(pbl) fibromyalgia: it's a pain in my neck!...(pbl) fibromyalgia: it’s a pain in my neck!...

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(PBL) Fibromyalgia: It’s a Pain in My Neck!

Sheryl M. Beard, MD, FAAFP

ACTIVITY DISCLAIMERThe material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.

The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.

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DISCLOSUREIt is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

Sheryl M. Beard, MD, FAAFPSenior Associate Program Director, Via Christi Family Medicine Residency, Wichita, Kansas; Clinical Assistant Professor, Department of Family and Community Medicine, University of Kansas (KU) School of Medicine–Wichita

Dr. Beard earned her medical degree from the KU School of Medicine–Wichita and completed her family medicine residency at the Via Christi Family Medicine Residency in Wichita. Following residency, she joined the U.S. Air Force and was stationed at McConnell Air Force Base in Wichita, Kansas. Prior to beginning her academic career, she served a brief tour in Iraq at Kirkuk Air Base in 2006 and spent a short time in private practice. Dr. Beard became a faculty member at Via Christi in 2008 and has been the Senior Associate Program Director since 2009.

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Learning Objectives1. Practice applying new knowledge and skills gained from

Fibromyalgia sessions, through collaborative learning with peers and expert faculty.

2. Identify strategies that foster optimal management of fibromyalgia, within the context of professional practice.

3. Formulate an action plan to implement practice changes, aimed at improving patient care.

Associated Session

• Fibromyalgia: It’s a Pain in My Neck!

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On your table

• ACR 2010 Criteria

• R-FIQ

CASE 1Fibromyalgia

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History of present illness• 37 yo F, established• F/U Depression• Better on Citalopram • Trouble sleeping-wants a med, Initiation and

maintaining sleep• Most days of the week, wakes unrefreshed• Missing work, not thinking clearly• Tried Coffee• 6 months

ROS

• headaches and dizziness, some intermittent chest pain, heartburn, abdominal bloating, bilateral LBP, and neck pain.

• She does not think that this is depression and wants to “get to the bottom of this”

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Decision Point

• What is your differential diagnosis of her symptoms?

• What testing do you order to help you differentiate the diagnosis?

Differential Diagnosis• Myofascial pain syndrome: tender muscles,

localized, axial• Chronic fatigue syndrome: subclinical

inflammation• Hypothyroid: fatigue, malaise, muscle

weakness• Inflammatory myopathies: PMR, other rheum,

statins

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Labs/ROS

• Her TSH is 2.07

• Hgb is 13.6

• ESR was 3

• CRP was <0.5.

Decision point

What are the diagnostic criteria for FM and does this patient meet them?

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History of present illness• 37 yo F, established• F/U Depression• Better on Citalopram • Trouble sleeping-wants a med, Initiation and

maintaining sleep• Most days of the week, wakes unrefreshed• Missing work, not thinking clearly• Tried Coffee• 6 months

ROS

• headaches and dizziness, some intermittent chest pain, heartburn, abdominal bloating, bilateral LBP, and neck pain.

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Decision Point

• You have diagnosed this patient with Fibromyalgia.

• What is the first step after the diagnosis is made?

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Education

• Make the dx

• Reduce visits, testing and rx

• Overall cost of care

• Reduce symptoms

Education cont.

• Patient-physician interaction, organized groups

• Set expectations

• Chronic illness

• Not eliminate

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Question

• What medication(s) would you like to start on this patient?

Medications

• Duloxetine*: pain, sleep, and fatigue• Amitriptyline: improves pain, sleep, and

fatigue• Cyclobenzaprine: improves pain and sleep• Pregabalin*: reduces pain

*FDA approved

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Question

• You decide to start her on cyclobenzaprine 10mg at bedtime. She returns in one month and is still having some pain.

• What medications have been shown to NOT benefit fibromyalgia patients?

• What else could you start?

Medications without benefit

• Opioids

• Melatonin

• Steroids

• NSAIDs

• Thyroid hormone

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CASE 2Fibromyalgia

History of present illness-March

• 43 yo female

• Neck pain for the last 4 months

• Intermittent pain in her chest, arms, legs, low back, shoulders and hips.

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ROS

• Ear pain and trouble hearing, throat pain, chest pain which is related to acid

• Diarrhea, constipation, bloating, nausea, she doesn’t eat much due to this

• She has urinary urgency and frequency without incontinence

ROS

• She has dizzy spells

• She has SOA, usually associated with nerves

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ROS

• Fatigue is mild, but able to do activities

• Cognition seems ok to her

• Wakes up maybe twice a week feeling unrefreshed

Are you able to make the diagnosis of FM based on tenderpoints?

• Why or why not?

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Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, 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.

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History of Present Illness• 43 yo female, established patient• Has a diagnosis of FM which you diagnosed about 4

months ago.• You have been seeing her every month since

diagnosis• Meds: duloxetine 20mg daily, amitriptyline 25mg at

bedtime• Her sleeping and fatigue are better. Her somatic

symptoms are improved. She is still having pain.

HPI continued

• Over the last month she has been using her friend’s hydrocodone for pain.

• She has been using about two per day and says that it helps her pain when she takes it, but notices if she doesn’t take it her pain seems worse.

• She would like to get a prescription today

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http://fiqrinfo.ipage.com/index.html

Decision Point

• Please turn to your partner and have a conversation to explain your view point

• (The goal of this exercise is to NOT prescribe the Norco to the patient)

• Include in your discussion other modalities or medications that the patient can try.

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CASE 3Fibromyalgia

History of present illness

• 56 yo male with a diagnosis of fibromyalgia that you made 6 months ago.

• He is trying to exercise 3 days a week but finds it hard

• He is a construction worker and is working 60 hour weeks in a physically active job

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HPI cont. • His main concerns are his back pain and

neck pain. • He is extremely fatigued and finds it hard to

work everyday• He wakes up unrefreshed everyday except

Sunday (he works 6 days a week)• His cognitive symptoms are pretty bad, he

forgets stuff in his job and is reprimanded

Medications

• Cyclobenzaprine 10mg at bedtime

• Duloxetine 20mg daily

• Pregabalin 450mg daily

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ROS

• He has some constipation and abdominal bloating

• Otherwise he denies insomnia, CP, SOA, anxiety, depression, or other kinds of pain

• His biggest concern is that his wife is really frustrated with him and he feels helpless at home

Decision Point / Question

• What are his WPI and SSS?

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Decision Point / Question

• What other thoughts do you have about the patient’s condition?

• What more can you do for him?

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Cognitive Behavioral Therapy

• Address maladaptive thoughts

• Stress reduction

• Catastrophizing/helplessness

• Balance meaningful work and leisure

Complementary and Alternative Therapies

• Massage, hydrotherapy, acupuncture, anthocyanidins, capsaicin, homeopathic remedies, S-adenosylmethionine

• nutritional, herbal, hormonal, hypnosis• Consider symptom diaries to assess benefit, consider cost

and medication interactions• Biofeedback and acupuncture supported by some• No randomized controlled trials: yoga, chiropractic, Tai chi,

massage, magnetic therapy, tender point injections• One pilot study of OMM with meds

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Resources for the patient

• familydoctor.org

• Arthritis Foundation

• National Fibromyalgia Association

CASE 4Fibromyalgia

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History of present Illness

• 62 yo female, new patient for back pain• She was working at a factory and hurt her back

lifting when it started years ago• She was told she has degenerative disc disease • She has been on disability for the pain for the last

10 years• She uses a cane to get around due to the pain

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Case 4

• PMH: IBS, chronic insomnia, migraines, anxiety, GERD and interstitial cystitis

• Medications: polyethylene glycol daily, zolpidem 10mg at bedtime, amitriptyline 25 mg bedtime, oxycodone 10mg qid, oxybutynin 5mg daily, meclizine 25mg qid prn, omeprazole 20mg, ondansetron 4mg qid prn, hydroxyzine 25mg qidprn, donepezil 5mg daily

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ROS• Denies weight loss or weight gain, denies fever,

denies night sweats.• Endorses urinary frequency, urgency, dysuria and

stress incontinence; headaches are daily and worse in the morning; also fatigue, itchy rashes, dizziness, nausea with occasional vomiting; daytime fatigue and insomnia if she doesn’t take her meds.

• She has really bad memory, has trouble concentrating;

FM questions

• Fatigue: severe, will fall asleep while at red lights

• Wakes up very tired and does not want to get out of bed

• Cognitive symptoms: has to write everything down and sometimes she forgets where she is going

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Decision Point / Question

• What thoughts do you have about this patient’s condition?

• Does she have fibromyalgia?

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Questions

Contact Information

Sheryl Beard

sheryl.beard@ascension.org