Pain, fatigue, and sleep disturbance are the most common symptoms of Fibromyalgia. • Fibromyalgia is a pain condition in which sleep disturbance and fatigue occur in at least 86% of patients • Patients sometimes present with other comorbid conditions, including depression • As with other chronic pain conditions (for example, back pain, osteoarthritis, or rheumatoid arthritis), co-morbid mood disorders such as depression or anxiety may sometimes be present in Fibromyalgia. Fatigue is often unexpected, inappropriate, or a delayed reaction to physical exertion Presence of CWP differentiates FMS from chronic fatigue syndrome Cognitive disturbances may include: Difficulty in thinking Loss of short term memory Inability to multi-task Impaired speed of performance Easy distractability Feelings of cognitive overload Mood disorders are common In a study by Arnold, etc, 31% patients with FMS had a current diagnosis of MDD and 45% had moderate to severe anxiety
The ACR criteria are a sensitive (88.4%) and specific (81.1%) tool that can be used to differentiate Fibromyalgia from other rheumatological conditions The digital palpation examination should be performed with an approximate force of 4 kg/1.4 cm2 [pressure required to partially blanch the blood from under the thumbnail] This force can be standardized by pressing thumb on a weight scale. For a tender point to be considered “positive,” the subject must state that the palpation was painful. “Tender” is not to be considered “painful” Axial skeletal pain Cervical spine Anterior chest Thoracic spine Low back
Sodium oxybate Central nervous system depressant with marked sedative properties Enhances slow-wave sleep Sodium oxybate (sodium salt of GHB) granted Orphan Drug Status for the treatment of cataplexy and excessive daytime sleepiness in narcolepsy Dose 4.5-9.0 g/day 2 equally divided doses (HS and 4 hours later) Milcinapran Primary mechanism of action is balanced reuptake inhibition Also weakly antagonizes NMDA receptor Approved in 30 countries as an antidepressant .
Key Points The challenges that fibromyalgia presents call for a systematic, stepwise approach to treatment. Once a diagnosis is confirmed, it is crucial to identify the extent and severity of symptoms and possible comorbidities. This may require referral to a specialist. Educating the patient and reviewing all treatment options will also contribute to successful treatment. References Arnold LM. Biology and therapy of fibromyalgia: New therapies in fibromyalgia. Arthritis Res Ther . 2006;8:212. Available online: http://arthritis-research.com/content/8/4/212.
Key Points The recent increase in interest and research in fibromyalgia has resulted in new, evidence-based approaches to treatment. Cognitive-behavioral therapy that addresses disability, function, and self-efficacy can yield positive results when added to medical treatment, as can exercise, as long as it is tailored to the individual’s general level of fitness. 1 Non-narcotic drugs with proven efficacy should be the first-line approach. Drugs with a likelihood of abuse or dependence should generally be avoided in patients with fibromyalgia. References Arnold LM. Biology and therapy of fibromyalgia: New therapies in fibromyalgia. Arthritis Res Ther . 2006;8:212. Available online: http://arthritis-research.com/content/8/4/212.
MANAGEMENT OF FIBROMYALGIC SYNDROME Prof. A.V. SRINIVASAN M.D,D.M,PhD,DSc,FIAN,FAAN Emeritus Professor – The Tamil Nadu Dr. MGR Medical University
OUTLINEWhat is Fibromyalgia (FMS)?What causes it?Who gets it?How is it diagnosed?How is it treated?What are some of the common misconceptionsabout the syndrome?
What is Fibromyalgia (FMS)?A clinical syndrome characterized bywidespread muscular pain (usuallychronic),fatigue andmuscle tenderness (tender points)
What is FMS? (cont.) Additional symptoms are common and include:- poor sleep almost always- headaches- irritable bowel syndrome- cognitive and memory problems “fibro fog”- numbness and tingling in fingers and toes
What is FMS? (cont.)- irritable bladder- temporomandibular joint (TMJ) disorder- restless leg syndrome- dry eyes and dry mouth- morning stiffness- anxiety and depressionSymptoms including pain may wax and wane over time
FMS Symptom Complex Pain, fatigue, & sleep disturbance are present in at least 86% patientsACR Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site. Available at:http://www.nfra.net/Diagnost.htm. Accessed October 18, 2007.
What causes FMS?Cause is unknownAbnormally high levels of Substance P in spinalfluid in some patientsSubstance P important in transmission andamplification of pain signals to and from brain“Volume control” is turned up too high in brain’spain centers
What causes FMS? (cont)Familial tendency to develop FMS suggestsgenetic roleCan be triggered by physical, emotional orenvironmental stressors such as car accidents,repetitive injuries and certain diseasesPatients with Rheumatoid arthritis and SLE(Lupus) are more likely to develop FMS
What causes FMS? (cont.)Other conditions such as Lyme disease andobstructive sleep apnea (OSA) have beenassociated with FMSSleep deprivation with disruption of delta-wavesleep (non-REM stage IV) is associated withday-time fatigue andfibromyalgia syndrome
Who gets FMS?Affects as many as 1 in 50 AmericansMost common in middle-aged womenMen and children may also develop the disorderPatients with RA, SLE and Ankylosingspondylitis are more likelyWomen who have a family member with FMSare more likely to develop it
How is FMS diagnosed?A diagnosis is made by evaluation of symptomsand presence of tender pointsAmerican College of RheumatologyClassification Criteria for Fibromyalgia (1990)…….widespread pain for at least 3 months andpain in 11 out of 18 tender point sites on digitalpalpation
ACR classification criteria: fibromyalgiaBoth criteria must be satisfied – History of widespread pain for more than 3 months, on both sides of the body, above and below the waist, and axial skeleton (cervical spine, anterior chest, thoracic pain, or low back) – Pain in 11 of 18 tender point sites on digital palpation with approximate force of 4 kg.Presence of second clinical disorder does not excludediagnosis of fibromyalgia.
ACR Diagnostic Criteria for FMS History of widespread pain for at least 3 months – Pain on both sides of the body PLUS – Pain above and below the waist PLUS – Axial skeletal pain Pain in at least 11 of 18 tender-point sites on digital palpation – Thumb Pressure is Applied to 18 tender-point sites – Until Nail Bed is Starting to Blanch (~ 4 kg of pressure)Wolf et al. Arthritis Rheum. 1990;33:160-172.
How is FMS diagnosed? (cont.)X-rays, blood tests, specialized scans such asnuclear medicine and CT, muscle biopsies areall normalObjective “markers of inflammation” such asESR (erythrocyte sedimentation rate) are normalMust be distinguished from other commondiffuse pain conditions such as RA, SLE,Hypothyroidism and Polymyalgia Rheumatica(PMR)
How is FMS treated?Fibromyalgia is a chronic condition managedwith both medications and physical modalitiesMedication therapy is largely symptomatic, asthere is no definitive treatment cure forfibromyalgia
General RecommendationsFibromyalgia should be recognized as a heterogeneouscondition comprising of a range of symptoms & features – Effective management should take into account all these factorsOptimal treatment therefore requires a multidisciplinaryapproach with – Combination of non-pharmacological and pharmacological treatment modalities – Tailored according to pain intensity, sleep disturbance, fatigue & other symptoms, and function – Associated co-morbidities – In discussion with the patient
Available Treatment ModalitiesMease P. J Rheumatol. 2005; 32 (suppl 75): 6.Carville, et al. Ann Rheum Dis. Doi:10.1136/ard.2007.071522.Goldenberg et al. JAMA. 2004; 292: 2388.Clauw DJ, Crofford LJ. Best Pract Res Clin Rheumatol. 2003; 17: 685.Arnold LM, et al. Arthritis Rheum. 2007;56:1336-1344.
Stepwise Treatment of Fibromyalgia Confirm diagnosis Identify important symptom domains, their severity, and level of patient function Evaluate for comorbid medical and psychiatric disorders Assess psychosocial stressors, level of fitness, and barriers to treatment Provide education about fibromyalgia Review treatment optionsArnold LM. Arthritis Res Ther. 2006;8:212. Available online: http://arthritis-research.com/content/8/4/212.Accessed February 28, 2007.
Stepwise Treatment of Fibromyalgia (cont’d) As a first-line approach for patients with moderate to severe pain, trial with evidence-based medications Provide additional treatment for comorbid conditions Adjunctive CBT for patients with prominent psychosocial stressors, and/or difficulty coping, and/or difficulty functioning Encourage exercise according to fitness levelArnold LM. Arthritis Res Ther. 2006;8:212. Available online: http://arthritis-research.com/content/8/4/212.Accessed February 28, 2007.
How is FMS treated? (cont.) Current studies suggest that the best pharmacologic treatment for treating pain and improving sleep disturbance includes:- Tricyclic compounds such as cyclobenzaprine (FLEXERIL) and amitriptyline (ELAVIL)- Dual reuptake inhibitors such as venlafaxine (EFFEXOR), duloxetine (CYMBALTA) and tramadol (ULTRAM)
- SSRIs/ antidepressants such as fluoxetine (PROZAC), paroxetine (PAXIL) and sertraline (ZOLOFT) for depression and pain- Recent studies have shown that the anti- epileptics (seizure meds) gabapentin (NEURONTIN) and pregabalin (LYRICA) have been effective
- NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen and naproxen are generally ineffective- Long acting opioids (narcotics) generally are not of great benefit either- Benzodiazepines such as diazepam (VALIUM) and clonazepam (KLONIPIN) may be useful for patients with restless leg syndrome or very severe sleep disturbance who have not responded to other therapies
Other Therapies for FMS Complementary and alternative therapies have been used although not well studied in FMS- Therapeutic massage- Myofascial release therapy- Acupuncture
Other Therapies for FMS Patient Self-Management- Schedule time to relax, including deep breathing and meditation- Establish routine for going to bed and waking up- Aerobic exercise on regular basis- Self-education i.e. Arthritis Foundation, National Fibromyalgia Assn.- Support group- Cognitive Behavioral Therapy (CBT)
Common MisconceptionsEleven (11) out of 18 tender points needed to make the diagnosis of FMS (2005 ACR Classification Criteria) FALSETenderness can be widespread without tender points
The major symptom in FMS is pain FALSEA variety of neurologic abnormalities may be described including numbness and tingling of the extremities, cognitive and memory problems, irritable bowel symptoms, etc.
It’s not a real illness, it’s in the “patient’s head” FALSEA real condition with severe physical effects in some, although psychologic factors including depression may be the major determinant of pain in others
The prognosis is “hopeless” FALSEEarly, aggressive treatment can prevent physical deconditioning and loss of function
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