Fibromyalgia is a chronic pain syndrome characterized by widespread musculoskeletal pain and tenderness. It is more common in women than men. While pain is the primary symptom, it also involves fatigue, sleep issues, cognitive problems, anxiety and depression. There is no known cause but factors like genetics and abnormal pain processing in the central nervous system may play a role. Treatment involves lifestyle changes like exercise and stress management as well as medications like antidepressants. While not curable, some patients are able to adapt well through treatment, but a minority have severe, treatment-resistant symptoms.

1. Fibromyalgia
Dr. Md Rashedul Islam
FCPS, MRCP(UK)
Registrar, Neurology, BIRDEM

2. Definition
 Fibromyalgia (FM) is characterized by chronic
widespread musculoskeletal pain and tenderness.
Although it is defined primarily as a pain syndrome.
 FM patients also commonly complain of associated
neuropsychological symptoms of fatigue, unrefreshing
sleep, cognitive dysfunction, anxiety, and depression.

3. Epidemiology
 FM is far more common in women than in men,
with a ratio of about 9:1.
 In population-based studies worldwide, there is
general agreement that the prevalence rate is
approximately 2–3%, with rates of closer to 5–10%
in primary care practices.

4. Pathophysiology
A number of abnormalities in pain processing have been
demonstrated in fibromyalgia. Among them are the
following:
 Excess excitatory (pronociceptive) neurotransmitters (eg,
substance P, glutamate levels in the insula)
 Low levels of inhibitory neurotransmitters (eg, serotonin
and norepinephrine) in descending antinociceptive
pathways in the spinal cord
 Maintained enhancement of temporal summation of
second pain

5. Genetics and Physiology
 Catechol-O-methyltransferase, which controls the
synaptic levels of norepinephrine and dopamine, has
been associated with FM.
 Polymorphisms of the -adrenergic receptor and
dopamine receptor are also associated with FM
 Genes associated with metabolism, transport, and
receptors of serotonin and other monoamines have also
been implicated in FM and overlapping conditions.

6. Etiology
Engel's biopsychosocial model of chronic illness (ie,
health status and outcomes in chronic illness are
influenced by the interaction of biologic,
psychological, and sociologic factors) provides a
useful way to conceptualize fibromyalgia.The model is
pictured in the image below.

8. Clinical Manifestations

9. Clinical Manifestations
 The most common presenting complaint of a patient with
FM is "pain all over."
 Patients with FM have pain that is typically above and
below the waist on both sides of the body and involves
the axial skeleton (neck, back, or chest).
 The pain attributable to FM is poorly localized, difficult to
ignore, severe in its intensity, and associated with a
reduced functional capacity.
 Pain should have been present most of the day on most
days for at least 3 months.

10. DIAGNOSTIC CRITERIA
 The clinical pain of FM is associated with increased
evoked pain sensitivity.
 In clinical practice, this is determined by a tender point
examination in which the examiner uses the thumbnail to
exert pressure of approximately 4 kg/m2, or the pressure
leading to blanching of the tip of the thumbnail, on well-
defined musculotendinous sites.
 American College of Rheumatology classification criteria
previously required that 11 of 18 sites be perceived as
painful for a diagnosis of FM.

12. Neuropsychological Symptoms
 FM patients typically complain of fatigue, stiffness, sleep
disturbance, cognitive dysfunction, anxiety, and
depression.
 Pain, stiffness, and fatigue often are worsened by exercise
or unaccustomed activity (postexertional malaise).
 Sleep complaints include difficulty falling asleep, difficulty
staying asleep, and early-morning awakening.

13. Neuropsychological Symptoms
 Cognitive complaints are characterized as slowness in
processing, difficulties with attention or concentration,
problems with word retrieval, and short-term memory
loss.
 Symptoms of anxiety and depression are common, and
the lifetime prevalence of mood disorders in patients with
FM approaches 80%.

14. Overlapping Syndromes
 Headaches, facial/jaw pain,
 Regional myofascial pain particularly involving the
neck or back, and arthritis.
 Visceral pain complaints involving the
gastrointestinal tract, bladder, and pelvic or perineal
region are also often present.

15. Comorbid Conditions
 FM is often co morbid with chronic musculoskeletal,
infectious, metabolic, or psychiatric conditions.
 it occurs in 20% or more of patients with degenerative
or inflammatory rheumatic disorders,

16. Psychosocial Considerations
 Understanding current psychosocial stressors will aid
in patient management as many factors that
exacerbate symptoms cannot be addressed by using
pharmacologic approaches.
 There is a high prevalence of exposure to previous
interpersonal and other forms of violence in patients
with FM and related conditions.
 If posttraumatic stress disorder is an issue, the
clinician should be aware of it and consider
treatment options.

17. Functional Impairment
 It is crucial to evaluate the impact of FM symptoms
on function and role fulfillment.
 In defining the success of a management strategy,
improved function is a key measure.
 Understanding where role functioning falls short will
assist in establishing treatment goals.

18. Differential Diagnosis
 Inflammatory
Polymyalgia rheumatica
Inflammatory arthritis: rheumatoid arthritis,
spondyloarthritides
Connective tissues diseases: systemic lupus
erythematosus, Sjögren's syndrome
 Infectious
Lyme disease
Parvovirus B19
Epstein-Barr virus

19. Differential Diagnosis
 Noninflammatory
Degenerative joint/spine/disk disease
Bursitis, tendinitis, repetitive strain injuries
 Endocrine
Hypo- or hyperthyroidism
Hyperparathyroidism
 Neurologic diseases
Neuropathic pain syndromes
 Psychiatric disease Major depressive disorder
 Drugs Statins, Aromatase inhibitors

20. Laboratory or Radiographic Testing
Routine
 Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
 Complete blood count (CBC)
 Complete metabolic panel
 Thyroid-stimulating hormone (TSH)
Guided by history and physical examination
 Antinuclear antibody (ANA)
 Anti-SSA (anti-Sjögren's syndrome A) and anti-SSB
 Rheumatoid factor and anticyclic citrullinated peptide (anti-CCP)
 Creatine phosphokinase (CPK)
 Viral and bacterial serologies
 Spine and joint radiographs

21. Treatment: Fibromyalgia
Nonpharmacologic Treatment
 Providing explanation of the genetics, triggers, and
physiology of FM can be an important
 patients must be educated regarding the
expectations for treatment. The physician should
focus on improved function and quality of life rather
than elimination of pain.

22. Nonpharmacologic Treatment
 Physical conditioning, with encouragement to begin at
low levels of aerobic exercise with slow but consistent
advancement.
 Supervised or water-based programs to start.
 Relaxation, such as yoga and Tai Chi.
 Strength training may be recommended after a patient
has reached his or her aerobic goals.
 Exercise programs
 Cognitive-behavioral strategies to improve sleep hygiene

23. Pharmacologic Approaches
 Antidepressants: balanced
serotonin:norepinephrine reuptake inhibition
Amitryptiline
Duloxetinea
Milnaciprana
 Anticonvulsants: ligands of the alpha-2-delta
subunit of voltage-gated calcium channels
Gabapentin
Pregabalina

24. Prognosis
 Fibromyalgia is a chronic relapsing condition.
 In academic medical centers, long-term follow-up care of
patients with fibromyalgia reportedly averages 10
outpatient visits per year and 1 hospitalization every 3
years.
 Chronic pain and fatigue in fibromyalgia increases the
risk for metabolic syndrome.

25. Prognosis
Three distinct subsets of patients with varying prognoses
have been termed
 Adaptive copers,
 Interpersonally distressed
 Dysfunctional.

26. Prognosis
 Adaptive copers, who often do not seek care for their
symptoms, do well with respect to pain, sleep, and
fatigue.
 Interpersonally distressed patients may respond to
resolution of life stressors and interdisciplinary
therapeutic approaches, including counseling.
 Dysfunctional patients have high levels of pain and
anxiety, major impairment in daily functioning, and, quite
often, opioid dependence. These patients have a very
poor prognosis.