fibromyalgia educational awareness

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Fibromyalgia Educational Awareness

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Course description

This program is designed to explore the assessment required in

the diagnosis of fibromyalgia. The program also emphasizes an

overview of possible pathophysiology, treatment modalities and

management.

CEU: 1 hour

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Learning objectives

Demonstrate the complexity of fibromyalgia in patients

Identify therapeutic pharmacological agents used in the

management of fibromyalgia

Recognize non-pharmacological treatment for fibromyalgia pain

management

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Demonstrate the complexity of fibromyalgia in patients

Describe fibromyalgia as a clinical condition and its social

impact.

Differentiate fibromyalgia symptoms from other similar

symptoms by applying the American College of Rheumatology

diagnostic criteria.

Identify possible pathophysiology related to fibromyalgia.

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Identify therapeutic pharmacological agents used in the management of fibromyalgia

Recognize the pharmacological choices in the management of

fibromyalgia.

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Recognize non-pharmacological treatment for fibromyalgia pain management

Identify the role of proper nutrition, cognitive behavioral therapy,

relaxation techniques, exercise in the management of

fibromyalgia and other non-pharmacological treatments.

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Program Outcomes

Upon successful completion of the course, the participants will

be able to:

Identify assessment criteria to use in the diagnosis of fibromyalgia.

Apply pharmacological and non-pharmacological treatment options

in the management of fibromyalgia.

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Learning Assessment:

One case study and 14 questions total (4 throughout the content

and 10 at the end of the course).

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Case study

Maria, Age 35

C/O pain

Difficult to get out of bed in am

Does not feel like eating

Does not want to move

Staying in bed for hours

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Case study continued

Tired all the time

Husband states that she cries, looks sad, cannot work due to

pain

Missing 2 out of 5 days of work

Physician not understanding, suggested acetaminophen

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Case study continued

Referred to many different providers

Diagnosed with fibromyalgia after 2 years

Specific diagnostic tests not available to diagnose fibromyalgia

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Complexity of fibromyalgia in patients

Choy and colleagues as discussed by Arnold (2012) found that

patients reported

2.3 years and 3.7 physicians

NMC faculty study

Evaluated nurse practitioners’ education and awareness

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NMC faculty study (Hughes, Adair, Feng, Maciejewski, &

Sharma, 2016).

95% of Nurse Practitioners reported difficulty diagnosing

68% were worried about labeling patients

62% aware of American College of Rheumatology criteria

76% spent time on self-education

55% wanted more education

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Women 9x more likely to develop fibromyalgia than men

(Lawrence et al., 1998).

The mean number of physician office visits higher among

fibromyalgia patients

Patients in poorer health and had greater levels of healthcare

utilization (Robinson et al., 2003; Goldenberg, Burckhardt &

Crofford, 2004).

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Disorder seen in families, with symptoms being displayed by

children as well as adults (National Fibromyalgia Association,

2009).

Over 5% are affected with symptoms generally appearing

between the ages of 20 and 55 years of age with a tendency to

increase with age (Berger, Dukes, Martin, Edelsber, & Oster,

2007).

May be 3-6 million American adults suffering with this condition.

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Fibromyalgia is the third most prevalent rheumatologic disorder

in the United States (Baumstark and Buckelew, 2002)

Fibromyalgia is a common chronic widespread pain disorder that

has a worldwide prevalence between 0.55 and 5%. (Arnold,

2012),

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History and Symptoms of Fibromyalgia

1700’s, physicians in Germany and Scandinavia were finding a

condition with pain in muscles and soft tissue.

1904, Sir William Gowers named the disorder, fibrocitis

1943, Slocumb examined connective tissue nodules and found

normal tissue without inflammation.

1981, Yunas et al. coined the condition, fibromyalgia, which

indicates the presence of pain but not necessarily, inflammation.

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Some physicians may not recognize fibromyalgia as a real

medical condition.

Diagnosis is based on patient history, physical examination and

the exclusion of symptoms of other conditions (Wierwille, 2012).

2001).

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The majority of patients have symptoms of

chronic fatigue,

widespread musculoskeletal pain,

poor sleep,

morning stiffness

mood disorders such as anxiety or depression

(Park, Glass, Minear & Crofford, 2001).

Some experience “fibromyalgia fog”

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Hughes (2002) study of 107 fibromyalgia patients described pain

as aching, throbbing, sharp, tender, burning, gnawing, shooting,

and pulling.

The participants thought that the pain was exhausting,

sickening, wretched, and caused them to be fearful.

Participants were recorded as having up to 26 awakenings

during the course of one night’s sleep.

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Symptoms can appear and disappear along with the degree and

severity of pain.

Many patients feel hopeless.

Fibromyalgia patients may look healthy and move around with

no noted difficulty.

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American College of Rheumatology Criteria used for Diagnosis

Definition of fibromyalgia is a medical condition based on the

following criteria:

At least 3 months of widespread pain

Pain occurs in all four quadrants of the body with moderate pain

sensitivity in specific tender points.

The pain should occur on digital examination (4 kg. of pressure) in

at least 11 out of 18 specified tender point sites (Wolfe et al., 1990).

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1990 ACA Criteria for Fibromyalgia Main Points

1. “History of widespread pain”

left side of the body,

right side of the body,

above the waist,

below the waist.

axial skeletal pain must be present.

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1990 ACA Criteria for Fibromyalgia Main Points

2. Pain in 11 of 18 tender points sites, on digital palpation.

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Tender points sites

Occiput

Low cervical

Trapezius

Supraspinatus

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Tender points sites

Second rib

Lateral epicondyle

Gluteal

Greater trochanter

Knee

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Digital palpation

approximate force of 4 kg for a tender point to be considered

“positive”

The subject must state that the palpation was painful. “Tender” is

not to be considered “Painful” (Wolfe et al., 1990).

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Objections

The restrictiveness of the tenderpoint count was not performed at

the Primary Care Providers office

The accuracy of the tenderpoint assessment was not consistent.

Philosophically, other important patient symptoms that interfered

with a quality of life occurred, that included fatigue, cognitive

symptoms and the extent of other somatic symptoms,

(Wolfe, Clauw, Fitzcharles, Goldenbert, Katz, Mease, Russell, . . .

Yunas, 2010).

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In 2010, the ACR changed the diagnostic criteria to include:

assessment of pain and symptoms over a period of a week.

symptoms lasting over three months.

ruling out any other health problem that would present the same

pain and symptomology.

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2010 ACR Criteria for Fibromyalgia Main Points

A patient satisfies diagnostic criteria for fibromyalgia if the

following 3 conditions are met.

1. Widespread Pain Index (WPI) > 7 and Symptom Severity (SS)

scale score > 5 or WPI 3-6 and SS scale score > 9.

2. Symptoms have been present at a similar level for at least 3

months.

3. The patient does not have a disorder that would otherwise explain

the pain.

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Shoulder girdle

Upper arm

Lower arm

Hip (buttock, trochanter)

Upper leg

Lower leg

Jaw

Chest

Abdomen

Upper back

Lower back

Neck

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The SS scale score includes:

1. Fatigue

2. Waking unrefreshed

3. Cognitive symptoms

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Indicate the level of severity over the past week using the

following scale:

1. no symptoms

2. few symptoms

3. a moderate number of symptoms

4. a great deal of symptoms

( Wolfe et al., 2010)

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The 2010 criteria will probably be utilized to a greater

extent.

Refer to Fibromyalgia Network | www.fmnetnews.com

| (800) 853-2929 for more details about the 2010

criteria.

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Test your knowledge

1. In 2010, the American College of Rheumatology (ACR)

identified that the pain must occur on digital exam in 11 out of

18 body parts to be considered the pain of fibromyalgia.

True or False

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Test your knowledge




True or False

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Test your knowledge




True or False

Rationale: This is from the 1990, American College of

Rheumatology Diagnosis Criteria

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Test your knowledge

2. Symptom severity (SS) score consists of the severity of pain,

decreased mobility, and cognitive symptoms.

True or False

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Test your knowledge



True or False

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Test your knowledge



True or False

Rationale: Incorrect symptoms are listed; it should list the following

symptoms –severity of fatigue, unrefreshed sleep and cognitive

symptoms.

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Possible Pathophysiology of Fibromyalgia

Cause unknown

Several theories have been proposed.

Genetic predisposition with family members over several

generations being diagnosed with the condition.

First degree relatives more likely to develop fibromyalgia

(Arnold, Hudson and Hess, 2004).

Traumatic events, infection, and psychological stress

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Clauw and Crofford (2003), suspect abnormalities in the

hypothalamic-pituitary-adrenal axis.

The concept of sensory hypersensitivity or central sensitization

has been studied resulting in increased muscle sensitivity by a

normally non-painful stimulus, and increased pain intensity

triggered by normally painful stimuli (Staud & Smitherman 2002;

Arendt-Nielsen & Graven-Nielsen, 2003).

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Patients have demonstrated a deficiency in the production of

cortisol.

Serotonin levels have been lower than normal.

Many have an increased level of Substance P and glutamate

accounts for an increased awareness of pain and nerve sensitivity

Increases in glutamate concentrations in specific brain regions

have been noted (Harris, Sundgren, Craig et al., 2009; Valdes,

Collado & Bargallo, 2010).

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The functional changes and pathological mechanisms behind the

fibromyalgia chronic pain may include:

1. “central nervous system (CNS) sensitization,

2. dysfunction of the descending inhibitory pain pathways,

3. peripheral nervous system (PNS) sensitizations,

4. release of inflammatory mediators,

5. endocrine irregularity in the hypothalamic-pituitary-adrenal (HPA) axis,

and

6. neurotransmitter abnormalities”,

(Wierwille, 2012, p. 185).

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Wierville cited evidence of demyelination of neurons and

inflammation of peripheral nerve fibers in skin biopsies from the

tender points of fibromyalgia patients which could result from

chronic stress and HPA axis dysfunction.

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Specific steps of diagnosis and treatment of Fibromyalgia for the Healthcare Provider

According to Goldenberg, Burckhardt and Crofford (2004) found

in the article by Marter and Agruss (2008), possible steps in the

diagnosis and treatment of fibromyalgia could be the following:

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Step One

Obtain a history using the 2010 ACR Criteria.

Perform a physical examination.

Consider such diagnostic tests as Complete Blood Count,

Complete Metabolic Panel, Thyroid Stimulating Hormone, and

Erythrocyte Sedimentation Rate.

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Step Two

Provide patient education about their condition.

Assess and treat comorbid conditions that impact fibromyalgia

such as depression, anxiety, and sleep disorders.

Administer the Revised Fibromyalgia Impact Questionnaire (FIQR)

to evaluate current status.

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Step Three

Begin pharmacologic treatment trial with pregabalin (Lyrica),

amitriptyline (Elavil), or cyclobenzaprine (Flexeril).

Begin non-pharmacologic treatment such an aerobic exercise

program, including pool-based work for deconditioned patients.

Try a multidisciplinary approach with referral for cognitive behavior

therapy.

Schedule follow-up appointments with the primary care provider

every 4-6 weeks, with re-evaluation with the FIQR.

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Step Four

If minimal or no improvement:

Consider referral to a rheumatology, pain management, or other

specialists as indicated.

Consider alternate pharmacologic treatment with selective

serotonin reuptake inhibitors (SSRI), or use of combination

serotonin and norepinephrine reuptake inhibitors, or use of

tramadol (Ultram) with acetaminophen.

Consider use of two or more pharmacologic options in

combination.

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Revised Fibromyalgia Impact Questionnaire (FIQR)

Revised Fibromyalgia Impact Questionnaire.

Originally, the FIQ used a visual analog scale that required the

practitioner to measure the patient response.

One question also required reverse scoring and the use of constants to convert the first 13 questions to a standardized scale

of 0 to 10.

Questions in the FIQ directed to patient function assumed that the

patient possessed a car, vacuum cleaner and a washing machine.

There were no questions directed to problems with cognition,

tenderness, balance and sensitivity to the environment.

(Bennett et al., 2009).

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The FIQR was developed to ease the scoring, address the

limitations stated previously, and promote more widespread

clinical use.

21 individual questions based on an 11-point numeric rating

scale from 0 to 10 with 0 being the best and 10 being the worst.

The tool is framed in the context of the past 7 days in the life of

the fibromyalgia patient.

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Divided into three sets of domains:

function with 9 questions ranging from brushing/combing hair to

shopping for groceries,

overall impact of fibromyalgia with two questions related to

accomplishment of weekly goals

impact of symptom severity, and rating of symptoms experienced

by the patient.

(Bennett et al., 2009)

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The scoring consists of a summed score for the function (0-90

divided by 3)

the summed score for overall impact (0-20)

summed score for symptoms (0-100 divided by 2).

The total FIQR is the sum of the three modified domain scores.

The maximal score of the FIQR is 100

(Bennett et al., 2009).

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In the psychometric testing of the FIQR,

the total scores of the FIQR and FIQ were closely correlated (r =

0.88, P < 0.01).

The FIQR also demonstrated good correlation with comparable

instrument domains in the SF-36.

The tool had good discriminant ability between fibromyalgia

patients and healthy controls, rheumatoid arthritis, systemic lupus

erythematosus, and major depressive disorder patients

(Bennett et al. 2009)

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The FIQR is available in paper and electronic form.

It takes 2 minutes to complete.

The authors of the instrument have published a document with

the interpretation of the FIQR results with the following scale

related to the scoring:

mild fibromyalgia (0-42),

moderate fibromyalgia (43-59),

severe fibromyalgia (60-74),

extreme fibromyalgia (75-100).

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There is a user agreement that needs to be completed

requesting the following information:

licensee details of name etc.,

context of use,

project financing,

language translations needed

listing of the details of the user agreement.

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There is no fee for use of this tool unless the licensee is involved

with a “for profit” organization.

For further information on the use of the FIQR, the

corresponding author is Robert M. Bennett at

[email protected] at the Fibromyalgia research Unit,

Oregon Health and Science University, 3455 SW Veterans

Road, Portland Oregon 97239.

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RevisedFibromyalgiaImpact Questionnaire (FIQR)

(Bennett et al. 2009)

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Pharmacology in the treatment for Fibromyalgia

European League Against Rheumatism (EULAR)

Pharmacological

Non-pharmacological

mailto:[email protected]

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Pharmacological

tramadol (Ultram)

weak opioids

Amitriptyline (Elavil)

Tropisetron (Navoban)

Pramipexole (Mirapex)

Pregabalin (Lyrica)

(Carville et al., 2008).

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Pharmacological

Pregabalin (Lyrica) – 450 mg/day

Amitriptyline (Elavil) – as well as duloxetine (Cymbalta) and

milnacipran (Savella)

Gabapentin (Neurontin)

Cyclobenzaprine (Flexeril)

Not recommended: Zolpidem (Ambien) or benzodiazepine

medications

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Also Not recommended:

Corticosteroids

Strong Opioids

NSAIDS

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High Benefit:

Duloxetine (Cymbalta)

Alprazolam (Xanax), lorazepam (Ativan), and clonazepam

(Klonopin)

Pregabalin (Lyrica)

Tizanidine (Zanaflex) and carisoprodol (Soma)

Modafinil (Provigil)

Tramadol hydrochloride (Ultram)

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Non-Pharmacologic treatments for Fibromyalgia

EULAR recommended the following non-pharmacologic

approaches:

Heated pool therapy

Exercise programs

Cognitive behavioral therapy

Relaxation and psychological support

Education about the syndrome

Eat proper nutrition to manage weight

Moderate exercise and stress-relieving techniques

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The American College of Rheumatology self-care tips:

Making time to relax each day,

Set a sleep routine and exercise often

“start low, go slow”

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Combination of patient education, aerobic exercise and cognitive

behavioral therapy most beneficial for fibromyalgia patients

Symptoms improved using

warm aqua therapy

aerobic exercise

psychological-educational therapy

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Alternative and complementary therapies

Tai Chi and yoga

Massage therapy

Heat therapy

chiropractic therapy

icing

electrical stimulator

biofeedback

acupuncture, acupressure

magnet therapy

healing touch

zPharmacological Treatment Non Pharmacological Treatment

Drugs Drug Classes

alprazolam (Xanax)- note may cause

drowsiness, fatigue

Benzodiazepine, Antianxiety, Sedative-

Hypnotic

Aerobic exercise program (to include pool based

work out)

amitriptyline (Elavil)** TCA* Cognitive behavioral therapy

carisoprodal (Soma) Muscle Relaxant Complementary and Alternative Medicine (CAM)

clonazepam (Klonipin) Benzodiazepine, Antianxiety, Sedative-

Hypnotic

Nutrition

cyclobenzaprine (Flexeril) Skeletal Muscle Relaxant Physical activity (exercise)

duloxetine (Cymbalta)** Antidepressant, SNRI* Relaxation techniques

lorazepam (Ativan)- note may cause

drowsiness, fatigue

Benzodiazepine, Antianxiety, Sedative-

Hypnotic

gabapentin (Neurontin) Anticonvulsant

milnacipran (Savella)** SNRI

modafinil (Provigil) CNS* Stimulants

pramipexole (Mirapex) Dopamine Agonist

pregabalin (Lyrica) Anticonvulsants

tizanidine (Zanaflex) Muscle Relaxant

tramadol (Ultram) Opioid Analgesic

tropisetron (Navoban) Serotonin 5-HT₃ Receptor Antagonist

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Conclusion

With 2010 criteria, the diagnosis of fibromyalgia should be more

consistent.

Healthcare practitioners can follow the guidelines of EULAR and

the American College of Rheumatology

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Conclusion

More research is needed:

Pain flare-ups

Amount of effective activity each day

Interventions devoted to restorative sleep and the

Role of physical trauma as an antecedent to fibromyalgia pain.

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Conclusion

The economic cost of fibromyalgia is high

The healthcare professional can now better understand the

syndrome of fibromyalgia so that the patient need not suffer in

silence.

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References

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fibromyalgia educational awareness

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