assessment and management of fibromyalgia · 2017-03-24 · – pain in multiple body regions –...

Assessment and Management of Fibromyalgia

FM-LYR-0023 - 1-0Approved

For your personal use. Not for further distribution

22

Managing FM can be like managing other chronic conditions2

Fibromyalgia (FM) is manageable in the primary care setting1,2

1. Brown TM, et al. Pain Week® ’10, the Annual Meeting of the ASPE; September 8-11, 2010; Las Vegas, NV.

2. McCarberg BH, et al, eds. Fibromyalgia. New York, NY: Informa Healthcare; 2009:152-158.

3. Arnold LM, et al. Mayo Clin Proc. 2011;86(5):457-464.

4. McCarberg BH. Am J Therap. 2012;19(5):357–368.

Program Discussion Points:

Screening and diagnostic tools are available to facilitate identification of potential FM patients3,4

Effective management integrates multimodalnonpharmacologic and pharmacologic approaches2



33

Goals of FM management:

• Result in fewer visits to the healthcare provider (HCP) and has the potential to save money for the primary care practice1

• Streamline follow-up visits2

• Empower patients to better manage their disease2,3

• Improve patients’ functional ability2,3

HCP=healthcare provider.




Potential Benefits of Appropriate Fibromyalgia Management



4

• Managing FM is similar to managing other complex chronic conditions (eg, asthma, diabetes)

• Key features of FM and other chronic conditions:

– There is no cure

– The condition is associated with comorbidities

– The condition affects many aspects of patients’ lives

– The condition requires patient self-management

• Key features of disease management:

– Pharmacologic therapy

– Nonpharmacologic therapy

– Patient self-management strategies and behaviors


Patients With FM Often Present and Seek Ongoing Care in the Primary Care Setting1



5

Set TreatmentGoals

• Assess symptom severity

• Prioritize functional areas and symptoms to be treated

Explain the Condition

• Integrate disease education with diagnosis

• Provide credible information sources

• Set expectations for patients


A Chronic Disease Management Framework for Managing FM1

Apply Multimodal Therapy

• Consider pharmacotherapy as appropriate

• Treat comorbid conditions

• Incorporate nonpharmacologictherapies

TrackProgress

• Measure progress againsttreatment goals

• Adjust treatment plan accordingly



6

• Diagnosis and subsequent education sets the stage for effective management

– Diagnosis provides validation, relief, and reassurance1

• May improve certain outcomes2

– Education provides empowerment, leading to betterself-management2,3

• Setting basic expectations for you and your patient can help establish a productive, more efficient partnership, and may minimize frustration4

1. Sim J, Madden S. Soc Sci Med. 2008;67(1):57-67.

2. Burckhardt CS. Disabil Rehabil. 2005;27(12):703-709.


4. Paiva ES, Jones KD. Best Pract Res Clin Rheumatol. 2010;24(3):341-352.

What Are the Benefits of Engaging the Patient to Understand FM?



7

Pain Pathophysiology



Chronic Pain Conditions Can Be Classified Based on Type of Pain Pathophysiology

Three Main Types of Pain Pathophysiology:

Phillips K, Clauw DF. Best Pract Res Clin Rheumatol. 2011;25(2):141-154.

Nociceptive

Pain

Neuropathic

Pain

Sensory

Hypersensitivity

Pain related to

damage of somatic or

visceral tissue, due to

trauma or inflammation

EXAMPLES:

rheumatoid arthritis,

osteoarthritis, gout

Pain related to

damage of peripheral

or central nerves

EXAMPLES:

painful diabetic peripheral

neuropathy (pDPN),

postherpetic neuralgia

Pain without identifiable

nerve or tissue damage;

thought to result from persistent

neuronal dysregulation

EXAMPLES:

fibromyalgia



• Patients with FM often exhibit1,2:

– Pain in multiple body regions

– Multiple somatic symptoms

• eg, fatigue, memory difficulties, sleep problems, mood disturbance

– Higher current and lifetime history of chronic pain inseveral body regions

– Family history of chronic pain

– More sensitive to other sensory stimuli

• eg, bright light, loud noises, odors

– Pain may be triggered or exacerbated by stressors

– Generally normal physical examination except for diffuse tenderness and nonspecific neurologic signs


2. Staud R, et al. Arthritis Research & Therapy. 2006;8(3):208.

FM Is the Prototype"Sensory Hypersensitivity" Condition

9



Identifying the FM Patient

10



1111

1. Leavitt F, et al. Arthritis Rheum. 1986;29(6):775-781.

2. Staud R. Arthritis Res Ther. 2006;8(3):208-214.

3. Wolfe F, et al. Arthritis Rheum. 1995;38(1):19-28.

4. Yunus MB. Semin Arthritis Rheum. 2008;37(6):339-352.

5. Vadivelu N, et al, eds. Essentials of Pain Management. New York, NY: Springer Science; 2011:57-74.

Chronic Widespread Pain1

• CORE criteria of FM

• Pain is in all 4 quadrants of the body ≥3 months

• Patient descriptors of pain include:

• Aching, exhausting, nagging, and hurting

Tenderness2,3

• Sensitivity to pressure stimuli

• Tender point exam given to assess tenderness

• Features of FM

• Hyperalgesia

• Allodynia

Other Symptoms3,4,5

• Fatigue3

• Pain-related conditions/symptoms

• Chronic headaches/migraines

• Subjective morning stiffness

• Neurologic symptoms

• Subjective, tingling in extremities

• Sleep disturbances

• Non-restorative sleep, RLS

Other

Symptoms

Clinical Features of FM



• Other Pain States1

– IBS

– Headaches/migraines

• Infection and Inflammation2

– Crohn’s disease

• Psychological Disorders1

– Depression

– Anxiety disorders

• Rheumatic Disorders3

– Rheumatoid arthritis

– Systemic lupus erythematosus

Consider FM in patients with chronic conditions who also suffer from chronic widespread pain, fatigue, and sleep disturbances4

1. Chakrabarty S, Zoorob R. Am Fam Physician. 2007; 76(2):247-254.

2. Hershfield NB. Can J Gastroenterol. 2005; 19(4):231-234.

3. Weir PT, et al. J Clin Rheumatol. 2006; 12(3):124-128.4. Mease P. J Rheumatol. 2005; 32 (suppl 75):6-21.

FM Often Seen With Other Chronic Medical Conditions

12



• Proper screening is a critical first step to managing fibromyalgia1

– Several validated screening tools include:

• FibroDetect2

• Fibromyalgia Survey Questionnaire (FSQ)3– ACR 2010 modified for patient report

• London FM Epidemiology Study Screening Questionnaire (LFES-SQ)4

These screening tools are provided to inform choice and their use is not prescriptive. They are not a clinical diagnosis, nor designed to

take the place of a physician consultation.3,4


2. Data on file. Pfizer Inc. FibroDetect; 2011.

3. Wolfe, et al. J Rheumatol. 2011;38(6):1113-1122.

4. White KP, et al. J Rheumatol.1999;26(4):880-884.

Screening Tools for Identifying Potential FM Patients

13



14

• The 1990 ACR criteria for the classification of FM include:

– Chronic widespread pain (core feature)for ≥3 months

• Pain above and below the waist

• Pain on left and right sides of body

• Pain in the axial skeleton

– Pain at ≥11 of 18 tender points when palpated with 4 kg/cm2 of digital pressure

Diagram Showing 18 Tender Points

1. Wolfe F, et al. Arthritis Rheum. 1990;33(2):160-172.

The 1990 ACR criteria are1:

• Sensitive (88.4%) – proportion of patients correctly identified as having the condition

• Specific (81.1%) – proportion of patients correctly identified as not having the condition

1990 American College of Rheumatology (ACR) Classification Criteria for Fibromyalgia1



15

1. Widespread pain index (WPI)

– The number of painful body regions

2. Symptom severity (SS) scale that assesses the severity of:

– Fatigue

– Waking unrefreshed

– Cognitive symptoms

– Quantifies the occurrence of other somatic symptoms

3. Pain and symptoms present for 3 months or longer

According to the 2010 ACR preliminary criteria, FM can be diagnosed based on a HCP-administered questionnaire:

The 2010 preliminary ACR criteria1:

• Not meant to replace current ACR classification criteria, but to offer an alternative method of FM diagnosis

• Accurately identified 88% of the same FM cases initially identified by the 1990 ACR classification criteria

1. Wolfe F, et al. Arthritis Care Res. 2010;62(5):600-610.

2010 ACR Preliminary DiagnosticCriteria for FM1



16

Parameter

1990 Classification

Criteria1

2010 Preliminary

Diagnostic Criteria2

Consider pain to be a

central symptom of FM

Yes YesAlthough definition of FM is broadened to

include other symptoms

Include assessment of

symptoms other than

pain in diagnosis

No YesSymptom Severity Scale assesses somatic

symptoms such as fatigue, sleep, cognition

Specify use of a tender

point exam

Yes NoHowever, a physical exam is

recommended for all patients

1. Wolfe F, et al. Arthritis Rheum.1990;33(2):160-172.

2. Wolfe F, et al. Arthritis Care Res. 2010; 62(5):600-610.

• A May 2010 article in Arthritis Care & Research proposed new criteria for the diagnosis of FM2

• Among the objectives of the study was to identify non-tender point diagnostic criteria2

• These criteria are not intended to replace the 1990 ACR Classification Criteria, but to represent an

alternative method of diagnosis2

ACR: Two Types of Classification and Preliminary Diagnosis Criteria for FM



17

Managing the

Fibromyalgia Patient



18

Manage Expectations Upfront

Expectations Regardingthe Course of Disease

Expectations Regardingthe Treatment Process

• Goal of treatment = improvement in function and symptoms (not cure)1

• FM is dynamic, with potentialfor flare-ups and setbacks2

• Process of care utilizes a collaborative healthcare team2

– The patient is a critical member of this team

• Other expectations may include:

– Frequency of office visits

– How much time will be available at each visit

– Prioritization of goals

– Position on disability

1. McCarberg BH, et al, eds. Fibromyalgia. New York, NY: Informa Healthcare; 2009:152-158.2. Arnold LM, et al. Mayo Clin Proc. 2012;87(5):488-496.



19

What Are the Benefits of Setting Meaningful Treatment Goals?

• Goal setting helps focus and streamline follow-up visits1,2

– Provides a plan of action

– Focuses the patient on targeted functional outcomes

– Provides structure for follow-up visits

• Appropriate goals for FM management2,3

– Specific

– Realistic

– Measurable

– Reflect the patient’s priorities

– Have a target date for completion

– Aim for improved functionality in key domains

• Assess potential barriers and help the patientproblem-solve to minimize them4




4. Filoramo MA. Pain Manag Nurs. 2007;8(2):96-101.



20

Tools to Document Baseline Status and Manage Treatment Progress

1. Bennett RM, et al. Arthritis Res Ther. 2009;11(4):R120.

2. Boomershine CS, Crofford LJ. Nat Rev Rheumatol. 2009;5(4):191-199.

3. Wolfe F, et al. Arthritis Care Res. 2010;62(5):600-610.

4. Johnson C. J Chiropr Med. 2005;4(1):43-44.

Tool Description

Revised Fibromyalgia Impact Questionnaire (FIQR)1

• 21 questions to assess functional status and symptoms over

previous 7 days

• Can be used to track specific functional domains or symptoms at initial

assessment and at each visit thereafter

• Physician or office staff administer, taking <2 minutes

Modified Visual Analog Scale of the Fibromyalgia Impact Questionnaire (mVASFIQ)2

• Quantifies the severity of individual FM symptoms

• Provides the basis for initial treatment plan

• Identifies most bothersome symptoms

• Patients can complete, taking <2 minutes

ACR 2010 Preliminary Diagnostic Criteria3

• Comprises widespread pain index (WPI) and

2 symptom severity (SS) scales

• Provides alternative FM diagnostic criteria to ACR Tender Point Exam;

SS portion may be used to track progress over time

• Valid, reliable diagnostic tool; not yet validated for tracking progress

• Physician or office staff administer

Numeric rating scale (NRS)4

• Can be used to assess functional impact/symptom severity

• Values directly entered into patient’s chart or electronic medical record

• Patient can complete, taking <2 minutes



21

The Multimodal Approach



22

Sleep disturbance1

Chronic widespread pain and tenderness1


2. Mease P. J Rheumatol. 2005;32(suppl 75):6-21.

Mood disturbance1

Morning stiffness1

Fatigue1

Why Apply Multimodal Therapy?

No single treatment approach for FM

targets every symptom; a multimodal treatment approach can enhance

care and maximize results2



23

Be proactive and

prepared:

know your patient,

team, and community1


2. Goldenberg DL. Clinical Management of Fibromyalgia. 1st ed. West Islip, NY: Professional Communications, Inc; 2009.

3. Jones KD, et al. Rheum Dis Clin North Am. 2009;35(2):373-391.4. Mease P. J Rheumatol. 2005;32(suppl 75):6-21

Key Facets of the Multimodal Treatment Approach

Maximize the

effectiveness of

pharmacotherapy2

Promote

nonpharmacologic

therapies for FM

management1

Offer strategies

to improve adherence

to physical activity3

Provide sleep

hygiene advice4



24

Management of FM: A Multidisciplinary Approach

Pharmacotherapy1

Cognitive behavioral

Therapy4

• Biofeedback

• Communication

skills training

Patient education2,3

• Diet/nutrition

• Sleep hygiene

• Management of expectations

• Journaling

Exercise1

• Cardiovascular exercise

• Strength training

• Stretching

Alternative/complementary1

• Massage

• Acupuncture

• Chiropractic

Treatment

Approaches

1. Goldenberg DL, et al. JAMA. 2004;292(19):2388-2395. 2. Arnold LM, et al. Mayo Clin Proc. 2012;87(5):488-496.

3. American Chronic Pain Association. ACPA Fibro Log. 2009.

4. Williams DA, et al. In: McCarberg BH, Clauw DJ, eds. Fibromyalgia. New York, NY: Informa Healthcare; 2009.



Pharmacotherapy

General Strategies When Initiating Medication Therapy

• Evaluate previous or existing pharmacological/nonpharmacologicaltherapies:

– Determine if previous drug treatment trials were adequate (duration and dose)

– Consider potential drug interactions

• Educate patients regarding rationale for medication therapy1

• To help manage medication intolerance2:

– Start with one drug at a time

– Initiate at lower dose and titrate up

– Discuss strategies for managing side effects

• If more than one medication is needed, be aware of potentialdrug interactions2


2. Boomershine CS, et al. Nat Rev Rheum. 2009;5(4):191-199. 25



26

Integrate Patient Education Into Practice

Provide patients with educational literature1

Provide supplemental education• Patient advocacy organizations

• Group education programs

• Suggested reading/resources

• Use of supplemental support staff

Have patients do theirown research andbring in questions

1. D’Arcy Y, et al. J Nurse Pract. 2005;1(4):218-225.

Review educational messaging with patients

Plan and makeoptimal use of existing

resources



Patient Education

• Diet/Nutrition1,2

– Foods to recommend: fruits and vegetables, possibly omega-3 containing fish, multi-vitamins

• Sleep hygiene3,4

– 76% of FM patients report sleep problems

– Counsel patients to:

• Keep a regular sleep schedule and reserve bed for sleeping

• Keep bedroom quiet, dark, and at a comfortable temperature

1. Arranz LI, et al. Rheumatol Int. 2010;30(11):1417-1427.

2. Ko GD. Clin J Pain. 2010; 26(2):168-172.

3. Harding SM. Am J Med Sci. 1998;315(6):367-376.

4. Williams DA, et al. In: McCarberg BH, Clauw DJ, eds. Fibromyalgia. New York, NY: Informa Healthcare; 2009:136-151. 27



• Journaling1

– Keeping track of stress, activities, sleep, weather, etc, can help patients recognize and understand pain triggers and other symptoms

– This may empower them to control/minimize their pain

• Management of patient expectations2,3

– Goal setting

– Coping strategies to get through flares

– Myths and misconceptions discussion

1. American Chronic Pain Association. ACPA Fibro Log. 2009.



Patient Education

28



Exercise Recommendations

• Studies have shown that physical fitness reduces FM symptoms through1:

– Decreased pain sensitivity

– Increased tolerance to pain

– Muscles that are less susceptible to damage

• Appropriate exercises1,2:

– Low impact activity

• Eg, walking, water running, bicycling

– Strength training

• Avoid eccentric muscle contractions

– Stretching

• Stretch to feel tightness but not pain

• Hold for 20 to 30 seconds


2. Busch AJ, et al. J Rheumatol. 2008;35(6):1130-1144 29



Alternative/Complementary

• Massage1,2

– Myofascial release, connective tissue, and manual lymph drainage massages have all shown to significantly decrease pain scores in FM patients

– All massages should be conducted PAIN FREE!!

– Benefits are short-lived; for maximum benefit, have 1-2 massage sessions/week

1. Kalichman L. Rheumatol Int. 2010;30(9):1151-1157.

2. Castro-Sánchez AM, et al. Evid Based Complement Alternat Med. 2011:561753. 30



• Scientific evidence suggests that chiropractic therapies do not significantly improve pain control in FM patients with mixed findings for acupuncture1,2

– Acupuncture and chiropractic therapies are not recommended for FM patients

1. Langhorst J, et al. Rheumatology. 2010;49(4):778-788.

2. Terry R, et al. Clin Rheumatol. 2012;31(1):55-66.

Alternative/Complementary

31



Cognitive Behavioral Therapy (CBT)1

• Focuses on two treatment aspects:

– “Increasing a patient’s sense of personal control over their pain

– Decreasing dysfunctional thought patterns, such as those involved in ‘catastrophizing’ (ie, exaggerating the significance of a negative event) about the pain and its effects and associated behavioral improvements in function”

• Studies have shown CBT significantly improves self-efficacy, coping strategies, and physical function in FM patients

• It may be considered as an adjunctive therapy in the management of FM patients who are emotionally distressed

1. Bennett R. Nat Clin Pract Rheumatol. 2006;2(8):416-424. 32



Cognitive Behavioral Therapy (CBT)1

Key elements for FM

• Educate patients about the pathophysiology of FM (eg, sensory hypersensitivity) and interaction between emotions, behavior, and cognition in coping and functioning

• Realistic goal setting for work, social, and family interactions

• Relaxation training

• Appropriate behavioral pacing of activities (not over- or under-do)

• Identification of dysfunctional thought patterns and techniques to counter negative automatic thoughts

• Communication skills training

• Strategies for relapse prevention and for managing painful flare-ups

1. Bennett R. Nat Clin Pract Rheumatol. 2006;2(8):416-424. 33



34

Follow-up



35

Function

Symptom

Severity

Time

Improvement

Improvement

The course of FM is often not straightforward1; tracking progress helps keep patients from getting discouraged and

helps monitor the effectiveness of the treatment plan2

What Is the Advantage of Tracking Patient Progress?

1. Harris RE et al. Arthritis Rheum. 2005;52(11):3670-3674.




36

Follow-up Visits Should Be Structured to Track and Promote Progress

• Structure office visits to focus on desired functional outcomes and monitoring symptoms in key domains1

• Ask patients about their physical activity levels and how much they use self-management techniques1

• Use each visit to assess the progress of the patient’s goals to cover important education and self-help topics2

• Encourage patients to take ownership for managing FM by giving simple “homework”





Treatment Adherence in Fibromyalgia

• A prospective study of 142 women with FM showed that adherence to both medications and general treatment (eg, exercise) was poor1

— About 50% of patients were non-adherent to medicines

• Another prospective study of 127 women with FM assessed factors affecting medication non-adherence2

—About 1/3 of patients were intentionally and unintentionallynon-adherent

• Patients diagnosed with FM are often on multiple medications, which may contribute to poor adherence1,2

—70% to 80% are on 3 or more medicines while 9% to 20% are on over 8 medicines

1. Dobkin PL, et al. Clin J Pain. 2006;22(3):286-294.

2. Sewitch MJ, et al. Rheumatology. 2004;43(5):648-654. 37



Predictors of Adherence

• A composite of barriers to treatment such as time, effort, stress, social support, cost, pain, and self-motivation contribute to overall treatment adherence1,2

• A greater sense of self-efficacy (self-confidence) is associated with increased levels of adherence2

• Lower discordance between patient and physician perception of disease and treatment is associated with increased levels of adherence1

• A multimodal approach to treatment results in increased treatment adherence and positive outcomes2


2. Dobkin PL, et al. J Rheumatol. 2008;35(11):2255-2264. 38



Enhancing Treatment Adherence in Patients With FM

• Ensure patient has a thorough understanding of FM and is involved in treatment decisions1

• Educate patient on the role of treatment and set realistic expectations and timelines with regard to treatment outcomes2

• Utilize a multimodal approach to treatment3

– For example, nursing, physiotherapy, occupational therapy, and psychology have been used to provide disease education, coping skills, stress management skills, and fitness training3


2. Sewitch MJ, et al. Rheumatology. 2004;43(5):648-654.




Enhancing Treatment Adherence in Patients With FM

• Individualize treatment regimens (eg, custom tailor exercise programs)1

• Simplify medication dosing regimens2

• Provide written and verbal instructions and use reminder aids2

• Identify, discuss, and reduce potential barriers to treatment such as time constraints, psychological stress, lack of social support, cost, and low motivation3

• Seek to instill a sense of patient self-efficacy (self-confidence)3

1. Rooks D. Curr Opin Rheumatol. 2007;19(5):111-117.

2. Haynes RB, et al. JAMA. 2002;288(22):2880-2883..




41





Summary

PBP665503-01 © 2014 Pfizer Inc. All rights reserved. June 2014

Managing FM can be like managing other chronic conditions2

FM is manageable in the primary care setting1,2

Screening and diagnostic tools are available to facilitate identification of potential FM patients3,4

Effective management integrates multimodalnonpharmacologic and pharmacologic approaches2



assessment and management of fibromyalgia · 2017-03-24 · – pain in multiple body regions –...

Documents