10 M. Cazzola et al.Table IV - Conditions that simulate fibromyalgia.CommonHypothyroidismPolymyalgia rheumaticaEarly in course of autoimmunedisorders: e.g. rheumatoid arthritisor SLESjogren’s syndromeLess commonHepatitis CSleep apneaChiari malformationnosed as FM. A recent study (26) has providedsome evidence concerning inaccuracy in diagnosingFM in a cohort of patients referred to a rheumatologyclinic: FM was confirmed in only 34% ofpatients presenting with musculoskeletal pain, witha 66% diagnostic error rate. TPs (p
Fibromyalgia syndrome: definition and diagnostic aspects 11Table V - Clinical criteria for a diagnosis of myofascial pain syndrome caused by active trigger points.To make a clinical diagnosis of myofascial pain syndrome, the findings should include the five main criteria and at least one of the threeminor criteria. The five main criteria are:1. Reported symptom of regional pain.2. Symptoms of pain or altered sensation in the expected distribution, or pain transferred from a myofascial trigger point.3. Palpable tense fascia in an accessible muscle.4. Point of great tenderness along the tense fascia.A certain limitation in the amplitude of movement, when measurable.The three minor criteria are:1. Clinical symptom of pain or altered sensitivity reproduced by pressure on the tender point.2. Provocation of local contraction response by means of sharp transversal palpation on the tender point, or the insertion of a needle inthe tender point of the tense fascia.3. Pain relived by lengthening (stretching) the muscle or by injecting the tender point (trigger point).Note: Additional symptoms are often present, such as sensitivity to the weather, disturbed sleep and depression, but they are not diagnostic because they may be attributable tochronic severe pain perpetuated by numerous mechanical and/or systemic factors. From: Simons AG: Muscular pain syndromes. In : Friction JR, Awad EA (eds.), Advances inPain Research and Therapy, Vol. 17: Myofascial Pain and Fibromyalgia. New York, Raven Press, 1990, p. 18.Table VI - Diagnostic criteria for chronic fatigue syndrome.• Clinically ascertained, persistent, recurrent and unexplainablechronic fatigue• of recent onset or temporally identifiable• not due to an ongoing period of effort• not relievd by rest• occupationally, socially or personally disabling.The concomitant presence of at least four of the followingsymptoms, each of which must have been present continuouslyor have recurred occasionally for at least six or more consecutivemonths of disease, and not prevailing over the fatigue:• patient report of a deterioration in short-term memory thatis sufficiently severe as to cause a reduction in previousworking, scholastic, social or personal activities• pharyngodynia• cervical or axillary lymphadenopathy• muscle pain• polyarticular pain without tumefaction or reddening• headaches with new characteristics or of different severity• unrefreshing sleep• malaise following effort and lasting more than 24 hours.whether HCV infection is associated with FM,since there is no proof of an epidemiological linkbetween the two (44).<strong>CFS</strong> frequently overlaps FM (Tab. VI). More than70% of FM patients have <strong>CFS</strong> symptoms, and thepatients who meet the criteria for both FMS and<strong>CFS</strong> have a worse overall health status (45).Myofascial pain syndrome has been defined aschronic pain accompanied by trigger points (TrPs)in one or more muscles or group of muscles (Tab.V). TrPs may easily be mistaken for TPs and, thus,lead to the overdiagnosis of FM; therefore, physiciansmust be able to distinguish TrPs and TPs withthe aid of a pain drawing (25).CONCLUSIONSIn the light of current knowledge, we can defineFM as a “central sensitisation syndrome characterisedby dysfunction in the neurocircuits involvingthe perception, transmission and processing ofnociceptive afferents, with the prevalent manifestationof pain at the level of the musculoskeletalsystem”.Together with pain, which is characterised by hyperalgesiaand allodynia, symptoms of debilitatingfatigue, disrupted or non-restorative sleep, functionalbowel disturbances, and a variety of neuropsychiatricproblems including cognitive dysfunction,anxiety and depressive symptoms combineto define FM (46). Women are the most affected,and the disease has a familial connectionlinked to genetic variances in the serotonin,dopamine and catecholamine intracerebral system(47). The physical symptoms of FM express themselvesprimarily in the presence of a psychologicalcondition that reduces the individual capacity totolerate stessors (48).Despite widespread criticism, the diagnostic criteriaof FM are still based on the 1990 ACR recommendations,which require a specific case history(widespread pain lasting more than three months,sleep disturbance, debilitating fatigue, paresthesia),and tenderness upon pressure (4 kg/cm 2 ) in at least11 of the 18 TPs distinguishing the disease, on bothsides of the body and simultaneously above and belowthe waist. On the basis of these diagnostic cri-
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