1. N. Movaffagh MD Rheumatologist
Fibromylgia
N. Movaffagh MD Rheumatologist

2. DEFINITION chronic widespread musculoskeletal pain and tenderness.
fatigue, unrefreshing sleep, cognitive dysfunction, anxiety, and depression
increased prevalence of chronic fatigue syndrome, chronic headaches, irritable bowel syndrome,interstitial cystitis/painful bladder syndrome

3. EPIDEMIOLOGY ∼2% of the population female-to-male ratio ∼9:1
in population-based survey studies worldwide, the prevalence rate is ∼2–5%, with a female-to-male ratio of only 2–3:1

4. CLINICAL MANIFESTATIONS
Pain and Tenderness
Neuropsychological Symptoms

5. Pain and Tenderness
pain that is typically both above and below the waist on both sides of the body and involves the axial skeleton
poorly localized, difficult to ignore, severe in its intensity, and associated with a reduced functional capacity
Pain present most of the day on most days for at least 3 months

6. elevated sensitivity determined by :
A tender-point examination in which the examiner uses the thumbnail to exert pressure of ∼4 kg/m2 or the amount of pressure leading to blanching of the tip of the thumbnail on well-defined musculotendinous sites

7. Tender-point assessment in patients with fibromyalgia
Occiput
Trapezius
Supraspinatus
Gluteal
Greater trochanter
Low cervical
Second rib
Lateral epicondyle
Knee

8. Newer criteria focus instead on clinical symptoms of widespread pain and neuropsychological symptoms

9. Patients with FM often have peripheral pain generators that are
thought to serve as triggers for the more widespread pain attributed
to central nervous system factors
peripheral pain generators including:
arthritis, bursitis, tendinitis, neuropathies, and other inflammatory or degenerative conditions
subtle pain generators may include joint hypermobility and scoliosis

10. chronic myalgias triggered by infectious, metabolic, or psychiatric condition(triggers for the development of FM)

11. Neuropsychological Symptoms
fatigue, stiffness, sleep disturbance, cognitive dysfunction anxiety, and depression
Relative to pain,equal or even greater impact on function and quality of life
Fatigue is highly prevalent
Pain, stiffness, and fatigue often are worsened by exercise or unaccustomed activity (postexertional malaise)

12. The sleep complaints include :
difficulty falling asleep
difficulty staying asleep
early-morning awakening

13. patients awake feeling unrefreshed
restless legs syndrome
sleep-disordered breathing
frank sleep apnea

14. Cognitive issues are characterized as:
slowness in processing
difficulties with attention or concentration
problems with word retrieval
short-term memory loss
speed of processing is age-appropriate

15. Symptoms of anxiety and depression are common
prevalence of mood disorders in FM 80%

16. Overlapping Syndromes
headaches
facial/jaw pain
Regional myofascial pain particularly involving the neck or back
Arthritis
Visceral pain

17. Comorbid Conditions
chronic musculoskeletal infectious ,metabolic,psychiatric conditions(mimicer or trigger for FM)
inflammatory rheumatic disorders
Degenerative disorders
These conditions serve as peripheral pain generators to
alter central pain- processing pathways

18. Psychosocial Considerations
onset and exacerbation of Symptoms often during stress
This pattern may reflect an interaction among central stress
physiology, anxiety, and central pain-processing
pathways
Understanding of current psychosocial stressors will aid in
patient management
If post traumatic stress disorder is an issue, the clinician should be aware of it and consider treatment options

19. Functional Impairment
Functional assessment should include physical, mental, and social domain

20. Common Conditions in the Differential Diagnosis of Fibromyalgia
Inflammatory
Polymyalgia rheumatica
Inflammatory arthritis
Connective tissue diseases
Infectious
Hepatitis C
HIV infection
Parvovirus B19 infection
Epstein-Barr virus infection

21. Common Conditions in the Differential Diagnosis of Fibromyalgia
Noninflammatory
Degenerative joint/spine/disk disease
Myofascial pain syndromes
Bursitis, tendinitis
Endocrine
Hypo- or hyperthyroidism
Hyperparathyroidism

22. Common Conditions in the Differential Diagnosis of Fibromyalgia
Neurologic Diseases
Multiple sclerosis
Psychiatric Disease
Drugs
Statins
Aromatase inhibitors

23. LABORATORY TESTING Routine laboratory tests are normal
diagnostic testing is focused on exclusion of other diagnoses
Most patients with new chronic widespread pain should be assessed for the most common entities in the differential diagnosis

24. RADIOGRAPHIC TESTING
Radiographic testing should be used sparingly and only for diagnosis of inflammatory arthritis
MRI of the spine for features suggesting inflammatory spine disease or neurologic symptoms

25. Laboratory Testing
Routine
ESR
CRP
CBC
TSH

26. Laboratory and Radiographic Testing
Guided by History and Physical Examination
ANA
Anti-SSA and anti-SSB
Rf and anti–cyclic citrullinated peptide (anti-CCP)
CPK
Viral and bacterial serologies
Spine and joint radiographs

27. GENETICS AND PHYSIOLOGY
Genes associated with metabolism,transport, and receptors of serotonin
Psychophysical testing of patients with FM has demonstrated
altered sensory afferent pain processing and impaired descending
noxious inhibitory control leading to hyperalgesia and allodynia

28. TREATMENT
NONPHARMACOLOGIC TREATMENT
PHARMACOLOGIC APPROACHES

29. NONPHARMACOLOGIC TREATMENT
focus on improved function
Discourage of Illness behaviors, such as frequent physician visits

30. Treatment strategies should include:
low levels of aerobic exercise
water-based programs (in postexertional malaise)
Activities that promote improved physical function with relaxation
(yoga and Tai Chi)
Strength training

31. Exercise programs are helpful in reducing tenderness and enhancing self efficacy
Cognitive-behavioral strategies to improve sleep hygiene
and reduce illness behaviors

32. PHARMACOLOGIC APPROACHES
opioid analgesics are to be avoided
Treatment of pain and sleep disturbance:
sedating antidepressants such as amitriptyline and alpha-2-delta ligands
Treatment of fatigue, anxiety, or depression:
Duloxetine or milnacipran, may be the best first choice