1、Fibromyalgia Syndrome:A Therapists GuideBy: Michelle Lee WilliamsWhat does Fibromyalgia mean? The word fibromyalgia comes from both ancient Latin and Greek, combining the Latin word for fibrous tissue (fibro) and the Greek words for muscle (myo) and pain (algia)(Yu & McNett, 2006) Fibromyalgia is a
2、chronic pain syndrome and not a disease. A disease is a medical condition where there is a particular cause or causes as well as signs and symptoms that a doctor can recognize. A syndrome is a collection of signs, symptoms, and medical problems that occur together but are not related to one specific
3、 identifiable cause. (Mitchell, 2011)Who gets fibromyalgia? Fibromyalgia can be found in 3-5% of the general population It is more common in women than in men It is diagnosed most frequently in middle aged women The frequency of the diagnosis increases progressively with age It does occur in childre
4、n and in as many as 1-2% of adolescents 15% of patients hospitalized in internal medicine wards have fibromyalgia, 91% of whom are women(Velkura & Colburn, 2009) EtiologyEtiologyThe etiology and pathophysiology remain elusive however, there are many theories explaining the cause of fibromyalgia. Som
5、e include: “muscle injury, non-refreshing sleep, neurohormonal abnormalities, psychophysiology, and abnormal sensory processing of pain signals” (para. 5) Environmental stress factors such as war, catastrophic events, physical trauma, accidents, illness or emotional stress can trigger fibromyalgia s
6、ymptoms(Velkura & Colburn, 2009)Etiology continued Chronic pain in adulthood correlates to adverse childhood experiences such as poverty or physical or sexual abuse. “Several retrospective studies suggested that physical trauma may precipitate fibromyalgia” (para. 10) Fibromyalgia patients who have
7、psychological trauma associated with anxiety related to childhood trauma or sexual abuse appear to have a greater number of tender points(Velkura & Colburn, 2009)Etiology continued Elevated levels of the neurotransmitter Substance P have been found in people with fibromyalgia Substance P is associat
8、ed with enhanced pain perception Serotonin and baseline cortisol levels have been found to be low and there is a blunted adrenal cortical response to Adrenocorticotropic hormone (ACTH)(Velkura & Colburn, 2009)Etiology continued “Derangement of the hypothalamic-pituitary-adrenal (HPA) axis and the au
9、tonomic nervous system along with hyperactivity of the stress response was observed in patients with fibromyalgia” (para. 11) The APA axis activity may be related to trauma experienced in childhood especially if it was physical Early exposure to chronic stress can permanently affect the HPA axis whi
10、ch can then lead to fibromyalgia(Velkura & Colburn, 2009)CharacteristicsCharacteristicsPeople with fibromyalgia experience a number of symptoms including but not limited to: Allodynia when a normally non-painful stimuli is painful Hyperalgesia extreme sensitivity to what is considered painful stimul
11、i Fatigue often worse in the morning and persistent throughout the day Symptoms can be aggravated by cold and humid weather, physical and mental stress and poor sleep It is common for their symptoms to wax and wane(Velkura & Colburn, 2009)Characteristics continued Lightheadedness Fluid retention Pos
12、t-exertion pain Palpitations Night sweats Dysmenorrhea (pain during menstruation) Sexual dysfunction(Velkura & Colburn, 2009) Allergic symptoms Parethesias (sensations of numbness, tingling, crawling or burning) Mood disturbances (depression, anxiety, and personality disorders) Cognitive dysfunction
13、 (difficulty with concentration and short-term memory) Headaches (both muscular and migraine types)(Velkura & Colburn, 2009)Characteristics continuedThe most common regional pain syndromes that coexist with fibromyalgia are: Temporomandibular joint disorder (TMJ) Myofascial pain syndrome Irritable b
14、owel syndrome Irritable bladder syndrome Interstitial cystitis Restless leg syndrome Chronic fatigue syndrome(Velkura & Colburn, 2009)Characteristics continuedHistory of the medical diagnosisHistory In 1977 Smythe & Moldofsky were the first to describe fibrositis syndrome, This label was given to a
15、group of patients who did not fit the usual disease process or patterns “the label has had such historically inconsistent clinical, psychological, and pathological implications that about half of rheumatologists rarely make the diagnosis, while the other half believe it makes up an important and cha
16、llenging fraction of their practice”(p. 928)(Smythe & Moldofsky, 1977)History continuedSmythe & Moldofsky introduced a criteria of diagnostic symptomatology Chronic aching Exaggerated tender point pain in 12 or more of 14 specific sites Non restorative sleep patterns with morning fatigue and stiffne
17、ss The electroencephalography (EEG) result of alpha intrusion in non rapid eye movement (REM) sleep(Smythe & Moldofsky, 1977)History continued“These criteria may also help to differentiate fibrositic pain from pain which is purely malingering pretense, or neurotically symbolic” (Smythe & Moldofsky,
18、1977, p.931). Smythe & Moldofsky 1977 “In our opinion, the existence of exaggerated tenderness at anatomically reproducible locations is central to the acceptance and recognition of the syndrome” (Smythe & Moldofsky, 1977, p. 928) “Location of 14 typical sites of deep tenderness in “Fibrositis” (Smy
19、the & Moldofsky, 1977, p. 928)History continuedThe researchers hoped, with this criteria, to “identify this subset of patients, and direct the therapist away from purely disease suppressive measures, and away from purely psychologic explanations” (Smythe & Moldofsky, 1977, p.931)History continued Th
20、ere was new interest in the neglected syndrome after the release of the Smythe & Moldofsky (1977) article, more than 60 research papers were written about fibrositis. Frederick Wolfe M.D. and his associates, in association with the American College of Rheumatology (ACR), established the diagnostic c
21、riteria for fibromyalgia syndrome, formerly known as fibrositis.(Wolfe et al., 1990)1990 ACR Diagnostic CriteriaThe criteria included:1. A history of widespread pain for at least three months Pain is considered widespread when all of the following are present: pain in the left side of the body, pain
22、 in the right side of the body, pain above the waist, and pain below the waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side “low back” pai
23、n is considered lower segment pain (Wolfe et al., 1990, p.171)(Wolfe et al., 1990)1990 ACR Diagnostic Criteria2. Pain must be present, to a degree of mild or greater, in 11 of 18 tender points when digital palpation is performed with approximately 4 kg (9 lbs.) of force(Wolfe et al. 1990)Tender Poin
24、ts 1990Wolfe et al. (1990) “The Three Graces” 1990 criteria labeledWolfe et al. 1990Must have pain to the touch with 9 lbs. of force in at least 11 of the 18 points (9 bilateral areas totaling 18) Occiput Low cervical Trapezius Supraspinatus Second rib Lateral epicondyle Gluteal Greater trochanter K
25、neeTender Point evolution“fibrositis”14 tender points (Smythe & Moldofsky,1977)Fibromyalgia 18 tender points (Wolfe et al.1990)History Continued Wolfe et al. (1990) found sleep disturbances, fatigue, and stiffness to be central symptoms of fibromyalgia, occurring in more than 75% of those with the s
26、yndrome In addition, anxiety and irritable bowel syndrome were more common in people with fibromyalgia than controls yet were left out of the diagnostic criteria Fibromyalgia often occurs in association with other rheumatic disorders and the presence of a second disorder does not exclude the diagnos
27、is of fibromyalgia(Wolfe et al., 1990) Controversy Mease and Seymour (2008) write that the 1990 criteria was only meant for research purposes “although the tender point examination helps physicians discriminate fibromyalgia syndrome FMS as a condition characterized by augmented tenderness, an increa
28、sed number of tender points is associated with female sex and distress” (Mease & Seymour, 2008, para. 3) The exclusion of patients with chronic widespread pain but not enough tender points as well as the lack of “clear-cut biomarkers” has lead to skepticism among physicians as well as the frustratio
29、n of patients(Mease & Seymour, 2008)A different PerspectiveIn the Bulletin of the World Health Organization (WHO) Ehrlich (2003) wrote:Although classification criteria were promulgated for study purposes, these have been taken as diagnostic criteria by some and thus seem to validate the diagnosis. F
30、ibromyalgia is, however, an example of a meme disorder an infectious disease not caused by a microcosm but by imitative behavior. Associated symptoms are self reported and thus not subject to verification and other “symptoms” have been imputed, so that the name given to the symptoms depends on the p
31、reponderance of associated features reported. No real working definition of fibromyalgia has been formulated, however, so that patient diagnosed do not differ materially from others who have widespread chronic pain. This subgroup, however, is more likely to display socially maladaptive traits(Ehrlic
32、h, 2003, p. 673)History continued20 years later there would be a proposed third change to the diagnostic criteriaWolfe et al. (2010) postulated that although the 1990 ACR diagnostic criteria remains effective, an alternative diagnostic procedure was needed1. They found that the tender point count wa
33、s rarely performed in the primary care setting where most fibromyalgia diagnosis were being made. Many primary care physicians did not know how to perform the tender point examination or refused to do the procedure. The consequence being, in practice, fibromyalgia became a symptom based diagnosis.(W
34、olfe et al., 2010)History continued2. The 1990 ACR criteria left out what became increasingly known as key fibromyalgia features: fatigue, cognitive symptoms, and a range of somatic symptoms The new criteria would acknowledge “a number of fibromyalgia experts who believed that tender points obscured important considerations and erroneously linked the disorder to peripheral muscle abnormality” (Wolfe et al., 2010, p. 601)(Wolfe et al., 2010)
