Fibromyalgia Syndrome (FMS)

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Fibromyalgia Syndrome (FMS)

• Epidemiology
• Rheumatic syndrome
• Conditions associated with pain
• Either affecting the articular origins or
  muscoloskeletal system
• FMS
• Chronic condition characterized by fatigue and
  widespread pain in your muscles, ligaments and
  tendons
• Does not appear to be an inflammatory process!
• Not associated with the development of joint
  deformities
• Most common rheumatic cause of chronic widespread
  pain

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Epidemiology

• Predominantly diagnosed in Caucasian women
• Approximately 75 of the cases are
• Middle to upper socioeconomic status
• Affects approximately 3 to 8 million Americans
• 80 to 90 are woman
• Between the ages of 20 to 60 years
• Prevalence of FMS increases with age

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Who May Suffer from Fibromyalgia?

• The American College of Rheumatologys Criteria1
• Widespread musculoskeletal pain for at least 3
  months
• Axial skeletal pain
• Pain in at least 11 out of 18 trigger points

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Pathophysiology

• Etiology is unknown!
• Research suggests possible factors but nothing is
  conclusive!
• Pain amplification syndrome
• Patients perception of pain is 3 times greater
  than normal
• Pain may be due to
• Genetic factors
• Genetic susceptibility to microtrauma of the
  musculature
• Neurohormonal dysfunction
• Peripheral mechanisms
• Muscle tissue abnormalities and microtrauma

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Pathophysiology

• Central mechanisms
• EEG abnormalities during sleep
• Neuroendocrine abnormalities
• Hypothalamic-pituitary-adrenal axis
• Low blood serum levels of serotonin
• High CSF levels of substance P and low levels of
  somatomedin C
• Immunologic factors
• Physical or psychological trauma
• Abnormalities in CNS structures (thalamus
  caudate nucleus)

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Common Signs Symptoms

• Widespread musculoskeletal pain
• Fatigue
• Multiple tender points
• Soft tissue tenderness
• Sleep disturbances
• Morning stiffness
• Irritable bowel syndrome
• Anxiety/depression

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Common sites for pain

• Neck
• Back
• Shoulders
• Pelvic Girdle
• Hands
• But any part of the body can be affected!

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Methods of Treatment

• Pharmacological treatment
• Aerobic exercise
• Biofeedback and relaxation
• Cognitive-behavioral treatment
• Heat
• Walking
• Vitamins
• Stretching
• Diet/Nutrition
• Aquatic therapy

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Pharmacologic Treatments

• Tricyclic Antidepressants
• Amitriptyline2
• Can reduce symptoms 25 - 35 over short and long
  term3-6
• Nontricyclic Antidepressants
• Venlafaxine
• Improved pain, fatigue, sleep quality, morning
  stiffness, depression, and anxiety7
• Lidocaine
• Injections in tender points
• Small but significant improvements in pain
  intensity and range of motion8

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Pharmacologic Treatments

• NSAIDS
• Viox
• Aleve
• Non-narcotic pain relievers
• Tylenol
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Paxil
• Wellbutrin

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Non-Pharmacologic Treatments

• Exercise
• Short term pain relief can be achieved by
  engaging in aerobic exercise three times a week9
• Types of Exercise
• Aerobic dance
• Stationary bicycling
• Aerobic walking

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Non-Pharmacologic Treatments

• Biofeedback
• Decreases the number of tender points, overall
  pain intensity, and morning stiffness
• Benefits last up to six months10
• Shows an even greater effect when combined with
  relaxation training11

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Non-Pharmacologic Treatments

• Cognitive-behavioral treatment12,13
• Includes a combination of
• 1) relaxation training
• 2) meditation
• 3) cognitive restructuring
• 4) aerobic exercise and stretching
• 5) activity pacing
• 6) patient and family education
• Treatments last three to 24 weeks
• Improvements shown in pain intensity, the number
  of tender points, emotional distress, and sense
  of pain control (lasting from 6 to 30 months)

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Effects of Exercise Training

• British Medical Journal
• Claims that exercise is the best way to treat
  this disease
• Possible reason could be the ability to help
  restore neurotransmitter imbalance
• Stimulates the release of Endorphins
• Improves QOL

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Exercise Guidelines

• Individualized responses to exercise
• Must know how the client is feeling
• Monitor how the client responds to previous
  workout
• High drop out rate at beginning
• Symptoms may get worse before they get better
• Conservative approach

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Client Classifications

• Must divide clients into 3 categories
• Beginners
• Intermediate
• Advanced

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Exercise Prescription

• Due to pain, inflammation, fatigue, and joint ROM
  limitations
• Peripheral deconditioning is more of the problem
  than central conditioning
• Initial programming should focus on the
  limitations!

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Beginners

• Aerobic Training
• Start with 5 min walking
• Add additional 2 min per week if appropriate
• Want to build up to 30 min at 70-75 of max heart
  rate or corresponding VO2 value
• Resistance training
• Start with no added resistance
• Focus on ROM
• Avoid eccentric contractions
• 4-6 Reps with 1-2 sets
• 2-3 minutes rest in between sets
• Flexibility
• 5 to 15 minutes of mild stretching daily
• Yoga is a great alternative!

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Intermediate

• Aerobic Training
• Approx. 40 - 80 of HR peak or corresponding VO2
  value
• Accumulation of 30 minutes
• Resistance Training
• May incorporate light resistance
• Bands
• Dumbbells
• Flexibility
• 10 to 15 minutes of mild stretching daily
• Yoga is a great alternative!

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Advanced

• Very Rare
• No restrictions
• May use heavier weights and increased reps
• Advanced Clients characterized by
• No longer experiencing chronic fatigue
• Has restorative sleep
• Occasional tiredness/fatigue

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Frequency

• Flexibility training
• Daily
• Yoga
• Aerobic training
• 3-4 days per week
• Resistance training
• 2-3 days per week

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Exercises to Avoid

• Squats
• Upright Row
• Knee Extensions
• Some cases

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Exercise Testing

• Sub-maximal testing
• Cycle ergometer test is better for most
  individuals
• Monitor symptoms throughout test
• Muscle fatigue
• Pain
• ROM limitations

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Warm Up and Cool Down

• Warm up
• 15-20 minutes
• Low intensity
• ROM exercises
• Cool Down
• 20 minutes
• Focus on stretching and ROM

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References

• 1) Wolfe, F., Anderson, J., Harkness, D.,
  Bennett, RM., Caro, XJ., Goldenberg, DL.,
• The American College of Rheumatology.
  1990 Criteria for the Classification of
• Fibromyalgia. Arthritis Rheum., 1990
  33 160-172.
• 2) Maurizio SJ, Rogers, JL. Recognizing and
  treating Fibromyalgia. Nurse
• Practitioner. 1997 2218-23.
• 3) Carette S, McCain GA, Bell DA, Fam AG.
  Evaluation of amitriptyline in primary
• fibrositis A double-blind,
  placebo-controlled study. Arthritis Rheum.
• 198629655-9.
• 4) Goldenberg DL, Felson DT, Dinerman H. A
  random, controlled trial of amitripyline
• and naproxen in the treatment of
  patients with fibromyalgia. Arthritis Rheum.
  
• 1986 291371-7.
• 5) Scudds, RA, McCain GA, Rollman GB, Harth M.
  Improvements in pain
• responsiveness in patients with
  fibrositis after successful treatment with
• amitriptyline. J Rheumatol.
  19891698-103.
• 6) Jaeschke R, Adachi J. Guyatt G, Keller J,
  Wong B. Clinical usefulness of
• amitriptyline in fibromyalgia the
  results of 23 N-of-1 randomized controlled
  trials.
• 199118447-51.
• 7) Dwight MM, Arnold LM, OBrien H, Metzger R,
  Morris-Park E, Keck PE Jr. An
• clinical trial of venlataxine treatment
  of fibromyalgia. Psychosomatics 19983914-7.

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References

• 8) Hong CZ, Hsueh TC. Difference in pain
  relief after trigger point injections in
• myofascial pain patients with and
  without fibromyalgia. Arch Phys Med Rehabit.
• 1996771161-66.
• 9) Wigers SH, Stiles TC, Vogel PA. Effects
  of aerobic exercise versus stress
• management treatment in fibromyalgia.
  J Rheumatol. 19962577-86.
• 10) Sarnoch H, Adler F, Scholz B. Relevance of
  muscular sensitivity, muscular
• activity,
• and cognitive variables for pain
  reduction associated with EMG biofeedback in
• fibromyalgia. Percept. Mot. Skills.
  1997841043-50.
• 11) Buckelew SP, Conway R, Parker J, Deuser WE,
  Read J, Witty TE, et al.
• Biofeedback/relaxation training and
  exercise interventions for fibromyalgia a
• prospective trial. Arthritis Rheum.
  199811196-209.
• 12) Turk DC, Okifuji A, Sinclair JD, Starz TW.
  Interdisciplinary treatment for
• fibromyalgia syndrome clinical and
  statistical significance. Arthritis Care Res.
• 199811186-195.
• 13) White KP, Nielson WR. Cognitive behavioral
  treatment of fibromyalgia syndrome
• a followup assessment. J Rheumatol.
  199522717-21.