1. MANAGEMENT OF FIBROMYALGIC
SYNDROME
Prof. A.V. SRINIVASAN
M.D,D.M,PhD,DSc,FIAN,FAAN
Emeritus Professor – The Tamil Nadu
Dr. MGR Medical University

2. OUTLINE
What is Fibromyalgia (FMS)?
What causes it?
Who gets it?
How is it diagnosed?
How is it treated?
What are some of the common misconceptions
about the syndrome?

3. What is Fibromyalgia (FMS)?
A clinical syndrome characterized by
widespread muscular pain (usually
chronic),
fatigue and
muscle tenderness (tender points)

4. What is FMS? (cont.)
Additional symptoms are common and include:
- poor sleep almost always
- headaches
- irritable bowel syndrome
- cognitive and memory problems
“fibro fog”
- numbness and tingling in fingers and toes

5. What is FMS? (cont.)
- irritable bladder
- temporomandibular joint (TMJ) disorder
- restless leg syndrome
- dry eyes and dry mouth
- morning stiffness
- anxiety and depression
Symptoms including pain may wax and wane over
time

6. FMS Symptom Complex
Pain, fatigue, & sleep disturbance are
present in at least 86% patients
ACR Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site. Available at:
http://www.nfra.net/Diagnost.htm. Accessed October 18, 2007.

7. What causes FMS?
Cause is unknown
Abnormally high levels of Substance P in spinal
fluid in some patients
Substance P important in transmission and
amplification of pain signals to and from brain
“Volume control” is turned up too high in brain’s
pain centers

8. What causes FMS? (cont)
Familial tendency to develop FMS suggests
genetic role
Can be triggered by physical, emotional or
environmental stressors such as car accidents,
repetitive injuries and certain diseases
Patients with Rheumatoid arthritis and SLE
(Lupus) are more likely to develop FMS

9. What causes FMS? (cont.)
Other conditions such as Lyme disease and
obstructive sleep apnea (OSA) have been
associated with FMS
Sleep deprivation with disruption of delta-wave
sleep (non-REM stage IV) is associated with
day-time fatigue and
fibromyalgia syndrome

10. Who gets FMS?
Affects as many as 1 in 50 Americans
Most common in middle-aged women
Men and children may also develop the disorder
Patients with RA, SLE and Ankylosing
spondylitis are more likely
Women who have a family member with FMS
are more likely to develop it

11. How is FMS diagnosed?
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

12. ACR classification criteria:
fibromyalgia
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.
Presence of second clinical disorder does not exclude
diagnosis of fibromyalgia.

13. ACR Diagnostic Criteria for FMS
History of widespread pain for at least 3 months
– Pain on both sides of the body PLUS
– Pain above and below the waist PLUS
– Axial skeletal pain
Pain in at least 11 of 18 tender-point sites on digital
palpation
– Thumb Pressure is Applied to 18 tender-point sites
– Until Nail Bed is Starting to Blanch (~ 4 kg of pressure)
Wolf et al. Arthritis Rheum. 1990;33:160-172.

14. Fibromyalgia: tender points
(diagram)

15. How is FMS diagnosed? (cont.)
X-rays, blood tests, specialized scans such as
nuclear medicine and CT, muscle biopsies are
all normal
Objective “markers of inflammation” such as
ESR (erythrocyte sedimentation rate) are normal
Must be distinguished from other common
diffuse pain conditions such as RA, SLE,
Hypothyroidism and Polymyalgia Rheumatica
(PMR)

16. How is FMS treated?
Fibromyalgia is a chronic condition managed
with both medications and physical modalities
Medication therapy is largely symptomatic, as
there is no definitive treatment cure for
fibromyalgia

17. General Recommendations
Fibromyalgia should be recognized as a heterogeneous
condition comprising of a range of symptoms & features
– Effective management should take into account all
these factors
Optimal treatment therefore requires a multidisciplinary
approach with
– Combination of non-pharmacological and
pharmacological treatment modalities
– Tailored according to pain intensity, sleep disturbance,
fatigue & other symptoms, and function
– Associated co-morbidities
– In discussion with the patient

18. Available Treatment Modalities
Mease P. J Rheumatol. 2005; 32 (suppl 75): 6.
Carville, et al. Ann Rheum Dis. Doi:10.1136/ard.2007.071522.
Goldenberg et al. JAMA. 2004; 292: 2388.
Clauw DJ, Crofford LJ. Best Pract Res Clin Rheumatol. 2003; 17: 685.
Arnold LM, et al. Arthritis Rheum. 2007;56:1336-1344.

19. Pharmacological Modalities
Short-Term Long-Term
Drugs Efficacy Efficacy Safety/ Tolerability
Amitriptyline Multiple - Anti-cholinergic, anti-
small RCTs adrenergic, anti-
histaminic, cardiac muscle
suppressant effects
Duloxetine 2 RCTs 1 RCT Insomnia, GI & CV effects
(Pain)
Gabapentin 1 RCT - Dizziness, somnolence,
weight gain
Pregabalin 4 RCTs 1 RCT (pain Dizziness, somnolence,
& function) weight gain
Tramadol 1 RCT - Dizziness, somnolence,
headache, GI effects

20. Stepwise Treatment of
Fibromyalgia
Confirm diagnosis
Identify important symptom domains, their severity,
and level of patient function
Evaluate for comorbid medical and psychiatric
disorders
Assess psychosocial stressors, level of fitness,
and barriers to treatment
Provide education about fibromyalgia
Review treatment options
Arnold LM. Arthritis Res Ther. 2006;8:212. Available online: http://arthritis-research.com/content/8/4/212.
Accessed February 28, 2007.

21. Stepwise Treatment of
Fibromyalgia (cont’d)
As a first-line approach for patients with moderate to
severe pain, trial with evidence-based medications
Provide additional treatment for comorbid conditions
Adjunctive CBT for patients with prominent psychosocial
stressors, and/or difficulty coping, and/or difficulty
functioning
Encourage exercise according to
fitness level
Arnold LM. Arthritis Res Ther. 2006;8:212. Available online: http://arthritis-research.com/content/8/4/212.
Accessed February 28, 2007.

22. How is FMS treated? (cont.)
Current studies suggest that the best
pharmacologic treatment for treating pain and
improving sleep disturbance includes:
- Tricyclic compounds such as cyclobenzaprine
(FLEXERIL) and amitriptyline (ELAVIL)
- Dual reuptake inhibitors such as venlafaxine
(EFFEXOR), duloxetine (CYMBALTA) and
tramadol (ULTRAM)

23. - SSRIs/ antidepressants such as fluoxetine
(PROZAC), paroxetine (PAXIL) and
sertraline (ZOLOFT) for depression and
pain
- Recent studies have shown that the anti-
epileptics (seizure meds) gabapentin
(NEURONTIN) and pregabalin (LYRICA)
have been effective

24. - NSAIDs (non-steroidal anti-inflammatory drugs) such as
ibuprofen and naproxen are generally ineffective
- Long acting opioids (narcotics) generally are not of great
benefit either
- Benzodiazepines such as diazepam (VALIUM) and
clonazepam (KLONIPIN) may be useful for patients with
restless leg syndrome or very severe sleep disturbance
who have not responded to other therapies

25. Other Therapies for FMS
Complementary and alternative therapies have
been used although not well studied in FMS
- Therapeutic massage
- Myofascial release therapy
- Acupuncture

26. Other Therapies for FMS
Patient Self-Management
- Schedule time to relax, including deep breathing
and meditation
- Establish routine for going to bed and waking up
- Aerobic exercise on regular basis
- Self-education i.e. Arthritis Foundation,
National Fibromyalgia Assn.
- Support group
- Cognitive Behavioral Therapy (CBT)

27. Common Misconceptions
Eleven (11) out of 18 tender points needed to
make the diagnosis of FMS
(2005 ACR Classification Criteria)
FALSE
Tenderness can be widespread without tender
points

28. The major symptom in FMS is pain
FALSE
A variety of neurologic abnormalities may
be described including numbness and
tingling of the extremities, cognitive and
memory problems, irritable bowel
symptoms, etc.

29. It’s not a real illness, it’s in the
“patient’s head”
FALSE
A real condition with severe physical effects in
some, although psychologic factors including
depression may be the major determinant of
pain in others

30. The prognosis is “hopeless”
FALSE
Early, aggressive treatment can prevent
physical deconditioning and loss of
function

31. Dedicated to my family
for making everything worthwhile

33. READ not to contradict or confute
Nor to Believe and Take for Granted
but TO WEIGH AND CONSIDER
THANK YOU
MY SINCERE THANKS TO
PFIZER