Fibromyalgia Syndrome (FMS)

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?

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

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

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

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

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

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 fibromyalgia syndrome

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

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 pain in 11 out of 18 tender point sites on digital palpation

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.

Fibromyalgia: tender points (diagram)

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)

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

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) - Tricyclic compounds such as cyclobenzaprine (FLEXERIL) and amitriptyline (ELAVIL) - Dual reuptake inhibitors such as venlafaxine (EFFEXOR), duloxetine (CYMBALTA) and tramadol (ULTRAM) - Dual reuptake inhibitors such as venlafaxine (EFFEXOR), duloxetine (CYMBALTA) and tramadol (ULTRAM)

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

- NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen and naproxen are generally ineffective - 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 - 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 - 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

N.B. N.B. The US Food and Drug Administration has not yet approved any medications to treat FMS The US Food and Drug Administration has not yet approved any medications to treat FMS

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

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

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

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

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

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