Fibromyalgia and Chronic Fatigue Tory Davis PA-C.
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Transcript of Fibromyalgia and Chronic Fatigue Tory Davis PA-C.
Fibromyalgia One of the most common rheumatic
syndromes in ambulatory medicine 3-10% of the population 10-20% of pts seeing rheumatologists Annual cost for direct care about $20
billion or $2300/pt More common in females, ages 20-50 No objective findings No diagnostic labs or imaging
Diagnostic Criteria History of widespread pain for at least
3 months – Achy and stiff– Bilateral symptoms– Above and below waist– Worse at neck, shoulders, low back, hips
11 of 18 tender points (elicited by pressure of 4 kg/cm2)
Other common symptoms
Fatigue Sleep disorder Headache IBS (irritable bowel
syndrome) Irritable bladder “Fibro fog” - haze
Low back pain Mood disorder Multiple chemical
sensitivities Sexual dysfunction TMJ dysfunction Bruxism – grinding
teeth at night
…and the list goes on Pelvic pain Dysmenorrhea Restless leg syndrome Subjective numbness – feels numb,
but can sense on neuro test Exercise-induced pain and fatigue
Central Sensitization Pathophysiologic abnormality of CNS Sensory impulses amplified at spinal
cord level– In dorsal horn nocioceptive neurons
Proposed Causes Serotonin (much lower levels in women
compared to men) Substance P- aberrant pain perception? Sleep disturbance Injury/trauma Infection Psychological stressors- may increase pro-
inflammatory cytokines via impaired cortisol response
Hormones- ?neuroendocrine dysfunction
DDx Polymyalgia rheumatica – proximal
weaknesss Rheumatoid arthritis Sleep apnea Lupus Multiple sclerosis Thyroid disorder (hypo, usually) Neuropathies Mental illness
DDx continued Substance abuse Cancer Infection Medication side effects Malingering – people use it to get other
benefits
Work-up Dx of exclusion – must exclude! TSH (thyroid stimulating hormone) ESR (erythrocyte sedimentation rate) CBC (complete blood count) ANA (antinuclear antibody) RF (rheumatoid factor) Sleep study Psych screening tools
Physical Exam: Normal, except: Pain is present at multiple FM points
when pressure is applied. – Interestingly, it can felt virtually anywhere
pressure is applied, including control areas (forehead, thumbnail), which are relatively insensitive to pain in normal subjects.
Allodynia – “other pain”– Pain from stimuli that are not normally painful
Risk factors Sex (female, that is) Family history (nature/nurture?) Age- early/mid adulthood Other rheumatic dz: lupus, RA,
ankylosing spondylitis Disturbed sleep: OSA, RLS
Treatment This is a chronic disease. Requires
more than a Rx pad. Pt self-management Meds- only treating the symptoms.
Not curative nor disease-modifying except as they improve pt ability to self-manage and improve QOL
Self-Management Pts unwilling to engage in proactive
self care have poorer prognosis Regular low-impact exercise Regular sleep- no naps, limit caffeine Education about the dx and about self Support groups
Prognosis Better if ongoing stressors are relieved
and self-efficacy for pain control can be achieved.
Worse for patients who are highly distressed and have longstanding FM, major psych disease, or ingrained pattern of work avoidance.
Complementary and alternative treatment
Massage Acupuncture/ acupressure Myofascial release therapy Chiropractic treatment or OMT Cognitive behavioral therapy (CBT)
CBT Cognitive Behavioral Therapy Purpose: to redefine illness beliefs and
learn symptom reduction skills to change behavioral response to pain.
Need to sell this idea- not therapy “because it’s all in your head” but as a tool to improve prognosis.
Tools: gate control, relaxation, reframing
Pharm Tx TCAs: amitriptyline (Elavil) SNRIs: duloxetine (Cymbalta), milnacipran
(Savella) venlafaxine (Effexor) SSRIs: (paroxetine, fluoxetine, et al) Muscle relaxants: cyclobenzaprine Antiseizure meds: gabapentin (Neurontin),
pregabalin (Lyrica) Sleep aids- eszolpiclone (Lunesta),
zolpidem (Ambien)
Just say NO No narcotics No benzodiazepines To treat the pain use tramadol
(Ultram)– better proven efficacy than
acetominophen or OTC NSAIDS
CFS Profound fatigue not improved by rest,
worsened by physical or mental activity.
No clear cause. No definitive work-up. No good tx.
Fibromyalgia:pain::CFS:lassitude
CFS- Who? Female > male (3:1)
Usually not pediatric patients, but otherwise, any age, racial, ethnic or SES group
CFS Diagnostic Criteria Severe chronic fatigue ≥ 6 months
with other medical conditions excluded
AND…
AT LEAST 4 OF THESE ↓ STM or concentration Sore throat Tender cervical or axillary lymph nodes Muscle pain Headache (new type, pattern or severity) Unrefreshing sleep Post-exertional malaise lasting ≥ 24 hours Multi-joint pain without swelling or redness
Associated symptomsThese are NOT diagnostic criteria
Abd pain Etoh intolerance Bloating Chest pain Chronic cough Diarrhea Dizzy Dry eyes/mouth Paresthesias
Otalgia Palpitations Jaw pain Morning stiffness Nausea Night sweats Dyspnea Wt loss Etc etc etc etc etc etc etc etc etc…
Course Sx can remit and recur, or can
fluctuate in severity. Some pts will recover 100%, but
when? Some pts have progressively
worsening sx Can be lifelong
Causes A sampling of proposed, not proven
etiologies: Iron deficiency anemia Hypoglycemia Hx allergies Viral infection Immune system dysfunction Mild chronic hypotension Alteration in HPA axis function Sleep dysfunction Other
Risk factors What is a risk factor?
– A condition or value that alters the likelihood of the occurrence of a disease
Females more likely to be affected Gulf War veterans have 10-fold increased
incidence vs non-deployed vets Other?
We don’t know.
Role of Sleep Diagnosable sleep disorder present in
40-80% of CFS cases, but tx of sleep d/o only results in modest improvement of CFS sx.
? Effect rather than cause?
Differential diagnosis Fibromyalgia Multiple chemical
sensitivities Chronic mono Thyroid dysfunction Sleep apnea Narcolepsy Mental illness
Cancer Eating disorder Obesity Substance abuse Medication side
effect Somatization d/o Malingering
Labs/Work-up CBC CMP TSH ESR ANA RF UA
PPD HIV Lyme serology in
endemic areas ?CXR or other imaging MRI may show non-
diagnostic subcortical frontal lobe punctate hyperintensities
CFS Complications Deconditioning Med side fx Social isolation Loss of job Lifestyle restrictions Depression (from sx or lack of dx)
CFS Treatment Tx is directed at sx- Goal is to regain
some level of previous function and well-being.
Try NOT to aggravate existing sx or to create new ones.
Limit cost
CFS Tx- Non Pharm Physical activity- “Know thyself.” Pace
thyself. Avoid push-crash phenom Massage Acupuncture Acupressure Chiropractic tx OMT Yoga, tai chi Meditation
More non-pharm tx Education- knowledge is power. CBT Colonics?! Go ahead and Google it. Strive for health, but don’t grasp at
straws.
CFS Treatment- Meds Pts with CFS seems very sensitive to meds,
so START LOW, GO SLOW NSAIDS for pain- *these work for CFS, not
for fibromyalgia– Remember fibromyalgia pain responds better to
tramadol Low dose TCAs to improve sleep, decrease
pain Antidepressants/anxiolytics