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全身の疼痛

著者: 吉見祐輔 名古屋第二赤十字病院 総合内科

監修: 野口善令 豊田地域医療センター 総合診療科

著者校正済:2021/10/20
現在監修レビュー中
参考ガイドライン:
  1. 「慢性疼痛診療システムの均てん化と痛みセンター診療データベースの活用による医療向上を目指す研究」研究班:慢性疼痛診療ガイドライン
患者向け説明資料

概要・推奨   

  1. 痛みの原因を筋痛、関節痛、神経障害性疼痛、骨痛、それ以外の説明できない痛みに分類し、そこから鑑別をすすめるとよいと考えられる(推奨度1)。
  1. 全身の疼痛の原因として主なものに感染症、全身性リウマチ性疾患、内分泌疾患、薬剤性、非炎症性疼痛性症候群、神経筋疾患などがある(推奨度1)。
  1. 「全身の疼痛」を来す筋痛が主体の鑑別疾患には、皮膚筋炎、多発筋炎血管炎の一部、リウマチ性多発筋痛症、甲状腺機能低下症、副腎不全、薬剤性(スタチンなど)、線維筋痛症などがある。
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  1. 神経炎の評価において血液検査は診断の役に立たないことが多いが、血糖値、ビタミンB12およびその代謝産物の測定、血清蛋白の電気泳動もしくは免疫固定法は有効である。また遺伝性多発神経炎の診断には遺伝子検査が有効である(推奨度1)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要と
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
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  1. 対症療法としてNSAIDsを使用する場合には胃潰瘍の予防にPPI、プロスタグランジン製剤、高容量のH2受容体拮抗薬がすすめられる。またCOX2阻害薬もCOX1阻害薬に比較して胃潰瘍の発生率を下げる(推奨度1)。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
吉見祐輔 : 未申告[2021年]
監修:野口善令 : 特に申告事項無し[2021年]

改訂のポイント:
  1. ガイドラインを参照に線維筋痛症について一部追記
  1. CK上昇を認めない皮膚筋炎の一群について追記

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 全身の疼痛の原因には関節痛、筋肉痛、骨痛、神経障害性疼痛、線維筋痛症、疼痛性障害などさまざまなものがある。頻度的に多いものはウイルス感染症などに伴う非特異的な筋痛であると考えられるが、診断には困らないと思われる。
  1. まずは痛みが関節、筋肉、骨、末梢神経由来のいずれであるかの診断を、病歴、身体所見からめどを立てる。
  1. 関節痛、筋痛、骨痛、神経障害性疼痛の可能性が高ければそれぞれに応じた鑑別疾患に従って検索をすすめていく。
  1. 病歴、身体所見だけでは関節、筋肉、骨、末梢神経由来のいずれであるか区別がつかないことがあるのでその場合には可能性があるものについて検索をする。特に骨痛は筋痛か骨痛か判断できないことは多く、副腎不全も筋痛か関節痛か判断つかないことも多いため注意が必要である。
  1. 上記で診断がはっきりしない場合には、身体症状症(somatic symptom disorders)や線維筋痛症などの鑑別を行う。
 
  1. 痛みの原因を筋痛、関節痛、神経障害性疼痛、骨痛、それ以外の説明できない痛みに分類し、そこから鑑別をすすめるとよいと考えられる(推奨度1)。
  1. 全身の疼痛に関する疫学的調査の論文はなく、患者はさまざまな種類の痛みを「全身の疼痛」として訴えることから、「全身の疼痛」から直接鑑別をすすめることは困難と考えられる。
  1. そのため「全身の疼痛」を、より鑑別のあげやすい問題点に言い換えることが重要である。
  1. 具体的には病歴、身体所見、検査所見から筋痛、関節痛、神経障害性疼痛、骨痛に分類し、それぞれに応じて鑑別をすすめると診断しやすくなる。
  1. また、どの疾患にもあてはまらない場合には線維筋痛症や疼痛性障害などを検討するのがよいだろう。
 
  1. 全身の筋痛の原因として主なものに感染症、全身性リウマチ性疾患、内分泌疾患、薬剤性、非炎症性疼痛性症候群、神経筋疾患などがある(推奨度1)。(参考文献:[1]
  1. 急いで鑑別すべきは敗血症や感染性心内膜炎などの感染症であり、これらは筋痛や関節痛に加え悪寒、戦慄を伴う発熱を来す。
  1. 横紋筋融解症は急性腎不全を来すため、これも鑑別が重要である。
  1. 病歴:病歴では発症形式、痛みの部位、筋力低下の有無、随伴症状、薬剤使用歴が鑑別を狭めるのに必要である。急性発症であれば敗血症、インフルエンザ、急性B型肝炎が示唆される。高齢者の頚、両肩、上肢、殿部、大腿部の急性発症の筋痛はリウマチ性多発筋痛症に特徴的である。亜急性の発症であればスタチンなどの薬剤性の筋痛の可能性が高く、薬剤開始後数週間から数カ月後に認められる。緩徐な発症の場合、甲状腺機能低下症、高カルシウム血症が考えられる。また線維筋痛症なども慢性の経過を来す。朝の強い筋痛はリウマチ性多発筋痛症やその他のリウマチ性疾患を強く示唆する。椅子から立ち上がれない、頭の上に手をのばすことができないなどの病歴がある場合には近位筋の筋力低下が示唆され、客観的な筋力低下を認める場合には線維筋痛症やリウマチ性多発筋痛症などは考えにくい。便秘、倦怠感、体重増加は甲状腺機能低下症を示唆し、皮膚色素沈着は副腎不全を示唆する。スタチンの使用歴は薬剤性の筋痛の可能性を高める。
  1. 身体所見:身体所見では筋痛の有無、炎症、筋力低下などの評価が有用である。検査異常がなく症状が軽度であれば自然経過で改善することも多く、経過観察は有効な手立てである。近位筋優位の筋力低下は炎症性筋炎(皮膚筋炎、多発筋炎)や薬剤性筋炎、甲状腺機能低下症の可能性が高い。また局所の激しい痛みに加え水疱や発赤を認めた場合には、壊死性筋膜炎を鑑別する必要がある。色素沈着や起立性低血圧は副腎不全にみられる。関節炎を認めれば関節炎の鑑別を行う。特異的な圧痛点は線維筋痛症でみられる。アキレス腱反射の遅延、皮膚乾燥、嗄声、ゆっくりとした話し方は甲状腺機能低下症でみられる。
  1. 検査所見:血液培養は敗血症を疑ったときに重要である。CRP上昇、ESR上昇は感染や全身性リウマチ性疾患でみられるが特異的ではない。ANCAは血管炎で特異的な所見であるため、疑った場合にはチェックが必要である。甲状腺機能低下症を疑った場合にはTSH、freeT4を、副腎不全を疑った場合にはACTH/コルチゾールを測定する必要がある。
 
  1. 「全身の疼痛」を来す関節痛が主体になる疾患としてはウイルス性関節炎、リウマチの一部、SLE、RS3PE、結晶沈着性関節炎の一部などが考えられる。
  1. 詳細は多関節痛の項目参照のこと
 
  1. 「全身の疼痛」を来す神経障害性疼痛としては、急性の対称性神経炎(急性多発神経炎)、慢性の対称性神経炎(慢性多発神経炎)、多発単神経炎に分類し、そこから鑑別をすすめる。また原因は糖尿病、アルコール、HIV、種々の薬物、ビタミン不足、炎症性脱髄性疾患、遺伝性疾患など多岐にわたる(推奨度1)。
  1. 糖尿病性やアルコール性の多発痰神経炎は比較的多いと思われる。ビタミンB1欠乏やB12欠乏も比較的見逃されていることが多い。
 
  1. 「全身の疼痛」を来す骨痛が主体の疾患としては骨軟化症、転移性骨腫瘍などが比較的多い。
  1. 病歴、身体所見からは骨痛であると確定することが難しい。ALP高値が参考になる。また悪性腫瘍の示唆するような体重減少、喀血、血便、黒色便などあれば転移性骨腫瘍の可能性が高まる。
 
  1. 慢性全身疼痛の持続化する危険因子としては身体化障害がある(推奨度1 O)。(参考文献:[2]
  1. まとめ:全身疼痛を訴える患者において身体化障害を伴う場合には治療が長期的になることを覚悟する必要がある。逆に一定数の患者では疼痛が改善することも判明しており、根気よく治療を行うことも必要である。
  1. 代表事例:252人の全身疼痛患者を1年間フォローしたところ126人(56%)において全身疼痛が継続、74人(33%)において他の痛みが出現、25人(11%)において痛みが消失していた。全身疼痛が持続する危険因子として心理的苦痛と倦怠感が関連しており、日常生活に影響が出るほどの頻回の医療機関受診として表現されていた
  1. 結論:以上から身体化障害が全身疼痛の持続化の危険因子と考えられる。逆に一部の患者では1年以内に疼痛が消失することもわかる。
問診・診察のポイント  
  1. 問診、診察で関節痛、筋肉痛、骨痛、神経障害性疼痛のいずれであるかを確認する。

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文献 

著者: J McBeth, G J Macfarlane, I M Hunt, A J Silman
雑誌名: Rheumatology (Oxford). 2001 Jan;40(1):95-101.
Abstract/Text BACKGROUND: Chronic widespread pain is the cardinal clinical feature of the fibromyalgia syndrome, which, in the majority of clinic patients, is persistent. By contrast, in community-derived patients, pain is persistent in only half of the affected individuals, particularly those with psychological distress. Whether such distress is a consequence of the pain or a manifestation of a wider process of somatization which is associated with the persistence of pain is unclear.
OBJECTIVES: We tested in a large, prospective, population-based study the hypothesis that features of somatization predict the persistence of chronic widespread pain.
METHODS: In all, 252 (13%) of 1953 adult subjects selected from a population register were classified as having chronic widespread pain based on a detailed questionnaire which included a pain drawing. The patients also completed a number of psychosocial instruments which measure features known to be associated with somatization. Two hundred and twenty-five (91%) of the patients were successfully followed up after 12 months and provided data on pain status using the same instruments.
RESULTS: In all, 126 (56%) patients reported chronic widespread pain at follow-up, 74 (33%) reported other pain and 25 (11%) reported no pain. Persistent chronic widespread pain was strongly associated with baseline test scores for high psychological distress and fatigue. In addition, these subjects were more likely to display a pattern of illness behaviour characterized by frequent visits to medical practitioners for symptoms which disrupt daily activities. The prevalence of persistent pain increased with the number of risk factors the subjects were exposed to.
CONCLUSIONS: Although almost half of the cases of chronic widespread pain resolved within 1 yr, this study has demonstrated for the first time that those subjects who display features of somatization are more likely to have widespread pain which persists. These findings have implications for the identification and treatment of persons with persistent chronic widespread pain.

PMID 11157148  Rheumatology (Oxford). 2001 Jan;40(1):95-101.
著者: Maija L Haanpää, Misha-Miroslav Backonja, Michael I Bennett, Didier Bouhassira, Giorgio Cruccu, Per T Hansson, Troels Staehelin Jensen, Timo Kauppila, Andrew S C Rice, Blair H Smith, Rolf-Detlef Treede, Ralf Baron
雑誌名: Am J Med. 2009 Oct;122(10 Suppl):S13-21. doi: 10.1016/j.amjmed.2009.04.006.
Abstract/Text Management of patients presenting with chronic pain is a common problem in primary care. Essentially, the classification of chronic pain falls into 3 broad categories: (1) pain owing to tissue disease or damage (nociceptive pain), (2) pain caused by somatosensory system disease or damage (neuropathic pain), and (3) pain without a known somatic background. Key challenges in developing a targeted holistic approach to treatment include appropriate diagnosis of the cause or causes of pain; identifying the type of pain and assessing the relative importance of its various components; and determining appropriate treatment. In clinical examination, sensory abnormalities are the crucial findings leading to a diagnosis of neuropathic pain, for which pharmacotherapy with antidepressants and anticonvulsants represents the cornerstone of medical treatment. Chronic neuropathic pain is underrecognized and undertreated, yet primary care physicians are uniquely placed on the frontlines of patient management, where they can play a pivotal role in treatment and prevention through diagnosis, therapy, follow-up, and referral. This review provides guidance in understanding and identifying the neuropathic contribution to pain presenting in primary care; assessing its severity through patient history, physical examination, and appropriate diagnostic tests; and establishing a rational treatment plan.

PMID 19801048  Am J Med. 2009 Oct;122(10 Suppl):S13-21. doi: 10.1016/j・・・
著者: A J Barsky, J F Borus
雑誌名: Ann Intern Med. 1999 Jun 1;130(11):910-21.
Abstract/Text The term functional somatic syndrome has been applied to several related syndromes characterized more by symptoms, suffering, and disability than by consistently demonstrable tissue abnormality. These syndromes include multiple chemical sensitivity, the sick building syndrome, repetition stress injury, the side effects of silicone breast implants, the Gulf War syndrome, chronic whiplash, the chronic fatigue syndrome, the irritable bowel syndrome, and fibromyalgia. Patients with functional somatic syndromes have explicit and highly elaborated self-diagnoses, and their symptoms are often refractory to reassurance, explanation, and standard treatment of symptoms. They share similar phenomenologies, high rates of co-occurrence, similar epidemiologic characteristics, and higher-than-expected prevalences of psychiatric comorbidity. Although discrete pathophysiologic causes may ultimately be found in some patients with functional somatic syndromes, the suffering of these patients is exacerbated by a self-perpetuating, self-validating cycle in which common, endemic, somatic symptoms are incorrectly attributed to serious abnormality, reinforcing the patient's belief that he or she has a serious disease. Four psychosocial factors propel this cycle of symptom amplification: the belief that one has a serious disease; the expectation that one's condition is likely to worsen; the "sick role," including the effects of litigation and compensation; and the alarming portrayal of the condition as catastrophic and disabling. The climate surrounding functional somatic syndromes includes sensationalized media coverage, profound suspicion of medical expertise and physicians, the mobilization of parties with a vested self-interest in the status of functional somatic syndromes, litigation, and a clinical approach that overemphasizes the biomedical and ignores psychosocial factors. All of these influences exacerbate and perpetuate the somatic distress of patients with functional somatic syndromes, heighten their fears and pessimistic expectations, prolong their disability, and reinforce their sick role. A six-step strategy for helping patients with functional somatic syndromes is presented here.

PMID 10375340  Ann Intern Med. 1999 Jun 1;130(11):910-21.
著者: Peter Henningsen, Stephan Zipfel, Wolfgang Herzog
雑誌名: Lancet. 2007 Mar 17;369(9565):946-55. doi: 10.1016/S0140-6736(07)60159-7.
Abstract/Text Although functional somatic syndromes (FSS) show substantial overlap, treatment research is mostly confined to single syndromes, with a lack of valid and generally accepted diagnostic criteria across medical specialties. Here, we review management for the full variety of FSS, drawn from systematic reviews and meta-analyses since 2001, and give recommendations for a stepped care approach that differentiates between uncomplicated and complicated FSS. Non-pharmacological treatments involving active participation of patients, such as exercise and psychotherapy, seem to be more effective than those that involve passive physical measures, including injections and operations. Pharmacological agents with CNS action seem to be more consistently effective than drugs aiming at restoration of peripheral physiological dysfunction. A balance between biomedical, organ-oriented, and cognitive interpersonal approaches is most appropriate at this truly psychosomatic interface. In view of the iatrogenic component in the maintenance of FSS, doctor-centred interventions and close observation of the doctor-patient relationship are of particular importance.

PMID 17368156  Lancet. 2007 Mar 17;369(9565):946-55. doi: 10.1016/S014・・・
著者: Richard A C Hughes
雑誌名: BMJ. 2002 Feb 23;324(7335):466-9.
Abstract/Text
PMID 11859051  BMJ. 2002 Feb 23;324(7335):466-9.
著者: J D England, G S Gronseth, G Franklin, G T Carter, L J Kinsella, J A Cohen, A K Asbury, K Szigeti, J R Lupski, N Latov, R A Lewis, P A Low, M A Fisher, D N Herrmann, J F Howard, G Lauria, R G Miller, M Polydefkis, A J Sumner, American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Academy of Physical Medicine and Rehabilitation
雑誌名: PM R. 2009 Jan;1(1):5-13. doi: 10.1016/j.pmrj.2008.11.010.
Abstract/Text BACKGROUND: Distal symmetric polyneuropathy (DSP) is the most common variety of neuropathy. Since the evaluation of this disorder is not standardized, the available literature was reviewed to provide evidence-based guidelines regarding the role of laboratory and genetic tests for the assessment of DSP.
METHODS: A literature review using MEDLINE, EMBASE, Science Citation Index and Current Contents was performed to identify the best evidence regarding the evaluation of polyneuropathy published between 1980 and March 2007. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based upon the level of evidence.
RESULTS AND CONCLUSIONS: 1. Screening laboratory tests may be considered for all patients with polyneuropathy (Level C). Those tests that provide the highest yield of abnormality are blood glucose, serum B12 with metabolites (methylmalonic acid with or without homocysteine) and serum protein immunofixation electrophoresis (Level C). If there is no definite evidence of diabetes mellitus by routine testing of blood glucose, testing for impaired glucose tolerance may be considered in distal symmetric sensory polyneuropathy (Level C). 2. Genetic testing is established as useful for the accurate diagnosis and classification of hereditary neuropathies (Level A). Genetic testing may be considered in patients with cryptogenic polyneuropathy who exhibit a hereditary neuropathy phenotype (Level C). Initial genetic testing should be guided by the clinical phenotype, inheritance pattern, and electrodiagnostic (EDX) features and should focus on the most common abnormalities which are CMT1A duplication/HNPP deletion, Cx32 (GJB1), and MFN2 mutation screening. There is insufficient evidence to determine the usefulness of routine genetic testing in patients with cryptogenic polyneuropathy who do not exhibit a hereditary neuropathy phenotype (Level U).

PMID 19627867  PM R. 2009 Jan;1(1):5-13. doi: 10.1016/j.pmrj.2008.11.0・・・
著者: Bernard Bannwarth, Francis Blotman, Katell Roué-Le Lay, Jean-Paul Caubère, Etienne André, Charles Taïeb
雑誌名: Joint Bone Spine. 2009 Mar;76(2):184-7. doi: 10.1016/j.jbspin.2008.06.002. Epub 2008 Sep 25.
Abstract/Text OBJECTIVE: To estimate the prevalence of fibromyalgia (FM) syndrome in the French general population.
METHODS: A validated French version of the London Fibromyalgia Epidemiology Study Screening Questionnaire (LFESSQ) was administered via telephone to a representative community sample of 1014 subjects aged over 15 years, selected by the quota method. A positive screen was defined as: (1) meeting the 4-pain criteria alone (LFESSQ-4), or (2) meeting both the 4-pain and 2-fatigue criteria (LFESSQ-6). To estimate the positive predictive value of LFESSQ-4 and LFESSQ-6, this questionnaire was submitted to a sample of rheumatology outpatients (n=178), who were then examined by a trained rheumatologist to confirm or exclude the diagnosis of FM according to the 1990 American College of Rheumatology criteria. The prevalence of FM in the general population was estimated by applying the predictive positive value to eligible community subjects (i.e., positive screens).
RESULTS: In the community sample, 9.8% and 5.0% screened positive for LFESSQ-4 and LFESSQ-6, respectively. Among rheumatology outpatients, 47.1% screened positive for LFESSQ-4 and 34.8% for LFESSQ-6 whereas 10.6% were confirmed FM cases. Based on positive screens for LFESSQ-4, the prevalence of FM was estimated at 2.2% (95% CI 1.3-3.1) in the French general population. The corresponding figure was 1.4 % (95% CI 0.7-2.1) if positive screens for LFESSQ-6 were considered.
CONCLUSION: Our findings suggest that FM is also a major cause of widespread pain in France since a point prevalence of 1.4% would translate in approximately 680,000 patients.

PMID 18819831  Joint Bone Spine. 2009 Mar;76(2):184-7. doi: 10.1016/j.・・・
著者: Peter T Weir, Gregory A Harlan, Flo L Nkoy, Spencer S Jones, Kurt T Hegmann, Lisa H Gren, Joseph L Lyon
雑誌名: J Clin Rheumatol. 2006 Jun;12(3):124-8. doi: 10.1097/01.rhu.0000221817.46231.18.
Abstract/Text BACKGROUND: The epidemiology of fibromyalgia is poorly defined. The incidence of fibromyalgia has not been determined using a large population base. Previous studies based on prevalence data demonstrated that females are 7 times more likely to have fibromyalgia than males and that the peak age for females is during the childbearing years.
OBJECTIVE: We have calculated the incidence rate of fibromyalgia in a large, stable population and determined the strength of association between fibromyalgia and 7 comorbid conditions.
METHODS: We conducted a retrospective cohort study of a large, stable health insurance claims database (62,000 nationwide enrollees per year). Claims from 1997 to 2002 were examined using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify fibromyalgia cases (ICD code 729.1) and 7 predetermined comorbid conditions.
RESULTS: A total of 2595 incident cases of fibromyalgia were identified between 1997 and 2002. Age-adjusted incidence rates were 6.88 cases per 1000 person-years for males and 11.28 cases per 1000 person-years for females. Females were 1.64 times (95% confidence interval = 1.59-1.69) more likely than males to have fibromyalgia. Patients with fibromyalgia were 2.14 to 7.05 times more likely to have one or more of the following comorbid conditions: depression, anxiety, headache, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosus, and rheumatoid arthritis.
CONCLUSION: Females are more likely to be diagnosed with fibromyalgia than males, although to a substantially smaller degree than previously reported, and there are strong associations for comorbid conditions that are commonly thought to be associated with fibromyalgia.

PMID 16755239  J Clin Rheumatol. 2006 Jun;12(3):124-8. doi: 10.1097/01・・・
著者: I M Hunt, A J Silman, S Benjamin, J McBeth, G J Macfarlane
雑誌名: Rheumatology (Oxford). 1999 Mar;38(3):275-9.
Abstract/Text OBJECTIVE: We examine the descriptive epidemiology of chronic widespread pain using the 'Manchester' definition [CWP(M)] and assess psychosocial and other features which characterize subjects with such pain according to these more stringent criteria.
METHODS: A population postal survey of 3004 subjects was conducted in the Greater Manchester area of the UK.
RESULTS: The point prevalence of Manchester-defined chronic widespread pain was 4.7%. CWP(M) was associated with psychological disturbance [risk ratio (RR) = 2.2, 95% confidence interval (CI) (1.4-3.5)], fatigue [RR = 3.8, 95% CI (2.3-6.1)], low levels of self-care [RR = 2.2, 95% CI (1.4-3.6)] and with the reporting of other somatic symptoms [RR = 2.0, 95% CI (1.3-3.1)]. Hypochondriacal beliefs and a preoccupation with bodily symptoms were also associated with the presence of CWP(M).
CONCLUSION: This definition of chronic widespread pain is more precise in identifying subjects with truly widespread pain and its associated adverse psychosocial factors. Clear associations with other 'non-pain' somatic symptoms were identified, which further supports the hypothesis that chronic widespread pain is one feature of somatization.

PMID 10325667  Rheumatology (Oxford). 1999 Mar;38(3):275-9.
著者: Lars Cöster, Sally Kendall, Björn Gerdle, Chris Henriksson, Karl G Henriksson, Ann Bengtsson
雑誌名: Eur J Pain. 2008 Jul;12(5):600-10. doi: 10.1016/j.ejpain.2007.10.001. Epub 2007 Nov 19.
Abstract/Text Fibromyalgia is currently classified as chronic widespread pain with widespread allodynia to pressure pain. There are few data describing pain characteristics, quality of life, consequences for daily living, and psychosocial status in patients who meet the classification criteria for fibromyalgia proposed by the American College of Rheumatology compared with patients with chronic widespread pain but not widespread allodynia. This study used a randomly selected sample from the general population. A postal questionnaire and a pain mannequin were sent to 9952 people. The response rate was 76.7%. The pain drawings showed that 345 people had widespread pain; that is, they noted pain in all four extremities and axially. Clinical examination, which included a manual tender point examination, was performed in 125 subjects. These people answered commonly used questionnaires on pain, quality of life, coping strategies, depression, and anxiety. Compared with chronic widespread pain without widespread allodynia, fibromyalgia was associated with more severe symptoms/consequences for daily life and higher pain severity. Similar coping strategies were found. Chronic widespread pain without widespread allodynia to pressure pain was found in 4.5% in the population and fibromyalgia in 2.5%.

PMID 18024204  Eur J Pain. 2008 Jul;12(5):600-10. doi: 10.1016/j.ejpai・・・
著者: L Lindell, S Bergman, I F Petersson, L T Jacobsson, P Herrström
雑誌名: Scand J Prim Health Care. 2000 Sep;18(3):149-53.
Abstract/Text OBJECTIVE: To explore the prevalence of fibromyalgia and chronic widespread musculoskeletal pain in a general population using the criteria of the American College of Rheumatology from 1990.
DESIGN: Structured interview and clinical examination, including tender-point count and pain threshold measured with a dolorimeter, of subjects with suspected chronic widespread musculoskeletal pain.
SETTING: The general population in south-west Sweden 1995-1996.
SUBJECTS: 303 individuals with suspected chronic widespread pain were identified in a previously defined cohort containing 2425 men and women aged 20-74 years. 202 individuals were invited and 147 agreed to participate.
MAIN OUTCOME MEASURES: Tenderpoint count, pain threshold and prevalence of chronic widespread pain and fibromyalgia.
RESULTS: The prevalence of fibromyalgia was estimated to 1.3% (95% CI 0.8-1.7; n = 2425) and that of all chronic widespread pain to 4.2% (95% CI 3.4-5.0; n = 2425). The mean pain threshold measured with a dolorimeter was lower in subjects with chronic widespread pain (p < 0.01) and correlated with the number of tender points (r = -0.59, p < 0.01) but could not be used to distinguish the subjects with fibromyalgia.
CONCLUSION: Compared to other studies, fibromyalgia and chronic widespread musculoskeletal pain seemed to be relatively rare conditions in the south-west of Sweden.

PMID 11097099  Scand J Prim Health Care. 2000 Sep;18(3):149-53.
著者: P Croft, A S Rigby, R Boswell, J Schollum, A Silman
雑誌名: J Rheumatol. 1993 Apr;20(4):710-3.
Abstract/Text OBJECTIVE: To establish the prevalence of chronic widespread pain and associated symptoms in a general population sample.
METHODS: Cross sectional postal survey of 2,034 adults in the north of England.
RESULTS: The point prevalence of chronic widespread pain was 11.2%. The symptom was strongly associated with other somatic complaints and with measures of depression and anxiety.
CONCLUSION: In the general population, this cardinal symptom of fibromyalgia is common and identifies a group who are more likely also to report symptoms of fatigue and depression.

PMID 8496870  J Rheumatol. 1993 Apr;20(4):710-3.
著者: F Wolfe, H A Smythe, M B Yunus, R M Bennett, C Bombardier, D L Goldenberg, P Tugwell, S M Campbell, M Abeles, P Clark
雑誌名: Arthritis Rheum. 1990 Feb;33(2):160-72.
Abstract/Text To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in greater than or equal to 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.

PMID 2306288  Arthritis Rheum. 1990 Feb;33(2):160-72.
著者: Frederick Wolfe, Daniel J Clauw, Mary-Ann Fitzcharles, Don L Goldenberg, Robert S Katz, Philip Mease, Anthony S Russell, I Jon Russell, John B Winfield, Muhammad B Yunus
雑誌名: Arthritis Care Res (Hoboken). 2010 May;62(5):600-10. doi: 10.1002/acr.20140.
Abstract/Text OBJECTIVE: To develop simple, practical criteria for clinical diagnosis of fibromyalgia that are suitable for use in primary and specialty care and that do not require a tender point examination, and to provide a severity scale for characteristic fibromyalgia symptoms.
METHODS: We performed a multicenter study of 829 previously diagnosed fibromyalgia patients and controls using physician physical and interview examinations, including a widespread pain index (WPI), a measure of the number of painful body regions. Random forest and recursive partitioning analyses were used to guide the development of a case definition of fibromyalgia, to develop criteria, and to construct a symptom severity (SS) scale.
RESULTS: Approximately 25% of fibromyalgia patients did not satisfy the American College of Rheumatology (ACR) 1990 classification criteria at the time of the study. The most important diagnostic variables were WPI and categorical scales for cognitive symptoms, unrefreshed sleep, fatigue, and number of somatic symptoms. The categorical scales were summed to create an SS scale. We combined the SS scale and the WPI to recommend a new case definition of fibromyalgia: (WPI > or =7 AND SS > or =5) OR (WPI 3-6 AND SS > or =9).
CONCLUSION: This simple clinical case definition of fibromyalgia correctly classifies 88.1% of cases classified by the ACR classification criteria, and does not require a physical or tender point examination. The SS scale enables assessment of fibromyalgia symptom severity in persons with current or previous fibromyalgia, and in those to whom the criteria have not been applied. It will be especially useful in the longitudinal evaluation of patients with marked symptom variability.

PMID 20461783  Arthritis Care Res (Hoboken). 2010 May;62(5):600-10. do・・・
著者: Frederick Wolfe, Daniel J Clauw, Mary-Ann Fitzcharles, Don L Goldenberg, Winfried Häuser, Robert S Katz, Philip Mease, Anthony S Russell, I Jon Russell, John B Winfield
雑誌名: J Rheumatol. 2011 Jun;38(6):1113-22. doi: 10.3899/jrheum.100594. Epub 2011 Feb 1.
Abstract/Text OBJECTIVE: To develop a fibromyalgia (FM) survey questionnaire for epidemiologic and clinical studies using a modification of the 2010 American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia (ACR 2010). We also created a new FM symptom scale to further characterize FM severity.
METHODS: The ACR 2010 consists of 2 scales, the Widespread Pain Index (WPI) and the Symptom Severity (SS) scale. We modified these ACR 2010 criteria by eliminating the physician's estimate of the extent of somatic symptoms and substituting the sum of 3 specific self-reported symptoms. We also created a 0-31 FM Symptom scale (FS) by adding the WPI to the modified SS scale. We administered the questionnaire to 729 patients previously diagnosed with FM, 845 with osteoarthritis (OA) or with other noninflammatory rheumatic conditions, 439 with systemic lupus erythematosus (SLE), and 5210 with rheumatoid arthritis (RA).
RESULTS: The modified ACR 2010 criteria were satisfied by 60% with a prior diagnosis of FM, 21.1% with RA, 16.8% with OA, and 36.7% with SLE. The criteria properly identified diagnostic groups based on FM severity variables. An FS score ≥ 13 best separated criteria+ and criteria- patients, classifying 93.0% correctly, with a sensitivity of 96.6% and a specificity of 91.8% in the study population.
CONCLUSION: A modification to the ACR 2010 criteria will allow their use in epidemiologic and clinical studies without the requirement for an examiner. The criteria are simple to use and administer, but they are not to be used for self-diagnosis. The FS may have wide utility beyond the bounds of FM, including substitution for widespread pain in epidemiological studies.

PMID 21285161  J Rheumatol. 2011 Jun;38(6):1113-22. doi: 10.3899/jrheu・・・
著者: Chie Usui, Kotaro Hatta, Satoko Aratani, Naoko Yagishita, Kenya Nishioka, Teruhisa Kanazawa, Kenji Itoh, Yoshihisa Yamano, Hiroyuki Nakamura, Toshihiro Nakajima, Kusuki Nishioka
雑誌名: Mod Rheumatol. 2013 Sep;23(5):846-50. doi: 10.1007/s10165-012-0759-x. Epub 2012 Sep 24.
Abstract/Text PURPOSE: The aim of this study is to investigate the reliability and validity of the Japanese version of the modified American College of Rheumatology (ACR) Preliminary Diagnostic Criteria for Fibromyalgia (mACR 2010-J) and the Fibromyalgia Symptom Scale (mFS-J).
METHODS: According to the ACR 1990 classification criteria, patients with chronic pain were divided into the fibromyalgia group and nonfibromyalgia group (rheumatoid arthritis and osteoarthritis). Patients in both groups were assessed using mACR 2010-J and mFS-J.
RESULTS: 294 of 462 (64 %) patients in the fibromyalgia group met mACR 2010-J, whereas 4 % (9/231) of the nonfibromyalgia group did, with sensitivity of 64 %, specificity of 96 %, positive predictive value of 97 %, negative predictive value of 56 %, and positive likelihood ratio of 16.3. Mean total scores on mFS-J significantly differentiated the fibromyalgia from the nonfibromyalgia group. According to the value of the Youden index, the best cutoff score for the mFS-J was 9/10.
CONCLUSION: Our findings indicate that mACR 2010-J as a positive test and mFS-J as a quantification scale might be suitable for assessing fibromyalgia among Japanese chronic pain populations.

PMID 23001748  Mod Rheumatol. 2013 Sep;23(5):846-50. doi: 10.1007/s101・・・
著者: S F Carville, L Arendt-Nielsen, S Arendt-Nielsen, H Bliddal, F Blotman, J C Branco, D Buskila, J A P Da Silva, B Danneskiold-Samsøe, F Dincer, C Henriksson, K G Henriksson, E Kosek, K Longley, G M McCarthy, S Perrot, M Puszczewicz, P Sarzi-Puttini, A Silman, M Späth, E H Choy, EULAR
雑誌名: Ann Rheum Dis. 2008 Apr;67(4):536-41. doi: 10.1136/ard.2007.071522. Epub 2007 Jul 20.
Abstract/Text OBJECTIVE: To develop evidence-based recommendations for the management of fibromyalgia syndrome.
METHODS: A multidisciplinary task force was formed representing 11 European countries. The design of the study, including search strategy, participants, interventions, outcome measures, data collection and analytical method, was defined at the outset. A systematic review was undertaken with the keywords "fibromyalgia", "treatment or management" and "trial". Studies were excluded if they did not utilise the American College of Rheumatology classification criteria, were not clinical trials, or included patients with chronic fatigue syndrome or myalgic encephalomyelitis. Primary outcome measures were change in pain assessed by visual analogue scale and fibromyalgia impact questionnaire. The quality of the studies was categorised based on randomisation, blinding and allocation concealment. Only the highest quality studies were used to base recommendations on. When there was insufficient evidence from the literature, a Delphi process was used to provide basis for recommendation.
RESULTS: 146 studies were eligible for the review. 39 pharmacological intervention studies and 59 non-pharmacological were included in the final recommendation summary tables once those of a lower quality or with insufficient data were separated. The categories of treatment identified were antidepressants, analgesics, and "other pharmacological" and exercise, cognitive behavioural therapy, education, dietary interventions and "other non-pharmacological". In many studies sample size was small and the quality of the study was insufficient for strong recommendations to be made.
CONCLUSIONS: Nine recommendations for the management of fibromyalgia syndrome were developed using a systematic review and expert consensus.

PMID 17644548  Ann Rheum Dis. 2008 Apr;67(4):536-41. doi: 10.1136/ard.・・・
著者: Don L Goldenberg, Carol Burckhardt, Leslie Crofford
雑誌名: JAMA. 2004 Nov 17;292(19):2388-95. doi: 10.1001/jama.292.19.2388.
Abstract/Text CONTEXT: The optimal management of fibromyalgia syndrome (FMS) is unclear and comprehensive evidence-based guidelines have not been reported.
OBJECTIVE: To provide up-to-date evidence-based guidelines for the optimal treatment of FMS. DATA SOURCES, SELECTION, AND EXTRACTION: A search of all human trials (randomized controlled trials and meta-analyses of randomized controlled trials) of FMS was made using Cochrane Collaboration Reviews (1993-2004), MEDLINE (1966-2004), CINAHL (1982-2004), EMBASE (1988-2004), PubMed (1966-2004), Healthstar (1975-2000), Current Contents (2000-2004), Web of Science (1980-2004), PsychInfo (1887-2004), and Science Citation Indexes (1996-2004). The literature review was performed by an interdisciplinary panel, composed of 13 experts in various pain management disciplines, selected by the American Pain Society (APS), and supplemented by selected literature reviews by APS staff members and the Utah Drug Information Service. A total of 505 articles were reviewed.
DATA SYNTHESIS: There are major limitations to the FMS literature, with many treatment trials compromised by short duration and lack of masking. There are no medical therapies that have been specifically approved by the US Food and Drug Administration for management of FMS. Nonetheless, current evidence suggests efficacy of low-dose tricyclic antidepressants, cardiovascular exercise, cognitive behavioral therapy, and patient education. A number of other commonly used FMS therapies, such as trigger point injections, have not been adequately evaluated.
CONCLUSIONS: Despite the chronicity and complexity of FMS, there are pharmacological and nonpharmacological interventions available that have clinical benefit. Based on current evidence, a stepwise program emphasizing education, certain medications, exercise, cognitive therapy, or all 4 should be recommended.

PMID 15547167  JAMA. 2004 Nov 17;292(19):2388-95. doi: 10.1001/jama.29・・・
著者: Lesley M Arnold, Don L Goldenberg, Sharon B Stanford, Justine K Lalonde, H S Sandhu, Paul E Keck, Jeffrey A Welge, Fred Bishop, Kevin E Stanford, Evelyn V Hess, James I Hudson
雑誌名: Arthritis Rheum. 2007 Apr;56(4):1336-44. doi: 10.1002/art.22457.
Abstract/Text OBJECTIVE: To assess the efficacy and safety of gabapentin in patients with fibromyalgia.
METHODS: A 12-week, randomized, double-blind study was designed to compare gabapentin (1,200-2,400 mg/day) (n=75 patients) with placebo (n=75 patients) for efficacy and safety in treating pain associated with fibromyalgia. The primary outcome measure was the Brief Pain Inventory (BPI) average pain severity score (range 0-10, where 0=no pain and 10=pain as bad as you can imagine). Response to treatment was defined as a reduction of >or=30% in this score. The primary analysis of efficacy for continuous variables was a longitudinal analysis of the intent-to-treat sample, with treatment-by-time interaction as the measure of effect.
RESULTS: Gabapentin-treated patients displayed a significantly greater improvement in the BPI average pain severity score (P=0.015; estimated difference between groups at week 12=-0.92 [95% confidence interval -1.75, -0.71]). A significantly greater proportion of gabapentin-treated patients compared with placebo-treated patients achieved response at end point (51% versus 31%; P=0.014). Gabapentin compared with placebo also significantly improved the BPI average pain interference score, the Fibromyalgia Impact Questionnaire total score, the Clinical Global Impression of Severity, the Patient Global Impression of Improvement, the Medical Outcomes Study (MOS) Sleep Problems Index, and the MOS Short Form 36 vitality score, but not the mean tender point pain threshold or the Montgomery Asberg Depression Rating Scale. Gabapentin was generally well tolerated.
CONCLUSION: Gabapentin (1,200-2,400 mg/day) is safe and efficacious for the treatment of pain and other symptoms associated with fibromyalgia.

PMID 17393438  Arthritis Rheum. 2007 Apr;56(4):1336-44. doi: 10.1002/a・・・
著者: Kenji Kato, Patrick F Sullivan, Birgitta Evengård, Nancy L Pedersen
雑誌名: Arch Intern Med. 2006 Aug 14-28;166(15):1649-54. doi: 10.1001/archinte.166.15.1649.
Abstract/Text BACKGROUND: Chronic widespread pain (CWP), the cardinal symptom of fibromyalgia, is prevalent and co-occurs with numerous symptom-based conditions such as chronic fatigue syndrome, joint pain, headache, irritable bowel syndrome, and psychiatric disorders. Few studies have examined the comorbidities of CWP in the general population. Furthermore, little is known about the importance of familial (genetic and family environmental) factors in the etiology of co-occurrence.
METHODS: Data were obtained from 44 897 individuals in the Swedish Twin Registry via computer-assisted telephone interview from 1998 through 2002 (age >/=42 years; 73.2% response rate). Screening for CWP was based on the American College of Rheumatology criteria without clinical evaluation. Measures for comorbidities were based on standard criteria when available. Odds ratios (ORs) were calculated in case-control and co-twin control designs to assess the effect of familial confounding in the associations.
RESULTS: Considerable co-occurrences were found in CWP cases for chronic fatigue (OR, 23.53; 95% confidence interval [CI], 19.67-28.16), joint pain (OR, 7.41; 95% CI, 6.70-8.21), depressive symptoms (OR, 5.26; 95% CI, 4.75-5.82), and irritable bowel syndrome (OR, 5.17; 95% CI, 4.55-5.88). In co-twin control analyses, ORs were no longer significant for psychiatric disorders, whereas they decreased but remained significant for most other comorbidities. No changes in ORs were observed for headache.
CONCLUSIONS: Associations between CWP and most comorbidities are mediated by unmeasured genetic and family environmental factors in the general population. The extent of mediation via familial factors is likely to be disorder specific.

PMID 16908799  Arch Intern Med. 2006 Aug 14-28;166(15):1649-54. doi: 1・・・

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