15 grossa fibromyalgia · 2018-04-06 · 4/5/18 4 tender point exam acr criteria: pain at 11 of 18...

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Fibromyalgia: It’s Real, It’s Manageable

Andrew J. Gross, MDProfessor of Clinical Medicine

Rheumatology Clinic ChiefAssociate Chair of Ambulatory Care, Dept of Medicine

University of California, San Francisco

Disclosures

• none

Learning Objectives

• Recognize patients with Fibromyalgia and other Pain Sensitization Syndromes, identify the mechanisms of pain, and explain the importance of making these diagnoses.

• Describe the basic treatment approach for fibromyalgia.

Clinical Case I49 year old woman comes to you complaining of fatigue. She also notes problems with pain in many areas.

She tells you that she wakes up frequently at night either from pain or thinking about stressful problems from her work. She wakes up in the morning with pain in her shoulders, neck and low back with stiffness, feeling very tired. The stiffness improves quickly, but as the day wears on, pain gets worse and she feels exhausted. She has gained 20 lbs in the past 2 years. She feels depressed because of the poor quality of her life.

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Clinical Case II (more subtle)

A 27 year old woman comes to see you with the chief complaint of ankle pain…

You see she has had multiple visits for same problem, but she has not responded well to any of the usual treatments. X-ray and MRI are unremarkable

On further review of her record, she has been seen over the past 6 years for many other problems including tinnitus, eye discomfort, right upper quadrant pain, shoulder pain, neck pain, and problems with her memory. Workup for each of these problems has been unrevealing.

Fibromyalgia Epidemiology

Wolfe F, et al; Arthritis & Rheum; 1995

women

men

Percentage of the population with fibromyalgia

Wolfe F et al; 2013, Arthritis Rheum; PMID 23424058

Vincent A, et al; 2012, Arthritis Care & Res PMID 23203795

Using 2011 ACR diagnostic criteria in 2445 German People:

• Prevalence of 2.1%

• Prevalence increased with age• 0.8% ≤40 years of age• 2.5% in 40–59.9 years• 3.0% in ≥60 years of age

• Similar prevalence in women and men (2.4% versus 1.8%; P =0.372)

Olmsted County prevalence 6.4%(7.5% of women and 4.9% of men)

Fibromyalgia Epidemiology

Vincent A, et al; 2012, Arthritis Care & Res PMID 23203795

Using 2011 ACR diagnostic criteria Olmsted County prevalence 6.4%

Similar prevalence in women & men: 7.5% women, 4.9% men

Fibromyalgia:

• Can it be reliably diagnosed?• Is it physical or psychological?• Is a diagnosis helpful or harmful?• Is there any effective treatment?

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Fibromyalgia:


What are the hallmarks of fibromyalgia? (choose 3)

a) Widespread painb) Joint Painc) Non-restful sleepd) Depressione) Fatiguef) Obesity

Diagnosis of Fibromyalgia

ACR classification criteria – Wolfe F, et al, Arthritis Rheum 1990ACR diagnostic criteria – Wolfe F, et al, Arthritis Rheum 2010

Widespread Pain

(>3 months)

www.ehow.com/about_5059501_fibromyalgia-diagnosis-symptoms.html



Widespread Pain

(>3 months)

Characteristic Tender Points

• Fatigue• Poor Sleep• Cognitive Problems• Other Sx

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Tender Point Exam

ACR criteria: pain at 11 of 18 points



Widespread Pain

(>3 months)


• Fatigue• Poor Sleep• Cognitive

Problems• Other Sx

A score of ≥13 points is consistent with a diagnosis of fibromyalgia• Sensitivity 93.1%• Specificity 91.7%

Clauw D, 2014, JAMA, PMID 24737367 Ferrari R, Russell AS, 2013, J Rheumatol

Wolfe F et al, J Rheumatol 2011, PMID 24737367

Which of the following suggests to youthat a patient might have fibromyalgia:

A. Multiple different pain complaints– Eg. Back pain, knee pain, neck/shoulder pain

B. “Pan-positive review of systems”

C. The patient has various hypersensitivity complaints (e.g. your exam room lights are making them sick)

D. The patient starts the interview with their birth history

E. You are exhausted after the interview

ALL OF THE ABOVE!

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Fibromyalgia

Headache/Migraine

TMJ disorder

Dermatitis/ pruritis

Chronic eye irritation/dryness

Atypical chest pain

Irritable bowel syndrome

Polyuria/frequency(“interstitial

cystitis”)

Dyspareunia/ vulvodynia

ParesthesiaChronic fatigue

Muscle Cramps

Dypsnea

Multiple sensitivities

Wolfe F et al; 2013, Arthritis Care & Res; PMID 23424058Aaron LA, et al. 2000, Arch Int Med. PMID 10647761

Wolfe F, et al, 2013, Arch Int Med 2013Buchwald D, Garrity D, Arch Int Med 1994

In a German Study of FMS patients 53.8% had ≥1 severe somatic symptoms32.7% had ≥2 symptoms

Fibromyalgia overlaps with other Somatic Syndromes

Dutch Study of 94,516 participants between 2006-12, Janssens KAM, et al, Psychosomatic Med 2015



Widespread Pain

(>3 months)


• Fatigue• Poor Sleep• Cognitive

Problems• Other Sx

other disease

…but how do I make sure my patient does not have something “bad”

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It is difficult to be sure…Cervical Myelopathy

PellagraAcute IntermittentPorphyria

Polyarteritis NodosaOvarian Cancer

Systemic LupusErythematosus

Pituitary Adenoma

Fabry’s Disease

AmyloidosisWhipple’s Disease

Hypothyroidism Mitochondrial Myopathy

Work-up

• Laboratory Tests– ESR, CRP

– CBC w/ diff– Comprehensive Metabolic

Panel (inc. LFTs, Calcium)

– Fasting Glucose– Hepatitis B & C

– TSH, free T4

– Vitamin D 25-OH– CPK (if appropriate)

– ANA (rarely)

Work-up

• Laboratory Tests– ESR, CRP

– CBC w/ diff– Comprehensive Metabolic

Panel (inc. LFTs, Calcium)

– Fasting Glucose– Hepatitis B & C

– TSH, free T4

– Vitamin D 25-OH– CPK (if appropriate)

– ANA (rarely)

• X-rays of affected areas to investigate joint damage

• Biopsy tissues that appear affected (ie. skin rashes)

• EMG for persistent neurologic symptoms

Tips to detect underlying disease

• Perform routine laboratory Screening• Evaluate objective findings• Invite patients to return to see you if they

develop new symptoms

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When To ReferFibromyalgia does not require specialist evaluation for diagnosis or management

Referrals to specialists should be made when workup identifies another process such as:• Endocrine disease (Thyroid, Adrenal)• Rheumatic Disease (PMR, Ankylosing

Spondylitis)• GI Disease (Malabsorption - Celiac Sprue)• Heart Failure• Neurologic disease (MS, ALS, Parkinson's)

Fibromyalgia:


What is causing pain?

a) Abnormal metabolism of muscle fibers causes persistent tissue degeneration/regeneration

b) Increased sensitization of central pain signalingc) Small fiber perineural ischemiad) Psychiatric illness

What is causing pain?

a) Abnormal metabolism of muscle fibers causes persistent tissue degeneration/regeneration

b) Increased sensitization of central pain signalingc) Small fiber perineural ischemiad) Psychiatric illness

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How Do We Sense Pain?Nociceptive Networks

Brain

Abeles AM, et al, Ann Intern Med 2007

Patients with Fibromyalgia experience pain differently from unaffected individuals

Subjective EvidenceIncreased sensitivity to heat, cold, and

pressure• Marques AP, et al, Clin Rheumatol 2005• Maquet D, et al, Eur J Pain 2004• Gibson SJ, et al, Pain 1994

Baraniuk JN, et al, BMC Musculoskel Disor, 2004

www.tutrin.com

Patients with Fibromyalgia sense pain differently from unaffected individuals

Central sensitization to pain

Desmeules JA, et al, Arthritis & Rheum 2003Also see Banic B, et al, Pain 2004

Objective EvidenceNociceptive flexion reflex

Brain

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Pain Processing Mechanisms

Schmidt-Wilcke T and Clauw DJ; Nat Rev Rheumatol, 2011, PMID 21769128

CNS neurotransmitters that are known to either inhibit or facilitate sensory/pain transmission are

perturbed in patients with Fibromyalgia

What causes pain sensitization?

What Causes Increased Sensitivity to Pain?

EmotionalTrauma(violence &

stress & loss)

PhysicalTrauma/Illness

(infections & injuries)

GeneticVunerability

Crofford LJ; Trauma, Violence, & Abuse, 2007, PMID 17596347

EndorphinsCortisolNeurotransmitters


Pain Sensitization

Arnold LM, et al, Arthritis Rheum, 2013, PMID 23280346

Fibromyalgia Pathophysiology:Biological Stress

• 5–10% of individuals exposed to certain types of infections (for example, Lyme disease, Epstein–Barr virus, parvovirus or Q fever) develop CWP, and infections in other regions of the body can also trigger chronic regional pain.

• Similarly, 10–15% of individuals with acute gastrointestinal infections (for example, with Campylobacter spp., Salmonella spp. or Shigella spp.) subsequently develop IBS.


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Fibromyalgia Pathophysiology:Psychological Distress

• Individuals with high levels of distress but without pain are 2-fold more likely to develop chronic widespread pain

• Having psychologically stressful events in early life (death of a parent, prolonged hospitalization, MVA) increase the risk of developing chronic widespread by 50–100% in later life

• Sexual and physical abuse in childhood and adulthood are associated with FMS in adulthood

• PTSD reported in 15% to 56% of patients with fibromyalgia

Fietta P et al, Acta Biomed 2007Hauser W, at al, Arthritis Care Res, 2011

Hauser W, et al, 2013, Pain, PMID 23685006Schmidt-Wilcke T and Clauw DJ; Nat Rev Rheumatol, 2011, PMID 21769128

Fibromyalgia:


Should I tell the patient they have fibromyalgia?

Should I tell the patient they have fibromyalgia?

�No: the label of FMS might lead to increased illness behavior, dependence on health care providers, and increased health service costs.�

�Yes: making a definite diagnosis will reduce the number of referrals, use of multiple health care providers, and costs.�

Costs Related to a Diagnose FMS and Failure to Diagnose FMS

Annemans et al, Arthritis Rheum 2008; 58:895

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The Importance of Knowing

• Health care costs are reduced by diagnosing fibromyalgia– Fewer PCP visits– Fewer tests ordered– Fewer referrals made– Fewer drugs prescribed

• Critical to help set expectations

Annemans et al, Arthritis Rheum 2008; 58:895

How do I tell my patient they have fibromyalgia?“Here’s what people with

fibromyalgia usually tell me….”

Fibromyalgia:


Which intervention is likely to lead to a 50% reduction in pain?

a. Cymbaltab. Gabapentinc. Cognitive Behavior Therapyd. Exercise & Physical Therapye. None of the above

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Which intervention is likely to lead to a 50% reduction in pain?

a. Cymbaltab. Gabapentinc. Cognitive Behavior Therapyd. Exercise & Physical Therapye. None of the above

Treatment of Fibromyalgia

Medication

Body

Mind

A multidisciplinary approach

Scascighini L, et al, Rheumatology 2008

How can we control pain?

Brain

Gabapentin (Neurontin)Pregabalin (Lyrica)

How can we control pain?

Brain

ElavilCymbaltaSavellaEffexor

Norepi-nephrine

Norepinephrine impedes pain signaling

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Cochrane Systematic Review 2013 of duloxetine & milnacipran for fibromyalgiaOutcome: Pain Reduction of 50%

– 28% of Rx group achieved 50% pain reduction– 19% of placebo achieved 50% pain reduction

NNTB = 11• Little improvement in fatigue• No significant change in quality of life

Häuser W, et al, Cochrane Database Syst Rev 2013

Treatment of Fibromyalgia SyndromeRecommended• Tricyclic antidepressants

– amitriptyline (Elavil) 25-100mg

qHS

• Dual-reuptake inhibitors (SNRIs)

– milnacipran (Savella)

– duloxetine (Cymbalta) 30-120

mg/d

– venlafaxine (Effexor)

• gabapentin (Neurontin)

• pregabalin (Lyrica)

• cyclobenzaprine (Flexeril)

• tramadol 200-300mg/d

Not Recommended• Growth Hormone

• Sodium oxybate

• Corticosteroids

• Opioids

Goldenberg DL et al, JAMA 2004, PMID 15547167MacFarlane GJ et al, Ann Rheum Dis 2016, PMID 27377815

Equivocal• NSAIDs

• Serotonin reuptake inhibitors

(SSRIs)

TIP: Go Slow

FDA approved for FMS


Medication

Body

Mind


Scascighini L, et al, Rheumatology 2008Häuser W, et al, Arthritis Care & Res 2008

I.

• Aerobic Exercise (Cochrane Review 2002) (Mannerkorpi K, Curr Opin Rheum 2005) Walking, elliptical machine, cycling, aquatic therapy/exercise

• Tai Chi (Wang C, et al, NEJM 2010, PMID 20818876 )

• Lifestyle physical activity (pedometer)

• Aquatic Exercise • Stretching & Physical Therapy• Weight Training (Resistance)

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II. Eat Healthy

A. Higher body mass index (BMI) is associated with fibromyalgia (Yunus MB, et al, Scand J Rheumatol 2002)

B. Weight loss in obese patients with Fibromyalgia is associated with improved function (Shapiro JR, et al, J Psychosom Res 2005) and quality of life (Senna MK, et al, Clin Rheumatol 2012)

There is no convincing data to indicate that one diet will help to reduce pain or improve energy levels

Holton KF, Kindler KL and Jones KD, Rheum Dis Clin North Am, 2009, PMID 19647151

III. Get A Good Night Sleep

• Sleep deprivation (of stage 4 or �delta-wave� sleep deprivation) is associated with development of widespread pain.

• Patients with Fibromyalgia commonly have disturbances in their sleep with periodic arousals (alpha wave intrusion)

• Improvement in restorative sleep through sleep hygiene tips is associated with improvement in pain

Moldofsky H, Rheum Dis Clin North Amer, 2009, PMID 19647142Orlandi AC, et al, Rev Bras Rheumatol, 2012, PMID 23090368

TIPS FOR A BETTER NIGHT'S SLEEP

DO:• Establish and maintain a regular bedtime and wake-up time every day.• Find the amount of sleep you need to feel consistently refreshed.• Create a comfortable, quiet, clean and dark environment for sleeping. Your bed

and the temperature of your bedroom should be comfortable.• Establish a regular pattern of relaxing behaviors for 10-60 minutes before bedtime.• Use the bed and bedroom for sleeping and sex only.• Exercise on a regular basis (but not too close to bedtime).

DON'T:• Don't nap during the day or evening.• Don't eat heavy meals or drink large amounts of liquid before bedtime.• Don't allow worrying, anger or frustration to keep you awake in bed.• Don't lie awake in bed for long periods of time. If not asleep within 20-30 minutes,

leave your bedroom and do something relaxing until you feel sleep again.• Don't allow your sleep to be disturbed by your phone, pets, family, etc.• Don't use alcohol, caffeine, or nicotine. Also please turn off TV, computer and cell

phone at least 30-60 minutes before bed. All of these may worsen sleep.

Courtesy of David Claman, MD, UCSF Sleep Disorders Center


Medication

Body

Mind


Scascighini L, et al, Rheumatology 2008Häuser W, et al, Arthritis Care & Res 2008

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What would life be like if you could influence the way you think and feel?

www.amysullivanmft.com/CognitiveBehavioralTherapy.htm

The Vicious Cycle of Chronic Pain

Emotional stress exacerbates pain and impairs functioning

Brain

Melzack & WallGate Control Theory

DepressionAnxiety

Catastrophizing(–)

Descending Signals Modulate Sensitivity To

Pain

Pain

Emotional stress exacerbates pain and impairs functioning

DepressionAnxiety

Catastrophizing

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Train The BrainCognitive Behavioral Therapy Goals:• Education about the nature of fibromyalgia• Realistic Goal Setting• Relaxation Training• Identification of dysfunction thought

patterns and Techniques to counteract negative automatic thoughts

• Strategize for maintenanceand management of flares

Bennett RM & Nelson D, Nat Clin Pract Rheumatol, 2006, PMID 16932733

Physical Response

Behavior

Thoughts Feelings

Does CBT Work?

Bennett RM & Nelson D, Nat Clin Pract Rheumatol, 2006, PMID 16932733

EULAR 2016 Fibromyalgia Recommendations

Weak Recommendation For• Cognitive Behavioral Therapy• Mindfulness / mind-body• Acupuncture• Meditative Movement• Hydrotherapy/spa

No Evidence for Efficacy• Trigger point injection

Strong Recommendation For• Aerobic & Strengthening Exercise

Weak Recommendation Against• Biofeedback• Hypnotherapy• Massage

Strong Recommendation Against

• Chiropractic therapy

MacFarlane GJ et al, Ann Rheum Dis 2016, PMID 27377815


Medicine

Mind

Body


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• Referral by Pain Medicine MD

or rheumatologist

• Admission criteria – chronic

pain that interferes with lives

and have interest/motivation

• Interdisciplinary evaluation:team then meets to decide if

patient will be “admitted”.

• Focus of program is on

“whole body” – away from

medical management (no Rx)

12 week program• Classes 3-4 hrs, 2-3 times/week

• Textbook/Manual

Team:• Nurse coordinator

• Psychologist

• Physical Therapist

• Nutritionist

• Pharmacist (works with PCP)

• Social Worker (case management)

Summary• Fibromyalgia represents a condition of

central sensitization to pain• Systemic disease should be excluded in

patients with fibromyalgia• Fibromyalgia is important to diagnose to

limit unnecessary medical utilization• Fibromyalgia is manageable with a

interdisciplinary approach– Non-pharmacologic– Pharmacologic

Thanks!

15 grossa fibromyalgia · 2018-04-06 · 4/5/18 4 tender point exam acr criteria: pain at 11 of 18...

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