HOW TO TAME FIBROMYALGIA - Dr Gillick1000+ new patients per year 100 +/- Fibromyalgia – 30 /w Dx ....
Transcript of HOW TO TAME FIBROMYALGIA - Dr Gillick1000+ new patients per year 100 +/- Fibromyalgia – 30 /w Dx ....
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HOW TO TAME
FIBROMYALGIA
By Dr. John Gillick, MD, MPH, FACP
jsgillick
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Aarrggg!!
Controversies of FIBROMYALGIA jsgillick
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FIBROMYALGIA
is the name given to a
CHRONIC PAIN
SYNDROME
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FIBROMYALGIA
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FIBROMYALGIA
is
UNDERSTANDABLE
as well as,
readily
TREATABLE
jsgillick
SUMMARY
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Anesthesiology / Internal Medicine
Preventive Medicine: Occupational Medicine Associate Professor of Medicine & Anesthesiology, non-salaried, UCSD
Anesthesia and Pain Medicine (1970-94)
Private (77-94) / Military (70-77)
Army Reserve disability evaluation, fitness for duty, and
Preventive Medicine (1977-present).
Occupational Medicine - Internal Medicine
Comprehensive Disability Evaluation
(1993/4-present)
jsgillick
BACKGROUND
John S. Gillick, MD, MPH
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PRACTICE
Disability Evaluation
Occupational Medicine
Two-thirds
VA
Comprehensive Disability Evaluations
1000+ new patients per year
100 +/- Fibromyalgia – 30 /w Dx
. One-third
UCSD
Work Injuries
350 +/- new injuries per year
25 +/- active fibromyalgics - 5 /w Dx half of these, the fibromyalgia is intertwined with the work injury
jsgillick
John S. Gillick, MD, MPH
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COMMONALITY
1 Heralding trauma(s)
or a history of cumulative traumas
2 Identifiable daily cumulative traumas
Simple traumas which
exceed the individual’s short-term recovery powers (coping) .
3 amplified pain perception
“hyperalgesia”
&
“allodynia”
jsgillick
John S. Gillick, MD, MPH
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FIBROMYALGIA
Demystify
Simplify
Treat
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PURPOSE OF PRESENTATION
John S. Gillick, MD, MPH
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CLINICAL PRESENTATION
based upon
MY EXPERIENCE
PAST
THREE+ YEARS
> 300+ Meet ACR criterion
Treat about thirty each year
80% significant improvement
John S. Gillick, MD, MPH
jsgillick
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Zero budget
Clinical or Research
Successful Management --> Premise Theory Seems to explain the condition
No hard Numbers
Burden of proof
requires
PROSPECTIVE SCIENTIFIC STUDY
jsgillick
John S. Gillick, MD, MPH
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WHAT IS FIBROMYALGIA? (ACCEPTED MEDICAL COMMUNITY EXPLAINATION)
Idiopathic
----------------------
Chronic pain disorder – (most frequent)
-----------------
Widespread muscle pains
With associated fatigue, sleep dysfunction
and
Multiple systemic symptoms
------------------
Not a specific disease
nor a diagnosis of exclusion
-------------------
CLINICAL SYNDROME
with similar physical and constitutional manifestations
---------------------
Confirm the diagnosis
by history and clinical exam alone
no specific blood test, scan, etc.
jsgillick
HISTORY & DEFINITION
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a. 440 BC Hypocrites - regional and diffuse muscle pain
b. 1783 Ramizziniz - muscle pain and fatigue with repetitive motion
c. 1816 Balfour - a British surgeon described widespread muscle /
joint pains
d. 1841 Velliex - muscular rheumatism and widespread tender points
e. 1869 Beard - myelasthenia / neurasthenia
f. 1904 Glowers - fibrositis / lumbago
"ladies of blameless habits and abstemious clergymen“
g. 1915 Llewellyn & Jones - Fibrositis, myofibrositis
h. 1927 Albee - myofascitis, mimicry of other disorders
i. 1942 Travell - Myofascial trigger points, idiopathic myalgia
j. 1977 Smythe and Modofsky - Fibrositis syndrome
k. 1981 Yunis - fibromyalgia
l. 1990 American College of Rheumatology - definition (Wolfe, et al)
m. 1993 World Health Organization - recognition
(#2 most frequent Rheumatology diagnosis made) jsgillick
HISTORY:
HISTORY & DEFINITION
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DEFINING THE
CONDITION
1990
Rheumatologists collaborated, 1986-90
criterion & name
for
fibrositis, neuro-myasthenia, myofascitis, etc.
Fibromyalgia Syndrome
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HISTORY & DEFINITION
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jsgillick
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American College of Rheumatology
(ACR) diagnosis requires
1) Chronic widespread myalgia (>3-6 months)
2) Pain in at least 11 of 18 ACR designated tender areas,
(including axial, above and below the waist,
and right and left sides)
3) Systemic manifestations
- fatigue, sleep dysfunction
- worsening with weather, stiffness
- numbness, tingling
- irritable bowel syndrome
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HISTORY & DEFINITION
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18 Points
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HISTORY & DEFINITION
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WHO GETS FIBROMAYALGIA ?
Almost anyone
5 to 10 times more frequent in women
High-functioning, hard-driving, over-achievers
Hereditary vulnerability
Population prevalence across cultures
2 and 8 percent
The US admits to about 2.5%
jsgillick
HISTORY & DEFINITION
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VIEWS OF FIBROMYALGIA
General medical community
The lay public
The Fibromyalgic
Myself
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VIEWPOINTS
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General Medical Community
Skepticism
Disbelief
Compassion
Suspicion
Frustration
Irritation
Avoidance
Detachment, and even,
Disdain
Arrogance
Dismissal jsgillick
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Mainline explanation:
Growing pains, hysteria, somatization
Mainline treatment:
None specific
Centers on pain alleviation
Physical therapy & exercise
Then to the psychiatrist and/or pain doctor
jsgillick
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PROF IN A BOX
Who are they?
Practitioners or lecturers who:
--armchair clinicians--
--know about it by lectures/reading--
--see the condition infrequently--
--refuse to deal with it-- --don't get to know their patients with the condition…
jsgillick
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What do they do?
LABEL
fibromyalgia
as a psychiatric condition and
fibromyalgics
as malingerers -- people short in moral fiber and
those who treat fibromyalgia
as "quacks" jsgillick
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What’s their rationale?
"If we don't understand it
and
If we can't measure it, or cure it with surgery or a pill
then
It doesn't exist in reality
Therefore
The condition is in the mind, a mental disorder,
or the person is faking it.”
jsgillick
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Lay Community’s View
Curiosity & fear…
The sufferers must be exaggerating, etc.
They are faking
whiners & wimps
jsgillick
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Fibromyalgic’s View
When active or hyper-active
Hurt all over
All the time, without relief
24 / 7
Afraid to talk about it
No decent sleep, have diarrhea
Social recluses
Snowed by pain meds, that don't work
Basic tasks require great concentration
Mask their feelings
Wonder if they are crazy
jsgillick
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The rest of the time (low active):
Dread weather changes
Ache and hurt
Smoldering pain: exacerbates and calms
They just "want to be normal."
Only look for help when totally "spent."
What’s beneath:
Fear, anger, blame
Defense, denial, and masking.
Frustration with health specialists
Search alternative medicine
* Call 'em liars or fakes and you anger them
*There's no better way to disable a person than to label
them as faker, liar, malingerer, exaggerator…. jsgillick
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My View
A lot out there
Many more than we like to admit
Real and believable people
Deserve to be heard and helped
Beyond temporary pain alleviation
Real condition
Can be understood
Can be controlled
by the individual …
IEWPOINTVS
jsgillick
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UNDERSTAND
FIBROMYALGIA (FM)
(REMOVE THE MYSTERY) jsgillick
THE MYSTERY
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THE KING
WITH MANY COSTUMES
THE MYSTERY
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KING WITHOUT
CLOTHES
THE MYSTERY
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FIVE CONCEPTS
To understand Fibromyalgia (FM)
It is necessary to understand:
I. Vulnerability
II. Cushion & Overload
III. Triggers & Enablers
IV. Active Fibromyalgia
V. Ownership
CONCEPTS
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I. VULNERABILITY
Appears to be familial
Women more vulnerable than men
No significant cultural, ethnic, geographic,
or generational predisposes or protectors
Increased vulnerability for some
Others - same triggers - no signs
(alcohol, nicotine addiction, diabetes)
Trigger anyone with enough trauma
CONCEPTS - I
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II. COPING, CUSHION, OVERLOAD,
OVERWHELM
Healthy coping mechanism rapid recovery from trauma and stress
Normal individuals readily cope with
ongoing traumas of daily life
Exceptional individuals can endure prolonged torture
Chronically stressed individuals (whether from illness, physical/mental stress, sleep depravation)
decreased coping capacity -- recovery can’t keep up
jsgillick
CONCEPTS - II
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Medically
neuro-muscular
restorative system
= coping capability
and
If restoration of neuro-muscular neutrality
cannot keep pace with daily trauma coping capacity
becomes overwhelmed
CONCEPTS - II
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When coping mechanisms are overwhelmed
PAIN AMPLIFICATION
occurs
pain-begets-pain
CONCEPTS - II
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Neurophysiology
of
Chronic Pain
Dickerson (5) & Yaksh(11)
Experimentally induced
Chronic pain In animal experimentation
document reproducible
anatomical / biochemical
central nervous system changes
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CONCEPTS - II
DETOUR
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FINDINGS
0n-going hyper-stimulation of
Peripheral nociceptors
Causes anatomical changes spino-thalamic tract
anti-nociceptors & dorsal horn cells
dendritic nerve remodeling
&
inhibition
of the normal
Thalamic down regulation
of pain stimulus transmission
CONCEPTS - II
jsgillick
DETOUR
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CNS mechanism for
neutralizing pain reception
THALAMIC DOWN-REGULATION
= coping
With ongoing hyper-stimulation
anti-nociceptive system
doesn’t recover
&
Dysfunctional thalamic down-regulation
jsgillick
CONCEPTS - II
DETOUR
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With ongoing hyper-stimulation
inter-relationship between dorsal horn dendrites,
the nociceptive and anti-nociceptive receptors doesn’t recover
Nerve remodeling occurs with:
a) dendritic new growth toward the thalamus;
b) sympathetic nerve sprouting; &
c) crossing over of spino-thalamic lamina fibers
Nerve remodeling
dorsal horn hyper-excitability
and
Retrograde activation of nocioceptors by the hyper-active
remodeled anti-nocioceptors,
jsgillick
CONCEPTS - II
DETOUR
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Retrograde activation of nocioceptors,
RENEGADE neuropathic behavior
- perhaps the cause of visceral manifestations-
Also plays a role in the
allodynia and hyperalgesia common to the
chronic pain
syndromes
jsgillick
CONCEPTS - II
DETOUR
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III. T&E's
TRIGGERS AND ENABLERS
Triggers Fibromyalgia (FM)
has a beginning.
The initial cause is its TRIGGER
Enablers Once activated,
FM is kept active by
ongoing irritations or traumas
which I dub ENABLERS
jsgillick
CONCEPTS - III
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Triggers May be single or multiple
Commonly: macro-trauma
May be multiple micro-trauma
Enablers
Usually multiple
Ongoing (micro) traumas **
Residuals of macro-trauma triggers
Both
Macro-trauma
Commonly recognized injuries or
happenings with pain-producing consequences
Micro-trauma
Small traumas, often irritants for many,
the usual daily stuff that the ordinary Joe “sucks-up”
jsgillick
CONCEPTS - III
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Macro-trauma examples:
Multiple-trauma auto accidents; back injuries;
acute into chronic whiplash; difficult pregnancy;
shoulder trauma; non-union fractures; fall injury to
hip,leg, coccyx; arthropathies; etc.
Most commonly associated with TRIGGERS
Micro-trauma examples:
Chronic allergic sinusitis/rhiniitis; recurring
cervical / thoracic subluxations; wallet sciatica; feet:
shoe/arch problems; sleeping position/comfort
dysfunction; exercise/work traumas; gout; automobile
stick-shift, etc.
Most commonly associated with ENABLERS jsgillick
CONCEPTS - III
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FIBROMYALGIA IS CATEGORIZED by itsTriggers
“Secondary” FM (10-30%) specific macro=trauma
rapid onset (3 mo)
“Delayed-secondary” FM: (20-30%) (concomitant)
onsets six months to several years
traumatic episode or disease (macro-trauma)
persists as residual on-going micro-trauma
"Primary” FM (50% +/-) "idiopathic" gradual onset
cumulative micro-traumas
no immediately obvious trigger(s)
jsgillick
CONCEPTS - III
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IV. FMS
THE FIBROMYALGIA SYNDROME “THE ULTIMATE CUMULATIVE TRAUMA OVERLOAD SYNDROME”
Systemic condition
“Hyperalgesia” - hypersensitive to noxious stimulus
“Allodynia" - identify non-noxious stimuli as noxious
Widespread neuro-muscular-spasm
"pain-begetting-pain“
“pain-amplification-chamber”
Daily activity trauma amplification
Neuro-physiological basis / explanation jsgillick
CONCEPTS - IV
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Fibromyalgia starts:
WHEN :
coping mechanism overwhelmed (dysfunctional thalamic down-regulation)
(dysfunctional anti-nociceptive system)
MANIFESTS:
"pain amplification"
hyperalgesia and allodynia
widespread muscle spasm & pain
Fibromyalgia is kept active by:
ENABLERS:
Amplified by a dysfunctional CNS
“daily activity trauma amplification”
CONTINUES UNTIL:
enablers and triggers
neutralized
jsgillick
CONCEPTS - IV
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V. RESPONSIBILITY
& OWNERSHIP
FMS activity / control: - the individual - not the health professional.
Tools: - education
- behavior modification training
- adjunctive medications
- physical modalities
- emotional support
CONTROL by the individual
TOOLS from the health professional jsgillick
CONCEPTS - V
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CONTROL OWNERSHIP
Fibromyalgia controls the individual
dominant factor limiting home and employment activities
Fibromyalgia may co-exists within the individual
temporarily “shut-it-down”
The fibromyalgic owns the condition
“turn-down," then "turn-off”
neutralize the triggers and enablers
jsgillick
CONCEPTS - V
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TREATMENT
(MANAGEMENT)
THREE AVENUES
1. CHANGE VULNERABILITY = ideal
2. PAIN MANAGEMENT = the most common, placation
3. T&E APPROACH = most effective
NEUTRALIZATION OF THE TRIGGERS AND ENABLERS
jsgillick
TREATMENT SELECTION / EXPECTATIONS
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T & E
NEUTRALIZE
the
TRIGGERS & ENABLERS
APPROACH
jsgillick
T&E APPROACH
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jsgillick
T&E
Approach
Trigger & Enabler
Disabler
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T&E APPROACH
REASONABLE GOALS
80%
80% calmed in a month
80% controlled in two months
80% "ownership" within four months
80% 80% TAMED IN SIX MONTHS
jsgillick
TREATMENT SELECTION / EXPECTATIONS
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PROVIDED 1. Primary patient agenda rid the condition
2. Knowledgeable healer as a guide
3. Individualized plan
- focused
- comprehensive
4. Educable, fully-committed, co-operative, persistent patient
5. Availability of modest and appropriate
a. pharmacologic tools
b. orthotic devices
c. work-home modifications
d. physical medicine resources
6. Co-operation and co-ordination of health care resources
jsgillick
TREATMENT SELECTION / EXPECTATIONS
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T&E APPROACH Control of Triggers and Enablers
1. Diagnosis
2. Selection
3. Educate
4. Identify T & E’s
5. Draft solutions
6. Apply solutions
7. Prevention
T&E APPROACH
jsgillick
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1
T&E #1a - Diagnosis
jsgillick
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DIFFERENTIAL
DIAGNOSIS
R/O other organic condition
differentiate from:
polymyalgia rheumatica
polymyositis
collagen vascular diseases
endcocrinopathies
etc.
jsgillick
T&E #1b - Diagnosis
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SCREENING LABS
CBC, ESR
CRP and CPK
Chemistries:
Include: glucose, BUN, creatinine, electrolytes,
calcium and phosphate, alkaline phosphatase,
ALT, AST, thyroid function screen, ANA, and
Rheumatoid Factor
jsgillick
T&E #1c - Diagnosis
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**PATIENT SELECTION** Attitude, Agenda, Attention - - - 80%
1. Doesn’t need the condition or diagnosis
- income, disability or other secondary gain
2. Is committed to self-control of the condition
- ready to make behavioral change
3. Has realistic expectations
- does not expect a magic pill or surgical / diet cure
4. Does not have a fixed agenda
5. Will use and continue successful adjunctive treatments
- give up problem behaviors
- terminate overload activities
6. Hates the condition more than loves enablers
- (shoes, car, activity)
jsgillick
T&E #2 - Patient Selection
2
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EDUCATION
The patient and the healer must clearly understand
and agree:
It is the healer’s role to:
- diagnose, teach, guide and assist
It is the patient’s role is to:
- make the necessary behavioral modifications
- review and maintain the necessary treatment remedies
- discover other helpful/harmful factors and seek aid for
remedies
- secure/pay for
necessary ancillary services, medicines and devices
jsgillick
T&E #3a - Education
3
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FIVE CONCEPTS
I. Vulnerability
II. Cushion & Overload
III. Triggers & Enablers
IV. Active Fibromyalgia
V. Ownership
jsgillick
T&E #3b - Education
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IDENTIFY T&E's
Fibro-specific exam
History
Physical
jsgillick
T&E #4a - Identify T&E’s -- examination
4
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Common discrete TRIGGERS
Traumas
Whiplash
Back injury
Non-healing fractures
Arthropathies (i.e., osteoarthritis)
Psych stress
Pregnancy
jsgillick
T&E #4b - Identify T&E’s -- exam
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Common ENABLERS
and enabler-triggers
Sinusitis/rhiniitis (breathe 168 hrs/wk)
Sleep -- position (bed – 50 hrs/wk)
Foot and shoe dysfunction (stand /walk –50 hrs/wk)
Repetitive impact loading (exercise – 5+ hrs/wk)
Driving equipment / behaviors (travel 15 hrs/wk)
Sitting (sit / slouch 60 hrs/wk)
Clothing, environment – day & night (clothed 160 hrs/wk)
jsgillick
T&E #4c
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History Fully list the symptoms & conditions :
Sinus or breathing problems
Medical problems
Orthopedic problems
Occupational and Environmental conditions / problems
Current treatments & past Specifically address and ask about:
thoracic and cervical spine low back
neck-shoulder bowel – diarrhea
shoes hip, back, knee
foot, ankle problems occupational injuries
automobile sports, workouts
hobbies second jobs
home work station psychological stressors
jsgillick
T&E #4d - Identify T&E’s -- exam
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Physical
"Fibro-thorough“
“Fibro-specific”
physical examination and observation
Different from standard classical
“physical exam”
Exam of observation and listening start and finish
patient clothed
Understanding and familiarity daily living ergonomics
myofascial trigger
jsgillick
T&E #4e - Identify T&E’s -- exam
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NAME & ID # SYMPTOMS # # #
DATE #1 Sinusitis / rhiniitis
DATE #2 Sleep disorder
DATE #3 Multiple allergies
DATE #4 Fatigue
Headaches
TENDER AREAS Light headednessR L FELT AS PAIN R L R L R L Jaw Pain (TMJ)
1 Occiput Chest pain
2 Low cervical Irregular Heart
3 Trapezius Stiffness
4 Supraspinatus Cold intolerance
5 Second rib Worsen /w weather
6 Lateral epicondyle Anxiety
7 Outer gluteal Numbness & weak
8 Greater Trochanter Raynaud's
9 Knee fat pad Shoulder dysfunction
Feel swollen
Carpal tunnel
#1 Global Function #2 #3 #4 Heartburn
Fibro Functional Level Upset stomach
scale of 0 - 4 Irritable bowel
Standard Pain Scale Diarrhea/Constipation
scale of 1 to 10 Irritable bladder
Ovarian pain
Dysmenorrhea
#1REMEDIES
#
2
#
3
#
4
Endometriosis
Orthotics-shoe change Cervical SpineSleep position Thoracic SpineAutomobile - Stick shift Low backWallet in pocket - Sacro/CoccyxGlasses change Hip painsClothing Radiculopathy / armsSinus medication Radiculopathy / legsAllergy medication Patello-femoralTricyclic Ankle sprain, etc.Analgesic Plantar fasciitisGabapentin Flat feet
Bunions / Morton's
#1 #2 #3 #4
jsgillick
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jsgillick