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Fibromyalgia
- 1. FIBROMYALGIA Dr Amit KumarMallik RIMS, Imphal (INDIA) 09/05/16 1
- 2. Introduction Characterized by chronicwidespread musculoskeletal pain associated with considerable distress, generalized fatigue, disturbance of sleep, anxiety and depression. Also known asNeurastheniaor fibrositis 09/05/16 2
- 3. FM leadsto significant decreased function and work capacity and the quality of life is seriously affected Although defined primarily as pain syndromes there are associated neuropsychological symptoms 09/05/16 3
- 4. Epidemiology Prevalence rate of2-3% Fibromyalgia affects predominantly women in a ratio of 9:1 compared to men Most patients present with fibromyalgia between the ages of 30–50 years This disorder is found in most countries, in most ethnic groups, and in all types of climate 09/05/16 4
- 5. Proposed etiology of Fibromyalgia Emergingevidence of genetic component of FM - Specific gene mutations may predispose individuals to FM - Polymorphism in Catechol O-methyl transferase(COMT) enzyme gene and serotonin transporter are potentially associated with FM 09/05/16 5
- 6. Environmental factorsthat may trigger the onset of FM - Physical trauma and injury - Infections (hepatitis C, lyme’s disease) - Psychological stressor FM may occur concurrently with arthritis (OA), autoimmune diseases (RA,SLE) 09/05/16 6
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- 8. Mechanism of decreasepain threshold •Wind up •Central sensitization 09/05/16 8
- 9. Wind Up • Drs.Price and Staud have demonstrated that increasing repetitive nociceptive stimuli will activate a wide range of dorsal horn neuronal pain discharges in the CNS called “wind up” • Temporal summation of pain on repetitive stimulation of peripheral nociceptive afferents Price, D and Staud, R, J Rheumatol 2005:32(75):22-28 09/05/16 9
- 10. • “Wind up”involves recruitment of NMDA pain receptors in the CNS and neural plasticity of nociceptive spinal cord pathway in central sensitization 09/05/16 10
- 11. Central sensitization ofFM patients • Increased levels of excitatory neuro-transmitters glutamate and substance P • Compared with normal controls, CSF levels of substance P are 3-fold higher in FM patients • There are decreased levels of serotonin and norepinephrine which are needed for pain modulation 09/05/16 11
- 12. Neurotransmitters ◦ Substance P,an excitatory neurotransmitter which is elevated in CSF of FM patients compared with controls ◦ Glutamate acting at the A and C ascending pain fibersᶞ 1. Russell IJ, et al. Arthritis Rheum. 1994;37:1593-1601. 4. Russell IJ, et al. J Rheumatol. 1992;19:104-109. 2. Vaerøy H et al., Pain. 1988. 32:21-26. 5. Russell IJ, et al. Arthritis Rheum. 1992;35:550-556. 3. Watkins LR, et al. Brain Res. 1994;664:17-24. 6. Fields HL, et al. Annu Rev Neurosci. 1991;14:219- 245. 09/05/16 12
- 13. Serotonin and Norepinephrine •Serotonin and norepinephrine mediate pain modulation through the descending inhibitory pain pathways in the brain and dorsal horn of the spinal cord • Dysfunction in fibromyalgia 09/05/16 13
- 14. Clinical features Pain andtenderness “ Pain all over” typically above and below the waist on both sides and involves the axial skeleton Neuropshychological symptoms Fatigue, sleep disturbance, cognitive dysfunction, anxiety and depression 09/05/16 14
- 15. Overlapping syndromes- Can overlapin presentation with other chronic conditions Comorbid conditions- Often associated with chronic musculoskeletal, infectious, metabolic or psychiatric conditions Functional impairment 09/05/16 15
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- 17. Associated with • Chronicfatigue syndrome • Depression • Irritable bowel syndrome • Migraine • Headache • Irritable bladder • Temporomandibular joint pain 09/05/16 17
- 18. Diagnostic criteria The AmericanCollege of Rheumatology 1990: (1) A history of widespread pain for 3 month or more (2) Pain in at least 11 of 18 defined tender point sites on digital palpation with a force of 4 kg with thumb 09/05/16 18
- 19. ACR 201O • WidespreadPain Index (WPI) • Symptom Severity Score (SS) 09/05/16 19
- 20. Widespread Pain Index(WPI) Pain in any of the ff areas in the last 7 days • R/L Jaw • Neck • R/L Shoulder • R/L Upper Arm • R/L Forearm • Upper Back • Chest • Abdomen • Lower Back • R/L Hip • R/L Thighs • R/L Calves 09/05/16 20
- 21. Symptom Severity Score SomaticSymptoms – Have you had any of the following in the last 6 months • Blurred vision • Tinnitus • Mouth sores • Dry mouth • Headache • Dizziness • Fever • Chest pains • Dyspnea • Wheezing • Anorexia • Nausea • Diarrhea • Constipation • Itching • Vomiting • Easy bruising • Hair loss 09/05/16 21
- 22. • WPI >7and SS Score > 5 • WPI 3-6 and SS Score > 9 • Symptoms present for at least 3 months 09/05/16 22
- 23. a. Pain inthe right side of the body b.Pain in the left side of the body c. Pain above the waist d. Pain below the waist e. Trunk and extremities 09/05/16 23
- 24. Sites for controlpoints • Mid forehead • Junction of proximal 2/3rd and Distal 1/3rd of forearm • Thumbnail 09/05/16 24
- 25. Sites for elicitationof tender points Pain on digital palpation in at least 11 of the following 18 tender point sites a. Occiput: bilateral, at the suboccipital muscle insertion b. Low cervical: bilateral, at the anterior aspect of the intertransverse spaces at C5–7 c. Trapezius: bilateral, at the midpoint of the upper border 09/05/16 25
- 26. d. Supraspinatus: bilateral,at the origin, above the scapular spine near the medial border e. Second rib: bilateral, at the second costochondral junction, just lateral to the junction on the upper surface f. Lateral epicondyle: bilateral, 2 cm distal to the epicondyle 09/05/16 26
- 27. • g.Gluteal: bilateral,in the upper outer quadrant of the buttock • h.Greater trochanter: bilateral, posterior to the trochanteric prominence • i.Knee: bilateral, at the medial fat pad proximal to the joint line 09/05/16 27
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- 30. Differential diagnosis Inflammatory Infectious Non inflammatory Endocrine Neurologic diseases Psychiatric diseases Drugs 09/05/16 30
- 31. Investigations Routine - CBC,ESR, CRP, TSH Guided by history and physical examination -ANA, anti-SSA&SSB, Rh.factor, anti-CCP, CPK, viral and bacterial serologies, spine and joint radiographs 09/05/16 31
- 32. Management Think of FMas a multisystem disorder with multiple pathways creating dysfunction ◦ Non-restorative sleep ◦ Myofascial pain ◦ Neuromuscular dysfunction/deconditioning ◦ Anxiety and reactive depression ◦ Abnormal pain processing ◦ Excess sympathetic tone and Autonomic dysfunction 09/05/16 32
- 33. Treatment Pharmacological treatment Antidepressants -Amitryptiline - Duloxetine - Milnacipran -Fluvoxetine 09/05/16 33
- 34. Anticonvulsants - Gabapentin - Pregabalin Glucocorticoidsor NSAIDs are not effective in FM Utilization of single agents to treat multiple symptom domain is strongly encouraged 09/05/16 34
- 35. Non pharmacological treatment 1.Self-managementstrategies - Education and active participation with reassurance 2. Multi component therapy - Comprise of one educational or other psychological therapy and at least one exercise therapy 09/05/16 35
- 36. Rehabilitation of FM Painreduction modalities •Cryotherapy •Therapeutic heat •Administration of local anesthetics 09/05/16 36
- 37. Aerobic and flexibilityexercise • Exercise can activate endogenous opioids and reduce “wind up” • Low level of exercise • Progress slowly 09/05/16 37
- 38. • Begin withgentle warm up • Low impact aerobic exercise for atleast 3 time wkly • Target exercise regimen- 4 to 5 times a wk for at least 20-30 minutes every session 09/05/16 38
- 39. Psychological rehabilitation • Cognitiveand behavioral therapy • Relaxation training • Biofeedback • Stress management 09/05/16 39
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