FibromyalgiaFibromyalgia

Erin FouchErin Fouch

October 31, 2005October 31, 2005

Diagnostic CriteriaDiagnostic Criteria

American College of Rheumatology American College of Rheumatology Diagnostic Criteria (1990)Diagnostic Criteria (1990)11

1.1. Pain in all 4 quadrants of body and Pain in all 4 quadrants of body and axial skeleton.axial skeleton.

2.2. Tenderness in 11/18 previously Tenderness in 11/18 previously defined “tender points.”defined “tender points.”

Fulfillment of both criteria results Fulfillment of both criteria results in approximately 80% sensitivity in approximately 80% sensitivity and specificity for diagnosis.and specificity for diagnosis.

Tender PointsTender Points

Appropriate pressure is 4 kg/cm– Appropriate pressure is 4 kg/cm– approximately enough to turn the approximately enough to turn the examiner’s nailbed white.examiner’s nailbed white.

http://fibromyalgia.ncf.ca22

Case PresentationCase Presentation

A 35-year-old woman presents to your A 35-year-old woman presents to your office complaining of diffuse “joint pain” office complaining of diffuse “joint pain” for the past several months. On further for the past several months. On further questioning, she states that the pain is all questioning, she states that the pain is all over her body, in her muscles and joints. over her body, in her muscles and joints. It is there throughout the day, and It is there throughout the day, and worsened by exercise. worsened by exercise.

She gets minimal relief with She gets minimal relief with acetaminophen. acetaminophen.

EpidemiologyEpidemiology

Most common cause of musculoskeletal Most common cause of musculoskeletal pain in women aged 20-55pain in women aged 20-55

Prevalence ~3.5% in women, ~0.5% in Prevalence ~3.5% in women, ~0.5% in menmen

Some familial aggregationSome familial aggregation 50% of cases preceded by a stressor 50% of cases preceded by a stressor

(injury, viral illness– e.g. Lyme disease)(injury, viral illness– e.g. Lyme disease) Patients with FM have a 50% lifetime Patients with FM have a 50% lifetime

hx of depression, although only 25% hx of depression, although only 25% meet criteria at the time of diagnosismeet criteria at the time of diagnosis

ROSROS: Positive for daytime fatigue, : Positive for daytime fatigue, constipation, and occasional palpitations.constipation, and occasional palpitations.

PMH:PMH: None. None.

Meds:Meds: Acetaminophen prn Acetaminophen prn

FHFH: Mother has RA, sister has : Mother has RA, sister has hypothyroidism.hypothyroidism.

Case Cont’dCase Cont’d

Case Cont’dCase Cont’d

Physical ExamPhysical Exam T 36.5; BP 125/78; P 65 T 36.5; BP 125/78; P 65Genl: WNWD, thin woman, NAD, slightly flat Genl: WNWD, thin woman, NAD, slightly flat

affectaffectNeck: No thyromegaly, no LAD.Neck: No thyromegaly, no LAD.CV: RRR, no murmurCV: RRR, no murmurLungs: ClearLungs: ClearAbd: Soft, slightly tender throughout, NDAbd: Soft, slightly tender throughout, NDMSK: No joint swelling nor erythema. Normal MSK: No joint swelling nor erythema. Normal

range of motion in all joints. 8/18 tender range of motion in all joints. 8/18 tender points positivepoints positive

Skin: No rashes.Skin: No rashes.

Case Cont’dCase Cont’d

What is your differential diagnosis?What is your differential diagnosis? What further work-up does she What further work-up does she

need?need?

Differential DiagnosisDifferential Diagnosis

1.1. Polyarticular arthritisPolyarticular arthritis Rheumatoid arthritisRheumatoid arthritis SLESLE Polymyalgia rheumaticaPolymyalgia rheumatica

2.2. Endocrine disordersEndocrine disorders HypothyroidismHypothyroidism Hyperparathyroidism (hypercalcemia)Hyperparathyroidism (hypercalcemia)

3.3. MyopathiesMyopathies PolymyositisPolymyositis RhabdomyolysisRhabdomyolysis

Differential Diagnosis Differential Diagnosis

4.4. NeuropathiesNeuropathies

5.5. DepressionDepression

6.6. Chronic fatigue syndromeChronic fatigue syndrome

7.7. Myofascial pain syndromeMyofascial pain syndrome

8.8. AnemiaAnemia

Case Cont’dCase Cont’d

What further work-up does our What further work-up does our patient need?patient need?

Diagnostic EvaluationDiagnostic Evaluation

Careful history and physicalCareful history and physical This is the most important component This is the most important component

and often leads to the diagnosisand often leads to the diagnosis Labs to evaluate for:Labs to evaluate for:

Causes of fatigue (CBC, TSH)Causes of fatigue (CBC, TSH) Causes of myalgias (CK, ? Chemistry Causes of myalgias (CK, ? Chemistry

panel)panel) Evidence of inflammation (ESR)Evidence of inflammation (ESR)

Diagnostic EvaluationDiagnostic Evaluation

Generally NOT recommendedGenerally NOT recommended ANA, Rheumatoid factorANA, Rheumatoid factor

Diagnostic EvaluationDiagnostic EvaluationDifferentiating FM from other Differentiating FM from other disordersdisordersRARA Elevated RF, ? ESR, joint Elevated RF, ? ESR, joint

swelling/deformity, swelling/deformity, systemic symptomssystemic symptoms

SLESLE Systemic symptoms, ESRSystemic symptoms, ESR

PMRPMR Stiffness, ESR. Usually Stiffness, ESR. Usually older patients.older patients.

Myositis/RhabdoMyositis/Rhabdo Weakness, elevated CKWeakness, elevated CK

DepressionDepression Tender points negativeTender points negative

Myofascial pain Myofascial pain syndromesyndrome

Localized painLocalized pain

Chronic fatigue Chronic fatigue syndromesyndrome

Fatigue > painFatigue > pain

Case Cont’dCase Cont’d

Your patient’s CBC, Chem 7, TSH, and Your patient’s CBC, Chem 7, TSH, and ESR are normal. She returns to clinic ESR are normal. She returns to clinic for a follow-up visit to review her labs. for a follow-up visit to review her labs. You are about to begin explaining her You are about to begin explaining her diagnosis of fibromyalgia when she diagnosis of fibromyalgia when she tells you that she forgot to mention last tells you that she forgot to mention last time that she has joint swelling in her time that she has joint swelling in her hands, wrists, knees, and ankles, as hands, wrists, knees, and ankles, as well as mild shortness of breath with well as mild shortness of breath with exertion. exertion.

Case Cont’dCase Cont’d

Concerned, you repeat an exam. She Concerned, you repeat an exam. She states that the joint swelling is states that the joint swelling is present now, but you see no present now, but you see no synovitis. Lungs are clear, but you synovitis. Lungs are clear, but you remain worried that you have made remain worried that you have made the wrong diagnosis.the wrong diagnosis.

Overlapping Syndromes and Overlapping Syndromes and SymptomsSymptomsCommon ComorbiditiesCommon Comorbidities::

Rheumatoid Rheumatoid arthritis (12%)arthritis (12%)

SLESLE Hepatitis CHepatitis C Myofascial pain Myofascial pain

syndromesyndrome TMJTMJ IBSIBS

Osteoarthritis (7%)Osteoarthritis (7%) Depression Depression Migraine Migraine

headachesheadaches OSAOSA Restless legsRestless legs

Overlapping Syndromes and Overlapping Syndromes and SymptomsSymptomsCommon Common

symptomssymptoms FatigueFatigue Subjective Subjective

joint/muscle joint/muscle swelling swelling

Difficulty sleepingDifficulty sleeping Night sweatsNight sweats DyspneaDyspnea

PalpitationsPalpitations Pelvic painPelvic pain DysmenorrheaDysmenorrhea Non-cardiac chest Non-cardiac chest

painpain Diarrhea/Diarrhea/

constipation (IBS)constipation (IBS)

In young, otherwise healthy patients In young, otherwise healthy patients with a variety of diffuse complaints with a variety of diffuse complaints and a relatively straightforward and a relatively straightforward diagnosis of fibromyalgia, it is diagnosis of fibromyalgia, it is reasonable to monitor most reasonable to monitor most symptoms rather than investigate symptoms rather than investigate exhaustively.exhaustively.

Case Cont’dCase Cont’d

Case Cont’dCase Cont’d

You inform your patient that you believe she You inform your patient that you believe she has fibromyalgia. She becomes tearful and has fibromyalgia. She becomes tearful and says that she has read about this disease on says that she has read about this disease on the internet and it is clearly not a real illness. the internet and it is clearly not a real illness. Furthermore, she has read that fibromyalgia Furthermore, she has read that fibromyalgia is strongly associated with depression, and is strongly associated with depression, and she adamantly states that she is not she adamantly states that she is not depressed. She would love to get back to the depressed. She would love to get back to the activities she used to enjoy, if only she did not activities she used to enjoy, if only she did not have so much pain. She demands a referral to have so much pain. She demands a referral to a rheumatologist for further evaluation. a rheumatologist for further evaluation.

Depression and Depression and FibromyalgiaFibromyalgia Of patients with fibromyalgia, 50% have had Of patients with fibromyalgia, 50% have had

or will have depression at some time in their or will have depression at some time in their liveslives

25% of FM patients will meet criteria for 25% of FM patients will meet criteria for depression at the time of diagnosisdepression at the time of diagnosis

This means that 75% of patients will NOT be This means that 75% of patients will NOT be depressed when diagnosed with fibromyalgiadepressed when diagnosed with fibromyalgia

Disturbed sleep and fatigue could be Disturbed sleep and fatigue could be symptoms of either illnesssymptoms of either illness

Some antidepressants have been used to Some antidepressants have been used to treat fibromyalgiatreat fibromyalgia

Case Cont’dCase Cont’d

Your patient accepts that you are not Your patient accepts that you are not diagnosing her with depression, and diagnosing her with depression, and asks you what treatments are asks you what treatments are available. Her friend is on oxycodone available. Her friend is on oxycodone for her chronic pain, and your for her chronic pain, and your patient would like a prescription for patient would like a prescription for this as it is the only thing that has this as it is the only thing that has helped her friend.helped her friend.

Treatment of Treatment of FibromyalgiaFibromyalgiaPatient EducationPatient Education Patients generally have fewer symptoms Patients generally have fewer symptoms

if they are told their diagnosisif they are told their diagnosis Group sessions (6-17 sessions), lectures, Group sessions (6-17 sessions), lectures,

written materials seem to improve written materials seem to improve quality-of-life, pain, sleep, energy levelsquality-of-life, pain, sleep, energy levels33; ; improvements lasted 3-12 monthsimprovements lasted 3-12 months

One 1.5-day educational session One 1.5-day educational session improved energy, stiffness, pain severity, improved energy, stiffness, pain severity, and depressionand depression44

Treatment of Treatment of FibromyalgiaFibromyalgiaAerobic ExerciseAerobic Exercise A 2002 Cochrane reviewA 2002 Cochrane review55 found that aerobic found that aerobic

exercise is an effective treatment for exercise is an effective treatment for fibromyalgia. Patients had improved pain fibromyalgia. Patients had improved pain thresholds, decreased pain, and improved thresholds, decreased pain, and improved aerobic exercise capacity.aerobic exercise capacity.

Strengthening exercises appear to provide Strengthening exercises appear to provide some improvement.some improvement.

Both aerobic exercise and strengthening Both aerobic exercise and strengthening exercises appear to be more effective than exercises appear to be more effective than stretching.stretching.

Treatment of Treatment of FibromyalgiaFibromyalgiaAerobic ExerciseAerobic Exercise Patients should be counseled to start Patients should be counseled to start

slowly– they will often feel worse if slowly– they will often feel worse if they embark on a strenuous exercise they embark on a strenuous exercise regimen quickly.regimen quickly.

Swimming and water sports appear Swimming and water sports appear to be well-tolerated.to be well-tolerated.

Treatment of Treatment of FibromyalgiaFibromyalgiaCognitive-Behavioral TherapyCognitive-Behavioral Therapy A review by Goldenberg et al A review by Goldenberg et al

concluded that patients receiving concluded that patients receiving CBT had decreased pain and CBT had decreased pain and improved function over 6-30 month improved function over 6-30 month follow-up.follow-up.33

Treatment of Treatment of FibromyalgiaFibromyalgiaMedications-- SSRIsMedications-- SSRIs

Variable results with fluoxetine, but it Variable results with fluoxetine, but it appears to improve pain when appears to improve pain when providers are allowed to escalate the providers are allowed to escalate the dose to up to 80 mg/daydose to up to 80 mg/day66

No improvement found with a fixed No improvement found with a fixed dose of fluoxetine (20 mg/day)dose of fluoxetine (20 mg/day)77

Pain appears to improve regardless of Pain appears to improve regardless of improvement in moodimprovement in mood

Treatment of Treatment of FibromyalgiaFibromyalgiaMedications– Tricyclic antidepressantsMedications– Tricyclic antidepressants Amitriptyline 25-50 mg qhs effective in Amitriptyline 25-50 mg qhs effective in

multiple RCTsmultiple RCTs Cyclobenzaprine (Flexeril) 10-40 mg Cyclobenzaprine (Flexeril) 10-40 mg

qhs also effective in multiple RCTsqhs also effective in multiple RCTs Patients should be allowed to Patients should be allowed to

determine the maximum effective dosedetermine the maximum effective dose Side effects limit use and dose Side effects limit use and dose

escalationescalation

Treatment of Treatment of FibromyalgiaFibromyalgiaMedications-- OtherMedications-- Other

Pregabalin (a new anticonvulsant) was Pregabalin (a new anticonvulsant) was found to decrease severity of pain in one found to decrease severity of pain in one RCTRCT88

Combination of carisoprodol (Soma), Combination of carisoprodol (Soma), Tylenol, and caffeine improved sleep, pain, Tylenol, and caffeine improved sleep, pain, and pain threshold more than placeboand pain threshold more than placebo99

Tramadol 75 mg q 6 hrs appears to Tramadol 75 mg q 6 hrs appears to improve pain; effect may be greater with improve pain; effect may be greater with Acetaminophen 650 mg q 6 hrsAcetaminophen 650 mg q 6 hrs1010

Treatment of FibromyalgiaTreatment of Fibromyalgia

Medications with “strong” or Medications with “strong” or “moderate” evidence for efficacy“moderate” evidence for efficacy33

AmitriptylineAmitriptyline CyclobenzaprineCyclobenzaprine TramadolTramadol FluoxetineFluoxetine

VenlafaxineVenlafaxine DuloxetineDuloxetine PregabalinPregabalin

Treatment of Treatment of FibromyalgiaFibromyalgiaIneffective Ineffective

MedicationsMedications

CorticosteroidsCorticosteroids OpioidsOpioids NSAIDsNSAIDs BenzodiazepinesBenzodiazepines GuaifenesinGuaifenesin

LevothyroxineLevothyroxine CacitoninCacitonin MelatoninMelatonin MagnesiumMagnesium

Case ContinuedCase Continued

You work out a treatment plan with You work out a treatment plan with your patient. She agrees to exercise your patient. She agrees to exercise daily, and try Amitriptyline at night. daily, and try Amitriptyline at night. She asks you if she should take time She asks you if she should take time off work or expect to be debilitated off work or expect to be debilitated from her illness.from her illness.

Natural history of Natural history of fibromyalgiafibromyalgia Patients should be reassured that Patients should be reassured that

fibromyalgia is not life-threatening. fibromyalgia is not life-threatening. Most patients have waxing and Most patients have waxing and

waning symptoms throughout life, but waning symptoms throughout life, but generally remain very functional. generally remain very functional.

Most patients report that they are Most patients report that they are able to work full-time.able to work full-time.

Patients should be encouraged to take Patients should be encouraged to take an active role in disease management.an active role in disease management.

Fibromyalgia: take-home Fibromyalgia: take-home pointspoints Defined as diffuse pain and 11/18 Defined as diffuse pain and 11/18

positive tender points, though some positive tender points, though some patients will not strictly meet criteriapatients will not strictly meet criteria

Check CBC, ESR, TSH, CK depending Check CBC, ESR, TSH, CK depending on symptomson symptoms

Most effective treatments: Patient Most effective treatments: Patient education; aerobic exercise; CBT; TCAseducation; aerobic exercise; CBT; TCAs

Most patients will continue to have Most patients will continue to have some pain but will function relatively some pain but will function relatively normallynormally

ReferencesReferences1.1. Wolfe F, Smythe HA, Yunus MB, Bennett RM, et al. The American College of Wolfe F, Smythe HA, Yunus MB, Bennett RM, et al. The American College of

Rheumatology 1990 criteria for the classification of fibromyalgia: Report of the Rheumatology 1990 criteria for the classification of fibromyalgia: Report of the Multicenter Criteria Committee. Multicenter Criteria Committee. Arthritis Rheum.Arthritis Rheum. 1990; 33:160 1990; 33:160

2.2. Fibromyalgia Information website: Fibromyalgia Information website: http://fibromyalgia.ncf.cahttp://fibromyalgia.ncf.ca3.3. Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia

syndrome. syndrome. JAMA.JAMA. 2004; 292 (19); 2388 2004; 292 (19); 23884.4. Pfeiffer A, Thompson JM, Nelson A, et al. Effects of a 1.5-day multidisciplinary Pfeiffer A, Thompson JM, Nelson A, et al. Effects of a 1.5-day multidisciplinary

outpatient treatment program for fibromyalgia: a pilot study. outpatient treatment program for fibromyalgia: a pilot study. Am J Phys Med Am J Phys Med Rehabil. Rehabil. 2003; 82: 186.2003; 82: 186.

5.5. Busch A, Schachter CL, Peloso PM, Bombardier C. Exercise for treating Busch A, Schachter CL, Peloso PM, Bombardier C. Exercise for treating fibromyalgia syndrome. fibromyalgia syndrome. Cochrane Review Datatbase Systematic Review.Cochrane Review Datatbase Systematic Review. 2003; 3. 2003; 3.

6.6. Arnold LM, Hess EV, Hudson JI, Berno SE, Keck PEA. Randomized, placebo-Arnold LM, Hess EV, Hudson JI, Berno SE, Keck PEA. Randomized, placebo-controlled, double-blind study of fluoxetine in the treatment of women with controlled, double-blind study of fluoxetine in the treatment of women with fibromyalgia. fibromyalgia. Am J Med.Am J Med. 2002; 112: 191. 2002; 112: 191.

7.7. Wolfe F, Cathey MA, Hawley DJA. Double-blind placebo controlled trial of Wolfe F, Cathey MA, Hawley DJA. Double-blind placebo controlled trial of fluoxetine in fibromyalgia. fluoxetine in fibromyalgia. Scand J Rheumatol.Scand J Rheumatol. 1994; 23: 255. 1994; 23: 255.

8.8. Crofford L, Russell IJ, Mease P, et al. Pregabalin improves pain associated with Crofford L, Russell IJ, Mease P, et al. Pregabalin improves pain associated with fibromyalgia syndrome in a multicenter, randomized, placebo-controlled fibromyalgia syndrome in a multicenter, randomized, placebo-controlled monotherapy trial. monotherapy trial. Arthritis Rheum. Arthritis Rheum. 2002; 46: S613.2002; 46: S613.

9.9. Vaeroy H, Abrahamsen A, Forre O, Kass E. Treatment of fibromyalgia (fibrositis Vaeroy H, Abrahamsen A, Forre O, Kass E. Treatment of fibromyalgia (fibrositis syndrome): a parallel double blind trial with carisoprodol, paracetamol and syndrome): a parallel double blind trial with carisoprodol, paracetamol and caffeine versus placebo. caffeine versus placebo. Clin RheumatolClin Rheumatol. 1989; 8:245.. 1989; 8:245.

10.10. Bennett RM, Kamin M, Karim R, Rosenthal N. Tramadol and acetaminophen Bennett RM, Kamin M, Karim R, Rosenthal N. Tramadol and acetaminophen combination tablets in the treatment of fibromyalgia pain: a double-blind, combination tablets in the treatment of fibromyalgia pain: a double-blind, randomized, placebo-controlled study. randomized, placebo-controlled study. Am J MedAm J Med. 2003; 114:537.. 2003; 114:537.

11.11. Goldenberg DL. Clinical manifestations and diagnosis of fibromyalgia in adults. Goldenberg DL. Clinical manifestations and diagnosis of fibromyalgia in adults. UpToDate UpToDate 2005.2005.

12.12. Goldenberg DL. Differential diagnosis of fibromyalgia. Goldenberg DL. Differential diagnosis of fibromyalgia. UpToDateUpToDate . 2004. . 2004.13.13. Goldenberg DL. Treatment of fibromyalgia in adultsGoldenberg DL. Treatment of fibromyalgia in adults. UpToDate.. UpToDate. 2005. 2005.14.14. Tofferi JK, Jackson JL, O’Malley PG. Treatment of fibromyalgia with Tofferi JK, Jackson JL, O’Malley PG. Treatment of fibromyalgia with

cyclobenzaprine: a meta-analysis. cyclobenzaprine: a meta-analysis. Arthritis Rheum.Arthritis Rheum. 2004: 51:9. 2004: 51:9.15.15. Klippel JH. Klippel JH. Primer on the Rheumatic Diseases, Edition 12.Primer on the Rheumatic Diseases, Edition 12.