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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Fibromyalgia vs Polymyalgia
Richard A. Pascucci D.O., F.A.C.O.I
PCOM Professor Emeritus
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Disclosures
⚫ I have no relevant financial relationships or
conflicts of interest to disclose.
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MONOARTICULAR POLYARTICULAR
Crystals Infections CTD Seronegative Spondylo
Gout Septic Arth. RA A.S.
CPPD Bursitis SLE Reiter’s
HADD Lyme PSS Psoriatic Oligo.
Oxalate Fungus PM/DM Colitic
TB Vasculitis Yersinia
MONO/Oligo
NON-ARTICULAR ENDOCRINE & DEGENERATIVE
METABOLIC
Primary
Fibromyalgia Thyroid Osteoarthritis
Bursitis Crystals DISH Secondary
Tendinitis Amyloid Mono.
RSD Aseptic Necrosis
PMR METABOLIC BONE DISEASE Charcot’s
Osteoporosis
Paget’s
Osteomalacia
Hyperpara
CLINICAL CLASSIFICATION OF THE RHEUMATIC
DISEASES
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
NON-ARTICULAR RHEUMATISM
Fibromyalgia (Fibrositis)
Bursitis/Tendinitis
Tenosynovitis
Viral Myalgia
Hematoma (Muscular)
Reflex Dystrophies
Referred Pain
Nerve Entrapment
Pyschogenic Rheumatism
Phlebitis
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CASE PRESENTATION
A 35 year old female presents to the office with the
complaint of “Pain All Over”. Her multiple aches and
pains have been present for at least 18 months and are
associated with AM stiffness for at least 2 hours.
Physical exam fails to reveal any true joint abnormality
and laboratory data is unremarkable. She has associated
sleep disturbance and weather change aggravates her
symptoms.
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Fibrositis
Myositis
Myofascial pain syndrome
Myofasciitis
PRIMARY FIBROMYALGIA SYNDROME
• No Inflammation
• Consistent symptom spectrum
• No underlying cause
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
FIBROMYALGIA
Non-articular rheumatism characterized by:
1. Chronic musculoskeletal aches, pains
and stiffness, mostly in muscles,
articular and periarticular areas.
2. “Tender (trigger) points” – exaggerated
tenderness in specific spots.
3. Absence of articular pathology.
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FIBROMYALGIA
1. DEFINITION
2. CLINICAL FEATURES
a) Age
b) Sex
c) Primary vs, Secondary
d) Aggravating Conditions
3. HISTOLOGY
a) Skin Biopsy (“Triggers”)
b) Immunofluorescence
4. ASSOCIATED CLINICAL PROBLEMS
- Other “Soft Tissue” problems
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PFS: MODULATING FACTORS
AGGRAVATING FACTORS
Cold or humid weather
Non-restorative sleep
Physical/mental fatigue
Excess physical activity
Physical inactivity
Anxiety/stress
RELIEVING FACTORS
Warm/dry weather
Hot shower/bath
Restful sleep
Moderate activity
Stretching exercises
Massage
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
PFS: EXAMINATION
POSITIVE
Multiple Tender
Points
Mild soft tissue
swelling (fingers)
Skin pinch
Tenderness
Hyperemia of skin
NEGATIVE
Muscle weakness
Neurologic examination
Joint examination
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ACR CRITERIA FOR FIBROMYALGIA
(1990)
1. History of Widespread Pain
- Left and right side, above and below waist.
- Axial skeletal pain (cervical, thoracic, anterior
chest or low back) also present.
2. Pain in 11 of 18 tender point sites
Occiput Lateral Epicondyle
Low Cervical Gluteal
Trapezius Greater Trochanter
Supraspinatus Knee
Second Rib
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
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⚫ ACR Criteria (Revised 2010)
⚫ - Supplement 1990 Criteria, not replace
⚫ ** Includes Sleep Disturbance
⚫ -Widespread Pain Index (WPI) -7/19 areas
⚫ -Symptom Severity (SS) Score (0-3 scale
⚫ for fatigue, cognitive Sx and
⚫ awakening unrefreshed) + 0-3 for Somatic
⚫ symptoms for a Total Score of 0-12
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CRITERIA FOR DIAGNOSIS
OF FIBROMYALGIA
1) Widespread aching >3 months
2) Local tenderness at 12 of 14 specified sites
3) “Skin roll” tenderness in upper scapular region
4) Disturbed sleep
5) Normal Lab (ESR, SGOT, RF, ANA, CPK, and SI)
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
DIFFERENTIAL DX. of FIBROMYALGIA
1) PSYCHOGENIC RHEUMATISM
2) RA OR OTHER CTD
3) PALINDROMIC RHEUMATISM
4) OSTEOARTHRITIS
5) POLYMYALGIA RHEUMATICA
6) HYPOTHYROIDISM
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LABORATORY DATA (FIBROMYALGIA)
1) CBC
2) SED. RATE (ESR)
3) CMP
4) SEROLOGIES
5) EEG, EMG
6) BIOPSY
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ETIOLOGY (FIBROMYALGIA)
1) SLEEP DISTURBANCE
a) Non-REM
b) Alpha Intrusion
2) ?METABOLIC DERANGEMENT
a) Serotonin (Brain)
b) Tryptophan
3) ANXIETY AND/OR DEPPRESSION
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
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MANAGEMENT OF FIBROMYALGIA
1) REASSURANCE
2) ORGIN OF PAIN – explain
3) RELIEF OF MECHANICAL STRESSES – exercise
4) MEDICAL TREATMENT
a) NSAID
b) Heat, Massage, Relaxation, ?OMT
c) Antidepressants
d) Injections
e) Systemic Steroids – Relatively CI
f) Avoid Narcotics!
g) Experimental – Acupuncture, TENS, etc.
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ADDITIONAL THERAPIES
SSRIs - ? EFFECT ON PAIN
TRAMADOL ↓ PAIN IN CONTROLLED TRIAL
(100-400 MG/day)
DULOXETINE 10-60mg/day (SNRI)
PREGABALIN—Analogue to GABA-ion channel modulator
UNCONTROLLED TRIALS
A) Guafenesin
B) Valerian Root
C) Ginseng
D) Melatonin
E) DHEA
4) NO SUPPORTIVE DATA ON TYLENOL OR NSAIDs
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
Additional Therapies (Con’t)
⚫ -Quetiapine (Seroquel)—may benefit but
⚫ may cause weight gain
⚫ -Nabilone (Cesamet)—Cannabinoid
⚫ -Memantine (Namenda)
⚫ -Pramipexole (Mirapex)-Dopamine
⚫ promoter
⚫ -Xyrem-Use in Narcolepsy (Schedule III)
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COMBINATION THERAPY OF
FIBROMYALGIA
“A Randomized Double-Blind Crossover Trail
of Fluoxetine and Amitriptyline in the Treatment
of Fibromyalgia”
D.L.GOLDENBERG, ET AL: A&R 1996; 39: 1852
Conclusion: Combination Better than either Drug Alone
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Combination Therapy
⚫ Utilization of an Anti-Epileptic (e.g.
Pregabalin) plus an Anti-Depressant (e.g.
Amitriptyline or an SNRI) may yield
improvement in pain and fatigue
⚫ --Pain 2016 Jul; 157 (7): 1532
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
GROWTH HORMONE
(NUTROPIN ®)
Dosage
0.006 - 0.025 MG/KG (≤ age 35)
0.006 - 0.125 MG/KG (≥ age 35)
7 Doses/Week
10 mg vial @ $605 or $765 /month
Eg 70kg = 0.42 x 30 days = 12.6 MG/Month
or * 70 X 0.025 = 1.75 X 30 DAYS = 52.5 MG/Month
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A 63-year old female presents to the office with
the complaint of difficulty getting out of a
chair. She also has vague symptoms such as
fatigue and lack of energy in association with
morning stiffness and aching in the proximal
portions of her arms and legs. Lab data reveals
a mild anemia, normal biochemistry profile, and
a Westergren sedimentation rate of 75 mm/hr.
PE is unremarkable.
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
CLINICAL FEATURES OF PMR
[SYMPTOMS AND SIGNS]
Pain
Stiffness
Fatigue
Depression
Disability
Tenderness
Limitation of Motion
- areas involved
Arthritis
Carpal Tunnel Syndrome
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DEFINITION OF PMR
1. Pain in neck, shoulders, and pelvic girdle for
at least one month. Morning stiffness and
gelling without muscle atrophy or weakness.
2. Age ≥ 50 years old
3. ESR ≥ 50 mm/hr
4. Relief of symptoms within 4 days with as low
as 10-15 mg Prednisone per day.
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DIFFERENTIAL DIAGNOSIS
OF PMR_____________________________________________________________________________
RA and other CTD
Viral Myalgias
Polymyositis
Multiple Myeloma
Osteoarthritis
Fibromyalgia
Occult CA
Occult Infection
Endocrine Disturbance
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
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LAB IN PMR
Anemia
ESR ( ≥ 50 MM/HR)
RA (-)
ANA (-)
Muscle Enzymes – Normal
EMG – Normal
Liver Profile
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PMR - THERAPY
A) NSAIDS – trial warranted?
- will not prevent vascular
complications
B) Corticosteroids - *Drug of choice (low dose)
If Sx free x 6-12 months, may D/C steroids
50% may relapse
? Add MTX (steroid sparing)
conflicting reports
Prognosis
? Assoc. with ↑ CV mortality
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
MANAGEMENT OF PMR
ASA or NSAID’s
Corticosteroids
- Dosage
- Duration
Biopsy
- Indications
Education
** N.B. 1 – Sudden Blindness 7 years After Dx.
N.B. 2 - PMR May Evolve into RA
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CONTRASTS BETWEEN FM AND PMR
FM PMR
AGE
STIFFNESS
POOR SLEEP
TENDER PTS.
CONSTITUTIONAL
SYMPTOMS
ESR
30-45
+ -
+++
+++
(-)
NL
>50
+++
+ -
+ -
++
↑↑
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CONTRAST IN THERAPY FM VS PMR
NSAIDS
EXERCISE
TCA’S
STEROIDS
MTX
FM
+
+
++
CI
CI
PMR
-
+-
+-
+++
++
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
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RELATION OF POLYMYALGIA RHEUMATICA
TO TEMPORAL ARTERITIS
Polymyalgia Rheumatica
Biopsy
Pos.
Symptomatic
Temporal
Arteritis
(Biopsy
Positive)
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SYMPTOMS SUGGESTIVE OF
TEMPORAL ARTHERITIS (GCA)
Temporal Cephalgia
Diplopia
Amaurosis Fugax
Scalp Tenderness
Jaw Claudication
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“Fibromyalgia vs. Polymyalgia”Richard A. Pascucci, DO
POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019
DIAGNOSIS OF GCA
Clinical Suspicion
Biopsy of Temporal Artery
- Pathology
- Skip Lesions
- One or Both?
- Negative Biopsy?
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GCA - THERAPY
Corticosteroids 0.7 – 1.0mg/kg/day
- maintain x one month before tapering
* Addition of 81mg ASA
May prevent occlusive disease
* Add Imuran /CTX / MTX
Steroid sparing
* Tocilizumab (Actemra) IV or SubQ
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