Fibromyalgia

Imad Uthman, MD, MPH, FRCP

The Fibromyalgia Syndrome (FMS)

Definition:
A non-articular, non-inflammatory rheumatic syndrome
characterized by diffuse achiness, stiffness, and
fatigue coupled with an examination demonstrating
multiple symmetrical tender points.

The Fibromyalgia Syndrome (FMS)

Clinical features:
Generalized aches: axial location (neck, chest and lowback).
Diffuse stiffness: worse in the morning, can mimick the AM
stiffness of RA.

Sxs exacerbated by environmental stimuli (Heavy physical

exercise, inactivity, poor sleep, emotional stress, weather
changes, humidity).

The Fibromyalgia Syndrome (FMS)

No laboratory or radiographic abnormalities attributable to FMS.
Other problems seen in FMS include:
Irritable bowel syndrome.
Tension headaches.
Paresthesias.
Sensation of swollen hands.
Fatigue.
Non-restorative or non-refreshing sleep.

Fibromyalgia Diagnostic Criteria

The American College of Rheumatology (ACR) in
1990 established the first diagnostic criteria for
fibromyalgia.
However, in May 2010 it published new provisional
criteria, not to replace the old ones but to address
certain limitations in the 1990 criteria.

1990 Fibromyalgia Diagnostic Critieria

Once other possible conditions were ruled out, a

fibromyalgia diagnosis requires:

Pain on both sides of the body, above and below

the waist, and axial skeleton (cervical spine, anterior
chest, thoracic pain, or low back) present on a more
or less continuous basis for at least three months.
Pain in at least 11 of 18 tender points, which are
specific spots on the body that hurt when pressure is
applied.

ACR classification criteria: fibromyalgia

Pain in 11 of 18 tender point sites on digital palpation with approximate force of 4 kg (test
also for non tender control points (mid forehead, anterior thigh):
Occiput: Bilateral, at the suboccipital muscle insertions.
Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7.
Trapezius: bilateral, at the midpoint of the upper border.
Supraspinatus: bilateral, at origins, above the scapula spine near the medial border.
Second rib: bilateral, at he second costochondral junctions, just lateral to the junctions on
upper surfaces.
Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.
Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.

Greater trochanter: bilateral, posterior to the trochanteric prominence.

Knee: bilateral, at the medial fat pad proximal to the joint line.

Fibromyalgia: tender points (diagram)

Diagnostic criteria for fibromyalgia 2010

The Fibromyalgia Syndrome (FMS)

Etiology:
Etiology is unknown
Some evidence exists that FMS patients have a generalized lower pain
threshold
A number of observational and biologic studies suggest that chronic
widespread pain and fibromyalgia have, in part, a genetic basis .
First degree relatives of patients with FMS are 8.5 times more likely to
have FMS than relatives of patients with rheumatoid arthritis .

The Fibromyalgia Syndrome (FMS)

Pathophysiology:
FM and psychopathology:
A higher prevalence of sexual and physical abuse, drug abuse
and eating disorders in patients with FM compared to controls, thus
supporting the view that psychologically traumatic events may
predispose to to the development of this condition.
The majority of patients do not have an active psychiatric illness,
although major depression is found in 25% of patients and a lifetime
history of major depression in 50% of patients. There is also a greater
family history of depression in fibromyalgia compared to normal controls.

There is no evidence for a specific personality type, such as

obsessive-compulsive disorder, and somatoform disorders are unususal.

The Fibromyalgia Syndrome (FMS)

Pathophysiology:
FM and sleep
With the discovery of a specific sleep abnormality in FM patients,
namely the alpha EEG non-rapid eye movement sleep anomaly
(The low frequency EEG waves of stage 3 and 4 sleep were
interrupted by high frequency alpha waves (alpha wave intrusion),
came the first objective marker that supported the concept that FM
was unrelated to inflammation, muscle tension, and
psychopathology.
This theory was supported by the induction of signs and symptoms
of fibrositis in healthy individuals by stage 4 sleep deprivation that
induced the alpha-delta sleep.

The Fibromyalgia Syndrome (FMS)

Pathophysiology:
FM and muscles
No inflammation in muscles and soft tissues of patients with FM,
biopsies of tender points have revealed no histologic
abnormalities when compared to controls.
At present there is no evidence to suggest that FM patients have
any primary muscle abnormality nor that they suffer from defects
in energy metabolism, however most of them were found to be
physically unfit, and aerobic fitness training was shown to have
some therapeutic value.

The Fibromyalgia Syndrome (FMS)

FM, neurotransmitters :
Serotonin Deficiency: Proposed to be a cause of FM since this
neurotransmitter is known to regulate both pain perception and NREM
sleep.
Endorphins and substance P: were also studied in FM patients.
Endorphins were found to be normal while substance P was shown to be
increased in the CSF of patients with fibromyalgia (increased release in
response to mild nocioceptive stimuli) (one of the many functions of
substance P is to facilitate pain transmission.

The Fibromyalgia Syndrome (FMS)

Despite the numerous abnormalities described in patients with
fibromyalgia, there is as yet no generally agreed upon explanation for the
pathogenesis of the disorder.

The most plausible hypothesis suggests that, in genetically

predisposed individuals, various stressors induce a heightened sense of
pain and hypersensitivity to numerous stimuli

Pathways of pain processing implicated in chronic pain and fibromyalgia

Treatment
Non Phamacological :
Reassurance
Improve sleep
Aerobic exercice
Cognitive behavioral therapy.
Pharmacological (FDA approved):
Pregabalin
Duloxetine
Milnacipran