Download Fibromyalgia

Fibromyalgia
• Definition: chronic widespread musculoskeletal pain syndrome
characterized by chronic diffused pain & tenderness at specific
locations or, “tender points”
• Epidemiology & Risk factors
– 3rd most prevalent rheumatological disorder in USA: affects 3-10% of
population (~6 million people)
– 80% of those afflicted are women between 20-55 yr of age
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Fibromyalgia
• Etiology & pathogenesis: specific cause is unknown!
• Proposed contributing factors include
(1) Changes in levels of “pain-related” neurotransmitters
• Serotonin, norepinephrine, Substance P, nerve growth factor
(2) Immune system function
• Abnormally elevated levels of some cytokines
(3) Sleep disturbances
• Disturbed sleep pattern may be cause rather than symptom
(4) Injury or other medical condition
• Particularly to upper spinal region
• Other disorders such as RA, lupus, or hyperthyroidism
(5) Infection
• Viral or bacterial infection may trigger FM
(6) SNS abnormalities
(7) Changes in muscle metabolism
• Deconditioning & decreased blood flow may contribute to weakness & fatigue
(8) Psychological stress or hormonal changes
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Fibromyalgia
Clinical Presentation
 Chronic aching PAIN: often involves entire body with prominence
around neck, shoulders, low back, hips
 Morning stiffness
• Fatigue
• Sleep disturbance
• Paresthesias in extremities
• Chronic headaches
• Minor exertion aggravates pain & increases fatigue
• Depression & anxiety
• Irritable bowel syndrome
• Varying secondary symptoms: impaired functional ability, poor physical
fitness, social isolation, low self-esteem, poor quality of life (QOL)
• Physical Exam is normal, except for “tender points”…
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Fibromyalgia
 Diagnosis
 Widespread pain for ≥ 3 months, defined as presence of
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Pain on both sides of body
Pain above/below the waist (including shoulder & buttock)
Pain in axial skeleton
Pain on palpation with 4 kg force in 11 of 18 sites (next slide)
• Differential Diagnosis
– Fibromyalgia is a diagnosis of exclusion: no specific lab exam
– Must rule out autoimmune disorders (RA, SLE, polymyalgia rheumatica),
hypothyroidism
– Should not be the diagnosis if fever, weight loss, or other objective signs
are present
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Fibromyalgia “Tender Points”
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Fibromyalgia “Tender Points”
 Sites (shown in previous picture)
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Low cervical (SCM)
Second rib (lateral to 2nd costochondral junction)
Lateral epicondyle (2 cm distal to lateral epicondyle)
Knee (medial fat pad proximal to the joint line)
Occiput
Trapezius (occiput insertion & midpoint of upper border)
Supraspinatus (above scapular spine near medial border)
Gluteal (upper outer quadrant of buttocks, at anterior edge of gluteus
maximus m.)
– Greater trochanter (posterior to trochanteric prominence)
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Fibromyalgia
Treatment Options: Multidisciplinary approach is paramount!
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Patient education (includes self-management of symptoms)
Stress management
Work simplification & ergonomic principles
Psychotherapy
Medications: analgesics, antidepressants, anxiolytics/benzodiazepines
Hypnosis
Acupuncture
Exercise: designed to increase function, decrease pain, and improve/maintain
fitness…
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Fibromyalgia
 General exercise considerations
 Avoid early morning exercise
 Avoid overhead movements & eccentric exercises
 Use large muscle groups for aerobic exercise
 Stop with increased pain or pain secondary to weather
– Low to non-impact such as biking, walking & swimming best
• Aquatic therapy may be ideal low-level progressive exercise program
– Use same guidelines as with any patient who fatigues easily
• Short exercise sessions (possibly only 5-8 minutes initially)
• Goal of 30 min of continuous exercise (2-3 day/wk) may take weeks-months
• Keep intensity ≈50-60% age-predicted HR max
– Flexibility: general stretching for increased tolerance to aerobic exercise &
may also be used for stress relief
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Consider aquatic exercise!
• Aquatic exercise in warm pool 3X per week for 16 weeks improved
most FM symptoms (tender point count, sleep quality, cognitive
and physical function) in 60 females (Munguia-Izquierdo & LegazArrese, Arch Phys Med Rehab, 2008).
• Systematic review of 10 RCTs using hydrotherapy in management
of FM found positive outcomes for pain, health status and tender
point count (McVeigh et al., Rheumatol Int, 2008).
• Links for patients
– http://www.emedicinehealth.com/slideshow_fibromyalgia_friendly_exercis
es/article_em.htm
 http://www.emedicinehealth.com/slideshow_fibromyalgia_pictures/article_
em.htm
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