Best practice & research. Clinical rheumatology
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Best Pract Res Clin Rheumatol · Oct 2007
ReviewExtra-articular manifestations and complications of rheumatoid arthritis.
Rheumatoid arthritis (RA) is a systemic inflammatory disease that can involve other tissues and organs as well as synovial joints. This chapter reviews the clinical aspects of extra-articular RA, from the early descriptions in rheumatology texts to reports from more recent cross-sectional and inception cohort studies. There is no agreed classification for these manifestations and, because criteria and definitions vary so much, this report includes not only the classic extra-articular features but also the non-articular complications of RA, for example normochromic normocytic anaemia and chronic leg ulcers, and the important disease-associated comorbidities, including non-Hodgkin's lymphoma, ischaemic heart disease and osteoporosis. ⋯ Pulmonary fibrosis in RA has a poor prognosis whether treated with large doses of steroids, cytotoxic or disease modifying drugs like cyclosporine, or biologics. In summary, extra-articular features and non-articular complications of RA are common and are generally related to worse disease. They need to be recognised early and managed promptly.
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Best Pract Res Clin Rheumatol · Jun 2007
ReviewPathophysiological mechanisms in chronic musculoskeletal pain (fibromyalgia): the role of central and peripheral sensitization and pain disinhibition.
Chronic musculoskeletal pain has biological, psychological and social components. This review deals with the biological factors, with emphasis on the fibromyalgia syndrome (FMS). ⋯ Further research is necessary in order to determine which methods are best for diagnosis of the pain hypersensitivity in clinical practice. FMS may be the far end of a continuum that starts with chronic localized/regional musculoskeletal pain and ends with widespread chronic disabling pain.
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Best Pract Res Clin Rheumatol · Jun 2007
ReviewChronic widespread pain in the spectrum of rheumatological diseases.
Chronic pain is very common in all European countries, with musculoskeletal problems predominating. About 1% of the adult population develops a syndrome of chronic muscle pain, fibromyalgia (FMS), characterized by multiple tender points, back or neck pain, and a number of associated problems from other organs, including a high frequency of fatigue. Evidence points to central sensitization as an important neurophysiological aberration in the development of FMS. ⋯ Fibromyalgia patients need recognition of their pain syndrome if they are to comply with treatment. Lack of empathy and understanding by healthcare professionals often leads to patient frustration and inappropriate illness behavior, often associated with some exaggeration of symptoms in an effort to gain some legitimacy for their problem. FMS is multifaceted, and treatment consists of both medical interventions, with emphasis on agents acting on the central nervous system, and physical exercises.
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Best Pract Res Clin Rheumatol · Jun 2007
ReviewPharmacological treatment of fibromyalgia and other chronic musculoskeletal pain.
The pharmacologic management of fibromyalgia is based on the emerging evidence that pain in this disorder is primarily related to central pain sensitization. There is strong evidence that tricyclic antidepressants are effective, and moderate evidence for the effectiveness of serotonin reuptake inhibitors and dual serotonin-norepinephrine reuptake inhibitors. Recent work suggests that the anti-seizure medications pregabalin and gabepentin are also effective. The only analgesic demonstrated to be helpful is tramadol.
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Best Pract Res Clin Rheumatol · Jun 2007
ReviewRole of central sensitization in symptoms beyond muscle pain, and the evaluation of a patient with widespread pain.
Patients with widespread pain or fibromyalgia syndrome have many symptoms besides musculoskeletal pain: e.g. fatigue, sleep difficulties, a swollen feeling in tissues, paresthesia, cognitive dysfunction, dizziness, and symptoms of overlapping conditions such as irritable bowel syndrome, headaches and restless legs syndrome. There is evidence for central sensitization in these conditions, but further studies are needed. Anxiety, stress and depression are also present in 30-45% of patients. ⋯ Fibromyalgia should be diagnosed by its own characteristic features. Some patients with otherwise typical symptoms of fibromyalgia may have as few as four to six tender points in clinical practice. Patients with rheumatoid arthritis and systemic lupus erythematosus should be evaluated for fibromyalgia, since 20-30% of them have associated fibromyalgia, requiring a different treatment approach.