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Fibromyalgia Syndrome (FMS)

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

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Fibromyalgia Syndrome (FMS)

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  1. 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

  2. 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

  3. Who May Suffer from Fibromyalgia? The American College of Rheumatology’s Criteria1: • Widespread musculoskeletal pain for at least 3 months • Axial skeletal pain • Pain in at least 11 out of 18 trigger points

  4. Pathophysiology • Etiology is unknown! • Research suggests possible factors but nothing is conclusive! • Pain amplification syndrome • Patient’s 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

  5. 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)

  6. Common Signs & Symptoms • Widespread musculoskeletal pain • Fatigue • Multiple tender points • Soft tissue tenderness • Sleep disturbances • Morning stiffness • Irritable bowel syndrome • Anxiety/depression

  7. Common sites for pain • Neck • Back • Shoulders • Pelvic Girdle • Hands • But any part of the body can be affected!

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

  9. 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

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

  11. 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

  12. 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

  13. 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)

  14. 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

  15. 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

  16. Client Classifications • Must divide clients into 3 categories: • Beginners • Intermediate • Advanced

  17. 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!

  18. 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!

  19. 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!

  20. 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

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

  22. Exercises to Avoid • Squats • Upright Row • Knee Extensions • Some cases

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

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

  25. 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; 22:18-23. 3) Carette S, McCain GA, Bell DA, Fam AG. “Evaluation of amitriptyline in primary fibrositis: A double-blind, placebo-controlled study. Arthritis Rheum. 1986;29:655-9. 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; 29:1371-7. 5) Scudds, RA, McCain GA, Rollman GB, Harth M. “Improvements in pain responsiveness in patients with fibrositis after successful treatment with amitriptyline.” J Rheumatol. 1989;16:98-103. 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. 1991;18:447-51. 7) Dwight MM, Arnold LM, O’Brien H, Metzger R, Morris-Park E, Keck PE Jr. “An clinical trial of venlataxine treatment of fibromyalgia. Psychosomatics 1998;39:14-7.

  26. 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. 1996;77:1161-66. 9) Wigers SH, Stiles TC, Vogel PA. “Effects of aerobic exercise versus stress management treatment in fibromyalgia.” J Rheumatol. 1996;25:77-86. 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. 1997;84:1043-50. 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. 1998;11:196-209. 12) Turk DC, Okifuji A, Sinclair JD, Starz TW. “Interdisciplinary treatment for fibromyalgia syndrome: clinical and statistical significance.” Arthritis Care Res. 1998;11:186-195. 13) White KP, Nielson WR. “Cognitive behavioral treatment of fibromyalgia syndrome: a followup assessment.” J Rheumatol. 1995;22:717-21.

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