Case study

Presenter:
Dr.Yusra Amir
Dr. Fatima Ahmed
• Subjective history :
Rabia Asghar, 35 year old female patient came to our clinic
with the chief complain of persistent pain in the body for the
past 6 months. She complain that her daily activity work are
now disturb due to persistent pain throughout the day and is
most severe in the morning and late evening. She also stated
that she was advised to undergo physiotherapy by her
physician, who diagnosed her with fibromyalgia.
• Objective history:
She appears fatigued, anxious and overwhelmed by chronic
pain, sleep disturbance and morning stiffness.
Tender points noted in 12 out of 18 specific sites (including neck,
shoulders, back, hips, and knees)
Numbness and tingling sensation.
• Assessment:
Patient is a known case of Fibromyalgia (diagnosis is typically based on a
combination of patient history, physical examination)
Fibromyalgia:
It is a medical syndrome which cause
chronic, widespread pain throughout
the body or in multiple areas. Pain is
often felt in the arms, legs, head,
chest, abdomen, back, and buttocks.
People often describe it as aching,
burning, or throbbing. Fibromyalgia
can make you extremely sensitive to
pain all over your body, and you may
find that even the slightest touch is
painful.
https://www.mdpi.com/1422-0067/22/8/3891
Feature of fibromyalgia:
Presenting complaints include pain at multiple sites,
fatigue, and poor sleep. Patients often complain of
low back pain, which may radiate into the buttocks
and legs. Others complain of pain and tightness in
the neck and across the upper posterior shoulders.
Patients complain of feeling exhausted, even upon
waking. Many patients with fibromyalgia complain of
cognitive difficulties such as memory problems,
groping for words, and poor vocabulary. Other
manifestations include episodes of light-headedness,
dizziness, anxiety, or depression. Patient feel extreme
pain on even light touch due to tenderness.
Cause:
• The exact cause of fibromyalgia is unknown, but it's thought to be
related to abnormal levels of certain chemicals in the brain and
changes in the way the central nervous system (the brain, spinal cord
and nerves) processes pain messages carried around the body.
• Certain genes you inherit from you biological parents might make you
more likely to develop fibromyalgia. Studies have found a link
between biological parents who have fibromyalgia and their children
this might mean it’s passed down through families.
https://www.nature.com/articles/s41584-020-00506-w
Prevalence:
• Fibromyalgia is most commonly diagnosed in middle-aged adults,
typically between the ages of 30 and 50. However, it can occur at any
age, including in children and older adults
• Fibromyalgia is more commonly diagnosed in women than in men.
Approximately 80-90% of those diagnosed with fibromyalgia are
women. The reason for this gender disparity is not fully understood but
may involve hormonal differences, genetic factors, or differences in pain
perception and reporting.
https://www.researchgate.net/profile/Manuel-Martinez-Lavin/publication/
344303745_Fibromyalgia_in_women_Somatisation_or_stress-evoked_sex-
dimorphic_neuropathic_pain/links/6079a4b3907dcf667ba43140/Fibromyalgia-in-women-
Somatisation-or-stress-evoked-sex-dimorphic-neuropathic-pain.pdf
Diagnosis:
• The ACR criteria have two components: (1) widespread pain involving
both sides of the body, above and below the waist as well as the axial
skeletal system, for at least three months; and (2) presence of 11
tender points among the nine pairs of specified sites (18 points) A
moderate and consistent degree of pressure should be used in digital
palpation (using the thumb of the dominant hand) of these tender
points.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9847104/
• Tender point test is being replace with the widespread pain index
(WPI) and symptom severity score (SSS).
The diagnosis is based on the score:
WPI score of 3-5 or SS score of 9
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9847104/
Diagnostic Criteria for Fibromyalgia
DIFFERENTIAL DIAGNOSE FOR
FIBROMYALGIA
• Fibromyalgia may mimic other conditions due to multiple nonspecific
symptoms. The differentials include:
• Polymyalgia rheumatic (Polymyalgia rheumatica is an inflammatory
disorder that causes muscle pain and stiffness, especially in the
shoulders and hips.)
• Spondyloarthritis (Spondyloarthritis is a group of diseases characterized
by inflammation in the spine (“spondylitis”) and joints (“arthritis”)
• Inflammatory myopathy (The inflammatory myopathies are a group of
rare diseases that involve chronic (long-standing) muscle inflammation,
muscle weakness)
Treatment protocol :
• Stress management, depression, pain and life style modification.
• Strength training
• Cardiovascular exercise
• Aerobic exercise
• Manual therapy
• ACCUPUNTURE
• Cai Tai
• Spinal Manipulation
• The goals of fibromyalgia treatments are:
• To alleviate pain
• Increase restorative sleep
• Improve physical function through a reduction in associated
symptoms.
• The AMERICAN PAIN SOCIETY (APS) & the ASSOCIATION of the SCIENTIFIC MEDICAL SOCIETIES in
GERMANY (AWMF) gave the highest level of recommendation to followings for the treatment of
fibromyalgia:

Aerobic Exercises Cognitive behavioral Aquatic Exercises

Soft tissue
manipulation
How aerobic exercise helps to treat
fibromyalgia?
• People with fibromyalgia typically experience widespread chronic
pain. Exercise may help prevent chronic pain by strengthening the
muscles, preventing muscle wasting, and reducing muscle damage.
Exercise may also help with other fibromyalgia symptoms, including
depression, difficulty concentrating, and sleep problems.
How CBT helps to treat fibromyalgia?
• CBT may help you modify activities that cause pain or other
symptoms, approach exercise in a way that doesn't lead to a flare,
improve your sleep habits, consistently follow your treatment
regimen, and pace yourself more effectively.
How Aquatic exercises helps to treat
fibromyalgia?
• The advantage of exercising in water versus on land is that the
buoyancy of the water supports joints and the body overall,
eliminating the impact of land.
 REFERENCES
• https://www.slideshare.net/punita85/fibromyalgia-30578889
• https://www.google.com/search?q=How+Aquatic+exercises+helps+to
+treat+fibromyalgia%3F&sca_esv=32726a2924a7740e&sca_upv=1&rl
z=1C1CHBF_enPK1030PK1030&
• https://www.google.com/search?q=DD+for++fibromyalgia%3F&sca_e
sv=32726a2924a7740e&sca_upv=1&rlz=1C1CHBF_enPK1030PK1030
&sxsrf=ADLYWI
• https://www.sciencedirect.com/science/article/abs/pii/
S0002934309008237