This document summarizes information about fibromyalgia syndrome (FMS), including its classification, symptoms, pathogenesis, diagnosis, and treatment. FMS is characterized by widespread pain, joint stiffness, and other symptoms like fatigue, sleep issues, and mood disorders. It affects 2-8% of the population. The cause is unclear but may involve central and peripheral nervous system sensitization. Diagnosis involves evaluating symptoms and tender points while ruling out other conditions. Treatments aim to reduce pain and improve sleep, mood, and function, and may include medications like duloxetine, milnacipran, and gabapentin.

1. Fibromyalgia Syndrome
Marwa Abo Elmaaty Besar
Lecturer of Internal Medicine
(Rheumatology Immunology Unit)
(Pediatric Rheumatology)

2. Fibromyalgia Syndrome:
A functional somatic syndrome, bodily distress syndrome or as a somatoform
disorder.
Fms is classified to be a first rank syndrome (unknown aetiology, heterogenous
pathogenesis and defined phenotype).
A typical group of symptoms and the exclusion of a somatic disease sufficiently
explaining the symptoms.
A syndrome characterized by chronic wide-spread pain at multiple tender
points, joint stiffness, and systemic symptoms (e.G., Mood disorders, fatigue,
cognitive dysfunction, and insomnia).
Eich W, Häuser
W;etal2012

3. • 2 % to 8 % of general population.
• 0.5% to 5.8% in North America and Europe.
• Gowers, “fibrositis” which was used until the seventies and eighties of the last
century.
• fibromyalgia had already been described in the nineteenth century, “pain
syndrome” in the absence of a specific organic disease.
• Only in 1990 did the American College of Rheumatology committee write up the
widely used diagnostic criteria.

5. Pathogenesis:-
• Central sensitization (or pain centralization);
• ‘ windup”, (NMDA) receptor; Impaired descending inhibitory pain pathways.
• Serotonin (5-HT), substance P
.
• Changes in brain morphology; Grey matter volume, decreases in cortical thickness and overall
brain volume.
• Peripheral abnormality with changes consistent with small fibre neuropathy.
• Genetic Factors. several familial studies, polygenic, the serotonin transporter gene, the
catechol-O methyltransferase gene , the dopamine D4 receptor gene , and the HLA-region

6. • Musculoskeletal factors: fear-avoidance behaviours and kinaesiophobia (fear of
movement)
• Sleep disturbance: disruption to stage four non rapid eye movement sleep.
• Other mechanisms; (HPA) dysfunction, low cortisol, GH.
• Psychological factors; depression, anxiety, obsessive–compulsive disorder and post-
traumatic stress disorder.
• Trigger Factors:
• Infections; viruses such as HCV, HIV, Coxsackie B, and Parvovirus and bacteria like
Borrelia.
• Physical trauma, vaccinations and chemical substances.

7. Symptoms And Sign:

8. Pain diagram from a female patient diagnosed with fibromyalgia
syndrome ‘ All over’ Pain diagram from a female patient diagnosed with fibromyalgia
syndrome
Reumatismo, 2012; 64 (4): 194-205

9. Diagnosis:
History:
Family history of early chronic pain (e.g. low back pain, "rheumatism" etc.).
Personal history of pain (head, abdomen, joints) in childhood and adolescence
Long history of local pain
Onset of widespread pain related to physical and / or psychosocial stress
History of physical or psychosocial stress, e.g. child abuse
General hypersensitivity to touch, smell, noise, taste
Hypervigilance
Multiple somatic symptoms (gastrointestinal, urology, gynecology, neurology) with previous diagnosis of
functional dyspepsia, irritable bowel syndrome, painful bladder syndrome, tension headache, migraine,
temporomandibular disorder
High symptom-related emotional strain

10. a) Blood sedimentation rate, C-reactive protein, red and white cell blood count
(polymyalgia rheumatica, rheumatoid arthritis).
b) Creatinin kinase (muscle disease).
c) Calcium (hypercalcaemia).
d) Thyroid-stimulating hormone (hypothyroidism).
e) Depending on history and examination further blood tests can be necessary if
other differential diagnoses are suspected.

11. Coexisting conditions: considerations and
challenges:
• Osteoarthritis and Inflammatory arthritis (IA) and Joint hypermobility syndrome.
• Patients with IA and FM can be at risk of overtreatment of one condition and
undertreatment of the other in either direction,
• Patients with rheumatoid arthritis (RA) and FM have higher Disease Activity Score
(DAS28) scores and worse outcomes.
• The various inflammatory outcome measures utilized such as DAS28 in RA, Bath
Ankylosing Spondylitis Disease Activity Index and Psoriatic Arthritis Response Criteria
scores require patient pain ratings and cannot differentiate inflammatory from
noninflammatory pain, and clinical judgement is still required.

12. Differential Diagnosis:-
(1) inflammatory arthritis (IA) and spondylo-arthropathies,
(2) autoimmune connective tissue disease,
(3) myositis,
(4) myopathies,
(5) primary generalized osteoarthritis,
(6) polymyalgia rheumatica,
(7) hypothyroidism,
(8) malignancies.

13. https://www.researchgate.net/publication/23385
0271

14. This table is from the 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria article, which appeared in Volume 46, Issue 3 of the Seminars inArthritis and
Rheumatism journal.

15. Wolfe F,etal2011
Screening tool
1-The Fibromyalgia Rapid Screening
Tool (FiRST);
Cut off 5 or 6.
Sensitivity 90.5%, specificity
85.7%.
2- The Fibromyalgia Diagnostic Screen
(FSQ)

16. H Cohen,2017

18. • Amitriptyline; 25 mg/day improved pain, sleep and fatigue at 6–8 weeks of treatment but not at 12
weeks while 50 mg/day did not demonstrate efficacy.
• Anticonvulsants: Gabapentin, 30% reduction of pain.
• Cyclobenzaprine: improve sleep not pain.
• Growth hormone: not recommended.
• NSAIDs: not effective.
• Monoamine oxidase inhibitors: not effective sleep nor fatigue.
• Serotonin-noradrenalin reuptake inhibitor:-duloxetine, (pain, fatigue and sleep problems),
Milnacipran (MLN)

19. Biomedicines 2017

20. Macfarlane GJ, et al. Ann Rheum Dis 2016;0:1–11. doi:10.1136/annrheumdis-2016-209724

21. Reference:-
• http://ard.bmj.com/content/early/2016/07/04/annrheumdis-2016-209724.
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measurement of symptom severity. Arthritis Care Res (Hoboken). 2010; 62: 600-10.
• Eich W, Häuser W, Arnold B, et al. Definition, classification, clinical diagnosis and prognosis of fibromyalgia syndrome. Schmerz. 2012; 26:
in press.
• Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of
the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 2011;38: 1113-22.
• Briggs EV, Battelli D, Gordon D, et al. Current pain education within undergraduate medical studies across Europe: Advancing the
Provision of Pain Education and Learning (APPEAL)study. BMJ Open 2015; 5(8): e006984.
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for the classification of fibromyalgia. Report of the multicenter criteria committee. Arthritis Rheum. 1990, 33, 160–172.
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