15 GrossA Fibromyalgia · 2018-04-06 · 4/5/18 4 Tender Point Exam ACR criteria: pain at 11 of 18...
Transcript of 15 GrossA Fibromyalgia · 2018-04-06 · 4/5/18 4 Tender Point Exam ACR criteria: pain at 11 of 18...
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Fibromyalgia: It’s Real, It’s Manageable
Andrew J. Gross, MDProfessor of Clinical Medicine
Rheumatology Clinic ChiefAssociate Chair of Ambulatory Care, Dept of Medicine
University of California, San Francisco
Disclosures
• none
Learning Objectives
• Recognize patients with Fibromyalgia and other Pain Sensitization Syndromes, identify the mechanisms of pain, and explain the importance of making these diagnoses.
• Describe the basic treatment approach for fibromyalgia.
Clinical Case I49 year old woman comes to you complaining of fatigue. She also notes problems with pain in many areas.
She tells you that she wakes up frequently at night either from pain or thinking about stressful problems from her work. She wakes up in the morning with pain in her shoulders, neck and low back with stiffness, feeling very tired. The stiffness improves quickly, but as the day wears on, pain gets worse and she feels exhausted. She has gained 20 lbs in the past 2 years. She feels depressed because of the poor quality of her life.
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Clinical Case II (more subtle)
A 27 year old woman comes to see you with the chief complaint of ankle pain…
You see she has had multiple visits for same problem, but she has not responded well to any of the usual treatments. X-ray and MRI are unremarkable
On further review of her record, she has been seen over the past 6 years for many other problems including tinnitus, eye discomfort, right upper quadrant pain, shoulder pain, neck pain, and problems with her memory. Workup for each of these problems has been unrevealing.
Fibromyalgia Epidemiology
Wolfe F, et al; Arthritis & Rheum; 1995
women
men
Percentage of the population with fibromyalgia
Wolfe F et al; 2013, Arthritis Rheum; PMID 23424058
Vincent A, et al; 2012, Arthritis Care & Res PMID 23203795
Using 2011 ACR diagnostic criteria in 2445 German People:
• Prevalence of 2.1%
• Prevalence increased with age• 0.8% ≤40 years of age• 2.5% in 40–59.9 years• 3.0% in ≥60 years of age
• Similar prevalence in women and men (2.4% versus 1.8%; P =0.372)
Olmsted County prevalence 6.4%(7.5% of women and 4.9% of men)
Fibromyalgia Epidemiology
Vincent A, et al; 2012, Arthritis Care & Res PMID 23203795
Using 2011 ACR diagnostic criteria Olmsted County prevalence 6.4%
Similar prevalence in women & men: 7.5% women, 4.9% men
Fibromyalgia:
• Can it be reliably diagnosed?• Is it physical or psychological?• Is a diagnosis helpful or harmful?• Is there any effective treatment?
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Fibromyalgia:
• Can it be reliably diagnosed?• Is it physical or psychological?• Is a diagnosis helpful or harmful?• Is there any effective treatment?
What are the hallmarks of fibromyalgia? (choose 3)
a) Widespread painb) Joint Painc) Non-restful sleepd) Depressione) Fatiguef) Obesity
Diagnosis of Fibromyalgia
ACR classification criteria – Wolfe F, et al, Arthritis Rheum 1990ACR diagnostic criteria – Wolfe F, et al, Arthritis Rheum 2010
Widespread Pain
(>3 months)
www.ehow.com/about_5059501_fibromyalgia-diagnosis-symptoms.html
Diagnosis of Fibromyalgia
ACR classification criteria – Wolfe F, et al, Arthritis Rheum 1990ACR diagnostic criteria – Wolfe F, et al, Arthritis Rheum 2010
Widespread Pain
(>3 months)
Characteristic Tender Points
• Fatigue• Poor Sleep• Cognitive Problems• Other Sx
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Tender Point Exam
ACR criteria: pain at 11 of 18 points
Diagnosis of Fibromyalgia
ACR classification criteria – Wolfe F, et al, Arthritis Rheum 1990ACR diagnostic criteria – Wolfe F, et al, Arthritis Rheum 2010
Widespread Pain
(>3 months)
Characteristic Tender Points
• Fatigue• Poor Sleep• Cognitive
Problems• Other Sx
A score of ≥13 points is consistent with a diagnosis of fibromyalgia• Sensitivity 93.1%• Specificity 91.7%
Clauw D, 2014, JAMA, PMID 24737367 Ferrari R, Russell AS, 2013, J Rheumatol
Wolfe F et al, J Rheumatol 2011, PMID 24737367
Which of the following suggests to youthat a patient might have fibromyalgia:
A. Multiple different pain complaints– Eg. Back pain, knee pain, neck/shoulder pain
B. “Pan-positive review of systems”
C. The patient has various hypersensitivity complaints (e.g. your exam room lights are making them sick)
D. The patient starts the interview with their birth history
E. You are exhausted after the interview
ALL OF THE ABOVE!
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Fibromyalgia
Headache/Migraine
TMJ disorder
Dermatitis/ pruritis
Chronic eye irritation/dryness
Atypical chest pain
Irritable bowel syndrome
Polyuria/frequency(“interstitial
cystitis”)
Dyspareunia/ vulvodynia
ParesthesiaChronic fatigue
Muscle Cramps
Dypsnea
Multiple sensitivities
Wolfe F et al; 2013, Arthritis Care & Res; PMID 23424058Aaron LA, et al. 2000, Arch Int Med. PMID 10647761
Wolfe F, et al, 2013, Arch Int Med 2013Buchwald D, Garrity D, Arch Int Med 1994
In a German Study of FMS patients 53.8% had ≥1 severe somatic symptoms32.7% had ≥2 symptoms
Fibromyalgia overlaps with other Somatic Syndromes
Dutch Study of 94,516 participants between 2006-12, Janssens KAM, et al, Psychosomatic Med 2015
Diagnosis of Fibromyalgia
ACR classification criteria – Wolfe F, et al, Arthritis Rheum 1990ACR diagnostic criteria – Wolfe F, et al, Arthritis Rheum 2010
Widespread Pain
(>3 months)
Characteristic Tender Points
• Fatigue• Poor Sleep• Cognitive
Problems• Other Sx
other disease
…but how do I make sure my patient does not have something “bad”
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It is difficult to be sure…Cervical Myelopathy
PellagraAcute IntermittentPorphyria
Polyarteritis NodosaOvarian Cancer
Systemic LupusErythematosus
Pituitary Adenoma
Fabry’s Disease
AmyloidosisWhipple’s Disease
Hypothyroidism Mitochondrial Myopathy
Work-up
• Laboratory Tests– ESR, CRP
– CBC w/ diff– Comprehensive Metabolic
Panel (inc. LFTs, Calcium)
– Fasting Glucose– Hepatitis B & C
– TSH, free T4
– Vitamin D 25-OH– CPK (if appropriate)
– ANA (rarely)
Work-up
• Laboratory Tests– ESR, CRP
– CBC w/ diff– Comprehensive Metabolic
Panel (inc. LFTs, Calcium)
– Fasting Glucose– Hepatitis B & C
– TSH, free T4
– Vitamin D 25-OH– CPK (if appropriate)
– ANA (rarely)
• X-rays of affected areas to investigate joint damage
• Biopsy tissues that appear affected (ie. skin rashes)
• EMG for persistent neurologic symptoms
Tips to detect underlying disease
• Perform routine laboratory Screening• Evaluate objective findings• Invite patients to return to see you if they
develop new symptoms
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When To ReferFibromyalgia does not require specialist evaluation for diagnosis or management
Referrals to specialists should be made when workup identifies another process such as:• Endocrine disease (Thyroid, Adrenal)• Rheumatic Disease (PMR, Ankylosing
Spondylitis)• GI Disease (Malabsorption - Celiac Sprue)• Heart Failure• Neurologic disease (MS, ALS, Parkinson's)
Fibromyalgia:
• Can it be reliably diagnosed?• Is it physical or psychological?• Is a diagnosis helpful or harmful?• Is there any effective treatment?
What is causing pain?
a) Abnormal metabolism of muscle fibers causes persistent tissue degeneration/regeneration
b) Increased sensitization of central pain signalingc) Small fiber perineural ischemiad) Psychiatric illness
What is causing pain?
a) Abnormal metabolism of muscle fibers causes persistent tissue degeneration/regeneration
b) Increased sensitization of central pain signalingc) Small fiber perineural ischemiad) Psychiatric illness
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How Do We Sense Pain?Nociceptive Networks
Brain
Abeles AM, et al, Ann Intern Med 2007
Patients with Fibromyalgia experience pain differently from unaffected individuals
Subjective EvidenceIncreased sensitivity to heat, cold, and
pressure• Marques AP, et al, Clin Rheumatol 2005• Maquet D, et al, Eur J Pain 2004• Gibson SJ, et al, Pain 1994
Baraniuk JN, et al, BMC Musculoskel Disor, 2004
www.tutrin.com
Patients with Fibromyalgia sense pain differently from unaffected individuals
Central sensitization to pain
Desmeules JA, et al, Arthritis & Rheum 2003Also see Banic B, et al, Pain 2004
Objective EvidenceNociceptive flexion reflex
Brain
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Pain Processing Mechanisms
Schmidt-Wilcke T and Clauw DJ; Nat Rev Rheumatol, 2011, PMID 21769128
CNS neurotransmitters that are known to either inhibit or facilitate sensory/pain transmission are
perturbed in patients with Fibromyalgia
What causes pain sensitization?
What Causes Increased Sensitivity to Pain?
EmotionalTrauma(violence &
stress & loss)
PhysicalTrauma/Illness
(infections & injuries)
GeneticVunerability
Crofford LJ; Trauma, Violence, & Abuse, 2007, PMID 17596347
EndorphinsCortisolNeurotransmitters
Schmidt-Wilcke T and Clauw DJ; Nat Rev Rheumatol, 2011, PMID 21769128
Pain Sensitization
Arnold LM, et al, Arthritis Rheum, 2013, PMID 23280346
Fibromyalgia Pathophysiology:Biological Stress
• 5–10% of individuals exposed to certain types of infections (for example, Lyme disease, Epstein–Barr virus, parvovirus or Q fever) develop CWP, and infections in other regions of the body can also trigger chronic regional pain.
• Similarly, 10–15% of individuals with acute gastrointestinal infections (for example, with Campylobacter spp., Salmonella spp. or Shigella spp.) subsequently develop IBS.
Schmidt-Wilcke T and Clauw DJ; Nat Rev Rheumatol, 2011, PMID 21769128
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Fibromyalgia Pathophysiology:Psychological Distress
• Individuals with high levels of distress but without pain are 2-fold more likely to develop chronic widespread pain
• Having psychologically stressful events in early life (death of a parent, prolonged hospitalization, MVA) increase the risk of developing chronic widespread by 50–100% in later life
• Sexual and physical abuse in childhood and adulthood are associated with FMS in adulthood
• PTSD reported in 15% to 56% of patients with fibromyalgia
Fietta P et al, Acta Biomed 2007Hauser W, at al, Arthritis Care Res, 2011
Hauser W, et al, 2013, Pain, PMID 23685006Schmidt-Wilcke T and Clauw DJ; Nat Rev Rheumatol, 2011, PMID 21769128
Fibromyalgia:
• Can it be reliably diagnosed?• Is it physical or psychological?• Is a diagnosis helpful or harmful?• Is there any effective treatment?
Should I tell the patient they have fibromyalgia?
Should I tell the patient they have fibromyalgia?
�No: the label of FMS might lead to increased illness behavior, dependence on health care providers, and increased health service costs.�
�Yes: making a definite diagnosis will reduce the number of referrals, use of multiple health care providers, and costs.�
Costs Related to a Diagnose FMS and Failure to Diagnose FMS
Annemans et al, Arthritis Rheum 2008; 58:895
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The Importance of Knowing
• Health care costs are reduced by diagnosing fibromyalgia– Fewer PCP visits– Fewer tests ordered– Fewer referrals made– Fewer drugs prescribed
• Critical to help set expectations
Annemans et al, Arthritis Rheum 2008; 58:895
How do I tell my patient they have fibromyalgia?“Here’s what people with
fibromyalgia usually tell me….”
Fibromyalgia:
• Can it be reliably diagnosed?• Is it physical or psychological?• Is a diagnosis helpful or harmful?• Is there any effective treatment?
Which intervention is likely to lead to a 50% reduction in pain?
a. Cymbaltab. Gabapentinc. Cognitive Behavior Therapyd. Exercise & Physical Therapye. None of the above
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Which intervention is likely to lead to a 50% reduction in pain?
a. Cymbaltab. Gabapentinc. Cognitive Behavior Therapyd. Exercise & Physical Therapye. None of the above
Treatment of Fibromyalgia
Medication
Body
Mind
A multidisciplinary approach
Scascighini L, et al, Rheumatology 2008
How can we control pain?
Brain
Gabapentin (Neurontin)Pregabalin (Lyrica)
How can we control pain?
Brain
ElavilCymbaltaSavellaEffexor
Norepi-nephrine
Norepinephrine impedes pain signaling
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Treatment of Fibromyalgia
Cochrane Systematic Review 2013 of duloxetine & milnacipran for fibromyalgiaOutcome: Pain Reduction of 50%
– 28% of Rx group achieved 50% pain reduction– 19% of placebo achieved 50% pain reduction
NNTB = 11• Little improvement in fatigue• No significant change in quality of life
Häuser W, et al, Cochrane Database Syst Rev 2013
Treatment of Fibromyalgia SyndromeRecommended• Tricyclic antidepressants
– amitriptyline (Elavil) 25-100mg
qHS
• Dual-reuptake inhibitors (SNRIs)
– milnacipran (Savella)
– duloxetine (Cymbalta) 30-120
mg/d
– venlafaxine (Effexor)
• gabapentin (Neurontin)
• pregabalin (Lyrica)
• cyclobenzaprine (Flexeril)
• tramadol 200-300mg/d
Not Recommended• Growth Hormone
• Sodium oxybate
• Corticosteroids
• Opioids
Goldenberg DL et al, JAMA 2004, PMID 15547167MacFarlane GJ et al, Ann Rheum Dis 2016, PMID 27377815
Equivocal• NSAIDs
• Serotonin reuptake inhibitors
(SSRIs)
TIP: Go Slow
FDA approved for FMS
Treatment of Fibromyalgia
Medication
Body
Mind
A multidisciplinary approach
Scascighini L, et al, Rheumatology 2008Häuser W, et al, Arthritis Care & Res 2008
I.
• Aerobic Exercise (Cochrane Review 2002) (Mannerkorpi K, Curr Opin Rheum 2005) Walking, elliptical machine, cycling, aquatic therapy/exercise
• Tai Chi (Wang C, et al, NEJM 2010, PMID 20818876 )
• Lifestyle physical activity (pedometer)
• Aquatic Exercise • Stretching & Physical Therapy• Weight Training (Resistance)
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II. Eat Healthy
A. Higher body mass index (BMI) is associated with fibromyalgia (Yunus MB, et al, Scand J Rheumatol 2002)
B. Weight loss in obese patients with Fibromyalgia is associated with improved function (Shapiro JR, et al, J Psychosom Res 2005) and quality of life (Senna MK, et al, Clin Rheumatol 2012)
There is no convincing data to indicate that one diet will help to reduce pain or improve energy levels
Holton KF, Kindler KL and Jones KD, Rheum Dis Clin North Am, 2009, PMID 19647151
III. Get A Good Night Sleep
• Sleep deprivation (of stage 4 or �delta-wave� sleep deprivation) is associated with development of widespread pain.
• Patients with Fibromyalgia commonly have disturbances in their sleep with periodic arousals (alpha wave intrusion)
• Improvement in restorative sleep through sleep hygiene tips is associated with improvement in pain
Moldofsky H, Rheum Dis Clin North Amer, 2009, PMID 19647142Orlandi AC, et al, Rev Bras Rheumatol, 2012, PMID 23090368
TIPS FOR A BETTER NIGHT'S SLEEP
DO:• Establish and maintain a regular bedtime and wake-up time every day.• Find the amount of sleep you need to feel consistently refreshed.• Create a comfortable, quiet, clean and dark environment for sleeping. Your bed
and the temperature of your bedroom should be comfortable.• Establish a regular pattern of relaxing behaviors for 10-60 minutes before bedtime.• Use the bed and bedroom for sleeping and sex only.• Exercise on a regular basis (but not too close to bedtime).
DON'T:• Don't nap during the day or evening.• Don't eat heavy meals or drink large amounts of liquid before bedtime.• Don't allow worrying, anger or frustration to keep you awake in bed.• Don't lie awake in bed for long periods of time. If not asleep within 20-30 minutes,
leave your bedroom and do something relaxing until you feel sleep again.• Don't allow your sleep to be disturbed by your phone, pets, family, etc.• Don't use alcohol, caffeine, or nicotine. Also please turn off TV, computer and cell
phone at least 30-60 minutes before bed. All of these may worsen sleep.
Courtesy of David Claman, MD, UCSF Sleep Disorders Center
Treatment of Fibromyalgia
Medication
Body
Mind
A multidisciplinary approach
Scascighini L, et al, Rheumatology 2008Häuser W, et al, Arthritis Care & Res 2008
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What would life be like if you could influence the way you think and feel?
www.amysullivanmft.com/CognitiveBehavioralTherapy.htm
The Vicious Cycle of Chronic Pain
Emotional stress exacerbates pain and impairs functioning
Brain
Melzack & WallGate Control Theory
DepressionAnxiety
Catastrophizing(–)
Descending Signals Modulate Sensitivity To
Pain
Pain
Emotional stress exacerbates pain and impairs functioning
DepressionAnxiety
Catastrophizing
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Train The BrainCognitive Behavioral Therapy Goals:• Education about the nature of fibromyalgia• Realistic Goal Setting• Relaxation Training• Identification of dysfunction thought
patterns and Techniques to counteract negative automatic thoughts
• Strategize for maintenanceand management of flares
Bennett RM & Nelson D, Nat Clin Pract Rheumatol, 2006, PMID 16932733
Physical Response
Behavior
Thoughts Feelings
Does CBT Work?
Bennett RM & Nelson D, Nat Clin Pract Rheumatol, 2006, PMID 16932733
EULAR 2016 Fibromyalgia Recommendations
Weak Recommendation For• Cognitive Behavioral Therapy• Mindfulness / mind-body• Acupuncture• Meditative Movement• Hydrotherapy/spa
No Evidence for Efficacy• Trigger point injection
Strong Recommendation For• Aerobic & Strengthening Exercise
Weak Recommendation Against• Biofeedback• Hypnotherapy• Massage
Strong Recommendation Against
• Chiropractic therapy
MacFarlane GJ et al, Ann Rheum Dis 2016, PMID 27377815
Treatment of Fibromyalgia
Medicine
Mind
Body
A multidisciplinary approach
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• Referral by Pain Medicine MD
or rheumatologist
• Admission criteria – chronic
pain that interferes with lives
and have interest/motivation
• Interdisciplinary evaluation:team then meets to decide if
patient will be “admitted”.
• Focus of program is on
“whole body” – away from
medical management (no Rx)
12 week program• Classes 3-4 hrs, 2-3 times/week
• Textbook/Manual
Team:• Nurse coordinator
• Psychologist
• Physical Therapist
• Nutritionist
• Pharmacist (works with PCP)
• Social Worker (case management)
Summary• Fibromyalgia represents a condition of
central sensitization to pain• Systemic disease should be excluded in
patients with fibromyalgia• Fibromyalgia is important to diagnose to
limit unnecessary medical utilization• Fibromyalgia is manageable with a
interdisciplinary approach– Non-pharmacologic– Pharmacologic
Thanks!