Fibromyalgia

1. Fibromyalgia Susanne Lester-Bennett FNP-S

2. What exactly is fibromyalgia? • Fibromyalgia is a common cause of chronic musculoskeletal pain. • It is a disorder that affects muscles, tendons and ligaments. • It is not associated with tissue inflammation and the etiology is mostly unknown. • Fibromyalgia is a disorder of pain regulation. • There is conclusive evidence that alterations in central nervous system pain processing which contribute to many of the clinical features of the syndrome.

3. The pathophysiology is not clearly defined . • Multiple physical and emotional stressors can produce the recurrence of symptoms. • Some of these triggers can be infections, viral illness, physical or emotional trauma, Lyme disease. • Genetic and environmental factors may also contribute to fibromyalgia.

4. PATHOGENESIS • Fibromyalgia, a central rather than peripheral pain disorder, shares some of the same highlights of conditions such as temporo-mandibular joint disorder, migraine headaches, and irritable bowel syndrome. • These characteristics involve genetic and central nervous system pain processing issues. • Previously fibromyalgia was thought to be a muscle disorder, but there has been no evidence to support this theory. • Now it is thought that mitochondrial dysfunction may play a role in this disease.

5. PREVALENCE • Fibromyalgia in adults is the most common cause of generalized widespread pain in women ages 20-55 years old. • The incidence increases with age and is approximately 2% of the population in the US and Europe. • It is six times more common in females. • To meet diagnostic criteria, over 40% of patients are referred to specialty pain clinics.

6. PREVALENCE IN CHILDREN • Fibromyalgia in children and adolescence is controversial but it is estimated at 1-2 % • The criteria for diagnosing fibromyalgia in children is based on the Yunus criteria and was derived from a published review of 33 children in 1985. • The application of this criterion has not been validated.

7. 6 CLINICAL SIGNS & SYMPTOMS • 1.- Primary manifestation is widespread musculoskeletal pain. Common descriptions are “I hurt all over” or “I feel like I have the flu”. Pain is primarily in muscles but can also occur in joints. Pain can be diffuse or multifocal and frequently migrates. Chest pain, pelvic pain, abdominal pain, headaches, chronic sore throats can be common. Pain can come and go, get better and worsen . • 2.- Paresthesias. Tingling, burning, numbness to extremities. Neurological testing, nerve conduction studies and/or electromyography is often negative and not recommended.

8. 3.- Fatigue. Particularly after awaking from sleep; peaks again mid-afternoon. Stiff in the morning and feeling unrested even after 8-10 hours of sleeping. Frequent wakefulness with difficulty getting back to sleep. Common descripton is, “no matter how much sleep I get I feel like a truck ran me over”. Minor activities aggravate fatigue. • 4.- “Fibro Fog”. Cognitive disturbances are present in majority of patients. Typically activities that require quick thinking and attention are difficult. Distraction when performing memory tasks are common. • 5.- Depression. Anxiety and/or depression and other psychiatric conditions are present in 30-50 % of patients. • 6.- Physical Signs Tenderness on examination at the soft tissue trigger points is the only physical sign. (10 lb. pressure applied to trigger points)

9. American College of Rheumatology 2010 Diagnostic Criteria • 1.-Widespread pain index =/> 7 (Each trigger point = 1 point) symptom severity scale score =/>5 -------- or---------- Widespread pain index of 3-6 (Each trigger point = 1 point) symptom severity scale score of =/>9 • 2.-Symptoms present for at least 3 months. • 3.-Patient doesn’t have a disorder that would otherwise explain the pain.

10. PHYSICAL EXAMINATION • Widespread Pain: *Note the number of areas (trigger points) patient has had pain in the last week; score will range from 1-18.

11. SYMPTOM SEVERITY SCALE • *Note the severity of symptoms from 0-4 0=no symptoms 1=few symptoms 2=moderate 3=severe • *Fatigue • *Waking un-refreshed • *Cognitive symptoms

12. DFFERENTIAL DIAGNOSIS • The focus of diagnosing fibromyalgia is based on eliminating other rheumatic and systemic diseases. Co-occurring diseases can be excluded during the history, physical and laboratory assessment process. • Systemic lupus erythematosis, polymyalgia rheumatica, rheumatoid arthritis, andSjogren syndromes can present with diffuse fatigue and pain but have characteristics that can distinguish them from fibromyalgia.

13. DIFFERENTIAL DIAGNOSIS • Ankylosingspondylitis also mimics symptoms of skeletal pain and stiffness but radiologic exam will differentiate from fibromyalgia. • Hypothyroidism may explain fatigue and muscle aches which can also mimic symptoms of fibromyalgia. • Headaches and peripheral paresthesias may be reported. • Entrapment syndromes and neurologic disorders such as carpal tunnel syndrome, multiple sclerosis, and myasthenia gravis are sometimes considered in the differential diagnosis

14. DIFFERENTIAL DIAGNOSIS • Many fibromyalgia patients describe numbness, tingling and burning as symptoms and can mistakenly be diagnosed with neurologic disorders; however in fibromyalgia the neurologic exam is generally unremarkable. • Patients may also describe cognitive problems with short-term memory. There is no evidence of intellectual deterioration from fibromyalgia.

15. DIAGNOSTIC TESTING • Laboratory testing can include ESR, CRP, thyroid and liver functions, CPK, ANA, and X-Rays. • If neurological exam is abnormal then EMG and nerve conduction is recommended; otherwise not recommended.

16. TREATMENTMEDICATIONSEXERCISECOGNITIVE BEHAVIORAL THERAPYEDUCATION & COUNSELING

17. MEDICATIONS • Medications that have been the best studied and have consistently been effective include select anticonvulsants’ and antidepressants. Tricyclic antidepressants such as amitriptyline and cyclobenzaprine, SNRI’s such as duloxetine and milnacipran, and anticonvulsants such as gabapentin and pregabalin have been shown to be beneficial. Treatment usually begins with tricyclic. in patients that have more severe sleep disturbance or intolerance to tricyclic, a SNRI or anticonvulsant may be used as alternate therapy.

18. MEDICATIONS • Non-steroidal anti-inflammatory drugs are not recommended in the treatment of fibromyalgia. Several, small randomized trials have failed to show effectiveness. There is no evidence that tissue inflammation is present in patients with fibromyalgia. • However, Tramadol 75mg and Acetaminophen 650mg have shown to be effective when used in combination.

19. EXERCISE • Active aerobic physical exercises are pivotal in the treatment of fibromyalgia, but patients often find starting and maintaining exercise program difficult. • Stength training vs. aerobic training—Both are effective however, studies show aerobic is more beneficial. • Referral to physical therapy

20. COGNITIVE BEHAVIORAL THERAPY • A meta-analysis of 23 studies of 30 psychological treatment conditions, involving 1396 patients found significant short and long term benefits from several treatment measures (Glombiewski, Sawyer, Guterman, 2010). Cognitive behavior treatment resulted in significantly greater benefit in pain reduction. • Relaxation and biofeedback were more effective than other psychological treatments in reducing sleep problems.

21. EDUCATION AND COUNSELING • Patient education about the disease has an impact on how the patient views the illness, how well the patient copes with the illness, and how the patient relates to their role in their own treatment. • 1.-Reassurance that fibromyalgia is a real illness and it is not “in your head”. • 2.-Role of stress and mood disorder. Learning how stress and mood disorder effects fibromyalgia will encourage the patient to learn simple relaxation techniques.

22. EDUCATION AND COUNSELING • 3.-Role of sleep disorder and sleep hygiene. Patients should be educated about good sleep hygiene and the potential benefits of correcting poor sleep habits. Patients need to recognize that poor sleep habits contribute to fibromyalgia. • 4.-Role of exercise. It has been suggested that blood flow is sluggish to muscles and skin. Exercise for reconditioning and functional capacity has been shown to be beneficial. • 5.-Prognosis. Patients need to understand that their condition will wax and wane but the pain will persist. It is important to let the patient know that they can go on to live a normal life.

23. ROLE OF MOOD DISORDERS • Depression, fatigue, lack of energy, and sleep disorders are all characteristics of mood disturbance. Approximately 25 percent of patients have concurrent major depression, and 50 percent have a lifetime history of depression. Many clinicians believe that fibromyalgia is primarily a psychiatric illness; however studies are uncovering evidence that fibromyalgia is not a psychiatric illness but rather a mood disturbance being important in the expression and outcome of the condition (Goldenberg, 2012). • Sleep disturbance which include non-specific interruption in stage 4 sleep, restless leg syndrome, and sleep apnea, are common in fibromyalgia.

24. (TENS) STUDY • Transcutaneous electric nerve stimulation (TENS) works by activating central nerve inhibition pathways and decreasing central excitability of central nerve pathways. A small double-blinded randomized, placebo-controlled study of 43 patients was used to test the effects of TENS treatment on pain and fatigue, at rest and during movement. This study showed significant improvement with pain during movement but not pain at rest when compared to placebo and no TENS (Daily, Rakel, Vance, Liebano, Amrit, Bush, Lee, Sluka, 2013).

25. QUESTIONS • 1.-Fibromyalgia is a condition that is caused by: a. Muscle, ligaments and tendon pain b. A disturbance in pain regulation c. Is associated with inflammation of the muscles, ligaments & tendons d. A psychiatric condition • 2.-Fibromyalgia is seen mostly in: a. Caucasian women b. Caucasian men c. Children and young adults d. nurses • 3.-Treatment approach of Fibromyalgia is a. Pharmacological b. Exercise and counseling c. cognitive behavior therapy d. good sleep hygiene e. all of the above

26. QUESTIONS • 4.-What medications are used to treat fibromyalgia? (select all that apply) a. NSAID’s b. tricyclic antidepressives or NSRI’s c. anticonvulsants d. Tylenol • 5.-Exercise is beneficial in treating fibromyalgia. a. true b. false • 6.-Fibromyalgia is frequently associated with which of the following: a. seizures b. psychosis c. celiac disease d. irritable bowel syndrome

27. QUESTIONS • 7.- In a patient with fibromyalgia physical findings on exam would be: a. swollen stiff joints b. decreased ROM c. tender soft tissue trigger points d. weakness • 8.-Which of the laboratory findings below would you expect to see in a patient with fibromyalgia? a. slightly elevated WBC b. positive ANA c. elevated ESR d. all of the above e. none of the above • 9.- What is the most commonly affected age group? a. 20-55yo b. 30-65yo c. 65-85yo d. all of the above • 10.-Fibromyalgia is a psychiatric condition. a. true b. false

28. ANSWERS • 1. b • 2. a • 3. e • 4. b, c, d • 5. a • 6. d • 7. c • 8. e • 9. a • 10. b

29. REFERENCES Daily, D., Rakel, B., Vance, C., Liebano, R., Amrit, A., Bush, H…..Sluka, K. (2013). Transcutaneous electrical nerve stimulation reduces pain, central inhibition in primary fibromyalgia. International association for the study of pain, Retrieved from www.elsevier.com/locate/pain Glombiewski, J., Sawyer, A., Guterman, J. et al. (2010). Psychological treatments for fibromyalgia: A meta-analysis. Pain, (151) p. 280.

30. Goldenberg, D.(2013). Pathogensis of fibromyalgia Retrieved from www.uptodate.com Goldenberg, D. (2009). Diagnosis and differential diagnosis of fibromyalgia, The American journal of medicine, doi: 10.1016/jamjmed.2009.09.007 *American College of Rheumatology* Diagnostic Criteria for Fibromyalgia Clinical Tool http://www.fmmgmt.com/pdf/Quiz/ACR.pdf