Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

BHC Chronic Widespread Pain 2018

316 views

Published on

Pain is one of the most troubling and hard-to-manage symptoms of ME/CFS and FM. Dr. Bateman teaches about the various types of pain, how pain is amplified, and treatment strategies to improve your own pain management.

Compassionate patient care is at the heart of what we do.
We set the standard for excellence in patient care through early diagnosis and evidence-based precision medicine. We reject the current healthcare system’s model of 10 minute visits. That doesn’t work for our patients. Our patient care is methodical, in-depth and allows us to really understand an individual and their illness.

We are a 501 c(3) dedicated to improving the lives of those that suffer from these devastating diseases.

Visit Batemanhornecenter.org to learn more.

Published in: Health & Medicine
  • Discover How to Cure uterine fibroids and PCOS At Any Age, Even If You’ve Tried Everything And Nothing Has Ever Worked For You Before ◆◆◆ http://t.cn/Aig7V1M7
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • How can I improve my memory book? How can I improve my memory recall? visit to learn...●●● https://bit.ly/2GEWG9T
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

BHC Chronic Widespread Pain 2018

  1. 1. Important Principles of Management: FM and ME/CFS u 1) Good differential diagnosis to identify and address all aspects of illness and comorbid conditions u 2) “Pace” activity to prevent symptom escalation (preventive activity management). Avoid push/crash. u 3) Address the major aspects of illness u SLEEP: Achieve most restorative u MENTAL HEALTH/COGNITION: bolster u PAIN: control severe pain and learn to manage chronic pain u FITNESS: Achieve best fitness based on tolerance and illness relapse u ORTHOSTATIC INTOLERANCE– if applicable
  2. 2. Chronic Widespread Pain: ~present by definition in FM and ~common in ME/CFS, especially in PEM
  3. 3. Chronic Widespread Pain u Pain is highly variable in terms of cause, type, treatment u Chronic pain usually responds to treatment but may be difficult to cure u Pain specialists and physiatrists can help with many aspects of pain management
  4. 4. Assess and treat pain by type u Osteoarthritis u Inflammatory conditions (Rheumatoid arthritis, Lupus, gout…) u Spine---cervical and lumbar DJD/DDD: a combination of OA and nerve pain with muscle spasm u Hyperalgesia, generalized pain amplification (FM) u Headaches, tension or chronic daily headaches u Migraine headaches: a vascular phenomenon with hyperalgesia u IBS, interstitial cystitis, pelvic pain---mostly hyperalgesia u Neuropathies: peripheral and other… u Neuralgia, arthralgia, myalgia
  5. 5. Osteoarthritis and inflammation u Low impact exercise and range of motion u Anti-inflammatories (NSAIDS and COXII) u ibuprofen, naproxen. diclofenac absorbed topically (Voltarin) u meloxicam (Mobic) u celecoxib (Celebrex) easiest on the stomach u Corticosteroids---short term use much safer than long term use u prednisone, methylprednisolone, etc Oral or injectable u Immune suppressing and targeted agents for inflammatory arthritis u Numerous drugs through rheumatology specialists
  6. 6. Assess and treat pain by type u Osteoarthritis (OA) u Inflammatory conditions (Rheumatoid arthritis, Lupus, gout) u Spine---cervical and lumbar DJD/DDD: a combination of OA and nerve pain with muscle spasm u Hyperalgesia, generalized pain amplification (FM) u Headaches, tension or chronic daily headaches u Migraine headaches: a vascular phenomenon with hyperalgesia u IBS, interstitial cystitis, pelvic pain---mostly hyperalgesia u Neuropathies: peripheral and other… u Neuralgia, arthralgia, myalgia
  7. 7. Commons.Wikimedia.org
  8. 8. Commons.Wikimedia.org
  9. 9. Cervical, thoracic or lumbar spine disease warrant evaluation u Facet arthritis—multiple small joints u Lateral foraminal narrowing (stenosis) u Central canal narrowing (stenosis) u Mild nerve compression-à muscle spasm and pain u Moderate to severe nerve compression-à loss of sensation, reflex, motor u All aspects of spine disease pain can be worsened by the pain amplification of FM
  10. 10. Assess and treat pain by type u Osteoarthritis u Inflammatory conditions (RA, Lupus, gout, etc) u Spine---cervical and lumbar DJD/DDD: a combination of OA and nerve pain with muscle spasm u Hyperalgesia, generalized pain amplification (FM) u Headaches, tension or chronic daily headaches u Migraine headaches: a vascular phenomenon with hyperalgesia u IBS, interstitial cystitis, pelvic pain---mostly hyperalgesia u Neuropathies: peripheral and other… u Neuralgia, arthralgia, myalgia
  11. 11. 12 Tender Points (TP) drawn in black by examiner at time of physical exam The black marks are FM tenderpoints noted on exam by the Medical provider. The red ink was drawn by the FM patient to Indicate areas of pain.
  12. 12. 13 13
  13. 13. Knife bed of nails
  14. 14. Fibromyalgia (ACR 1990) Chronic (>3 months) Widespread (4 quadrants of body & spine) Pain and Tenderness (>11/18 tender points) Hyperalgesia (amplified pain signaling) stiffness and pain in the muscles and joints, headache, bowel, bladder, pelvis, chest, tingling and numbness, photophobia, etc Wolfe F, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160–72.
  15. 15. 16 16 Four quadrants and the spine
  16. 16. BECOME SKILLED at utilizing life-style adjustments Preventive and maintenance strategies are effective, safe, inexpensive and promote general health
  17. 17. FM and hyperalgesia respond to: u Restorative sleep u Relaxation, meditation and mindfulness, emotional calm, mental distraction u Physical activity in the right amount: u not too little (being sedentary) u not too much (low impact--not intense--exercise) u Massage, acupuncture, other manual methods. u Warm baths and other relaxation techniques
  18. 18. FM pain and hyperalgesia--- Respond to drugs that target the central and peripheral nervous system u FDA approved drugs for FM u Anticonvulsants: pregabalin (Lyrica) u SNRI: duloxetine and milnacipran (Savella) u Non-FDA approved drugs used for FM “off label” u Anticonvulsants: gabapentin, topiramate, zonisamide… u SNRI: levomilnacipran (Fetzima), venlafaxine, desvenlafaxine (Pristiq) u Low dose TCA: amitriptyline, nortriptyline, doxepin, etc u Muscle relaxants: cyclobenzaprine, tizanidine, methocarbamol, baclofen… u tramadol, buprenorphine variants, opioids (hydrocodone, oxycodone…) u LDN (low dose naltrexone)… Topical agents can be helpful (lidocaine, diclofenac, gabapentin, etc)
  19. 19. Opioids used daily for hyperalgesia Quickly become ineffective and actually INCREASE hyperalgesia over time!
  20. 20. LDN (low dose naltrexone) u naltrexone hydrochloride is an opioid receptor antagonist, FDA approved for treatment of alcohol and opioid dependence (50 mg). u In very low doses (1-5 mg) LDN may: u paradoxically decrease pain due an increase in the release of endogenous opioids with transient opioid receptor blockade u calm microglial cell activation in the CNS (anti-inflammatory or neuroinflammatory agent) Low-dose naltrexone for the treatment of fibromyalgia: findings of a small, randomized, double-blind, placebo-controlled, counterbalanced, crossover trial assessing daily pain levels. Younger J1, Noor N, McCue R, Mackey S. Arthritis Rheum. 2013 Feb;65(2):529-38. doi: 10.1002/art.37734 The use of low-dose naltrexone (LDN) as a novel anti-inflammatory treatment for chronic pain. Younger J, Parkitny L, McLain D. Clin Rheumatol. 2014 Apr;33(4):451-9. doi: 10.1007/s10067-014-2517-2. Epub 2014 Feb 15. Review.
  21. 21. Low dose naltrexone (LDN) u LDN works gradually to reduce pain. Observe at least 3 months to determine efficacy. Most generally take the LDN at bedtime. u Naltrexone is a generic drug, but is not made in a pill smaller than 50 mg, so a compounding pharmacist must make the smaller dose capsules u LDN can sometimes disrupt sleep, but this usually resolves. Some people start at a lower dose (0.5-2 mg) and work up gradually. u LDN cannot be used in combination with other opioids (hydrocodone, oxycodone, tramadol) because LDN inhibits or blocks the opioid receptors and opioids stimulate the receptors. u Stop LDN in advance of elective surgery or other situations where short acting opioids might be needed. Inform all medical personnel that you are taking LDN. In an emergency situation requiring opioids, it may take a higher dose to control pain if LDN has not been stopped in advance.
  22. 22. All medications work better/longer in combination with effective life- style modifications
  23. 23. USE ONLY medications that add benefit and are low in side effects Use the lowest effective doses Gradually try to replace medications with lifestyle adjustments
  24. 24. PAIN amplification restorative SLEEP EMOTIONAL wellness FITNESS Function.. general well-being Many familiar treatments and FDA approved drugs FM FDA approved drugs and many off label treatments duloxetine milnacipran pregabalin gabapentin amitriptyline Choose medications That can treat more than one thing…
  25. 25. “ ” People respond in various ways to medications, so your experience with a drug is ultimately all that matters. I will show you using gene expression following an exercise stressor how research subjects have completely opposite results from a trial of Lyrica.
  26. 26. Subject LYR06 --vs-- Controls 0.1 1 10 baseline 8 hr 24 hr 48 hr baseline 8 hr 24 hr 48 hr LY06A on placebo Controls FoldincreasesinmRNA ASIC3 P2X4 TRPV1 AD2A ADB1 ADB2 COMT IL6 TNF beta TLR4 NR3C1 Gene expression after exercise challenge
  27. 27. LYR06 (on Lyrica) –vs-- LYR06 (on Placebo) 0.1 1 10 baseline 8 hr 24 hr 48 hr baseline 8 hr 24 hr 48 hr LYR06B (on Lyrica) LYR06A (on Placebo) FoldincreasesinmRNA ASIC3 P2X4 TRPV1 AD2A ADB1 ADB2 COMT IL6 TNF beta TLR4 NR3C1
  28. 28. LYR11 (on Lyrica) –vs-- LYR11 (on Placebo) Subject ranks symptoms much better on Lyrica 0.1 1 10 baseline 8 hr 24 hr 48 hr baseline 8 hr 24 hr 48 hr LYR11B (on Lyrica) LYR11A (on Placebo) FoldincreasesinmRNA ASIC3 P2X4 TRPV1 AD2A ADB1 ADB2 COMT IL6 TNF beta TLR4 NR3C1 Arrows indicate genes encoding pain
  29. 29. 0 10 20 30 40 50 60 70 80 MF base MF mid MF imm MF 30 MF 8 MF 24 MF 48 Mental Fatigue before, during and after 25 min exercise Subject 11 OFF Lyrica Subject 11 ON Lyrica
  30. 30. 0 10 20 30 40 50 60 70 80 90 100 PF base PF mid PF imm PF 30 PF 8 PF 24 PF 48 Physical fatigue Before, during and after 25 min exercise Subject 11 OFF Lyrica Subject 11 ON Lyrica
  31. 31. 0 10 20 30 40 50 60 70 80 90 100 Pain base Pain mid Pain imm Pain 30 Pain 8 Pain 24 Pain 48 Subject 11 ON Lyrica Subject 11 OFF Lyrica Pain Scores Before, during and after 25 min exercise
  32. 32. Mental Fatigue Ratings Subject 12 Lyrica vs Placebo 0 10 20 30 40 50 60 70 80 90 100 MFbaseL MFmidL MFimmL MF30L MF8L MF24L MF48L On Lyrica On Placebo Physical Fatigue Ratings Subject 12 Lyrica vs Placebo 0 10 20 30 40 50 60 70 80 90 100 PFbaseL PFmidL PFimmL PF30L PF8L PF24L PF48L On Placebo On Lyrica Pain Ratings Subject 12 Lyrica vs Placebo 0 10 20 30 40 50 60 70 80 90 100 PFbaseL PFmidL PFimmL PF30L PF8L PF24L PF48L On Placebo On Lyrica Subject 12 had the opposite response to Lyrica
  33. 33. LYR12 on Placebo vs LYR12 on Lyrica 0.6 0.8 1 1.2 1.4 1.6 1.8 2 baseline 8 hr 24 hr 48 hr baseline 8 hr 24 hr 48 hr LYR12A Placebo LYR12B Lyrica FoldincreasesinmRNA ASIC3 P2X4 TRPV1 AD2A ADB1 ADB2 COMT IL6 TNF beta TLR4 NR3C1 This slide compares the gene responses of Subject 12 on placebo to those on Lyrica. These are the same genes as in the Journal of Internal Medicine article.
  34. 34. LYR12 on placebo vs Controls 0.6 0.8 1 1.2 1.4 1.6 1.8 2 2.2 baseline 8 hr 24 hr 48 hr baseline 8 hr 24 hr 48 hr LYR12A placebo Controls FoldincreasesinmRNA ASIC3 P2X4 TRPV1 AD2A ADB1 ADB2 COMT IL6 TNF beta TLR4 NR3C1 On PLACEBO, Subject 12 shows decreases in genes that control metabolites in skeletal muscle (ASICS, P2X, TRPV1, and ADrenergic receptors). Genes involved in immune response show reverse regulation, indicating activation when suppression should predominate and suppression when activation should occur.
  35. 35. LYR12 on Lyrica vs Controls 8 hr 24 hr 48 hr baseline 8 hr 24 hr 48 hr LYR12B Lyrica Controls 0.6 0.8 1 1.2 1.4 1.6 1.8 2 2.2 baseline FoldincreasesinmRNA ASIC3 P2X4 TRPV1 AD2A ADB1 ADB2 COMT IL6 TNF beta TLR4 NR3C1 On Lyrica, Subject 12 shows increases in genes that signal pain and fatigue following exercise, and even stronger reverse regulation of immune function genes. This agrees with the patient’s complaints of muscle and joint pain, headache, mental fog, depression and anxiety symptom increases when on Lyrica, and also her increased pain scores when on Lyrica.
  36. 36. Additional genes were tested to expand the original categories of ---Ion channel (sensory) ---Adrenergic (sympathetic n.s.) ---Immune genes (cytokines)
  37. 37. Expanded gene expression fatigue and pain genes LYR12 placebo LYR12 Lyrica Controls 6.00E-01 8.00E-01 1.00E+00 1.20E+00 1.40E+00 1.60E+00 1.80E+00 2.00E+00 LYR12A placebo LYR12B Lyrica Controls FoldIncreasefrombaseline ASIC1 ASIC3 P2X1 P2X4 P2X7 P2Y1 P2Y2 TRPV1 TRPV4 baseline 8 hr 24 hr 48 hr baseline 8 hr 24 hr 48 hr baseline 8 hr 24 hr 48 hr
  38. 38. Expanded sympathetic genes 1.00E-02 1.00E-01 1.00E+00 1.00E+01 1.00E+02 baseline 8 hr 24 hr 48 hr baseline 8 hr 24 hr 48 hr 12A placebo 12B Lyrica Controls FoldIncreasefrombaseline ADRA2A ADRA2C ADRB1 ADRB2 DRD4 HTR1D SULT1A1 COMT VIPR2 VEGFA baseline 8 hr 24 hr 48 hr LYR12 placebo LYR12 Lyrica Controls
  39. 39. Fold increase in Immune and Inflammation genes 4.00E-01 6.00E-01 8.00E-01 1.00E+00 1.20E+00 1.40E+00 1.60E+00 1.80E+00 2.00E+00 baseline 8 hr 24 hr 48 hr baseline 8 hr 24 hr 48 hr 12A placebo 12B Lyrica Controls FoldIncreasefrombaseline APP CXCR4 GZMA IL10 IL6 NFKB1 PSMA4 TLR4 TNFalpha TNFBeta Expanded immune and inflammation genes LYR12 placebo LYR12 Lyrica Controls
  40. 40. Fold increase in HPA and stress genes 0.00E+00 2.00E-01 4.00E-01 6.00E-01 8.00E-01 1.00E+00 1.20E+00 1.40E+00 1.60E+00 1.80E+00 2.00E+00 baseline 8 hr 24 hr 48 hr baseline 8 hr 24 hr 48 hr 12A placebo 12B Lyrica Controls FoldIncreasefrombaseline DBI HSPA2 NR3C1 NR3C2 PPARA STAT5A VEGFA LYR12 placebo LYR12 Lyrica Controls New gene expression of HPA-axis and Stress genes
  41. 41. Fold increase in mitochondrial genes 6.00E-01 8.00E-01 1.00E+00 1.20E+00 1.40E+00 1.60E+00 1.80E+00 2.00E+00 baseline 8 hr 24 hr 48 hr baseline 8 hr 24 hr 48 hr LYR12A placebo LYR12B Lyrica Controls FoldIncreasefrombaseline ATP5E COX5B NDUFS5 SOD2 SIRT1 LYR12 placebo LYR12 Lyrica Controls New gene expression of mitochondrial genes
  42. 42. Important Principles of Management: FM and ME/CFS u 1) Good differential diagnosis to identify and address all aspects of illness and comorbid conditions u 2) “Pace” activity to prevent symptom escalation (preventive activity management). Avoid push/crash. u 3) Address the major aspects of illness u SLEEP: Achieve most restorative u MENTAL HEALTH/COGNITION: bolster u PAIN: control severe pain and learn to manage chronic pain u FITNESS: Achieve best fitness based on tolerance and illness relapse u ORTHOSTATIC INTOLERANCE– if applicable
  43. 43. PAIN reduction Restorative SLEEP MENTAL HEALTH FITNESS ORTHOSTATIC INTOLERANCE… CHRONIC UNWELLNESS PACING and activity management

×