Review of pathophisiology of Fibromyalgia and its therapy with acupuncture

1. FIBROMYALGIA
DR. OSCAR MENDIZABAL POLANCO
MÉDICO CIRUJANO UNAM
ESPECIALISTA EN ACUPUNTURA HUMANA IPN

2. WHAT IS IT?
 Clinical syndrome defined by:
• WIDESPREAD PAIN
• Fatigue
• Sleep disturbances
• Variable somatic complaints
• Cognitive dysfunction
• Mood disturbances
Clauw DJ, Arnold LM, McCarberg BH. The Science of Fibromyalgia. Mayo Clin Proc. 2011;
86(9): 907-9011

3. EPIDEMIOLOGY
 2-5% of general population
 2ª cause of rheumatologic consultations
(EUA)
 6 times more frequent in women
 > prevalence between ages 20-50
Clauw DJ, Arnold LM, McCarberg BH. The Science of Fibromyalgia. Mayo Clin Proc.
2011; 86(9): 907-9011.

5. ETHIOLOGY
Genetic factors
Neuroendocrine factors
Environmental factors
Close relationship
Russell IJ, Larson AA. Neurophysiopathogenesis of fibromyalgia syndrome: a
unified hypothesis. Rheum Dis Clin North Am. 2009;35(2):421-435.

6. GENETIC FACTORS
Positive family history
Monoamine related genes:
• HTR2A
• HTTLPR
• D4R
• COMT
Central pain
processing
abnormalities
Staud R. Abnormal pain modulation in patients with spatially distributed
chronic pain: Fibromyalgia. Rheum Dis Clin North Am. 2009;35(2):263-274.

7. NEUROENDOCRINE FACTORS
 P substance
 Hypothalamic-Pituitary-Adrenal axis activity
reduction
 Diminished release of CRH and GH
 Hypothalamic-Pituitary-Adrenal axis
hyperactivity
 Augmented serum cortisol
Staud R. Abnormal pain modulation in patients with spatially distributed
chronic pain: Fibromyalgia. Rheum Dis Clin North Am. 2009;35(2):263-274.

8. ENVIRONMENTAL FACTORS
Child abuse history
Physical violence in adulthood
Emotional stress situations
Arnold LM. The pathophysiology, diagnosis, and treatment of fibromyalgia.
Psychiatr Clin North Am. 2010;33(2):375-408

10. SIMPTOMS
 Allodynia
 Sleep disturbances (+/-)
 Fatigue
 Weakness
 Cognitive dysfunction
 Headache (tensional or migraine)
 Depression
 IBS
 Paresthesia
Arnold LM. The pathophysiology, diagnosis, and treatment of fibromyalgia. Psychiatr
Clin North Am. 2010;33(2):375-408

11. Allodynia
Abnormal pain processing
Clauw DJ, Arnold LM, McCarberg BH. The Science of Fibromyalgia. Mayo Clin Proc.
2011; 86(9): 907-9011

12. DIAGNOSIS
1990 ACR criteria:
• Widespread pain for 3 or more
months
• Pain in 11 of 18 points
Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology
1990 criteria for the classiication of fibromyalgia: report of a multi-center
criteria committee. Arthtiis Rheum. 1990;33(2):160-172.

14. DIAGNOSIS
 At least 4 of the following:
• Fatigue
• Sleep disturbances
• Neuropsychiatric symptoms
• Headache
• Paresthesia
• IBS
• Not caused by other condition
Arnold LM. The pathophysiology, diagnosis, and treatment of fibromyalgia.
Psychiatr Clin North Am. 2010;33(2):375-408.

15. OTHER SYMPTOMS
 Articular stiffness
 Cold sensation
 Raynaud’s fenomena
 Cystitis
 Temporo – mandibular dysfunction
 Chronic pelvic pain
 Multiple chemical sensitivity
Arnold LM. The pathophysiology, diagnosis, and treatment of fibromyalgia. Psychiatr
Clin North Am. 2010;33(2):375-408.

16. DIAGNOSIS
 ACR 2010 preliminary criteria:
• Widespread index (WPI) of > 7 and
• Symptom severity scale (SS) > 5
• Or WPI 3-6 y SS > 9
• 3 months or more
• Not caused by other conditions
Wolfe F, Clauw DJ, Fitzcharles M, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell
IJ, Winfield JB, Yunus MB. The American College of Rheumatology preliminary
diagnostic driteria for dibromyalgia and measurement of symptom severity. Arthritis
Care Res. 2010;62:600–610.

17. LAB WORKUP
 CBC
 ESR
 PCR
 Blood Chem.
 TSH
Longo DL, Fauci AS, et al. Harrison’s Principles of Internal Medicine. 2012. 18 ed.
Ch. 335. Mc Graw Hill.

18. DIFERENTIAL
 RA
 Polymyalgia rheumatica
 SLE
 HIV
 HCV
 Lyme
 Hypothyroidism
 Etc.
Clauw DJ, Arnold LM, McCarberg BH. The Science of Fibromyalgia. Mayo Clin Proc.
2011; 86(9): 907-9011.

19. TREATMENT

20. PHARMACOLOGIC
TREATMENT
 Aimed to symptom control
• Paint management
• Sleep improvement
 Antidepressants (tricyclic, SSRI)
 Anticonvulsants
 Central acting analgesics
Arnold LM. The pathophysiology, diagnosis, and treatment of fibromyalgia.
Psychiatr Clin North Am. 2010;33(2):375-408.

21. NON PHARMACOLOGIC
TREATMENT
 Symptom control and improvement of
life quality
• Exercise (yoga, tai-chi)
• Group therapy
• Cognitive-conductual therapy
• Acupuncture
Rakel D. Integrative Medicine. 2012. 3rd ed. Saunders. Ch. 46, pp 438-455.

22. ACUPUNCTURE AND FIBROMYALGIA

23. WHAT IS ACUPUNCTURE?
 TCM discipline
• Yin/Yang
theory
• Jing-luo
theory
• Zang fu
theory
• Wu xing
theory
Maciocia G. The Foundations of Chinese Medicine. 2 ed. Elsevier. 2005. Ch 1-4, pp 1-
92.

24. WHAT IS ACUPUNCTURE?
 Needle
insertion at
specific sites
(acupoint)
 Point selection
according to
TCM diagnosis
 Reestablish
Qi/Xue
circulation
Maciocia G. The Foundations of Chinese Medicine. 2 ed. Elsevier. 2005. Ch 1-4, pp 1-92.

25. HOW DOES IT WORK?
 Multiple
action
mechanisms
 Mostly
mediated by
endorphin
release
 Regulates
ANS
Stux G; Hammerschlag R. Clinical Acupuncture: Scientific Basis. 2001. Springer. Ch. 1-3,
pp 1-68.

26. IN FIBROMYALGIA…
 Inhibits ascending pathways (endorphins)
 Stimulates descending pathways (serotonin)
 Regulates cortisol production
 Increases GH production
 Improves sleep quality
Han JS. Acupuncture and Endorphins. Neurosci Lett. 2004. May 6;361 (1-3): 258-261
Lin JG, Chen WL. Acupuncture analgesia: A review of its mechanisms of action. 2008.
Am J Chin Med. 2008;36(4):635-45.
Zhao ZQ. Neural Mechanisms underlying acupuncture. Prog Neurobilol. 2008
Aug;85(4):355-75.