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Fibromyalgia

• "fibromyalgia" derives from new Latin, fibro-, meaning "fibrous tissues", Greek myo-, "muscle", and Greek algos-, "pain"; thus the term literally means "muscle and connective tissue pain".

Other Terms Used

• Muscular rheumatism

• Fibrositis

• Psychogenic rheumatism

• Neurasthenia

• Fibromyalgia has been recognized as a diagnosable disorder by the US National Institutes of Health and the American College of Rheumatology

Fibromyalgia

• affect 2–4% of the population

• female to male incidence ratio of approximately 9:1

Fibromyalgia Symptoms

• brain fog • insomnia• Digestive distress• joint pains• headaches • depression

Hallmark Symptoms • widespread pain

• extreme fatigue.

• allodynia (a heightened and painful response to pressure)

• Sleep disturbances

• Joint stiffness

Symptoms

• Difficulty with swallowing

• Bowel and bladder abnormalities

• Numbness and tingling

• Cognitive dysfunction

Comorbid with Psychiatric Conditions

• Depression

• Anxiety

• Stress-related disorders

• Posttraumatic stress disorder

What is Fibrofog?

Fibrofog

• Many patients experience cognitive dysfunction, which may be characterized by impaired concentration, problems with short and long-term memory, short-term memory consolidation, impaired speed of performance, inability to multi-task, cognitive overload and diminished attention span.

• Fibromyalgia is often associated with anxiety and depressive symptoms.

Other Symptoms• Myofascial pain syndrome,• Bowel disturbances and irritable bowel syndrome genitourinary

symptoms and interstitial cystitis dermatological disorders,• Headaches• Myoclonic twitches• Symptomatic hypoglycemia. • Pain may also be localized in areas such as the shoulders, neck,

low back, hips, or other areas.• High rates of comorbid temporomandibular joint disorder. • 20–30% of patients with rheumatoid arthritis and systemic

lupus erythematosus may also have fibromyalgia.[26]

Causes

• Psychological

• Genetic

• Neurobiological and environmental factors

Central pain result from

• neuro-chemical imbalances including activation of inflammatory pathways in the brain which results in abnormalities in pain processing

Classification

The International Classification of Diseases (ICD-10) lists fibromyalgia as a diagnosable disease under "Diseases of the musculoskeletal system and connective tissue" and states that fibromyalgia syndrome should be classified as a functional somatic syndrome rather than a mental disorder.

Although mental disorders and some physical disorders commonly are co-morbid with fibromyalgia — especially anxiety, depression and irritable bowel syndrome and chronic fatigue syndrome — the ICD states that these should be diagnosed separately.

Fibromyalgia subtypes.

1."extreme sensitivity to pain but no associated psychiatric conditions" (may respond to medications that block the 5-HT3 receptor)

2."fibromyalgia and comorbid, pain-related depression" (may respond to antidepressants)

3."depression with concomitant fibromyalgia syndrome" (may respond to antidepressants) 4."fibromyalgia due to somatization" (may respond to psychotherapy)

Central Sensitization • This theory proposes that fibromyalgia patients have a lower threshold

for pain because of increased reactivity of pain-sensitive nerve cells in the spinal cord or brain.[1]

• pain in fibromyalgia results primarily from pain processing pathways functioning abnormally. In simple terms it can be described as the volume of the neurones being set too high and this hyper-excitability of pain processing pathways and under-activity of inhibitory pain pathways in the brain results in the affected individual experiencing pain.

• Some of the neurochemical abnormalities that occur in fibromyalgia also regulate mood, sleep and energy, thus explaining why mood, sleep and fatigue problems are commonly co-morbid with fibromyalgia

Psychological factors

• There is strong evidence that major

depression is associated with fibromyalgia

Genetics

• • There is evidence that genetic factors may play a role in the

development of fibromyalgia. For example, there is a high aggregation of fibromyalgia in families

• Monozygotic twins with CWP have a 15% chance that their twin has CWP

• Dizygotic twins with CWP have a 7% chance that their twin has CWP

• The mode of inheritance is currently unknown,

Lifestyle

•

• Stress may be an important precipitating factor in the development of fibromyalgia.

• Fibromyalgia is frequently comorbid with stress-related disorders such as chronic fatigue syndrome, posttraumatic stress disorder, irritable bowel syndrome and depression.[10]

• A systematic review found significant association between fibromyalgia and physical and sexual abuse in both childhood and adulthood, although the quality of studies was poor.[39]

• Poor lifestyles including being a smoker, obesity and lack of physical activity all act to increase the risk of an individual developing fibromyalgia.[3]

• Some authors have proposed that, because exposure to stressful conditions can alter the function

of the hypothalamic-pituitary-adrenal (HPA) axis, the development of fibromyalgia may stem from stress-induced disruption of the HPA axis.[42]

Sleep disturbances

• • In 1975, Moldofsky and colleagues reported the

presence of anomalous alpha wave activity (typically associated with arousal states) measured by electroencephalogram (EEG) during non-rapid eye movement sleep of "fibrositis syndrome" patients.

• By disrupting stage IV sleep consistently in young, healthy subjects, the researchers reproduced a significant increase in muscle tenderness

Physical trauma

• Neck trauma has been reported to increase

the risk of developing fibromyalgia.

PathophysiologyDopamine dysfunction

• The "dopamine hypothesis of fibromyalgia" proposes that the central abnormality responsible for symptoms associated with fibromyalgia is a disruption of normal dopamine-related neurotransmission.

• Dopamine is a catecholamine neurotransmitter with roles in pain perception and natural analgesia.

• There is also strong evidence for a role of dopamine in restless leg syndrome, which is a condition found frequently in patients with fibromyalgia

Serotonin metabolism

• In 1975, researchers hypothesized that serotonin, a neurotransmitter that regulates sleep patterns, mood, concentration and pain, could be involved in the pathophysiology of fibromyalgia-associated symptoms.

• In 1992, decreased serotonin metabolites in patient blood samples and cerebrospinal fluid were reported.

• However, selective serotonin reuptake inhibitors (SSRIs) have met with limited success in alleviating the symptoms of the disorder,

Poly-modal sensitivity

• • Results from studies examining responses to

experimental stimulation suggest that fibromyalgia patients may have heightened sensitivity of the nociceptive system, which senses pressure, heat, cold, electrical and chemical stimulation.

• display an exaggerated wind-up in response to repetitive stimulation and an absence of exercise-induced analgesic response.

Neuroendocrine disruption

• • These changes might result from chronic stress, which, after

being perceived and processed by the central nervous system,

• activates hypothalamic corticotrophin-releasing hormone neurons.

• Chronic overactivity of these neurons could disrupt normal function of the pituitary-adrenal axis and cause an increased stimulation of hypothalamic somatostatin secretion, which, in turn, could inhibit the secretion of other hormones.

Sympathetic hyperactivity

• • Functional analysis of the autonomic system in

patients with fibromyalgia has demonstrated disturbed activity characterized by hyperactivity of the sympathetic nervous system at baseline[78] with reduced sympathoadrenal reactivity in response to a variety of stressors including physical exertion and mental stress.[79][80]

Controversy as to the cause

Rheumatologists, neurologists, and pain specialists tend to view fibromyalgia as a pathology of both biological and neurobiological origin.

Psychiatrists often view fibromyalgia as being a type of affective disorder, and specialists in psychosomatic medicine tend to view fibromyalgia as being somatoform disorder.

Brain imaging studies

• • Evidence of abnormal brain involvement in

fibromyalgia has been provided via functional neuroimaging. The first findings reported were decreased blood flow within the thalamus and elements of the basal ganglia and mid-brain (i.e., pontine nucleus).

Diagnosis -ACR 1990"

• • The most widely accepted set of classification criteria for research purposes

was elaborated in 1990 by the Multicenter Criteria Committee of the American College of Rheumatology.

• A history of widespread pain lasting more than three months—affecting all four quadrants of the body, i.e., both sides, and above and below the waist.

• Tender points—there are 18 designated possible tender points (although a person with the disorder may feel pain in other areas as well). The patient no longer must feel pain at 11 or more of these points for fibromyalgia to be considered.

•

• The ACR criteria for classification of patients were originally established as inclusion criteria for research purposes and were not intended for clinical

• Fibromyalgia is widely under-diagnosed with up to 75 percent of people suffering with fibromyalgia not being diagnosed.

Management

• As with many other medically unexplained syndromes, there is no universally accepted treatment or cure for fibromyalgia, and treatment typically consists of symptom management.

• Prescription medication, • Behavioral intervention, • Alternative and complementary medicine. • Patient education, • Aerobic exercise • Cognitive-behavioral therapy

Psychological therapies

• • Cognitive behavioural therapy (CBT) and related

psychological/behavioral therapies are treatments which have been shown to be have a small to moderate effect in reducing symptoms of fibromyalgia in randomized controlled trials.

• The greatest benefit occurs when CBT is used along with exercise.

•

Medications

• Three medications that have been approved by the FDA for treatment of

fibromyalgia.

• Pregabalin was approved in June 2007, • Duloxetine was approved in June 2008, and

• Milnacipran was approved in January 2009

• The use of NSAIDs are not recommended as first line therapy.

• It can take up to three months to derive benefit from amitriptyline and up to six months to gain maximal response from duloxetine, milnacipran, and pregabalin.

Antidepressants

• Antidepressants are "associated with improvements in pain, depression, fatigue, sleep disturbances, and health-related quality of life in patients with FMS

Anti-seizure medication

• The anti-convulsant drugs gabapentin (Neurontin)[114] and

pregabalin (Lyrica) have been tested in fibromyalgia.

• Gabapentin is approved for use in treatment of neuropathic pain but not in fibromyalgia.

• • Pregabalin – originally labeled for the treatment of nerve

pain suffered by diabetics – has been cleared by the US Food and Drug Administration for the treatment of fibromyalgia.

Opioids

• • Opioids (other than tramadol) have not been studied via randomized

controlled trials, and "should be considered only after all other medicinal and nonmedicinal therapies have been exhausted.

• An analysis of insurance claims by 52,000 fibromyalgia patients showed that 40% had received opioids in any given year (predominantly short-acting agents).[120] As of 2010, there is insufficient evidence to recommend the routine use of opioids in fibromyalgia, and are not recommended as they can worsen mood, such as depression in fibromyalgia, have abuse and dependence potential as well as have a significant adverse effect profile

• Tramadol, a centrally acting analgesic with atypical opioid and antidepressant-like activity, is moderately effective in treating fibromyalgia pain.

Exercise

• • Improves fitness and sleep and may reduce pain and fatigue in some people with

fibromyalgia.

• In particular, there is strong evidence that cardiovascular exercise is effective for some patients.[119]

• Long-term aquatic-based exercise has been proven beneficial as it combines cardiovascular exercise with resistance training.[128]

• However, due to the cold sensitivities of people with fibromyalgia syndrome, aquatic therapy must take place in a warm pool

• Tai chi may result in benefit.

Prognosis

• • Although in itself neither degenerative nor

fatal, the chronic pain of fibromyalgia is pervasive and persistent.

• Most fibromyalgia patients report that their symptoms do not improve over time.

Economics

• • that persons with fibromyalgia used twice as

much pain-related medication as those without fibromyalgia. Furthermore, the use of medications and medical necessities increased markedly across many measures once diagnosis was made.[144]

Controversies

• not completely understood, a diagnosis that sometimes is disputed

• Rheumatologists, neurologists, and pain specialists tend to view fibromyalgia as a pathology due to dysfunction of muscles, connective tissue as well as being due to functional abnormalities in the central nervous system.

• ,psychiatrists often view fibromyalgia as being a type of affective disorder whereas specialists in psychosomatic medicine tend to view fibromyalgia as being somatoform disorder.

• no discrete boundary separates syndromes such as FMS, chronic fatigue syndrome, irritable bowel syndrome, or chronic muscular headaches.

• this considerable symptomatic overlap, some researchers have proposed that fibromyalgia and other syndromes with overlapping symptoms be classified as functional somatic syndromes for some purposes.