Information and updates on chronic pain associated with Fibromyalgia

1. Fibromyalgia

2. Bridgit Finley, PT, DPT, M.Ed., OCS
bfinley@ptcentral.org
www.ptcentral.org
579-1600
Check us out on Facebook

3. Objectives
State the ACR clinical definition of FM.
Identify 5 or more overlapping co-morbidities.
Outline the risk factors.
Describe the non-pharmacologic approach to
treatment.
Review the prognoses for FM patients.

4. Pre Test
FM is caused by a virus?
3-6% of the population
has FM?
FM is progressive and
fatal?
FM is diagnosed with a
blood test?
Exercise has been shown
to decrease FM
symptoms?
False
True
False
False
True

5. Introduction
Fibromyalgia – what is it?
Be skeptical if you read something that says it will
“cure” symptoms.
Patients need to understand their symptoms so that
they can begin to take control and manage their pain.

6. Overview
Common condition characterized by long-term,
body-wide pain and tender points in joints, muscles,
tendons, and other soft tissue.
A chronic pain state.
Nerve stimuli causing pain (reduced pain threshold).
Symptoms: fatigue, morning stiffness, sleep
problems, headaches, depression and anxiety.

7. Definition of Fibromyalgia
“Chronic and widespread pain located at 11
or more of 18 tender points.”
American College of Rheumatology,
1990.
In 1908, Gowen first described FMS.

8. Fibromyalgia
A common and complex chronic pain disorder that
affects people physically, mentally and socially.
It is a syndrome rather than a disease.
A syndrome is a collection of signs and symptoms
that occur together without an identifiable cause.

9. Disease
A disease, which is a medical condition with specific
cause or causes and recognizable signs and
symptoms.
Fibromyalgia is a set of symptoms not caused by a
disease.
Tissue pathology with distinctive symptoms and a
causative agent.
Tuberculosis, causing a chronic cough, tubercle
bacillus is causative agent and can be cured.

10. Science of Fibromyalgia
Tends to be treated rather dismissively by Medical
Community.
Controversy – not disease process, can’t be cured.
Problem with doctors is that it can not be understood
according to the classic medical model.
This model is used with all medical training.

11. What is the problem?
It is not a primary psychological disorder.
As in many chronic conditions, psychological factors
may play a role.
May “up regulate” the central nervous system.
Abnormal pain transmission response
Disordered sensory processing.

12. What is the problem?
The stimuli causing pain originates mainly in the
muscles.
Skeletal muscle metabolism – decrease blood flow
which causes chronic fatigue and weakness.
Hence the increased pain with strenuous exertion.

13. Causes
The bottom line – unknown
Sleep disturbances, which are common in FB
patients, may actually cause the condition.
Pilot studies have shown a possible inherited
tendency toward the disease. Very preliminary.

14. Perception of Pain
Pain is a universal experience that serves the vital
function of triggering avoidance.
Cardinal symptom of FM is widespread body pain.
Tender points at musculoskeletal junction.
Amplification of nervous system.

15. Pain is Personal
Some 30 years ago, Melzeck and Wall proposed that
pain is a complex integration of noxious stimuli, and
cognitive factors. In other words, the emotional
aspects of having a chronic pain state and one's
rationalization of the problem may both influence the
final experience of pain.

16. Description
A chronic musculoskeletal syndrome characterized
by widespread:
musculoskeletal aches and pain
stiffness in the muscle tissue, ligaments, and tendons
soft tissue tenderness
general fatigue
sleep disorders
gastrointestinal disorders
depression

17. FMS
affects the neck, shoulders, chest, legs, and lower
back
symptoms similar to those of chronic fatigue
syndrome and myofascial pain syndrome.

18. Epidemiology
10 million US  3-6% of population
~ 80% are women
highest incidence  women 20 to 55 years of age
Genetic component
Among siblings and mothers and daughters
Incidence rises with age, by 80 years old – 8% of the
population.

19. Risk Factors
Age more common in young adults, increases with
age
Gender  10 x more common in women
Genetic  familial patterns suggest the disorder may
be inherited
Often follows a trauma  infectious or stress

20. Risk Factors
Sleep disorders  unknown whether sleep difficulties
are a cause or a result of fibromyalgia
Rheumatic Disease  RA or Lupus more likely to
develop FA

21. Pathophysiology
unknown etiology
produces vague symptoms that may be associated
with diminished blood flow to certain parts of the
brain and increased amounts of substance P
substance P  thought to be a sensory
neurotransmitter involved in the communication of
pain, touch, and temperature from body to brain.
Lowers the threshold of synaptic excitability

22. Pathophysiology
several other possible causes:
autonomic nervous system dysfunction
chronic sleep disorders
emotional stress or trauma
immune or endocrine system dysfunction
upper spinal cord injury
viral or bacterial infection

23. Signs and Symptoms
vary, depending on stress level, physical activity, time
of day, and the weather
pain  primary symptom
pain and tenderness in specific trigger points when
pressure is applied
aching, burning, throbbing, or move around the body
(migratory)
muscle tightness, soreness, and spasms

24. S & S Continued
unable to carry out normal daily activities even
though muscle strength is not affected
pain  often worse in morning, improves throughout
day, worsens at night
symptoms may be constant or intermittent for years

25. Co-morbidities
sleep disorders/fatigue  restless leg syndrome, sleep apnea
gastrointestinal  abdominal pain, bloating, gas, cramps,
alternating diarrhea and constipation, IBS
numbness or tingling sensations
chronic headaches  may include facial and jaw pain (TMJ)
frequent urination, strong urge to urinate, painful urination
(dysuria)
sensation of swelling (edema) in hands and feet even though
not present
cognitive or memory impairment

26. Co-morbidities and FM
Post-exertional malaise and muscle pain
Morning Stiffness
Numbness and Tingling
Dizziness or Light-headedness
Increased chemical, mechanical, and thermal
sensitivities.

27. Trigger Points
 Main points of pain
in Fibromyalgia patients
Neck
Back
Shoulders
Pelvic Girdle
Hands
Knees
Elbows
Hips

28. Diagnosis
No laboratory tests
Must rely on patients self reported symptoms
3 month history
Exam based on American College of Rheumatology
criteria.
Estimated that it takes an average of five years to get
diagnosed.

29. To receive a diagnosis of FM
Medical History
widespread pain in all four quadrants of their body for a
minimum of three months
at least 11 of the 18 specified tender points when
pressure is applied.

30. Rule Out other Conditions
Cancer
Cervical & Lumbar DDD
Chronic Fatigue
Depression
Hypothyroidism
Irritable Bowel
Syndrome
Hypothyroidism
Polymyalgia
Lyme Disease
Viral hepatitis
Rheumatoid Arthritis
Sleep Disorders

31. Myth
Fibromyalgia Damages Your Joints
Increase pain has not been correlated with any joint or
muscle damage.
It is important to understand that activity is good for
your joints and will help patients with Fibromyalgia
control pain.
Fibromyalgia is not fatal
True

32. Myth
You look fine, so nothing is wrong with you.
Pain is cultural
Our society does not really want to know “How are
you?”
You were diagnosed with fibromyalgia because your
doctor couldn’t find anything wrong with you.
American College of Rheumatology

33. Treatment
Pain Management
Lifestyle adjustment
 avoid nonessential activities
Good Nutrition
Stress Management
 Use of relaxation techniques  meditation, biofeedback
Exercise
Sleep Management
 Avoid caffeine
 Regular sleep routine

34. Nutrition
Avoid sugar
Avoid caffeine – this will improve your sleep
Limit alcohol
Maintain proper body weight
Limit processed food
Chocolate is OK and may release serotonin

35. Pain Management
Goal  reduce pain, improve sleep, and relieve
associated symptoms
Medication
antidepressant agents  relieve sleep disorders, reduce
muscle pain, treat depression
small doses of aspirin or acetaminophen  relief of
pain and muscle stiffness
Lyrica/cymbalta/Savella -

36. Pain Management
Trigger point injections  injection of local
anestheticand/or corticosteroid into a tender point
and then stretching involved muscle
local anesthetic   blood flow to the muscle
corticosteroids   inflammation

37. Treatment
Exercise  low-impact aerobic activity and strength
training.
Improved Fitness – symptoms are decreased with
aerobic exercise.
25-60% HHR, 3days/week, 20-30 minutes
Significant decrease in the Fibromyalgia Impact
Questionnaire
ACSM Guidelines are too strenuous

38. Physical Therapy
Physical Therapy  Modalities
Manual therapy
Stretching
C-V
Home Program
Capsaicin creams
Massage tools
Rice bags
Warm clothes
Pillows - Beds

39. Prognosis
No cure – lifelong condition. Very rare for them to
develop lupus or MS
Better ways to diagnose and treat the chronic pain
disorder continue to be developed.
FDA – new medications
Clinical studies demonstrate that can reduce
symptoms.
Does not shorten life span.

40. Support Groups
National Fibromyalgia Association
www.fmaware.org
Podcasts
Walk of FAME (Fibromyalgia Awareness Means
Everything)
Emotional/Social Support and Education

41. Post Test
There is no cure for FM?
FM has been shown to
shorten a persons life
span?
FM will cause joint
damage?
FM is a disease?
FM has an unknown
etiology?
True
False
False
False
True

42. Case Study
34 yo female with
diagnosis of FM
Wants to be start an
exercise program
Goals are to loose
weight and be able to
sleep better
What questions will you
ask her?
What exercises are
appropriate?
Do you feel comfortable
working with the client?

43. TED Talks
Use your brain to control pain.
Pain

44. Questions