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Fibromyalgia   Ramona Carter-Burdine, M.D.   UTMB Galveston
Goals For Attendees <ul><li>Lecture attendees will able to:  </li></ul><ul><li>Name the American College of Rheumatology (...
Question for Audience <ul><li>How many people (raise your hand) have seen a patient with FM? </li></ul><ul><li>How many ha...
Skepticism in Perspective  <ul><li>Who is Dr William Harvey  (1578-1657)  ?   </li></ul><ul><li>Credited with first correc...
 
Definition of Fibromyalgia (FM) <ul><li>Tender points/pain in fibrous tissues, muscles, tendons, ligaments without inflamm...
American College of Rheumatology (ACR) Criteria* <ul><li>Widespread pain for at least 3 months including:  </li></ul><ul><...
Pain on palpation with a 4-kg force in 11 out of  18 sites <ul><ul><li>Occiput  -  Low cervical </li></ul></ul><ul><ul><li...
Tender Points of FM Nontender control points  = mid forehead and  anterior thigh
ACR Criteria <ul><li>Is established on the basis of clinical observations. </li></ul><ul><li>Is a condition with signs and...
Difference between FM and Myofascial Pain Syndrome <ul><li>Defined by presence of trigger points  </li></ul><ul><li>Trigge...
Prevalence of FM <ul><li>Estimates of prevalence are 3.4 percent for women and 0.5 percent for men  </li></ul><ul><li>Fema...
Cost Burden  <ul><li>Outpatient follow-up averages 10 visits/year </li></ul><ul><li>Hospitalization average once every 3 y...
Mortality/Morbidity  <ul><li>FM is a chronic relapsing condition.  </li></ul><ul><li>Long term follow up: </li></ul><ul><l...
Etiology <ul><li>Etiology remains unclear </li></ul><ul><li>Require a biopsychosocial, not  just a biomedical, viewpoint <...
Common Biopsychocial Features Given in Explanatory Models <ul><li>Likely related: </li></ul><ul><li>Stress </li></ul><ul><...
Biomedical Factors <ul><li>Dysregulation of  autonomic system </li></ul><ul><li>Dysregulation of neuroendocrine system  </...
Neuroendocrine System <ul><li>Changes in neuroendocrine transmitters: serotonin, substance P, growth hormone and cortisol ...
Core Concepts in Understanding Pain in FM <ul><li>Generalized decrease pain perception threshold </li></ul><ul><li>Hyperal...
Autonomic System <ul><li>Provocation of symptoms during tilt table testing with significant prevalence of neurally mediate...
Diagnostic Testing <ul><li>Minimum of testing  </li></ul><ul><li>To Rule out other Causes may consider: </li></ul><ul><li>...
Clinical Diagnosis <ul><li>Widespread pain – 98% </li></ul><ul><li>Soft tissue pain/tender points </li></ul><ul><li>Sleep ...
Why is Diagnosis Important? <ul><li>“ Making a definite diagnosis of fibromyalgia reduces patients' utilization of medical...
Key Patient Education Points <ul><li>Chronic but nonprogressive disease </li></ul><ul><li>Education about pain modificatio...
Treatment <ul><li>The goals of treatment for fibromyalgia are to control pain and improve function.  </li></ul><ul><li>The...
Antidepressants <ul><li>Tricyclic antidepressants (TCA’s) 25-50 mg  </li></ul><ul><li>of amitriptyline (Elavil)  (Best Evi...
Medications with Unproven Efficacy  <ul><li>Nonsteroidal Anti-Inflammatory Agents (NSAIDs):  Although commonly prescribed ...
Graded Exercise Therapy <ul><li>Aerobic exercise programs more beneficial than flexibility or relaxation programs </li></u...
Alternative Approaches to <ul><li>Conventional therapies…. </li></ul>
Alternative Medicine Approaches <ul><li>Acupuncture </li></ul><ul><li>Supportive counseling/psychotherapy </li></ul><ul><l...
Acupuncture <ul><li>Has had little or no benefit in recent meta- analysis review*  </li></ul><ul><li>Supported by 1-2 rand...
SAM-e (S-adenosylmethionine)  <ul><li>Not an herb, hormone, vitamin, or nutrient  </li></ul><ul><li>Synthetic form of chem...
Counseling/Psychotherapy <ul><li>Cognitive Behavioral Therapy:  </li></ul><ul><li>Based on the theory that our thoughts ca...
Therapeutic Touch Disciplines <ul><li>Integrated with conventional treatments to meet the challenge of treating Fibromyalg...
Reiki (pronounced ray-key) <ul><li>Means “universal life energy.”  </li></ul><ul><li>Natural form of hands-on energy trans...
Summary Of Treatment Recommendations* <ul><li>Amitriptyline 25-50 mg nightly </li></ul><ul><li>Aerobic exercise, efficacy ...
Status of EBM in Treatment of FM <ul><li>Student:  There seems to be a need for good quality research in the field of hypn...
EBM cont’d <ul><li>Professor:  Because it has no serious published literature.  </li></ul><ul><li>Student:  Why is there n...
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  • Transcript of "Fibromyalgia.Rc Burdine.Fmdrl"

    1. 1. Fibromyalgia Ramona Carter-Burdine, M.D. UTMB Galveston
    2. 2. Goals For Attendees <ul><li>Lecture attendees will able to: </li></ul><ul><li>Name the American College of Rheumatology (ACR) diagnostic criteria </li></ul><ul><li>Recognize typical History and Physical findings </li></ul><ul><li>List Treatment options and their efficacy </li></ul>
    3. 3. Question for Audience <ul><li>How many people (raise your hand) have seen a patient with FM? </li></ul><ul><li>How many have continuity patients they see regularly with FM? </li></ul><ul><li>If you had one –two words to describe the tx of pt of FM – what would it be? (ask about 5 people) then repeat back to group </li></ul><ul><li>I think it’s important for physicians to recognize it is common to feel frustration, irritation, skepticism, and avoidance with these patients </li></ul><ul><li>Fibromyalgia is chronic disease without definite etiology or treatment and commonly both the physician and pt dissatisfied with chronic follow up visits </li></ul>
    4. 4. Skepticism in Perspective <ul><li>Who is Dr William Harvey (1578-1657) ? </li></ul><ul><li>Credited with first correctly describing, in exact detail, the properties of blood being pumped around the body by the heart. </li></ul><ul><li>Who is Dr Ignaz Semmelweis (1818-1865) ? </li></ul><ul><li>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. </li></ul><ul><li>Who is Dr Joseph Lister (1827-1912) ? </li></ul><ul><li>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. </li></ul>
    5. 6. Definition of Fibromyalgia (FM) <ul><li>Tender points/pain in fibrous tissues, muscles, tendons, ligaments without inflammation (fibromyositis) </li></ul><ul><li>Any fibromuscular tissues may be involved, but those of the occiput, neck, shoulders, thorax, low back, and thighs are especially affected </li></ul>
    6. 7. American College of Rheumatology (ACR) Criteria* <ul><li>Widespread pain for at least 3 months including: </li></ul><ul><ul><li>Pain on the right and left sides of body </li></ul></ul><ul><ul><li>Pain above and below the waist </li></ul></ul><ul><ul><li>Pain in the axial skeleton </li></ul></ul><ul><li>AND………. </li></ul><ul><li>* Arthritis Rheum 1990 Feb;33(2):160 </li></ul>
    7. 8. Pain on palpation with a 4-kg force in 11 out of 18 sites <ul><ul><li>Occiput - Low cervical </li></ul></ul><ul><ul><li>Trapezius - Supraspinatus </li></ul></ul><ul><ul><li>Lateral epicondyle - Greater trochanter </li></ul></ul><ul><ul><li>Knee - Gluteus Maximus </li></ul></ul><ul><ul><li>Lateral to second costochondral junction </li></ul></ul>
    8. 9. Tender Points of FM Nontender control points = mid forehead and anterior thigh
    9. 10. ACR Criteria <ul><li>Is established on the basis of clinical observations. </li></ul><ul><li>Is a condition with signs and symptoms that exist on a continuum. </li></ul><ul><li>Often requires observation over time to firmly establish the diagnosis </li></ul>
    10. 11. Difference between FM and Myofascial Pain Syndrome <ul><li>Defined by presence of trigger points </li></ul><ul><li>Trigger points often have nodular texture similar to a pencil eraser </li></ul><ul><li>Trigger points located within taut bands of muscle (tender points are not) </li></ul><ul><li>Pain pattern limited to particular region </li></ul><ul><li>Palpation of trigger points often reproduces pain radiation pattern/muscle twitch </li></ul>
    11. 12. Prevalence of FM <ul><li>Estimates of prevalence are 3.4 percent for women and 0.5 percent for men </li></ul><ul><li>Female-to-Male ratio of 9:1 </li></ul><ul><li>Typically women aged 20-50 years </li></ul>
    12. 13. Cost Burden <ul><li>Outpatient follow-up averages 10 visits/year </li></ul><ul><li>Hospitalization average once every 3 yrs </li></ul><ul><li>Mean annual cost of medical care = $2,274/patient* </li></ul><ul><li>Many patients report receiving some type of disability payment. </li></ul><ul><li>*Arthritis Rheum 1997 Sep;40(9):1553 </li></ul>
    13. 14. Mortality/Morbidity <ul><li>FM is a chronic relapsing condition. </li></ul><ul><li>Long term follow up: </li></ul><ul><li>50% dissatisfied with their health </li></ul><ul><li>59% rate their health as fair/poor. </li></ul><ul><li>More comorbid medical conditions and surgical interventions compared to other rheumatic disorders. </li></ul>
    14. 15. Etiology <ul><li>Etiology remains unclear </li></ul><ul><li>Require a biopsychosocial, not just a biomedical, viewpoint </li></ul>
    15. 16. Common Biopsychocial Features Given in Explanatory Models <ul><li>Likely related: </li></ul><ul><li>Stress </li></ul><ul><li>Depression </li></ul><ul><li>Fatigue </li></ul><ul><li>Chronic Illness </li></ul><ul><li>Not shown to be related: </li></ul><ul><li>Toxins </li></ul><ul><li>Immune System Dysfunction </li></ul><ul><li>Infection due to yeast or viruses </li></ul>
    16. 17. Biomedical Factors <ul><li>Dysregulation of autonomic system </li></ul><ul><li>Dysregulation of neuroendocrine system </li></ul><ul><li>Infectious mononucleosis (Epstein Barr Virus) not likely causative* </li></ul><ul><li>* Arch Intern Med 1999 Apr 26;159(8):865 </li></ul>
    17. 18. Neuroendocrine System <ul><li>Changes in neuroendocrine transmitters: serotonin, substance P, growth hormone and cortisol </li></ul><ul><li>Elevation of CSF substance P levels to three times normal levels. </li></ul><ul><li>Alteration in hypopituitary - adrenal axis with low production of cortisol. </li></ul>
    18. 19. Core Concepts in Understanding Pain in FM <ul><li>Generalized decrease pain perception threshold </li></ul><ul><li>Hyperalgesia </li></ul><ul><li>amplification of pain experienced from peripheral stimuli that are expected to be painful </li></ul><ul><li>Allodynia </li></ul><ul><li>pain with stimuli that should not cause pain such as gentle touching </li></ul>
    19. 20. Autonomic System <ul><li>Provocation of symptoms during tilt table testing with significant prevalence of neurally mediated hypotension. </li></ul>
    20. 21. Diagnostic Testing <ul><li>Minimum of testing </li></ul><ul><li>To Rule out other Causes may consider: </li></ul><ul><li>TSH – R/O Hypothyroidism </li></ul><ul><li>ESR, CBC –R/O Rheumatic Disease </li></ul><ul><li>CPK –R/O Myopathies </li></ul><ul><li>ANA, RF, serum complement levels, </li></ul><ul><li>Lyme titer, PPD, RPR, HIV, Hep C </li></ul>
    21. 22. Clinical Diagnosis <ul><li>Widespread pain – 98% </li></ul><ul><li>Soft tissue pain/tender points </li></ul><ul><li>Sleep disturbance </li></ul><ul><li>Chronic fatigue </li></ul><ul><li>Associated co morbid conditions </li></ul><ul><li>Associated rheumatic diseases </li></ul>
    22. 23. Why is Diagnosis Important? <ul><li>“ Making a definite diagnosis of fibromyalgia reduces patients' utilization of medical resources and improves satisfaction with healthcare.” </li></ul><ul><li>Quotation excerpt: </li></ul><ul><li>DynaMed@ www.dynamicmedical.com </li></ul>
    23. 24. Key Patient Education Points <ul><li>Chronic but nonprogressive disease </li></ul><ul><li>Education about pain modification </li></ul><ul><li>More healthful lifestyle </li></ul><ul><li>Reassurance that fibromyalgia is not a psychiatric disturbance and not rare </li></ul>
    24. 25. Treatment <ul><li>The goals of treatment for fibromyalgia are to control pain and improve function. </li></ul><ul><li>These goals can be met using a variety of techniques </li></ul><ul><li>Clinical studies have shown mild to moderate improvement with low-dose antidepressant therapy and exercise. </li></ul>
    25. 26. Antidepressants <ul><li>Tricyclic antidepressants (TCA’s) 25-50 mg </li></ul><ul><li>of amitriptyline (Elavil) (Best Evidence – Level 1) </li></ul><ul><li>Selective serotonin reuptake inhibitors (SSRI’s) 20 mg of fluoxetine (Prozac) </li></ul><ul><li>Combinations of the two may be more effective than either agent taken alone. </li></ul>
    26. 27. Medications with Unproven Efficacy <ul><li>Nonsteroidal Anti-Inflammatory Agents (NSAIDs): Although commonly prescribed in analgesic doses, NSAIDs have not been proved to be effective in the treatment of fibromyalgia. </li></ul><ul><li>Avoid corticosteroids and narcotics </li></ul>
    27. 28. Graded Exercise Therapy <ul><li>Aerobic exercise programs more beneficial than flexibility or relaxation programs </li></ul><ul><li>Appropriate pacing should be encouraged </li></ul><ul><li>Respect that fluctuations in symptoms will influence ability to participate </li></ul><ul><li>Encourage adequate rest and recovery time </li></ul>
    28. 29. Alternative Approaches to <ul><li>Conventional therapies…. </li></ul>
    29. 30. Alternative Medicine Approaches <ul><li>Acupuncture </li></ul><ul><li>Supportive counseling/psychotherapy </li></ul><ul><li>Therapeutic touch disciplines </li></ul><ul><li>SAM-e </li></ul>
    30. 31. Acupuncture <ul><li>Has had little or no benefit in recent meta- analysis review* </li></ul><ul><li>Supported by 1-2 randomized trials </li></ul><ul><li>May be helpful for select patients </li></ul><ul><li>* Ann Intern Med 2005Jul5;143(1):10 </li></ul>
    31. 32. SAM-e (S-adenosylmethionine) <ul><li>Not an herb, hormone, vitamin, or nutrient </li></ul><ul><li>Synthetic form of chemical produced naturally in the body </li></ul><ul><li>Sold as &quot;natural&quot; treatment for depression, arthritis, and liver disease </li></ul><ul><li>SAM-e for fibromyalgia = limited evidence but some trials are encouraging* </li></ul><ul><li>* J Musculoskel Med 2004 Jul;21(7):361 </li></ul>
    32. 33. Counseling/Psychotherapy <ul><li>Cognitive Behavioral Therapy: </li></ul><ul><li>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. </li></ul>
    33. 34. Therapeutic Touch Disciplines <ul><li>Integrated with conventional treatments to meet the challenge of treating Fibromyalgia </li></ul><ul><li>Massage therapy with lighter to medium pressure </li></ul><ul><li>Aromatherapy massage </li></ul><ul><li>Energy therapies such as Reiki and Foot Reflexology. </li></ul><ul><li>“Relaxation response” may help chronic pain </li></ul>
    34. 35. Reiki (pronounced ray-key) <ul><li>Means “universal life energy.” </li></ul><ul><li>Natural form of hands-on energy transfer. </li></ul><ul><li>Reiki Practitioner channels universal life energy to enhance the recipient’s own bodily energies and natural response to illness. </li></ul>
    35. 36. Summary Of Treatment Recommendations* <ul><li>Amitriptyline 25-50 mg nightly </li></ul><ul><li>Aerobic exercise, efficacy not maintained if exercise stops </li></ul><ul><li>Cognitive behavioral therapy </li></ul><ul><li>Patient education </li></ul><ul><li>*JAMA November 17, 2004;292:2388-95 </li></ul>
    36. 37. Status of EBM in Treatment of FM <ul><li>Student: There seems to be a need for good quality research in the field of hypnosis. </li></ul><ul><li>Professor: I would never allow it in my department. </li></ul><ul><li>Student: Why not? </li></ul><ul><li>Professor: Because hypnosis is not a respectable field for research. </li></ul><ul><li>Student: Why not? </li></ul>
    37. 38. EBM cont’d <ul><li>Professor: Because it has no serious published literature. </li></ul><ul><li>Student: Why is there no literature? </li></ul><ul><li>Professor: Because nobody has done the research. </li></ul><ul><li>Student: Why has nobody done the research? </li></ul><ul><li>Professor: Because it's not a respectable field of research. </li></ul>
    38. 39. Questions ?
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