Fibromyalgia (FM).

Dr.Debanjan Mondal (PT).Mphil, MPT, BPT, CMT, CE.www.korecphysiocare.com

Fibromyalgia is a disorder of unknown cause characterized by widespread
pain, abnormal pain proceeding, sleep disturbance, fatigue & often
psychological distress.
Causes of Fibromyalgia:A. Emerging evidence of a genetic component of Fibromyalgia:

Specific gene mutations may predispose individuals to

Fibromyalgia.
Polymorphisms in the COMT enzyme & the Serotonin
transporter are potentially associated with Fibromyalgia.

B. Environmental factors that may trigger the onset of Fibromyalgia:

Physical trauma or injury.

Infection (Lyme disease, Hepatitis).
Psychological stress.

C. Fibromyalgia may occur concurrently with arthritis (O.A), autoimmune

diseases (R.A, SLE) &
Hypothyroidism.
D. Gender differences:-Women are more likely to be diagnosed with
Fibromyalgia.(F:M=4-9:1).
E. Central Nervous System:-Central Nervous System plays a significant
role in Fibromyalgia that it is ultimately a state of heightened sensitivity
may be explaining this increasing pain that patient is suffering .There are
some excitatory neurotransmitter(glutamine & substance P).Everything
should be in a balance Excitation & inhibition, but if excitation
neurotransmitter increase & too little of inhibition neurotransmitterpatient will end up with the pain .So substance P & glutamine happened to
be a excitatory neurotransmitter they caused to increase excitatory
aspect so patient got too much information coming into the brain ,it leads
to them experience of pain.
So what is pain?
International Association for the Study of Pain (IASP) Defined pain is a An
unpleasant sensory & emotional experience associated with actual or
potential tissue damage or described in terms of such damage. We cant
measure, we cant touch, and we cant feel it. So each and every person

has their own pain & there is no way to alternatively objectified. Each of
everyone has their own pain score in same stimulus. The fundamental
understanding of pain Neuroanatomy of Nociceptive pathways Pain starts
with a stimulus, It could be an Incision, burns, It could be a trauma, it all
has a common threat, It activate the primary nociceptor. Now this
nociceptor is the transducers, they lie in the soft tissue or deep tissue.
What the transducer does-It convert one form of energy to another form
of energy. Mechanical energy to a chemical energy in a form of
phchanges, it takes temperature changes & it converts something which
is called action potential. There are 2 basic nerves fibrous that transmit
the signal of the body A & c fiber .And one is response for our first pain
& other one is response for the slow pain.
A (DELTA) is
very first- 10mitter/sec.
C Fibrous is bit slower-1mitter/sec.

This signals of this fibrous synapse to the posterior or dorsal horn of the
spinal cord they cross over the other side then they gos to the brain in
Thalamus. It serves to send the signals of two major area of our brainouter side area of the brain, lateral area of the brain known as
Somatosensotory cortex area of the brain. This is where we feel the
intensity, quality, location character of it, and another area where the
signals gows-Medio forebrain system (Limbic System) .This has
descending inhibitory systems. They come down from the brain-they head
down to the spinal cord-they serve negative feedback to the brain. It
prevents, it provides a very nice balance between Excitation & Inhibition.
What we learn in chronic pain in fibromyalgia,
this system get out of lack, its disrupted & disorder. Limbic system is your
Emotional brain. This is where our basic emotion is process & proceeds.
This is your fear, joy, anger, hate, love, stress, pain where it is generated
& proceeds. Now recent research are showing that the some area of our
brain involved with our basic emotion which are the same region involved
with the emotion aspect of the pain .So if we defined our self that our
parents or spouse or children or boss is angry/upset/unhappy with us we
find that our back is hearting more, our neck is more stiff, feel more pain.
There is Neurophysiology basis for it because when we have an increase
negative emotion we are increasing ,we are amplifying those same circuits
involved with the emotional aspect of the pain, They are directly link to
one another. So stress or negative feeling aggravate the situation, so it is
very much important to understand that factor & reduce some of those
negative emotion. But it is not just a psychological concept, something
else occurring in our nervous system in a phase of pain after an injury. Its
a idea of Neuroplasticity ,this idea the brain is changing ,its highly
maliable. Its not fixed after certain age which is we learn in new research;

if we got an injury after some time or day its reduce its pain, what is
happening actually? In our nervous system it rewired spinal cord & brain
that pathway changed over a period of time & it is expended the area that
is preceded pain full. Now why would do that to us? Well it serves a
survival massage for us, what happens in the normal situation is the injury
heals, the nerve switches are turn off they go back to normal. In chronic
pain & Fibromyalgia may be the neurons switches are not turn off. Its
believed that is going on in Fibromyalgia. Fibromyalgia patient are getting
an expension of this areas that are now proceed it pain full & its all being
driven by the Central Nervous System. In comparison to normal healthy
people to fibromyalgia patient, fibromyalgia patients have dramatic
increase in brain increase brain activity (according to Functional Magnetic
Resonance Imagine Study) in pressure stimulus. There is an enhance
sensitivity that occurs in the brain. There is another study in fMRI Results
for fibromyalgia is:

Individuals with severe Fibromyalgia were given a cognitive task

that required a rapid physical response.
Functional MRI showed that these individuals recruited many more
areas of the brain that did contrils; this increased activity was
present whether or not standard Neurocognitive tests were
abnormal.
Fibromyalgia patients could accomplish the task but had to work
harder to do that task than the normal healthy people does, And this
get back to the concept of Cognitive issues. Another way of looking
of brain imaging is looking at the chance in the Gray matter in the
brain. In recent study its found that people with fibromyalgia &
normal healthy people has a huge difference in Gray matter. There is
premature atrophy, premature aging of the brain in specific region
of the brain involved with the emotional aspect of pain, the thinking
aspect of pain and are excreted function some are frontal region of
our brain and then par hippocampus gyri which is involved with our
stress response suggesting that this area of brain are atrophying
prematurely and may be playing a significant role in why this
patients develop fibromyalgia and why it gets maintain. In term of
longer you have fibromyalgia -the more brain atrophy you end up
getting. In neuropathic pain study its found that
Accelerated brain gray matter less in fibromyalgia patients:
premature aging of brain
Voxel-base morphometry (VBM is a neuroimaging
analysis technique that allows investigation of focal
differences in brain anatomy, using the statistical
approach of statistical parametric mapping)
10 fibromyalgia patients 10 healthy individuals

Gray matter loss

Healthy 1.1 cm3/ year
Fibromyalgia- 3.3 cm3/ year
Cingulated, insular and medial frontal cortices,
Para hippocampus gyri.
Greater the duration of fibromyalgia- greater the
gray matter loss.

Fibromyalgia pathophysiology
1. Recent data suggests that alteration of the CNS may be contribute
to the chronic widespread pain of fibromyalgia
2. Central sensitization is emerging as a leading theory of fibromyalgia
pathophysiology
3. fMRI data provide supporting evidence that fibromyalgia is a central
pain processing disorder.
4. Therapeutic agents that reduce neuronal hyperactivity by reducing
the release of neurotransmitters may be one way to relieve the
chronic pain of fibromyalgia.

Clinical feature/ diagnostic criteria:

1.
2.
3.
4.
5.

History of chronic widespread pain for more than 3 months.

Sleep disturbance.
Fatigue.
Morning stiffness.
Patient with fibromyalgia are more likely to have co morbidities
such as painful neuropathies and circulatory disorders.
6. There are number of different criteria that have been used to
diagnose to fibromayelgia. ACR and Canadian criteria may be
used to diagnose fibromayelgia.
7. Some of the symptoms are overlap like irritable bowel syndrome,
chronic fatigue syndrome, SLE, RA, OA, Lyme disease, major
depression.
We need to able to distinguish this when we think about the fibromyalgia.
1. Wide spread pain: patient had pain in multiple part of body, 11 out
of 18 tender points should be present.
2. Sleep disturbance: fatigue and early morning stiffness and this
tenderness (presence of the tender points)
Widespread pain is the defining feature of fibromyalgia, this patient hurt
all over, they hurts on the most of the parts of their body and sleep
disturbance play a significant role. So there is a concept of non restorative
sleep. So in healthy people go to sleep for 8 to 9 hours, when they wake
up they feel fresh in the morning. Fibromyalgia patient dont feel fresh.

Nonrestrictive sleep is a prominent feature of fibromyalgia.

Fibromyalgia patients report insomnia, early morning awakening and
poor quality sleep.
Alpha-wave intrusion is common but nonspecific EEG finding in
fibromyalgia patients.
*Interfere with sleep function and contribute to worsening of
pain after sleep.
*Phasic, tonic and low alpha are subtypes of alpha Sleep
intrusion observed in patients with fibromyalgia.

In EEG study its found that in fibromyalgia patient, there is a concept of

alpha wave intrusion. Alpha waves part of an EEG is there is present
predominantly during wake alertness, so slower waves are involved with
our deep sleep so when patients are in a sleep state the finding is -they
are getting the burst of this alpha waves, they are intruding, they are
preventing them from getting a good restful restorative night sleep. The
relationship between the sleep and pain is really fascinating, getting a lot
of research going on.
People who are sleeping only for 5/6 hours but not continuously, it
like over an extended hour of sleep. They wake up intermittently whole
night, they feel terrible next day. People who have sleep disturbance/ less
sleep they have dramatic abnormality in their pain threshold & pain
tolerance. Sleep plays an extraordinary important role for all of us. We are
just beginning to understand what it is doing and its relationship to pain.

Mood disorder: Rates of mood disorder in fibromyalgia are similar to

other rheumatologic disorder. It is found that there is a area in brain
increasing activity called posterior insular cortex is as well as called the
hippocampus as well as amigdilla. This is an area involved in major
depression. So it gives the idea that the depression and pain are
overlapping those sharing similar networks. So treatment should be both
for more responsive result.
We cannot simply treat the pain & except the depression goes away.
We cannot simply treat the depression & except that the pain goes away.
Education & appropriate diagnosis plays a crucial role for patient
with fibromyalgia. We find that if we actually can help the patient to
understand what they have & whats going on with it. Why they are
experiencing what they are expressing. There is significant improvement
in patient health satisfaction from baseline to after this education. Just
the very idea having validation, lifting him know its not just all med up,
its not something due to stress, that is a real condition and helping them

to understand, what is all about & what they can do about it leads to a
significant improvement in healthcare satisfaction.

Diagnostic criteria: American college of Rheumatology Diagnostic criteria

came out 20 years ago. It is a research criteria which is not meant to
diagnose necessarily individual patients. But what it involves is -1) patient
have to be at least 3 months of wide spread body pain.
2) Patient must exhibit more than 11 out of 18 tender points (pain on
digital palpation must be present in at least 11 of the following tender
points).
3) Wide spread pain was found in 97% of patients with fibromyalgia.
If patient have that problems-patient meet the diagnostic criteria for
fibromyalgia
Now the Canadians took this to another level. What they did they
added some additional symptoms into the diagnostic criteria
1.
2.
3.
4.

Sleep disturbance
Fatigue
Chronic widespread pain & tenderness are core diagnostic feature
Clinical case definition of fibromyalgia include evaluation of
additional clinical signs and symptoms commandingly observed in
patients with fibromyalgia (neurocognitive manifestations, sleep
disturbance ,fatigue)

So the idea is ultimately to do an appropriate history and physical

examination on a patient, we need to rule out the other condition so we
cant just jump to fibromyalgias the cause of the patients pain and
when we have to confirm the process of the tender points and with that
we can ultimately say you got fibromyalgia.
Now the key is how we go to managing it. How do we make an
impact on patient life who is suffering with fibromyalgia? So we have to
do this using a variety of tools and technique. We approach a using a
multidisciplinary treatment approach, in the other word we applied this
4 approach.

Multidisciplinary treatment

Pharmacologic
psychological
procedural

Physiotherapy

And this all should be done in an integration manner that means teams of
people working together coming together each of their own areas
expertise towards the treatment & management of the patient with
chronic pain.

Orthopedics/G.P.
Physiotherapist (specific pain management)
Dietician
Ergonomist
Occupational therapist

Managing of fibromyalgia pain: Non pharmacological approach:1. Aerobic exercise.

2. Cognitive behavior therapy
3. Patient education
4. Myofascial release therapy
5. Massage.
6. Alexander technique
7. Strength training
8. Breathing exercise for relaxation
9. Biofeedback
10.
Hypnotherapy
11.
Relaxation therapy
Pharmacological approach:-What you can see in general pain management
& fibromyalgia patient. General NSAIDs are ineffective in fibromyalgia
patient. Some antidepressant medications help a bit but there are some
side effects also.
REFERRENCES1. Alpha sleeps characteristics in
fibromyalgia,roizenblatts1.WWW.NCBI.NLM.NIH.GOV/PUBMED/11212164
2. www.korecphysiocare.com
3. travell & simons Myofascial pain & dysfunction, 2nd edition
4. www.healthlibrary.stanford.edu
5. Dr.Sean Mackey.