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1
FibromyalgiaFibromyalgia
WHPLWHPL
22
What is Fibromyalgia?
• Pathogenesis of Fibromyalgia
• Clinical Features and Diagnosis of Fibromyalgia
• Management of Fibromyalgia
• Summary
3
Categorization of Pain ConditionsCategorization of Pain Conditions
Chronic PainChronic PainAcute PainAcute Pain
Central Pain Central Pain AmplificationAmplificationCentral Pain Central Pain AmplificationAmplification
Abnormal pain Abnormal pain processing by CNSprocessing by CNS
(ie, Fibromyalgia)(ie, Fibromyalgia)
Nociceptive PainNociceptive PainNociceptive PainNociceptive Pain
Noxious stimuliNoxious stimuli
(ie, Burn)(ie, Burn)
Inflammatory PainInflammatory PainInflammatory PainInflammatory Pain
InflammationInflammation
(ie, Rheumatoid arthritis)(ie, Rheumatoid arthritis)
Neuropathic PainNeuropathic PainNeuropathic PainNeuropathic Pain
Neuronal damageNeuronal damage
(ie, Herpes zoster)(ie, Herpes zoster)
4
Fibromyalgia (FM): A Chronic Fibromyalgia (FM): A Chronic Widespread Neurologic Pain ConditionWidespread Neurologic Pain Condition
FM is a neurological condition associated with chronic widespread pain (CWP) and tenderness
American College of Rheumatology (ACR) criteria for the diagnosis of FM:– Chronic widespread pain
• Pain for ≥3 months
• Pain above and below the waist
• Pain on left and right sides of body and axial skeleton
– Pain at ≥11 of 18 tender points when palpated with 4 kg of digital pressure
.
5
Risk Factors for FMRisk Factors for FM
Genetic factors– Relatives of FM patients are at higher risk for FM
• First-degree relatives are significantly more likely to have FM• Have significantly more tender points
Environmental factors– Physical trauma or injury– Infections (Lyme disease, hepatitis C)– Other stressors (eg, work, family, life-changing events)– Concurrent medical illness (e.g., SLE, RA, OA, hypothyroidism,
hepatitis)– Medications (steroid)
Gender– Women are diagnosed with FM about 7 times as often as men– peak age 40-60
.
6
CONCURRENT DISEASES WITH FMCONCURRENT DISEASES WITH FM
•Chronic fatigue syndromeChronic fatigue syndrome•Irritable bowel syndromeIrritable bowel syndrome•Muscle, migraine headachesMuscle, migraine headaches•Irritable bladder syndromeIrritable bladder syndrome•Mood disturbancesMood disturbances•VulvodyniaVulvodynia•Temporomandibular joint (TMJ) disorderTemporomandibular joint (TMJ) disorder
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• What is Fibromyalgia?
Pathogenesis of Fibromyalgia
• Clinical Features and Diagnosis of Fibromyalgia
• Management of Fibromyalgia
8
The Normal Pain Processing PathwayThe Normal Pain Processing Pathway
3. A signal is sent via the ascendingascending tract to the brain, and perceived as pain
2. Impulses from afferents depolarize dorsal horn neurons, then, extracellular Ca2+ diffuse into neurons causing the release of Pain Associated Neurotransmitters – GlutamateGlutamate and Substance PSubstance P
1. Stimulus sensed by the peripheral nerve (ie, skin)
4. The descendingdescending tract carries modulating impulses back to the dorsal horn
Pain Pain PerceivedPerceived
Glutamate
Substance P
9
Central Sensitization: A Theory for Central Sensitization: A Theory for Neurological Pain Amplification in FMNeurological Pain Amplification in FM
Central sensitization is believed to be an underlying cause of the amplified pain perception that results from dysfunction in the CNS– May explain hallmark features of generalized heightened pain sensitivity
• Hyperalgesia – Amplified response to painful stimuli • Allodynia - Pain resulting from normal stimuli
Theory of central sensitization is supported by:– Increased levels of pain neurotransmitters
• Glutamate • Substance P
fMRI data demonstrates low intensity stimuli in patients with FM comparable to high intensity stimuli in controls
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Central Sensitization Produces Abnormal Central Sensitization Produces Abnormal Pain SignalingPain Signaling
After nerve injury, increased input to the dorsal horn can induce central sensitizationPerceived pain
Ascendinginput
Descendingmodulation
Nerve dysfunction
Nociceptive afferent fiber
Minimalstimuli
Perceived pain(hyperalgesia/allodynia)
Induction of central sensitization
Increased release of pain neurotransmitters glutamate and substance P
Pain amplification
Increased pain perceptionIncreased pain perception
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FM: An Amplified Pain ResponseFM: An Amplified Pain Response
Pain Pain amplificationamplification
responseresponse
Su
bje
ctiv
e p
ain
in
ten
sity
Su
bje
ctiv
e p
ain
in
ten
sity
Stimulus intensityStimulus intensity
Normal painNormal painresponseresponse
(when a pinprick causes an intense stabbing sensation)
Hyperalgesia
10
8
6
4
2
0
Adapted from Gottschalk A and Smith DS. Am Fam Physician. 2001;63:1979-1986.
Allodynia(hugs that feel painful)
Pain in FMPain in FM
12
fMRI Study Supports the Amplification of fMRI Study Supports the Amplification of Normal Pain Response in Patients With FMNormal Pain Response in Patients With FM
14
12
10
8
6
4
2
0
4.51.5 2.5 3.5
Stimulus intensity (kg/cm2)
Pai
n i
nte
ns
ity
FM (n=16)Subjective pain controlStimulus pressure control
(n=16)
Patients with FM experienced high pain with low grade stimuli
Yellow: Area of overlap (ie, area activated at high intensity stimuli in control patients was activated by low intensity stimuli in patients with FM)
Green: Activated only at high intensity stimulus in controls
Red: Activation at low intensity stimulus in patients with FM
13
FM Pathophysiology: Summary FM Pathophysiology: Summary Central sensitization is a leading theory of FM pathophysiology1
Elevated pain neurotransmitters in CSF of patients with FM– Several studies showed elevated levels of glutamate and
substance P– Elevated levels suggest that this may contribute to pain
amplification
fMRI data supports FM as a disorder of central pain amplification
– Areas activated by high intensity stimuli in control patients were activated by low intensity stimuli in patients with FM
1414
• What is Fibromyalgia?
• Pathogenesis of FibromyalgiaClinical Features and Diagnosis of Fibromyalgia
• Management of Fibromyalgia
1515
Chronic Widespread PainChronic Widespread Pain• CORE criteria of FMCORE criteria of FM
• Pain is in all 4 quadrants of the body ≥3 monthsPain is in all 4 quadrants of the body ≥3 months• Patient descriptors of pain include:Patient descriptors of pain include:44
• Aching, exhausting, nagging, and hurtingAching, exhausting, nagging, and hurting
TendernessTenderness• Sensitivity to pressure stimuliSensitivity to pressure stimuli
• Hugs, handshakes are painfulHugs, handshakes are painful• Tender point exam given to assess tendernessTender point exam given to assess tenderness
• Hallmark features of FMHallmark features of FM44
• HyperalgesiaHyperalgesia• AllodyniaAllodynia
Other SymptomsOther Symptoms• FatigueFatigue• Pain-related conditions/symptomsPain-related conditions/symptoms
• Chronic headaches/migraines, IBC, IC, TMJ, PMSChronic headaches/migraines, IBC, IC, TMJ, PMS• Subjective morning stiffnessSubjective morning stiffness
• Neurologic symptomsNeurologic symptoms• Nondermatomal paresthesiasNondermatomal paresthesias• Subjective numbness, tingling in extremitiesSubjective numbness, tingling in extremities
• Sleep disturbance Sleep disturbance • Non-restorative sleep, RLSNon-restorative sleep, RLS
Clinical Features of FMClinical Features of FM
Other Other SymptomsSymptoms
16
17
Patients With FM Present With Patients With FM Present With a Global Pain Disordera Global Pain Disorder
While the ACR classification criteria focuses on 18 points, patients do not usually speak of tender points1
This is a pain drawing—a patient colors all areas of the body in which they feel pain2
The diagram shows that the pain of FM is widespread1
FrontBack
18
ACR-Recommended Manual Tender Point ACR-Recommended Manual Tender Point Survey for the Diagnosis of FMSurvey for the Diagnosis of FM
Manual Tender Points SurveyManual Tender Points Survey:: • Presence of 11 tender points on palpation to a maximum of 4 kg Presence of 11 tender points on palpation to a maximum of 4 kg
of pressure (just enough to blanch examiners thumbnail)of pressure (just enough to blanch examiners thumbnail)
OCCIPUT –OCCIPUT – At nuchal muscle At nuchal muscle insertioninsertion
GLUTEAL – GLUTEAL – Upper outer quadrant of Upper outer quadrant of gluteal musclesgluteal muscles
GREATER GREATER TROCHANTER –TROCHANTER – Muscle attachments just Muscle attachments just posterior to GTposterior to GT
SUPRASPINATUS – SUPRASPINATUS – At attachment to medial At attachment to medial border of scapulaborder of scapula
TRAPEZIUS – TRAPEZIUS – Upper border of trapezius, Upper border of trapezius, midportionmidportion
LOW CERVICAL –LOW CERVICAL – Anterior aspects of C5, C7 Anterior aspects of C5, C7 intertransverse spacesintertransverse spaces
SECOND RIB SPACESECOND RIB SPACE –– about 3 cm lateral to sternal about 3 cm lateral to sternal
borderborder
ELBOW – ELBOW – Muscle attachments to Muscle attachments to
Lateral EpicondyleLateral Epicondyle
KNEE – KNEE – Medial fat pad of knee Medial fat pad of knee
proximal to joint lineproximal to joint line
RIGHT FOREARMRIGHT FOREARM
FOREHEADFOREHEAD
LEFT LEFT THUMBTHUMB
Control PointsControl Points
Tender PointsTender Points
1919
• What is Fibromyalgia?
• Pathogenesis of Fibromyalgia
• Clinical Features and Diagnosis of Fibromyalgia
Summary
2020
Rule out other conditions that may present with chronic Rule out other conditions that may present with chronic widespread pain (“Operator dependent”)widespread pain (“Operator dependent”)
History of chronic, History of chronic, widespread pain for ≥3 monthswidespread pain for ≥3 months
Confirm presence of tender points Confirm presence of tender points (Fibromyalgia may be present, even if <11 of 18)(Fibromyalgia may be present, even if <11 of 18)
General physical exam, neurologic exam, selected laboratory General physical exam, neurologic exam, selected laboratory testing (ESR, thyroid tests; avoid screening serologic tests)testing (ESR, thyroid tests; avoid screening serologic tests)
Confirm diagnosis Confirm diagnosis of fibromyalgiaof fibromyalgia
Rule out other conditions that may present with chronic widespread pain Rule out other conditions that may present with chronic widespread pain Depending on physicianDepending on physician: Mental health evaluation, sleep evaluation: Mental health evaluation, sleep evaluation
History of chronic, History of chronic, widespread pain for ≥3 monthswidespread pain for ≥3 months
Confirm presence of tender points Confirm presence of tender points (Fibromyalgia may be present, even if <11 of 18)(Fibromyalgia may be present, even if <11 of 18)
General physical exam, neurologic exam, selected laboratory testing General physical exam, neurologic exam, selected laboratory testing (ESR, thyroid tests; avoid screening serologic tests)(ESR, thyroid tests; avoid screening serologic tests)
Confirm diagnosis Confirm diagnosis of fibromyalgiaof fibromyalgia
Is There Any Effective Management of Is There Any Effective Management of Fibromyalgia?Fibromyalgia?
All patients● Reassurance re diagnosis ● Give explanation, including, but not solely,
psychological factors● Promote return to normal activity, exercise
Most patients● Medication trial● Cognitive behavior therapy, counseling● Physical rehabilitation
Initial Treatment of FibromyalgiaInitial Treatment of Fibromyalgia
May require referral to a specialist for May require referral to a specialist for full evaluation; for example: full evaluation; for example: To psychiatry, sleep clinicTo psychiatry, sleep clinic
Assess psychosocial stressors, level of Assess psychosocial stressors, level of fitness, and barriers to treatmentfitness, and barriers to treatment
Provide education about fibromyalgiaProvide education about fibromyalgia
Confirm diagnosisConfirm diagnosis
Identify important symptom domains, their severity,Identify important symptom domains, their severity,and level of patient functionand level of patient function
Evaluate for comorbid medical and Evaluate for comorbid medical and psychiatric disorderspsychiatric disorders
Nonpharmacologic Strategies: Nonpharmacologic Strategies: Evidence of EfficacyEvidence of EfficacyStrong EvidenceStrong EvidenceExerciseExercise
Physical and psychological benefitsPhysical and psychological benefits
May increase aerobic performance and tender May increase aerobic performance and tender point pain pressure threshold,point pain pressure threshold,and improve painand improve pain
Efficacy not maintained if exercise stopsEfficacy not maintained if exercise stops
Cognitive-behavioral therapyCognitive-behavioral therapy
Improvements in pain, fatigue, mood,Improvements in pain, fatigue, mood,and physical functionand physical function
Improvement often sustained for monthsImprovement often sustained for months
Patient education/self-managementPatient education/self-management
Improves pain, sleep, fatigue, andImproves pain, sleep, fatigue, andquality of life quality of life
Combination (multidisciplinary therapy)Combination (multidisciplinary therapy)
Modest EvidenceModest EvidenceStrength trainingStrength trainingAcupunctureAcupunctureHypnotherapyHypnotherapyEMG biofeedbackEMG biofeedbackBalneotherapy (medicinal bathing)Balneotherapy (medicinal bathing)Transcranial electrical stimulationTranscranial electrical stimulation
Weak EvidenceWeak EvidenceChiropracticChiropracticManual and massage therapyManual and massage therapyUltrasoundUltrasound
No EvidenceNo EvidenceTender-point injectionsTender-point injectionsFlexibility exerciseFlexibility exercise