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1) A brief introduction to
Fibromyalgia
2) Treatment strategies including
Traditional and Medical Acupuncture.
Karavis Y. Miltiades, MD, FICAE
Consultant in Physical Medicine & Rehabilitation
President Hellenic Medical Acupuncture Society
Director of acupuncture Dpt FILOKTITIS Medical Rehabilitation Center
 Up to 2% of the general population has fibromyalgia syndrome.
 The ratio of women to men equals to 7 to 1. Today (new diagnostic
criteria), 3/1. Hence, 80 to 90% of all patients are women.
 Diagnosis of FMS is difficult to set. Usually, the time between the
beginning of the symptoms and the diagnosis of FMS is 5 years.
 60% of patients continue to suffer from pain of mild or severe
intensity many years after diagnosis.
 90% of patients remain symptomatic during all their lives.
17% of patients call themselves handicapped or disabled.
 6% receive regularly a disability allowance (USA, UK, France).
Fibromyalgia syndrome (FMS) is a known rheumatologic condition
of unknown etiology characterized by generalized - widespread
chronic musculoskeletal pain and tenderness on palpation of
tendino-musculo-skeletal sites called tender points.
In addition to pain, the syndrome is associated with a variety of
other symptoms such as fatigue, headache, insomnia, irritable bowel
syndrome, depression and/or anxiety, dysmenorrhea, Raynaud’s like
syndromes etc.
It belongs to a specific category of chronic pain syndromes
which is called Pain Amplification Syndromes.
ACR, 1990
Acupuncture for fibromyalgia
Clinical examination
Upper border of Trapezius – mid portion
Acupuncture for fibromyalgia
What is FM syndrome ???
Is it a musculo-skeletal disorder ?
Is it a inflammatory / rheumatologic problem ?
Is it an illness of central nervous system ?
Is it a mental condition ?
Is it a psychological disease ?
Fibromyalgia is a prototype of
Central Pain Syndromes.
It is a Chronic Pain
Syndrome.
Chronic Pain usually involves
CNS Changes.
Hypersensitization
(a form of neuropathic pain)
What is Central
Sensitization Syndrome
Central = Central nervous system (brain, Spinal cord)
Sensitization = describes the end result of a process that leaves
someone sensitive on a particular kind of input (stimulus). Neuro-
physiologically means that peripheral nociceptors could became
sensitive to stimuli.
Syndrome = Is a collection of signs and symptoms that occur
together and characterize a particular abnormality.
Manifestations = pain hypersensitivity, tactile allodynia, pressure
hyperalgesia, after-responce and temporal summation = which
characterizes a phenomenon called “wind-up”.
Other Central
Sensitizing Syndromes
Somatic
expression
disorders
• Irritable bowel syndrome
• Irritable bladder syndrome
• Chronic pelvic pain
• Chronic fatigue syndrome
• Chronic TMJ
• Chronic Headache
• Restless leg syndrome
• Non-cardiac chest pain
Psycho-
pathological
syndromes
• Depression
• PTSD
• Bipolar disorder
• Primary Insomnia
• OCD
• Anxiety
No tests, no biomarkers, only history ???
The main characteristic is hypersensitivity to external stimuli.
Nociceptive
Pain
Neuropathic
Pain
Mixed
A combination of primary
injury and secondary
effects from the CNS.
• Arthritis
• Sports injury
• Postoperative pain
• Diabetic neuropathy
• Post-herpetic neuralgia
• Trigeminal neuralgia
Chronic LBP
Fibromyalgia
Chronic neck pain
TPs
Peripheral component Neuropathic component
Diagnosis of FM
It is a diagnosis of EXCLUSION
There are NO specific tests (it is a syndrome, not a disease)
The diagnosis is based on History and Physical examination.
S: Subjective signs
O: Objective signs
A: Assessment
P: Plan
Rarely: The patient will say: I think I have 13/18 FM tender points
More often: I’m depressed, I can’t sleep, I’m tired all the time, I ache
all over, I'm afraid I’m going to lose my job, my nerves are shot.
S.O.A.P.: A “rule” which is
followed by doctors in order
to address to chronic pain
patients…
What is new ???
The second exclusion refers to
Depression. Depression is a
common symptom which can be
observed in many other
rheumatological patients, such as
patients with osteoarthritis, lupus,
and rheumatoid arthritis. So, it is
not representative of FMS, and
that’s the reason why it is also
excluded.
First exclusion: the Tender Points.
Pain, fatigue, sleep disturbances,
multiple somatic symptoms, and
cognitive difficulties are now
believed to be the most
significant features of the
syndrome.
That’s why Tender Points are
excluded from the diagnostic
criteria.
ACR, 2010
Fibromyalgia – New definition
Fibromyalgia is a disorder
characterized by widespread
musculoskeletal pain
accompanied by fatigue, sleep,
memory and mood issues.
Fibromyalgia is a disorder of
unknown etiology
characterized by widespread
pain, abnormal pain
processing, sleep
disturbance, fatigue and
often psychological
distress.
Mayo clinic stuff.
CDC (centers for
disease control and
prevention).
ACR, 2010
ACR 2010 FM diagnostic criteria
• Widespread pain (the hallmark symptom)
• Fatigue
• Unrefreshing sleep
• Cognitive symptoms
Plus
• Headache
• Depression
• Lower abdominal pain / cramping
Arthritis Care Res (Hoboken). 2010 May;62(5):600-10. doi: 10.1002/acr.20140.
The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of
symptom severity.
Wolfe F1, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB
My preferable
Neurophysiological
definition of FM
“…A chronic disorder characterized by abnormal somatosensory
processing stemming from changing within the Central Nervous
System (brain, spinal cord.)...”
“…An imbalance between excitatory and inhibitory influences on
pain-related pathways of the CNS…”
“…A change in the way the brain and spinal cord “listen” to the
body …”
Patrick B. Wood
ACR 2010 FM criteria
A patient satisfies diagnostic criteria for fibromyalgia
if the following 3 conditions are met:
1.Widespread pain index (WPI) ≥7 and symptom
severity scale score (SS) ≥5 or WPI 3 - 6 and SS scale
score ≥9.
2.Symptoms have been present at a similar level for
at least 3 months.
3.The patient does not have a disorder that would
otherwise explain the pain.
Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and
measurement of symptom severity. Arthritis Care Res (Hoboken). 2010;62:600-610.
MacFarlane GJ, Croft PR, Schollum J, Silman AJ. Widespread pain: is an improved classification possible? J Rheumatol. 1996;23:1628-1632.
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;38:1113-1122.
- See more at: http://www.rheumatologynetwork.com/fibromyalgia/new-and-modified-fibromyalgia-diagnostic-criteria#sthash.i3bKSmH4.dpuf
WPI: Note the number of areas in which the patient has had pain
over the last week. Score will be between 0 and 19.
Shoulder girdle, left
Shoulder girdle, right
Upper arm, left
Upper arm, right
Lower arm, left
Lower arm, right
Hip (buttock, trochanter), left
Hip (buttock, trochanter), right
Upper leg, left
Upper leg, right
Lower leg, left
Lower leg, right
Jaw, left
Jaw, right
Chest
Abdomen
Upper back
Lower back
Neck
Example, Score = 10
Find and download
this form from the
internet.
Learn how to
complete the form.
Use it to your patients.
Acupuncture for fibromyalgia
 Diffused pain which is localized in the extremities and in the central skeleton. It
is described as muscular pain.
 The intensity of pain changes. Periods without pain are rare. Pain deteriorates
with cold, wet, anxiety or other somatic or psychological stress. It ameliorates
with local application of heat, massage and light physical activity (aerobic
exercise).
 Morning stiffness, which in some cases lasts all day. In most of the cases lasts
half an hour up to 2 hours. It improves with activity and massage and deteriorates
with cold.
 Intense physical fatigue, which leads to full inactivity.
 A non revitalizing sleep. The patients do not awake refreshed but tired.
All symptoms are more intense during morning hours, they ameliorate during midday and deteriorate
again during afternoon and evening hours.
Acupuncture for fibromyalgia
Mechanism underline
Pain Perception
Somatic sensations
in FM patients
Enhanced pain
sensitivity to painful
stimulation:
Hyperalgesia
Painful response to
normally innocuous
stimulus:
Allodynia
Brain Function in Fibromyalgia: Altered Pain Processing and Cognitive Dysfunction
Francisco Mercado1, Paloma Barjola1, Marisa Fernández-Sánchez1, Virginia Guerra1 and Francisco Gómez-Esquer2
[1] Department of Psychology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain
[2] Department of Anatomy and Human Embryology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain
Are the
characteristics
of Neuropathic
Pain
What really happens ???
Brain Function in Fibromyalgia: Altered Pain Processing and Cognitive Dysfunction
Francisco Mercado1, Paloma Barjola1, Marisa Fernández-Sánchez1, Virginia Guerra1 and Francisco Gómez-Esquer2
[1] Department of Psychology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain
[2] Department of Anatomy and Human Embryology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain
Hyperalgesia / allodynia: Show a Central Sensitization Syndrome.
That means that the brain amplifies sensory information and/or pain
perception.
The “Brain factor” is more significant than “peripheral factor”
(inflammation??).
Nowadays, we believe that FM is accompanied by alterations in specific areas
of the brain.
This hypothesis is confirmed with fMRI findings.
Brain chemistry
fMRI
FM: chemical imbalance
• Low serotonin (deep sleep, anxiety, pain)
• Low NE (fatigue, pain)
• Low dopamine (cognitive, pleasure, increase sympathetic tone, libido)
• High SP, Glu (pain amplification)
• +/- Growth factors (nerve growth factors)
ALL OF THEM POSSES COMMUNICATING CHEMICALS
When any piece of that
system is disregulated
then, all the other
elements of the system
are disregulated at the
same time.
In order to treat: re-
regulate all of them.
The longer the pain,
the harder the cure.
Summary
• FMS is a neuro-biological entity.
• The Main characteristic is Pain and sensory amplification.
• There is Strong evidence of increased pro-nociceptive
neurotransmitters (glu, SP…) and decreased levels of anti-
nociceptive neurotransmitters (seroronin, NE …).
• It is Easy to diagnose, the diagnosis is history-based.
Three new concepts …
• FM patients are best managed in primary care setting.
• The ideal treatment has to be multimodal, drugs have only modest effect.
• Goals: Maintain function, control pain, remain in workforce.
Dr Ruth Dubin, 202-800 Princess St, Kingston, ON K7L 5E4;
e-mail rdubin@kingston.net
Can Fam Physician. Jul 2014; 60(7): 599–601.
Keep it simple
Easing the care burden of fibromyalgia
Ruth Dubin, MD PhD FCFP
Treatment of FM
patients
Fibromyalgia
Symptoms based
treatments
Pain
Fatigue
Sleep
Mood
Others
Mechanisms based
treatments
Symptoms
Function
Management
Modified from: R Jovey, Canadian Pain society 2009, R. Dubin, fibromyalgia: not as hard as it looks, 2013, Action Plan, Nova Scotia 2006.
Guide management
• There is No ideal treatment
• The approach is Symptom-based
• A combination of Non-pharmacological + pharmacological
strategies is required.
• Our goal is to maintain and improve functions of our patients
• Treat peripheral pain generators.
• Self-management is imperative
• Patient active participation
• Multimodal approach
• Realistic goals, coping strategies
• Pacing, but continue normal life
• Exercise
• Best available evidence
• Any type (aerobics, water, stretching, flexibility…)
• Movement is Key (Tai Chi, Qi Qong, Yoga, Pilates)
• CAM
• Insufficient evidence
• Symptoms oriented / acupuncture best of all
“The individual’s ability to manage
the symptoms, treatment, physical
and social consequences and lifestyle
changes inherent in living with a
chronic condition”. Barlow 2002
Active is better than passive
Keep wellness in the foreground
The patient is the expert
Patient takes responsibility for the program
Ruth E. Dubin, MD, PhD, FCFP., Karavis M. 2012
Management Strategy
Non pharmacological
Therapies
Goldenberg DL et al, JAMA, 2004;292:2388-2395.
Williams DA et al, J Reumatol. 2002;29:1280-1286.
Busch AJ et al, Cochrane Database Syst Rev, 2007;(4):CD003786
What do we cure ???
Brain Function in Fibromyalgia: Altered Pain Processing and Cognitive Dysfunction
Francisco Mercado1, Paloma Barjola1, Marisa Fernández-Sánchez1, Virginia Guerra1 and Francisco Gómez-Esquer2
[1] Department of Psychology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain
[2] Department of Anatomy and Human Embryology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain
Acupuncture:
General information
Two major Schools of
thought
Medical Acupuncture Approach
Or all of them ….
Basic Assumptions
Acupuncture stimulus is carried by
afferent peripheral nerves:
• The effect can be blocked by procaine.
• No Acupoints on somatosensory paralysis.
• No AP points on spinal cord injury.
• We observe profound AP effects from points
overlying major peripheral nerves.
• The 55% of the APs were located at the cluster
of the muscles.
Conclusions:
For Acupuncture points:
• Some acu-points are close to neuro-vascular bundles where the
nerves penetrate the body fascia (superficial nerves).
• Some of them are motor points (end-plate zone) (LI4, GB21)
• Some points where nerves bifurcate (GB 34, Per 4,6).
• Some points are associated with vascular elements and perivascular
plexuses (B 40, Lu 9).
• Some of them are in musle-tendon junction (B 57)
For acupuncture Meridians:
• Some of them have close relation with peripheral nerve pathways.
• Some of them have close relation with motor lines (mechanical
connection of the myofascial chains (lines) (ex 12 cutaneous regions
(Pi Bu) and the 12 muscle channels (Jing Jin).
ΣΤ 2
ΣΤ 3
ΙΙnd branch of
Trigeminal nerve
Relation between nerves and acupuncture meridians.
We can observe the correlation between the above…
Neil R. Borley. Clinical Surface Anatomy. Manson publishing. 1997
Neil R. Borley. Clinical Surface Anatomy. Manson publishing. 1997
Neil R. Borley. Clinical Surface Anatomy. Manson publishing. 1997
Neil R. Borley. Clinical Surface Anatomy. Manson publishing. 1997
GB 20, B 10
LI 14, 15, SJ 14
LI 10, SJ 8, 9
SJ 5
SJ 5
LI 10, SJ 8, 9
SI 9, SJ 12, 13
SI, B
SI 3
SI, B
points
These muscle groups act as one muscle.
Photos from: Anatomy Trains, Thomas W. Myers, Churchill Livingstone, 1995.
Acupoints and meridians in relation to muscle
groups that have similar function.
Acupuncture for FMS
patients
We always look at the
patient’s symptoms.
Not at the name of the
disease.
TCM Acupuncture for
FMS patients
Diffuse - widespread pain
Musculoskeletal pain
Fatigue
Insomnia
Depression
Stiffness
Swelling
Main symptomes
of FMS
Wind
Humidity (phlegm)
Female / male = 7 / 1
Menstruation + labors =
Lowering Kidney energy=
Disequilibrium Kidney Yin - Yang =
Deficiency of Chi and blood =
Exopathic attack of wind and dump.
Wind = L 3, TW 5,6
Phlegm = SP 6,9, PER 4,6
Energy in blood = LI 4, 11, ST 36, RM 12
Spleen 6 (SanYinJiao)
Liver 8 (QuQuan)
Urinary Bladder 20 (Pi Shu)
Urinary Bladder 23 (Shen Shu)
Stomach 36 (ZuSanLi)
Ren Mai 6 (QiHai)
Ren Mai 4 (GuanYuai)
Biomedical Acupuncture
for FMS patients
Bio-medical Acupuncture
Approach
Any type of peripheral stimulation
(mechanical, thermal, chemical, injury,
touch …) is ultimately transformed into
nerve pulses that travel along the peripheral
nerves to the central neuroaxis.
Nerve signals generate electrical and
chemical events that are decoded by the
central nervous system according to the type,
frequency, duration and intensity of
stimulus.
Sensory – dependent neural plasticity
Casale R, Atzeni F, Sarzi-Puttini P, Neurophysiological background fro physical therapies in fibromyalgia,
Reumatismio, 4/2012, Department of Clinical Neurophysiology and Rehabilitation Unit.
Physical medicine / rehabilitation
Local (peripheral) pain = Physical therapies, acupuncture
Segmental pain = physical therapies (+/-) & acupuncture
Widespread somatic pain = exercise, pool, groups, acupuncture, drugs
Fibrofog = Systemic acupuncture points
Small fiber polyneuropathy = Anti-inflammatory acu points
Acupuncture for fibromyalgia
Local points
for the local
pain
Dermatome or
Myotome (segmental
Innervation of the …)
Acupuncture
points
Physiological
effect
Neck C4 - C7
Arm C5 - C8
Autonomic arm T1 - T3
Lumbar & leg L1 - S1
Kidneys - suprarenal
glands T11 - L1
ACTH, cortizole
Anti-inflammation
Vascularization
Analgesia
Analgesia
Analgesia
AnalgesiaLI 4, 10, TW 5, 15, GB 21, GV 14,
SI 13, 14, 15,
B 21-27, 44-47, GV 5,4,3, B 31
G 30, B 54, B 57, B 60, K 5,6,7
B 11, 12, 13, 36, 37, GV 14, 13
B 20, 21, 23, 44, 45, GV 6,7
RM 12
Pains in:
Cervical region
Upper Limb
Pains in:
Lumbar region
Lower Limb
Pains in:
Thoracic region
Abdominal pains
Zoster-like pain
Locations
of Segmental
Acu-points
Locations
of Systemic
Acu-points
GB 20, B 10
CV 5, 6
Phrenic n.
CV 22, 21, 19, 18
B 15 - 18 Esophagus
CV 17,16,15
K 22
B 15-18 Stomach
CV 11,10,9
B 18-20
Small intestine
CV 9,7,6
St 25
Sp 15
B 21-23
B 27-28
Large intestine
Large intestine
Th 6 – Th 5
S 1 – S 4
Esophagus
Th2 – Th 5-7
Active zones
Stomach
Th5 – Th 10-12
Small intestine
Th 5 – Th 12
Karavis M. MD, FICAE, Physiatrist, Athens 2014.
Acupuncture for fibromyalgia
Concha of the Ear is the only place
on the surface of the body where the
Vagus nerve can be easily stimulated
producing a broad parasympathetic
effect (Ulett et al 1998, 2002)
Anti-inflammatory regions
of the ear and mastoid
process.
Vagus
innervation
Karavis M. MD, FICAE,
Physiatrist, Athens 2012.
Relationship of Vagus with Ansa Cervicalis: C1 – C3
Karavis M. MD, FICAE, Physiatrist, Athens 2012.
Greater and lesser
Splachnic nerves
and
Right vagus nerve
Coeliac ganglion
L1
Mastoid process (ΟΚ 10, ΧΚ 12, 20, ΤΘ 17)
Shu – Mu of the Spleen, Liver, adrenal T5 – T12
OK 18, OK 20, OK 23 and CV 12, CV 6, CV 3
Celiac plexus
(or coeliac or Solar)
Karavis M. MD, FICAE, Physiatrist, Athens 2014.
Immune system
Stress response system
Hormones
Psychosomatic disorders
Celiac plexus area= T5-T12
Celiac ganglia – L1
(just below the 12th rib)
Anti-inflammatory areas
According to segmental innervation
B 18
B 20
B 23
CV 15
CV 12
CV 6
Fibrofog: Acupuncture points
GV 20
GB 20
Yintang
Taiyang
Th 1 – Th 3 level (ANS)
Per 6 (L-arginine – NO)
Specific effect in cerebral hemodynamics
Acupoint-brain correlation (for fibrofog)
Acupuncture points
traditionally implicated
for visual functions were
shown to modulate the
blood flow velocity of the
corresponding cerebral
arteries (Hegu, Zusanli,
Kunlun, Zhiyin).
Neuropetides & hormones
related with :
Pain
Emotions
Behavior
Endocrine function
Immune response
All vegetative reactions
Psycho-neuro-endocrino-immunology
The science of chemical communication between
Body (nervous, endocrine, immune system) and
Mind.
Per 6
TW 5
SI 3
LI 4, 10, 11
ST 36, 39, 40
SP 6, 9
L 3
K 6
GB 34, 39
Experimental data:
Modulation of pain,
emotional state and
psychic state.
Systemic action
Pain: Acupuncture points
Upper limb
Lower limb
Auricular points
Karavis M, Physiatris, 2014
Design: Labretsa D, 2010
Pain Inflammation
Mood, fibrofog,
systemic
Anxiety / depression points
Depression: some more ideas…
H 7
Per 7
Lu 9
Per 6
H 7
Per 7
Lu 9
Per 6
Points to improve deep sleep
Median nerve stimulation.
Also for fibrofog (increase NO)
R
Shenmen
Subcortex
Anti-aggression
Anti-fear point
Anti-aggression point
Psychosomatic point
Celiac plexus
Cardiac plexus
Vagus
Fibromyalgia still remains a controversial
but very interesting field for both clinical
doctors and researchers.

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Acupuncture for fibromyalgia

  • 1. 1) A brief introduction to Fibromyalgia 2) Treatment strategies including Traditional and Medical Acupuncture. Karavis Y. Miltiades, MD, FICAE Consultant in Physical Medicine & Rehabilitation President Hellenic Medical Acupuncture Society Director of acupuncture Dpt FILOKTITIS Medical Rehabilitation Center
  • 2.  Up to 2% of the general population has fibromyalgia syndrome.  The ratio of women to men equals to 7 to 1. Today (new diagnostic criteria), 3/1. Hence, 80 to 90% of all patients are women.  Diagnosis of FMS is difficult to set. Usually, the time between the beginning of the symptoms and the diagnosis of FMS is 5 years.  60% of patients continue to suffer from pain of mild or severe intensity many years after diagnosis.  90% of patients remain symptomatic during all their lives. 17% of patients call themselves handicapped or disabled.  6% receive regularly a disability allowance (USA, UK, France).
  • 3. Fibromyalgia syndrome (FMS) is a known rheumatologic condition of unknown etiology characterized by generalized - widespread chronic musculoskeletal pain and tenderness on palpation of tendino-musculo-skeletal sites called tender points. In addition to pain, the syndrome is associated with a variety of other symptoms such as fatigue, headache, insomnia, irritable bowel syndrome, depression and/or anxiety, dysmenorrhea, Raynaud’s like syndromes etc. It belongs to a specific category of chronic pain syndromes which is called Pain Amplification Syndromes. ACR, 1990
  • 5. Clinical examination Upper border of Trapezius – mid portion
  • 7. What is FM syndrome ??? Is it a musculo-skeletal disorder ? Is it a inflammatory / rheumatologic problem ? Is it an illness of central nervous system ? Is it a mental condition ? Is it a psychological disease ?
  • 8. Fibromyalgia is a prototype of Central Pain Syndromes. It is a Chronic Pain Syndrome. Chronic Pain usually involves CNS Changes. Hypersensitization (a form of neuropathic pain)
  • 9. What is Central Sensitization Syndrome Central = Central nervous system (brain, Spinal cord) Sensitization = describes the end result of a process that leaves someone sensitive on a particular kind of input (stimulus). Neuro- physiologically means that peripheral nociceptors could became sensitive to stimuli. Syndrome = Is a collection of signs and symptoms that occur together and characterize a particular abnormality. Manifestations = pain hypersensitivity, tactile allodynia, pressure hyperalgesia, after-responce and temporal summation = which characterizes a phenomenon called “wind-up”.
  • 10. Other Central Sensitizing Syndromes Somatic expression disorders • Irritable bowel syndrome • Irritable bladder syndrome • Chronic pelvic pain • Chronic fatigue syndrome • Chronic TMJ • Chronic Headache • Restless leg syndrome • Non-cardiac chest pain Psycho- pathological syndromes • Depression • PTSD • Bipolar disorder • Primary Insomnia • OCD • Anxiety No tests, no biomarkers, only history ??? The main characteristic is hypersensitivity to external stimuli.
  • 11. Nociceptive Pain Neuropathic Pain Mixed A combination of primary injury and secondary effects from the CNS. • Arthritis • Sports injury • Postoperative pain • Diabetic neuropathy • Post-herpetic neuralgia • Trigeminal neuralgia Chronic LBP Fibromyalgia Chronic neck pain TPs Peripheral component Neuropathic component
  • 12. Diagnosis of FM It is a diagnosis of EXCLUSION There are NO specific tests (it is a syndrome, not a disease) The diagnosis is based on History and Physical examination. S: Subjective signs O: Objective signs A: Assessment P: Plan Rarely: The patient will say: I think I have 13/18 FM tender points More often: I’m depressed, I can’t sleep, I’m tired all the time, I ache all over, I'm afraid I’m going to lose my job, my nerves are shot. S.O.A.P.: A “rule” which is followed by doctors in order to address to chronic pain patients…
  • 13. What is new ??? The second exclusion refers to Depression. Depression is a common symptom which can be observed in many other rheumatological patients, such as patients with osteoarthritis, lupus, and rheumatoid arthritis. So, it is not representative of FMS, and that’s the reason why it is also excluded. First exclusion: the Tender Points. Pain, fatigue, sleep disturbances, multiple somatic symptoms, and cognitive difficulties are now believed to be the most significant features of the syndrome. That’s why Tender Points are excluded from the diagnostic criteria. ACR, 2010
  • 14. Fibromyalgia – New definition Fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Fibromyalgia is a disorder of unknown etiology characterized by widespread pain, abnormal pain processing, sleep disturbance, fatigue and often psychological distress. Mayo clinic stuff. CDC (centers for disease control and prevention). ACR, 2010
  • 15. ACR 2010 FM diagnostic criteria • Widespread pain (the hallmark symptom) • Fatigue • Unrefreshing sleep • Cognitive symptoms Plus • Headache • Depression • Lower abdominal pain / cramping Arthritis Care Res (Hoboken). 2010 May;62(5):600-10. doi: 10.1002/acr.20140. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Wolfe F1, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB
  • 16. My preferable Neurophysiological definition of FM “…A chronic disorder characterized by abnormal somatosensory processing stemming from changing within the Central Nervous System (brain, spinal cord.)...” “…An imbalance between excitatory and inhibitory influences on pain-related pathways of the CNS…” “…A change in the way the brain and spinal cord “listen” to the body …” Patrick B. Wood
  • 17. ACR 2010 FM criteria A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met: 1.Widespread pain index (WPI) ≥7 and symptom severity scale score (SS) ≥5 or WPI 3 - 6 and SS scale score ≥9. 2.Symptoms have been present at a similar level for at least 3 months. 3.The patient does not have a disorder that would otherwise explain the pain. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010;62:600-610. MacFarlane GJ, Croft PR, Schollum J, Silman AJ. Widespread pain: is an improved classification possible? J Rheumatol. 1996;23:1628-1632. 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;38:1113-1122. - See more at: http://www.rheumatologynetwork.com/fibromyalgia/new-and-modified-fibromyalgia-diagnostic-criteria#sthash.i3bKSmH4.dpuf
  • 18. WPI: Note the number of areas in which the patient has had pain over the last week. Score will be between 0 and 19. Shoulder girdle, left Shoulder girdle, right Upper arm, left Upper arm, right Lower arm, left Lower arm, right Hip (buttock, trochanter), left Hip (buttock, trochanter), right Upper leg, left Upper leg, right Lower leg, left Lower leg, right Jaw, left Jaw, right Chest Abdomen Upper back Lower back Neck Example, Score = 10
  • 19. Find and download this form from the internet. Learn how to complete the form. Use it to your patients.
  • 21.  Diffused pain which is localized in the extremities and in the central skeleton. It is described as muscular pain.  The intensity of pain changes. Periods without pain are rare. Pain deteriorates with cold, wet, anxiety or other somatic or psychological stress. It ameliorates with local application of heat, massage and light physical activity (aerobic exercise).  Morning stiffness, which in some cases lasts all day. In most of the cases lasts half an hour up to 2 hours. It improves with activity and massage and deteriorates with cold.  Intense physical fatigue, which leads to full inactivity.  A non revitalizing sleep. The patients do not awake refreshed but tired. All symptoms are more intense during morning hours, they ameliorate during midday and deteriorate again during afternoon and evening hours.
  • 23. Mechanism underline Pain Perception Somatic sensations in FM patients Enhanced pain sensitivity to painful stimulation: Hyperalgesia Painful response to normally innocuous stimulus: Allodynia Brain Function in Fibromyalgia: Altered Pain Processing and Cognitive Dysfunction Francisco Mercado1, Paloma Barjola1, Marisa Fernández-Sánchez1, Virginia Guerra1 and Francisco Gómez-Esquer2 [1] Department of Psychology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain [2] Department of Anatomy and Human Embryology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain Are the characteristics of Neuropathic Pain
  • 24. What really happens ??? Brain Function in Fibromyalgia: Altered Pain Processing and Cognitive Dysfunction Francisco Mercado1, Paloma Barjola1, Marisa Fernández-Sánchez1, Virginia Guerra1 and Francisco Gómez-Esquer2 [1] Department of Psychology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain [2] Department of Anatomy and Human Embryology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain Hyperalgesia / allodynia: Show a Central Sensitization Syndrome. That means that the brain amplifies sensory information and/or pain perception. The “Brain factor” is more significant than “peripheral factor” (inflammation??). Nowadays, we believe that FM is accompanied by alterations in specific areas of the brain. This hypothesis is confirmed with fMRI findings. Brain chemistry fMRI
  • 25. FM: chemical imbalance • Low serotonin (deep sleep, anxiety, pain) • Low NE (fatigue, pain) • Low dopamine (cognitive, pleasure, increase sympathetic tone, libido) • High SP, Glu (pain amplification) • +/- Growth factors (nerve growth factors) ALL OF THEM POSSES COMMUNICATING CHEMICALS When any piece of that system is disregulated then, all the other elements of the system are disregulated at the same time. In order to treat: re- regulate all of them.
  • 26. The longer the pain, the harder the cure.
  • 27. Summary • FMS is a neuro-biological entity. • The Main characteristic is Pain and sensory amplification. • There is Strong evidence of increased pro-nociceptive neurotransmitters (glu, SP…) and decreased levels of anti- nociceptive neurotransmitters (seroronin, NE …). • It is Easy to diagnose, the diagnosis is history-based. Three new concepts … • FM patients are best managed in primary care setting. • The ideal treatment has to be multimodal, drugs have only modest effect. • Goals: Maintain function, control pain, remain in workforce. Dr Ruth Dubin, 202-800 Princess St, Kingston, ON K7L 5E4; e-mail rdubin@kingston.net Can Fam Physician. Jul 2014; 60(7): 599–601. Keep it simple Easing the care burden of fibromyalgia Ruth Dubin, MD PhD FCFP
  • 28. Treatment of FM patients Fibromyalgia Symptoms based treatments Pain Fatigue Sleep Mood Others Mechanisms based treatments Symptoms Function
  • 29. Management Modified from: R Jovey, Canadian Pain society 2009, R. Dubin, fibromyalgia: not as hard as it looks, 2013, Action Plan, Nova Scotia 2006.
  • 30. Guide management • There is No ideal treatment • The approach is Symptom-based • A combination of Non-pharmacological + pharmacological strategies is required. • Our goal is to maintain and improve functions of our patients • Treat peripheral pain generators. • Self-management is imperative • Patient active participation • Multimodal approach • Realistic goals, coping strategies • Pacing, but continue normal life • Exercise • Best available evidence • Any type (aerobics, water, stretching, flexibility…) • Movement is Key (Tai Chi, Qi Qong, Yoga, Pilates) • CAM • Insufficient evidence • Symptoms oriented / acupuncture best of all “The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition”. Barlow 2002 Active is better than passive Keep wellness in the foreground The patient is the expert Patient takes responsibility for the program Ruth E. Dubin, MD, PhD, FCFP., Karavis M. 2012
  • 32. Non pharmacological Therapies Goldenberg DL et al, JAMA, 2004;292:2388-2395. Williams DA et al, J Reumatol. 2002;29:1280-1286. Busch AJ et al, Cochrane Database Syst Rev, 2007;(4):CD003786
  • 33. What do we cure ??? Brain Function in Fibromyalgia: Altered Pain Processing and Cognitive Dysfunction Francisco Mercado1, Paloma Barjola1, Marisa Fernández-Sánchez1, Virginia Guerra1 and Francisco Gómez-Esquer2 [1] Department of Psychology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain [2] Department of Anatomy and Human Embryology, Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain
  • 35. Two major Schools of thought
  • 37. Basic Assumptions Acupuncture stimulus is carried by afferent peripheral nerves: • The effect can be blocked by procaine. • No Acupoints on somatosensory paralysis. • No AP points on spinal cord injury. • We observe profound AP effects from points overlying major peripheral nerves. • The 55% of the APs were located at the cluster of the muscles.
  • 38. Conclusions: For Acupuncture points: • Some acu-points are close to neuro-vascular bundles where the nerves penetrate the body fascia (superficial nerves). • Some of them are motor points (end-plate zone) (LI4, GB21) • Some points where nerves bifurcate (GB 34, Per 4,6). • Some points are associated with vascular elements and perivascular plexuses (B 40, Lu 9). • Some of them are in musle-tendon junction (B 57) For acupuncture Meridians: • Some of them have close relation with peripheral nerve pathways. • Some of them have close relation with motor lines (mechanical connection of the myofascial chains (lines) (ex 12 cutaneous regions (Pi Bu) and the 12 muscle channels (Jing Jin).
  • 39. ΣΤ 2 ΣΤ 3 ΙΙnd branch of Trigeminal nerve
  • 40. Relation between nerves and acupuncture meridians. We can observe the correlation between the above… Neil R. Borley. Clinical Surface Anatomy. Manson publishing. 1997
  • 41. Neil R. Borley. Clinical Surface Anatomy. Manson publishing. 1997
  • 42. Neil R. Borley. Clinical Surface Anatomy. Manson publishing. 1997
  • 43. Neil R. Borley. Clinical Surface Anatomy. Manson publishing. 1997
  • 44. GB 20, B 10 LI 14, 15, SJ 14 LI 10, SJ 8, 9 SJ 5 SJ 5 LI 10, SJ 8, 9 SI 9, SJ 12, 13 SI, B SI 3 SI, B points These muscle groups act as one muscle. Photos from: Anatomy Trains, Thomas W. Myers, Churchill Livingstone, 1995. Acupoints and meridians in relation to muscle groups that have similar function.
  • 46. We always look at the patient’s symptoms. Not at the name of the disease. TCM Acupuncture for FMS patients
  • 47. Diffuse - widespread pain Musculoskeletal pain Fatigue Insomnia Depression Stiffness Swelling Main symptomes of FMS Wind Humidity (phlegm) Female / male = 7 / 1 Menstruation + labors = Lowering Kidney energy= Disequilibrium Kidney Yin - Yang = Deficiency of Chi and blood = Exopathic attack of wind and dump. Wind = L 3, TW 5,6 Phlegm = SP 6,9, PER 4,6 Energy in blood = LI 4, 11, ST 36, RM 12
  • 48. Spleen 6 (SanYinJiao) Liver 8 (QuQuan) Urinary Bladder 20 (Pi Shu) Urinary Bladder 23 (Shen Shu) Stomach 36 (ZuSanLi) Ren Mai 6 (QiHai) Ren Mai 4 (GuanYuai)
  • 51. Any type of peripheral stimulation (mechanical, thermal, chemical, injury, touch …) is ultimately transformed into nerve pulses that travel along the peripheral nerves to the central neuroaxis. Nerve signals generate electrical and chemical events that are decoded by the central nervous system according to the type, frequency, duration and intensity of stimulus. Sensory – dependent neural plasticity Casale R, Atzeni F, Sarzi-Puttini P, Neurophysiological background fro physical therapies in fibromyalgia, Reumatismio, 4/2012, Department of Clinical Neurophysiology and Rehabilitation Unit. Physical medicine / rehabilitation
  • 52. Local (peripheral) pain = Physical therapies, acupuncture Segmental pain = physical therapies (+/-) & acupuncture Widespread somatic pain = exercise, pool, groups, acupuncture, drugs Fibrofog = Systemic acupuncture points Small fiber polyneuropathy = Anti-inflammatory acu points
  • 54. Local points for the local pain
  • 55. Dermatome or Myotome (segmental Innervation of the …) Acupuncture points Physiological effect Neck C4 - C7 Arm C5 - C8 Autonomic arm T1 - T3 Lumbar & leg L1 - S1 Kidneys - suprarenal glands T11 - L1 ACTH, cortizole Anti-inflammation Vascularization Analgesia Analgesia Analgesia AnalgesiaLI 4, 10, TW 5, 15, GB 21, GV 14, SI 13, 14, 15, B 21-27, 44-47, GV 5,4,3, B 31 G 30, B 54, B 57, B 60, K 5,6,7 B 11, 12, 13, 36, 37, GV 14, 13 B 20, 21, 23, 44, 45, GV 6,7 RM 12
  • 56. Pains in: Cervical region Upper Limb Pains in: Lumbar region Lower Limb Pains in: Thoracic region Abdominal pains Zoster-like pain Locations of Segmental Acu-points Locations of Systemic Acu-points
  • 57. GB 20, B 10 CV 5, 6 Phrenic n. CV 22, 21, 19, 18 B 15 - 18 Esophagus CV 17,16,15 K 22 B 15-18 Stomach CV 11,10,9 B 18-20 Small intestine CV 9,7,6 St 25 Sp 15 B 21-23 B 27-28 Large intestine
  • 58. Large intestine Th 6 – Th 5 S 1 – S 4 Esophagus Th2 – Th 5-7 Active zones Stomach Th5 – Th 10-12 Small intestine Th 5 – Th 12 Karavis M. MD, FICAE, Physiatrist, Athens 2014.
  • 60. Concha of the Ear is the only place on the surface of the body where the Vagus nerve can be easily stimulated producing a broad parasympathetic effect (Ulett et al 1998, 2002) Anti-inflammatory regions of the ear and mastoid process. Vagus innervation Karavis M. MD, FICAE, Physiatrist, Athens 2012.
  • 61. Relationship of Vagus with Ansa Cervicalis: C1 – C3 Karavis M. MD, FICAE, Physiatrist, Athens 2012.
  • 62. Greater and lesser Splachnic nerves and Right vagus nerve Coeliac ganglion L1 Mastoid process (ΟΚ 10, ΧΚ 12, 20, ΤΘ 17) Shu – Mu of the Spleen, Liver, adrenal T5 – T12 OK 18, OK 20, OK 23 and CV 12, CV 6, CV 3 Celiac plexus (or coeliac or Solar) Karavis M. MD, FICAE, Physiatrist, Athens 2014. Immune system Stress response system Hormones Psychosomatic disorders
  • 63. Celiac plexus area= T5-T12 Celiac ganglia – L1 (just below the 12th rib) Anti-inflammatory areas According to segmental innervation B 18 B 20 B 23 CV 15 CV 12 CV 6
  • 64. Fibrofog: Acupuncture points GV 20 GB 20 Yintang Taiyang Th 1 – Th 3 level (ANS) Per 6 (L-arginine – NO)
  • 65. Specific effect in cerebral hemodynamics Acupoint-brain correlation (for fibrofog) Acupuncture points traditionally implicated for visual functions were shown to modulate the blood flow velocity of the corresponding cerebral arteries (Hegu, Zusanli, Kunlun, Zhiyin).
  • 66. Neuropetides & hormones related with : Pain Emotions Behavior Endocrine function Immune response All vegetative reactions Psycho-neuro-endocrino-immunology The science of chemical communication between Body (nervous, endocrine, immune system) and Mind.
  • 67. Per 6 TW 5 SI 3 LI 4, 10, 11 ST 36, 39, 40 SP 6, 9 L 3 K 6 GB 34, 39 Experimental data: Modulation of pain, emotional state and psychic state. Systemic action Pain: Acupuncture points Upper limb Lower limb
  • 68. Auricular points Karavis M, Physiatris, 2014 Design: Labretsa D, 2010 Pain Inflammation Mood, fibrofog, systemic
  • 70. Depression: some more ideas… H 7 Per 7 Lu 9 Per 6 H 7 Per 7 Lu 9 Per 6 Points to improve deep sleep Median nerve stimulation. Also for fibrofog (increase NO)
  • 72. Anti-fear point Anti-aggression point Psychosomatic point Celiac plexus Cardiac plexus Vagus
  • 73. Fibromyalgia still remains a controversial but very interesting field for both clinical doctors and researchers.