Doctor, everything hurts in me. A reflection on the World Fibromyalgia Day.

First there is sporadic, but recurring pain. Later, the pain becomes more intense, widespread and more constant. An unpleasant feeling that the whole body hurts. Joints and muscles, even the bones seem to hurt. Fatigue sets in and sleep is not restful. Persistent headaches and abdominal cramping pains appear, with periods of diarrhoea and constipation. There are other symptoms which, although less intense, are worrying: sometimes the muscles become strangely more tense, other times tingles appear in various parts of the body and there is an enormous painful sensitivity to the touch in various parts of the body. The situation becomes progressively more desperate because the blood tests and other tests performed are normal and the drugs have no effect. There is no clear diagnosis and the situation seems to eternalize and worsen, making it difficult to work, also preventing leisure. A feeling of anguish and lack of motivation sets in.

This scenario of suffering is well portrayed in the self-portrait of Frida Khalo, a well-known Mexican painter, who, after a serious accident at the age of 18, in 1925, developed a complex and incapacitating clinical condition. Her life was characterized by widespread pain, fatigue, sleep disturbances, multiple symptoms that are difficult to interpret. It was not possible to establish an accurate diagnosis, but in the light of current knowledge, it is very likely that Frida Khalo suffered from fibromyalgia, a clinical condition that was only clearly recognized in the 1970s. Some cases arise in the context of previous chronic pain (trauma, orthopaedic problems or chronic rheumatic disease, such as rheumatoid arthritis). Fibromyalgia results from a chronic process of generalization and painful amplification and is currently considered as a central pain integration disorder (cerebral cortex). There is intensification of the nociceptive signal with a decrease in the pain threshold. Therapeutic intervention is difficult, but the patients’ correct perception of their diagnosis and what fibromyalgia consists of are essential. Along the same lines, the cognitive-behavioural psychological intervention is an important reinforcement in the positive evolution of the clinical condition. Other critical aspects include the correction of sleep problems and/or depression and regular physical exercise. Pharmacological therapy has many limitations. Muscle relaxants, especially cyclobenzaprine, may offer some pain control and benefit in the sleep pattern. Antiepileptics such as pregabalin and gabapentin can be used for the same purpose. Treatment of episodes of worsening pain should be started with paracetamol or with the paracetamol-tramadol combination. The use of antidepressants should be considered in a perspective of interference with painful symptoms and/or, if justified, for the treatment of concomitant depression.

It is very important that the patient and the doctor are aware that the biggest actor in the improvement process is the patient himself. Gaining a correct understanding of what is happening to them, have adaptation strategies and being able to maintain an active life are concrete goals that can completely transform a long-term prognosis.

João Eurico Cabral da Fonseca

Rheumatology and Metabolic Bone Diseases Unit, Santa Maria Hospital, CHULN

Rheumatology Research Unit, Institute of Molecular Medicine

Faculty of Medicine, University of Lisbon