FIBROMYALGIA

Dr. Punita Adajania

INTRODUCTIONFibromyalgia is a commonly encountered disorder characterized by chronic widespread musculoskeletal pain, stiffness, paresthesia, disturbed sleep, and easy fatigability along with multiple painful tender points, which are widely and symmetrically distributed.

 Fibromyalgia affects predominantly women in a ratio of 9:1 compared to men.

Newly defined as a disease complex or syndrome.

PREVALENCE Wolfe 1995 reported the prevalence of

FMS (all ages) to be 2% (females 3.4%, males 0.5%).

Prevalence increased with age

It affects an estimated 3.7 million people in the United States (1), and women (most often ranging in age from the mid-thirties to the late fifties) account for more than 75% of patients

THE AMERICAN COLLEGE OF RHEUMATOLOGY CRITERIA: A history of widespread pain for at least 3

months.

Pain is considered widespread when all of the

following are present:

pain in the left and right side of the body

Below and above the waist.

In addition there should be axial pain (cervical

spine or anterior chest or thoracic spine or

low back).

Pain in 11 of 18 tender point sites on digital pressure.

The sites are all bilateral and are situated:

Occiput: bilateral, at the suboccipital muscle insertion

Low cervical: bilateral, at the anterior aspect of the intertransverse spaces at C5–7

Trapezius: bilateral, at the midpoint of the upper border

Supraspinatus: bilateral, at the origin, above the scapular spine near the medial border.

Second rib: bilateral, at the second costochondral junction, just lateral to the junction on the upper surface

Lateral epicondyle: bilateral, 2 cm distal to the epicondyle

Gluteal: bilateral, in the upper outer quadrant of the buttock

Greater trochanter: bilateral, posterior to the trochanteric prominence

Knee: bilateral, at the medial fat pad proximal to the joint line.

SYMPTOMS OTHER THAN PAIN Headache

restless legs

dysmenorrhoea

extreme sensitivity to cold

odd patterns of numbness and tingling

intolerance to exercise

Stiffness

paresthesia

easy fatigability

Palpitations

Irritable bladder

 functional bowel disturbances

chronic sleep disturbances

 impaired concentration

 problems with memory

 inability to multi-task

diminished attention span

anxiety and depressive symptoms

ACR DIAGNOSTIC CRITERIA ACR is proposing a new set of diagnostic

criteria for fibromyalgia that includes common symptoms such as fatigue, sleep disturbances, and cognitive problems, as well as pain.

The tender point test is being replaced with a widespread pain index(WPI) and a symptom severity (SS) score.

Jahan, F., Nanji, K., Qidwai, W., & Qasim, R. (2012). Fibromyalgia syndrome: an overview of pathophysiology, diagnosis and management. Oman medical journal, 27(3), 192–5. doi:10.5001/omj.2012.44

In place of the tender point count, patients may endorse 19 body regions in which pain has been experienced during the past week. One point is given for each area, so the score is between 0-19. This number is referred to as the Widespread Pain Index (WPI)

The second part of the score involves the evaluation of a person's symptoms. The patient ranks specific symptoms on a scale of 0-3. These symptoms include: Fatigue, Waking unrefreshed, Cognitive symptoms, Somatic (physical) symptoms in general (such as headache, weakness, bowel problems, nausea, dizziness, numbness/tingling, hair loss). The numbers assigned to each are added up, for a total of 0-12.Jahan, F., Nanji, K., Qidwai, W., & Qasim, R. (2012). Fibromyalgia syndrome: an overview of pathophysiology,

diagnosis and management. Oman medical journal, 27(3), 192–5. doi:10.5001/omj.2012.44

The diagnosis is based on both the WPI score and the SS score either:

• WPI of at least 7 and SS scale score of at least 5 OR • WPI of 3-6 and SS scale score of at least 9.

Jahan, F., Nanji, K., Qidwai, W., & Qasim, R. (2012). Fibromyalgia syndrome: an overview of pathophysiology, diagnosis and management. Oman medical journal, 27(3), 192–5. doi:10.5001/omj.2012.44

PATHOPHYSIOLOGY

Changes in neuroendocrine transmitters such as serotonin, substance P, growth hormone and cortisol suggest that regulation of the autonomic and neuro-endocrine system appears to be the basis of the syndrome.

Central sensitization, blunting of inhibitory pain pathways and alterations in neurotransmitters lead to aberrant neuro-chemical processing of sensory signals in the CNS, thus lowering the threshold of pain and amplification of normal sensory signals causing constant pain.

The frequent co-morbidity of fibromyalgia with mood disorders suggests a major role for the stress response and for neuroendocrine abnormalities.

stress adaptation response is disturbed.

Can be triggered by physical, emotional or environmental stressors such as car accidents, repetitive injuries and certain diseases

Sleep deprivation with disruption of delta-wave sleep (non-REM stage IV) is associated with day-time fatigue and fibromyalgia syndrome.

FMS could be a neuroendocrine disturbance,particularly involving thyroid hormone imbalances and/or hypophyseal growth hormone imbalances.

Duna & Wilke (1993) propose that disordered sleep leads to reduced serotonin production, and consequent reduction in the pain modulating effects of endorphins and increased ‘substance P’ levels, combined with sympathetic nervous system changes resulting in muscle ischaemia and increased sensitivity to pain (Duna & Wilke 1993).

IMPACT ON WORK & PRODUCTIVITY Researchers have reported an alarming impact of FMS on ability to work and productivity. 20 to 50% of persons with FMS could

work only a few, or no days (Ledingham 1993, Wolfe 1997)

36% had an average of two or more absences from work per month (Martinez 1995)

26.5% to 55% had received disability or social security payments at some time (Wolfe 1997, Martinez 1995).

Many individuals with FMS are sedentary (Clark 1993) and have levels of cardiorespiratory fitness well below average (Clark 1993,Bennett 1989, Burckhardt 1989, Clark 1994).

pain, fatigue and depression are likely to contribute to sedentary lifestyles and therefore low levels of fitness

the studies evaluated suggest that individuals with FMS are able to perform maximal tests of cardiorespiratory fitness, low to moderate intensity aerobic exercise, flexibility and muscle strengthening exercise.

DIAGNOSIS A diagnosis is made by evaluation of

symptoms and presence of tender points American College of Rheumatology

Classification Criteria for Fibromyalgia (1990)…….widespread pain for at least 3 months and pain in 11 out of 18 tender point sites on digital palpation.Both criteria must be satisfied History of widespread pain for more

than 3 months, on both sides of the body, above and below the waist, and axial skeleton (cervical spine, anterior chest, thoracic pain, or low back)

Pain in 11 of 18 tender point sites on digital palpation with approximate force of 4 kg.

X-rays, blood tests, specialized scans such as nuclear medicine and CT, muscle biopsies are all normal

ESR (erythrocyte sedimentation rate) is normal

Fibromyalgia Impact Questionnaire

MANAGEMENT Evidence-based guidelines by the

American Pain Society (APS) for the optimal treatment of FMS.

MEDICATIONS: Strong Evidence for Efficacy(Tricyclic Antidepressant Medications) • Amitriptyline• Cyclobenzaprine• CNS agents, antidepressants, muscle

relaxants, or anticonvulsants are the most successful pharmacotherapies.

NONMEDICINAL THERAPIES

managing stress, depression, pain and life style modification

CBT Patient education Strength training Cardiovascular exercise Acupuncture hypnotherapy biofeedback Balneotherapy

Life Style Modifications: Stress Management: cognitive behavioral therapy relaxation training group therapy biofeedback Exercise: Aerobic exercises pilates Ultrasound Exercising in water

Alternative Therapies: Chinese herbal medications Chinese herbal tea acupuncture Tai-chi yoga

RECENT STUDIES Abnormal electromyographic activity

and reduced muscular sensitivity have been reported in fibromyalgia.

Electromyographic biofeedback training may therefore be a therapeutic option in treating fibromyalgia pain.

RECENT STUDIES Cognitive-Behavioral Treatment: combinations of relaxation training,

meditation, cognitive restructuring, aerobic exercise and stretching, activity pacing, and patient and family education.

Length of treatment ranged from 3 to 24 weeks.

At the end of treatment, improvement was observed in the overall impact of fibromyalgia, pain intensity,number of tender points, emotional distress, and sense of control over pain.

RECENT STUDIES A recent study demonstrated that the

addition of exercise training to biofeedback and relaxation training intervention resulted in significantly greater benefit and longer-lasting improvements than did either treatment alone.

In a controlled study comparing eight sessions of hypnotherapy with physical therapy, patients with refractory fibromyalgia experienced greater benefit from hypnotherapy.

ACSM GUIDELINESCARDIORESPIRATORY ENDURANCE

(AEROBIC TRAINING): DOSAGE: a) frequency of exercise at least 2 days per

weekb) intensity of exercise sufficient to achieve

40 to 85% of heart rate reserve or 55 to 90%predictedmaximum heart rate

c) duration of sessions of at least 20 minutes duration (range 20-60minutes), either as continuous exercise or spread intermittently throughout the day

d) total time period of at least 6 weeks.

ACSM GUIDELINES MUSCLE STRENGTHENING: DOSAGE: a) frequency of 2-3 days per week, b) a minimum of one set of 8-12 repetitions at the 8 to 12 Repetition Maximum of each exercise

ACSM GUIDELINES FLEXIBILITY TRAINING: Controlled static stretching DOSAGE: a) frequency of exercise equal to or greater than two days per weekb) intensity to a position of mild discomfort c) 3 to 4 repetitions for each stretch held for a duration of 10-30 seconds

REFERENCES Fibromyalgia Syndrome:A practitioner’s guide to Treatment,Leon

Chaitow,3rd edition

Jahan, F. et al., 2012. Fibromyalgia syndrome: an overview of pathophysiology, diagnosis and management. Oman medical journal, 27(3), pp.192–5.

Prevalence and characteristics of fibromyalgia in general population.

Don L. Goldenberg, MD; Carol Burckhardt, PhD; Leslie Crofford, M., 2004. Management of Fibromyalgia Syndrome.

Leventhal, L. J. (1999). Management of Fibromyalgia, 850–858.

Busch, A. J., Webber, S. C., Brachaniec, M., Bidonde, J., Bello-Haas, V. D., Danyliw, A. D., Overend, T. J., et al. (2011). Exercise therapy for fibromyalgia. Current pain and headache reports, 15(5), 358–67. doi:10.1007/s11916-011-0214-2

Aj, B., Kar, B., Tj, O., Pmj, P., & Cl, S. (2007). Exercise for treating fibromyalgia syndrome ( Review ), (3).