Fibromyalgia.

Fibromyalgia syndrome (FMS) is a condition characterized by a combination of chronic and diffuse musculoskeletal pain, stiffness, and tenderness, usually accompanied by sleep difficulties and fatigue.1 The majority of affected patients are women from age 30 to 60 years,2 as illustrated by the patient in this case study. Many other designations for FMS exist, including muscular rheumatism, fibrositis, fibromyositis, tension myalgia, musculoskeletal pain syndrome, generalized nonarticular rheumatism, and chronic pain amplification syndrome.3,4 Regardless of the name used, FMS consumes tremendous economic and social resources, in terms of individual loss of mobility, reduced productivity, and disability.5 FMS patients average at least a visit a month seeking medical or nontraditional/alternative treatment; 92% of them take at least 1 drug (usually a nonsteroidal anti-inflammatory drug [NSAID]) to treat their FMS, with a mean number of 2.7 fibromyalgiarelated drugs per patient.6 The average annual medical cost in 1996 for FMS patients was $2274,6 and as many of 25% of patients with FMS receive some form of disability payment or injury compensation.7 Such sobering statistics indicate the tremendous burden the disease imposes on these patients and suggest patients’ potential inability to obtain and maintain work activities,8 a reality that may further exacerbate their condition. The prevalence of FMS increases with age, with the incidence of the disease peaking among persons age 60 to 80 years.9 The incidence of FMS varies with the particular patient sample studied, with an incidence of 7% in the general population,6 2.1% to 5.7% in general medicine clinics and primary care practice,10 and 10% to 20% in rheumatology clinics.10 Moreover, geographic prevalence is different around the world; for example, population-based studies in Europe have indicated that overall prevalence of the syndrome is between 1% and 2%,11,12 whereas in North America, the prevalence is reported as 2%.13 Overall, women are most affected by the disease; the prevalence of the condition in women is 3.4%, compared with 0.5% in men, with the greatest rate of FMS occurring in women age 50 years and older.14 FMS is a major cause of disability in the United States and the second most common disorder seen by rheumatologists in North America.15 In most cases, vague symptoms of pain in women are reported first to primary care providers, thus potentially increasing the time before effective treatment begins. This problem is further exacerbated by the difficulty in diagnosis. Often, FMS is not recognized as a distinct clinical entity, and nonspecific symptoms of muscle pain make clear identification of the syndrome difficult; accompanying psychiatric conditions may further complicate the diagnosis.16,17 Additionally, chronic generalized pain, a frequent symptom of FMS, is common in many types of conditions and patients. At least 10.6% of patients in the United States report chronic widespread pain, and 20.1% report chronic regional pain.9 Thus, primary care providers have a distinct challenge in accurately diagnosing FMS. Another consideration making diagnosis of FMS difficult for primary care practitioners is the nonspecific nature of the accompanying pathophysiology. In patients with FMS, pain is usually identified at the fibrous tissues, muscles, ligaments, and tendons. However, there is an absence of histologic signs of inflammation or of any specific cellular abnormalities at the identified locations.18 Furthermore, the specific pathophysiology of the disease has yet to be elucidated; in fact, it has been suggested that the syndrome is not caused by any single etiologic factor.19,20