Fibromyalgiaand Chronic Fatigue

Tory Davis PA-C

Fibromyalgia One of the most common rheumatic

syndromes in ambulatory medicine 3-10% of the population 10-20% of pts seeing rheumatologists Annual cost for direct care about $20

billion or $2300/pt More common in females, ages 20-50 No objective findings No diagnostic labs or imaging

Diagnostic Criteria History of widespread pain for at least

3 months – Achy and stiff– Bilateral symptoms– Above and below waist– Worse at neck, shoulders, low back, hips

11 of 18 tender points (elicited by pressure of 4 kg/cm2)

Tender Points

Other common symptoms

Fatigue Sleep disorder Headache IBS (irritable bowel

syndrome) Irritable bladder “Fibro fog” - haze

Low back pain Mood disorder Multiple chemical

sensitivities Sexual dysfunction TMJ dysfunction Bruxism – grinding

teeth at night

…and the list goes on Pelvic pain Dysmenorrhea Restless leg syndrome Subjective numbness – feels numb,

but can sense on neuro test Exercise-induced pain and fatigue

Central Sensitization Pathophysiologic abnormality of CNS Sensory impulses amplified at spinal

cord level– In dorsal horn nocioceptive neurons

Proposed Causes Serotonin (much lower levels in women

compared to men) Substance P- aberrant pain perception? Sleep disturbance Injury/trauma Infection Psychological stressors- may increase pro-

inflammatory cytokines via impaired cortisol response

Hormones- ?neuroendocrine dysfunction

DDx Polymyalgia rheumatica – proximal

weaknesss Rheumatoid arthritis Sleep apnea Lupus Multiple sclerosis Thyroid disorder (hypo, usually) Neuropathies Mental illness

DDx continued Substance abuse Cancer Infection Medication side effects Malingering – people use it to get other

benefits

Work-up Dx of exclusion – must exclude! TSH (thyroid stimulating hormone) ESR (erythrocyte sedimentation rate) CBC (complete blood count) ANA (antinuclear antibody) RF (rheumatoid factor) Sleep study Psych screening tools

Physical Exam: Normal, except: Pain is present at multiple FM points

when pressure is applied. – Interestingly, it can felt virtually anywhere

pressure is applied, including control areas (forehead, thumbnail), which are relatively insensitive to pain in normal subjects.

Allodynia – “other pain”– Pain from stimuli that are not normally painful

Risk factors Sex (female, that is) Family history (nature/nurture?) Age- early/mid adulthood Other rheumatic dz: lupus, RA,

ankylosing spondylitis Disturbed sleep: OSA, RLS

Treatment This is a chronic disease. Requires

more than a Rx pad. Pt self-management Meds- only treating the symptoms.

Not curative nor disease-modifying except as they improve pt ability to self-manage and improve QOL

Self-Management Pts unwilling to engage in proactive

self care have poorer prognosis Regular low-impact exercise Regular sleep- no naps, limit caffeine Education about the dx and about self Support groups

Prognosis Better if ongoing stressors are relieved

and self-efficacy for pain control can be achieved.

Worse for patients who are highly distressed and have longstanding FM, major psych disease, or ingrained pattern of work avoidance.

Complementary and alternative treatment

Massage Acupuncture/ acupressure Myofascial release therapy Chiropractic treatment or OMT Cognitive behavioral therapy (CBT)

CBT Cognitive Behavioral Therapy Purpose: to redefine illness beliefs and

learn symptom reduction skills to change behavioral response to pain.

Need to sell this idea- not therapy “because it’s all in your head” but as a tool to improve prognosis.

Tools: gate control, relaxation, reframing

Pharm Tx TCAs: amitriptyline (Elavil) SNRIs: duloxetine (Cymbalta), milnacipran

(Savella) venlafaxine (Effexor) SSRIs: (paroxetine, fluoxetine, et al) Muscle relaxants: cyclobenzaprine Antiseizure meds: gabapentin (Neurontin),

pregabalin (Lyrica) Sleep aids- eszolpiclone (Lunesta),

zolpidem (Ambien)

Just say NO No narcotics No benzodiazepines To treat the pain use tramadol

(Ultram)– better proven efficacy than

acetominophen or OTC NSAIDS

CFS Profound fatigue not improved by rest,

worsened by physical or mental activity.

No clear cause. No definitive work-up. No good tx.

Fibromyalgia:pain::CFS:lassitude

CFS- Who? Female > male (3:1)

Usually not pediatric patients, but otherwise, any age, racial, ethnic or SES group

CFS Diagnostic Criteria Severe chronic fatigue ≥ 6 months

with other medical conditions excluded

AND…

AT LEAST 4 OF THESE ↓ STM or concentration Sore throat Tender cervical or axillary lymph nodes Muscle pain Headache (new type, pattern or severity) Unrefreshing sleep Post-exertional malaise lasting ≥ 24 hours Multi-joint pain without swelling or redness

Associated symptomsThese are NOT diagnostic criteria

Abd pain Etoh intolerance Bloating Chest pain Chronic cough Diarrhea Dizzy Dry eyes/mouth Paresthesias

Otalgia Palpitations Jaw pain Morning stiffness Nausea Night sweats Dyspnea Wt loss Etc etc etc etc etc etc etc etc etc…

Course Sx can remit and recur, or can

fluctuate in severity. Some pts will recover 100%, but

when? Some pts have progressively

worsening sx Can be lifelong

Causes A sampling of proposed, not proven

etiologies: Iron deficiency anemia Hypoglycemia Hx allergies Viral infection Immune system dysfunction Mild chronic hypotension Alteration in HPA axis function Sleep dysfunction Other

Risk factors What is a risk factor?

– A condition or value that alters the likelihood of the occurrence of a disease

Females more likely to be affected Gulf War veterans have 10-fold increased

incidence vs non-deployed vets Other?

We don’t know.

Role of Sleep Diagnosable sleep disorder present in

40-80% of CFS cases, but tx of sleep d/o only results in modest improvement of CFS sx.

? Effect rather than cause?

Differential diagnosis Fibromyalgia Multiple chemical

sensitivities Chronic mono Thyroid dysfunction Sleep apnea Narcolepsy Mental illness

Cancer Eating disorder Obesity Substance abuse Medication side

effect Somatization d/o Malingering

Work up Complete Hx Complete PE Psych screening tools Labs: Exclusionary, not confirmatory!

Labs/Work-up CBC CMP TSH ESR ANA RF UA

PPD HIV Lyme serology in

endemic areas ?CXR or other imaging MRI may show non-

diagnostic subcortical frontal lobe punctate hyperintensities

CFS Complications Deconditioning Med side fx Social isolation Loss of job Lifestyle restrictions Depression (from sx or lack of dx)

CFS Treatment Tx is directed at sx- Goal is to regain

some level of previous function and well-being.

Try NOT to aggravate existing sx or to create new ones.

Limit cost

CFS Tx- Non Pharm Physical activity- “Know thyself.” Pace

thyself. Avoid push-crash phenom Massage Acupuncture Acupressure Chiropractic tx OMT Yoga, tai chi Meditation

More non-pharm tx Education- knowledge is power. CBT Colonics?! Go ahead and Google it. Strive for health, but don’t grasp at

straws.

CFS Treatment- Meds Pts with CFS seems very sensitive to meds,

so START LOW, GO SLOW NSAIDS for pain- *these work for CFS, not

for fibromyalgia– Remember fibromyalgia pain responds better to

tramadol Low dose TCAs to improve sleep, decrease

pain Antidepressants/anxiolytics

More meds Stimulants: modafinil (Provigil) Antimicrobials- NO. Not unless proven

concurrent infection. Gamma globulin, Ampligen, antifungals,

corticosteroids- no evidence of efficacy Vitamins/herbals- many claim benefit, few

prove it. ASK what they’re using. – Natural ≠ good