Fibromyalgia:

Is there a way-out of
The Maze?
Dr Jagbir Singh
MD ; MIRA
Senior Consultant [Trained in R h e u m a t o l o g y ]
A R C & P A R C C l i n i c s , Bilaspur, C.G.
 I n t r o d u c t i o n and a D e f i n i t i o n
F i b r o m y a l g i a is a chronic disorder

that causes P a i n & T e n d e r n e s s t h ro u g h o u t the body,

Feel F a t i g u e d and have Tro u b l e S l e ep i n g .

Found in 2% (1%-5%) of General population ………………………………….

20% - 30% of Pts of
Causes – Mostly Unknown RA
• Car Accidents, E m o ti o n a l S t r e s s Heightened

???
• Post-Traumatic Stress Disorder (PTSD)
• Repetitive injuries. Sensitivity
• Injury from repetitive stress on a joint,
to
such as frequent knee bending.
• Illness (such as viral infections) Pain
 Heightened sensitivity to pain

Allodynia

Hyperalgesia
 The Pain Threshold in Fibromyalgia
S u b j e c ti v e P a i n I n t e n s i t y Pain in Normal Pain
FibroMyalgia Response

A mere Pin-prick
Feels like Stabbing Hyperalgesia

Normal Handshake
becomes Painful Allodynia

A B C

S ti m u l u s I n t e n s i t y
 Fibromyalgia : Much more than just a PAIN
We i g ht G a i n C h e st Pa i n Dizziness
C h ro n i c 1 8 Te n d e r
A nx i e t y &
Headache Po i nt s
D e p re s s i o n
Nausea Insomnia

IBS C o g n i ti ve
I m p a i r m e nt
M u s c l e Pa i n (F i b r o F o g )
Morning
S ti ff n e s s Fe e l i n g C o l d
S e n s i ti v i t y
Dry to Lights Blurry
Body Aches
Fati g u e Eye s & Sounds Vision
 Fibromyalgia : Much more than just a PAIN
We i g ht G a i n C h e st Pa i n Dizziness
A l w a yCsh rot nhi ci n k o f F1 8i bTernod em r ayalgia
A nx i e t y &
Headache Po i nt s
If the symptoms are Not only D e p re s s i o n
Nausea Insomnia
v e r y Va g u e a n d s e e m U n r e l a t e d
IBS C o g n i ti ve
I m p a i r m e nt
M u s c lB u ti n
e Pa are very Elaborate as well
(F i b r o F o g )
Morning
S ti ff n e s s … … . . … .To o s e n s i ti v e t oFe e l i n g C o l d
S e n s i ti v i t y
Dry to Lights Blurry
Body Aches
Fati g u e t o oEyems a n y t h i n gVsi s i …
& Sounds o n… … .
 History of what we call FIBROMYALGIA
today
?? Muscular Central ? Auto-Immunity ?
Te n d e r - P o i n t s
R h e u m a ti s m ? ? S e n s i ti z a ti o n
Neuro-
- I n fl a m m a ti o n
Fibrositi s Fibromyalgia

1990s (Pain)
2012 (RA) 1994/
PAST 1904 1972 1976 FUTURE
2014 (FMS) 2021 (FMS)

Because of the presence of varied Non-Musculoskeletal Symptoms,

F i b ro m y a l g i a … … … . s h o u l d a c t u a l l y b e c a l l e d

Fibromyalgia Syndrome (FMS)

Is there a way out of this Maze of FM?
• M u l ti p l e E n t r y P o i n t s
Symptoms
• M u l ti p l e E x i t P o i n t s
Management
• M u l ti p l e R o u t e s
Pathophysiology

Central N e u ro - I n fl a m m ati o n
/ ? ? A u to - I m m u n i t y
S e n s i ti z a ti o n
 I………………
n t e g r a ti o n
The Central Sensitisation In Fibromyalgia … &
I n t e r p r e t a ti o n
Musculoskeletal pain:
1. N o c i C E P T I V E pain Central
NociPLASTIC-

Combination
( Inflammatory/ Structural ) S e n s i ti s a ti o n
T R A U M A / A RT H R I T I S
Pain (3rd Pain)
2. N e u r o p a t h i c pain
DM / Herpes Zoster

3. N o c i P L A S T I C pain (2016)
Noxious
A n y C H R O N I C PA I N ( O A / R A ) S ti …..
mulus
M o d u l a ti o n
Fibromyalgia

P a i n P H E N O T Y P I N G may …………………
NociCEPTIVE-Pain
influence what pain management T r …………………
a n s d u c ti o n

T…………………
ransmission

treatments are best suited for Neuropathic-Pain

Spectrum of Central Sensitisation

Does
a l l C h r o n i c P a i n c o n d i ti o n s
have
similar degree of
C e n t r a l S e n s i ti s a ti o n ? . .
 Spectrum of Central Sensitisation
……………………………………………………………….

…………………………………………………………………………………
,,,

Mild / Few Moderate/Some Severe / Most

….
…..
H o w d o w e d i a g n o s e F I B R O M YA L G I A ?

• ACR 1990 Diagnostic Criteria for FMS

• ACR 2010 Diagnostic Criteria for FMS

• ACR 2011 modified Diagnostic Criteria for FMS

• ACR 2016 modified Diagnostic Criteria for FMS

• ACTTION-American Pain Society Pain Taxonomy (AAPT) criteria

• Modified 2019 Fibromyalgia Assessment Status (FAS) criteria

ACR 1990 Fibromyalgia Classification Criteria

n ’s
i c i a
y s o n
P h a ti
i n
x a m e d 11 out of 18
E a s
b Te n d e r p o i n t s
 Modified ACR 2010 Diagnostic Criteria for FMS
,,,………………,,,,,

m s
t o
m p d
S y s e
B a Te n d e r p o i n t s N O T r e q u i r e d

S e l f a d m i n i s t e r e d Q u e s ti o n n a i r e

Concept of “WideSpread Pain” (5/5)

Other Mimics MUST BE RULED-OUT

ACR 2016 F i b r o m y a l g i a
D i a g n o s t i c Criteria

1. Widespread pain index (WPI) > 7 4-6

Musculoskeletal
Symptoms
Or
Symptom Severity Score (SSS) > 5 >9

Non-
2. Generalised pain Pa i n i n 4 / 5 re g i o n s
-Musculoskeletal
Symptoms
3. Symptoms duration > 3 months A l l t h r e e C r i t e r i o n m u s t b e f u l fi l l e d
NO LONGER
a D iagnosis of EXCLUSION
ACR 2016 F i b r o m y a l g i a
D i a g n o s t i c Criteria

1. Widespread pain index (WPI) > 7 Or

4-6
Symptom Severity Score (SSS) > 5 >9

2. Generalised pain Pa i n i n 4 / 5 re g i o n s

3. Symptoms present > 3 months A l l t h r e e C r i t e r i o n m u s t b e f u l fi l l e d

Involvement of Only 4 regions requrd
N O LON G ER a di agno s i s o f EXCLUS ION
ACR 2016 F i b r o m y a l g i a
D i a g n o s t i c Criteria
W i d e s p r e a d Pain Index (WPI) To t a l
n Ri
rre
gio

gh
t U
pp
Possible Score
p pe er
U (1)
Le
ft
w de r G irdle 

R
RJ
S h
aw 2 )
ou
( re
gi
on
(0 - 19)
L J a l  R up lde
 S h ou arm R p e rG
L e r A x i a l lo r
we arm irdle
 u pp r arm ra
L we r e g i o n ( 5 ) rm
 L lo  Neck

W id Upper back
e s p re a d
 Lower back
Pa in…..
 Chest
L e ft  Abdomen Right
Lower region IF Lower region
(3) 4 / 5 re g i o n s (4) A l l t h r e e C r i t e r i o n m u s t b e f u l fi l l e d
 L hip (buttck/trochntr)  R hip (buttck / trochntr)
 L upper leg  R upper leg Involvement of Only 4 regions requrd
 L lower leg  R lower leg N O LON G ER a di agno s i s o f EXCLUS ION
ACR 2016 F i b r o m y a l g i a
D i a g n o s t i c Criteria

1. Widespread pain index (WPI)

Symptom Severity Score (SSS)

2. Generalised pain

3. Symptoms present > 3 months A l l t h r e e C r i t e r i o n m u s t b e f u l fi l l e d

Involvement of Only 4 regions requrd
N O LON G ER a di agno s i s o f EXCLUS ION
ACR 2016 F i b r o m y a l g i a
D i a g n o s t i c Criteria
Sy m p to m S e ve r i t y S co re ( SSS)
(0)
Rate your Symptoms ( 1 ) Slight ( 2 ) Modert ( 3 ) Severe
Over No or mild
considerable pervasive,
problem
Last Problem Often problm, oftn continuous
1 We e k intermittent present life disturbing

F a ti g u e . . . . .
Waking Unrefreshed . . . . To t a l
Cognitive Symptoms . . . .
Possible Score
(0)
Troubled by any of the following (1)
O v e r L a st 1 We e k No P r o b l e m
Problem (0 - 12)
. Headache . . . A l l t h r e e C r i t e r i o n m u s t b e f u l fi l l e d
Pain /Cramps- Lower Abd . . Involvement of Only 4 regions requrd
Depression . . N O LON G ER a di agno s i s o f EXCLUS ION
 Investigations in Fibromyalgia
L a b o r a t o r y Te s t s O t h e r Te s t s
• CBC, • X-rays, ,
• ESR,CRP, • CT / MRI
• RF, ANA, • Nuclear Medicine
• TSH, T3, T4, • Muscle Biopsy are
• CPK (total), Necessary to Rule out/Find Other

• vitamin D, \ OTHER Conditions, …

… .…b…
u t… …o…
n…l y. i f

• RFT , LFT ,
strong suspicion on clinical grounds.
C o m p a r i s o n o f t h e R e c o m m e n d a ti o n s f o r P H A R M A C O L O G I C A L
r Oo Nm- PyHaAlRgMi AaC OSLyOnG dI CrAoL mTer e: aTr
aFnidb N t m ee a
n ttsmoe
f n
F ItB RO
OMp Yt Ai oL GnI sA
EULAR Canadian Italian German
Pharmacological Management N S A I D s a r e N O T a t a l l e ff e c ti v e

+ PPrreeggaabbaal il ni n
D uu ll ooxxeetiti n ne or MMi ill nn aa c i pp rr aann
Weak for
Weak for
Strong for
Strong for
Strong for
Strong for
-
Weak for
Amitriptyline Weak for Strong for - Weak for
U S F DA
Cyclobenzaprine Weak for - Strong for Weak against
A p p ro ve d
Tramadol Weak for Strong against - -
Non-Pharmacological Management First line of treatment
E Ex xeer rcci iss ee Strong for Strong for Strong for Strong for

C o g n iCognitive
ti v e B ebehavioral
h a v i o rtherapy
al Therapy Weak for Strong for Strong for Strong for
Strong for Acupuncture
Physical Rx : A c u p u n c t u r e or Hydrotherapy Weak for - -
only
Meditative Movmnt Rx: Qigong, Yo g a or Tai Chi Weak for - Strong for Strong for
 Ta k e H o m e M e s s a g e
• Fibromyalgia S y n d ro m e is a relatively c o m m o n c/o Widespread pain

• In addition to the m u s c u l o s k e l e t a l symptoms , these patients

have significant n o n - m u s c u l o s k e l e t a l symptoms as well

• B/c of varied symptoms / multiple different pathophysiological basis

of the disease …….. D i a g n o s t i c D i l e m m a still persists

• Please d o n ’t d u m p them as “Functional”/Anxiety Neurosis/Malingerer

• M u l t i c o m p o n e n t therapy is more effective, and the treatment plans

should be i n d i v i d u a l i z e d based on each patient’s characteristics.

T h a n k Yo u
 Fibromyalgia
Misnomer
:
Understatement

I s t h e re a w a y o u t
of The Maze?
Dr Jagbir Singh
MD ; MIRA
Senior Consultant [Trained in R h e u m a t o l o g y ]
A R C & P A R C C l i n i c s , Bilaspur, C.G.