Fibromyalgia is a chronic musculoskeletal disease characterized by widespread muscle joint pain, fatigue, morning stiffness, subjective swelling, sleep disorder, intestinal problems, and multiple somatic and cognitive problems, especially in the back, neck, shoulders and hips. Possible causes include genetic, neurological, psychological, sleep-related and immunological factors. Although it can be seen at any age and in both sexes, it is most common between the ages of 30-60 and is more common in women than men. It is an important problem in approximately 2% of the society all over the world.

Pathophysiology

Although the etiopathogenesis of FMS cannot be fully explained, many different mechanisms have been proposed in recent years to explain abnormal pain perception, and researchers have formed central and peripheral theories as a result of studies. While changes in neuropeptide level, neuroendocrine dysfunction, sleep disorders, central sensitization and dysfunctions in the functional activity of the central nervous system are suspected within the scope of central theories; In the scope of peripheral theories, autonomic dysfunction, immunological dysfunction, muscle tissue and muscle dysfunctions and the pathogenesis of FMS are tried to be clarified.

Clinical Signs and Findings

There is widespread body pain lasting longer than 3 months. Pain is the main symptom. The pain felt in the muscles and joints can vary from day to day, week to week. Although the location of the pain tends to circulate in different parts of the body, it is most commonly felt in the neck, waist, arms, chest, hips and legs. Pain may increase especially with bad sleep, cold and humid weather, psychological stress and mechanical loads. Morning stiffness, which gradually decreases during the day and sometimes continues throughout the day, is observed along with the pain. The patient may feel their joints swollen, but there is no swelling or redness of the joints on the painful side.

Movement of that joint may be restricted due to pain. Pain can be relieved with rest. numbness and tingling, weakness, headaches, depression, Reynaud’s phenomenon, dry mouth and dry eyes, irritable bowel syndrome, dysmenorrhea, urethral syndrome, palpitations, chest pain, anxiety, jaw pain, memory and cognitive disorders, vestibular complaints, and esophageal dysmotility Many symptoms such as chronic widespread pain may accompany. You wake up tired from your night’s sleep, regardless of the duration of sleep. In the morning, patients report feeling “beaten” or “fighted” when they wake up. This complaint is present in more than 90% of patients with fibromyalgia syndrome. There may also be difficulty falling asleep, frequent awakenings during the night. The incidence of sleep apnea and restless legs is also increased in patients with Fibromyalgia Syndrome. It is more common in another syndrome, which is defined as “chronic fatigue syndrome” in these patients, which is severe enough to prevent doing work.

Diagnosis

The diagnosis of fibromyalgia is made by clinical evaluation; A laboratory test, radiographic examination and biomarker of the disease have not been detected yet. Diseases that can mimic the symptoms of fibromyalgia, such as hypothyroidism and rheumatic diseases, and drug-related conditions, such as statin-induced myopathy, need to be considered and ruled out. The first diagnostic criteria for fibromyalgia were published in 1990 by the American Rheumatology Society as research classification criteria. These criteria are widespread body pain (both sides of the body in the upper and lower parts of the waist) lasting for at least 3 months and tenderness in at least 11 of 18 tender points.

The sensitivity of these criteria was 88% and the specificity was 81%, which led to criticism. Therefore, in 2010, these criteria were updated to include the more subjective Widespread Body Pain Scale (YAS; WPI, Widespread Body Pain Index) and the Symptom Severity Scale (SSS), which includes cognitive symptoms, sleep, fatigue, and additional somatic symptoms. The 2010 criteria included 19 pain points and 41 somatic symptoms. In 2011, these criteria were also modified and sensitive point examination was removed and symptom-based evaluation was started due to the concern that tender point examination was not performed sufficiently in primary care. It was deemed necessary to get at least 7 points in YAS and at least 5 points in SSS, or 3-6 points in YAS and at least 9 points in SSS for diagnosis, and it was stated that SSS could also be used in the follow-up of disease severity after diagnosis. In 2013, alternative criteria were developed to these criteria; A new set of criteria was defined, comprising 28 painful areas and a 10-item assessment of symptom involvement, with 81% sensitivity and 80% specificity. In 28 painful regions, unlike 19 regions, the back and waist regions are divided into three as right, left and middle; wrists and wrists, knees, feet and ankles added; abdomen was removed.

Differential Diagnosis

The disease most often compared with fibromyalgia syndrome is Myofascial Pain Syndrome (MAS). Like FMS, this syndrome is very common. The most confusing reasons are the inability to distinguish the sensitive point (FMS) and trigger point (MAS) distinction.

The differences between these two diseases are;

• FMS is more common in women, MAS is equally common in men and women.
• FMS pain is widely distributed throughout the body, while the pain seen in MAS is regionally distributed.
• Stiffness is common in FMS, but localized in MAS.
• Fatigue is very common in FMS but rare in MAS.
• In FMS, the examination is determined by sensitive points, while in MAS it is determined by trigger points.
• While the duration is chronic in FMS, self-limitation can be seen in MAS.

EVALUATION IN FMS

Taking a History: First of all, a detailed history should be taken by interviewing the patient. The onset of the patient’s complaints, the factors that increase or decrease the complaints, the occupation, sleep pattern, habits such as stress, depression, caffeine, alcohol, exercise habits and which activities affect the sleep quality should be questioned.

Evaluation of Tender Point Number and Pain Threshold of Tender Points: Tender points are evaluated with digital palpation or algometry. While evaluation is made by applying pressure on the tender points until the tip of the thumb nail turns white during palpation, the pain threshold is evaluated numerically with an algometer. While testing in sitting position on the points 2 cm distal to the occiput, trapezius, supraspinatus, upper part of the gluteal region, lower cervical region, 2nd costochondral junction and lateral epicondyle; Evaluation is made in the side lying position for the greater trachanter and in the supine position for the medial knee.

Evaluation of Pain: The McGILL-MELZACK (MPQ) pain questionnaire is used to measure the localization of pain, its characteristics, the relationship of pain over time, and the severity of pain. The Visual Analogue Scale (VAS) is used to measure the level of pain.

Evaluation of Functional Status: The functional status of individuals is evaluated using the “Fibromyalgia Impact Scale”. The Fibromyalgia Impact Scale is a 10-item form that evaluates the functional status and quality of life of patients in daily life. In this scale, there are 10 sections in total, including physical activity, well-being, work disability, pain, fatigue, stiffness and psychological state. The patient is asked to fill in the scale, the score is usually between 0-10.

Fatigue Severity Scale (FSS): The scale consists of 9 questions and each question is scored between 1-7 (1: strongly disagree, 7: strongly agree). The scores obtained from each question are summed and the average is taken to obtain the total score. High scores indicate the presence of fatigue.

Pittsburgh Sleep Quality Index (Pittsburgh Sleep Quality Index, PSQI): It was developed to define good and bad sleep and to evaluate sleep quality. It consists of a total of 24 questions, 19 of which are self-evaluation and 5 of which are answered by the spouse or roommate of the person. The questions are collected in 7 subscales. These are subjective sleep quality, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleeping pills, and daytime dysfunction. Each subscale is scored between 0-3 points. The total score is between 0-21. A high total score indicates poor sleep quality.

Beck Depression Scale: In order to determine the degree of these symptoms by measuring the symptoms seen in depression; It is a 21-item scale. Each item receives a score between 0 and 3. The score that can be obtained from the inventory is between 0 and 63.

Beck Anxiety Inventory: It is a 21-item scale aiming to determine the frequency of anxiety symptoms experienced by individuals. Each item scores between 0 and 3. The score that can be obtained from the scale is between 0 and 63.

FIBROMYALGIA SYNDROME REHABILITATION

PATIENT EDUCATION

The most important factor in the treatment of FMS is patient education. The first condition is to tell the patient what his illness is and to gain his trust. It is beneficial to inform the family, especially the spouses, about the disease (3,7). Good communication should be established with patients and it should be explained how FMS is a disorder and does not cause tissue damage. It should be emphasized that the patient should avoid pain-increasing factors such as stress, bad posture, sleep disturbance. Patients should be taught to regulate their activities by taking rest breaks without increasing their pain. It is important that they express their feelings and thoughts clearly in stressful situations. The habit of keeping a diary can be beneficial for the patient to control himself.

COGNITIVE AND BEHAVIORAL THERAPY

Studies have shown that cognitive-behavioral therapy is effective in terms of pain severity, ability to control pain, emotional distress and functional capacity in patients with fibromyalgia. The therapy performed; It should aim to teach the patient’s reaction to experiences and repairing coping habits, making problem-solving thoughts more effective, ways of coping with chronic pain in daily life activities, relaxation techniques, sleep and rest, and methods of preventing attacks.

EXERCISE EDUCATION

The main purposes of exercise are to reduce stress, protect and increase muscle strength and endurance, and provide appropriate posture. It is known that fibromyalgia patients have a decrease in muscle strength and muscle condition. Low condition also increases the risk of muscles being affected by microtraumas, causing pain and fatigue, and a vicious circle is formed. It is aimed to break this vicious circle with exercise. (1,7) The exercise program should include warm-up and cool-down periods. Exercise programs can be organized as group training or home program. (3.7)

Aerobic exercises: The 2017 Cochrane review evaluating aerobic exercises in patients with fibromyalgia included 13 studies involving 839 people. Eight studies of 456 subjects showed low pain intensity, fatigue, stiffness, and physical function; provided moderate quality evidence for quality of life. It has been calculated that aerobic exercise provides 8% absolute and 15% relative improvement in quality of life; it was reported that these rates were 11% and 18% for pain severity, 8% and 11.4% for stiffness, 10% and 21.9% for physical functions, and 6% and 8% for fatigue. Absolute change in cessation of exercise was calculated as 5%.(1)

There is low-quality evidence that improvement in pain and function persists over the long term, but improvement in quality of life and fatigue do not. A conclusion could not be reached on whether aerobic exercise is superior to education, coping with stress, and drug treatments. As a result, aerobic exercise provides improvement in quality of life, physical functions and pain (1).

Strengthening exercises: Patient-specific, low-intensity and low-intensity strengthening training without causing an increase in pain is beneficial for patients with FMS. In general, it is recommended to do the exercises 3-5 times a week, 1-3 sets and 8-12 repetitions. The resistance should be adjusted individually and should not be increased more than 10% per week. (2,3)

Emphasis is placed on isotonic potentiation in patients with FMS. Eccentric reinforcement is thought to cause overload and pain. In isometric exercises, the contraction time should be kept shorter than normal. (2,3)
Low-quality evidence from a 2013 Cochrane review of five studies showed that moderate-to-moderate-intensity strengthening exercises provide significant improvement in pain, tenderness, function, and muscle strength. Evidence that fibromyalgia patients can safely perform moderate-to-vigorous exercise is also low. In the review, it was stated that aerobic exercise was more effective in pain relief than moderate strengthening exercises (1,2).

Stretching and flexibility exercises: Stretching exercises can be done every day, especially after daily static activities such as reading and writing. In exercise training, stretching should be done as part of warm-up and cool-down exercises. In patients who are new to exercise, the stretching time should be kept short and a small number of stretching should be done. Stretching should be applied lightly, stretching should not be done at the pain limit. As the program progresses, the number and duration should be increased (3).
Valim et al. compared the effects of aerobic and stretching exercises in 60 patients with FMS. As a result of the study, it was determined that aerobic exercise was more effective than stretching exercises on pain, number of tender points, functionality and aerobic capacity (2,3).

In-water exercises: Water is an ideal exercise environment. In the exercises performed in water, the support for the muscles increases with the decrease in weight, the movement becomes easier, the edema decreases with the effect of hydrostatic pressure, and the relaxation occurs in the special and general muscle groups with the effect of warm water, and as a result, the pain decreases. Exercise programs that start with warming up in water continue as stretching, flexibility, aerobic and strengthening exercises. Walking fast in water is a resistance exercise that is difficult to achieve outside of water. Exercises lasting approximately 30-60 minutes are terminated with a cool-down program and are generally recommended as 3 days a week (2).

PHYSICAL MODALITIES AND ELECTROTHERAPY

TENS: In FMS, TENS can be used to reduce pain with its gate control mechanism. (3) TENS is generally recommended for localized pain treatment in fibromyalgia. In a study conducted in our country, exercise and TENS application were evaluated in 66 patients and it was stated that adding TENS to exercise could provide positive results.

LOW POWER LASER THERAPY: Although it is claimed that low power laser therapy reduces pain by creating photochemical reactions that change neuronal activity, its use in fibromyalgia is controversial. In a study conducted in our country, 75 patients were compared with placebo and amitriptyline, and it was stated that laser therapy was effective in reducing pain (1).

ULTRASOUND THERAPY: Ultrasound, acting by mechanical and thermal means, increases cell permeability, reduces inflammatory responses, and ultimately reduces pain by reducing nerve conduction velocity; it also reduces muscle spasms by local vasodilation. In a study conducted in 20 patients to evaluate the effectiveness of ultrasound therapy in fibromyalgia patients in our country, a comparison was made with laser therapy and a decrease in the number of pain, stiffness and tender points was found with both methods (1).

ACUPUNCTURE: A total of 9 studies involving 395 patients were included in the 2014 Cochrane analysis evaluating the role of acupuncture in fibromyalgia, and it was shown that adding acupuncture to standard treatments provided a 30% reduction in pain. Although pain reduction is achieved in a short time with acupuncture, data on its long-term effects are insufficient.(1)

DRY NEEDING: Casanueva et al. investigated the effect of dry needling applied for 6 weeks in addition to drug treatment in a randomized controlled study conducted on 120 patients with FMS. It has been observed that with the treatment, improvement in pain, fatigue and tender point pain threshold has been achieved. However, there are not enough studies proving the effect of dry needling.(3)

REFLEXOLOGY: There is a case study investigating the effect of reflexology in the literature. In the study, it was stated that reflexology applied in 10 sessions in 6 women diagnosed with FMS can help reduce pain. However, there are not enough studies on this subject. (3)

AWARENESS (MINDFULNESS): Mindfulness is a method used in the behavioral treatment of patients with chronic pain; It includes sitting and walking meditations, body imagery and yoga exercises. Awareness aims to increase patients’ ability to cope with their situation. Although it was stated that mindfulness-based stress reduction provided pain relief in a review of 6 studies including 674 patients, the level of evidence for these effects is low. In another review published in 2017, it was stated that although the evidence obtained in the studies is controversial, mindfulness practices can be an effective complementary therapy, especially when used together with other techniques such as exercise and cognitive-behavioral treatment methods (1).

MEDITATIVE MOVEMENTS (TAI CHI, YOGA, QI GONG): In a 2017 review and complementary therapy guideline, meditative movements, which were stated to be effective in fibromyalgia patients, were strongly recommended. In another review, which included 8 studies and 559 patients, investigating the effectiveness of yoga in different rheumatic diseases, it was reported that the effect on pain was weak. 7 studies investigating the place of qi gong in fibromyalgia patients and a review including 395 patients found low-quality evidence regarding the effect of qi gong on pain, quality of life, and sleep. A review evaluating the effectiveness of tai chi in different chronic painful conditions noted a low level of evidence. In a study conducted in 2016 in which 44 fibromyalgia patients were recruited, Tai chi and training practice were compared randomly and significant improvements were found in pain, sleep and quality of life (1).

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