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1 Integumentary Physical Therapy 피부계물리치료학 Dong-Ryul Lee, PT, Ph.D. Movement Impairment Specialist & Performance Enhancement Specialist Neurofeedback, Robotics & Virtual Reality Research Specialites: NeuroRehabilitation & Pediatric Rehabilitation

2 Fibromyalgia ( 섬유근통 )

3 Fibromyalgia ( 섬유근통 ) Definition A Chronic Widespread Neurologic Pain Condition 신경병적만성통증 History In 1904, Dr. Gowers first described fibrositis ( 섬유조직의염증 ) In 1978, Drs. Smythe and Moldofsky published evidence of fibromyalgia sleep pathology and central pain sensitization In 1990, Fibromyalgia Syndrome was first defined by the American College of Rheumatology which allowed NIH funding for research In 1994, Dr. Russell found three fold increases of substance P in the CSF in fibromyalgia patients

4 Fibromyalgia ( 섬유근통 ) Definition A Chronic Widespread Neurologic Pain Condition

5 Categorization of Pain Conditions Nociceptive Pain Neuropathic Pain Inflammatory Pain Central Pain Amplification (ie, Burn) (ie, Herpes zoster) (ie, Rheumatoid arthritis) (ie, Fibromyalgia) Noxious stimuli Neuronal damage Inflammation Abnormal pain processing by CNS Acute Pain Chronic Pain Courtesy of Woolf C. Ann Intern Med. 2004;140:

The descending tract carries modulating impulses back to the dorsal horn 2.

neurons causing the release of Pain Associated Neurotransmitters Glutamate and Substance P 1.

6 The Normal Pain Processing Pathway 3. A signal is sent via the ascending tract to the brain, and perceived as pain Pain Perc eived 4. The descending tract carries modulating impulses back to the dorsal horn 2. Impulses from afferents depolarize dorsal horn neurons, then, extracellular Ca 2+ diffuse into neurons causing the release of Pain Associated Neurotransmitters Glutamate and Substance P 1. Stimulus sensed by the peripheral nerve (ie, skin) Glutamate Substance P 1. Staud R and Rodriguez ME. Nat Clin Pract Rheumatol. 2006;2: Gottschalk A and Smith DS. Am Fam Physician. 2001;63:

Neuronal damage Inflammation Abnormal pain processing by CNS 신경인성만성통증에서는통증의지각이무의식적으로발생하는데즉, 말초에서의 Acute 입력이

7 Categorization of Pain Conditions Nociceptive Pain Neuropathic Pain Inflammatory Pain Central Pain Amplification (ie, Burn) (ie, Herpes zoster) (ie, Rheumatoid arthritis) (ie, Fibromyalgia) Noxious stimuli Neuronal damage Inflammation Abnormal pain processing by CNS 신경인성만성통증에서는통증의지각이무의식적으로발생하는데즉, 말초에서의 Acute 입력이 Pain 없어도나타난다. 중추성민감화는유해수용기로부터신호가지속적으로전달되지않아도지속된다 Courtesy of Woolf C. Ann Intern Med. 2004;140: Chronic Pain 7

8 Central Sensitization Produces Abnormal Pain Signaling 중추성민감화 central sensitization

9 Central Sensitization: A Theory for Neurological Pain Amplification in FM Central sensitization is believed to be an underlying cause of the amplified pain perception that results from dysfunction in the CNS 1 May explain hallmark features of generalized heightened pain sensitivity 2 Hyperalgesia Amplified response to painful stimuli Allodynia - Pain resulting from normal stimuli Theory of central sensitization is supported by: Increased levels of pain neurotransmitters 3,4 Glutamate Substance P fmri data demonstrates low intensity stimuli in patients with FM comparable to high intensity stimuli in controls 5 fmri = functional magnetic resonance imaging 1. Staud R and Rodriguez ME. Nat Clin Pract Rheumatol. 2006;2: Williams DA and Clauw DJ. J Pain. 2009;10(8): Sarchielli P, et al. J Pain. 2007;8: Vaerøy H, et al. Pain. 1988;32: Gracely RH, et al. Arthritis Rheum. 2002;46:

10 Subjective pain intensity FM: An Amplified Pain Response 10 Pain in FM 8 6 Hyperalgesia (when a pinprick causes an intense stabbing sensation) Pain amplification response Normal pain response 4 Allodynia (hugs that feel painful) 2 0 Stimulus intensity Adapted from Gottschalk A and Smith DS. Am Fam Physician. 2001;63:

Pain intensity fmri Study Supports the Amplification of Normal Pain Response in

5 Red: Activation at low intensity stimulus in patients with FM Patients with FM

Stimulus pressure control (n=16) Green: Activated only at high intensity stimulus

in control patients was activated by low intensity stimuli in patients with FM)

11 Pain intensity fmri Study Supports the Amplification of Normal Pain Response in Patients With FM Stimulus intensity (kg/cm 2 ) 4.5 Red: Activation at low intensity stimulus in patients with FM Patients with FM experienced high pain with low grade stimuli FM (n=16) Subjective pain control Stimulus pressure control (n=16) Green: Activated only at high intensity stimulus in controls Yellow: Area of overlap (ie, area activated at high intensity stimuli in control patients was activated by low intensity stimuli in patients with FM) fmri = functional magnetic resonance imaging Gracely RH, et al. Arthritis Rheum. 2002;46:

1990;33:160-172 Chronic widespread pain Pain for 3 months Pain above and below the waist Pain on left and right sides of body and axial skeleton Pain

12 Definition Fibromyalgia ( 섬유근통 ) FM is a neurological condition associated with chronic widespread pain (CWP) and tenderness Wolfe F, et al. Arthritis Rheum. 1995;38(1): American College of Rheumatology (ACR) criteria for the diagnosis of FM: Wolfe F, et al. Arthritis Rheum. 1990;33: Chronic widespread pain Pain for 3 months Pain above and below the waist Pain on left and right sides of body and axial skeleton Pain at 11 of 18 tender points when palpated with 4 kg of digital pressure Diagram showing 18 tender points ACR criteria are both sensitive (88.4%) and specific (81.1%) 2 12

ACR-Recommended Manual Tender Point Survey* for the Diagnosis of FM LOW CERVICAL Anterior aspects of C5, C7 intertransverse spaces SECOND RIB SPACE about 3 cm lateral to sternal border ELBOW Muscle

13 ACR-Recommended Manual Tender Point Survey* for the Diagnosis of FM LOW CERVICAL Anterior aspects of C5, C7 intertransverse spaces SECOND RIB SPACE about 3 cm lateral to sternal border ELBOW Muscle attachments to Lateral Epicondyle KNEE Medial fat pad of knee proximal to joint line TRAPEZIUS Upper border of trapezius, midportion FOREHEAD LEFT THUMB OCCIPUT At nuchal muscle insertion SUPRASPINATUS At attachment to medial border of scapula RIGHT FOREARM GLUTEAL Upper outer quadrant of gluteal muscles GREATER TROCHANTER Muscle attachments just posterior to GT Manual Tender Points Survey: Presence of 11 tender points on palpation to a maximum of 4 kg of pressure (just enough to blanch examiners thumbnail) *Based on 1990 ACR FM Criteria 1. Adapted from Chakrabarty S and Zoorob R. Am Fam Physician. 2007;76(2); Control Points Tender Points 13

are between 25 and 60 years of age Women more likely to be diagnosed than men 1. Wolfe F, et al. Arthritis Rheum. 1995;38:19-28. 2. Weir PT, et al.

14 Fibromyalgia ( 섬유근통 ) Epidemiology FM is one of the most common CWP conditions 1 Prevalence in United States is estimated to be 2%-5% of the adult population 1 FM is highly underdiagnosed 2 Only 1 in 5 is diagnosed Diagnosis takes an average of 5 years 3 Impacts a wide range of patients 2 Most patients are between 25 and 60 years of age Women more likely to be diagnosed than men 1. Wolfe F, et al. Arthritis Rheum. 1995;38: Weir PT, et al. J Clin Rheumatol. 2006;12: National Pain Foundation. Available at: Accessed July 21,

15 Fibromyalgia ( 섬유근통 ) Risk Factors Genetic factors 1 Relatives of FM patients are at higher risk for FM First-degree relatives are significantly more likely to have FM (Odds ratio=8.5; P =0.0002) Have significantly more tender points Environmental factors 2 Physical trauma or injury Infections (Lyme disease, hepatitis C) Other stressors (eg, work, family, life-changing events) Gender 3 Women are diagnosed with FM about 7 times as often as men 1. Arnold LM, et al. Arthritis Rheum. 2004;50(3): Mease PJ. J Rheumatol. 2005;32(suppl 75): Arnold LM, et al. Arthritis Rheum. 2004;50(9):

16 Fibromyalgia ( 섬유근통 ) Causes 충분한수면상실 비정상적인신경생화학적반응 Tryptophan (serotonine( 수면조절, 통각전달, 기분, 공격성 ) 의전구물질 ) 감소 -> serotonine 대사장애초래 -> 깊은수면방해 -> 몸불편함, 우울증, 통증초래 교감신경계장애 -> 저산소증유발 국소조직요소 미토콘드리아의비정상적인패턴과지방갈색소포함물의생성 -> 각섬유 (angulary fiber) 위축 & 근필라멘트이상정렬 근수축시근섬유의 cross-sectional area 가 30-40% 감소 16

17 Fibromyalgia ( 섬유근통 ) Examinations & Evaluataions 방사선 (x-ray) 촬영 신경학적검사 관절 ROM검사 17

18 Fibromyalgia ( 섬유근통 ) Treatments PT 의학적처치 운동치료물리적인자치료약물 / 수술 운동치료 자세운동 자가신장운동 : pain x 저부하 - 저반복근력운동 저부하유산소운동 ( 싸이클, 수영, 보행..) 하루 5 분씩저강도로시작 3-4 일간격으로 1 분씩증가 최대 분씩 3-4 회 / 주 최대심방수 85% 이상적 도수치료 주로통증억제를위해압통점이있는근육내팽팽한띠의늘림과또다른통증유발 or 증상악화요소제거가목적 열치료기구 냉치료기구 전기치료기구 근육의뻣뻣함감소, 통증감소, 피로감감소, 숙면유도등을통해신체에너지양을증가시키는것이목적 약물치료 비스테로이드성진통제 항우울제 신경안정제 마약성진통제 18

19 Fibromyalgia ( 섬유근통 ) Treatments PT 의학적처치 운동치료물리적인자치료약물 / 수술 운동치료 자세운동 자가신장운동 : pain x 저부하 - 저반복근력운동 저부하유산소운동 ( 싸이클, 수영, 보행..) 하루 5 분씩저강도로시작 3-4 일간격으로 1 분씩증가 최대 분씩 3-4 회 / 주 최대심방수 85% 이상적 주로통증억제를위해압통점이있는근육내팽팽한띠의늘림과또다른통증유발 or 증상악화요소제거가목적 열치료기구 냉치료기구 전기치료기구 근육의뻣뻣함감소, 통증감소, 피로감감소, 숙면유도등을통해신체에너지양을증가시키는것이목적 약물치료 비스테로이드성진통제 항우울제 신경안정제 마약성진통제 도수치료 19

20 Fibromyalgia ( 섬유근통 ) Treatments PT 의학적처치 운동치료물리적인자치료약물 / 수술 운동치료 자세운동 자가신장운동 : pain x 저부하 - 저반복근력운동 저부하유산소운동 ( 싸이클, 수영, 보행..) 하루 5 분씩저강도로시작 3-4 일간격으로 1 분씩증가 최대 분씩 3-4 회 / 주 최대심방수 85% 이상적 주로통증억제를위해압통점이있는근육내팽팽한띠의늘림과또다른통증유발 or 증상악화요소제거가목적 열치료기구 냉치료기구 전기치료기구 근육의뻣뻣함감소, 통증감소, 피로감감소, 숙면유도등을통해신체에너지양을증가시키는것이목적 약물치료 비스테로이드성진통제 항우울제 신경안정제 마약성진통제 도수치료 20

21 Fibromyalgia ( 섬유근통 ) Treatments PT 의학적처치 운동치료물리적인자치료약물 / 수술 운동치료 자세운동 자가신장운동 : painx 저부하 - 저반복근력운동 저부하유산소운동 ( 싸이클, 수영, 보행..) 도수치료 허혈성압박 압통점을찾아충분한강도로압통점이비활성화될때까지지속적압박 근육최대신장시켜이완시켜엄지손가락을이용 -> 환자가참을수있는정도까지만압박 주로통증억제를위해압통점이있는근육내팽팽한띠의늘림과또다른통증유발 or 증상악화요소제거가목적 열치료기구 냉치료기구 전기치료기구 근육의뻣뻣함감소, 통증감소, 피로감감소, 숙면유도등을통해신체에너지양을증가시키는것이목적 약물치료 비스테로이드성진통제 항우울제 신경안정제 마약성진통제 21

22 참고문헌 피부물리치료학, 이재형외, 정담미디어, 2013 피부물리치료중재학, 박지환, 범문에듀케이션, 2013

23 Dong-Ryul Lee, PT, Ph.D. Copyright by Dong-Ryul Lee, PT, Ph.D.

ÀÇ»çÈ¸º¸-1202-443È£-14, page 1-12 @ Normalize ( 1202-443È£-14 )

ÀÇ»çÈ¸º¸-1202-443È£-14, page 1-12 @ Normalize ( 1202-443È£-14 ) THE DAEGU MEDICAL ASSOCIATION NEWS THE DAEGU MEDICAL ASSOCIATION NEWS THE DAEGU MEDICAL ASSOCIATION NEWS (월간) (제443호 / 광역시 제33호) 0년 월 8일 3 인도 캘커타 외각 오지서 의료봉사 ➊ ➏ ➋ ➌ ➍ ➎ ➐ ➊ 캘커타 라자핫 지역 고등학교 앞 ➋ ➌ 진료를 하는