Fibromyalgia. Manfred Harth MD FRCPC Professor Emeritus U.W.O. Potential Conflicts of Interest. Honoraria from : Solvay Jansen-Ortho Pfizer, Bristol-Myers Squibb Boehringer Ingelheim Review board for a Fralex trial
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Manfred Harth MD FRCPC
Professor Emeritus U.W.O
Honoraria from :
Review board for a Fralex trial
Grant support from Eli Lilly.
IMEs for several legal firms ,insurance
Betty M., a 50 year old woman, has developed
pain in her neck, shoulders, elbows, forearms,
low back, thighs, knees, ankles and feet over the
She has fatigue, and a non-refreshing sleep.
a) Polymyalgia Rheumatica
d) Galloping hypochondriasis
is a condition characterized by chronic
pain, fatigue, and a non-refreshing sleep.
Prove it !
ACR Classification Criteria
At least 3 regions of chronic pain (> 3 months) :
1 above the waist ;
1 below the waist ;
1 on each side of the body ;
1 in the centre of the body.
Betty M has Fibromyalgia
all over the world.
Its prevalence is 2-4%
About 85% of patients are women
The highest prevalence is between
40-60 years of age.
Chronic Fatigue Syndrome
Irritable bowel syndrome
Restless leg syndrome
Second Order Nerve
Sensory Nerve (First Order)
Allodynia = pain due to a stimulus that doesn’t normally provoke pain
Quantitative Sensory Testing uses the nociceptive flexion reflex R-III (NFR)
Normal Control Fibromyalgia
DB Cook et al J Rheumatol 2004; 31:364-78
Normal controls show activation of rostral anterior cingulate cortex (A), and pulvinar nucleus of thalamus (B) during painful stimulation.
K B Jensen et al Pain 2009;144:95-100;
Adapted from I J Russell et al Arthritis Rheum 1994;37:1593-1601
Adapted from SL Giovengo et al J Rheumatol 1999;26:1564-9
A Leal-Cerro et al J Clin Endocrinol Metab 1999; 84:3378-81
DJ Torpy et al Arthritis Rheum 2000; 43: 872-80
Half the patients with FMS have
phasic alpha sleep (compared to 7% of controls).
All of these have a non-refreshing sleep.*
* S Roizenblatt et al Arthritis and Rheum 2001; 44:222-30
Serotonin, Dopamine, GABA, Glutamate etc…
" What else can I do other than take
drugs ??? "
ENERGY, PAIN RELIEF,WORK CAPACITY
L Brosseau, Wells GA, Tugwell P et al. Physical Thrapy 2008; 88: 857-71
Brosseau L et al. Ottawa Panel evidence-based clinical practice guidelines for strengthening exercises in the management Phys Ther. 2008 Jul;88(7):873-86
Pain, Disability, Depression
Kati Thieme,Dennis Turk,Herta Flor
Arthritis Care Res 2007;57:830-6
3 FM groups (40-43)
CBT, OBT, Attention placebo(AP)
CBT:focus on patient thinking, problem solving, relaxation.
Operant-behavioural therapy : focus on pain behaviour rather than on thought.
15 weekly sessions of 2 hrs each
% ge with clinically significant
reduction or increase in pain
at 12 months
% ge with clinically significant
reduction or increase in physical impairment at 12 months
complains of pain and fatigue.
She is ready now to accept the use of medications
"What choices have I got ? "
μ opioid receptor
Effect on pain
p < 0.001<
RM Bennett et al Am J Med 2003;114:537-45
S Carette et al Arthritis Rheum 1994; 37:32-40
Blockage of α2δ subunit in Ca channel. Reduced release of glutamate,serotonin,noradrenalin,dopamine, substance P.
PJ Mease et al J Rheumatol 2008; 35:502-14
Pregabalin: Adverse Effects
Improvement in pain
I J Russell et al Pain 2008;136:432-44
Adverse effects : nausea,dry mouth, constipation,insomnia
All antidepressants not mentioned above
Tender point injections
team of health care professionals