Fibromyalgia syndrome: preventive, social and economic aspects.
ABSTRACT There many open questions concerning the concept of primary prevention in FM. Diagnostic or classification criteria are not universally accepted, and this leads to difficulties in establishing the onset and duration of the disease. In the case of FM, primary prevention may consist of the immediate care of acute pain or treatment for affective disturbances as we do not have any specific laboratory or instrumental tests to determine risk factors of the disease. The goal of secondary prevention is early detection of the disease when patients are largely asymptomatic and intervention improves outcome. Screening allows for identification of an unrecognized disease or risk factor, which, for potential FM patients, includes analysis of tender points, Fibromyalgia Impact Questionnaire (FIQ), pain location and intensity, and fatigue and sleep complaints. Tertiary prevention inhibits further deterioration or reduces complications after the disease has developed. In FM the aim of treatment is to decrease pain and increase function via multimodal therapeutic strategies, which, in most cases, includes pharmacological and non-pharmacological interventions. Patients with FM are high consumers of health care services, and FM is associated with significant productivity-related costs. The degree of disability and the number of comorbidities are strongly associated with costs. An earlier diagnosis of FM can reduce referral costs and investigations, thus, leading to a net savings for the health care sector. However, every social assessment is closely related to the socio-economic level of the general population and to the legislation of the country in which the FM patient resides.
- SourceAvailable from: Winfried Häuser[Show abstract] [Hide abstract]
ABSTRACT: A new definition of fibromyalgia syndrome (FMS) based on symptoms and without tender points is discussed from a rheumatological viewpoint. The German Fibromyalgia Association (DFV) developed a questionnaire on potential symptoms in FM based on a list of symptoms established by members of the DFV. The questionnaire was sent to all 3,996 members of the DFV. Of the 753 questionnaires 699 were returned (95% women, most frequent age between 50-60 years) and evaluated. The rank order of the most frequent symptoms (>or=97% of the respondents) was muscle pain with varying locations, low back pain, fatigue, morning stiffness, non-restorative sleep, concentration problems, lack of energy, low productivity and forgetfulness. The key symptoms of FM are chronic widespread pain, non-restorative sleep and subjective disabilities. The frequency of general and extra-musculoskeletal symptoms underlines that FMS is more than just a "pain disorder".Der Schmerz 05/2008; 22(2):176-83. · 1.50 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Stress is a state of disharmony, or threatened homeostasis. A stressor could have a psychological origin or a biological origin. Societies have become more intricate with industrialization, and modern individuals try to adapt to the new defiance by forcing their stress response system. The main component of the stress response network is the autonomic nervous system. The present article reviews current knowledge on autonomic dysfunction in fibromyalgia. Sympathetic hyperactivity has been consistently described by diverse groups of investigators. Fibromyalgia is proposed to be a sympathetically maintained neuropathic pain syndrome, and genomic data support this contention. Autonomic dysfunction may also explain other fibromyalgia features not related to pain.Arthritis research & therapy 02/2007; 9(4):216. · 4.12 Impact FactorThis article is viewable in ResearchGate's enriched formatRG Format enables you to read in context with side-by-side figures, citations, and feedback from experts in your field.
that is characterized, in part, by specific tender
ibromyalgia (FM) is a central pain syndrome
points (TPs) in the musculoskeletal system which
are exceptionally sensitive to pressure. Pain, specif-
ically characterized as hyperalgesia and allodynia,
is the cardinal symptom of FM; however, most pa-
tients also experience additional symptoms such
as debilitating fatigue, disrupted or nonrestorative
sleep, functional bowel disturbances, and a variety
of neuropsychiatric problems, including cognitive
dysfunction, anxiety and depressive symptoms (1).
Reumatismo, 2008; 60: Supplemento 1: 70-77
preventive, social and economic aspects
Gli aspetti preventivi, sociali ed economici della sindrome fibromialgica
L. Altomonte1, F. Atzeni2, G. Leardini3, A. Marsico4, R. Gorla5, R. Casale6, G. Cassisi7, S. Stisi8,
F. Salaffi9, F. Marinangeli10, M.A. Giamberardino11, M. Di Franco12, G. Biasi13, G. Arioli14,
A. Alciati15, F. Ceccherelli16, L. Bazzichi17, R. Carignola18, M. Cazzola19, R. Torta20, D. Buskila21,
M. Spath22, R.H. Gracely23, P. Sarzi-Puttini2
1UOC of Rheumatology Hospital S. Eugenio, Rome, Italy;2Rheumatology Unit, L. Sacco University Hospital, Milan, Italy;
3Rheumatology Unit, SS Giovanni e Paolo Hospital, Venice, Italy; 4Rheumatology Unit, Hospital of Taranto, Taranto, Italy;
5Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Italy; 6Department of Clinical Neurophysiology and
Pain Rehabilitation Unit, Foundation Salvatore Maugeri, IRCCS, Scientific Institute of Montescano, Montescano (PV), Italy;
7Rheumatology Branch, Specialist Outpatients’ Department, Belluno, Italy; 8Rheumatology Unit, “G. Rummo” Hospital, Benevento,
Italy; 9Department of Rheumatology, Polytechnic University of the Marche Region, Ancona, Italy; 10Department of Anesthesiology and
Pain Medicine, L'Aquila University, L’Aquila, Italy; 11Ce.S.I. “G. D’Annunzio” Foundation, Department of Medicine and Science of
Aging, “G. D’Annunzio”, University of Chieti , Italy; 12Chair of Rheumatology, University la Sapienza Rome, Rome, Italy;
13Unit of Rheumatology, University of Siena, Siena, Italy; 14Division of Rehabilitative Medicine and Rheumatology, General Hospital
of Pieve di Coriano (Mantua), Italy; 15Department of Psychiatry, L. Sacco University Hospital, Milan, Italy;
16IOV (Veneto Cancer Institute), IRCCS, Department of Pharmacology and Anesthesiology, University of Padua, Italy; 17Department of
Internal Medicine, Division of Rheumatology, S. Chiara Hospital, University of Pisa, Italy; 18S.C.D.U. Internal Medicine I, Department
of Clinical and Biological Science, University of Turin, Italy; 19Unit of Rehabilitative Medicine “Hospital of Circolo”, Saronno (VA),
Italy; 20Department of Neuroscience, University of Turin, A.S.O. San Giovanni Battista of Turin, Turin, Italy; 21Department of Medicine
H, Soroka Medical Center and Faculty of Health Sciences, Ben Gurion University, Beer Sheva, Israel; 22Friedrich-Baur-Institute,
University of Munich, Munich, Germany; 23Department of Medicine, University of Michigan Health System, Ann Arbor, Michigan USA
Piercarlo Sarzi-Puttini, MD
Director of Rheumatology Unit
L. Sacco Hospital, Milan, Italy
Diversi sono i problemi associati al concetto di prevenzione primaria nella FM. I criteri diagnostici o classificativi
non sono universalmente accettati e risulta difficile stabilire l’esordio e la durata della malattia. Nel caso della FM,
la prevenzione primaria potrebbe essere intensa come il trattamento del dolore acuto o dei disturbi affettivi data la
mancanza di test di laboratorio o strumentali specifici predittivi per lo sviluppo della FM. L’obiettivo della preven-
zione secondaria è nei pazienti ancora sintomatici la diagnosi e il trattmento precoce. Lo screening consente nei pa-
zienti che possono sviluppare la FM, di identificare la malattia latente o i fattori di rischio quali i TPs, il Fibromyal-
gia Impact Questionnaire (FIQ), l’intensità e la sede del dolore, l’astenia e disturbi del sonno. Per prevenzione ter-
ziaria si intende trattare la malattia al fine ridurne la disabilità e le possibili complicanze. Gli obiettivi terapeutici so-
no il controllo del dolore e miglioramento della funzionalità attraverso trattamenti farmacologici e non. I pazienti af-
fetti da FM determinano un utilizzano notevole delle risorse sanitarie, e conseguentemente un aumento della spesa
sanitaria. Il grado di disabilità e il numero delle malattie associate determina un marcato aumento dei costi. La dia-
gnosi precoce permettebbe di ridurre i costi e il numero delle indagini, consentendo un risparmio effettivo da parte
del sistema sanitario nazionale. Tuttavia, l’intervento sociale è strettamente correlato con il livello socio-economico
della popolazione generale e la legislazione del paese nel quale il paziente risiede.
Reumatismo, 2008; 60: Supplemento 1: 70-77
Fibromyalgia syndrome: preventive, social and economic aspects
(e.g., physical or psychological trauma); or it can
begin with localized pain (e.g., neck or low-back
pain) and develop further through pain amplifica-
tion (8, 9).
One major problem with primary prevention stems
from the simple fact that no markers of disease ex-
ists; a variety of clinical symptoms can be present
at onset and chronic widespread pain may or may
not develop into FM as defined by the 1990 ACR
In conclusion, the goal of primary prevention is to
reduce the incidence of FM in a population that
may have a diathesis toward developing FM but
has not presented with symptoms. This can be ac-
complished through diet and exercise, prevention
and cure of trauma, prevention and cure of anxiety
and depression, and finally, immunization against
viruses and bacteria (Table I).
Secondary prevention of fibromyalgia
The U.S. Guide of Clinical Preventive Services
(Ed. 1996) describes secondary prevention mea-
sures as those that “identify and treat asymptomatic
persons who have already developed risk factors or
preclinical disease but in whom the condition is
not clinically apparent”.
The purpose of screening is to identify an unrec-
ognized disease or risk factor (10). In general,
screening tests include history (e.g., asking if a pa-
tient smokes), physical examination (e.g., blood
pressure determination), lab tests (e.g., serum cho-
lesterol level) and procedures (e.g., colonscopy).
Such tests are not intended to be diagnostic and
should not be performed unless the patient and the
clinician are committed to further investigation and
treatment of abnormal results.
For patients in whom FM is suspected, preventive
strategies should be performed to identify risk fac-
tors or predictors of chronicity.
Table I - Predictors for chronicity (fibromyalgia) in recurrent wide-
Recurrent pain episodes
Pain reports from other locations
Trigger and tender points
Women are the most affected and the disease has
a familial connection that is linked to the genetic
variance of serotonin, dopamine and catecholamine
intra-cerebral system (2). The physical symptoms
of FM often express themselves in conjunction
with psychological conditions, which causes a re-
duction in the individual capacity to tolerate stres-
Despite some criticism, the diagnosis for FM is
based on the American College of Rheumatology
(ACR) 1990 criteria, which require a specific his-
tory (widespread pain lasting more than three
months, sleep disturbance, debilitating fatigue,
paresthesia) and tenderness to light touch
(4 kg/cm2)of at least 11 of 18 specific tender points
PREVENTION OF FIBROMYALGIA
FM has a general population prevalence of 2-4 %,is
more common among females than males (5), and
results from a combination of genetic aspects and
stressful events. Prevention may occur in clinical,
community or population settings and is often clas-
sified into primary, secondary and tertiary types.
Primary prevention of fibromyalgia
In general, primary prevention includes measures
that help avoid onset of a given health care prob-
lem (6, 7). In the case of FM, primary prevention
might include immediate care of acute pain
episodes and of somatoform disturbances. At pre-
sent, specific laboratory or instrumental markers
of FM do not exist, and many open questions re-
main concerning the concept of primary prevention
Over time, several issues have arisen with the ex-
isting diagnostic or classification criteria: a) crite-
ria are not likely to be applied uniformly by un-
trained assessors; b) patients may have the requi-
site TPs and yet not have FM; and c) TPs and wide-
spread pain do not capture the essence of FM; this
disorder is known for its multiple and varying
symptoms, which include fatigue, sleep distur-
bance and cognitive dysfunction, predominantly.
The road of onset and development of FM can be
long and winding. In fact, there are a variety of
different clinical histories that can describe the FM
road: a female FM patient may develop headaches
and dysmenorrhea in her 2ndor 3rddecade of life
and present with widespread pain and tenderness
later in life; FM can also start after a stressful event
L. Altomonte et al.
In a clinical setting special attention should be paid
to previous pain episodes, pain reports from vari-
ous locations on the body, tender points, distress,
somatisation, fatigue, and sleep disturbances. Pres-
ence of these symptoms may predict development
of chronic pain (8, 9).
The development and persistence of chronic mus-
culoskeletal pain may also be predicted by several
socio-demographic, lifestyle and psychosocial risk
Family history of chronic pain, low educational
level, low socioeconomic group and lack of social
support are other common risk factors.
Some ethic groups and immigrants have also been
shown to have an increased risk for development
of chronic pain (11).
Smoking, sedentary lifestyle and obesity are pre-
dictive factors that could be targets for intervention
A number of stressors have been temporally cor-
related with the onset of the syndrome, including
trauma, infection (e.g., hepatitis C virus, HIV, Ly-
me disease), emotional stress, catastrophic events
(e.g., war), autoimmune diseases and other pain
conditions (13, 14).
In conclusion, the goal of secondary prevention is
to facilitate early detection of disease development
when patients are asymptomatic and intervention
improves outcome. Early detection methods for
FM patients include analysis of tender points, Fi-
bromyalgia Impact Questionnaire (FIQ), pain lo-
cation and intensity, fatigue and sleep complaints
Tertiary prevention of fibromyalgia
Tertiary prevention inhibits further deterioration or
reduces complications after the disease has de-
clared itself. In FM the aim of treatment is to man-
age symptoms, specifically, to decrease pain and in-
crease function, via multimodal therapeutic strate-
gies, which, in most cases, include pharmacologi-
cal and non-pharmacological interventions (17,
18). As FM patients typically present with complex
symptoms and co-morbid conditions, they cannot
be managed realistically by primary care providers,
alone, but require the assistance of multidiscipli-
nary teams with expertise in a variety of physical,
cognitive, behavioural and educational strategies
In conclusion, prevention strategies for FM may be
of paramount importance. In fact, since no cure is
currently available, primary and secondary pre-
vention strategies may greatly reduce the preva-
lence of this syndrome. Tertiary prevention will
enable patients to implement therapeutic ap-
proaches as early as possible, to monitor the results
and to prevent the secondary effects of chronic
widespread pain and the ancillary symptoms.
The economic impact of fibromyalgia
Few studies have analyzed the economic impact of
FM in terms of costs of disease and pharmacoeco-
Aliterature search using keywords “Fibromyalgia”
and “Costs and Cost Analysis” identified only 51
publications; of these, only 9 addressed pharma-
coeconomic aspects (19-27) and 8 addressed dis-
ease costs both as direct costs, i.e., charged to pub-
lic health systems and to patients for diagnosis and
medical assistance, and as indirect costs, i.e., fi-
nancial consequences of reduced productivity by ill
patients (28-35). No publications analyzed the cost
or consequence of reduced quality of life for pa-
Over the last decade, the annual direct costs of FM
have increased considerably. Today, these costs
range between 4.500 and 7.500¤ per patient (28-
35). The variability in this range is due to different
methods being used to evaluate costs in different
years and in different socio-economic conditions of
FM patients. The same study, however, concludes
that the most important determinant of costs are co-
morbidities, subjective and objective health state,
emotional state and social conditions of the patient
(21, 24, 28).
Health costs comprise about 1/3 of direct costs, a
proportion that is accompanied by several causes
for concern. First, the cost of admission to the hos-
pital for diagnosis can have a significant impact on
overall costs due to the complexity of the clinical
Second, therapy can be quite expensive given the
overall poor response to treatment among many
patients (31, 32, 35). The lack of validated thera-
peutic protocols may explain the frequent use of
physiotherapy or alternative therapy without a cor-
responding increase in costs for the public health
Social support, whether support groups or person-
al networks, and education programs are inexpen-
sive and useful avenues for facilitating psycholog-
ical well being and optimizing available health re-
The indirect costs of FM range between 2.000 to
7.000 € per patient per year. Only one of three
economic studies in our search indicated that the
Fibromyalgia syndrome: preventive, social and economic aspects
indirect costs of FM were higher than the direct
costs, as is generally the case for other rheumatic
diseases (31, 32, 35).
If the body of literature for disease costs seems in-
sufficient for FM, the pharmacoeconomic litera-
ture is even more inadequate. The majority of these
studies have described the methodology of inves-
tigation rather than analysed the specific expenses
(19-25). Conclusions are not definitive and it is not
possible to define the best investment. The justifi-
cation for this is that well-defined indicators for
evaluating achievement of predetermined goals or
validated therapeutic protocols were not available.
Further, improvements from a specific therapy
were too short-lived to draw meaningful conclu-
sions (23, 26, 27).
Disability and employment in FM patients
It is difficult to assess disability and employment
in FM patients, given the limited data in the scien-
tific literature. Every social assessment is closely
related to the socio-economic level of the general
population and to the legislation of the country in
which the FM patient lives.
In clinical investigations, FM is well known and
studied; the case worker, however, is accustomed
to evaluating laboratory and physical data objec-
tively and may have reasonable doubts in evaluat-
ing the FM patient for insurance purposes and abil-
ity to work.
Therefore, it is understandable that there may be
fundamental differences in the assessment of dis-
ability and employment between Italy and other
countries, just as it is understandable that there may
be differences between the clinical and medical-le-
gal evaluation of FM patients.
Several difficult issues cloud the ability to estimate
the effect of FM in Italy with accuracy. The first is-
sue is the fundamental recognition of disease: Is
FM universally recognized by physicians or is it
identified with other diseases? How many diag-
noses of osteoarthtritis (OA) or how many depres-
sive syndromes or cases of “early arthritis” over-
lap with FM in clinical practice?
The second issue is the comparison of statistical da-
ta. In Italy, it is difficult to compare data from cen-
tralized databases that are involved in different as-
pects of public health: ISTAT (Central Statistic In-
stitute) (36), Ministry of Health, INPS (National In-
stitute of Social Insurance) (37), INAIL (National
Board for the Insurance against Accidents in In-
dustrial Work, responsible for occupational dis-
The ISTAT manages data from sample surveys re-
garding the influence of chronic diseases; and it
suggested the atypical classification of “osteoarth-
ritis-arthritis” that combines diseases which are
substantially different. FM has no place in this clas-
sification despite its significant incidence among
rheumatic diseases and chronic diseases. This in-
cidence of FM has been reported in Italian clinical
studies and has been confirmed in the internation-
al scientific literature.
INPS and INAIL do not include FM in their sta-
tistical data concerning the granting of partial and
total disability as paid by the two larger Italian pub-
lic insurance institutes.
In 1980, the International Classification of Impair-
ments (ICF), Disability and Health (ICDH) in-
cluded distinctions between impairment, disabili-
ty and handicap. In 2001, a new International Clas-
sification of Functioning (ICF), Disability and
Health was officially endorsed by 191 World
Health Organization Member States during the
54th World Health Assembly as “the international
standard to describe and measure health and dis-
ability” (38). The general aim of ICF is to develop
a common metric system to describe and measure
individual health conditions and contextual factors,
which are described by physical, individual, and
social perspectives and divided into Functions,
Bodily Structures, Participation and Activity. Fur-
thermore, the classification accounts for the envi-
ronmental factors that can impact the individual’s
life and interact to determine disability, and it is de-
fined as the consequence or the result of a complex
relationship between the health conditions, per-
sonal factors and environmental factors represent-
ing the circumstances where the individual lives.
ICF does not simply view disability only as a
“medical” or “biological” dysfunction; rather, it
provides a mechanism to document the impact of
the social and physical environment on a person’s
The clinical evaluation of disability involves spe-
cific assessments such as the FIQ (40), which has
been validated in Italy (15). Nevertheless, it is dif-
ficult to apply this and other evaluations in legal
medicine, especially if they do not refer to labora-
tory data. Then the claim of disability can lead to
additional difficulty for the FM patient if she ex-
periences negative feedback from official Institu-
tions that may not recognize the illness.
Aside from chronic pain, the FM patient may com-
plain of various, specific symptoms that may re-
duce work performance of the subject. For exam-
L. Altomonte et al.
ple, weakness and susceptibility to fatigue are sig-
nificant in manual laborers , morning stiffness in
subjects who begin working early in the morning,
such as farm workers, can be debilitating to their
livelihood; Raynaud phenomenon can pose severe
challenges to operators who are exposed to sudden
changes of temperature. Patients who work in ex-
ternal environments can be severely affected by
many weather elements such as wind, cold, and
rain. Several epidemiological surveys performed
in recent years in Great Britain and in Scandinavia
demonstrated that FM is greatly disabling and may
lead to early termination of employment, regardless
of whether this was voluntary or dictated by a med-
In Italy, FM is not recognized as a disabling illness
by Insurance Disability (ID), Pensionable Disabil-
ity (INPS) or Accident or Professional Illness (IN-
AIL). FM is not listed in the ID table of accepted
illnesses; therefore, the clinician or medical exam-
iner may refer only to illnesses that are, in a sense,
“equivalent” to FM and are included in the assess-
ment table such depressive syndrome and anxiety,
or neurosis with varying degrees of severity. It is
necessary to indicate comorbidity among illnesses
(e.g., FM with anxious syndrome or depressive
The same is true in INPS Pensionable Disability,
although it must be said that this social Institute
grants hydrotherapy for extra-articular rheumatic
diseases, including FM. With regard to hydrother-
apy we notice that INPS is granted to regular enti-
tled workers as a prevention of pensionable dis-
ability and not as non-pharmacologic therapy. In
INAIL, FM is not recognized as an industrial in-
jury or an occupational disease, and hydrotherapy
is not granted.
For some years, however, INAIL has given special
attention to working musculoskeletal disorders
(WMSD) that developed from both “heavier” la-
bor, as the manual handling of cargo, and “lighter”
labor, as the poor posture or repetitive movement
(RSI Repetitive Strain injury) of assembly line
workers, monitor operators, check-out clerks (see
Legge 626/94 Title V).
In INAIL it would be useful to compare WMSD in
a population that is not affected by FM versus FM
patients in whom it has been reported that symp-
toms often get worse as a result of having bad pos-
ture or disregarding ergonomics rules. Visitors to
the institutional INAIL site can download a useful
guide for WMSD (41). The next evaluation of dis-
ability and employment in FM could target differ-
ent populations such as housewives and students,
Afinal consideration, which is also a concrete, pos-
itive issue, comes from the Main Office in Health
Plan of Ministry of Health contemplated the pro-
posed inclusion of FM in Decree 329799 on chron-
ic disease, as a result of the criteria provided by De-
cree 124/98 (severity, chronicity and economic bur-
den). It could be a first step towards a new ap-
proach to the medico-legal evaluation of FM.
Table II lists web data with regard to the number of
hits from various search engines using certain terms
from this chapter; web search dated 12/02/08.
Patient associations, mass media and internet
Although fibromyalgia is a reasonably common
clinical condition, it is often left undiagnosed. Un-
fortunately, this syndrome is not well known to the
general practitioner or to physicians, in general.
Many patients have suggested the diagnosis to their
doctor after they have discovered the syndrome on
the internet or after the reading about it in maga-
zines or newspapers.
Prior to diagnosis, FM patients will often undergo
many specialist consultations, laboratory exami-
nations, instrumental examinations and pharmaco-
Patients are often frustrated by the lack of diagno-
sis and the meager credibility that physicians and
other family members assign to symptoms. Often,
Table II - Web hits from a search of the following terms and search
engines conducted on 12/02/08.
Google (Italian pages)
Early arthritis 1.900
INAIL (Internal internet search)
Rheumatoid arthritis 1
INPS (Internal internet search)
Early arthritis 0
Fibromyalgia syndrome: preventive, social and economic aspects
self-assessment loses its credibility for patients
who face disbelief from others and quickly become
vulnerable to depression.
In such cases, the satisfaction of a clear diagnosis
begins as relief from the fear of an occult neopla-
sia, but evolves to anger for the unnecessary time
spent researching this easy diagnosis, for the mon-
ey spent without benefit and, finally, for the lack of
recognition of this disease.
This aspect, in particular, gives patients a strong
motivation to participate in organized volunteer as-
Voluntary participation in patient associations is
not only a social obligation to encourage ac-
knowledgement of FM but also a new social en-
deavor with a substantial therapeutic benefit.
The primary mission of patient associations is to
defend patient rights. The main entities to address
are governing medical Institutions (Ministry of the
Health, regional Councillor of the Health, Local
Health Committee, Hospital Committee and
Rheumatology Units), and the main goal is to gain
acknowledgment of FM as a clinical entity and as
a rheumatic disease (43). A search of the Ministry
of Health website of using the terms, “fibromyal-
gia” or “fibromyalgic” did not yield any results. At
present, the only region that recognizes FM is the
The main request that FM patient associations have
for the Institutions includes exemption for expens-
es for pathology,the specialized consultations nec-
essary for diagnosis, for follow-up and monitoring,
for rehabilitation and for the purchase of specific
From Rheumatologists, patient associations request
specific outpatient activity for FM patients and co-
ordination of other professional specialists that are
beneficial to the care of the FM patient, in partic-
ular, psychologists and physiotherapists. Patient
associations may also provide information to physi-
cians and to the public. They may also request that
in-depth study of FM be provided in Rheumatol-
ogy and Internal Medicine courses at the Univer-
The Associations promote collaboration between
rheumatologists, general practitioners and other
specialists for the early diagnosis of FM, which
can be achieved via regular meetings sponsored
the by Local Health Committee. For easy admit-
tance to gymnasiums and pools for patients to par-
ticipate in aerobic exercise programs (44, 45), par-
ticipation of the Local Sport Committee is impor-
tant. Patient associations monitor information on
the internet to protect patients against speculative
or incorrect information.
The fundamental solidarity of patient associations
promotes the sense of community and connection
among patients. Patient associations promote local
meetings and also take advantage of electronic me-
dia, like chat rooms, discussion forums and self-
help group training (46).
To consolidate their power, FM patients may con-
sider themselves as rheumatic patients and coordi-
nate their voluntary associations with the national
associations of rheumatic patients; for example,
The Italian Association of FM is supported by the
National Association of Rheumatic Patients and by
the Italian Rheumatology Society.
Internet and Media
One of the most significant examples of coordina-
tion of information, research, care and voluntary
association came from the USA.
The ACR website offers information both to doc-
tors and to patients (47); and it highlights the
Rheumatology Units and the Rheumatologists of
reference along with links to the principal patient
associations (48, 49) and the National Institute of
Health (NIH). In this virtual strategy, the ACR in-
forms the medical, scientific and public communi-
ties about scientific progress; the NIH manages and
funds research projects; and the associations help
patients through community initiatives, public
awareness and collection of resources for research
This example is not followed in Italy, however;
with the exception of Rheumatology Units’ web-
sites and the official Italian Association of Fi-
bromyalgia Syndrome (51), where scientific infor-
mation is available without taking advantage of the
patient news, we can find news that is without sci-
entific merit, is exaggerated or is directed at sell-
ing products without regulatory oversight. People
who suffer from an illness often believe in mirac-
ulous cures (e.g., surgical or other alternatives to
drugs) that are not supported with any scientific
Scientific societies and patient associations are
watchful and denounce deceptive publicity of such
treatments, but an official medical effort is neces-
sary to control or monitor nonconventional medi-
cines that may be useful for FM patients. It is im-
portant to encourage Rheumatology Units to con-
sider meditation techniques and complementary
L. Altomonte et al.
treatments derived from traditional Chinese medi-
cine or from other disciplines.
Finally, a website developed by Dr. Weiss (52) pro-
vides interesting, evidence-based, accepted infor-
mation for FM patients This site provides a video
of exercise and muscle relaxation techniques that
patients can learn and use at home on TV; in addi-
tion, the site provides evidence for the positive ef-
fects crio-therapy on pain perception in FM pa-
Prevention may occur in clinical, community or
population settings and is often classified into pri-
mary, secondary and tertiary types. Few studies
have analyzed the economic impact of FM in terms
of costs of disease and pharmacoeconomic balance.
The internet is one of the most significant exam-
ples of coordination of information, research, care
and voluntary patient advocacy of FM.
There many open questions concerning the concept of primary prevention in FM. Diagnostic or classification criteria
are not universally accepted, and this leads to difficulties in establishing the onset and duration of the disease. In the
case of FM, primary prevention may consist of the immediate care of acute pain or treatment for affective disturbances
as we do not have any specific laboratory or instrumental tests to determine risk factors of the disease. The goal of sec-
ondary prevention is early detection of the disease when patients are largely asymptomatic and intervention improves
outcome. Screening allows for identification of an unrecognized disease or risk factor, which, for potential FM pa-
tients, includes analysis of tender points, Fibromyalgia Impact Questionnaire (FIQ), pain location and intensity, and
fatigue and sleep complaints. Tertiary prevention inhibits further deterioration or reduces complications after the dis-
ease has developed. In FM the aim of treatment is to decrease pain and increase function via multimodal therapeutic
strategies, which, in most cases, includes pharmacological and non-pharmacological interventions. Patients with FM
are high consumers of health care services, and FM is associated with significant productivity-related costs. The de-
gree of disability and the number of comorbidities are strongly associated with costs. An earlier diagnosis of FM can
reduce referral costs and investigations, thus, leading to a net savings for the health care sector. However, every social
assessment is closely related to the socio-economic level of the general population and to the legislation of the coun-
try in which the FM patient resides.
Key words - Prevention, economic aspects, screening, disability.
Parole chiave - Prevenzione, aspetti economici, screening, disabilità.
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