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Management of fibromyalgic syndrome


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Management of fibromyalgic syndrome

  1. 1. 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
  2. 2. 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?
  3. 3. What is Fibromyalgia (FMS)?A clinical syndrome characterized bywidespread muscular pain (usuallychronic),fatigue andmuscle tenderness (tender points)
  4. 4. 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
  5. 5. 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
  6. 6. 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: Accessed October 18, 2007.
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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.
  13. 13. 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.
  14. 14. Fibromyalgia: tender points (diagram)
  15. 15. 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)
  16. 16. 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
  17. 17. 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
  18. 18. 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.
  19. 19. Pharmacological Modalities Short-Term Long-TermDrugs Efficacy Efficacy Safety/ TolerabilityAmitriptyline Multiple - Anti-cholinergic, anti- small RCTs adrenergic, anti- histaminic, cardiac muscle suppressant effectsDuloxetine 2 RCTs 1 RCT Insomnia, GI & CV effects (Pain)Gabapentin 1 RCT - Dizziness, somnolence, weight gainPregabalin 4 RCTs 1 RCT (pain Dizziness, somnolence, & function) weight gainTramadol 1 RCT - Dizziness, somnolence, headache, GI effects
  20. 20. 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: February 28, 2007.
  21. 21. 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: February 28, 2007.
  22. 22. 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)
  23. 23. - 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
  24. 24. - 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
  25. 25. Other Therapies for FMS Complementary and alternative therapies have been used although not well studied in FMS- Therapeutic massage- Myofascial release therapy- Acupuncture
  26. 26. 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)
  27. 27. 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
  28. 28. 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.
  29. 29. 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
  30. 30. The prognosis is “hopeless” FALSEEarly, aggressive treatment can prevent physical deconditioning and loss of function
  31. 31. Dedicated to my familyfor making everything worthwhile
  32. 32. READ not to contradict or confuteNor to Believe and Take for Grantedbut TO WEIGH AND CONSIDERTHANK YOU MY SINCERE THANKS TO PFIZER