Fibromyalgia Syndrome (FMS)

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Fibromyalgia Syndrome (FMS)

  1. 1. Fibromyalgia SyndromeFibromyalgia Syndrome (FMS)(FMS) Mini-Med School 2007Mini-Med School 2007 Raymond H. Flores, MD, FACRRaymond H. Flores, MD, FACR Department of MedicineDepartment of Medicine Division of Rheumatology & Clinical ImmunologyDivision of Rheumatology & Clinical Immunology
  2. 2. OUTLINEOUTLINE What is Fibromyalgia (FMS)?What is Fibromyalgia (FMS)? What causes it?What causes it? Who gets it?Who gets it? How is it diagnosed?How is it diagnosed? How is it treated?How is it treated? What are some of the commonWhat are some of the common misconceptions about the syndrome?misconceptions about the syndrome?
  3. 3. What is Fibromyalgia (FMS)?What is Fibromyalgia (FMS)? A clinicalA clinical syndromesyndrome characterized bycharacterized by widespread muscularwidespread muscular painpain (usually(usually chronic),chronic), fatiguefatigue andand muscle tenderness (muscle tenderness (tendertender points)points)
  4. 4. What is FMS? (cont.)What is FMS? (cont.) Additional symptoms are common andAdditional symptoms are common and include:include: -- poor sleeppoor sleep almost alwaysalmost always - headaches- headaches - irritable bowel syndrome- irritable bowel syndrome - cognitive and memory problems- cognitive and memory problems ““fibro fog”fibro fog” - numbness and tingling in fingers and toes- numbness and tingling in fingers and toes
  5. 5. What is FMS? (cont.)What is FMS? (cont.) - irritable bladder- irritable bladder - temporomandibular joint (TMJ) disorder- temporomandibular joint (TMJ) disorder - restless leg syndrome- restless leg syndrome - dry eyes and dry mouth- dry eyes and dry mouth - morning stiffness- morning stiffness - anxiety and depression- anxiety and depression Symptoms includingSymptoms including painpain may wax and wanemay wax and wane over timeover time
  6. 6. What causes FMS?What causes FMS? Cause isCause is unknownunknown Abnormally high levels of Substance P inAbnormally high levels of Substance P in spinal fluid in some patientsspinal fluid in some patients Substance P important in transmissionSubstance P important in transmission and amplification of pain signals to andand amplification of pain signals to and from brainfrom brain ““Volume control” is turned up too high inVolume control” is turned up too high in brain’s pain centersbrain’s pain centers
  7. 7. What causes FMS? (cont)What causes FMS? (cont) Familial tendency to develop FMSFamilial tendency to develop FMS suggestssuggests geneticgenetic rolerole Can be triggered by physical, emotional orCan be triggered by physical, emotional or environmental stressors such as carenvironmental stressors such as car accidents, repetitive injuries and certainaccidents, repetitive injuries and certain diseasesdiseases Patients with Rheumatoid arthritis andPatients with Rheumatoid arthritis and SLE (Lupus) are more likely to developSLE (Lupus) are more likely to develop FMSFMS
  8. 8. What causes FMS? (cont.)What causes FMS? (cont.) Other conditions such as Lyme diseaseOther conditions such as Lyme disease and obstructive sleep apnea (OSA) haveand obstructive sleep apnea (OSA) have been associated with FMSbeen associated with FMS Sleep deprivation with disruption of delta-Sleep deprivation with disruption of delta- wave sleep (non-REM stage IV) iswave sleep (non-REM stage IV) is associated with day-time fatigue andassociated with day-time fatigue and fibromyalgia syndromefibromyalgia syndrome
  9. 9. Who gets FMS?Who gets FMS? Affects as many as 1 in 50 AmericansAffects as many as 1 in 50 Americans Most common in middle-aged womenMost common in middle-aged women Men and children may also develop theMen and children may also develop the disorderdisorder Patients with RA, SLE and AnkylosingPatients with RA, SLE and Ankylosing spondylitis are more likelyspondylitis are more likely Women who have a family member withWomen who have a family member with FMS are more likely to develop itFMS are more likely to develop it
  10. 10. How is FMS diagnosed?How is FMS diagnosed? A diagnosis is made by evaluation ofA diagnosis is made by evaluation of symptoms and presence ofsymptoms and presence of tendertender pointspoints American College of RheumatologyAmerican College of Rheumatology Classification Criteria for FibromyalgiaClassification Criteria for Fibromyalgia (1990)…….(1990)…….widespreadwidespread pain for at least 3pain for at least 3 monthsmonths andand pain inpain in 1111 out ofout of 1818 tendertender pointpoint sites onsites on digital palpationdigital palpation
  11. 11. ACR classification criteria:ACR classification criteria: fibromyalgiafibromyalgia Both criteria must be satisfiedBoth criteria must be satisfied – History of widespread pain for more than 3 months, on both sidesHistory of widespread pain for more than 3 months, on both sides of the body, above and below the waist, and axial skeleton (cervicalof the body, above and below the waist, and axial skeleton (cervical spine, anterior chest, thoracic pain, or low back)spine, anterior chest, thoracic pain, or low back) – Pain in 11 of 18 tender point sites on digital palpation withPain in 11 of 18 tender point sites on digital palpation with approximate force of 4 kg.approximate force of 4 kg. Presence of second clinical disorder does not exclude diagnosis ofPresence of second clinical disorder does not exclude diagnosis of fibromyalgia.fibromyalgia.
  12. 12. Fibromyalgia: tender pointsFibromyalgia: tender points (diagram)(diagram)
  13. 13. How is FMS diagnosed? (cont.)How is FMS diagnosed? (cont.) X-rays, blood tests, specialized scans such asX-rays, blood tests, specialized scans such as nuclear medicine and CT, muscle biopsies arenuclear medicine and CT, muscle biopsies are allall normalnormal Objective “markers of inflammation” such asObjective “markers of inflammation” such as ESR (erythrocyte sedimentation rate) are normalESR (erythrocyte sedimentation rate) are normal Must be distinguished from other commonMust be distinguished from other common diffuse pain conditions such as RA, SLE,diffuse pain conditions such as RA, SLE, Hypothyroidism and Polymyalgia RheumaticaHypothyroidism and Polymyalgia Rheumatica (PMR)(PMR)
  14. 14. How is FMS treated?How is FMS treated? Fibromyalgia is a chronic conditionFibromyalgia is a chronic condition managed with both medications andmanaged with both medications and physical modalitiesphysical modalities Medication therapy is largely symptomatic,Medication therapy is largely symptomatic, as there is no definitive treatment cure foras there is no definitive treatment cure for fibromyalgiafibromyalgia
  15. 15. How is FMS treated? (cont.)How is FMS treated? (cont.) Current studies suggest that the bestCurrent studies suggest that the best pharmacologic treatment for treating painpharmacologic treatment for treating pain and improving sleep disturbance includes:and improving sleep disturbance includes: - Tricyclic compounds such as- Tricyclic compounds such as cyclobenzaprine (FLEXERIL) andcyclobenzaprine (FLEXERIL) and amitriptyline (ELAVIL)amitriptyline (ELAVIL) - Dual reuptake inhibitors such as- Dual reuptake inhibitors such as venlafaxine (EFFEXOR), duloxetinevenlafaxine (EFFEXOR), duloxetine (CYMBALTA) and tramadol (ULTRAM)(CYMBALTA) and tramadol (ULTRAM)
  16. 16. - SSRIs/ antidepressants such as fluoxetine- SSRIs/ antidepressants such as fluoxetine (PROZAC), paroxetine (PAXIL) and(PROZAC), paroxetine (PAXIL) and sertraline (ZOLOFT) for depression andsertraline (ZOLOFT) for depression and painpain - Recent studies have shown that the anti-- Recent studies have shown that the anti- epileptics (seizure meds) gabapentinepileptics (seizure meds) gabapentin (NEURONTIN) and pregabalin (LYRICA)(NEURONTIN) and pregabalin (LYRICA) have been effectivehave been effective
  17. 17. - NSAIDs (non-steroidal anti-inflammatory drugs)- NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen and naproxen are generallysuch as ibuprofen and naproxen are generally ineffectiveineffective - Long acting opioids (narcotics) generally are not- Long acting opioids (narcotics) generally are not of great benefit eitherof great benefit either - Benzodiazepines such as diazepam (VALIUM)- Benzodiazepines such as diazepam (VALIUM) and clonazepam (KLONIPIN) may be useful forand clonazepam (KLONIPIN) may be useful for patients with restless leg syndrome or verypatients with restless leg syndrome or very severe sleep disturbance who have notsevere sleep disturbance who have not responded to other therapiesresponded to other therapies
  18. 18. N.B.N.B. The US Food and Drug AdministrationThe US Food and Drug Administration has not yet approved any medications tohas not yet approved any medications to treat FMStreat FMS
  19. 19. Other Therapies for FMSOther Therapies for FMS Complementary and alternative therapiesComplementary and alternative therapies have been used although not well studiedhave been used although not well studied in FMSin FMS - Therapeutic massage- Therapeutic massage - Myofascial release therapy- Myofascial release therapy - Acupuncture- Acupuncture
  20. 20. Other Therapies for FMSOther Therapies for FMS Patient Self-ManagementPatient Self-Management - Schedule time to relax, including deep breathing- Schedule time to relax, including deep breathing and meditationand meditation - Establish routine for going to bed and waking up- Establish routine for going to bed and waking up - Aerobic exercise on regular basis- Aerobic exercise on regular basis - Self-education i.e. Arthritis Foundation,- Self-education i.e. Arthritis Foundation, National Fibromyalgia Assn.National Fibromyalgia Assn. - Support group- Support group - Cognitive Behavioral Therapy (CBT)- Cognitive Behavioral Therapy (CBT)
  21. 21. Common MisconceptionsCommon Misconceptions Eleven (11) out of 18 tender points neededEleven (11) out of 18 tender points needed to make the diagnosis of FMSto make the diagnosis of FMS (2005 ACR Classification Criteria)(2005 ACR Classification Criteria) FALSEFALSE Tenderness can be widespreadTenderness can be widespread withoutwithout tendertender pointspoints
  22. 22. The major symptom in FMS is painThe major symptom in FMS is pain FALSEFALSE A variety of neurologic abnormalities mayA variety of neurologic abnormalities may be described including numbness andbe described including numbness and tingling of the extremities, cognitive andtingling of the extremities, cognitive and memory problems, irritable bowelmemory problems, irritable bowel symptoms, etc.symptoms, etc.
  23. 23. It’s not a real illness, it’s in theIt’s not a real illness, it’s in the ““patient’s head”patient’s head” FALSEFALSE A real condition with severe physical effectsA real condition with severe physical effects in some, althoughin some, although psychologic factorspsychologic factors including depression may be the majorincluding depression may be the major determinant of pain in othersdeterminant of pain in others
  24. 24. The prognosis is “hopeless”The prognosis is “hopeless” FALSEFALSE Early, aggressive treatment can preventEarly, aggressive treatment can prevent physical deconditioning and loss ofphysical deconditioning and loss of functionfunction

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