This document discusses fibromyalgia, including its characteristics, prevalence, risk factors, pathogenesis, diagnostic criteria, treatment approaches, and specific studies on treatments. It defines fibromyalgia as a syndrome characterized by widespread pain and tender points, stiffness, and other systemic symptoms. It notes the prevalence is highest in women ages 40-60 and discusses potential contributing factors and mechanisms. Diagnostic criteria including the 2010 ACR criteria are outlined. A variety of pharmacological and non-pharmacological treatment approaches are recommended, including exercise, CBT, manual therapy, and aquatic therapy. Specific studies demonstrating the effectiveness of treatments like tai chi, muscle energy technique, and perceptual rehabilitation are summarized.

1. Submitted To:
DR. SHABNAM JOSHI
Assistant Professor,
Dept. of Physiotherapy, GJUS&T
Submitted By:
HEMANT AGGARWAL
MPT(Musculoskeletal Disorders)
Roll No. -180171720002

2.  Fibromyalgia is a syndrome characterized by
 chronic widespread pain at multiple tender points,
 joint stiffness, and
 systemic symptoms (e.g., mood disorders, fatigue,
cognitive dysfunction, and insomnia) without a
well-defined underlying organic disease
 it can be associated with specific diseases such as
rheumatic pathologies, psychiatric or neurological
disorders, infections, and diabetes
 FMS is NOT just one condition, it's a complex
syndrome involving many different factors that can
severely impact and disrupt a person’s daily life

3.  FMS occurs in the general population between 0.2
and 6.6%; in women, values between 2.4 and
6.8%; in urban areas between 0.7 and 11.4% and in
rural areas between 0.1 and 5.2% worldwide
(Pasqual Amelia et al., 2017)
 In India, it occurs in more than 40% of the female
population, among which 36% in unskilled
workers and 24% in clerical job workers
 The age group that is majorly affected by
fibromyalgia is between 40-60 years of age
(Jilumudi AK et al., 2018)

4.  Exact etiology of FMS is still being researched
 Several trigger factors of FMS-
 Increased sensitivity to a different stimuli i.e.
 heat and cold,
 mechanical and ischemic pressure
 Abnormal functioning in the hypothalamic-pituitary-
adrenal (HPA) axis, which results into the inability to
suppress cortisol
 Genetic risk factors
 Conditions which are characterized by persistent or
recurrent pain and emotional distress i.e. IBS, TMD,
anxiety disorders, and chronic inflammatory diseases,
etc. (Laurence A. Bradley, et al., 2009)

5.  Changes in neuroendocrine transmitters i.e.
serotonin, substance P, growth hormone and
cortisol
 Central sensitization which results in lowering of
pain threshold and increased sensitivity of stimuli
 Prolonged inhibition of PNS alters the neuro-
immunoendocrine systems, directly affecting
growth hormone secretion by the pituitary gland.
This can result in non-restorative sleep, pain,
fatigue, and cognitive/mood symptoms
 With FMS, the auto-immune response get
heightened, causing an excess of glia in the body
which creates chronic pain

6. Excitatory Amino Acids (EAAs)

9.  The American College of Rheumatology 2010 criteria for the
classification of fibromyalgia
 The 31 point questionnaire was developed by ACR in 2010
 it does not require a tender-point count
 patients are assessed by
 the WIDESPREAD PAIN INDEX (WPI) - divides the body into 19
regions and scores how many regions are reported as painful
 a SYMPTOM SEVERITY SCORE (SSS) - assesses severity of
fatigue, unrefreshing sleep, and cognitive symptoms
 A patient satisfies diagnostic criteria for fibromyalgia if the
following 3 conditions are met:
 widespread pain index (WPI) ≥7 and symptom severity (SS) scale
score ≥5 or WPI 3 - 6 and SS scale score ≥9
 symptoms have been present at a similar level for at least 3
months
 the patient does not have a disorder that would otherwise explain
the pain (Wolfe et al., 2010)

11. Symptoms Severity Score:

12.  The goals of fibromyalgia treatment are-
 to alleviate pain,
 increase restorative sleep,
 improve physical function through a reduction in
associated symptoms
 Because pain, depression, and other symptoms of
fibromyalgia are linked to inherited and
environmental causes, a multifaceted treatment
approach is often required including-
 both non-pharmacological pain management
strategies and medication

13.  The American Pain Society (APS) and the
Association of the Scientific Medical Societies in
Germany (AWMF) gave the highest level of
recommendation to followings-
 aerobic exercise,
 cognitive-behavioral therapy (CBT),
 drug therapy (amitriptyline), and
 Multi-component therapy

14.  The European League Against Rheumatism
(EULAR) gave the highest level of
recommendations to a set of
 pharmacological treatments
(i.e., tramadol, amitriptyline, fluoxetine,
duloxetine, milnacipran, moclobemide, pirlindol,
tropisetron, pramipexole, and pregabalin)
 Both antidepressants and neuromodulating
antiepileptics substantially can be used to reduce
fibromyalgia symptoms

15.  Most consistently linked to fibromyalgia
improvements are seen with-
 patient education,
 aerobic exercise,
 strength training,
 stretching,
 reconditioning exercise,
 aquatic exercises and balneotherapy,
 Soft Tissue Manipulation,

16.  Supervised light aerobic exercise and strength or
resistance training is highly recommended
 It increases the capacity for activity
 improves psychological symptoms associated with
depression, cognitive decline, and sleep
disturbances
 Also, improves patient’s cellular metabolism and
respiratory capacity, increases lean muscle mass
and tone, and increases oxygen uptake within the
body’s system,
 which ultimately minimizes their complaints of
chronic pain and fatigue (L Brosseau et al.,
2017)

17. Aerobic Exercises Resistance Exercises

18.  Manual lymph drainage therapy and connective
tissue massage have been studied in women with
fibromyalgia
 showed improvements in both the FIQ and the
Nottingham Health Profile
 there were significantly greater improvements in
the group that received manual lymph drainage
therapy, suggesting that manual lymphatic
drainage therapy may be preferred over connective
tissue massage (Ekici G et al., 2009)

19.  It is a more tolerable workout for people with FMS pain
 aquatic therapy help in improving the quality of life of
those with FMS for long term
 central hypersensitivity and pain, may be alleviated by the
hydrostatic pressure
 effects of soothing temperature on the nerve endings,
along with general muscle relaxation ( Mannerkorpi K et
al., 2009)
 Balneotherapy (seated immersion or spatherapy) is
classically used in (eastern) European countries for
bathing in water without exercise
 by which immersion in mineral or thermal water or the
application of mud alleviates chronic pain and the
symptoms of fibromyalgia (T. Bender et al., 2005)

20.  Cognitive behavioral therapy (CBT) can be used for
the assessment and plan of patient’s care with chronic
pain
 Growing evidence continues to demonstrate that CBT
shows improvement in reducing pain, hyperalgesia,
and chronic pain-related brain response in FMS
(Moseley GL et al., 2005)
 CBT and relaxation were significantly more effective
than other psychological treatments in reducing sleep
problems associated with fibromyalgia
(J.W. S. Vlaeyen et al., 1996)

21.  Noninvasive repetitive trans-cranialmagnetic
stimulation (rTMS) of the primary motor cortex
 which induces analgesic effects both in
experimental pain and in various chronic pain
conditions (N. Andr´e-Obadia et al., 2006)
 probably by activating pain modulation systems
 it was demonstrated that 10 daily sessions of
unilateral M1 stimulation
 decrease chronic widespread pain and improve
health-related quality of life of patients with
fibromyalgia (J. P. Lefaucheur et al., 2006)

23. ARTICLE 1:
Effects of Manual Therapy on Fatigue, Pain,
and Psychological Aspects in Women with
Fibromyalgia
 Researchers: Yolanda Nadal-Nicolás et al., 2020
 Journal: International Journal of Environmental
Research and Public Health 2020
 Method: manual therapy group (n=14) whereas
the placebo group (n=10)
 Conclusion: Manual therapy with digital moderate
pressure for 15 min on the posterior cervical
musculature decreases the perception of pain,
muscle fatigue, and the state of tension-anxiety in
women with FM.

24. Effectiveness of the muscle energy technique on
respiratory muscle strength and endurance in
patients with fibromyalgia
 Researchers: Sümeyye Cildan Uysal et al., 2018
 Journal: Journal of Back and Musculoskeletal
Rehabilitation
 Methods: MET was applied to the scalene, upper
trapezius, and SCM muscles of 37 females after a
superficial heat application. The treatment was
continued for 3 weeks with 3 sessions per week
 Conclusion: MET showed positively increase in
respiratory muscle strength and endurance,
cervical flexibility, and decrease in pain intensity,
fatigue and disability.

25. Effect of tai chi versus aerobic exercise for
fibromyalgia: comparative effectiveness
randomized controlled trial
 Researchers: Chenchen Wang et al., 2018
 Journal: BMJ 2018
 Method: 226 adults with fibromyalgia were
included in the intention to treat analyses: 151
were assigned to one of for tai chi groups and 75 to
an aerobic exercise group
 Conclusion: Tai chi mind-body treatment for 24
weeks results greater improvement in reducing
FIQR scores than aerobic exercise. Longer
duration of tai chi showed greater improvement.

26. A New Rehabilitation Tool in Fibromyalgia: The
Effects of Perceptive Rehabilitation on Pain and
Function in a Clinical Randomized Controlled Trial
 Reseachers: Teresa Paolucci et al, 2016
 Journal: Evidence-Based Complementary and
Alternative Medicine
 Method: 62 patients were randomly allocated into 3
treatment groups (simple randomization) with the
different rehabilitation programs: perceptual surfaces
group (PS-group, 𝑛 = 20), physical exercises group
(PEgroup, 𝑛 = 21), and control group (CG, 𝑛 = 21).
 Conclusion: Perceptual surfaces are efficacious in
treating female patients with FM, similar to physical
group exercises, improving physical function and
mitigating pain.

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