muscular challenge, a focused atrophy or diffuse pain in the pressure of the muscles;

– Looking for a periungual erythema or edema of the eyelids suggestive of dermatomyositis, etc. ;

– Search for a pain on pressure from 0 reviews fibromyalgia points;

– Finally, general examination in particular for signs of hypothyroidism, dry syndrome, cutaneous manifestations of dermatomyositis, etc.

PARACLINIQUES REVIEWS:

Some diagnostic tests are routinely perform in the presence of a chronic pain syndrome, looking in particular of inflammatory joint disease or muscle disease. Other tests are to realize that second-line depending on the clinical context (Box 1).

Box 1. Investigations face a polyalgic syndrome
Exams first line
erythrocyte sedimentation rate (ESR), C-reactive protein, blood count, platelets
Protein electrophoresis
Serum electrolytes, renal function, blood sugar
serum iron
rheumatoid factor, antikeratin antibodies, antinuclear antibodies
calcium and phosphate
Transaminases, alkaline phosphatase
muscle enzyme (creatine phosphokinase-[CPK])
thyroid stimulating hormone (TSH)
Radiographs standards hands, feet, axial skeleton
second-line or in connection with clinical exams
Infectious Serology oriented in the anamnesis (HCV borreliosis)
dry syndrome research and salivary gland biopsy
angiotensin-converting enzyme
Electromyogram of 4 members and paraspinal muscles
technetium bone scan
Proof of metabolic stress, dosage of muscle enzymes after exercise
muscle biopsy
Magnetic resonance imaging (MRI) muscle, joint

DIAGNOSTIC ORIENTATION:

Following this review, two scenarios are possible: in the first, clinical and / or paraclinical abnormalities are in favor of an organic cause; in the second, nothing can explain the diffuse pain syndrome and then we are heading towards the diagnosis of lesion without explanation polyalgic syndrome whose most finished picture is fibromyalgia.

Inflammatory rheumatism:

In this case, arthralgia have an inflammatory time. Persistent to rest and especially at night, they are accompanied by prolonged morning stiffness. especially found in history, as in clinical, objective signs of inflammatory joint damage.

There are often inflammatory test abnormalities (elevated erythrocyte sedimentation rate, C-reactive protein [CRP]).

The technetium reveals articular uptake homes. Imaging (radiographs, MRI and ultrasound joint) and biological markers of inflammatory rheumatism (rheumatoid factor, anti-peptide antibodies citrullinated, antinuclear antibodies, HLA27, etc.) specifically oriented diagnosis: rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus, Sjogren’s syndrome, etc.

Muscle diseases:

Spontaneous muscle pain or stress and elevated creatine phosphokinase, (CPK) moving towards a muscular pathology:

– During myositis, myalgia are common and accentuated by pressure. There is especially a predominant muscular deficit rule at the belts. CPK is high variably, and electromyography, MRI and muscle biopsy confirmed the diagnosis;

– In the metabolic myopathies, myalgias occur mainly in the effort to cramping resulting in a decrease in muscle performance. muscle metabolism anomalies are found in the stress test, and biopsy remains essential for typing the disease;

– More rarely, tracks muscular dystrophy that rule is more loss than painful.

Various causes:

Many conditions that can present with diffuse pain are listed in Box 2.

Box 2. Causes various diffuse pains
infl ammatory joint disease: early inflammatory joint disease, as “entheseal pain” spondylarthropathies
systemic disease: systemic lupus diffuse, Sjögren’s syndrome, polymyalgia rheumatica
Fibromyalgia, chronic fatigue syndrome
infectious and post-infectious syndromes: parvovirus, hepatitis, Lyme disease, toxoplasmosis, toxocariasis, late post-polio syndrome
Endocrine: thyroid disease, hyperparathyroidism
bone causes osteomalacia, myeloma, bone metastases, phosphate diabetes
painful muscular diseases: myositis, metabolic myopathies and iatrogenic
Depression or psychiatric illness proved

In the majority of cases in practice, no objective abnormality is found. We are heading towards the diagnosis of fibromyalgia pain by seniority, their axial diffuse character and peripherals, both sides of the belt, the signs of accompaniments including the foreground asthenia and pain the pressure of trigger points.

Fibromyalgia:

This term originated in the 1980s, although the condition is long known by other names. She received international recognition in 1990 with the publication of the criteria of the American College of Rheumatology.

Fibromyalgia is a syndrome of unknown cause, characterized by diffuse and chronic pain, and musculotendinous joints, exacerbated by pressure, without explanation lesion, and associated signs of accompaniments including fatigue is the single most constant. Its prevalence is of the order of 2 to 5% of the population, with a female preponderance (3-9 females to 1 male). The average age of diagnosis is 45 years, but fibromyalgia can occur at any age and even in adolescents.

Clinical manifestations:

The pain of installation can be brutal (20% of cases) and immediately diffuse, or more often progressive with a readily initially localized pain. When the table is made, the pain is diffuse, bilateral sides of the waist, often poorly localized by the patient: joint and / or tendon and / or muscle. The pain is permanent, sometimes day and night insomniantes.

They are favored by physical exertion, cold or stress.They are accompanied by a morning joint stiffness may initially towards an inflammatory but there never rule ignition objective sign of joint inflammation. Typically, these pains are accentuated by the pressure of facing the tendon insertion areas (Fig. 1).

* Signs of accompaniments:

They are of prime importance in the clinical manifestations.

Tired:

It is constant, chronic evolution, overall both physical and mental. It is accompanied by a painful muscular fatigue on exertion, decreased physical performance, but there is no challenge cit goal, and muscle strength is preserved.This strain is very similar to that observed in the chronic fatigue syndrome, and there is an overlap between these two disorders.

Sleeping troubles:

Most patients complain of sleep disturbances with difficulty falling asleep and frequent nighttime awakenings. There are frequent and not fortuitous association between fibromyalgia and sleep pathology, including the sleep apnea syndrome and restless leg. The search for a disorder of vigilance by the Epworth Sleepiness Scale should be systematic and polysomnography in doubt is justified.

Cognitive disorders:

They are present in nearly 80% of patients: memory impairment, impaired concentration.

Other events:

Various functional manifestations may be associated with musculoskeletal pain: functional digestive disorders with irritable bowel syndrome, dizziness, paresthesia and dysesthesia, nervousness feeling, temporomandibular dystonia, cystalgia, etc.

Depressive elements:

The more or less ancient history of depression are found in 50-70% of patients, but moderate depression or active serious is observed that in 30 to 40% of them. These depressive elements may be different from those observed in other chronic pain conditions, and it would probably be a mistake to consider fibromyalgia as an expression of psychological distress or masked depression.

Diagnostic:

Diagnosis is based on the classification criteria established by the American College of Rheumatology in 1990 and speci fi ed in Box 3. One notices the absence of elimination criterion, and it is far from exceptional that authentic fibromyalgia come to associate with a no less true inflammatory rheumatism.

Box 3. Criteria of the American College of Rheumatology for the classification of fibromyalgia, 1990 (complete and literal translation)
diffuse pain Table
Pain is considered diffuse if the following elements are present:
– Pain in the left side of the body
– Pain in the right side of the body
– Pain above the waist
– Below the waist pain
– In addition, axial skeletal pain (cervical spine or anterior wall of the dorsal or back pain column) must be present; in this defi nition, pain in the shoulder or the buttock is considered as such for each side reached; low back pain is a pain of the lower segment
Pain on digital palpation of 11 of 18 tender points
Pain on digital palpation must be present in at least 11 of 18 tender points following:
– Occiput: bilateral, at the insertion of the muscles under the occipital
– Low cervical: bilateral, at the anterior part of intertransversaux spaces at C5-C7 level
– Trapezal: Bilateral average of the upper edge (muscle)
– Suspineux: bilateral, insertion above the spine of the scapula, near its inner edge
– 2nd side: bilateral, at the second chondrocostale junction, next to the junction to the upper surface
– Side épicondylien: bilateral, 2 cm below the epicondyles
– Gluteal: bilateral, at supero outer quadrant of the buttock, anterior gluteal fold
– Trochanter: bilateral, posterior to the projection of the greater trochanter
– Knee: bilateral, at the medial fat pad near the line spacing

Thus in Sjogren’s syndrome, fibromyalgia include elements in at least 25% of patients. Associations also exist with rheumatoid arthritis or systemic lupus erythematosus. In practice, it is important to recognize fibromyalgia elements in these patients to avoid escalation therapy with corticosteroids and / or immunosuppressants, who bring their side effects.

To meet the objective classification, patients will be required to have fibromyalgia to involve 2 criteria in Box 2.

The diffuse pain must have been present at least 3 months. Palpation (pressure) Digital must be made with an approximate force of 4 kg. For a sore point to be considered now, the subject should report that palpation is painful;sensitive is not considered painful. The presence of associated clinical picture does not exclude the diagnosis of fibromyalgia.

CARE THERAPEUTIC:

It is important to provide patients with an accurate diagnostic label linking all these symptoms which often puts an end to the misunderstanding of the entourage including medical and medical nomadism and stops the unnecessary multiplication of additional tests.

The therapeutic management should be comprehensive and multidisciplinary ideally combining three key elements:

– Correction of sleep disorders when they exist;

– Muscular rehabilitation effort;

– Drug treatments.

Correction of sleep disorders:

The correction requires first research and specific treatment of a sleep disorder. In case of insomnia, it is possible to use such hypnotic zolpidem or zopiclone, avoiding benzodiazepines which have the disadvantage of disturbing the sleep architecture.

Muscular rehabilitation effort:

Non-pharmacological treatment is based on aerobic exercise programs whose effectiveness has been demonstrated by numerous studies.

We suggest as walking, jogging, cycling, swimming, or therapy sessions. This rehabilitation effort should be gradual, not discourage patients due to the worsening of fatigue and the pain experienced after the start of program effort.

Medical treatment:

He appealed to antidepressants including tricyclides: amitriptyline (20-50 mg / day) was the most used drug after the publication of studies demonstrating its superior efficacy to placebo. Unfortunately, it seems limited in time with a therapeutic escape. Inhibitors of serotonin reuptake (IRS) have also proved more effective than placebo in some studies. The IRS-amitriptyline combination may potentiate.

Among the analgesics, tramadol relieves the patient during painful flare-ups. Opiates are against rule-indicated.

A therapeutic treatment often improve symptoms including pain, but complete remissions are still unfortunately rare.