Fibromyalgia Syndrome Fibromyalgia Syndrome (FMS)(FMS)

Mini-Med School 2007Mini-Med School 2007

Raymond H. Flores, MD, FACRRaymond H. Flores, MD, FACRDepartment of MedicineDepartment of Medicine

Division of Rheumatology & Clinical ImmunologyDivision of Rheumatology & Clinical Immunology

OUTLINEOUTLINE

What is Fibromyalgia (FMS)?What is Fibromyalgia (FMS)?

What causes it?What causes it?

Who gets it?Who gets it?

How is it diagnosed?How is it diagnosed?

How is it treated?How is it treated?

What are some of the common What are some of the common misconceptions about the syndrome?misconceptions about the syndrome?

What is Fibromyalgia (FMS)?What is Fibromyalgia (FMS)?

A clinical A clinical syndrome syndrome characterized by characterized by widespread muscular widespread muscular painpain (usually (usually chronic), chronic),

fatiguefatigue and and

muscle tenderness (muscle tenderness (tender tender points)points)

What is FMS? (cont.)What is FMS? (cont.)

Additional symptoms are common and Additional symptoms are common and include:include:

- - poor sleeppoor sleep almost always almost always- headaches- headaches- irritable bowel syndrome- irritable bowel syndrome- cognitive and memory problems- cognitive and memory problems “ “fibro fog”fibro fog”- numbness and tingling in fingers and toes- numbness and tingling in fingers and toes

What is FMS? (cont.)What is FMS? (cont.)

- irritable bladder- irritable bladder- temporomandibular joint (TMJ) disorder- temporomandibular joint (TMJ) disorder- restless leg syndrome- restless leg syndrome- dry eyes and dry mouth- dry eyes and dry mouth- morning stiffness- morning stiffness- anxiety and depression- anxiety and depression

Symptoms including Symptoms including painpain may wax and wane may wax and wane over timeover time

What causes FMS?What causes FMS?

Cause is Cause is unknownunknown

Abnormally high levels of Substance P in Abnormally high levels of Substance P in spinal fluid in some patientsspinal fluid in some patients

Substance P important in transmission Substance P important in transmission and amplification of pain signals to and and amplification of pain signals to and from brainfrom brain

““Volume control” is turned up too high in Volume control” is turned up too high in brain’s pain centersbrain’s pain centers

What causes FMS? (cont)What causes FMS? (cont)

Familial tendency to develop FMS Familial tendency to develop FMS suggests suggests genetic genetic roleroleCan be triggered by physical, emotional or Can be triggered by physical, emotional or environmental stressors such as car environmental stressors such as car accidents, repetitive injuries and certain accidents, repetitive injuries and certain diseasesdiseasesPatients with Rheumatoid arthritis and Patients with Rheumatoid arthritis and SLE (Lupus) are more likely to develop SLE (Lupus) are more likely to develop FMSFMS

What causes FMS? (cont.)What causes FMS? (cont.)

Other conditions such as Lyme disease Other conditions such as Lyme disease and obstructive sleep apnea (OSA) have and obstructive sleep apnea (OSA) have been associated with FMSbeen associated with FMS

Sleep deprivation with disruption of delta-Sleep deprivation with disruption of delta-wave sleep (non-REM stage IV) is wave sleep (non-REM stage IV) is associated with day-time fatigue andassociated with day-time fatigue and

fibromyalgia syndromefibromyalgia syndrome

Who gets FMS?Who gets FMS?

Affects as many as 1 in 50 AmericansAffects as many as 1 in 50 Americans

Most common in middle-aged womenMost common in middle-aged women

Men and children may also develop the Men and children may also develop the disorderdisorder

Patients with RA, SLE and Ankylosing Patients with RA, SLE and Ankylosing spondylitis are more likelyspondylitis are more likely

Women who have a family member with Women who have a family member with FMS are more likely to develop itFMS are more likely to develop it

How is FMS diagnosed?How is FMS diagnosed?

A diagnosis is made by evaluation of A diagnosis is made by evaluation of symptoms and presence of symptoms and presence of tender tender pointspoints

American College of Rheumatology American College of Rheumatology Classification Criteria for Fibromyalgia Classification Criteria for Fibromyalgia (1990)…….(1990)…….widespread widespread pain for at least 3 pain for at least 3 months months and and

pain in pain in 1111 out of out of 1818 tendertender pointpoint sites on sites on digital palpationdigital palpation

ACR classification criteria: ACR classification criteria: fibromyalgiafibromyalgia

Both criteria must be satisfiedBoth criteria must be satisfied– History of widespread pain for more than 3 months, on both History of widespread pain for more than 3 months, on both

sides of the body, above and below the waist, and axial skeleton sides of the body, above and below the waist, and axial skeleton (cervical spine, anterior chest, thoracic pain, or low back)(cervical spine, anterior chest, thoracic pain, or low back)

– Pain in 11 of 18 tender point sites on digital palpation with Pain in 11 of 18 tender point sites on digital palpation with approximate force of 4 kg.approximate force of 4 kg.

Presence of second clinical disorder does not exclude diagnosis of Presence of second clinical disorder does not exclude diagnosis of fibromyalgia.fibromyalgia.

Fibromyalgia: tender points Fibromyalgia: tender points (diagram)(diagram)

How is FMS diagnosed? (cont.)How is FMS diagnosed? (cont.)

X-rays, blood tests, specialized scans such as X-rays, blood tests, specialized scans such as nuclear medicine and CT, muscle biopsies are nuclear medicine and CT, muscle biopsies are all all normalnormal

Objective “markers of inflammation” such as Objective “markers of inflammation” such as ESR (erythrocyte sedimentation rate) are normalESR (erythrocyte sedimentation rate) are normal

Must be distinguished from other common Must be distinguished from other common diffuse pain conditions such as RA, SLE, diffuse pain conditions such as RA, SLE, Hypothyroidism and Polymyalgia Rheumatica Hypothyroidism and Polymyalgia Rheumatica (PMR)(PMR)

How is FMS treated?How is FMS treated?

Fibromyalgia is a chronic condition Fibromyalgia is a chronic condition managed with both medications and managed with both medications and physical modalitiesphysical modalities

Medication therapy is largely symptomatic, Medication therapy is largely symptomatic, as there is no definitive treatment cure for as there is no definitive treatment cure for fibromyalgiafibromyalgia

How is FMS treated? (cont.)How is FMS treated? (cont.)

Current studies suggest that the best Current studies suggest that the best pharmacologic treatment for treating pain pharmacologic treatment for treating pain and improving sleep disturbance includes:and improving sleep disturbance includes:

- Tricyclic compounds such as - Tricyclic compounds such as cyclobenzaprine (FLEXERIL) and cyclobenzaprine (FLEXERIL) and amitriptyline (ELAVIL)amitriptyline (ELAVIL)

- Dual reuptake inhibitors such as - Dual reuptake inhibitors such as venlafaxine (EFFEXOR), duloxetine venlafaxine (EFFEXOR), duloxetine (CYMBALTA) and tramadol (ULTRAM)(CYMBALTA) and tramadol (ULTRAM)

- SSRIs/ antidepressants such as fluoxetine - SSRIs/ antidepressants such as fluoxetine (PROZAC), paroxetine (PAXIL) and (PROZAC), paroxetine (PAXIL) and sertraline (ZOLOFT) for depression and sertraline (ZOLOFT) for depression and painpain

- Recent studies have shown that the anti-- Recent studies have shown that the anti-epileptics (seizure meds) gabapentin epileptics (seizure meds) gabapentin (NEURONTIN) and pregabalin (LYRICA) (NEURONTIN) and pregabalin (LYRICA) have been effectivehave been effective

- NSAIDs (non-steroidal anti-inflammatory drugs) - NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen and naproxen are generally such as ibuprofen and naproxen are generally ineffectiveineffective

- Long acting opioids (narcotics) generally are not - Long acting opioids (narcotics) generally are not of great benefit eitherof great benefit either

- Benzodiazepines such as diazepam (VALIUM) - Benzodiazepines such as diazepam (VALIUM) and clonazepam (KLONIPIN) may be useful for and clonazepam (KLONIPIN) may be useful for patients with restless leg syndrome or very patients with restless leg syndrome or very severe sleep disturbance who have not severe sleep disturbance who have not responded to other therapiesresponded to other therapies

N.B.N.B.

The US Food and Drug Administration The US Food and Drug Administration has not yet approved any medications to has not yet approved any medications to treat FMStreat FMS

Other Therapies for FMSOther Therapies for FMS

Complementary and alternative therapies Complementary and alternative therapies have been used although not well studied have been used although not well studied in FMSin FMS

- Therapeutic massage- Therapeutic massage

- Myofascial release therapy- Myofascial release therapy

- Acupuncture- Acupuncture

Other Therapies for FMSOther Therapies for FMS

Patient Self-ManagementPatient Self-Management - Schedule time to relax, including deep breathing - Schedule time to relax, including deep breathing

and meditationand meditation - Establish routine for going to bed and waking up- Establish routine for going to bed and waking up - Aerobic exercise on regular basis- Aerobic exercise on regular basis - Self-education i.e. Arthritis Foundation, - Self-education i.e. Arthritis Foundation, National Fibromyalgia Assn.National Fibromyalgia Assn. - Support group- Support group - Cognitive Behavioral Therapy (CBT)- Cognitive Behavioral Therapy (CBT)

Common Misconceptions Common Misconceptions

Eleven (11) out of 18 tender points needed Eleven (11) out of 18 tender points needed to make the diagnosis of FMS to make the diagnosis of FMS

(2005 ACR Classification Criteria)(2005 ACR Classification Criteria)

FALSEFALSE

Tenderness can be widespread Tenderness can be widespread without without tendertender pointspoints

The major symptom in FMS is painThe major symptom in FMS is pain

FALSEFALSE

A variety of neurologic abnormalities may A variety of neurologic abnormalities may be described including numbness and be described including numbness and tingling of the extremities, cognitive and tingling of the extremities, cognitive and memory problems, irritable bowel memory problems, irritable bowel

symptoms, etc.symptoms, etc.

It’s not a real illness, it’s in the It’s not a real illness, it’s in the

“ “patient’s head”patient’s head”

FALSEFALSE

A real condition with severe physical effects in some, although A real condition with severe physical effects in some, although psychologic factors psychologic factors including including depression may be the major determinant of pain in othersdepression may be the major determinant of pain in others

The prognosis is “hopeless”The prognosis is “hopeless”

FALSEFALSE

Early, aggressive treatment can prevent Early, aggressive treatment can prevent physical deconditioning and loss of physical deconditioning and loss of functionfunction