Fibromyalgia: Fact or Fiction? A Multi-disciplinary Approach


Published on

Published in: Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Fibromyalgia: Fact or Fiction? A Multi-disciplinary Approach

  1. 1. Fibromyalgia: Fact or Fiction? Bob Avina, MD Department of Family Medicine School of Medicine Loma Linda University
  2. 3. Goals and Objectives <ul><li>Goals: participant will be able to describe Fibromyalgia and a multi-disciplinary approach to therapy. </li></ul><ul><li>Objectives: </li></ul><ul><ul><li>1. State the ACR clinical definition of FM </li></ul></ul><ul><ul><li>2. Identify 5 or more overlapping co- </li></ul></ul><ul><ul><li>morbidities. </li></ul></ul><ul><ul><li>3. Outline the pharmacologic approach. </li></ul></ul><ul><ul><li>4. Describe the non-pharmacologic approach. </li></ul></ul>
  3. 4. Patient’s Medical Metaphors for FMS <ul><li>“ I’m trapped in this body that won’t do what I want it to do. It’s like it isn’t mine” </li></ul><ul><li>“ My muscles are pinched, my arms and legs are tightly bound up, and all of my energy has been sucked out of me” </li></ul>
  4. 5. Definition of Fibromyalgia <ul><li>“ Chronic and widespread pain located at 11 or more of 18 tender points ”-American College of Rheumatology </li></ul><ul><li>No specific diagnostic test and no cure. </li></ul>
  5. 6. History of Fibromyalgia <ul><li>Gowen 1908 first described FMS </li></ul><ul><li>Boland 1944 “psychogenic rheumatism” </li></ul><ul><li>Moldolfsky 1975 found non-restorative sleep very common in FMS patients. EEG’s in 1993 showed mainly alpha waves . </li></ul><ul><li>Jon Levine, MD and David Reichling, PhD, UCSF “Fibromyalgia: the Nerve of That Disease” Journal of Rheumatology 2005 </li></ul>
  6. 7. Current Researchers in FMS <ul><li>Muhammad Yunns, MD at Univ. Illinois, Chicago </li></ul><ul><li>Debra Buchwald, MD at University of Wash. </li></ul><ul><li>Anthony Komaroff, MD at Brigham and Womans Hospital </li></ul><ul><li>Don Goldberg, MD at Norton-Wellesley Hopsital </li></ul>
  7. 8. The Manual Tender Point Survey <ul><li>The American College of Rheumatology (ACR) conducted a multicenter study published in 1990 that specified (2) primary criteria needed for a diagnosis of FM: </li></ul><ul><ul><li>(1) three or more months of widespread pain occurring above/below the waist, both sides of body, and along the midline. </li></ul></ul><ul><ul><li>(2) report of pain at a minimum of 11/18 specified locations or tender points (TPs) </li></ul></ul>
  8. 10. Epidemiology <ul><li>2% of all U.S. citizens affected: 5.5 million </li></ul><ul><li>Most common cause of generalized musculoskeletal pain in women ages 20-55 y.o. </li></ul><ul><li>Prevalence increases with age: 2% ages 20-35 y.o. but 8% at age 70 y.o. </li></ul><ul><li>Females X10 more common than males: Why is that? </li></ul>
  9. 11. Clinical Manifestations <ul><li>Diffuse mskeletal pain, stiffness, fatigue </li></ul><ul><li>Chronic and persistent pain with varying intensity </li></ul><ul><li>Joints do not appear swollen or inflamed </li></ul><ul><li>Pain aggravated by exertion, stress, lack of sleep, weather changes: peak ACTH and sympatho-mimetic CNS and PNS activity </li></ul><ul><li>Sensations of numbness, tingling, burning, crawling is often described. </li></ul>
  10. 12. Poorly Understood Pain Symptoms in FMS Patients <ul><li>Abdominal wall pain </li></ul><ul><li>Chest wall pain </li></ul><ul><li>IBS </li></ul><ul><li>Pelvic pain </li></ul><ul><li>Irritable bladder sx’s </li></ul><ul><li>Fatigue: 90% </li></ul><ul><li>Unrefreshing sleep </li></ul><ul><li>Lightheaded, Dizziness </li></ul>
  11. 13. Physical Examination Findings in FMS <ul><li>Tender point examination: apply steady gradual pressure (4 kg/cm) over four seconds to tender points. </li></ul><ul><li>At least 11 of 18 specific tender areas. </li></ul><ul><li>Control areas are forehead, mid-forearm, and thumbnail (#1, 16,17) </li></ul><ul><li>Thorough neurological examination </li></ul>
  12. 14. Instruction for the Multiple Tender Points Survey <ul><li>Patient should wear a standard gown for the examination </li></ul><ul><li>Read the MTP Survey instructions to the patient before the exam </li></ul><ul><li>State “I want you to tell me what the level of pain was, “0” being no pain and “10” being the worst pain you ever experienced. </li></ul><ul><li>After applying pressure and removing thumb, ask the patient “Was that painfull?” </li></ul><ul><li>If yes, then “How would you rate the pain?” </li></ul>
  13. 15. Source: “The Manual Tender Point Survey”, D. Sinclair, T. Starz, D. Turk Univ. of Pittsburgh, School of Medicine .                                                                        
  14. 16. 18 Tender Points in FMS <ul><li>1: mid-forehead, control </li></ul><ul><li>2 & 3. L & R sub occipital/nuchal ridge </li></ul><ul><li>4 & 5. Trapezius: bilateratal, midpoint </li></ul><ul><li>6 & 7. Supraspinatus: bilateral at origins </li></ul><ul><li>8 & 9. Gluteal: bilateral upper outer quadrants </li></ul><ul><li>* Minimum of 3 months </li></ul>
  15. 17. 18 Tender Points of FMS <ul><li>10 & 11: Low cervical, transverse C5-7 </li></ul><ul><li>12 & 13. Second rib: bilateral at costo- sternal junction </li></ul><ul><li>14&15 Lateral epicondyl-2 cm distal </li></ul><ul><li>16. Right forearm, Control </li></ul><ul><li>17. Left thumb, Control </li></ul><ul><li>* Minimum of 3 months </li></ul>
  16. 18. 18 Tender Points of FM <ul><li>18 & 19. Greater Trochanter </li></ul><ul><li>20 & 21. Anterio-medial Knee </li></ul><ul><li>Scoring of the MTP Survey </li></ul><ul><ul><li>Average the pain score of 18 tender points: =>6 </li></ul></ul><ul><ul><li>Average the baseline pain score of the three control points: =<5 </li></ul></ul>
  17. 19. Co-morbidities and FM Symptoms <ul><li>Fatigue </li></ul><ul><li>IBS </li></ul><ul><li>Sleep disorder </li></ul><ul><li>Chronic headaches </li></ul><ul><li>Jaw pain, including TMJ dysfunction </li></ul><ul><li>Cognitive or memory impairment </li></ul>
  18. 20. Co-morbidities and FM Symptoms <ul><li>Post-exertional malaise and muscle pain </li></ul><ul><li>Morning stiffness </li></ul><ul><li>Numbness and tingling </li></ul><ul><li>Dizziness or light-headedness </li></ul><ul><li>Increased chemical, mechanical, and thermal sensitivities </li></ul>
  19. 21. FMS Differential Diagnosis <ul><li>Temporal arteritis / Hypothyroidism </li></ul><ul><li>Primary muscle disease / Polymyalgia rheumatica </li></ul><ul><li>Dermatomyositis / Muscle strain/sprain </li></ul><ul><li>Chronic Fatigue Syndrome </li></ul><ul><li>Lyme Disease: stage 1 or stage 3 </li></ul><ul><li>Viral hepatitis: B or C </li></ul><ul><li>Toxic myopathies, as with statins or fibric acid derivatives for hyperlipidemia. </li></ul>
  20. 22. Recommended Laboratory Tests in FMS <ul><ul><li>CBC </li></ul></ul><ul><ul><li>Comp. Metabol. </li></ul></ul><ul><ul><li>Panel </li></ul></ul><ul><ul><li>TSH / ESR </li></ul></ul><ul><li>CPK </li></ul><ul><li>Muscle aldolase </li></ul>
  21. 23. What’s Wrong with Getting an ANA or RF (Rheumatoid Factor) ? <ul><li>Older patients have higher false positives. </li></ul><ul><li>In absence of clinical criteria of RA or SLE, a positive RA factor or ANA is not helpful. </li></ul><ul><li>FMS can co-exist with RA, OA, SLE , other chronic diseases. </li></ul><ul><li>Worsening of musculoskeletal symptoms can be FMS and not primary disease, such as OA or RA. </li></ul>
  22. 24. Permission for photo granted by L. Castro
  23. 25. Multiple Overlapping Syndromes FMS, CFS, MPS RLS, IBS, MCS TMJD, PLMS, IB
  24. 26. Psychiatric Illness and FMS <ul><li>Major depression: 30% of FMS patients, PTSD </li></ul><ul><li>Rarely meet criteria for somatization disorders. </li></ul><ul><li>Anxiety: generalized or panic disorder </li></ul>
  25. 27. How is Chronic Fatigue Syndrome Different from FMS? <ul><li>CDC 1994 Guidelines in Annals IM 121(12):953 </li></ul><ul><li>Fatigue-severe, not relieved by rest, can cause disability, has identifiable onset. </li></ul>
  26. 28. Chronic Fatigue vs. Fibromyalgia <ul><li>4 or more of following : </li></ul><ul><ul><li>Impaired memory or concentration </li></ul></ul><ul><ul><li>Tender cervical or axillary lymph nodes </li></ul></ul><ul><ul><li>Sore throat </li></ul></ul><ul><ul><li>Muscle pain </li></ul></ul><ul><ul><li>Multiple joint pain w/o arthritis </li></ul></ul><ul><ul><li>New onset of headaches </li></ul></ul><ul><ul><li>Un-refreshing sleep </li></ul></ul><ul><ul><li>Post-exert ional malaise </li></ul></ul>
  27. 29. Goals of Therapy in FM <ul><ul><li>1. Establish specific tangible </li></ul></ul><ul><ul><li>goals, ie. Increase time out of </li></ul></ul><ul><ul><li>bed by 1 hour each week. </li></ul></ul><ul><ul><li>2. Empower patient to begin to </li></ul></ul><ul><ul><li>Identify and “brainstorm” </li></ul></ul><ul><ul><li>problems in family,home, </li></ul></ul><ul><ul><li>work, social life </li></ul></ul>
  28. 30. Strategy of Treatment <ul><li>Evaluate and treat sleep disorder: RLS, OSA </li></ul><ul><li>Medications that increase Stage 4 sleep: </li></ul><ul><ul><li>Trazodone, Benadryl, Caprisoprodol, Doxepin, Ambien, Lunesta, clonazepam </li></ul></ul><ul><li>Medications that decrease Stage 4 sleep: </li></ul><ul><ul><li>Narcotics, other benzodiazepams </li></ul></ul><ul><li>Begin gradual stretching and aerobic exercise program </li></ul><ul><li>Identify and treat depression with SSRI’s, amitriptyline, Cymbalta. </li></ul>
  29. 31. Treatment Options <ul><li>EMG feedback (Ferracioli, ’87) </li></ul><ul><li>Cognitive Behavioral Therapy (Goldenberg ‘91, White ’95) </li></ul><ul><li>Habits: avoid alcohol and caffeine </li></ul><ul><li>Trigger point injections with lidocaine </li></ul><ul><li>Physical therapy, Occupational therapy </li></ul><ul><li>Acupuncture, Acupressure </li></ul><ul><li>Osteopathic manipulation </li></ul>
  30. 32. Self-Management RCT <ul><li>Ann. Rheum. Dis 2004; 63:290-296 by C. Cedraschi, et all. Genev </li></ul><ul><li>164 pts allocated to either 6 week multi-disciplinary program based on aerobic pool exercises, individual counseling </li></ul>
  31. 33. Pregabalin (Lyrica) <ul><li>Placebo-controlled monotherapy study of 529 patients with FMS for safety and efficacy. </li></ul><ul><li>Randomized to receive placebo, 150/300/450 mg Pregabalin for 8 weeks. </li></ul><ul><li>29% of treated patients (450 mg/d) vs. 13% of placebo reported at least a 50% reduction of pain that was statistically significant. </li></ul>
  32. 34. FM Patient: Betty <ul><li>35 y.o. OR nurse for 10 years who complains of 6 months of bilateral, midline, upper and lower extremitiy pain which is associated with stiffness, insomnia due to pain, a 10 lb weight loss (BMI=30), loss of energy and pleasure in doing most things but no suicidal or homicidal ideation. She is married and has two children, 9 and 7 years old girls, does not drink alcohol, use illicit drugs or smoke. She was recently promoted to Head OR nurse. She denies in confidence any history of remote, recent, or current physical, emotional, or sexual abuse by her spouse. </li></ul>
  33. 35. Betty <ul><li>Physical Exam : anxious appearing 35 year old female. T:98.8F, BP:130/80, RR:16/min, P:90 in no acute distress. </li></ul><ul><li>Neck: no adenopathy or thyroid tenderness, lungs-CTA, heart-S1 S2 w/o MRG, abdomen-soft, no guarding or rebound, motor strength-4/5 in UE/LE, reflexes 2/3 bilateral and symmetric in UE/LE, joints w/ FROM and w/o swelling or tenderness. </li></ul>
  34. 36. Betty <ul><li>Multiple Tender Point Survey: 14/18 with average pain score of 8/10 vs. 5/10 control (forehead, mid-forearm, and thumbnail) </li></ul>
  35. 37. Betty <ul><li>Laboratory Studies ordered : </li></ul><ul><ul><li>CBC: WBC-11K with normal differential, H/H=12 gms/35% with MCV=65 </li></ul></ul><ul><ul><li>ESR (Westergren) was 40 </li></ul></ul><ul><ul><li>Complete Metabolic Panel: all within normal </li></ul></ul><ul><ul><li>TSH: 2.5 (1.5-5.0) </li></ul></ul><ul><ul><li>No Xrays, RA, ANA, ds/ss DNA or Smith Antibodies were ordered. </li></ul></ul>
  36. 38. Betty’s Problem List <ul><li>(1) Fibromyalgia </li></ul><ul><li>(2) Clinical Depression-Zung Score </li></ul><ul><li>65 </li></ul><ul><li>(3) Insomnia-onset type w/anxiety </li></ul><ul><li>(4) De-conditioned physical state </li></ul><ul><li>(5) Significant work stress with </li></ul><ul><li>promotion recently </li></ul>
  37. 39. SSRI’s and TCA’s <ul><li>Outcome measures: tender point score, FIQ score, Beck Depression or Zung score. </li></ul><ul><li>Conclusion: Significantly greater impact on pain and depression reduction at 6 weeks with combination . </li></ul>
  38. 40. FM Team (Cedars Sinai MC) Michael Gilewski, PhD <ul><ul><li>Primary physician </li></ul></ul><ul><ul><li>Psychologist or Psychiatrist with experience with FM </li></ul></ul><ul><ul><li>Physical therapist who has experience with FM </li></ul></ul><ul><ul><li>Nurse Practitioner or Physician Assistant with same approach as Primary physician </li></ul></ul><ul><ul><li>Fibromyalgia Patient Support Group </li></ul></ul><ul><ul><li>Key family member (s) who support patient </li></ul></ul>
  39. 41. Patient and Family Education <ul><ul><li>Explain to patient and family what is FM: a chronic heightened muscle/tendon sensory state resulting in pain, stiffness, de-conditioning, and weakness. It is associated with depression, anxiety, and possibly affects many other organ systems. </li></ul></ul>
  40. 42. Therapy Strategy <ul><ul><li>Review problem list with patient and key family member to validate and prioritize list. </li></ul></ul>
  41. 43. Insomnia <ul><ul><li>Restore or Correct sleep disorder: </li></ul></ul><ul><ul><li>Decrease daytime fatigue </li></ul></ul><ul><ul><li>Improve some of the cognitive deficits </li></ul></ul><ul><ul><li>Identify/Treat Restless Leg Syndrome </li></ul></ul><ul><ul><li>Identify/Treat Obstructive Sleep Apnea </li></ul></ul><ul><ul><li>Identify/Treat Anxiety </li></ul></ul><ul><ul><li>f. Treat nocturnal muscle pain: NSAID, Neurontin, Lyrica, Flexeril, Baclofen </li></ul></ul>
  42. 44. Pain Management <ul><ul><li>GOALS: </li></ul></ul><ul><ul><li>Reduce pain intensity and frequency </li></ul></ul><ul><ul><li>Utilize NSAID’s, Neurontin, Lyrica, </li></ul></ul><ul><ul><li>Opiates both short and long acting </li></ul></ul><ul><ul><li>3. Increase patient awareness of triggers </li></ul></ul><ul><ul><li>4. Provide patient self-management techniques using relaxation, CBT, low impact aerobic exercises. </li></ul></ul>
  43. 45. Meta-Analysis of RCT’s of Fibromyalgia Treatment Using Cochrane Collaboration Reviews <ul><li>JAMA ’04 Nov 17;292(19):2388-95 </li></ul><ul><li>Goldenberg DL; Burckhardt C; Crofford L </li></ul><ul><li>Conclusions: </li></ul><ul><ul><li>No specific medical therapies are FDA approved. </li></ul></ul>
  44. 46. Meta-analysis of Fibromyalgia RCT’s <ul><ul><li>Current evidence suggests that these work best: </li></ul></ul><ul><ul><li>Low dose TCA’s </li></ul></ul><ul><ul><li>Aerobic exercise </li></ul></ul><ul><ul><li>Cognitive behavioral therapy </li></ul></ul><ul><ul><li>Patient education. </li></ul></ul>
  45. 47. SSRI and TCA <ul><li>Goldenberg, Mayskly, Mossey, Ruthazer, Schmid </li></ul><ul><li>Arthritis Rheum 1996 Nov;39 (11): 1852-1853 </li></ul><ul><li>Randomized, double-blind crossover study but N=19 </li></ul><ul><li>Fluoxetine 20 mg/d vs. Amitriptyline 25 mg/d vs. combination of both drugs. </li></ul>
  46. 48. SSRI’s and TCA’s <ul><li>Outcome measures: tender point score, FIQ score, Beck Depression Inventory </li></ul><ul><li>Conclusion: Significantly greater impact on pain and depression reduction at 6 weeks with combination . </li></ul>
  47. 49. Venlafaxine: Inhibitor of NE and Serotonin in Fibromyalgia Patients <ul><li>Ann Pharm ’03 Nov;37(11):1561-5 </li></ul><ul><li>Sayar K; Adsu G; Tosun M </li></ul><ul><li>N=15 </li></ul><ul><li>Prospective trial with pre and post evaluations of pain (FIQ) and Beck Depression and Anxiety questionaires. </li></ul><ul><li>Significant decrease in pain, anxiety, depression scores at 12 weeks but not correlated to one another. </li></ul>
  48. 50. Pramipexole Added-on Therapy <ul><li>Arthritis Rheum ’05 Aug;52(8):2495 by Holman AJ and Myers RR. </li></ul><ul><li>Medication-a dopamine 3 agonist. Most common adverse effect was transient anxiety and weight loss. </li></ul><ul><li>Study type: 14 week, single-center, double-blind, placebo-controlled, parallel-group, escalating-dose trial. </li></ul>
  49. 51. Pramipexole Added-On Therapy <ul><li>N=60 </li></ul><ul><li>Primary outcome was improvement in pain score using VAS. Several secondary outcomes. </li></ul><ul><li>Pain reduction in 36% vs. 9% in placebo arm. </li></ul>
  50. 52. Duloxetine (Cymbalta) <ul><li>Mechanism: works as both a SSR and NE inhibitor. </li></ul><ul><li>Use: Antidepressant-40 to 60 mg/d, Diabetic Neuropathy-60 mg/d, Fibromyalgia 60 mg BID. </li></ul><ul><li>Precautions: reduced in CRF but not in ESRD, and not recommended in hepatic insufficiency. </li></ul><ul><li>Food-slows time to peak serum levels. </li></ul><ul><li>Protein Bindings: 95% </li></ul><ul><li>Metabolism-primarily hepatic; excretion primarily renal. </li></ul>
  51. 53. Depression <ul><ul><li>Begin treatment for depression with SSRI’s or Atypicals: </li></ul></ul><ul><ul><li>Fluoxetine (Prozac): start 20 mg/d to 80 </li></ul></ul><ul><ul><li>Paroxetine (Paxil): start 20 mg/d to 50 </li></ul></ul><ul><ul><li>Sertraline (Zoloft): start 50 mg/d to 200 </li></ul></ul>
  52. 54. Depression <ul><ul><li>5. Trazodone (Desyrel, Trazon): start 50 mg bid to 300 mg bid. </li></ul></ul><ul><ul><li>6. Buproprion (Wellbutrin, Zyban): 150 mg qam x4 days then 300 mg qam to 400 mg/d: reduces appetite and weight neutral. </li></ul></ul><ul><ul><li>7. Mirtazapine (Remeron): start 15-30 mg qhs to 45 mg qhs. Increases appetite and weight gain. </li></ul></ul>
  53. 55. Improve Physical Endurance <ul><ul><li>GOALS: </li></ul></ul><ul><ul><li>Ambulate-> Household activities -> Work </li></ul></ul><ul><li>Start Low, Go Slow </li></ul><ul><ul><li>Stretches: reduces muscle/tendon pain </li></ul></ul><ul><ul><li>Aerobic exercises: improve endurance by taking stairs not elevator, parking further away </li></ul></ul><ul><ul><li>Add walking, swimming, water aerobics </li></ul></ul>
  54. 56. Counseling <ul><li>1.Help patient to “re-frame” and </li></ul><ul><li>distinguish the patient from the </li></ul><ul><li>disease. </li></ul><ul><li>2.Regain control of their own body. </li></ul><ul><li>3.Behavior and lifestyle modification, listen for their body’s cues, intervene early before typical pain evolves using specific techniques. </li></ul>
  55. 57. Patient Instructions for FM-ACR <ul><li>1. Schedule time to relax each day. Deep-breathing exercises and meditation to reduce stress. </li></ul><ul><li>2. Exercise Regularly : just need to get moving into a comfortable routine and don’t give up. </li></ul><ul><li>3. Educate yourself : Arthritis Foundation and NFA are excellent sources of information to share with family, friends and co-workers. </li></ul>
  56. 58. Summary of FMS <ul><li>Criteria for diagnosis: minimum of 11 of 18 tender points or several other symptoms. </li></ul><ul><li>No active arthritis or swollen joints. </li></ul><ul><li>Normal laboratory results </li></ul><ul><li>Overlapping Co-Morbidities </li></ul><ul><li>Psychiatric symptoms very common </li></ul><ul><li>Specific Goals and Objectives for Patient </li></ul><ul><li>Multidisciplinary approach over long term. </li></ul><ul><li>Requires more physician and staff patience and compassion. </li></ul>