a syndrome of persistent widespread pain, stiffness, fatigue, disrupted and unrefreshing sleep, and cognitive difficulties, often accompanied by multiple other unexplained symptoms, and functional impairment of activities of daily living.

1. FIBROMYALGIA
BY: Kareem Hussein Kamel
No: 727

2. DEFINITION
• a syndrome of persistent widespread pain, stiffness, fatigue, disrupted and
unrefreshing sleep, and cognitive difficulties, often accompanied by
multiple other unexplained symptoms, and functional impairment of
activities of daily living.

3. INCIDENCE
• fibromyalgia have been reported by researchers from around the world with
no race predilection.
• Fibromyalgia has a prevalence of 35% in females and 0.5-1.6% in males.
• Fibromyalgia is the second most common disorder that rheumatologists
encounter, seen in 15% of evaluated patients.
• 8% of patients cared for in primary care clinics have fibromyalgia.

4. CLINICAL PICTURE
• Persistent (≥3 months) widespread pain/tenderness or Allodynia
• Stiffness and Fatigue
• Headache
• Disrupted and unrefreshing sleep
• Cognitive difficulties

5. PATHOPHYSIOLOGY
• Abnormalities in pain processing:
• Excess excitatory neurotransmitters
• Low levels of inhibitory neurotransmitters
• Maintained enhancement of temporal
summation of second pain
• Altered endogenous opioid analgesic
activity in several brain regions
• Dopamine dysregulation
• Dysfunction of the HPA axis:
• Low free cortisol levels in 24hour urine samples
• Loss of the normal circadian rhythm, with an
elevated evening cortisol level
• Insulin induced hypoglycemia associated with
an overproduction of ACTH
• Stimulated ACTH secretion leading to
insufficient adrenal release of glucocorticoids
• Low levels of GH
• Fibromyalgia is currently understood to be a disorder of central pain
processing or a syndrome of central sensitivity

6. • Abnormal levels of such neurotransmitters as substance P, serotonin,
dopamine, norepinephrine, and epinephrine may cause cognitive
dysfunction. Neuroendocrine imbalance of the HPA axis may play a
role. Another possible cause of cognitive dysfunction is the distracting
quality of pain in fibromyalgia
• Fibromyalgia is associated with a decline in short term, working,
episodic, semantic (predominantly verbal), and procedural (skills)
memory, SPECT shows decreased blood flow in the right and left
caudate nuclei and thalami

7. DIAGNOSIS
• A CLINICAL DIAGNOSIS
• MOSTLY DIAGNOSIS OF EXCLUSION
• 2010 ACR Diagnostic Criteria
• Widespread Pain Index (WPI):
• WPI quantifies the extent of bodily pain on a 0-19 scale by asking patients if they have
had pain or tenderness in 19 different body regions over the past week, with each
painful or tender region scoring one point.
• Symptom Severity Score (SS):
• quantifies symptom severity on a 0-12 scale by scoring problems with fatigue,
cognitive dysfunction and unrefreshed sleep over the past week on a scale from 0-3

8. • A patient is diagnosed with fibromyalgia if the following three conditions
are met:
1. TheWPI score is 7 or higher and the SS scale score is 5 or higher or theWPI is 3-6
and the SS scale score is 9 or higher
2. The symptoms have been present at a similar level for at least 3 months
3. The pt doesn’t have another disorder that would otherwise explain his or her pain

9. DIFFRENTIAL DIAGNOSIS
• Addison Disease
• Hepatitis C
• Hyperparathyroidism
• Hypochondriasis
• Hypothyroid Myopathy
• Personality Disorders
• Polymyalgia Rheumatica
• Posttraumatic Stress Disorder
• Malingering
• approximately 25% of patients with RA and approximately 50% of
patients with SLE also have fibromyalgia

10. WORKUP
• Patients with fibromyalgia do not have characteristic or consistent
abnormalities on laboratory testing.
• routine laboratory and imaging studies are important to help rule out
diseases with similar manifestations and to assist in diagnosis of certain
inflammatory diseases that frequently coexist with fibromyalgia.

11. • CBC, ESR, Urine analysis,
• Thyroid-stimulating hormone
• 25-Hydroxy vitamin D level
• Vitamin B-12 level
• Iron studies
• Magnesium
• The antipolymer antibody assay

12. MANAGEMENT
• The physician should inform the patient that NO cure exists for fibromyalgia
but that education, lifestyle changes including regular physical activity, and
proper medications can help the individual to regain control and achieve
significant improvement.
• Treatment should be tailored to the specific needs of the patient, with
combination of pharmacologic approaches with nonpharmacologic
,especially stress management, aerobic exercise, and, in some cases,
psychotherapy. Aggressively treat comorbid depression.

13. TREATMENT
Pharmacological
• Exercise (yoga, tai-chi)
• Group therapy
• Cognitive-conductual therapy
• Acupuncture
Non-Pharmacological
• Analgesics
• Antianxiety Agents
• Skeletal Muscle Relaxants
• Antidepressants
• Anticonvulsants

14. THANK
YOU