Download - Fibromyalgia.Rc Burdine.Fmdrl
Fibromyalgia Ramona Carter-Burdine, M.D. UTMB Galveston
Goals For Attendees
Lecture attendees will able to: Name the American College of Rheumatology
(ACR) diagnostic criteria Recognize typical History and Physical
findings List Treatment options and their efficacy
Skepticism in Perspective
Who is Dr William Harvey (1578-1657) ? Credited with first correctly describing, in exact detail, the properties of
blood being pumped around the body by the heart.
Who is Dr Ignaz Semmelweis(1818-1865)? Hungarian physician who demonstrated that puerperal fever was
contagious and that its incidence could be drastically reduced by enforcing appropriate hand-washing behavior by medical care-givers.
Who is Dr Joseph Lister (1827-1912) ? Father of modern surgery, he developed the principles of antiseptic
surgery after recognizing that postoperative wound infections did not arise spontaneously but rather were due to germs in the environment contaminating the wound.
Definition of Fibromyalgia (FM)
Tender points/pain in fibrous tissues, muscles, tendons, ligaments without inflammation (fibromyositis)
Any fibromuscular tissues may be involved, but those of the occiput, neck, shoulders, thorax, low back, and thighs are especially affected
American College of Rheumatology (ACR) Criteria*
Widespread pain for at least 3 months including:
Pain on the right and left sides of bodyPain above and below the waist Pain in the axial skeleton
AND……….
*Arthritis Rheum 1990 Feb;33(2):160
Pain on palpation with a 4-kg force in 11 out of 18 sites
Occiput - Low cervical Trapezius - Supraspinatus Lateral epicondyle - Greater trochanter Knee - Gluteus Maximus Lateral to second costochondral junction
Tender Points of FM
Nontender control points = mid forehead and anterior thigh
ACR Criteria
Is established on the basis of clinical observations.
Is a condition with signs and symptoms that exist on a continuum.
Often requires observation over time to firmly establish the diagnosis
Difference between FM and Myofascial Pain Syndrome
Defined by presence of trigger points Trigger points often have nodular texture
similar to a pencil eraser Trigger points located within taut bands of
muscle (tender points are not) Pain pattern limited to particular region Palpation of trigger points often reproduces
pain radiation pattern/muscle twitch
Prevalence of FM
Estimates of prevalence are 3.4 percent for women and 0.5 percent for men
Female-to-Male ratio of 9:1
Typically women aged 20-50 years
Cost Burden
Outpatient follow-up averages 10 visits/year
Hospitalization average once every 3 yrs Mean annual cost of medical care =
$2,274/patient* Many patients report receiving some type
of disability payment.
*Arthritis Rheum 1997 Sep;40(9):1553
Mortality/Morbidity
FM is a chronic relapsing condition. Long term follow up:
50% dissatisfied with their health
59% rate their health as fair/poor. More comorbid medical conditions and
surgical interventions compared to other rheumatic disorders.
Etiology
Etiology remains unclear Require a biopsychosocial, not just a
biomedical, viewpoint
Common Biopsychocial Features Given in Explanatory ModelsLikely related: Stress Depression Fatigue Chronic Illness
Not shown to be related: Toxins Immune System
Dysfunction Infection due to yeast or
viruses
Biomedical Factors
Dysregulation of autonomic system Dysregulation of neuroendocrine
system
Infectious mononucleosis (Epstein Barr Virus) not likely causative*
*Arch Intern Med 1999 Apr 26;159(8):865
Neuroendocrine System
Changes in neuroendocrine transmitters: serotonin, substance P, growth hormone and cortisol
Elevation of CSF substance P levels to three times normal levels.
Alteration in hypopituitary - adrenal axis with low production of cortisol.
Core Concepts in Understanding Pain in FM
Generalized decrease pain perception threshold
Hyperalgesia
amplification of pain experienced from peripheral
stimuli that are expected to be painful
Allodynia
pain with stimuli that should not cause pain such as
gentle touching
Autonomic System
Provocation of symptoms during tilt table testing with significant prevalence of neurally mediated hypotension.
Diagnostic Testing
Minimum of testing To Rule out other Causes may
consider: TSH – R/O Hypothyroidism
ESR, CBC –R/O Rheumatic Disease
CPK –R/O Myopathies
ANA, RF, serum complement levels,
Lyme titer, PPD, RPR, HIV, Hep C
Clinical Diagnosis
Widespread pain – 98% Soft tissue pain/tender points Sleep disturbance Chronic fatigue Associated co morbid conditions Associated rheumatic diseases
Why is Diagnosis Important?
“Making a definite diagnosis of fibromyalgia reduces patients' utilization of medical resources and improves satisfaction with healthcare.”
Quotation excerpt: DynaMed@ www.dynamicmedical.com
Key Patient Education Points
Chronic but nonprogressive disease Education about pain modification More healthful lifestyle Reassurance that fibromyalgia is not a
psychiatric disturbance and not rare
Treatment
The goals of treatment for fibromyalgia are to control pain and improve function.
These goals can be met using a variety of techniques
Clinical studies have shown mild to moderate improvement with low-dose antidepressant therapy and exercise.
Antidepressants
Tricyclic antidepressants (TCA’s) 25-50 mg of amitriptyline (Elavil) (Best Evidence – Level 1)
Selective serotonin reuptake inhibitors (SSRI’s) 20 mg of fluoxetine (Prozac)
Combinations of the two may be more effective than either agent taken alone.
Medications with Unproven Efficacy
Nonsteroidal Anti-Inflammatory Agents (NSAIDs): Although commonly prescribed in analgesic doses, NSAIDs have not been proved to be effective in the treatment of fibromyalgia.
Avoid corticosteroids and narcotics
Graded Exercise Therapy
Aerobic exercise programs more beneficial than flexibility or relaxation programs
Appropriate pacing should be encouraged Respect that fluctuations in symptoms will
influence ability to participate Encourage adequate rest and recovery time
Alternative Approaches to
Conventional therapies….
Alternative Medicine Approaches
Acupuncture Supportive counseling/psychotherapy Therapeutic touch disciplines SAM-e
Acupuncture
Has had little or no benefit in recent meta- analysis review*
Supported by 1-2 randomized trials
May be helpful for select patients
*Ann Intern Med 2005Jul5;143(1):10
SAM-e (S-adenosylmethionine)
Not an herb, hormone, vitamin, or nutrient Synthetic form of chemical produced naturally
in the body Sold as "natural" treatment for depression,
arthritis, and liver disease SAM-e for fibromyalgia = limited evidence but
some trials are encouraging* * J Musculoskel Med 2004 Jul;21(7):361
Counseling/Psychotherapy
Cognitive Behavioral Therapy:
Based on the theory that our thoughts cause our feelings and behaviors, not external things, like people, situations,and events. The benefit of this is that we can change the way we think to feel / act better even if the situation does not change.
Therapeutic Touch Disciplines
Integrated with conventional treatments to meet the challenge of treating Fibromyalgia
Massage therapy with lighter to medium pressure
Aromatherapy massage Energy therapies such as Reiki and Foot
Reflexology. “Relaxation response” may help chronic pain
Reiki (pronounced ray-key)
Means “universal life energy.”
Natural form of hands-on energy transfer.
Reiki Practitioner channels universal life energy to enhance the recipient’s own bodily energies and natural response to illness.
Summary Of Treatment Recommendations*
Amitriptyline 25-50 mg nightly Aerobic exercise, efficacy not
maintained if exercise stops Cognitive behavioral therapy Patient education
*JAMA November 17, 2004;292:2388-95
Status of EBM in Treatment of FM
Student: There seems to be a need for good quality research in the field of hypnosis.
Professor: I would never allow it in my department.
Student: Why not? Professor: Because hypnosis is not a
respectable field for research. Student: Why not?
EBM cont’d
Professor: Because it has no serious published literature.
Student: Why is there no literature? Professor: Because nobody has done the
research. Student: Why has nobody done the research? Professor: Because it's not a respectable field
of research.
Questions ?