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FibromyalgiaFibromyalgia

WHPLWHPL

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What is Fibromyalgia?

• Pathogenesis of Fibromyalgia

• Clinical Features and Diagnosis of Fibromyalgia

• Management of Fibromyalgia

• Summary

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Categorization of Pain ConditionsCategorization of Pain Conditions

Chronic PainChronic PainAcute PainAcute Pain

Central Pain Central Pain AmplificationAmplificationCentral Pain Central Pain AmplificationAmplification

Abnormal pain Abnormal pain processing by CNSprocessing by CNS

(ie, Fibromyalgia)(ie, Fibromyalgia)

Nociceptive PainNociceptive PainNociceptive PainNociceptive Pain

Noxious stimuliNoxious stimuli

(ie, Burn)(ie, Burn)

Inflammatory PainInflammatory PainInflammatory PainInflammatory Pain

InflammationInflammation

(ie, Rheumatoid arthritis)(ie, Rheumatoid arthritis)

Neuropathic PainNeuropathic PainNeuropathic PainNeuropathic Pain

Neuronal damageNeuronal damage

(ie, Herpes zoster)(ie, Herpes zoster)

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Fibromyalgia (FM): A Chronic Fibromyalgia (FM): A Chronic Widespread Neurologic Pain ConditionWidespread Neurologic Pain Condition

FM is a neurological condition associated with chronic widespread pain (CWP) and tenderness

American College of Rheumatology (ACR) criteria for the diagnosis of FM:– 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

.

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Risk Factors for FMRisk Factors for FM

Genetic factors– Relatives of FM patients are at higher risk for FM

• First-degree relatives are significantly more likely to have FM• Have significantly more tender points

Environmental factors– Physical trauma or injury– Infections (Lyme disease, hepatitis C)– Other stressors (eg, work, family, life-changing events)– Concurrent medical illness (e.g., SLE, RA, OA, hypothyroidism,

hepatitis)– Medications (steroid)

Gender– Women are diagnosed with FM about 7 times as often as men– peak age 40-60

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CONCURRENT DISEASES WITH FMCONCURRENT DISEASES WITH FM

•Chronic fatigue syndromeChronic fatigue syndrome•Irritable bowel syndromeIrritable bowel syndrome•Muscle, migraine headachesMuscle, migraine headaches•Irritable bladder syndromeIrritable bladder syndrome•Mood disturbancesMood disturbances•VulvodyniaVulvodynia•Temporomandibular joint (TMJ) disorderTemporomandibular joint (TMJ) disorder

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• What is Fibromyalgia?

Pathogenesis of Fibromyalgia

• Clinical Features and Diagnosis of Fibromyalgia

• Management of Fibromyalgia

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The Normal Pain Processing PathwayThe Normal Pain Processing Pathway

3. A signal is sent via the ascendingascending tract to the brain, and perceived as pain

2. Impulses from afferents depolarize dorsal horn neurons, then, extracellular Ca2+ diffuse into neurons causing the release of Pain Associated Neurotransmitters – GlutamateGlutamate and Substance PSubstance P

1. Stimulus sensed by the peripheral nerve (ie, skin)

4. The descendingdescending tract carries modulating impulses back to the dorsal horn

Pain Pain PerceivedPerceived

Glutamate

Substance P

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Central Sensitization: A Theory for Central Sensitization: A Theory for Neurological Pain Amplification in FMNeurological 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– May explain hallmark features of generalized heightened pain sensitivity

• Hyperalgesia – Amplified response to painful stimuli • Allodynia - Pain resulting from normal stimuli

Theory of central sensitization is supported by:– Increased levels of pain neurotransmitters

• Glutamate • Substance P

fMRI data demonstrates low intensity stimuli in patients with FM comparable to high intensity stimuli in controls

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Central Sensitization Produces Abnormal Central Sensitization Produces Abnormal Pain SignalingPain Signaling

After nerve injury, increased input to the dorsal horn can induce central sensitizationPerceived pain

Ascendinginput

Descendingmodulation

Nerve dysfunction

Nociceptive afferent fiber

Minimalstimuli

Perceived pain(hyperalgesia/allodynia)

Induction of central sensitization

Increased release of pain neurotransmitters glutamate and substance P

Pain amplification

Increased pain perceptionIncreased pain perception

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FM: An Amplified Pain ResponseFM: An Amplified Pain Response

Pain Pain amplificationamplification

responseresponse

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ain

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ten

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Stimulus intensityStimulus intensity

Normal painNormal painresponseresponse

(when a pinprick causes an intense stabbing sensation)

Hyperalgesia

10

8

6

4

2

0

Adapted from Gottschalk A and Smith DS. Am Fam Physician. 2001;63:1979-1986.

Allodynia(hugs that feel painful)

Pain in FMPain in FM

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fMRI Study Supports the Amplification of fMRI Study Supports the Amplification of Normal Pain Response in Patients With FMNormal Pain Response in Patients With FM

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12

10

8

6

4

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4.51.5 2.5 3.5

Stimulus intensity (kg/cm2)

Pai

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ity

FM (n=16)Subjective pain controlStimulus pressure control

(n=16)

Patients with FM experienced high pain with low grade stimuli

Yellow: Area of overlap (ie, area activated at high intensity stimuli in control patients was activated by low intensity stimuli in patients with FM)

Green: Activated only at high intensity stimulus in controls

Red: Activation at low intensity stimulus in patients with FM

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FM Pathophysiology: Summary FM Pathophysiology: Summary Central sensitization is a leading theory of FM pathophysiology1

Elevated pain neurotransmitters in CSF of patients with FM– Several studies showed elevated levels of glutamate and

substance P– Elevated levels suggest that this may contribute to pain

amplification

fMRI data supports FM as a disorder of central pain amplification

– Areas activated by high intensity stimuli in control patients were activated by low intensity stimuli in patients with FM

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• What is Fibromyalgia?

• Pathogenesis of FibromyalgiaClinical Features and Diagnosis of Fibromyalgia

• Management of Fibromyalgia

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Chronic Widespread PainChronic Widespread Pain• CORE criteria of FMCORE criteria of FM

• Pain is in all 4 quadrants of the body ≥3 monthsPain is in all 4 quadrants of the body ≥3 months• Patient descriptors of pain include:Patient descriptors of pain include:44

• Aching, exhausting, nagging, and hurtingAching, exhausting, nagging, and hurting

TendernessTenderness• Sensitivity to pressure stimuliSensitivity to pressure stimuli

• Hugs, handshakes are painfulHugs, handshakes are painful• Tender point exam given to assess tendernessTender point exam given to assess tenderness

• Hallmark features of FMHallmark features of FM44

• HyperalgesiaHyperalgesia• AllodyniaAllodynia

Other SymptomsOther Symptoms• FatigueFatigue• Pain-related conditions/symptomsPain-related conditions/symptoms

• Chronic headaches/migraines, IBC, IC, TMJ, PMSChronic headaches/migraines, IBC, IC, TMJ, PMS• Subjective morning stiffnessSubjective morning stiffness

• Neurologic symptomsNeurologic symptoms• Nondermatomal paresthesiasNondermatomal paresthesias• Subjective numbness, tingling in extremitiesSubjective numbness, tingling in extremities

• Sleep disturbance Sleep disturbance • Non-restorative sleep, RLSNon-restorative sleep, RLS

Clinical Features of FMClinical Features of FM

Other Other SymptomsSymptoms

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Patients With FM Present With Patients With FM Present With a Global Pain Disordera Global Pain Disorder

While the ACR classification criteria focuses on 18 points, patients do not usually speak of tender points1

This is a pain drawing—a patient colors all areas of the body in which they feel pain2

The diagram shows that the pain of FM is widespread1

FrontBack

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ACR-Recommended Manual Tender Point ACR-Recommended Manual Tender Point Survey for the Diagnosis of FMSurvey for the Diagnosis of FM

Manual Tender Points SurveyManual Tender Points Survey:: • Presence of 11 tender points on palpation to a maximum of 4 kg Presence of 11 tender points on palpation to a maximum of 4 kg

of pressure (just enough to blanch examiners thumbnail)of pressure (just enough to blanch examiners thumbnail)

OCCIPUT –OCCIPUT – At nuchal muscle At nuchal muscle insertioninsertion

GLUTEAL – GLUTEAL – Upper outer quadrant of Upper outer quadrant of gluteal musclesgluteal muscles

GREATER GREATER TROCHANTER –TROCHANTER – Muscle attachments just Muscle attachments just posterior to GTposterior to GT

SUPRASPINATUS – SUPRASPINATUS – At attachment to medial At attachment to medial border of scapulaborder of scapula

TRAPEZIUS – TRAPEZIUS – Upper border of trapezius, Upper border of trapezius, midportionmidportion

LOW CERVICAL –LOW CERVICAL – Anterior aspects of C5, C7 Anterior aspects of C5, C7 intertransverse spacesintertransverse spaces

SECOND RIB SPACESECOND RIB SPACE –– about 3 cm lateral to sternal about 3 cm lateral to sternal

borderborder

ELBOW – ELBOW – Muscle attachments to Muscle attachments to

Lateral EpicondyleLateral Epicondyle

KNEE – KNEE – Medial fat pad of knee Medial fat pad of knee

proximal to joint lineproximal to joint line

RIGHT FOREARMRIGHT FOREARM

FOREHEADFOREHEAD

LEFT LEFT THUMBTHUMB

Control PointsControl Points

Tender PointsTender Points

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• What is Fibromyalgia?

• Pathogenesis of Fibromyalgia

• Clinical Features and Diagnosis of Fibromyalgia

Summary

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Rule out other conditions that may present with chronic Rule out other conditions that may present with chronic widespread pain (“Operator dependent”)widespread pain (“Operator dependent”)

History of chronic, History of chronic, widespread pain for ≥3 monthswidespread pain for ≥3 months

Confirm presence of tender points Confirm presence of tender points (Fibromyalgia may be present, even if <11 of 18)(Fibromyalgia may be present, even if <11 of 18)

General physical exam, neurologic exam, selected laboratory General physical exam, neurologic exam, selected laboratory testing (ESR, thyroid tests; avoid screening serologic tests)testing (ESR, thyroid tests; avoid screening serologic tests)

Confirm diagnosis Confirm diagnosis of fibromyalgiaof fibromyalgia

Rule out other conditions that may present with chronic widespread pain Rule out other conditions that may present with chronic widespread pain Depending on physicianDepending on physician: Mental health evaluation, sleep evaluation: Mental health evaluation, sleep evaluation

History of chronic, History of chronic, widespread pain for ≥3 monthswidespread pain for ≥3 months

Confirm presence of tender points Confirm presence of tender points (Fibromyalgia may be present, even if <11 of 18)(Fibromyalgia may be present, even if <11 of 18)

General physical exam, neurologic exam, selected laboratory testing General physical exam, neurologic exam, selected laboratory testing (ESR, thyroid tests; avoid screening serologic tests)(ESR, thyroid tests; avoid screening serologic tests)

Confirm diagnosis Confirm diagnosis of fibromyalgiaof fibromyalgia

Is There Any Effective Management of Is There Any Effective Management of Fibromyalgia?Fibromyalgia?

All patients● Reassurance re diagnosis ● Give explanation, including, but not solely,

psychological factors● Promote return to normal activity, exercise

Most patients● Medication trial● Cognitive behavior therapy, counseling● Physical rehabilitation

Initial Treatment of FibromyalgiaInitial Treatment of Fibromyalgia

May require referral to a specialist for May require referral to a specialist for full evaluation; for example: full evaluation; for example: To psychiatry, sleep clinicTo psychiatry, sleep clinic

Assess psychosocial stressors, level of Assess psychosocial stressors, level of fitness, and barriers to treatmentfitness, and barriers to treatment

Provide education about fibromyalgiaProvide education about fibromyalgia

Confirm diagnosisConfirm diagnosis

Identify important symptom domains, their severity,Identify important symptom domains, their severity,and level of patient functionand level of patient function

Evaluate for comorbid medical and Evaluate for comorbid medical and psychiatric disorderspsychiatric disorders

Nonpharmacologic Strategies: Nonpharmacologic Strategies: Evidence of EfficacyEvidence of EfficacyStrong EvidenceStrong EvidenceExerciseExercise

Physical and psychological benefitsPhysical and psychological benefits

May increase aerobic performance and tender May increase aerobic performance and tender point pain pressure threshold,point pain pressure threshold,and improve painand improve pain

Efficacy not maintained if exercise stopsEfficacy not maintained if exercise stops

Cognitive-behavioral therapyCognitive-behavioral therapy

Improvements in pain, fatigue, mood,Improvements in pain, fatigue, mood,and physical functionand physical function

Improvement often sustained for monthsImprovement often sustained for months

Patient education/self-managementPatient education/self-management

Improves pain, sleep, fatigue, andImproves pain, sleep, fatigue, andquality of life quality of life

Combination (multidisciplinary therapy)Combination (multidisciplinary therapy)

Modest EvidenceModest EvidenceStrength trainingStrength trainingAcupunctureAcupunctureHypnotherapyHypnotherapyEMG biofeedbackEMG biofeedbackBalneotherapy (medicinal bathing)Balneotherapy (medicinal bathing)Transcranial electrical stimulationTranscranial electrical stimulation

Weak EvidenceWeak EvidenceChiropracticChiropracticManual and massage therapyManual and massage therapyUltrasoundUltrasound

No EvidenceNo EvidenceTender-point injectionsTender-point injectionsFlexibility exerciseFlexibility exercise