1. Dr. Punita Adajania

2. Fibromyalgia 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
syndrome.
as
a
disease
complex
or

3.  Wolfe
1995 reported the prevalence of FMS
(all ages) to be 2% (females 3.4%, males
0.5%).
 Prevalence
 It
increased with age
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

4. 
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).

5. 
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.

6. 
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.

8. 
Headache

Palpitations

restless legs

Irritable bladder

dysmenorrhoea


extreme sensitivity to cold
functional bowel
disturbances

odd patterns of numbness
and tingling

chronic sleep disturbances

impaired concentration

problems with memory

intolerance to exercise

inability to multi-task

Stiffness

diminished attention span

paresthesia


easy fatigability
anxiety and depressive
symptoms

9.  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

10. 
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 019. 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 012.
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

11.  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

14. 
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.

15. 
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 daytime fatigue and fibromyalgia syndrome.

16. 
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).

17. 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).

18.  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.

19. 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.


20. 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


21.  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.

22.  managing
stress, depression, pain and life
style modification
 CBT
 Patient education
 Strength training
 Cardiovascular exercise
 Acupuncture
 hypnotherapy
 biofeedback
 Balneotherapy

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

24.  Alternative





Therapies:
Chinese herbal medications
Chinese herbal tea
acupuncture
Tai-chi
yoga

25.  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.

26.  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.

27. A
recent study demonstrated that the
addition of exercise training to biofeedback
and relaxation training intervention resulted
in significantly greater benefit and longerlasting 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.

28. CARDIORESPIRATORY ENDURANCE (AEROBIC
TRAINING): DOSAGE:
a) frequency of exercise at least 2 days per
week
b) 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.

29.  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

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

31. 
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).