Fibromyalgia Ramona Carter-Burdine, M.D. UTMB Galveston

Goals For Attendees

Lecture attendees will able to: Name the American College of Rheumatology

(ACR) diagnostic criteria Recognize typical History and Physical

findings List Treatment options and their efficacy

Skepticism in Perspective

Who is Dr William Harvey (1578-1657) ? Credited with first correctly describing, in exact detail, the properties of

blood being pumped around the body by the heart.

Who is Dr Ignaz Semmelweis(1818-1865)? Hungarian physician who demonstrated that puerperal fever was

contagious and that its incidence could be drastically reduced by enforcing appropriate hand-washing behavior by medical care-givers.

Who is Dr Joseph Lister (1827-1912) ? Father of modern surgery, he developed the principles of antiseptic

surgery after recognizing that postoperative wound infections did not arise spontaneously but rather were due to germs in the environment contaminating the wound.

Definition of Fibromyalgia (FM)

Tender points/pain in fibrous tissues, muscles, tendons, ligaments without inflammation (fibromyositis)

Any fibromuscular tissues may be involved, but those of the occiput, neck, shoulders, thorax, low back, and thighs are especially affected

American College of Rheumatology (ACR) Criteria*

Widespread pain for at least 3 months including:

Pain on the right and left sides of bodyPain above and below the waist Pain in the axial skeleton

AND……….

*Arthritis Rheum 1990 Feb;33(2):160

Pain on palpation with a 4-kg force in 11 out of 18 sites

Occiput - Low cervical Trapezius - Supraspinatus Lateral epicondyle - Greater trochanter Knee - Gluteus Maximus Lateral to second costochondral junction

Tender Points of FM

Nontender control points = mid forehead and anterior thigh

ACR Criteria

Is established on the basis of clinical observations.

Is a condition with signs and symptoms that exist on a continuum.

Often requires observation over time to firmly establish the diagnosis

Difference between FM and Myofascial Pain Syndrome

Defined by presence of trigger points Trigger points often have nodular texture

similar to a pencil eraser Trigger points located within taut bands of

muscle (tender points are not) Pain pattern limited to particular region Palpation of trigger points often reproduces

pain radiation pattern/muscle twitch

Prevalence of FM

Estimates of prevalence are 3.4 percent for women and 0.5 percent for men

Female-to-Male ratio of 9:1

Typically women aged 20-50 years

Cost Burden

Outpatient follow-up averages 10 visits/year

Hospitalization average once every 3 yrs Mean annual cost of medical care =

$2,274/patient* Many patients report receiving some type

of disability payment.

*Arthritis Rheum 1997 Sep;40(9):1553

Mortality/Morbidity

FM is a chronic relapsing condition. Long term follow up:

50% dissatisfied with their health

59% rate their health as fair/poor. More comorbid medical conditions and

surgical interventions compared to other rheumatic disorders.

Etiology

Etiology remains unclear Require a biopsychosocial, not just a

biomedical, viewpoint

Common Biopsychocial Features Given in Explanatory ModelsLikely related: Stress Depression Fatigue Chronic Illness

Not shown to be related: Toxins Immune System

Dysfunction Infection due to yeast or

viruses

Biomedical Factors

Dysregulation of autonomic system Dysregulation of neuroendocrine

system

Infectious mononucleosis (Epstein Barr Virus) not likely causative*

*Arch Intern Med 1999 Apr 26;159(8):865

Neuroendocrine System

Changes in neuroendocrine transmitters: serotonin, substance P, growth hormone and cortisol

Elevation of CSF substance P levels to three times normal levels.

Alteration in hypopituitary - adrenal axis with low production of cortisol.

Core Concepts in Understanding Pain in FM

Generalized decrease pain perception threshold

Hyperalgesia

amplification of pain experienced from peripheral

stimuli that are expected to be painful

Allodynia

pain with stimuli that should not cause pain such as

gentle touching

Autonomic System

Provocation of symptoms during tilt table testing with significant prevalence of neurally mediated hypotension.

Diagnostic Testing

Minimum of testing To Rule out other Causes may

consider: TSH – R/O Hypothyroidism

ESR, CBC –R/O Rheumatic Disease

CPK –R/O Myopathies

ANA, RF, serum complement levels,

Lyme titer, PPD, RPR, HIV, Hep C

Clinical Diagnosis

Widespread pain – 98% Soft tissue pain/tender points Sleep disturbance Chronic fatigue Associated co morbid conditions Associated rheumatic diseases

Why is Diagnosis Important?

“Making a definite diagnosis of fibromyalgia reduces patients' utilization of medical resources and improves satisfaction with healthcare.”

Quotation excerpt: DynaMed@ www.dynamicmedical.com

Key Patient Education Points

Chronic but nonprogressive disease Education about pain modification More healthful lifestyle Reassurance that fibromyalgia is not a

psychiatric disturbance and not rare

Treatment

The goals of treatment for fibromyalgia are to control pain and improve function.

These goals can be met using a variety of techniques

Clinical studies have shown mild to moderate improvement with low-dose antidepressant therapy and exercise.

Antidepressants

Tricyclic antidepressants (TCA’s) 25-50 mg of amitriptyline (Elavil) (Best Evidence – Level 1)

Selective serotonin reuptake inhibitors (SSRI’s) 20 mg of fluoxetine (Prozac)

Combinations of the two may be more effective than either agent taken alone.

Medications with Unproven Efficacy

Nonsteroidal Anti-Inflammatory Agents (NSAIDs): Although commonly prescribed in analgesic doses, NSAIDs have not been proved to be effective in the treatment of fibromyalgia.

Avoid corticosteroids and narcotics

Graded Exercise Therapy

Aerobic exercise programs more beneficial than flexibility or relaxation programs

Appropriate pacing should be encouraged Respect that fluctuations in symptoms will

influence ability to participate Encourage adequate rest and recovery time

Alternative Approaches to

Conventional therapies….

Alternative Medicine Approaches

Acupuncture Supportive counseling/psychotherapy Therapeutic touch disciplines SAM-e

Acupuncture

Has had little or no benefit in recent meta- analysis review*

Supported by 1-2 randomized trials

May be helpful for select patients

*Ann Intern Med 2005Jul5;143(1):10

SAM-e (S-adenosylmethionine)

Not an herb, hormone, vitamin, or nutrient Synthetic form of chemical produced naturally

in the body Sold as "natural" treatment for depression,

arthritis, and liver disease SAM-e for fibromyalgia = limited evidence but

some trials are encouraging* * J Musculoskel Med 2004 Jul;21(7):361

Counseling/Psychotherapy

Cognitive Behavioral Therapy:

Based on the theory that our thoughts cause our feelings and behaviors, not external things, like people, situations,and events.  The benefit of this is that we can change the way we think to feel / act better even if the situation does not change.

Therapeutic Touch Disciplines

Integrated with conventional treatments to meet the challenge of treating Fibromyalgia

Massage therapy with lighter to medium pressure

Aromatherapy massage Energy therapies such as Reiki and Foot

Reflexology. “Relaxation response” may help chronic pain

Reiki (pronounced ray-key)

Means “universal life energy.”

Natural form of hands-on energy transfer.

Reiki Practitioner channels universal life energy to enhance the recipient’s own bodily energies and natural response to illness.

Summary Of Treatment Recommendations*

Amitriptyline 25-50 mg nightly Aerobic exercise, efficacy not

maintained if exercise stops Cognitive behavioral therapy Patient education

*JAMA November 17, 2004;292:2388-95

Status of EBM in Treatment of FM

Student: There seems to be a need for good quality research in the field of hypnosis.

Professor: I would never allow it in my department.

Student: Why not? Professor: Because hypnosis is not a

respectable field for research. Student: Why not?

EBM cont’d

Professor: Because it has no serious published literature.

Student: Why is there no literature? Professor: Because nobody has done the

research. Student: Why has nobody done the research? Professor: Because it's not a respectable field

of research.

Questions ?