APPROACH TO FIBROMYALGIA IN PRIMARY CARE

APPROACH TO FIBROMYALGIA IN PRIMARY

CAREASSOC. PROF DR HÜLYA AKAN

FAMILY MEDICINE

CASE38 yrs old Mrs E.B. addmitted with the complaint of left sided neck, chest, upper back, elbow, lower back, hip pain and accompanying stiffness for about three months. Also she complains of tiredness, difficulty in concentration, waking up tired. She awakens 3-4 times at night and has difficulty back to sleep recently. In the last week she also describes frequent urination, dyspnea, dry mouth. She has chronic constipation for years.

Medical History: Left knee injury due to trauma during exercize 2 yrs ago

5 packet/year cigarette smoking, gave up a year agoFamily History: Unremarkable Physical Exam.: BP: 120/70 mmHg Pulse: 78/min R

RR: 16/min regular SpO2:99• Systemic examination unremarkable

• What is your differantial diagnosis ?

• Fibromyalgia is an idiopathic, chronic, nonarticular pain syndrome with generalized tender points. It is a multisystem disease characterized by sleep disturbance, fatigue, headache, morning stiffness, paresthesias, and anxiety. .

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

• Mean age: 34-57, may affect children and older person

• 10 times more often women

• More common in relatives of patients- genetic or environmental?

Demographic and social characteristics

• Female sex

• Being divorced

• Failing to complete high school

• Low income

Physcological factors

• Somatization disorder

• Anxiety

• Personal or familial history of depression

Pathophysiology

• Substantial findings implicate disturbances in the neuroendocrine axis as central to its etiology. This is particularly true of the relationship between the neuroendocrine axis and sleep.

• The sleep electroencephalogram of patients with fibromyalgia indicates disturbance of the non-REM sleep phase by intrusions of alpha waves with infrequent progression to stage 3 and stage 4 sleep. These findings correlate with patient reports of awakening repeatedly and being "unrefreshed by sleep."

• The stages of sleep have concomitant hormone release activity. For example, release of growth hormone occurs primarily during stage 3 and stage 4 of non-REM sleep. One third of patients with fibromyalgia have low insulin growth factor (IGF) levels, an indication of low growth hormone secretion. Furthermore, symptoms of fibromyalgia may be created by disturbing non-REM sleep

• Elevation of cerebrospinal fluid substance P levels (a neurotransmitter associated with enhanced pain perception) to three times normal levels.

• Alteration in the hypopituitary-adrenal axis with low overall production of cortisol. This contrasts with the findings in depression, where a higher-than-normal cortisol level is found.

Presenting Complaints

• Presenting complaints: pain at multiple sites, fatigue, and poor sleep.

• Patients often complain of low back pain, which may radiate into the buttocks and legs. Others complain of pain and tightness in the neck and across the upper posterior shoulders. The pain may be described as a burning or gnawing soreness, stiffness, or aching. Stiffness is typically present on arising in the morning; for most patients, stiffness improves

• as the day progresses.

• Patients complain of feeling exhausted, even upon waking. Many patients awaken frequently at night and have difficulty falling back to sleep.

• A subjective swollen joint feeling without objective swelling, and paresthesias without objective neurologic findings, are two important features of fibromyalgia.

• Complain cold weather more often then others.

• Many patients with fibromyalgia complain of cognitive difficulties such as memory problems, grouping for words, and poor vocabulary.

• Headaches, including migraine type, also are common. Other manifestations include episodes of light-headedness, dizziness, anxiety, or depression.

• Symptoms are aggravated by cold and humid weather, poor sleep, and physical or mental stress. They are improved by warm and dry weather, moderate physical activity, adequate sleep, and relaxation.

DIAGNOSIS

• Fibromyalgia should be considered in any patient with musculoskeletal pain that is unrelated to a clearly defined anatomic lesion.

• Making the diagnosis of fibromyalgia depends on findings from the history and physical examination rather than on diagnostic testing.

• 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.

American College of Rheumatology Criteria for

Classification of Fibromyalgia • Widespread pain for at least three months, defined as the presence of all of the

following: Pain on the right and left sides of the body

Pain above and below the waist (including shoulder and buttock pain)Pain in the axial skeleton (cervical, thoracic or lumbar spine, or anterior chest)

• Pain on palpation with a 4-kg force in 11 of the following 18 sites (nine bilateral sites, for a total of 18 sites):

Occiput: at the insertions of one or more of the following muscles: trapezius, sternocleidomastoid, splenius capitus, semispinalis capitusLow cervical: at the anterior aspect of the interspaces between the transverse processes of C5-C7Trapezius: at the midpoint of the upper borderSupraspinatus: above the scapular spine near the medial borderSecond rib: just lateral to the second costochondral junctionsLateral epicondyle: 2 cm distal to the lateral epicondyleGluteal: at the upper outer quadrant of the buttocks at the anterior edge of the gluteus maximus muscleGreater trochanter: posterior to the greater trochanteric prominenceKnee: at the medial fat pad proximal to the joint line

Tender Points

Tender Points

Control points

• Dorsum of third finger, proximal, interfalangeal, and distal interfalangeal joints

• 1/3 medial and medial points of clavicula

• Frontal head

Table 4. Fibromyalgia diagnostic criteria

ACR 2010• Criteria• 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.

Çift-taraflı: omuz, kol, önkol, kalça (trokanter), bacak-üst, bacak-alt, alt bel, çene; ense, göğüs, abdomen

Yorgunluk, zinde uyanmama, bilişsel, genel somatik belirtiler

Wolfe F. et al. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care Res. 2010;62:600-610.

FİBROMİYALJİ TANI KRİTERLERİ - 2010

•≥ 3 ay süren ağrı• Açıklayıcı hastalık Ø

• Ascertainment• 1) WPI: note the number areas in which the patient has had pain

over the last week. In how many areas has the patient had• pain? Score will be between 0 and 19.• Shoulder girdle, left Hip (buttock, trochanter), left Jaw, left Upper

back• Shoulder girdle, right Hip (buttock, trochanter), right Jaw, right

Lower back• Upper arm, left Upper leg, left Chest Neck• Upper arm, right Upper leg, right Abdomen• Lower arm, left Lower leg, left• Lower arm, right Lower leg, right

• 2) SS scale score:

• Fatigue• Waking unrefreshed• Cognitive symptoms

For the each of the 3 symptoms above, indicate the level 0f severity over the past week using the following scale:

• 0 no problem• 1 slight or mild problems, generally mild or intermittent• 2 moderate, considerable problems, often present and/or

at a moderate level• 3 severe: pervasive, continuous, life-disturbing problems

• The SS scale score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is between 0 and 12.

* Somatic symptoms that might be considered: muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering problem, muscle,weakness, headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen,, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud’s phenomenon, hives/welts, ringing in ears,

• vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing

• difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms.

DİFFERENTIAL DIAGNOSIS

• Myofascial pain syndrome• Chronic fatique syndrome• Romatoid arthritis:Synovitis, positive

serologic tests, high sedimentation rate• Systemic lupus erythematosis:dermatistis,

serositis• Polymyalgia rheumatica:high

sedimentation rate, old patient, response to steroid

• Myositis: İncreased muscle enzymes, muscle fatique rather then pain,

• Hypothyroidism:Abnormal thyroid function tests• Neuropathies:clinical and electrophysiologic

findings of neuropathy• Drug- induced myopathies: statins• Sarcoidosis, osteomalacia, systemic

infections,paraneoplastic syndromes, hyperparathyroidism, inflammatory bowel syndrome, anemias

Fibromiyalji Ayırıcı Tanısı Goldenberg DL. Diagnosis and differential diagnosis of fibromyalgia. Am J Med. 2009;122:S14-S21

Differential DiagnosisMyofascial Pain Syndrome

• Myofascial pain syndrome is characterized by painful, tender areas in the muscles.

• It is a localized disorder without any systemic manifestations.

• It commonly affects the axial muscles. In contrast to the widespread pain of fibromyalgia, the pain in myofascial pain syndrome arises from trigger points in individual muscles.

• On examination, the presence of trigger points is characteristic of myofascial pain syndrome.

Fibromyalgia Myofascial pain s.Sex Women EqualSleep d. Continous Due to painPain Extensive LocalTiredness Common RareMorning stiff. Common RareTender point. Extensive LocalTreatement Drugs, exerc Local prev.Prognosis Chronic Responesive to treat. but may

repeat

Differential DiagnosisChronic Fatique Syndrome

• Chronic pain and fatigue are common to chronic fatigue syndrome and fibromyalgia.

• Chronic fatigue syndrome appears to be an ongoing subclinical inflammatory process manifested by low-grade fever, lymph gland enlargement, and acute onset of the illness, whereas there is no evidence of inflammatory response in fibromyalgia.

Comorbid Conditions Associated with Fibromyalgia

Migraine headache Chronic fatigueIrritable bowel syndromeIrritable bladder Dismenorrhea, menstruel irregularity DepressionRestless legs syndromeTemporomandibular joint syndrome

CASE• Biochemistry, ESR, CRP, RF , fANA, urine

analysis, Blood count are all in normal ranges

• Left hip, left shoulder MR: No pathology

OLGU• Widespread pain index (WPI) : 8

• Symptom severity (SS) scale : 11

Fallow-up:

Patient education

Amitriptilin 25 mg

Mild- moderate exercize

Cognitive behavioural therapy

Treatment Strong evidence

Pharmacologic Nonpharmacologic Amitriptyline, Cardiovascular exercise25 to 50 mg at bedtime Cognitive behavioral therapy

Cyclobenzaprine (Flexeril), Patient education (group form 10 to 30 mg at bedtime using lectures, written materials, demonstrations

Multidisciplinary therapy (e.g., exercise,and cognitive behavioral therapy, patient education and exercise)

TreatmentModerate evidence

Pharmacologic NonpharmacologicDual-reuptake inhibitors(serotonin-NE): Acupuncture

duloxetine (Cymbalta), venlafaxine (Effexor) Milnacipran (2009 FDA approved) Balneotherapy

Fluoxetine (Prozac), 20 to 80 mg at bedtime, Biofeedback with or without a tricyclic antidepressant HypnotherapyPregabalin (Lyrica)

Tramadol (Ultram), Strength training 200 to 300 mg daily, with or without acetaminophen

TreatmentWeak Evidence

Pharmacologic Nonpharmacologic

Chiropractic therapy

Electrotherapy

Manual and massage

therapy

Ultrasonography

TreatmentNo Evidence

Pharmacologic NonpharmacologicCorticosteroids Flexibility exercise

Melatonin Tender point injections

Nonsteroidal anti-inflammatory

drugs

Opioids

Thyroid hormone

Treatment

• GOAL: Control pain

Improve function

• First line: antideprassant + exercise

• Not enough response: Add hypnosis, behavior therapy, accupuncture and/or chiropactic

Fallow -up

• Fibromyalgia Impact Questionnaire (FIQ)• Is an assesment and evaluation instrument

developed to measure fibromyalgia patient status, progress and outcomes

• Composed of 10 items• Measure physical functioning, work diffuculty,

pain, fatique, morning tiredness, stiffness, anxiety and depression

• High scores indicate greater impact of the disease

Social Impact

• 10-25% of patients can not work

• The others needed some regulations in their work

• Ability and functional limitations of the disease still debatable

• Resistance of patients to accept the disease as a disabiliating one

• Vague role of doctors

Case Fallow-up• Fallow-up examination on 15th day: Dramatic

improvement. Regular sleep and no pain. She feels well and cheerfull as in old days. She has not begun regular exercize and has not got appoinment for cognitive behavioural therapy yet.

• She admitted with the complaint of fever, left sided pain one and half months later. There was no fever origin objectively. Temperature was 36,5. ESR ,CRP and leucocyte was in normal range. She had been asked to measure body temperature and record. She visited few days later and stated that she did not measure body tempertaure and she did not feel fever any more.