FibromyalgiaFibromyalgia

FibromyalgiaFibromyalgia What do you know about fibromyalgia?What do you know about fibromyalgia? Who gets it?Who gets it? What is the cause?What is the cause? What are the symptoms?What are the symptoms? How many of the tender sites can you How many of the tender sites can you

identify?identify? How is it treated?How is it treated?

Who gets Fibromyalgia?Who gets Fibromyalgia?

Lack of good population based studiesLack of good population based studies Prevalence ~0.5 - 4% Prevalence ~0.5 - 4% 70 – 90% female70 – 90% female 90% Caucasian90% Caucasian Average age of onset = 30 – 55 yrsAverage age of onset = 30 – 55 yrs Can start > 55 yrs old but usually due to Can start > 55 yrs old but usually due to

underlying disease (infection, neoplasm etc)underlying disease (infection, neoplasm etc) Up to 30% of patients in gen med OPDUp to 30% of patients in gen med OPD

Prevalence of FibromyalgiaPrevalence of Fibromyalgia

Population Prevalence (%)900 randomly selectedindividuals, aged 50-70years

1.0

200 consecutive generalmedical patients

5.0

Hospitalized patients 7.5

General medical clinic 5.7

Family practice clinic 2.1

Rheumatology clinic 14.0 - 20.0

AetiologyAetiology

UnknownUnknown Reports of preceding illnesses:Reports of preceding illnesses:

Viral (parvovirus, hep C)Viral (parvovirus, hep C) Lyme diseaseLyme disease Physical trauma (whiplash injury)Physical trauma (whiplash injury) Emotional traumaEmotional trauma Localised pain disorderLocalised pain disorder Drug withdrawal (glucocorticoids)Drug withdrawal (glucocorticoids)

AetiologyAetiology

Pain amplification:Pain amplification: ? Sleep disturbance? Sleep disturbance ? Disordered endorphin / enkephalin response ? Disordered endorphin / enkephalin response

in descending analgesic pathway (in descending analgesic pathway ( serotonin) serotonin) Substance P in CSFSubstance P in CSF

Fibromyalgia – ACR Fibromyalgia – ACR Criteria for classification Criteria for classification

19901990 History - widespread pain at lease History - widespread pain at lease

3/123/12

affecting affecting both sides of bodyboth sides of body

++ above and below waistabove and below waist

+ + axial skeletal painaxial skeletal pain Examination – Characteristic tender Examination – Characteristic tender

pointspoints

Otherwise unremarkableOtherwise unremarkable Laboratory tests – all normalLaboratory tests – all normal

Tender PointsTender Points

18 points (9 pairs)18 points (9 pairs)

>11/18 required for >11/18 required for > 3 months> 3 months

Pressure = 4kg/cmPressure = 4kg/cm22

Other symptoms often Other symptoms often present or reported in present or reported in

historyhistory Morning stiffnessMorning stiffness FatigueFatigue Sleep disturbanceSleep disturbance DepressionDepression AnxietyAnxiety HeadacheHeadache ParasthesiaParasthesia Impaired memory/concentrationImpaired memory/concentration

SymptomsSymptoms Fatigue:Fatigue:

Worse in morning / on minimal exertionWorse in morning / on minimal exertion Due to disturbed sleep Due to disturbed sleep (cf inflammatory disorders in which fatigue (cf inflammatory disorders in which fatigue

is due to pro-inflammatory cytokines)is due to pro-inflammatory cytokines)

Paraesthesia:Paraesthesia: 50%50% Assos with subjective weaknessAssos with subjective weakness No neurological abnormalitiesNo neurological abnormalities

SymptomsSymptoms

50%: 50%: Subjective joint swellingSubjective joint swelling(no swelling on exam(no swelling on examnn))

33%:33%: Depression (50-70% PMH depression)Depression (50-70% PMH depression) 15%:15%: Dry eyes & mouthDry eyes & mouth 10%: 10%: Raynaud’s PhenomenonRaynaud’s Phenomenon Also:Also: Migraine / Tension headacheMigraine / Tension headache

Irritable bowel syndromeIrritable bowel syndrome

DysmenorrhoeaDysmenorrhoea

AnxietyAnxiety

Differential Diagnosis Differential Diagnosis Differential Diagnosis Helpful Differential Features

Rheumatoid Arthritis Synovitis, acute phaseresponse

SLE Dermatitis, serositis, renaldisease

PMR ESR, elderly, steroidresponsive

Myositis muscle enzymes,weakness > pain

Hypothyroidism Abnormal TFT’s

Neuropathies Clinical and EMG evidenceof neuropathy

Concomitant Concomitant ConditionsConditions

Concomitant Conditions Relationship withFibromyalgia

Depression 25-60% fibromyalgiapatients

IBS 50-80% fibromyalgiapatients

Migraine 50% fibromyalgiapatients

Chronic fatigue syndrome 70% of CFS cases meetcriteria for fibromyalgia

Myofascial pain ? localised form offibromyalgia

ManagementManagement

““Multidisciplinary Approach”Multidisciplinary Approach”

Patient educationPatient education Correction of sleep disturbanceCorrection of sleep disturbance Graded aerobic exerciseGraded aerobic exercise Physical therapy / educationPhysical therapy / education Treatment of associated disordersTreatment of associated disorders Psychological behavioural councellingPsychological behavioural councelling

EducationEducation

1.1. FMS symptoms are FMS symptoms are realreal

2.2. There is no sinister underlying pathologyThere is no sinister underlying pathology

3.3. The patient has control over many The patient has control over many components that may modulate the components that may modulate the symptoms symptoms

Pain and sleep disturbance cyclePain and sleep disturbance cycle

Disease, illness,

Sleep disturbance

Insufficient, deep, non-REM sleep

Life crisis, anxiety

Functional disturbance, fatigue, widespread muscular pain and tenderness

Graded Exercise Graded Exercise

Improves muscle conditioningImproves muscle conditioning Interrupts feedback loopInterrupts feedback loop Can improve sleepCan improve sleep Releases endorphinsReleases endorphins Needs to be sustainable (be a tortoise not a Needs to be sustainable (be a tortoise not a

hare)hare) Aerobic / non-impactAerobic / non-impact Physio can help design regime for patientPhysio can help design regime for patient

MedicationsMedications NSAID (Ibuprofen and Naproxen) of no benefitNSAID (Ibuprofen and Naproxen) of no benefit Prednisolone no benefitPrednisolone no benefit Amitriptyline and Cyclobenzaprine significantly Amitriptyline and Cyclobenzaprine significantly

better than placebobetter than placebo Amitriptyline 25 mg-50 mg benefit seen 25-Amitriptyline 25 mg-50 mg benefit seen 25-

45% patients45% patients Fluoxetene comparable effect Amitriptyline Fluoxetene comparable effect Amitriptyline

single trialsingle trial Fluoxetene plus Amitriptyline better than either Fluoxetene plus Amitriptyline better than either

alone single study alone single study

MedicationsMedications AmitriptylineAmitriptyline

Taken at night (1 – 3 hrs before sleep)Taken at night (1 – 3 hrs before sleep) 10 – 25 mg initially increasing up to 100mg10 – 25 mg initially increasing up to 100mg Onset of relief of symptoms suggests that Onset of relief of symptoms suggests that

the mechanism is not anti-depressantthe mechanism is not anti-depressant

FluoxetineFluoxetine One study showed better results with 20mg One study showed better results with 20mg

od in conjunction with TCA than aloneod in conjunction with TCA than alone

PrognosisPrognosis Tertiary care centres:Tertiary care centres:

majority continue to experience symptoms despite majority continue to experience symptoms despite therapy therapy

Community based study:Community based study: 25% asymptomatic and 25% improved after Rx25% asymptomatic and 25% improved after Rx

Better results with a sympathetic patient – Better results with a sympathetic patient – physician relationship and organised approach physician relationship and organised approach to Rxto Rx

25% of FMS pts in USA on disability allowance25% of FMS pts in USA on disability allowance

Take-home messagesTake-home messages

1.1. FMS is part of a spectrum of pain & FMS is part of a spectrum of pain & fatigue disordersfatigue disorders

2.2. Can occur as a secondary feature of Can occur as a secondary feature of chronic disease and make management chronic disease and make management decisions difficult (e.g RA)decisions difficult (e.g RA)

3.3. Difficult to treat but better results with an Difficult to treat but better results with an organised sympathetic approachorganised sympathetic approach