Fibromyalgia is a common chronic condition involving widespread pain, cognitive symptoms, nonrestorative sleep, fatigue, and a number of somatic symptoms, along with a reduced quality of life ( Busch et al., 2011). In the 1763 by a French physician who described the condition as ‘muscular rheumatism” with symptoms including pain in the fleshy part without specific symptoms of fever (Traynor, Thiessen & Traynor, 2011). Later in 1904 the term fibrositis came into use because the symptoms were thought to be caused by inflammation of the fibrous tissue over the muscles. In the 1970s, the contemporary concept of fibrositis (i.e., a disorder characterized by sleep disturbance and tender points) was developed (Traynor et al., 2011). For couple of years efforts were made in the field of pharmacology to develop the medication of pain relief and muscular tender points. The condition was here by addressed as fibrositis secondary to severe pain and inflammation along with tender points. However, efforts did not show up positive results. In the year 1990, the American College of Rheumatology termed the condition as fibromyalgia instead of fibrositic to describe the condition.

Etiological Factors and Prevalence ratio of Fibromyalgia (FM).: Fibromyalgia is a chronic condition characterized by pain and tender points, decreased in sleep leading to sleep disorder, increase in fall injury rations and reduction in the quality of life. It has been estimated that Fibromyalgia affects an estimated 2% of the general U.S. population, and its incidence is sevenfold higher among women (Traynor et al., 2011). A number of pharmacological treatments have been studies in order to provide relief including the anti-depressants, anti-inflammatory agents and anti-convulsants.

Pathophysiology of Fibromyalgia (FM):

The diagnostic characteristics of fibromyalgia are chronic widespread pain, thought to arise from abnormalities of ascending pain and descending inhibitory sensory pathways, and allodynia on
palpation of specific tender points (Traynor et al., 2011). Moldofsky et al. (1970) conducted pioneering studies on the physiology of sleep in FM patients. These studies identified alpha-delta nonrapid eye movement sleep disruptions in FM patients postulated to be caused by abnormalities in central neurotransmission. Subsequent research has demonstrated an orchestra of central nervous system pathology, with a focus on abnormalities in sensory processing pathways (Mease & Seymour, 2008). It has been noted that FM patients experience hypersensitivity to both nonpainful and painful stimuli (allodynia and hyperalgesia) and
other sensory phenomena (eg, olfactory, visual) (Mease & Seymour, 2008).Researchers have noted dysregulation of the N-methyl –D-asparatic Acid (NMDA) in the dorsal horn of the brain in the individuals with FM. Researchers have also noted increased in the substance P,a pronociceptive peptide, in cerebrospinal fluid in FM patients compared with controls. Hansson [13] and others have noted abnormalities of the descending pain inhibition pathways (i.e., diffuse noxious inhibitory controls). Because norepinephrine and serotonin are key effector neurotransmitters in this pathway, it is postulated that this may be one site of action of drugs that
augment the function of these neurotransmitters, which have been shown to be effective in FM treatment (Mease & Seymour, 2008).

Signs and Symptoms of Fibromyalgia:

1) Pain or Physical Discomfort
2) Joint aching or pain
3) Lack of energy or fatigue
4) Impact on sleep (eg, difficulty falling asleep, staying asleep, or getting up in the morning)
5) Feeling tender where touched
6) Difficulty moving, walking or exercising.
7) Problems with attention or concentration (eg, difficulty concentrating on things, difficulty in thinking, “fibro-fog”)
8) Memory problems
9) Disorganized thinking (eg, difficulty in expressing yourself, difficulty in answering questions quickly, or difficulty making plans)
10) Stiffness
11) Depression (eg, disappointed, sad, resigned, or unmotivated)
12) Impact on ability to make plans, accomplish goals, or complete tasks
13) Having to push yourself to do things
14) Impacted/limited in doing normal daily life and household activities

Pharmacology in Fibromyalgia:

Fibromyalgia is treated with Monotherapy and also with combination therapy. Tricyclic Antidepressants were initially investigated and used for the treatment of FM. The other medications used for FM are Serotonin-non-epinephrine reuptake transmitters (SNRIs) along with amitriptyline which is a Tricyclic Antidepressant (TCA). Fluoxetine, citalopram, and paroxetine are selective serotonin reuptake inhibitors (SSRIs) that have been evaluated for efficacy in FM (Mease & Seymour).

I am not going to discuss the Pharmacology in depth here. The main points I am going to assimilate will be on the management.

Management of Fibromyalgia (FM): Fibromyalgia can be managed along with the monotherapy, combination therapy and along with physical therapy. It has been noted that Physical therapy works great in conjunct with the pharmacotherapy. The management of FM is based upon the concept of ADEPT Living;
A—Attitude –patient, health care professional, family and society etc.
D—Diagnosis—diagnosis and differential diagnosis
E—Education—didactic, group, reading, psychological, biomedical
P—Physical—home (pacing, exercise, heat) and /or formal physical therapy
T—-Treatment—medication or surgical treatments
Living—interval object assessment, adjustment and support.

These following points are postulated by Jon Russell in 2008 in his article Fibromyalgia syndrome: Approach to Management.

I am going to discuss briefly each and every point; however I will skip the physical therapy part and include it at the last along with exercise management.

Attitude: Attitude refers to the preparation, or frame of mind, that each participant brings to the therapeutic interaction. Clinicians must be prepared to accept FMS as a real condition that exerts a tremendous impact on the patient’s life. Empathy will be more therapeutic than baseless recriminations. It is similarly important for the patient to understand that FMS is just one of thousands of conditions that the healthcare provider must face and that the physician’s time with each patient is limited. The attitudes of family members, employers, policy makers,
and politicians all can impact importantly on the patient’s condition (Russell, 2008).

Diagnosis: Clinical diagnoses should not only identify FMS, but should also disclose any comorbid medical conditions. I am going to skip this concept over here as this is completely physician oriented.

Education: Education is crucial to the management of FMS. Patient understanding is power, when it comes to adapting to limitations and to the patients’ taking an active role
in the therapeutic program. Cognitive-behavioral therapy is a specific form of education that requires a guide and active participation. It has been shown to improve pain scores, pain coping, pain behavior, depression, and physical functioning.’ The benefits are often maintained for
6 months to a year or more. Support groups have been viewed negatively by some clinicians and patients for their tendency to be counterproductive, but patients who join a resource-oriented group can benefit from the supportive and educational aspects (Russell’s, 2008).

Physical Therapies: Please see below I have separated this section so I can include it with exercise management.

Treatment: Treatment refers to treatment provided by the health care professionals which is medications and any surgical treatment incorporated. Medications and surgical management are the part of this program. I am going to highlight the key parts of pharmacological management here which includes analgesics, precursors and tricyclic anti-depressants., Please navigate to my paragraph above on pharmacological management for further details.

Therapy Session 4 (Photo credit: Colorblind Seb)

Management of FM with Physical therapy and exercise therapy:

Useful physical modalities can be segregated into two categories: those that the patients can accomplish independently at home and those that require active participation by a trained therapist. At home, the patient can pace activities by setting a clock to time necessary work activity and then balance the work time with an equal period of rest. Progressive exercise, heat applied as shower or bath, and Jacobsonian relaxation techniques can all be self-directed
therapies at minimal cost. Aerobic exercise was among the first nonpharmacologic
strategies to evidence benefit for FMS. Besides improvement of cardiovascular fitness, it is believed to improve aerobic capacity, reduce pain, improve sleep, balance mood,
improve stamina, instill new perspectives, restore cognition, and facilitate a sense of well-being.’* Patients who are able to exercise sustain less negative impact of FMS in their lives.

Physiotherapie (Photo credit: Wikipedia)

On the other hand, imprudent bursts of exertion by a patient who is chronically deconditioned can temporarily worsen pain. When prescribing exercise for FMS patients, the clinician should begin with low intensity exercises, (such as walking in place in a swimming pool) and minimize eccentric muscle contractions. A potential role for pyridostigmine in this process has been proposed. Most patients report benefit from heat in the form of a hot bath, hot-water bottles, electric heat pads, or a sauna. A hot bath or shower can be more effective than an analgesic for headache, body pain, and stiffness. The application of heat can relax muscles, facilitate exercise, and improve a sense of well-being. Cold applications are preferred by some. Light massage that gradually progress to deep sedative palpation of large body surfaces can reduce muscle tension, but its influence on the body pain is transient (Russell, 2008).

Conclusion: Silva, Barret and Wiliams (2004) evaluated the effect of physical therapy and exercise and its outcome on the patients suffering from FM. The results showed that physical therapy produced high quality results in the patient with FM.