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Fibromyalgia (FM).
Dr.Debanjan Mondal (PT).Mphil, MPT, BPT, CMT, CE.www.korecphysiocare.com
Fibromyalgia is a disorder of unknown cause characterized by widespread pain, abnormal pain
proceeding, sleep disturbance, fatigue & often psychological distress.
Causes of Fibromyalgia:-
A. Emerging evidence of a genetic component of Fibromyalgia:-
 Specific gene mutations may predispose individuals to Fibromyalgia.
 Polymorphisms in the COMT enzyme & the Serotonin transporter are potentially
associated with Fibromyalgia.
B. Environmental factors that may trigger the onset of Fibromyalgia:-
 Physical trauma or injury.
 Infection (Lyme disease, Hepatitis).
 Psychological stress.
C. Fibromyalgia may occur concurrently with arthritis (O.A), autoimmune diseases (R.A, SLE) &
Hypothyroidism.
D. Gender differences:-Women are more likely to be diagnosed with Fibromyalgia.(F:M=4-9:1).
E. Central Nervous System:-Central Nervous System plays a significant role in Fibromyalgia that it is
ultimately a state of heightened sensitivity may be explaining this increasing pain that patient is
suffering .There are some excitatory neurotransmitter(glutamine & substance P).Everything should be
in a balance Excitation & inhibition, but if excitation neurotransmitter increase & too little of
inhibition neurotransmitter-patient will end up with the pain .So substance P & glutamine happened
to be a excitatory neurotransmitter they caused to increase excitatory aspect so patient got too much
information coming into the brain ,it leads to them experience of pain.
So what is pain?
International Association for the Study of Pain (IASP) Defined pain is a “An unpleasant sensory &
emotional experience associated with actual or potential tissue damage or described in terms of such
damage”. We can’t measure, we can’t touch, and we can’t feel it. So each and every person has their
own pain & there is no way to alternatively objectified. Each of everyone has their own pain score in
same stimulus. The fundamental understanding of pain Neuroanatomy of Nociceptive pathways Pain
starts with a stimulus, It could be an Incision, burns, It could be a trauma, it all has a common threat, It
activate the primary nociceptor. Now this nociceptor is the transducers, they lie in the soft tissue or
deep tissue. What the transducer does-It convert one form of energy to another form of energy.
Mechanical energy to a chemical energy in a form of ‘ph’changes, it takes temperature changes & it
converts something which is called action potential. There are 2 basic nerves fibrous that transmit the
signal of the body ‘A∂’ & ‘c’ fiber .And one is response for our first pain & other one is response for the
slow pain. ‘A∂’ (DELTA) is very first- 10mitter/sec.
‘C’ Fibrous is bit slower-1mitter/sec.
This signals of this fibrous synapse to the posterior or dorsal horn of the spinal cord they cross over
the other side then they go’s to the brain in Thalamus. It serves to send the signals of two major area
of our brain-outer side area of the brain, lateral area of the brain known as Somatosensotory cortex
area of the brain. This is where we feel the intensity, quality, location character of it, and another area
where the signals gows-Medio forebrain system (Limbic System) .This has descending inhibitory
systems. They come down from the brain-they head down to the spinal cord-they serve negative
feedback to the brain. It prevents, it provides a very nice balance between Excitation & Inhibition.
What we learn in chronic pain in fibromyalgia, this system get out of
lack, its disrupted & disorder. Limbic system is your Emotional brain. This is where our basic emotion is
process & proceeds. This is your fear, joy, anger, hate, love, stress, pain where it is generated &
proceeds. Now recent research are showing that the some area of our brain involved with our basic
emotion which are the same region involved with the emotion aspect of the pain .So if we defined our
self that our parents or spouse or children or boss is angry/upset/unhappy with us we find that our
back is hearting more, our neck is more stiff, feel more pain. There is Neurophysiology basis for it
because when we have an increase negative emotion we are increasing ,we are amplifying those same
circuits involved with the emotional aspect of the pain, They are directly link to one another. So stress
or negative feeling aggravate the situation, so it is very much important to understand that factor &
reduce some of those negative emotion. But it is not just a psychological concept, something else
occurring in our nervous system in a phase of pain after an injury. It’s a idea of Neuroplasticity ,this
idea the brain is changing ,its highly maliable. It’s not fixed after certain age which is we learn in new
research; if we got an injury after some time or day it’s reduce its pain, what is happening actually? In
our nervous system it rewired spinal cord & brain that pathway changed over a period of time & it is
expended the area that is preceded pain full. Now why would do that to us? Well it serves a survival
massage for us, what happens in the normal situation is the injury heals, the nerve switches are turn
off they go back to normal. In chronic pain & Fibromyalgia may be the neurons switches are not turn
off. It’s believed that is going on in Fibromyalgia. Fibromyalgia patient are getting an expension of this
areas that are now proceed it pain full & it’s all being driven by the Central Nervous System. In
comparison to normal healthy people to fibromyalgia patient, fibromyalgia patients have dramatic
increase in brain increase brain activity (according to Functional Magnetic Resonance Imagine Study)
in pressure stimulus. There is an enhance sensitivity that occurs in the brain. There is another study in
fMRI Results for fibromyalgia is:-
 Individuals with severe Fibromyalgia were given a cognitive task that required a rapid physical
response.
 Functional MRI showed that these individuals recruited many more areas of the brain that did
contrils; this increased activity was present whether or not standard Neurocognitive tests
were abnormal.
 Fibromyalgia patients could accomplish the task but had to work harder to do that task than
the normal healthy people does, And this get back to the concept of Cognitive issues. Another
way of looking of brain imaging is looking at the chance in the Gray matter in the brain. In
recent study it’s found that people with fibromyalgia & normal healthy people has a huge
difference in Gray matter. There is premature atrophy, premature aging of the brain in specific
region of the brain involved with the emotional aspect of pain, the thinking aspect of pain and
are excreted function some are frontal region of our brain and then par hippocampus gyri
which is involved with our stress response suggesting that this area of brain are atrophying
prematurely and may be playing a significant role in why this patients develop fibromyalgia
and why it gets maintain. In term of longer you have fibromyalgia -the more brain atrophy you
end up getting. In neuropathic pain study it’s found that
Accelerated brain gray matter less in fibromyalgia patients: premature aging of brain
 Voxel-base morphometry (VBM is a neuroimaging analysis technique that
allows investigation of focal differences in brain anatomy, using the statistical
approach of statistical parametric mapping)
 10 fibromyalgia patients 10 healthy individuals
 Gray matter loss
Healthy – 1.1 cm3
/ year
Fibromyalgia- 3.3 cm3
/ year
Cingulated, insular and medial frontal cortices, Para hippocampus gyri.
Greater the duration of fibromyalgia- greater the gray matter loss.
Fibromyalgia pathophysiology
1. Recent data suggests that alteration of the CNS may be contribute to the chronic widespread
pain of fibromyalgia
2. Central sensitization is emerging as a leading theory of fibromyalgia pathophysiology
3. fMRI data provide supporting evidence that fibromyalgia is a central pain processing disorder.
4. Therapeutic agents that reduce neuronal hyperactivity by reducing the release of
neurotransmitters may be one way to relieve the chronic pain of fibromyalgia.
Clinical feature/ diagnostic criteria:
1. History of chronic widespread pain for more than 3 months.
2. Sleep disturbance.
3. Fatigue.
4. Morning stiffness.
5. Patient with fibromyalgia are more likely to have co morbidities such as painful
neuropathies and circulatory disorders.
6. There are number of different criteria that have been used to diagnose to fibromayelgia.
ACR and Canadian criteria may be used to diagnose fibromayelgia.
7. Some of the symptoms are overlap like irritable bowel syndrome, chronic fatigue
syndrome, SLE, RA, OA, Lyme disease, major depression.
We need to able to distinguish this when we think about the fibromyalgia.
1. Wide spread pain: patient had pain in multiple part of body, 11 out of 18 tender points should
be present.
2. Sleep disturbance: fatigue and early morning stiffness and this tenderness (presence of the
tender points)
Widespread pain is the defining feature of fibromyalgia, this patient hurt all over, they hurts on the
most of the parts of their body and sleep disturbance play a significant role. So there is a concept of
non restorative sleep. So in healthy people go to sleep for 8 to 9 hours, when they wake up they feel
fresh in the morning. Fibromyalgia patient don’t feel fresh.
 Nonrestrictive sleep is a prominent feature of fibromyalgia.
 Fibromyalgia patients report insomnia, early morning awakening and poor quality sleep.
 Alpha-wave intrusion is common but nonspecific EEG finding in fibromyalgia patients.
*Interfere with sleep function and contribute to worsening of pain after sleep.
*Phasic, tonic and low alpha are subtypes of alpha Sleep intrusion observed in
patients with fibromyalgia.
In EEG study it’s found that in fibromyalgia patient, there is a concept of alpha wave intrusion. Alpha
waves part of an EEG is there is present predominantly during wake alertness, so slower waves are
involved with our deep sleep so when patients are in a sleep state the finding is -they are getting the
burst of this alpha waves, they are intruding, they are preventing them from getting a good restful
restorative night sleep. The relationship between the sleep and pain is really fascinating, getting a lot
of research going on.
People who are sleeping only for 5/6 hours but not continuously, it like over an extended hour
of sleep. They wake up intermittently whole night, they feel terrible next day. People who have sleep
disturbance/ less sleep they have dramatic abnormality in their pain threshold & pain tolerance. Sleep
plays an extraordinary important role for all of us. We are just beginning to understand what it is
doing and its relationship to pain.
Mood disorder: Rates of mood disorder in fibromyalgia are similar to other rheumatologic disorder. It
is found that there is a area in brain increasing activity called posterior insular cortex is as well as
called the hippocampus as well as amigdilla. This is an area involved in major depression. So it gives
the idea that the depression and pain are overlapping those sharing similar networks. So treatment
should be both for more responsive result.
We cannot simply treat the pain & except the depression goes away.
We cannot simply treat the depression & except that the pain goes away.
Education & appropriate diagnosis plays a crucial role for patient with fibromyalgia. We find
that if we actually can help the patient to understand what they have & what’s going on with it. Why
they are experiencing what they are expressing. There is significant improvement in patient health
satisfaction from baseline to after this education. Just the very idea having validation, lifting him know
it’s not just all med up, it’s not something due to stress, that is a real condition and helping them to
understand, what is all about & what they can do about it leads to a significant improvement in
healthcare satisfaction.
Diagnostic criteria: American college of Rheumatology Diagnostic criteria came out 20 years ago. It is
a research criteria which is not meant to diagnose necessarily individual patients. But what it involves
is -1) patient have to be at least 3 months of wide spread body pain.
2) Patient must exhibit more than 11 out of 18 tender points (pain on digital palpation must be
present in at least 11 of the following tender points).
3) Wide spread pain was found in 97% of patients with fibromyalgia.
If patient have that problems-patient meet the diagnostic criteria for fibromyalgia
Now the Canadians took this to another level. What they did they added some additional
symptoms into the diagnostic criteria
1. Sleep disturbance
2. Fatigue
3. Chronic widespread pain & tenderness are core diagnostic feature
4. Clinical case definition of fibromyalgia include evaluation of additional clinical signs and
symptoms commandingly observed in patients with fibromyalgia (neurocognitive
manifestations, sleep disturbance ,fatigue)
So the idea is ultimately to do an appropriate history and physical examination on a patient, we
need to rule out the other condition so we can’t just jump to fibromyalgia’s the cause of the
patient’s pain and when we have to confirm the process of the tender points and with that we can
ultimately say you got fibromyalgia.
Now the key is how we go to managing it. How do we make an impact on patient life who is
suffering with fibromyalgia? So we have to do this using a variety of tools and technique. We
approach a using a multidisciplinary treatment approach, in the other word we applied this 4
approach.
Multidisciplinary treatment
Pharmacologic psychological Physiotherapy procedural
And this all should be done in an integration manner that means teams of people working together –
coming together – each of their own area’s expertise towards the treatment & management of the
patient with chronic pain.
 Orthopedics/G.P.
 Physiotherapist (specific pain management)
 Dietician
 Ergonomist
 Occupational therapist
Managing of fibromyalgia pain: -
Non pharmacological approach:-
1. Aerobic exercise.
2. Cognitive behavior therapy
3. Patient education
4. Myofascial release therapy
5. Massage.
6. Alexander technique
7. Strength training
8. Breathing exercise for relaxation
9. Biofeedback
10. Hypnotherapy
11. Relaxation therapy
Pharmacological approach:-What you can see in general pain management & fibromyalgia patient.
General NSAID’s are ineffective in fibromyalgia patient. Some antidepressant medications help a bit
but there are some side effects also.
REFERRENCES-
1. Alpha sleeps characteristics in fibromyalgia,roizenblatts1.WWW.NCBI.NLM.NIH.GOV/PUBMED/11212164
2. www.korecphysiocare.com
3. travell & simons’ Myofascial pain & dysfunction, 2nd edition
4. www.healthlibrary.stanford.edu
5. Dr.Sean Mackey.

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Fibromyalgia

  • 1. Fibromyalgia (FM). Dr.Debanjan Mondal (PT).Mphil, MPT, BPT, CMT, CE.www.korecphysiocare.com Fibromyalgia is a disorder of unknown cause characterized by widespread pain, abnormal pain proceeding, sleep disturbance, fatigue & often psychological distress. Causes of Fibromyalgia:- A. Emerging evidence of a genetic component of Fibromyalgia:-  Specific gene mutations may predispose individuals to Fibromyalgia.  Polymorphisms in the COMT enzyme & the Serotonin transporter are potentially associated with Fibromyalgia. B. Environmental factors that may trigger the onset of Fibromyalgia:-  Physical trauma or injury.  Infection (Lyme disease, Hepatitis).  Psychological stress. C. Fibromyalgia may occur concurrently with arthritis (O.A), autoimmune diseases (R.A, SLE) & Hypothyroidism. D. Gender differences:-Women are more likely to be diagnosed with Fibromyalgia.(F:M=4-9:1). E. Central Nervous System:-Central Nervous System plays a significant role in Fibromyalgia that it is ultimately a state of heightened sensitivity may be explaining this increasing pain that patient is suffering .There are some excitatory neurotransmitter(glutamine & substance P).Everything should be in a balance Excitation & inhibition, but if excitation neurotransmitter increase & too little of inhibition neurotransmitter-patient will end up with the pain .So substance P & glutamine happened to be a excitatory neurotransmitter they caused to increase excitatory aspect so patient got too much information coming into the brain ,it leads to them experience of pain. So what is pain? International Association for the Study of Pain (IASP) Defined pain is a “An unpleasant sensory & emotional experience associated with actual or potential tissue damage or described in terms of such damage”. We can’t measure, we can’t touch, and we can’t feel it. So each and every person has their own pain & there is no way to alternatively objectified. Each of everyone has their own pain score in same stimulus. The fundamental understanding of pain Neuroanatomy of Nociceptive pathways Pain starts with a stimulus, It could be an Incision, burns, It could be a trauma, it all has a common threat, It activate the primary nociceptor. Now this nociceptor is the transducers, they lie in the soft tissue or deep tissue. What the transducer does-It convert one form of energy to another form of energy. Mechanical energy to a chemical energy in a form of ‘ph’changes, it takes temperature changes & it
  • 2. converts something which is called action potential. There are 2 basic nerves fibrous that transmit the signal of the body ‘A∂’ & ‘c’ fiber .And one is response for our first pain & other one is response for the slow pain. ‘A∂’ (DELTA) is very first- 10mitter/sec. ‘C’ Fibrous is bit slower-1mitter/sec. This signals of this fibrous synapse to the posterior or dorsal horn of the spinal cord they cross over the other side then they go’s to the brain in Thalamus. It serves to send the signals of two major area of our brain-outer side area of the brain, lateral area of the brain known as Somatosensotory cortex area of the brain. This is where we feel the intensity, quality, location character of it, and another area where the signals gows-Medio forebrain system (Limbic System) .This has descending inhibitory systems. They come down from the brain-they head down to the spinal cord-they serve negative feedback to the brain. It prevents, it provides a very nice balance between Excitation & Inhibition. What we learn in chronic pain in fibromyalgia, this system get out of lack, its disrupted & disorder. Limbic system is your Emotional brain. This is where our basic emotion is process & proceeds. This is your fear, joy, anger, hate, love, stress, pain where it is generated & proceeds. Now recent research are showing that the some area of our brain involved with our basic emotion which are the same region involved with the emotion aspect of the pain .So if we defined our self that our parents or spouse or children or boss is angry/upset/unhappy with us we find that our back is hearting more, our neck is more stiff, feel more pain. There is Neurophysiology basis for it because when we have an increase negative emotion we are increasing ,we are amplifying those same circuits involved with the emotional aspect of the pain, They are directly link to one another. So stress or negative feeling aggravate the situation, so it is very much important to understand that factor & reduce some of those negative emotion. But it is not just a psychological concept, something else occurring in our nervous system in a phase of pain after an injury. It’s a idea of Neuroplasticity ,this idea the brain is changing ,its highly maliable. It’s not fixed after certain age which is we learn in new research; if we got an injury after some time or day it’s reduce its pain, what is happening actually? In our nervous system it rewired spinal cord & brain that pathway changed over a period of time & it is expended the area that is preceded pain full. Now why would do that to us? Well it serves a survival massage for us, what happens in the normal situation is the injury heals, the nerve switches are turn off they go back to normal. In chronic pain & Fibromyalgia may be the neurons switches are not turn off. It’s believed that is going on in Fibromyalgia. Fibromyalgia patient are getting an expension of this areas that are now proceed it pain full & it’s all being driven by the Central Nervous System. In comparison to normal healthy people to fibromyalgia patient, fibromyalgia patients have dramatic increase in brain increase brain activity (according to Functional Magnetic Resonance Imagine Study) in pressure stimulus. There is an enhance sensitivity that occurs in the brain. There is another study in fMRI Results for fibromyalgia is:-  Individuals with severe Fibromyalgia were given a cognitive task that required a rapid physical response.
  • 3.  Functional MRI showed that these individuals recruited many more areas of the brain that did contrils; this increased activity was present whether or not standard Neurocognitive tests were abnormal.  Fibromyalgia patients could accomplish the task but had to work harder to do that task than the normal healthy people does, And this get back to the concept of Cognitive issues. Another way of looking of brain imaging is looking at the chance in the Gray matter in the brain. In recent study it’s found that people with fibromyalgia & normal healthy people has a huge difference in Gray matter. There is premature atrophy, premature aging of the brain in specific region of the brain involved with the emotional aspect of pain, the thinking aspect of pain and are excreted function some are frontal region of our brain and then par hippocampus gyri which is involved with our stress response suggesting that this area of brain are atrophying prematurely and may be playing a significant role in why this patients develop fibromyalgia and why it gets maintain. In term of longer you have fibromyalgia -the more brain atrophy you end up getting. In neuropathic pain study it’s found that Accelerated brain gray matter less in fibromyalgia patients: premature aging of brain  Voxel-base morphometry (VBM is a neuroimaging analysis technique that allows investigation of focal differences in brain anatomy, using the statistical approach of statistical parametric mapping)  10 fibromyalgia patients 10 healthy individuals  Gray matter loss Healthy – 1.1 cm3 / year Fibromyalgia- 3.3 cm3 / year Cingulated, insular and medial frontal cortices, Para hippocampus gyri. Greater the duration of fibromyalgia- greater the gray matter loss. Fibromyalgia pathophysiology 1. Recent data suggests that alteration of the CNS may be contribute to the chronic widespread pain of fibromyalgia 2. Central sensitization is emerging as a leading theory of fibromyalgia pathophysiology 3. fMRI data provide supporting evidence that fibromyalgia is a central pain processing disorder. 4. Therapeutic agents that reduce neuronal hyperactivity by reducing the release of neurotransmitters may be one way to relieve the chronic pain of fibromyalgia. Clinical feature/ diagnostic criteria: 1. History of chronic widespread pain for more than 3 months. 2. Sleep disturbance. 3. Fatigue. 4. Morning stiffness. 5. Patient with fibromyalgia are more likely to have co morbidities such as painful neuropathies and circulatory disorders. 6. There are number of different criteria that have been used to diagnose to fibromayelgia. ACR and Canadian criteria may be used to diagnose fibromayelgia.
  • 4. 7. Some of the symptoms are overlap like irritable bowel syndrome, chronic fatigue syndrome, SLE, RA, OA, Lyme disease, major depression. We need to able to distinguish this when we think about the fibromyalgia. 1. Wide spread pain: patient had pain in multiple part of body, 11 out of 18 tender points should be present. 2. Sleep disturbance: fatigue and early morning stiffness and this tenderness (presence of the tender points) Widespread pain is the defining feature of fibromyalgia, this patient hurt all over, they hurts on the most of the parts of their body and sleep disturbance play a significant role. So there is a concept of non restorative sleep. So in healthy people go to sleep for 8 to 9 hours, when they wake up they feel fresh in the morning. Fibromyalgia patient don’t feel fresh.  Nonrestrictive sleep is a prominent feature of fibromyalgia.  Fibromyalgia patients report insomnia, early morning awakening and poor quality sleep.  Alpha-wave intrusion is common but nonspecific EEG finding in fibromyalgia patients. *Interfere with sleep function and contribute to worsening of pain after sleep. *Phasic, tonic and low alpha are subtypes of alpha Sleep intrusion observed in patients with fibromyalgia. In EEG study it’s found that in fibromyalgia patient, there is a concept of alpha wave intrusion. Alpha waves part of an EEG is there is present predominantly during wake alertness, so slower waves are involved with our deep sleep so when patients are in a sleep state the finding is -they are getting the burst of this alpha waves, they are intruding, they are preventing them from getting a good restful restorative night sleep. The relationship between the sleep and pain is really fascinating, getting a lot of research going on. People who are sleeping only for 5/6 hours but not continuously, it like over an extended hour of sleep. They wake up intermittently whole night, they feel terrible next day. People who have sleep disturbance/ less sleep they have dramatic abnormality in their pain threshold & pain tolerance. Sleep plays an extraordinary important role for all of us. We are just beginning to understand what it is doing and its relationship to pain. Mood disorder: Rates of mood disorder in fibromyalgia are similar to other rheumatologic disorder. It is found that there is a area in brain increasing activity called posterior insular cortex is as well as called the hippocampus as well as amigdilla. This is an area involved in major depression. So it gives the idea that the depression and pain are overlapping those sharing similar networks. So treatment should be both for more responsive result. We cannot simply treat the pain & except the depression goes away. We cannot simply treat the depression & except that the pain goes away.
  • 5. Education & appropriate diagnosis plays a crucial role for patient with fibromyalgia. We find that if we actually can help the patient to understand what they have & what’s going on with it. Why they are experiencing what they are expressing. There is significant improvement in patient health satisfaction from baseline to after this education. Just the very idea having validation, lifting him know it’s not just all med up, it’s not something due to stress, that is a real condition and helping them to understand, what is all about & what they can do about it leads to a significant improvement in healthcare satisfaction. Diagnostic criteria: American college of Rheumatology Diagnostic criteria came out 20 years ago. It is a research criteria which is not meant to diagnose necessarily individual patients. But what it involves is -1) patient have to be at least 3 months of wide spread body pain. 2) Patient must exhibit more than 11 out of 18 tender points (pain on digital palpation must be present in at least 11 of the following tender points). 3) Wide spread pain was found in 97% of patients with fibromyalgia. If patient have that problems-patient meet the diagnostic criteria for fibromyalgia Now the Canadians took this to another level. What they did they added some additional symptoms into the diagnostic criteria 1. Sleep disturbance 2. Fatigue 3. Chronic widespread pain & tenderness are core diagnostic feature 4. Clinical case definition of fibromyalgia include evaluation of additional clinical signs and symptoms commandingly observed in patients with fibromyalgia (neurocognitive manifestations, sleep disturbance ,fatigue) So the idea is ultimately to do an appropriate history and physical examination on a patient, we need to rule out the other condition so we can’t just jump to fibromyalgia’s the cause of the patient’s pain and when we have to confirm the process of the tender points and with that we can ultimately say you got fibromyalgia. Now the key is how we go to managing it. How do we make an impact on patient life who is suffering with fibromyalgia? So we have to do this using a variety of tools and technique. We approach a using a multidisciplinary treatment approach, in the other word we applied this 4 approach. Multidisciplinary treatment Pharmacologic psychological Physiotherapy procedural
  • 6. And this all should be done in an integration manner that means teams of people working together – coming together – each of their own area’s expertise towards the treatment & management of the patient with chronic pain.  Orthopedics/G.P.  Physiotherapist (specific pain management)  Dietician  Ergonomist  Occupational therapist Managing of fibromyalgia pain: - Non pharmacological approach:- 1. Aerobic exercise. 2. Cognitive behavior therapy 3. Patient education 4. Myofascial release therapy 5. Massage. 6. Alexander technique 7. Strength training 8. Breathing exercise for relaxation 9. Biofeedback 10. Hypnotherapy 11. Relaxation therapy Pharmacological approach:-What you can see in general pain management & fibromyalgia patient. General NSAID’s are ineffective in fibromyalgia patient. Some antidepressant medications help a bit but there are some side effects also. REFERRENCES- 1. Alpha sleeps characteristics in fibromyalgia,roizenblatts1.WWW.NCBI.NLM.NIH.GOV/PUBMED/11212164 2. www.korecphysiocare.com 3. travell & simons’ Myofascial pain & dysfunction, 2nd edition 4. www.healthlibrary.stanford.edu 5. Dr.Sean Mackey.