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Brugermanual
<Provider Id="sundheddkcms"> <Item Id="{50FCFBBA-5275-40E6-8CC8-592F8EB9EAE5}" Name="fibromyalgi" Type="LHContentPage" ParentProviderId="sundheddkcms" ParentItemId="{F624484D-3970-4AE5-83E3-CC36A69EFF8F}" SortOrder="300" PublishDate="2010-03-09T15:43:00" DeleteDate="2999-12-31T00:00:00" PotItemType=""> <Content> <HtmlField Name="PageContent"><![CDATA[<h2>Diagnose</h2> <h3>Diagnostiske kriterier</h3> <ul> <li>Diagnosen er klinisk og baseres på sygehistorien, den kliniske undersøgelse og udelukkelse af anden sygdom som årsag til generne</li> <li>1990-ACR klassifikationskriterier og 2016 symptombaserede diagnostiske kriterier kan anvendes til at understøtte den kliniske diagnose </li> <li>Ikke alle patienter med generaliserede smerter opfylder klassifikations- eller diagnosekriterier for fibromyalgi. Den selekterede undergruppe, der ligger over de etablerede cut-of punkter (opfylder kriterier for fibromyalgi), regnes af mange for at repræsentere den øvre ende af et smertehypersensitivitetskontinuum</li> </ul> <h4>1990-ACR klassifikationskriterier </h4> <ul> <li>Generaliserede smerter <ul> <li>Dvs. smerter i mindst 4 ud af 5 kropsregioner (kroppens 4 kvadranter og aksialt) og af mindst 3 måneders varighed</li> </ul> </li> <li>Trykømhed med smerteoplevelse ved 4 kg tryk med fingerspids i mindst 11 af følgende 18 <a href="~/link.aspx?_id=8EA533EA9DBC4A2EA4009522E7311FBB&_z=z">tender points</a> (9 bilaterale) <ul> <li>Suboccipitalt</li> <li>Lavere cervikalt, lateralt ved processus transversus i niveau C5-C7</li> <li>Midt på øvre trapeziusbug</li> <li>Supraspinatusudspringet ved øvre mediale scapulahjørne</li> <li>Interkostalt over 2. costa, lige lateralt for costochondralovergangen</li> <li>2 cm distalt for laterale albueepikondyl</li> <li>Øvre laterale kvadrant af glutealregionen</li> <li>Trochanter major</li> <li>Medialsiden af femurkondylen, lige proksimalt for knæledsspalten</li> </ul> </li> </ul> <h4>2016 diagnostiske kriterier</h4> <ul> <li>Er baseret på et ’widespread pain index’ (WPI) med angivelse af smerte i 19 definerede kropsområder (score 0-19) og et ’symptom severity score’ (SSS), hvor typiske ledsage symptomer rates på en 0-3 skala (score 0-12)</li> <li>De diagnostiske kriterier er opfyldt, hvis <ul> <li>WPI > 7 og SSS > 5 eller WPI på 4-6 og SSS > 9, og</li> <li>Generaliserede smerter, dvs. smerte angivelse i mindst 4 ud af 5 kropsregioner og symptomvarighed på mindst 3 måneder</li> </ul> </li> </ul> <h3>Sygehistorie</h3> <h4>Typisk smertebeskrivelse</h4> <ul> <li>Langvarige udbredte smerter, ofte i muskulatur, men også i andre dele af kroppen, herunder i led og sv.t. ligament- senetilhæftninger</li> <li>Smerterne er hyppigt startet i ung alder</li> <li>Smerterne kan være startet mere lokaliseret, hyppigt i nakke- eller lænderegionen, hvorfra smerten siden har bredt sig </li> <li>Smerterne vil ofte variere i lokalisation</li> <li>Smertebeskrivelsen har mange fælles træk med den smertebeskrivelse, der ses ved de neurogene smertetilstande. Hyppigt beskrives flere smertekvaliteter. Dels dybe, murrende, ’influenzalignende’ smerter med ømhed og stivhed i vævene. Dels overfladiske brændende, sviende smerter og spontant optrædende smertejag </li> <li>Føleforstyrrelser i form af nedsat følesans og paræstesier typisk i hænder og fødder, trykømhed i vævene (hyperalgesi) og berøringsoverfølsomhed (allodyni) er hyppigt</li> <li>Kortlægning af smerteudbredelse og bidragende smertekvaliteter kan med fordel foregå ved udfyldelse af smertetegning</li> </ul> <h4>Hyppige ledsagesymptomer der medvirker til at stille diagnosen</h4> <ul> <li>Søvnforstyrrelser <ul> <li>overfladisk, afbrudt nattesøvn, manglende fornemmelse af at være udhvilet ved opvågning, og unaturlig dagtræthed (fatigue)</li> </ul> </li> <li>Kognitiv dysfunktion <ul> <li>hukommelses- koncentrationsbesvær, ordmobiliseringsbesvær, hurtig mental udtrætning</li> </ul> </li> <li>Negativ affekt <ul> <li>øget stress/ alarmberedskab, frustration/ irritabilitet, angst, forsænket stemningsleje</li> </ul> </li> <li>Polysensorisk hypersensitivitet <ul> <li>nedsat tærskel for oplevelse af ubehag i forbindelse med andre sanseindtryk fx lys, lyd, lugt, temperatur </li> </ul> </li> <li>Organmanifestationer <ul> <li>irritabel tyktarm, hyperaktiv blære, blæresmerter, underlivssmerter, hovedpine/ migræne, kæbe-tandsmerter</li> </ul> </li> <li>Øvrige <ul> <li>følelse af hævelse - gerne hænder/fødder</li> <li>ortostatisk svimmelhed</li> <li>hjertebanken</li> <li>synsforstyrrelser</li> <li>tørre slimhinder</li> <li>globulusfornemmelse</li> <li>øresusen</li> <li>urolige ben (RLS)</li> </ul> </li> </ul> <h4>Funktion og funktionsevnenedsættelse</h4> <ul> <li>Generelt er generaliserede smerter vist at være forbundet med en dårlig funktionsprognose</li> <li>Aktivitetsintolerance med øget smerteniveau og hurtig muskulær udtrætning er et fremtrædende klinisk træk hos mange patienter med fibromyalgi og medfører ofte begrænsninger i den almindelige daglige livsførelse</li> <li>Observationsbaseret, ergoterapeutisk evaluering af ADL-evnen hos kvinder med fibromyalgi rekrutteret fra specialafdeling viser, at denne målgruppe kan udvise betydeligt større funktionsevnenedsættelse end patienter med fx leddegigt</li> </ul> <h3>Kliniske fund</h3> <ul> <li>Udbredt palpationsømhed i vævene (muskler, led, sener) <ul> <li>Brug af <a href="~/link.aspx?_id=8EA533EA9DBC4A2EA4009522E7311FBB&_z=z">tender points</a> som diagnostisk test er omstridt, der er stor usikkerhed både om deres evne til at skelne mellem syge og raske (validitet) og testens reproducerbarhed</li> </ul> </li> <li>Den øvrige objektive undersøgelse er normal, herunder <ul> <li>Ledstatus og isometriske tests - selvom patienten føler hævelse i leddene</li> <li>Neurologisk undersøgelse – selvom patienten klager over paræstesier og føleudfald. Flere studier peger dog på en øget forekomst af småfiber neuropati hos patienter med fibromyalgi</li> </ul> </li> <li>Smertens udbredelse <ul> <li>En diffus smertefordeling i alle 4 kropskvadranter inkl. ekstremiteter understøtter diagnosen fibromyalgi</li> <li>Man kan med fordel anvende ”<a href="48DA4A93406C4C67B4013FC5119258E3-0-0">smertetegningen</a>” <ul> <li>Det er vigtigt at spørge patienten, om den aktuelle smerteangivelse på tegningen repræsenterer alle de steder, der er smerter. Mange patienter føler sig ’beklemte’ ved at angive så udbredte smerter og tegner så kun de steder, hvor det gør mest ondt</li> </ul> </li> </ul> </li> <li>Fibromyalgi eller anden reumatologisk lidelse <ul> <li>Er der kliniske fund tydende på inflammation, fx ledhævelse, eller hud- slimhindemanifestationer, negleforandringer (psoriasis), Raynaud fænomener og lignende er diagnosen fibromyalgi mindre sandsynlig</li> <li>Udbredte ledsmerter (artralgier) og ledømhed ses ofte ved fibromyalgi, men kan også være tegn på tidlig (evt. seronegativ) artrit </li> <li>Rygsøjlegigt (SpA) kan være en differentialdiagnose, hvor patienten præsenterer sig med udbredte smerter og udbredt ømhed svarende til sene og ligamenttilhæftninger (enteser) og normale blodprøver</li> </ul> </li> </ul> <h3>Supplerende undersøgelser i almen praksis</h3> <ul> <li>Blodprøver for at diagnosticere evt. <ul> <li>Reumatologisk sygdom</li> <li>Autoimmun sygdom eller bindevævssygdom</li> <li>Thyreoidealidelse</li> </ul> </li> <li>Aktuelle prøver er: Hb, leuko-dif, trombocytter, SR, CRP, TSH, FT4, kreatinin, elektrolytter, calcium, ALAT, ANA, CK, vitamin B12, D-vitamin</li> <li>Ved tørre øjne/mund også: anti-SSA og anti-SSB (autoantistoffer f.eks. ved Sjøgrens sygdom) og evt. <a href="~/link.aspx?_id=03C9AB5D078A44A0B0B5586C8CDE3706&_z=z">Schirmers test</a></li> <li>Yderligere diagnostiske undersøgelser, herunder billeddiagnostisk undersøgelse, skal kun gennemføres på klar lægelig indikation</li> <li>Hvis der efter gennemførelse af undersøgelsesprogrammet i almen praksis fortsat er tvivl om, hvorvidt der ligger andre sygdomme til grund for de generaliserede smerter i bevægeapparatet, bør patienten henvises til relevant anden speciallæge </li> </ul> <h3>Andre undersøgelser hos specialist</h3> <ul> <li>Psykiatrisk udredning kan, hvis symptomer peger i den retning, overvejes <ul> <li>Brugen af screeningsspørgeskemaer, herunder depressionsspørgeskemaer, er problematisk i kroniske smertepopulationer pga. et stort symptomoverlap, hvorfor fx depressionsdiagnosen bør baseres på klinisk interview</li> </ul> </li> <li>Polysomnografi <ul> <li>Ofte foreligger søvnforstyrrelser</li> <li>Undersøgelsen kan påvise alfa-frekvens-rytme (alfa-deltage søvnanomali), øgning i stadium 1 søvn, reduktion af deltage-søvn og øget antal opvågninger</li> <li>Søvnforstyrrelser er vanlige også ved depression og andre kroniske smertesyndromer</li> </ul> </li> </ul> <h3>Psykosociale forhold</h3> <h4>Kronificering – den negative smertespiral</h4> <ul> <li>At udvikle langvarige smerter omfatter en række smerteregulerende mekanismer, indlæring, følelsesmæssige, tankeregulerende og adfærdsmæssige forhold. Det vil sige, at hele mennesket berøres af det</li> <li>Kognitive og emotionelle faktorer, der kan være medvirkende til at forværre smertetilstanden, omfatter bl.a. <ul> <li>katastrofetanker</li> <li>negative forventninger til fremtiden</li> <li>fokusering på smerten</li> <li>angst for smerte</li> <li>manglende oplevelse af kontrol over smerten</li> <li>manglende accept af det ofte langvarige smerteforløb og svigtende funktionsevne</li> </ul> </li> <li>Alle disse faktorer øger oplevelsen af smerter og træthed og kan bidrage til en uhensigtsmæssig smertehåndtering, herunder tiltagende fysisk inaktivitet og social isolation, og yderlig forværring – den ’negative smertespiral’</li> </ul> <h4>Depression, angst, personlighedsforstyrrelse</h4> <ul> <li>Sammenhængen mellem kroniske smerter og affektiv lidelse (angst, depression) er velbeskrevet</li> <li>Forskningen peger på et muligt fælles prædisponerende genetisk grundlag og overlappende funktionsforstyrrelser i de områder af hjernen, der regulerer emotioner, smerter og stressrespons</li> <li>Prævalensraten af depression og angstlidelse i fibromyalgipopulationer angives at ligge på 20 til 60 %. Dette gælder studier af fibromyalgi-patienter henvist til specialiseret behandling og genfindes ikke i populationsbaserede studier. I en dansk populationsbaseret undersøgelse af patienter med fibromyalgi var forekomsten af depression 7 %</li> <li>Ubehandlet depressions- og angsttilstand vil forværre smerteoplevelsen og forhindre optimalt udbytte af de behandlingstiltag, der er målrettet at bedre smertetilstanden. Ledsagende depressions- og angsttilstande hos smertepatienter skal derfor erkendes og behandles </li> <li>Forekomsten af personlighedsforstyrrelse, særligt personlighedsforstyrrelse præget af frygt og angst (emotionelt ustabil, tvangspræget, og dependent personlighedsforstyrrelse) er øget hos patienter med fibromyalgi. Prævalensen angives at være 31 % mod 13 % i baggrundsbefolkningen</li> </ul> <h4>Stress</h4> <ul> <li>Forskningen tyder på en sammenhæng mellem udsættelse for tidlige traumatiske livsbegivenheder og senere udvikling af fibromyalgi</li> <li>Personer med fibromyalgi scorer højere på oplevet, langvarigt stress og belastning end andre smertepatienter</li> <li>Der er et stort symptomoverlap mellem posttraumatisk stresssyndrom og fibromyalgi. Lidelserne forekommer hyppigt sammen</li> <li>Stress er derfor foreslået som udløsende/vedligeholdende faktor både ved fibromyalgi og posttraumatisk stresssyndrom</li> </ul> <h4>Sociale faktorer</h4> <ul> <li>De omgivelser, det enkelte individ skal fungere i, herunder de krav, forventninger, og holdninger individet mødes med fra omgivelserne, influerer på smertetilstanden og personens evne til at håndtere smerterne</li> <li>Et sundhedsvæsen, som signalerer usikkerhed og mangel på tilgængelighed, vil utilsigtet kunne bidrage til at øge patientens utryghed</li> <li>Fibromyalgi fører hos nogle til tab af erhvervsevne – et forhold, der påvirker den sociale dimension, hvor ofte langvarige erhvervsevneafklaringsforløb spiller en væsentlig rolle. Dette har en stor indflydelse på individets livskvalitet og medfører vedvarende psykosocial belastning</li> <li>Tilsvarende vil manglende støtte i nære sociale netværk, herunder i den nære familie, have en negativ indflydelse</li> <li>Hos kroniske smertepatienter kan man – i modsætning til ved akutte smertetilstande – ofte ikke ud fra individets adfærd se, at han eller hun har ondt (det usynlige handicap). Dette betyder, at patienten med kroniske smerter ofte fejltolkes</li> <li>Den sociale dimension bør således tilgodeses i behandlingen, der også med fordel kan omfatte information til/undervisning af pårørende</li> </ul> <h3>Differentialdiagnoser</h3> <ul> <li><a href="~/link.aspx?_id=A6F030DC72254F5FA59D5924937494D0&_z=z">Hypotyreose</a></li> <li><a href="~/link.aspx?_id=145E2DFD993C41C790312325F017B5F7&_z=z">Hyperparatyreoidisme</a></li> <li><a href="~/link.aspx?_id=422A648683274385AE4336D863341A05&_z=z">Polymyalgia reumatika</a> (specielt hos ældre patienter)</li> <li><a href="~/link.aspx?_id=939AB6BE2EA74C2890648DEA4AF5E6C6&_z=z">Begyndende reumatoid artritis, psoriasisartritis, spondylartritis (SpA)</a></li> <li><a href="~/link.aspx?_id=68262A579C404E3B83DEDB66EB738254&_z=z">Systemisk lupus erythematosus</a></li> <li><a href="~/link.aspx?_id=B40D3570410648BC81FFAAC3393E172D&_z=z">Sjögrens syndrom</a></li> <li><a href="~/link.aspx?_id=45D0C37115B44649BABB98B7E3287AE9&_z=z">Polymyositis</a></li> <li>Vitamin B12-mangel</li> <li><a href="~/link.aspx?_id=56B311F186C845338F9C3E76EEE99DF6&_z=z">Lymes sygdom</a></li> <li><a href="~/link.aspx?_id=00548CAFEC844B9E8FC871B60BAA152B&_z=z">Osteoporose</a></li> <li>Neurologisk lidelse (MS, perifer neuropati) </li> <li>Malign sygdom</li> <li>Medikamentudløst myopati: f.eks. statiner, colchicine, kortikosteroider, antimalariamedikamenter</li> </ul> <h2>Behandling<a href="https://www.sst.dk/da/udgivelser/2018/~/media/82268C6BAF19461399C4FC8D1647DCC0.ashx" data-type="other-reference" data-value="National klinisk retningslinje for udredning og behandling/rehabilitering af patienter medgeneraliserede smerter i bevægeapparatet, Sundhedsstyrelsen, 2018" data-url="https://www.sst.dk/da/udgivelser/2018/~/media/82268C6BAF19461399C4FC8D1647DCC0.ashx" title="National klinisk retningslinje for udredning og behandling/rehabilitering af patienter medgeneraliserede smerter i bevægeapparatet, Sundhedsstyrelsen, 2018">1</a></h2> <h3>Behandlingsmål</h3> <ul> <li>Skabe tryghed for, at der ikke foreligger alvorlig sygdom gennem omhyggelig klinisk undersøgelse og information</li> <li>Hjælpe patienten til at kunne indgå aktivt i eget liv</li> <li>Forbedre livskvalitet og funktionsevne</li> <li>Bidrage til at patienten får en arbejdssituation, som gør det muligt for vedkommende at fortsætte i arbejde</li> </ul> <h3>Generelt om behandlingen</h3> <ul> <li>Der foreligger flere evidensbaserede retningslinjer for behandling af fibromyalgi, herunder Sundhedsstyrelsens nationale kliniske retningslinje for udredning og behandling/rehabilitering af patienter med generaliserede smerter i bevægeapparatet, revideret i 2018. Fælles for disse retningslinjer er anbefaling om: <ul> <li>Hurtig diagnostisk afklaring og information til patienten om smertediagnose, behandlingsmuligheder og prognose</li> <li>Vurdering af patienten i forhold til behandling, hvor ikke kun de fysiske, men også de psykologiske, emotionelle og sociale aspekter af smertetilstanden kortlægges</li> <li>Behandlingsoplæg, der er baseret på aktiv patientinddragelse, og som indeholder en eller flere af følgende behandlingsmodaliteter: patientuddannelse, øvelsesterapi/træning, kognitiv adfærdsterapi, og farmakologisk smertebehandling </li> <li>Behandlingsplan, der er individuelt tilrettelagt afhængigt af patientens behov og præferencer (stepped care model)</li> <li>Non-farmakologiske behandlingstiltag som 1. linjebehandling</li> </ul> </li> </ul> <h3>Håndtering i almen praksis</h3> <ul> <li>Udredning. Diagnosen fibromyalgi er klinisk og kan stilles i almen praksis baseret på et karakteristisk symptommønster samt fravær af anden somatisk eller psykisk lidelse, der bedre kan forklare patientens smerter og øvrige ledsagesymptomer</li> <li>Vurdering af behandlingsbehovet. Bør baseres på en individuel helhedsvurdering</li> <li>Primær behandling i umiddelbar tilknytning til at diagnosen stilles og med løbende evaluering af behandlingseffekten bør omfatte: <ul> <li><em>Patientuddannelse</em>: Kommuniker tilgrundliggende neurofysiologiske mekanismer (basal smertefysiologi), at det primære problem er ændringer i smertesystemet og ikke sygdom eller skader i vævene</li> <li>Forklar behandlingsstrategier (hjælp-til-selvhjælp). At fokus er aktiv egen håndtering ikke passiv behandling</li> <li>At fysisk aktivitet integreret i hverdagen er vigtig mhp. smertereduktion</li> <li>At målrettet aktiv involvering i hverdagens gøremål og balanceringen af aktiviteter og hviletid er vigtig for at undgå smerte-/symptomudsving</li> <li>Forklar principper for søvnhygiejne, stressreduktion (fx mindfulness, afspænding)</li> <li><em>Træningsvejledning</em> med fokus på at understøtte patientens hverdagsfunktioner og sociale roller, herunder fastholdelse af arbejdsevne, fritidsaktiviteter og generelle fysiske aktivitetsniveau. Afklar patientens erfaringer med selvstændigt at lave fysisk træning. Henvis evt. til fysioterapeut mhp. et superviseret træningsforløb eller fx træning i varmtvandsbassin</li> <li>Ofte vil det være hensigtsmæssigt at starte med lav træningsintensitet</li> </ul> </li> <li>Herudover kan overvejes: <ul> <li><em>Henvisning til psykolog</em> mhp. fx hjælp til manglende accept, højt stressniveau, uhensigtsmæssige copingstrategier, angst- depressionssymptomatologi</li> <li><em>Farmakologisk søvn- og smertestabiliserende behandling</em> til udvalgte patienter</li> </ul> </li> <li>Ved utilstrækkelig effekt af ovennævnte overvejes evt. henvisning til: <ul> <li><em>Praktiserende smertelæge</em>. Primært behov for hjælp til medicinering</li> <li><em>Tværfaglig smerteklinik</em>. Behov for koordineret, individuelt tilrettelagt tværfagligt behandlingsforløb</li> <li><em>Gigtforeningens SANO-center</em>. Behov for hjælp til optimering af det fysiske aktivitetsniveau, herunder hjælp til træningsdosering/udvikling af mere hensigtsmæssige kompensatoriske ADL-strategier</li> </ul> </li> </ul> <h3>Råd til patienten</h3> <ul> <li>Tage ansvar for en hensigtsmæssig egenhåndtering af smertetilstanden, hvilket forudsætter information om: <ul> <li>at ’helbredelse’ og symptomfrihed kun sjældent lader sig gøre</li> <li>at behandlingsindsatsen har til formål at styrke patientens egne ressourcer og hjælpe patienten til at leve bedst muligt med sin kroniske tilstand</li> <li>at fibromyalgismerterne ikke er forbundet med øget risiko for kræft, hjerte-karsygdom, gigtsygdom eller nedsat levetid</li> <li>at smerterne ikke er et advarselstegn, der signalerer sygdom i vævene, fx led og muskulatur, og derfor ikke bør medføre gentagne undersøgelser og ’søgen’ efter en vævsbaseret forklaring på smerterne </li> </ul> </li> </ul> <h3>Non-farmakologisk behandling</h3> <h4>Patientuddannelse</h4> <ul> <li>Har en stærk anbefaling i Sundhedsstyrelsens kliniske retningslinje og bør tilbydes alle patienter i tilknytning til, at diagnosen stilles</li> <li>Patientuddannelse adskiller sig fra generel information ved, at informationen er tilpasset patientens forståelsesramme og adresserer opfattelser, som kan være uhensigtsmæssige </li> <li>Undervisningen kan foregå i grupper eller 1:1, men inkluderer altid en fagperson og evt. andre patienter </li> <li>Patientuddannelse skal indeholde undervisning i smertefysiologi, behandlingsmuligheder, psykosociale faktorers betydning og er målrettet opbygning af handlingsstrategier, der understøtter den enkeltes mestringsevne</li> <li>Patientuddannelse tilbydes på nogle specialafdelinger og i kommunalt regi</li> </ul> <h4>Fysisk træning</h4> <p>Der er moderat grad af evidens for langvarig positiv effekt af gradueret fysisk træning på livskvalitet, smerter og fysisk funktion<a href="https://www.sst.dk/-/media/Udgivelser/2018/Fysisk-aktivitet-h%C3%A5ndbog-og-tr%C3%A6ning/Fysisk-aktivitet-%E2%80%93-h%C3%A5ndbog-om-forebyggelse-og-behandling.ashx" data-type="other-reference" data-value="Fysisk aktivitet – håndbog om forebyggelse og behandling, Sundhedsstyrelsen, 2018" data-url="https://www.sst.dk/-/media/Udgivelser/2018/Fysisk-aktivitet-h%C3%A5ndbog-og-tr%C3%A6ning/Fysisk-aktivitet-%E2%80%93-h%C3%A5ndbog-om-forebyggelse-og-behandling.ashx" title="Fysisk aktivitet – håndbog om forebyggelse og behandling, Sundhedsstyrelsen, 2018">2</a>. </p> <ul> <li>Metaanalyser af træningsstudier ved fibromyalgi dokumenterer en positiv effekt af træning generelt hos denne patientgruppe </li> <li>Der er stærk evidens for en positiv effekt på livskvalitet, smerteniveau, og fysisk funktion af aerob træning, samt moderat evidens for en positiv effekt på livskvalitet og smerter af træning i varmtvandsbassin</li> <li>Der er ikke tilsvarende dokumentation vedrørende effekten af styrketræning </li> <li>Træningsstudierne ved fibromyalgi er gennemgående præget af en stor inter-individ-variation i behandlingsresponset, et stort patientfrafald og mangelfuld fastholdelse af patienterne i træning. Hvilket understreger vigtigheden af et individuelt tilpasset træningsprogram med langsom optrapning og løbende justering af belastningen i forhold til patientens smerteniveau, fysiske formåen og motivation</li> <li>Hurtigt øget intensitet af træningen medfører risiko for træningsinduceret smerteforværring og virker demotiverende for den fremtidige træningsadfærd</li> <li>Det er ikke unormalt, at patienter, der starter på træning, oplever forværring af deres kendte smerter og/eller ’nye’ smerter. Der må godt være smerter/gener før/under/umiddelbart efter træning, men træningen bør ikke medføre længerevarende smerte/symptomforværring, der så fører til efterfølgende fysisk inaktivitet</li> <li>Nogle patienter har svært ved at dosere øvelserne i begyndelsen af et træningsforløb. Det kan her være relevant at tilbyde et superviseret og individualiseret træningsforløb hos fysioterapeut. Patienter, der er vant til at træne selvstændigt og motiverede for dette, vil næppe have gavn af supervision</li> <li> Bedringen fortsætter, så længe patienten træner, og de bør derfor vælge de træningsformer, de trives bedst med</li> <li>Der er ingen absolutte kontraindikationer mod træning. Nogle patienter med fibromyalgi er dog så træningsintolerante, at fokus primært bør være at øge niveauet af fysisk aktivitet i hverdagen, evt. som et springbræt til en egentlig træningsindsats</li> </ul> <h4>Ergoterapi</h4> <ul> <li>Der foreligger ikke studier af ergoterapi som enkeltstående intervention i behandling af fibromyalgi</li> <li>Fibromyalgipatienter har ofte en nedsat funktionsevne i dagligdagsaktivitet og dermed et behov for at lære at kompensere for disse nedsatte færdigheder ved hjælp af tilpasningsstrategier og mere hensigtsmæssig brug af ressourcer i dagligdagen</li> <li>Ved træning af aktivitetsformåen – som er et kerneområde inden for ergoterapi – er formålet, at patienten generhverver, udvikler eller bevarer sine funktionsfærdigheder, og at aktivitetsudførelsen bliver mere effektiv og mindre anstrengende</li> </ul> <h4>Psykoterapi</h4> <ul> <li>Kognitiv adfærdsterapi <ul> <li>Er den bedst dokumenterede psykologiske interventionsform ved fibromyalgi og er vist at reducere smerte og depression/angst, samt at bedre livskvalitet og funktionsevne </li> <li>Fokuserer på at påvirke uhensigtsmæssige tanker og handlingsmønstre relateret til smerte og erstatte dem med mere hensigtsmæssige coping-strategier </li> <li>Behandlingen er mest effektiv i patientundergrupper med et højt niveau af negativ affekt og/eller et uhensigtsmæssigt coping-repertoire</li> </ul> </li> <li>Stresshåndtering <ul> <li>Psykologiske interventioner målrettet stressreduktion, herunder afspænding og mindfulness, kan være nyttige både til at modvirke stressfaktorer, der forværrer smertetilstanden og til at reducere den stress, som selve smerteproblemet medfører </li> </ul> </li> </ul> <h4>Tværfaglig rehabilitering</h4> <ul> <li>Tværfaglige rehabiliteringsprogrammer, der integrerer flere forskellige behandlingskomponenter, anbefales til fibromyalgipatienter med kompliceret smertetilstand, dvs. patienter der er funktionstruet og/eller har en betydelig psykosocial tyngde i den samlede smerteproblematik</li> <li>Interventionen kan være individuel, men tilbydes ofte gruppebaseret. Her spiller gruppens erfaringsudveksling ofte en central rolle, da patienterne oplever, at andre har lignende symptomer og funktionsbegrænsninger i hverdagen, og at problemerne er mulige at løse</li> <li>Der er evidens for en positiv korttidseffekt af tværfaglig rehabilitering på kernesymptomerne og funktionsniveau ved fibromyalgi, hvorimod langtidseffekten er mindre veldokumenteret </li> <li>Tværfaglig rehabilitering tilbydes på nogle specialafdelinger, herunder de tværfaglige smerteklinikker, og Gigtforeningens SANO-centre</li> </ul> <h4>Anden non-farmakologisk intervention</h4> <ul> <li>Der er ingen dokumenteret langtidseffekt af passive behandlingsformer som akupunktur, massage, etc.</li> <li>I en metaanalyse omhandlende akupunktur var konklusionen, at der findes få studier, at studierne er små og i bedste fald viser kortvarig effekt. I alle studier, hvor man fandt effekt af akupunktur, blev der benyttet elektroakupunktur</li> </ul> <ul></ul> <h3>Farmakologisk behandling</h3> <h4>Generelle erfaringer</h4> <ul> <li>Medicinsk smertestillende behandling kan ikke stå alene og bør betragtes som et eventuelt brugbart og måske midlertidigt hjælpemiddel ved behov for stabilisering af patientens smertetilstand</li> <li>På linje med behandling af nervesmerter anvendes stoffer, der stabiliserer (antikonvulsiva) eller modulerer (antidepressiva) smertesystemets funktion</li> <li>De præparater, der anbefales i foreliggende kliniske retningslinjer til behandling af fibromyalgi, har alle været undersøgt i randomiseret, klinisk kontrolleret undersøgelse og vist effekt på smerteniveau, søvnkvalitet, og livskvalitet</li> <li>Studierne viser imidlertid, at der er stor inter-individ variation i behandlingsresponset og generelt påvises relativt små effektstørrelser </li> <li>I klinisk praksis begrænses brugen af disse lægemidler yderligere af stoffernes generelle bivirkningsprofil. De tolereres kun af en undergruppe af patienterne og må ofte seponeres pga. uacceptable bivirkninger</li> <li>For at minimere bivirkninger bør man derfor begynde med lavest mulig dosis og evt. dosisøgning bør foregå langsomt</li> <li>For at opnå optimalt resultat bør patienterne derfor følges tæt i starten. Medikamenter skal prøves enkeltvis, således at dosejusteringer kan foretages</li> <li>Der findes ingen dokumentation for, hvorvidt antidepressiva eller antikonvulsiva bør være førstevalgspræparat i behandlingen. Valg af præparat bør ske på baggrund af præparaternes sidevirkninger, bivirkninger og mulige komplikationer. Baseret på erfaringsgrundlag er det primære valg ofte tricykliske antidepressiva </li> <li>Der findes ingen dokumentation for en forbedret effekt af kombinationsterapi</li> <li>Pga. af bivirkningsprofilen ved de anbefalede præparater efterspørger mange patienter alternative behandlingsmuligheder, herunder behandling med lavdosis naltrexon (LDN) og cannabisbaseret medicin. Der foreligger endnu ikke dokumentation for disse præparaters virkning og sikkerhed ved behandling af fibromyalgi. Der pågår aktuelt to større danske studier, hvor resultaterne endnu ikke forligger</li> </ul> <h4>Forskellige medikamenter</h4> <ul> <li>Antidepressiva <ul> <li>De antidepressiva, der er bedst belæg for at anvende i smertebehandling, er antidepressiva med effekt på både serotonin- og noradrenalin-genoptagelsen (SNRI, TCA)</li> <li>Præparaterne har en selvstændig analgetisk effekt, der er uden sammenhæng med den antidepressive virkning</li> <li>Virkningsmekanismen antages primært at være via endogene monoaminafhængige smertemoduleringssystemer</li> <li>Selektive serotonin-genoptagelseshæmmere (SSRI) er uden dokumenteret smertelindrende effekt ved fibromyalgi</li> </ul> </li> <li>Antikonvulsiva <ul> <li>De antikonvulsiva, der er bedst belæg for at anvende, er gabapentanoider (gabapentin, pregabalin) </li> <li>Virkningsmekanismen antages primært at udøves via blokade af calciumkanaler på præsynaptiske nociceptive neuroner med nedsat neurotransmitterfrisættelse til følge</li> </ul> </li> </ul> <h4>Smertebehandling</h4> <ol> <li><a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/243030">Tricykliske antidepressiva</a> (amitriptylin) <ul> <li>Svag anbefaling for (overvej at tilbyde amitriptylin til smertelindring og søvnregulering i dosering 10-50 mg i døgnet)</li> <li>Indtagelse for tæt på sengetid kan give "bagrus" næste morgen. Medikamentet bør derfor tages 3-4 timer, før man lægger sig</li> <li>Effekten på søvnforstyrrelserne kommer hurtigt, mens eventuel reduktion af smerten først indtræder efter ugers brug forudsat kontinuerlig brug</li> </ul> </li> <li>SNRI (duloxetin) <ul> <li>Svag anbefaling for (overvej at tilbyde duloxetin til smertelindring i dosering 30-60 mg i døgnet)</li> </ul> </li> <li>Gabapentanoider (gabapentin, pregabalin) <ul> <li>Svag anbefaling for (overvej at tilbyde gabapentin til smertelindring i dosering 300-2.400 mg i døgnet)</li> <li>Svag anbefaling for (overvej at tilbyde pregabalin til smertelindring i dosering 150-450 mg i døgnet)</li> </ul> </li> <li>Tramadol <ul> <li>Svag anbefaling imod (kun i særlige tilfælde i dosering 50-300 mg i døgnet)</li> <li>Stærk anbefaling mod brug af opioider uden dual action (bør ikke anvendes)</li> </ul> </li> </ol> <h2>Henvisning</h2> <ul> <li>Ved tvivl om diagnose efter relevant undersøgelsesprogram i almen praksis kan patienten henvise til supplerende undersøgelse i specialist regi (speciallæge eller hospitalsafdeling)</li> <li>Ved utilstrækkelig effekt af behandlingstiltag iværksat i primærsektoren bør patienten henvises til specialiseret behandlingstilbud fx på tværfaglig smerteklinik eller Gigtforeningens SANO-centre</li> </ul> <h2>Opfølgning</h2> <h3>Plan</h3> <ul> <li>For mange af patienterne kan det være fornuftigt, at lægen tager initiativ til regelmæssige kontroller over en periode</li> <li>En stor del af disse patienter bliver storforbrugere af lægekonsultationer fordi <ul> <li>De har en vedvarende sygdomsangst</li> <li>De kroniske smerter slider dem op og medfører tiltagende funktionsbegrænsninger i den nære hverdag og svigtende ressourcer i forhold til at mestre den arbejdsmæssige og sociale situation </li> </ul> </li> </ul> <h3>Hvad bør man kontrollere</h3> <ul> <li>Vær en støtteperson for patienten. Det er vigtigt at opmuntre patienten til at være aktiv og tage ansvar for egen sundhed</li> <li>Bidrage til at lægge forholdene til rette, så patienten kan fungere i hverdags- og arbejdslivet</li> <li>Foretage en grundig udredning af patienten for at undgå gentagelse af prøver og tests</li> <li>Sæt gerne en skriftlig plan op sammen med patienten for hvilke mål, som er realistiske at opnå, og følg op på, om målet er nået, eller der er behov for justering</li> </ul> <h2>Sygdomsforløb, komplikationer og prognose</h2> <h3>Sygdomsforløb</h3> <ul> <li>Tilstanden udvikler sig oftest over måneder til år og har hos mange et fluktuerende forløb med ’gode’ og dårlige’ perioder</li> <li>Lidelsen medfører ikke skader på perifere vævsstrukturer eller organer, eller nedsat forventet levetid, og er således godartet</li> <li>Lægernes usikkerhed i forhold til udredning, diagnose og behandling kan bidrage til at forstærke patientens gener, ved at smertens trusselsværdi opretholdes</li> <li>Studier har vist, at en definitiv diagnose og forklaring på smerterne beroliger patienten, hjælper patienten til bedre at kunne håndtere smertetilstanden, og nedsætter forbruget af sundhedsydelser </li> </ul> <h3>Komplikationer</h3> <ul> <li>Kronificering af smertetilstanden, herunder progredierende funktionsevnetab, i forbindelse med omfattende og langvarige udredningsforløb før der stilles en endelig diagnose og tilbydes relevant behandling. En hurtig definitiv diagnostisk afklaring er vist at berolige patienten, lette egen håndteringen af smerterne, og reducere forbruget af sundhedsydelser</li> </ul> <h3>Prognose</h3> <ul> <li>Fibromyalgi er hos de fleste en kronisk forløbende lidelse med et relativt konstant symptomniveau over tid </li> <li>I en populationsbaseret undersøgelse, hvor 1.555 individer diagnosticeret med fibromyalgi blev fulgt halvårligt med spørgeskemaer i op til 11 år, rapporterede 36 % forværring i den samlede symptombyrde og 39 % øget smerteniveau over tid. 25 % rapporterede moderat forbedring af smerteniveauet</li> <li>Patienter henvist til specialiseret behandling i Danmark har i gennemsnit haft smerter i 10 år, er præget af betydeligt funktionstab, og kun omkring 20 % er fortsat tilknyttet arbejdsmarkedet </li> <li>En tidlig socialmedicinsk indsats og arbejdspladsinterventioner, der er målrettet en rettidig tilpasning af arbejdsbelastningen til patientens funktionsniveau og ressourcer, vil formentlig kunne bedre prognosen for arbejdsfastholdelse</li> </ul> <h2>Baggrundsoplysninger<a href="https://www.sst.dk/da/udgivelser/2018/~/media/82268C6BAF19461399C4FC8D1647DCC0.ashx" data-type="other-reference" data-value="National klinisk retningslinje for udredning og behandling/rehabilitering af patienter medgeneraliserede smerter i bevægeapparatet, Sundhedsstyrelsen, 2018" data-url="https://www.sst.dk/da/udgivelser/2018/~/media/82268C6BAF19461399C4FC8D1647DCC0.ashx" title="National klinisk retningslinje for udredning og behandling/rehabilitering af patienter medgeneraliserede smerter i bevægeapparatet, Sundhedsstyrelsen, 2018">1</a><sup>,</sup><a href=" " data-type="book-reference" data-value="Amris K. Smertesensibilisering og generaliserede smertetilstande. Anne Voss, Claus Manniche, Dzenan Masic, Ellen-Margrethe Hauge, Finn Elkjær Johannsen (red.). Reumatologi 4. udgave. : FADL’s Forlag; 2018" data-value-piped="Amris K|Smertesensibilisering og generaliserede smertetilstande. Anne Voss, Claus Manniche, Dzenan Masic, Ellen-Margrethe Hauge, Finn Elkjær Johannsen (red.). Reumatologi 4. udgave||FADL’s Forlag|2018" data-url="reference-link" title="Amris K. Smertesensibilisering og generaliserede smertetilstande. Anne Voss, Claus Manniche, Dzenan Masic, Ellen-Margrethe Hauge, Finn Elkjær Johannsen (red.). Reumatologi 4. udgave. : FADL’s Forlag; 2018">3</a><sup>,</sup><a href=" " data-type="journal-reference" data-value="Clauw DJ, Fibromyalgia: a clinical review. JAMA 2014;311: 1547-55" data-value-piped="Clauw DJ|Fibromyalgia: a clinical review.|JAMA|2014|311|1547-55|24737367" data-url="reference-link" data-pubmedid="24737367" title="Clauw DJ, Fibromyalgia: a clinical review. JAMA 2014;311: 1547-55">4</a><sup>,</sup><a href=" " data-type="journal-reference" data-value="Häuser W, Sarzi-Puttini P, Fitzcharles MA, Fibromyalgia syndrome: under-, over- and misdiagnosis. Clin Exp Rheumatol 2019;37 Suppl 116: 90-97" data-value-piped="Häuser W, Sarzi-Puttini P, Fitzcharles MA|Fibromyalgia syndrome: under-, over- and misdiagnosis.|Clin Exp Rheumatol|2019|37 Suppl 116|90-97|30747096" data-url="reference-link" data-pubmedid="30747096" title="Häuser W, Sarzi-Puttini P, Fitzcharles MA, Fibromyalgia syndrome: under-, over- and misdiagnosis. Clin Exp Rheumatol 2019;37 Suppl 116: 90-97">5</a><sup>,</sup><a href=" " data-type="journal-reference" data-value="Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Fluß E, Choy E, Kosek E, Amris K, Branco J, Dincer F, Leino-Arjas P, Longley K, McCarthy GM, Makri S, Perrot S, Sarzi-Puttini P, Taylor A, Jones GT, EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis 2017;76: 318-328" data-value-piped="Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Fluß E, Choy E, Kosek E, Amris K, Branco J, Dincer F, Leino-Arjas P, Longley K, McCarthy GM, Makri S, Perrot S, Sarzi-Puttini P, Taylor A, Jones GT|EULAR revised recommendations for the management of fibromyalgia.|Ann Rheum Dis|2017|76|318-328|27377815" data-url="reference-link" data-pubmedid="27377815" title="Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Fluß E, Choy E, Kosek E, Amris K, Branco J, Dincer F, Leino-Arjas P, Longley K, McCarthy GM, Makri S, Perrot S, Sarzi-Puttini P, Taylor A, Jones GT, EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis 2017;76: 318-328">6</a><sup>,</sup><a href=" " data-type="journal-reference" data-value="Nicholas M, Vlaeyen JWS, Rief W, Barke A, Aziz Q, Benoliel R, Cohen M, Evers S, Giamberardino MA, Goebel A, Korwisi B, Perrot S, Svensson P, Wang SJ, Treede RD, IASP Taskforce for the Classification of Chronic Pain., The IASP classification of chronic pain for ICD-11: chronic primary pain. Pain 2019;160: 28-37" data-value-piped="Nicholas M, Vlaeyen JWS, Rief W, Barke A, Aziz Q, Benoliel R, Cohen M, Evers S, Giamberardino MA, Goebel A, Korwisi B, Perrot S, Svensson P, Wang SJ, Treede RD, IASP Taskforce for the Classification of Chronic Pain.|The IASP classification of chronic pain for ICD-11: chronic primary pain.|Pain|2019|160|28-37|30586068" data-url="reference-link" data-pubmedid="30586068" title="Nicholas M, Vlaeyen JWS, Rief W, Barke A, Aziz Q, Benoliel R, Cohen M, Evers S, Giamberardino MA, Goebel A, Korwisi B, Perrot S, Svensson P, Wang SJ, Treede RD, IASP Taskforce for the Classification of Chronic Pain., The IASP classification of chronic pain for ICD-11: chronic primary pain. Pain 2019;160: 28-37">7</a><sup>,</sup><a href=" " data-type="journal-reference" data-value="Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RL, Mease PJ, Russell AS, Russell IJ, Walitt B, 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum 2016;46: 319-329" data-value-piped="Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RL, Mease PJ, Russell AS, Russell IJ, Walitt B|2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria.|Semin Arthritis Rheum|2016|46|319-329|27916278" data-url="reference-link" data-pubmedid="27916278" title="Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RL, Mease PJ, Russell AS, Russell IJ, Walitt B, 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum 2016;46: 319-329">8</a></h2> <h3>Definition</h3> <ul> <li>Fibromyalgi er et karakteristisk symptomkompleks eller syndrom, kendetegnet af generaliserede smerter i bevægeapparatet; dvs. smerter lokaliseret i mindst 4 ud af 5 kropsregioner (kroppens 4 kvadranter og aksialt) og med varighed i mindst 3 måneder. Smerterne er typisk ledsaget af ændringer i stressrespons, stemningsleje, kognition og søvn, samt varierende grader af organrelaterede klager </li> <li>Fibromyalgi betragtes i dag som en smertesensibiliseringstilstand, hvor ændringer i centrale smertesignalerende og smertemodulerende systemer har medført smertehypersensitivitet</li> <li>Ætiologien er ufuldstændigt belyst, men er formentlig multifaktoriel</li> </ul> <h3>Klassifikation</h3> <ul> <li>Der eksisterer flere kriterier anvendt til klassifikation og diagnostik af fibromyalgi <ul> <li>Klassifikationskriterier, primært udviklet til forskningsbrug af the American College of Rheumatology (ACR) i 1990. I henhold til disse kriterier klassificeres patienten med fibromyalgi på baggrund af 1) generaliserede smerter og 2) smertereaktion i mindst 11 ud af 18 foruddefinerede tender points </li> <li>Diagnostiske kriterier, der er rent symptombaserede, udviklet i 2010 og revideret i 2016</li> </ul> </li> </ul> <h3>Resume</h3> <ul> <li>En individuel helhedsvurdering som inddrager de fysiske, psykologiske og sociale aspekter af smertetilstanden er nødvendig for at karakterisere patientens fibromyalgitilstand og iværksætte relevant behandling. Der er tale om en heterogen patientgruppe med en kompleks symptomatologi og et differentieret behandlingsbehov</li> <li>Optimal behandling af fibromyalgi kræver en behandlingstilgang, der er baseret på aktiv patientinddragelse, og som indeholder en eller flere af følgende behandlingskomponenter: <ul> <li>Patientuddannelse</li> <li>Øvelsesterapi/træning</li> <li>Psykologisk intervention</li> <li>Farmakologisk smertebehandling</li> </ul> </li> <li>Efter aftale med patienten bør behandlingen tilpasses den enkelte patients smerteniveau, funktion og ledsagende træk som depression, udmattelse og søvnforstyrrelse</li> </ul> <h3>Forekomst</h3> <ul> <li>Fibromyalgi forekommer på alle alderstrin</li> <li>Afhængigt af de anvendte screeningskriterier angives prævalensen i baggrundspopulationen at være 2-5 %</li> <li>Udvikling af generaliserede smerter er hyppig i reumatologiske patientpopulationer. Forekomsten af fibromyalgi hos patienter med fx leddegigt, psoriasis gigt, rygsøjlegigt og systemiske bindevævslidelser angives at være 10 - 20 %</li> <li>Ved anvendelse af tender points som grundlag for diagnosen vil ca. 90 % af patienterne være kvinder. Kvinder har en veldokumenteret kønsbetinget øget smertefølsomhed, herunder lavere tærskler for eksperimentelt induceret smerte sammenlignet med mænd. Anvendes symptombaserede diagnostiske kriterier er kvinde:mand ratioen 2:1, som ved andre kroniske smertetilstande</li> <li>Forekomsten er vist at være den samme på tværs af lande, kulturer og etniske undergrupper</li> </ul> <h3>Ætiologi og patogenese</h3> <ul> <li>Ætiologi og patogenese ved fibromyalgi er ufuldstændigt belyst, men er sandsynligvis multifaktoriel</li> <li>Fibromyalgi betragtes i dag af mange som en smertesensibiliseringstilstand forårsaget af ændringer i smertesystemets indbyggede dynamik, der bl.a. omfatter central sensibilisering (hypersensitiv tilstand af de nociceptive neuroner i centralnervesystemet) og dysfunktion af descenderende smertemodulerende systemer (tab af central smertekontrol)</li> <li>Klinisk er smertesensibiliseringstilstande karakteriseret af spontane smerter ledsaget af nedsatte smertetærskler med hyperalgesi (øget reaktion på smertestimuli) og allodyni (smerte udløst af normalt ikke-smertevoldende stimuli) i de involverede kropsregioner. Da smerterne skyldes ændret nociceptiv funktion, vil der ikke være tegn til, at aktuel vævsskade har forårsaget aktivering af perifere nociceptorer i disse regioner, dvs. ingen forklaring på smerterne ved klinisk undersøgelse af de perifere væv</li> <li>Regulering af dynamikken i smertesystemet er kompleks, og udover interaktion med stresssystemet og det autonome nervesystem spiller både pro- og antiinflammatoriske processer en vigtig rolle for reguleringen af den synaptiske transmission. Der er påvist forhøjede niveauer af pro-inflammatoriske cytokiner i cerebrospinalvæsken ved fibromyalgi, foreneligt med teorier om, at neuroinflammation spiller en rolle ved kroniske smerter. Andre mekanismer, herunder ændringer i de descenderende smertemodulerende systemer, ændring af nervecelleaktiviteten via ændret gentransskription, samt ændringer i neuron-gliacelle-interaktionen vil formentlig også kunne initiere/vedligeholde central sensibilisering</li> <li>Serotonin og noradrenalin fungerer som neurotransmitterer i talrige neurale netværk, inklusive descenderende smertemodulerende systemer. Ubalance i disse systemer vil formentlig kunne bidrage til de typiske ledsagesymptomer fx ændringer i stressrespons, stemningsleje, kognition og søvn</li> </ul> <h4>Forklaringsmodel</h4> <ul> <li>Selv om forskning har bidraget med betydelig viden om de patofysiologiske mekanismer bag central sensibilisering, så er viden om, hvilke genetiske og miljømæssige faktorer der øger risikoen for at udvikle central sensibilisering, og nøjagtig hvad der udløser og vedligeholder fænomenet, ufuldstændig</li> <li>Fibromyalgi ses ofte forudgået af hyppige smerteepisoder over tid eller langvarig regional smerte. Vi ved i dag, at langvarig og ukontrolleret smerte kan medføre ændringer i det nociceptive system</li> <li>Kroniske smerter er imidlertid ikke et fænomen, der udelukkende udspilles indenfor smertesystemet. Hvor den akutte smerte typisk er et symptom relateret til vævsskade, kan den komplekse kroniske smerte betragtes som en selvstændig tilstand, hvor et langvarigt nociceptivt input som oftest ledsages af et komplekst samspil mellem de neurofysiologiske aspekter af smerte og psykologiske, eksistentielle og sociale faktorer</li> <li>Fibromyalgi betragtes derfor bedst som en biopsykosocial lidelse, hvor langvarig psykosocial stressbelastning, lokaliseret smerte, central sensibilisering, og neuroendokrin-, neuroimmunologisk- og autonom dysfunktion spiller en patogenetisk rolle i en selvopretholdende ond cirkel</li> </ul> <h3>Disponerende faktorer</h3> <ul> <li>Fibromyalgi forekommer ophobet indenfor familier, og prævalensen af fibromyalgi blandt førstegradsslægtninge er øget til 6,4 %. Genpolymorfier involverende gener i de serotonerge, dopaminerge og katekolaminerge systemer spiller muligvis en ætiologisk rolle</li> <li>Flertallet af patienterne (86 %) relaterer fibromyalgiudviklingen til belastende livshændelser eller personlige forhold som<br> <ul> <li>Høje krav til sig selv</li> <li>Skyldfølelse</li> <li>Problemer med at sætte grænser og tage vare på egne behov</li> </ul> </li> <li>Beskrevne risikofaktorer inkluderer <ul> <li>Køn (kvinde)</li> <li>Lokaliserede muskelsmerter</li> <li>Langvarig smerte</li> <li>Hypermobilitet</li> <li>Lav uddannelse</li> <li>Lavtlønsarbejde med lille mulighed for at påvirke egen arbejdssituation</li> <li>Gennemgået skilsmisse</li> <li>Depressive tendenser</li> <li>Langvarig psykisk og/eller fysisk stress</li> <li>Søvnhæmning</li> <li>Uhensigtsmæssig sygdoms- og smerteadfærd</li> <li>Overgreb eller fysiske traumer/ kirurgiske indgreb</li> </ul> </li> </ul> <h3>ICPC-2</h3> <p>[ICPC]</p> <h3>ICD-10/SKS-koder</h3> <p>[ICD10]</p> <p>I ICD-11 klassificeres fibromyalgi som en kronisk primær smertetilstand af generaliseret type, ikke en reumatologisk lidelse som i ICD-10</p> <ul> <li>MG30.0 Chronic primary pain <ul> <li>MG30.01 Chronic widespread pain (CWP), including fibromyalgia</li> </ul> </li> <li>CWP er i ICD-11 defineret som generaliserede smerter lokaliseret i mindst 4 af 5 kropsregioner, der er associeret med betydelig negativ affekt (angst, vrede/ frustration eller depressivt forsænket stemningsleje) eller betydelig smerterelateret nedsat funktion (begrænsninger i almindelig dagligdags aktivitet og udfyldelse af sociale roller)</li> <li>Diagnosen anvendes iht. retningslinjer, når smerten ikke kan tilskrives en nociceptiv proces i de involverede kropsregioner, og der er kliniske træk foreneligt med nociplastisk smerte (smertehypersensitivitet), og identificerede psykologiske og sociale bidragende faktorer</li> <li>Fibromyalgi regnes for en undergruppe af CWP og får ikke en selvstændig diagnosekode</li> </ul> <h2>Patientinformation</h2> <h3>Hvad du bør informere patienten om</h3> <ul> <li>Det drejer sig om en oftest kronisk forløbende smertetilstand, hvor ændringer i centralnervesystemets funktion har medført smerteoverfølsomhed</li> <li>Årsagen er ukendt, men tilstanden kan have sammenhæng med langvarig fysisk og psykisk overbelastning</li> <li>Der findes ingen "kur" mod fibromyalgi, og behandlingen er primært målrettet at hjælpe patienten til bedst mulig at håndtere smerterne og de øvrige ledsagesymptomer (’hjælp-til-selvhjælp’)</li> <li>At selvhjælpsteknikker, der reducerer smerte og stress, og tilpasning af hverdagens aktiviteter, så de står mål med de faktiske ressourcer, er vigtige handlingsstrategier</li> <li>At fysisk træning er vigtig og ikke kun har til formål at reducere smerter, men også at forebygge fysisk inaktivitet, livsstilssygdomme og øge funktionsevnen i hverdagen</li> <li>Smertestillende medikamenter er ofte til mindre hjælp, men antidepressiv medicin og epilepsimedicin kan være nyttig</li> <li>Tilrettelæggelse af hverdagsliv og arbejdet har stor betydning</li> </ul> <h3>Hvad findes af skriftlig patientinformation</h3> <ul> <li><a href="~/link.aspx?_id=6BA2586E8FD74C0395CFFBE6387AA7BA&_z=z">Fibromyalgi, oversigt</a></li> <li><a href="https://www.frederiksberghospital.dk/afdelinger-og-klinikker/led-bindevaev-og-ryg/sygdom-og-behandling/Sider/til-dig-med-fibromyalgi.aspx">Til dig med fibromyalgi, tværfaglige patientuddannelsesvideoer</a></li> <li><a href="~/link.aspx?_id=0F903C0FF80D4FD29D7F516393BCF04D&_z=z">Fysisk aktivitet i forebyggelse, behandling og rehabilitering af reumatiske tilstande</a></li> <li><a href="https://aktivsundhed.dk/da/fysisk-aktivitet/traening-som-behandling/22-fibromyalgi">Center for Aktiv Sundhed, Træning som behandling, Fibromyalgi</a></li> </ul> <h3>Patientorganisationer</h3> <ul> <li><a href="http://www.fibromyalgi.dk/">Fibromyalgi - & Smerteforeningen</a></li> </ul> <h2>Socialmedicin</h2> <ul> <li>Patienten bør ikke tilbydes førtidspension, før rehabilitering er prøvet</li> <li><a href="~/link.aspx?_id=03C528B70C854B94BBEF062DC7B0DD40&_z=z">Nedsat funktionsevne og muligheder på arbejdsmarkedet</a></li> <li><a href="~/link.aspx?_id=AC83E84E5A1A4207BF74058E75D04BE2&_z=z">Revalidering</a></li> <li><a href="~/link.aspx?_id=A79F808C68814802A9CEA1DEF447CA58&_z=z">Fleksjob</a></li> <li><a href="~/link.aspx?_id=0825F077F7244800AA13D372DABFB116&_z=z">Førtidspension</a></li> </ul> <h3>Funktionsvurdering</h3> <ul> <li>Funktionsvurderingen har fået en central plads i opfølgningen af sygemeldte patienter bl.a. for at hindre en varig udelukkelse fra arbejdslivet</li> <li>Dette er en drejning væk fra betydningen af diagnosen for i stedet at fæste opmærksomheden på individets funktionsevne og ressourcer</li> <li>Kravene til medicinsk dokumentation fra lægens side vil bestå, men der vil blive øgede krav til en beskrivelse af patientens funktion</li> <li>For patienter med fibromyalgi har tilværelsen ofte været præget af usikkerhed med hensyn til behandling og af tvivl om rettigheder til f.eks. fleksjob eller førtidspension</li> <li>Forhåbentligt vil mere nøjagtige funktionsbeskrivelser resultere i en mere målrettet intervention og bedre socialmedicinsk opfølgning</li> <li>Det vil ofte være nødvendigt med praktiske prøver i rehabiliteringsgrupper og afprøvning i arbejdslivet</li> </ul> <h2>Link til vejledninger</h2> <ul> <li><a href="https://www.sst.dk/da/udgivelser/2018/nkr-udredning-og-behandling-af-patienter-med-generaliserede-smerter-i-bevaegeapparatet">National klinisk retningslinje forudredning og behandling/rehabilitering af patienter med generaliserede smerter i bevægeapparatet, Sundhedsstyrelsen, 2018</a></li> <li>Forløbsbeskrivelser og pakkeforløb [ICPC] </li> </ul> <h2>Illustrationer</h2> <h3>Plancher eller tegninger</h3> <ul> <li> <a href="~/link.aspx?_id=8EA533EA9DBC4A2EA4009522E7311FBB&_z=z">Tender points</a></li> </ul>]]></HtmlField> <HtmlField Name="Resume"><![CDATA[<h2>Resumé</h2> <h3>Diagnose</h3> <ul> <li>Kroniske, generaliserede smerter i bevægeapparatet, der ofte er ledsaget af udbredt ømhed i vævene (mange tender points)</li> <li>Karakteristiske ledsagesymptomer: søvnforstyrrelser, træthed, kognitiv dysfunktion, emotionel belastning, og overfølsomhed over for andre sanseindtryk (lys, lyd, lugt) </li> <li>Hyppig samforekomst med andre primære smertesyndromer fx hovedpine, migræne, kæbesmerter, irritabel tyktarm, vulvodyni, etc. </li> <li>Diagnosen er klinisk og stilles på baggrund af det karakteristiske symptombillede samt fravær af anden sygdom, der bedre kan forklare symptombilledet</li> </ul> <h3>Behandling</h3> <ul> <li>Hurtig diagnostik og information til patienten om smertediagnose og behandlingsmuligheder </li> <li>Behandlingstilgang baseret på aktiv patientinddragelse og omfatter: patientuddannelse, øvelsesterapi/træning, psykologisk intervention, og farmakologisk smertebehandling</li> <li>Behandlingsplan, der er individuelt tilrettelagt afhængigt af patientens behov og præferencer</li> </ul> <h3>Henvisning</h3> <ul> <li>Ved tvivl om diagnose efter relevant undersøgelsesprogram i almen praksis </li> <li>Ved utilstrækkelig effekt af behandlingstiltag iværksat i primærsektoren bør patienten henvises til specialiseret behandlingstilbud</li> </ul>]]></HtmlField> <LinkListField Name="Spot2"> <LinkField linktype="internal">{99A85AFD-2F7A-4B5D-A1C9-C2701D5E7D30}</LinkField> </LinkListField> <TextField Name="DoctorsHandbookID">1226</TextField> <TextField Name="PageTitle">Fibromyalgi</TextField> <TextField Name="NavigationTitle">Fibromyalgi</TextField> <CheckBoxField Name="ShowInMenu">true</CheckBoxField> <CheckBoxField Name="ShowInContentField">true</CheckBoxField> <DateTimeField Name="RevisedDate">2023-02-14T12:31:00</DateTimeField> <LinkListField Name="Authors"> <LinkField linktype="internal">{E95D91DE-3B32-477B-9E8E-F525CAF2C6EB}</LinkField> <LinkField 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