Fibromyalgia is a disease, which is difficult to diagnose. These slides include ACR criteria 1990 and 2010 with Wide spread pain index(WPI) and Symptom severity score(SSS)

1. FIBROMYALGIA
Dr Amit Kumar Mallik
RIMS, Imphal (INDIA)
09/05/16 1

2. Introduction
Characterized by chronic widespread
musculoskeletal pain associated with considerable
distress, generalized fatigue, disturbance of sleep,
anxiety and depression.
Also known asNeurastheniaor fibrositis
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3.  FM leads to significant decreased function
and work capacity and the quality of life is
seriously affected
 Although defined primarily as pain
syndromes there are associated
neuropsychological symptoms
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4. Epidemiology
Prevalence rate of 2-3%
 Fibromyalgia affects predominantly women in a ratio
of 9:1 compared to men
 Most patients present with fibromyalgia between the
ages of 30–50 years
 This disorder is found in most countries, in most
ethnic groups, and in all types of climate
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5. Proposed etiology of
Fibromyalgia
Emerging evidence of genetic component of FM
- Specific gene mutations may predispose individuals to
FM
- Polymorphism in Catechol O-methyl
transferase(COMT) enzyme gene and serotonin transporter
are potentially associated with FM
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6.  Environmental factors that may trigger the onset of
FM
- Physical trauma and injury
- Infections (hepatitis C, lyme’s disease)
- Psychological stressor
 FM may occur concurrently with arthritis (OA),
autoimmune diseases (RA,SLE)
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7. Pathophysiology
Abnormal pain processing
Hyperalgesia
Allodynia
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8. Mechanism of decrease pain
threshold
•Wind up
•Central sensitization
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9. Wind Up
• Drs. Price and Staud have demonstrated that
increasing repetitive nociceptive stimuli will activate
a wide range of dorsal horn neuronal pain discharges
in the CNS called “wind up”
• Temporal summation of pain on repetitive stimulation
of peripheral nociceptive afferents
Price, D and Staud, R, J Rheumatol 2005:32(75):22-28
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10. • “Wind up” involves recruitment of NMDA pain
receptors in the CNS and neural plasticity of
nociceptive spinal cord pathway in central
sensitization
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11. Central sensitization of FM
patients
• Increased levels of excitatory neuro-transmitters
glutamate and substance P
• Compared with normal controls, CSF levels of
substance P are 3-fold higher in FM patients
• There are decreased levels of serotonin and
norepinephrine which are needed for pain modulation
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12. Neurotransmitters
◦ Substance P, an excitatory neurotransmitter which is
elevated in CSF of FM patients compared with
controls
◦ Glutamate acting at the A and C ascending pain fibersᶞ
1. Russell IJ, et al. Arthritis Rheum. 1994;37:1593-1601. 4. Russell IJ, et al. J Rheumatol. 1992;19:104-109.
2. Vaerøy H et al., Pain. 1988. 32:21-26. 5. Russell IJ, et al. Arthritis Rheum. 1992;35:550-556.
3. Watkins LR, et al. Brain Res. 1994;664:17-24. 6. Fields HL, et al. Annu Rev Neurosci. 1991;14:219-
245.
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13. Serotonin and Norepinephrine
• Serotonin and norepinephrine mediate pain
modulation through the descending inhibitory pain
pathways in the brain and dorsal horn of the spinal
cord
• Dysfunction in fibromyalgia
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14. Clinical features
Pain and tenderness
“ Pain all over” typically above and below the waist
on both sides and involves the axial skeleton
 Neuropshychological symptoms
Fatigue, sleep disturbance, cognitive dysfunction,
anxiety and depression
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15. Overlapping syndromes-
Can overlap in presentation with other chronic
conditions
 Comorbid conditions-
Often associated with chronic musculoskeletal,
infectious, metabolic or psychiatric conditions
 Functional impairment
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16. 09/05/16 16

17. Associated with
• Chronic fatigue syndrome
• Depression
• Irritable bowel syndrome
• Migraine
• Headache
• Irritable bladder
• Temporomandibular joint pain
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18. Diagnostic criteria
The American College of Rheumatology 1990:
(1) A history of widespread pain for 3 month or
more
(2) Pain in at least 11 of 18 defined tender point
sites on digital palpation with a force of 4 kg with
thumb
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19. ACR 201O
• Widespread Pain Index (WPI)
• Symptom Severity Score (SS)
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20. Widespread Pain Index (WPI)
Pain in any of the ff areas in the last 7 days
• R/L Jaw
• Neck
• R/L Shoulder
• R/L Upper Arm
• R/L Forearm
• Upper Back
• Chest
• Abdomen
• Lower Back
• R/L Hip
• R/L Thighs
• R/L Calves
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21. Symptom Severity Score
Somatic Symptoms – Have you had any of the following in the
last 6 months
• Blurred vision
• Tinnitus
• Mouth sores
• Dry mouth
• Headache
• Dizziness
• Fever
• Chest pains
• Dyspnea
• Wheezing
• Anorexia
• Nausea
• Diarrhea
• Constipation
• Itching
• Vomiting
• Easy bruising
• Hair loss
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22. • WPI >7 and SS Score > 5
• WPI 3-6 and SS Score > 9
• Symptoms present for at least 3 months
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23. a. Pain in the right side of the body
b.Pain in the left side of the body
c. Pain above the waist
d. Pain below the waist
e. Trunk and extremities
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24. Sites for control points
• Mid forehead
• Junction of proximal 2/3rd
and Distal 1/3rd
of forearm
• Thumbnail
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25. Sites for elicitation of tender
points
Pain on digital palpation in at least 11 of the following
18 tender point sites
a. Occiput: bilateral, at the suboccipital muscle
insertion
b. Low cervical: bilateral, at the anterior aspect of the
intertransverse spaces at C5–7
c. Trapezius: bilateral, at the midpoint of the upper
border
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26. d. Supraspinatus: bilateral, at the origin, above the
scapular spine near the medial border
e. Second rib: bilateral, at the second costochondral
junction, just lateral to the junction on the upper
surface
f. Lateral epicondyle: bilateral, 2 cm distal to the
epicondyle
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27. • g.Gluteal: bilateral, in the upper outer quadrant of the
buttock
• h.Greater trochanter: bilateral, posterior to the
trochanteric prominence
• i.Knee: bilateral, at the medial fat pad proximal to
the joint line
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28. Tender points
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29. 09/05/16 29

30. Differential diagnosis
 Inflammatory
 Infectious
 Non inflammatory
 Endocrine
 Neurologic diseases
 Psychiatric diseases
 Drugs
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31. Investigations
 Routine
- CBC, ESR, CRP, TSH
 Guided by history and physical examination
-ANA, anti-SSA&SSB, Rh.factor, anti-CCP, CPK,
viral and bacterial serologies, spine and joint
radiographs
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32. Management
Think of FM as a multisystem disorder with multiple
pathways creating dysfunction
◦ Non-restorative sleep
◦ Myofascial pain
◦ Neuromuscular dysfunction/deconditioning
◦ Anxiety and reactive depression
◦ Abnormal pain processing
◦ Excess sympathetic tone and Autonomic
dysfunction
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33. Treatment
Pharmacological treatment
 Antidepressants
- Amitryptiline
- Duloxetine
- Milnacipran
-Fluvoxetine
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34. Anticonvulsants
- Gabapentin
- Pregabalin
Glucocorticoids or NSAIDs are not effective in FM
 Utilization of single agents to treat multiple
symptom domain is strongly encouraged
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35. Non pharmacological treatment
1.Self-management strategies
- Education and active participation with reassurance
2. Multi component therapy
- Comprise of one educational or other psychological
therapy and at least one exercise therapy
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36. Rehabilitation of FM
Pain reduction modalities
•Cryotherapy
•Therapeutic heat
•Administration of local anesthetics
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37. Aerobic and flexibility exercise
• Exercise can activate endogenous opioids and reduce
“wind up”
• Low level of exercise
• Progress slowly
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38. • Begin with gentle warm up
• Low impact aerobic exercise for atleast 3 time wkly
• Target exercise regimen- 4 to 5 times a wk for at least
20-30 minutes every session
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39. Psychological rehabilitation
• Cognitive and behavioral therapy
• Relaxation training
• Biofeedback
• Stress management
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