Fibromyalgia Syndrome

(FMS)
Mini-Med School 2007

Raymond H. Flores, MD, FACR

Department of Medicine
Division of Rheumatology & Clinical Immunology
 OUTLINE
What is Fibromyalgia (FMS)?
What causes it?
Who gets it?
How is it diagnosed?
How is it treated?
What are some of the common
misconceptions about the syndrome?
What is Fibromyalgia (FMS)?

A clinical syndrome characterized by

widespread muscular pain (usually
chronic),
fatigue and
muscle tenderness (tender points)
 What is FMS? (cont.)
Additional symptoms are common and
include:
- poor sleep almost always
- headaches
- irritable bowel syndrome
- cognitive and memory problems
“fibro fog”
- numbness and tingling in fingers and toes
 What is FMS? (cont.)
- irritable bladder
- temporomandibular joint (TMJ) disorder
- restless leg syndrome
- dry eyes and dry mouth
- morning stiffness
- anxiety and depression

Symptoms including pain may wax and wane

over time
 What causes FMS?
Cause is unknown
Abnormally high levels of Substance P in
spinal fluid in some patients
Substance P important in transmission
and amplification of pain signals to and
from brain
“Volume control” is turned up too high in
brain’s pain centers
 What causes FMS? (cont)
Familial tendency to develop FMS
suggests genetic role
Can be triggered by physical, emotional or
environmental stressors such as car
accidents, repetitive injuries and certain
diseases
Patients with Rheumatoid arthritis and
SLE (Lupus) are more likely to develop
FMS
 What causes FMS? (cont.)
Other conditions such as Lyme disease
and obstructive sleep apnea (OSA) have
been associated with FMS
Sleep deprivation with disruption of delta-
wave sleep (non-REM stage IV) is
associated with day-time fatigue and
fibromyalgia syndrome
 Who gets FMS?
Affects as many as 1 in 50 Americans
Most common in middle-aged women
Men and children may also develop the
disorder
Patients with RA, SLE and Ankylosing
spondylitis are more likely
Women who have a family member with
FMS are more likely to develop it
 How is FMS diagnosed?
A diagnosis is made by evaluation of
symptoms and presence of tender points
American College of Rheumatology
Classification Criteria for Fibromyalgia
(1990)…….widespread pain for at least 3
months and
pain in 11 out of 18 tender point sites on
digital palpation
 ACR classification criteria:
fibromyalgia
Both criteria must be satisfied
– History of widespread pain for more than 3 months, on both sides
of the body, above and below the waist, and axial skeleton
(cervical spine, anterior chest, thoracic pain, or low back)

– Pain in 11 of 18 tender point sites on digital palpation with

approximate force of 4 kg.

Presence of second clinical disorder does not exclude diagnosis of

fibromyalgia.
Fibromyalgia: tender points
(diagram)
How is FMS diagnosed? (cont.)
X-rays, blood tests, specialized scans such as
nuclear medicine and CT, muscle biopsies are
all normal
Objective “markers of inflammation” such as
ESR (erythrocyte sedimentation rate) are normal
Must be distinguished from other common
diffuse pain conditions such as RA, SLE,
Hypothyroidism and Polymyalgia Rheumatica
(PMR)
 How is FMS treated?

Fibromyalgia is a chronic condition

managed with both medications and
physical modalities

Medication therapy is largely symptomatic,

as there is no definitive treatment cure for
fibromyalgia
 How is FMS treated? (cont.)
Current studies suggest that the best
pharmacologic treatment for treating pain
and improving sleep disturbance includes:
- Tricyclic compounds such as
cyclobenzaprine (FLEXERIL) and
amitriptyline (ELAVIL)
- Dual reuptake inhibitors such as
venlafaxine (EFFEXOR), duloxetine
(CYMBALTA) and tramadol (ULTRAM)
- SSRIs/ antidepressants such as fluoxetine
(PROZAC), paroxetine (PAXIL) and
sertraline (ZOLOFT) for depression and
pain
- Recent studies have shown that the anti-
epileptics (seizure meds) gabapentin
(NEURONTIN) and pregabalin (LYRICA)
have been effective
- NSAIDs (non-steroidal anti-inflammatory drugs)
such as ibuprofen and naproxen are generally
ineffective

- Long acting opioids (narcotics) generally are not

of great benefit either

- Benzodiazepines such as diazepam (VALIUM)

and clonazepam (KLONIPIN) may be useful for
patients with restless leg syndrome or very
severe sleep disturbance who have not
responded to other therapies
N.B.
The US Food and Drug Administration
has not yet approved any medications to
treat FMS
 Other Therapies for FMS
Complementary and alternative therapies
have been used although not well studied
in FMS

- Therapeutic massage
- Myofascial release therapy
- Acupuncture
 Other Therapies for FMS
Patient Self-Management
- Schedule time to relax, including deep breathing
and meditation
- Establish routine for going to bed and waking up
- Aerobic exercise on regular basis
- Self-education i.e. Arthritis Foundation,
National Fibromyalgia Assn.
- Support group
- Cognitive Behavioral Therapy (CBT)
 Common Misconceptions
Eleven (11) out of 18 tender points needed
to make the diagnosis of FMS
(2005 ACR Classification Criteria)

FALSE

Tenderness can be widespread without

tender points
 The major symptom in FMS is pain

FALSE

A variety of neurologic abnormalities may be

described including numbness and tingling
of the extremities, cognitive and memory
problems, irritable bowel
symptoms, etc.
It’s not a real illness, it’s in the
“patient’s head”

FALSE

A real condition with severe physical effects in some, although psychologic factors including
depression may be the major determinant of pain in others
 The prognosis is “hopeless”

FALSE

Early, aggressive treatment can prevent

physical deconditioning and loss of
function