1813 01 REUMA3 Editoriale - ME/CFS Australia

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ORIGINAL ARTICLEReumatismo, 2008; 60: Supplemento 1: 70-77Fibromyalgia syndrome:preventive, social and economic aspectsGli aspetti preventivi, sociali ed economici della sindrome fibromialgicaL. Altomonte 1 , F. Atzeni 2 , G. Leardini 3 , A. Marsico 4 , R. Gorla 5 , R. Casale 6 , G. Cassisi 7 , S. Stisi 8 ,F. Salaffi 9 , F. Marinangeli 10 , M.A. Giamberardino 11 , M. Di Franco 12 , G. Biasi 13 , G. Arioli 14 ,A. Alciati 15 , F. Ceccherelli 16 , L. Bazzichi 17 , R. Carignola 18 , M. Cazzola 19 , R. Torta 20 , D. Buskila 21 ,M. Spath 22 , R.H. Gracely 23 , P. Sarzi-Puttini 21UOC of Rheumatology Hospital S. Eugenio, Rome, Italy; 2 Rheumatology Unit, L. Sacco University Hospital, Milan, Italy;3Rheumatology Unit, SS Giovanni e Paolo Hospital, Venice, Italy; 4 Rheumatology Unit, Hospital of Taranto, Taranto, Italy;5Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Italy; 6 Department of Clinical Neurophysiology andPain Rehabilitation Unit, Foundation Salvatore Maugeri, IRCCS, Scientific Institute of Montescano, Montescano (PV), Italy;7Rheumatology Branch, Specialist Outpatients’ Department, Belluno, Italy; 8 Rheumatology Unit, “G. Rummo” Hospital, Benevento,Italy; 9 Department of Rheumatology, Polytechnic University of the Marche Region, Ancona, Italy; 10 Department of Anesthesiology andPain Medicine, L'Aquila University, L’Aquila, Italy; 11 Ce.S.I. “G. D’Annunzio” Foundation, Department of Medicine and Science ofAging, “G. D’Annunzio”, University of Chieti , Italy; 12 Chair of Rheumatology, University la Sapienza Rome, Rome, Italy;13Unit of Rheumatology, University of Siena, Siena, Italy; 14 Division of Rehabilitative Medicine and Rheumatology, General Hospitalof Pieve di Coriano (Mantua), Italy; 15 Department of Psychiatry, L. Sacco University Hospital, Milan, Italy;16IOV (Veneto Cancer Institute), IRCCS, Department of Pharmacology and Anesthesiology, University of Padua, Italy; 17 Department ofInternal Medicine, Division of Rheumatology, S. Chiara Hospital, University of Pisa, Italy; 18 S.C.D.U. Internal Medicine I, Departmentof Clinical and Biological Science, University of Turin, Italy; 19 Unit of Rehabilitative Medicine “Hospital of Circolo”, Saronno (VA),Italy; 20 Department of Neuroscience, University of Turin, A.S.O. San Giovanni Battista of Turin, Turin, Italy; 21 Department of MedicineH, Soroka Medical Center and Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel; 22 Friedrich-Baur-Institute,University of Munich, Munich, Germany; 23 Department of Medicine, University of Michigan Health System, Ann Arbor, Michigan USACompeting interests: none declaredRIASSUNTODiversi sono i problemi associati al concetto di prevenzione primaria nella FM. I criteri diagnostici o classificativinon sono universalmente accettati e risulta difficile stabilire l’esordio e la durata della malattia. Nel caso della FM,la prevenzione primaria potrebbe essere intensa come il trattamento del dolore acuto o dei disturbi affettivi data lamancanza di test di laboratorio o strumentali specifici predittivi per lo sviluppo della FM. L’obiettivo della prevenzionesecondaria è nei pazienti ancora sintomatici la diagnosi e il trattmento precoce. Lo screening consente nei pazientiche possono sviluppare la FM, di identificare la malattia latente o i fattori di rischio quali i TPs, il FibromyalgiaImpact Questionnaire (FIQ), l’intensità e la sede del dolore, l’astenia e disturbi del sonno. Per prevenzione terziariasi intende trattare la malattia al fine ridurne la disabilità e le possibili complicanze. Gli obiettivi terapeutici sonoil controllo del dolore e miglioramento della funzionalità attraverso trattamenti farmacologici e non. I pazienti affettida FM determinano un utilizzano notevole delle risorse sanitarie, e conseguentemente un aumento della spesasanitaria. Il grado di disabilità e il numero delle malattie associate determina un marcato aumento dei costi. La diagnosiprecoce permettebbe di ridurre i costi e il numero delle indagini, consentendo un risparmio effettivo da partedel sistema sanitario nazionale. Tuttavia, l’intervento sociale è strettamente correlato con il livello socio-economicodella popolazione generale e la legislazione del paese nel quale il paziente risiede.Reumatismo, 2008; 60: Supplemento 1: 70-77INTRODUCTIONFibromyalgia (FM) is a central pain syndromethat is characterized, in part, by specific tenderCorresponding author:Piercarlo Sarzi-Puttini, MDDirector of Rheumatology UnitL. Sacco Hospital, Milan, ItalyE-mail: sarzi@tiscali.itpoints (TPs) in the musculoskeletal system whichare exceptionally sensitive to pressure. Pain, specificallycharacterized as hyperalgesia and allodynia,is the cardinal symptom of FM; however, most patientsalso experience additional symptoms suchas debilitating fatigue, disrupted or nonrestorativesleep, functional bowel disturbances, and a varietyof neuropsychiatric problems, including cognitivedysfunction, anxiety and depressive symptoms (1).
Fibromyalgia syndrome: preventive, social and economic aspects 71Women are the most affected and the disease hasa familial connection that is linked to the geneticvariance of serotonin, dopamine and catecholamineintra-cerebral system (2). The physical symptomsof FM often express themselves in conjunctionwith psychological conditions, which causes a reductionin the individual capacity to tolerate stressors(3).Despite some criticism, the diagnosis for FM isbased on the American College of Rheumatology(ACR) 1990 criteria, which require a specific history(widespread pain lasting more than threemonths, sleep disturbance, debilitating fatigue,paresthesia) and tenderness to light touch(4 kg/cm 2 ) of at least 11 of 18 specific tender points(4).PREVENTION OF FIBROMYALGIAFM has a general population prevalence of 2-4 %,ismore common among females than males (5), andresults from a combination of genetic aspects andstressful events. Prevention may occur in clinical,community or population settings and is often classifiedinto primary, secondary and tertiary types.Primary prevention of fibromyalgiaIn general, primary prevention includes measuresthat help avoid onset of a given health care problem(6, 7). In the case of FM, primary preventionmight include immediate care of acute painepisodes and of somatoform disturbances. At present,specific laboratory or instrumental markersof FM do not exist, and many open questions remainconcerning the concept of primary preventionin FM.Over time, several issues have arisen with the existingdiagnostic or classification criteria: a) criteriaare not likely to be applied uniformly by untrainedassessors; b) patients may have the requisiteTPs and yet not have FM; and c) TPs and widespreadpain do not capture the essence of FM; thisdisorder is known for its multiple and varyingsymptoms, which include fatigue, sleep disturbanceand cognitive dysfunction, predominantly.The road of onset and development of FM can belong and winding. In fact, there are a variety of differentclinical histories that can describe the FMroad: a female FM patient may develop headachesand dysmenorrhea in her 2 nd or 3 rd decade of lifeand present with widespread pain and tendernesslater in life; FM can also start after a stressful eventTable I - Predictors for chronicity (fibromyalgia) in recurrent widespreadpain.Recurrent pain episodesPain reports from other locationsSleep alterationsAnxietyDepressionHeadacheGenderAgeFatigueTrigger and tender pointsStress events(e.g., physical or psychological trauma); or it canbegin with localized pain (e.g., neck or low-backpain) and develop further through pain amplification(8, 9).One major problem with primary prevention stemsfrom the simple fact that no markers of disease exists;a variety of clinical symptoms can be presentat onset and chronic widespread pain may or maynot develop into FM as defined by the 1990 ACRcriteria.In conclusion, the goal of primary prevention is toreduce the incidence of FM in a population thatmay have a diathesis toward developing FM but hasnot presented with symptoms. This can be accomplishedthrough diet and exercise, prevention andcure of trauma, prevention and cure of anxiety anddepression, and finally, immunization against virusesand bacteria (Table I).Secondary prevention of fibromyalgiaThe U.S. Guide of Clinical Preventive Services(Ed. 1996) describes secondary prevention measuresas those that “identify and treat asymptomaticpersons who have already developed risk factors orpreclinical disease but in whom the condition isnot clinically apparent”.The purpose of screening is to identify an unrecognizeddisease or risk factor (10). In general,screening tests include history (e.g., asking if a patientsmokes), physical examination (e.g., bloodpressure determination), lab tests (e.g., serum cholesterollevel) and procedures (e.g., colonscopy).Such tests are not intended to be diagnostic andshould not be performed unless the patient and theclinician are committed to further investigation andtreatment of abnormal results.For patients in whom FM is suspected, preventivestrategies should be performed to identify risk factorsor predictors of chronicity.
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