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Fibromyalgia & Soft Tissue Rheumatism

Fibromyalgia & Soft Tissue Rheumatism. Shin-Seok Lee, M.D. Chonnam National University Medical School. Musculoskeletal Disorder. Articular. Periarticular. Inflammatory. Noninflammatory. Inflammatory. Noninflammatory. Monarticular Localized.

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Fibromyalgia & Soft Tissue Rheumatism

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  1. Fibromyalgia & Soft Tissue Rheumatism Shin-Seok Lee, M.D. Chonnam National University Medical School

  2. Musculoskeletal Disorder Articular Periarticular Inflammatory Noninflammatory Inflammatory Noninflammatory Monarticular Localized Septic arthritis Trauma Bursitis Carpal tunnel Gout Osteonecrosis Tendinitis Sickle cell Pseudogout Osteoarthritis Tenosynovitis Multiple myeloma Viral arthritis Charcot joint Epicondylitis Osteoid Osteoma Juvenile arthritis Hemarthrosis Periostitis Reflex sympathetic Sarcoid PVNS Costochondritis dystrophy Fungal Foreign body Polyarticular Systemic Rheumatoid arthritis Osteoarthritis PMR Fibromyalgia SpA Sickle cell Polymyositis Multiple myeloma SLE Hemarthrosis Periostitis Myxedema Rheumatic fever Hemochromatosis Enthesitis Osteoporosis Juvenile arthritis Hypertrophic Eosinophilic fasciitis Pagets Scleroderma osteoarthropathy Myasthenia gravis Lyme Polychondritis

  3. 섬유근통 증후군에 관한 설명 중 틀린 설명은? • 80-90%가 여성이며, 호발 연령은 25-55세이다. • 만성 근골격계의 증후군으로 미만성 통증과 압통점이 특징적이며 이럴 경우 NSAID와 steroid가 도움이 된다. • stage 4(non-REM) sleep 장애, serotonin의 결핍, 우울증 등이 이 질환과 관계 있다. • 주요 압통 부위는 thumbnail, forehead, distal dorsal forearm 등이 있다. • 가. 1,2,3 나. 1,3 다. 2,4 라. 4 마. 1,2,3,4

  4. Chronic Widespread Pain and Fibromyalgia www.themegalllery.com Prevalence of chronic widespread pain • Prevalence of chronic widespread pain • US study – 10.6%, 95% CI (9.5, 12) • UK study – 11% • Prevalence of fibromyalgia • Wolfe et al – 2.0% 95% CI (1.4, 2.7) • Finland study – 0.8%

  5. Prevalence of CWP and FM in Korea www.themegalllery.com • Uljin and Pohang, Kyongsangbuk-do • 1028 participants in 2004 • Prevalence of chronic widespread pain • 144/1028 cases (14.0%) • F:M = 103:14 • Increasing trend in older age • Prevalence of fibromyalgia • 23/1028 cases (2.2%) • F:M = 21:2 • Increasing trend in older age Kim S, et al. JKRA 2005;12:S71

  6. Chronic Widespread Pain and Fibromyalgia www.themegalllery.com Prevalence of fibromyalgia Rheumatology clinics 20% Internal medicine clinics 6% Family practice clinics 2% General medicine inpatients (UK) 5% General population 1% Percentile Individuals with fibromyalgia Tenderness

  7. What is Fibromyalgia? www.themegalllery.com Fibromyalgia Healthy control Pressure pain threshold (kg) 4kg Allodynia Hyperalgesia

  8. 1990 ACR Classification Criteria www.themegalllery.com • History of chronic widespread pain involving all 4 quadrants of the body • Pain in 11 of 18 tender points on digital palpation • Occiput: bilateral, at the suboccipital muscle insertions. • Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7. • Trapezius: bilateral, at the midpoint of the upper border. • Supraspinatus: bilateral, at origins, above the scapula spine near the medial border. • Second rib: bilateral, at 2nd costochondral junctions. • Lateral epicondyle: bilateral, 2 cm distal to the epicondyles. • Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle. • Greater trochanter: bilateral, posterior to the trochanteric prominence. • Knee: bilateral, at the medial fat pad proximal to the joint line. Wolfe F, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee. Arthritis Rheum 1990;33:160-172.

  9. Tender Point www.themegalllery.com

  10. Tender Point www.themegalllery.com Control anatomic sites • Thumbnail, mid forearm, forehead • Processus styloideus on the right side • In the middle of os sacrum • Fold of the skin on the dorsal side of the right antebrachium • Fold of the skin over m. gluteus maximum on the right side

  11. What is Fibromyalgia? www.themegalllery.com Definition of fibromyalgia • Chronic widespread pain with a reduced threshold for pain, generally identified by an increased sensitivity to pressure at particular points on the body • Associated subjective symptoms such as fatigue, sleep disturbance, headache, migraine, variable bowel habits, diffuse abdominal pain, and urinary frequency. • One third of patients experience significant minor depression or anxiety.

  12. What is Fibromyalgia? www.themegalllery.com Tension/migraine headache Chronic sinusitis Temporomandibular joint syndrome Sicca symptoms, vasomotor rhinitis Non-cardiac chest pain, “Syndrome X”, costochondritis Regional musculoskeletal pain (e.g. chronic cervical or lumbar pain, “tendinosis”, repetitive strain syndrome, myofascial pain syndrome) Biliary dyskinesia, post- cholecystectomy syndrome Interstitial cystitis, female urethral syndrome, vulvar vestibulitis, vulvodynia Irritable bowel syndrome

  13. Pathogenesis www.themegalllery.com • Increased nociception • Deficiency of stage II/IV sleep • Alpha EEG NREM sleep anomaly • Aberrant CNS function • Abnormalities in sensory processing • Hypothalamic-pituitary axis dysfunction • Autonomic dysfunction • Psychobehavioral factor • Cytokines

  14. The pain–brain–pain loop www.themegalllery.com OA, RA, Inflammation, Neuropathies, Injuries, Disc disorders, Visceral pain, Chronic headaches, TMJ, Spinal stenosis, Repetitive strain, Endometriosis, Myofascial pain pain peripheral tissues generators central spinal cord and brain sensitization

  15. Altered central pain processing www.themegalllery.com Lower rCBF in the Thalamus and the Caudate Nucleus by SPECT Normal Control Fibromyalgia Mountz JM, et al, Arthritis Rheum 1995;38:926-38

  16. Altered central pain processing www.themegalllery.com fMRI Imaging Evidence of Augmented Pain Processing in Fibromyalgia Gracely RH, et al. Arthritis Rheum 2002;46:1333-43

  17. Altered central pain processing www.themegalllery.com Mean CSF levels of substance P in fibromyalgia • Threefold higher concentrations of substance P in CSF of FM patients • Low levels of norepinephrine and its metabolite, 3-methoy-4-hydroxy phenethylene, in CSF of FM patients • Low levels of serotonin and its precursor, L-tryptophan, in the serum and low levels of the principal metabolite, 5-hydroxy indoleacetic acid in CSF

  18. 섬유근통 증후군에 관한 설명 중 틀린 설명은? • 80-90%가 여성이며, 호발 연령은 25-55세이다. • 만성 근골격계의 증후군으로 미만성 통증과 압통점이 특징적이며 이럴 경우 NSAID와 steroid가 도움이 된다. • stage 4(non-REM) sleep 장애, serotonin의 결핍, 우울증 등이 이 질환과 관계 있다. • 주요 압통 부위는 thumbnail, forehead, distal dorsal forearm 등이 있다. • 가. 1,2,3 나. 1,3 다. 2,4 라. 4 마. 1,2,3,4

  19. 58세 여자환자로 6개월 전부터 지속된 쇠약감과 전신적인 근육통을 주소로 내원하였다. 승모근, 늑골, 늑역골 관절, 내측 무릎등에 대칭적인 통점을 가지고 있었다. 환자는 류마티스 인자 및 항핵항체는 음성이었고 적혈구 침강속도도 정상이었으며 기타 신경학적 검사에서 이상소견은 없었다. 상기 환자에 대한 설명 중 옳은 것은? • 주로 여자에게서 발생하며 대부분 연령은30-50대 이다. • 대부분의 환자들이 활동성의 정신의학적 질환을 가지고 있다. • 류마티스 관절염에 병발할 수 있다. • 특징적인 REM sleep의 장애를 동반한다. • 가. 1,2,3 나. 1,3 다. 2,4 라. 4 마. 1,2,3,4

  20. 45세 여자가 수 년간 지속되는 전신 통증으로 왔다. 관절의 압통과 종창은 없었고, 전신 근육에 압통점이 뚜렷하게 있었다. 류마티스 인자, 항핵항체는 음성이었고 갑상선 기능검사는 정상이었으며 다른 특이소견은 없었다. 치료로 적절한 것은? 1. amitriptyline 2. 유산소운동 3. tramadol 4. prednisolone 가. 1,2,3 나. 1,3 다. 2,4 라. 4 마. 1,2,3,4

  21. Management www.themegalllery.com • Education • Nonprogressive condition that is not causing damage or inflammation • Not focusing on symptoms. All symptoms are from the same underlying condition. • Existential crisis from denial, searching for ‘the cure’, to eventual acceptance • Pharmacologic therapy • Antidepressants (TCA, SSRI, SNRI, MAOI) • Analgesics, sedative hypnotics, muscle relaxant • Nonpharmacologic therapy • Exercise, cognitive behavioral therapy

  22. Pharmacologic therapy www.themegalllery.com Antidepressant: summary of randomized, controlled trials Class Compound(s) Pharmacology Pain Sleep Fatigue Mood Treating other FSS TCAAmitriptyline 5-HT/NE reuptake inhibitor + + + - IBS Clomipramine Cation channel blocker TMJD Doxepin NMDA antagonist CLBP? Anticholinergic CTTH prophylaxis Antihistaminergic SSRIFluoxetine 5-HT reuptake inhibitor + + + + CTTH prophylaxis Citalopram 5-HT reuptake inhibitor - - - + CTTH prophylaxis Sertraline 5-HT reuptake inhibitor + + + CTTH prophylaxis SNRIVenlafaxine 5-HT > NE reuptake inhibitor - - - - CTTH prophylaxis Milnacipran NE > 5-HT reuptake inhibitor + - + + NMDA antagonist MAOI Moclobemide Reversible, MAO inhibitor - - - - CTTH prophylaxis, CFS Pirlindole Reversible, MAO inhibitor + + + + CTTH prophylaxis

  23. Pharmacologic therapy www.themegalllery.com Summary of randomized, controlled trials Class Compound(s) Pharmacology Pain Sleep Fatigue Mood Other FSS MuscleCyclobenzaprine 5-HT2 antagonist + + +/- IBS relaxant Anticholinergic Antihistaminergic Anti-epilepticsPregabalin Ca channel blocker + + + Sedative Zopiclone BZ receptor agonist - + - - Hypnotics Zolpidem NSAIDs Ibuprofen Nonspecific COX inhibitor - - - - CLBP Naproxen TMJD Opiates Morphine (IV) Mu agonist - Tramadol Mu agonist + CTTH 5-HT/NE reuptake inhibitor CLBP Other Tropisetron 5-HT3 antagonist + + IBS? Growth hormone Growth hormone + + +

  24. Pharmacologic therapy www.themegalllery.com • Antidepressant – rationale • Alpha-delta NREM sleep abnormality mediated by an abnormality in central serotonergic neurotransmission • Personal and family history of depression in FM patients • TCA studies on chronic pain syndromes • Antidepressant – mechanism • Increase neurotransmission mediated by the monoamine neurotransmitters, particularly serotonin (5-HT) and/or norepinephrine (NE)

  25. Pharmacologic therapy www.themegalllery.com Treatment of Fibromyalgia with Tricyclic Antidepressants: A Meta-Analysis 9% 11.6 12 treatment mean* 10.6 placebo mean* 10 23% 26% 18% 8 14% 6.5 6.5 rating scale 5.8 5.8 6 5.2 5.0 5.0 4.3 4 2 0 fatigue trigger pain sleep well- points being symptoms O’Malley PG, et al. J Gen Intern Med 2000;15:659

  26. Pharmacologic therapy www.themegalllery.com TCA Treatment of Fibromyalgia: A Meta-Analysis 1.5 1.0 Effect Size (Standard Deviations) 0.5 0.0 -0.5 Patient Global Assessment M.D. Global Assessment Pain Fatigue Sleep Tenderness Stiffness Outcome Measure Arnold LM, et al. Psychosomatics 2000;41:104

  27. Pharmacologic therapy www.themegalllery.com • Recommendations • Start with amitriptyline at a dose 5 mg 1-2h before bedtime. The dose can be gradually increased to a maximum of 50 mg/day • If these are ineffective, institute trials of SSRI such as fluoxetine. • Consider the combination of SSRI and low dose TCA. • If ineffective, substitute SNRI such as venlafaxine for SSRI. • For insomnia in patients intolerant of TCA, bedtime doses of zolpidem and zopiclone may be of benefit. • For pain control, use the tramadol. Limit the use of antiinflammatory agents, narcotic analgesics, and muscle relaxants.

  28. 45세 여자가 수 년간 지속되는 전신 통증으로 왔다. 관절의 압통과 종창은 없었고, 전신 근육에 압통점이 뚜렷하게 있었다. 류마티스 인자, 항핵항체는 음성이었고 갑상선 기능검사는 정상이었으며 다른 특이소견은 없었다. 치료로 적절한 것은? 1. amitriptyline 2. 유산소운동 3. tramadol 4. prednisolone 가. 1,2,3 나. 1,3 다. 2,4 라. 4 마. 1,2,3,4

  29. 35세 여자 환자가 전신통증과 피로감을 주소로 내원하였다. 평소에 만성 근육통과 수면장애가 있었다. 목, 어깨, 하지에 걸치는 전신적인 통증이 있었고 약간의 움직임에도 악화되었다. 신체검사에서 뒷목, 양어깨, 허리, 무릎에 대칭적인 압통점이 있었으나 방사선 검사에서 이상소견은 관찰되지 않았다. 항핵항체와 류마티스 인자는 음성이었고 ESR은 10 mm/hr였다. 이 환자에서 적절하지 않은 치료는? 1. 유산소운동 2. cyclobenzaprine 3. prednisolone 4. tricyclic antidepressants 5. zolpidem

  30. 삼환계 항우울제와 플루옥세틴(fluoxetine)으로 증상이 조절되지 않는 섬유근통 환자에서 다음 단계로 투여해 볼 수 있는 약제로 옳은 것은? 1. 플루옥세틴 대신 벤라팍신(venlafaxine)을 투여한다. 2. 트라마돌(tramadol)을 추가한다. 3. 플루옥세틴을 둘록세틴(duloxetine)으로 교체한다. 4. 저용량의 프레드니솔론을 추가한다. 가. 1,2,3 나. 1,3 다. 2,4 라. 4 마. 1,2,3,4

  31. 손목굴증후군 (carpal tunnel syndrome)을 진단하기 위한 신체검사 두 가지는? 답) Tinel's sign과 Phalen's sign • Tinel’s sign • percussion of median nerve at the flexor retinaculum (just radial to the palmaris longus tendon at the distal wrist crease) produces paresthesia in the median nerve distribution: thumb, index and middle fingers and the radial half of the ring finger • Phalen’s sign • sustained palmar flexion of the wrist for 30-60 seconds induces finger paresthesia

  32. 다음 사진에서 보이는 검사는 어떤 질병을 진단하기 위한 것인가? 답) de Quervain's tenosynovitis • de Quervain’s stenosing tenosynovitis • tenosynovitis of abductor pollicis longus and extensor pollicis brevis • Finkelstein test • passive ulnar deviation of the wrist with the fingers flexed over the thumb placed in the palm

  33. 50세 여자가 왼쪽 어깨관절의 통증을 주소로 내원하였다. 환자는 3개월 전부터 왼쪽 어깨의 통증을 느끼기 시작했으며 최근 들어서는 왼쪽으로는 누워 자기가 힘들 정도로 통증이 심하다고 하였다. 과거력상 당뇨는없었고 신체검사에서 왼쪽 어깨의 수동 능동 운동 모두에 제한이 있었고 X선 촬영에서 뚜렷한 이상 소견은 발견되지 않았다. 상기 환자의 가능한 진단은? 답)유착관절낭염 (adhesive capsulitis)

  34. Differential Diagnosis of Shoulder Pain

  35. 55세 여자가 6개월 전부터 서서히 진행하는 우측 어깨의 통증과 운동 장애를 주소로 내원하였다. 신체검사에서 부종이나 종창, 발적은 동반되지 않았으나 환자 스스로 우측 어깨를 모든 방향으로 움직일 수 없었으며 검사자의 도움으로도 비슷한 정도의 운동 장애를보였다. 방사선 촬영에서는 우측 어깨 관절 주위의 골감소 이외에 특이 소견은 없었다. 이 환자에 맞는 소견은? 1. 관절의 진행성 미란을 동반한다. 2. 당뇨병, 갑상선 질환, 폐질환에 동반되기도 한다. 3. 진단을 위해 관절경 검사가 필수적이다. 4. 관절강내 코르티코스테로이드 주사가 증상 개선에 도움이 된다. 가. 1,2,3 나. 1,3 다. 2,4 라. 4 마. 1,2,3,4

  36. Thank you for your attention

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