diagnosing & treating chronic msk pain in working-aged adults
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Diagnosing & Treating Musculoskeletal Pain In Working-Aged Adults
The Importance of Identifying The Central Pain Phenotype
2/5/17
Presented By:Paul C. Coelho, MD
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Disclosures:Dr. Coelho has no disclosures. He will not be discussing any off-label uses of medications or devices.
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Table of Contents
Early Pain Models
Modern Pain Models
FMS, HA, and LBP
The Central Pain Phenotype
Evidence-Based Treatments
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1980 Model of MSK PainNociceptive Neuropathic
Primarily due to inflammation or tissue damage in the periphery
Damage or entrapment of peripheral nerves.
NSAID/Opioid Responsive Responds to both peripheral and central pharmacotherapy.
Responds to procedures. Does not respond to procedures.
Behavioral factors minor. Behavioral factors minor.Examples: Osteoarthritis, Rheumatoid arthritis, cancer pain.
Examples: Diabetic peripheral neuropathy, post-herpetic neuralgia.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
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1990 FMS
https://www.rheumatology.org/Portals/0/Files/1990_Criteria_for_Classification_Fibro.pdf
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US Overdose Deaths1980-2014
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
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012500250003750050000
Wolfe ACR FMS1990
FDA Approves OxyContin1995
APS Pain as a 5th Vital Sign1996
Wolfe Recants FMS2008
IOM 100M In Pain2011
Peak Incidence of Prescription OD 45-54
Portenoy Portenoy/Foley1986
Portenoy Recants2012
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Variation in Opioid Rx’ing forFMS 2007-2009
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346177/
Peak Incidence of Prescription OD 45-54
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35% of FMS Pt’s Receive SSDI
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151179/
Disabled Medicare Beneficiaries Rx’d Opioids
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FMS Patients Report High PainLevels In Spite of High Dosages
https://www.ncbi.nlm.nih.gov/pubmed/24310048
N = 582
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Opioids In FMS: Once StartedSeldom Stopped
https://www.ncbi.nlm.nih.gov/pubmed/26443495
N = 100K, 60% Received Opioids.
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Opioids In FMS: Once StartedSeldom Stopped
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5117947/
N = 64K, 44% Received Opioids.
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FMS Is Not Opioid Responsive
https://www.ncbi.nlm.nih.gov/pubmed/26975749
OrganizationAmerican Pain SocietyAmerican Academy of Pain MedicineAmerican Academy of NeurologyEuropean League Against RheumatismCanadian Pain SocietyCanadian Rheumatology AssociationBritish Pain Society
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2017 Model of MSK PainNociceptive Neuropathic Central
Primarily due to inflammation or tissue damage in the periphery
Damage or entrapment of peripheral nerves.
Primarily due to a central disturbance in pain processing.
NSAID/Opioid Responsive
Responds to both peripheral and central pharmacotherapy.
Tricyclic neuro-active compounds. Opioid unresponsive.
Responds to procedures.
Does not respond to procedures.
Does not respond to procedures.
Behavioral factors minor.
Behavioral factors minor.
Behavioral Factors Prominent.
Examples: Osteoarthritis, Rheumatoid arthritis, cancer pain.
Examples: Diabetic peripheral neuropathy, post-herpetic neuralgia.
Examples: FMS, cLBP, cHA, IBS.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
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Prevalence of LBP & HA in FMS
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
2007 Internet Survey of 2596 FMS Pts
Ave Age = 47If due to chance aloneLBP .3 x .05 =1.5% HA: .2 x .05 =1%
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Prevalence of FMS in cLBP 42%
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1829161/
Chance Alone: .3 x .05 = 1.5%
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Prevalence of FMS in Migraineurs 56%
Chance Alone:.2 x .05 += 1%
https://www.ncbi.nlm.nih.gov/pubmed/25994041
N = 1,730
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Comorbid Pain in FMS is the Norm
https://www.ncbi.nlm.nih.gov/pubmed/22364327
Fibromyalgia
Head AcheLow Back Pain
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Comorbid Pain in FMS is the Norm
https://www.ncbi.nlm.nih.gov/pubmed/22364327
Low Back Pain
“Overwhelming evidence reveals that what isoften labeled as a single chronic regional painsyndrome is, upon closer evaluation, a chronicillness beginning much earlier in life, where thepain merely occurs at different points of the bodyat different points in time and is given different labels by subspecialists focusing on “their region” of the body.”
Daniel Clauw, MD
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Central Sensitivity Spectrum Disorders
https://www.ncbi.nlm.nih.gov/pubmed/17350675
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Overlapping Chronic Pain Conditions
https://www.ncbi.nlm.nih.gov/pubmed/27586833
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Prescribers are Poor at DiagnosingCentral Pain Syndromes
https://www.ncbi.nlm.nih.gov/pubmed/23071343
23% Sensitivity
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Prescribers are Poor at DiagnosingCentral Pain Syndromes
https://www.ncbi.nlm.nih.gov/pubmed/23071343
27% Specificity
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Prescribers are Poor at DiagnosingCentral Pain Syndromes
https://www.ncbi.nlm.nih.gov/pubmed/20461781
“You cannot guess at the extent of fatigue, unrefreshed sleep, cognitive problems, multiplicity of symptoms, and extent of pain without a detailed interview. The new criteria obligate you to pay careful attention to the patient if you want to diagnose fibromyalgia.”
Fredrick Wolfe
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Diagnosing Central Sensitivity Spectrum Disorders
https://www.ncbi.nlm.nih.gov/pubmed/26266995
1. Pain in many body regions. 2. Higher current and lifetime history of chronic pain in several body regions.3. Multiple somatic symptoms (e.g., fatigue, memory difficulties, sleep problems, mood disturbance)4. More sensitive to other sensory stimuli (e.g., bright light, loud noises, odors, other sensations in internal organs)5. 1.5 to 2x more common in women.6. Strong family history of chronic pain.7. High self-reported pain & distress (VAS/NPS/PSD/PCS)8. Pain triggered or exacerbated by stressors.9. Peak prevalence of FMS age 50-59 (working-age).*10. Essentially normal physical examination +/- diffuse tenderness.
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2016 Fibromyalgia Screening Questionnaire (FSQ)
https://www.ncbi.nlm.nih.gov/pubmed/26266995
96% Sensitivity, 92% Specificity
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Why Is Dx’ing FMS/CSS Important?
https://www.ncbi.nlm.nih.gov/pubmed/26266995
1. It is opioid unresponsive.2. Prognosis: It does not improve with time.3. When present, it is the primary source of morbidityIn chronic non-cancer pain.
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FMS Is Opioid Unresponsive
https://www.ncbi.nlm.nih.gov/pubmed/26975749
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Natural Hx of FMS
https://www.ncbi.nlm.nih.gov/pubmed/21765102
N = 1,555 11yr f/u
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Natural Hx of FMS
https://www.ncbi.nlm.nih.gov/pubmed/28077978
N = 762yr f/u
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FMS is the Primary Source of Morbidity in CNP
https://www.ncbi.nlm.nih.gov/pubmed/27049402
N = 383, 76 FMS+
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Evidence-Based Treatments of FMS
https://www.ncbi.nlm.nih.gov/pubmed/28077978
Treatment Evidence Level
Patient Education 1AGraded Exercise 1ACBT 1ATricyclics 1ASNRI’s 1AGabapentenoids 1ANSAIDS 5DOpioids 5D
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Evidence-Based Treatments for FMS
https://www.youtube.com/watch?v=pgCfkA9RLrM
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Evidence-Based Treatments for FMS
https://fibroguide.med.umich.edu/
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Centralized Pain Pt Handout
https://www.painscience.com/articles/central-sensitization.php
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ResourcesFibromyalgia Screening Questionnairehttp://www.slideshare.net/101N/pcp-pain-screening-tool
Evidence-Based Treatments for FMS, Dr. Clauw JAMAhttp://www.slideshare.net/101N/fibromyalgia-clinical-review
Daniel Clauw, MD Youtube Video for patientshttps://www.youtube.com/watch?v=pgCfkA9RLrM&t=6s
Salmple Centralized Pain Patient Handouthttp://www.slideshare.net/101N/central-sensitization-70569194
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Paul.Coelho@salemhealth.org
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