MANAGEMENT OF FIBROMYALGIC MANAGEMENT OF FIBROMYALGIC SYNDROMESYNDROME

Prof. A.V. SRINIVASANM.D,D.M,PhD,DSc,FIAN,FAAN

Emeritus Professor – The Tamil Nadu Dr. MGR Medical University

Prof. A.V. SRINIVASANM.D,D.M,PhD,DSc,FIAN,FAAN

Emeritus Professor – The Tamil Nadu Dr. MGR Medical University

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 misconceptions What are some of the common misconceptions about the syndrome?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 include:Additional symptoms are common and 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 toesnumbness 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 over may wax and wane over timetime

FMS Symptom Complex FMS Symptom Complex

Pain, fatigue, & sleep disturbancePain, fatigue, & sleep disturbance are present in at least 86% are present in at least 86% patientspatients

ACR Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site. Available at: http://www.nfra.net/Diagnost.htm. Accessed October 18, 2007.

What causes FMS?What causes FMS?

Cause is Cause is unknownunknown

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

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

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

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

Familial tendency to develop FMS suggests Familial tendency to develop FMS suggests genetic genetic rolerole

Can be triggered by physical, emotional or Can be triggered by physical, emotional or environmental stressors such as car accidents, environmental stressors such as car accidents, repetitive injuries and certain diseasesrepetitive injuries and certain diseases

Patients with Rheumatoid arthritis and SLE Patients with Rheumatoid arthritis and SLE (Lupus) are more likely to develop FMS(Lupus) are more likely to develop FMS

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

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

Sleep deprivation with disruption of delta-wave Sleep deprivation with disruption of delta-wave sleep (non-REM stage IV) is associated with sleep (non-REM stage IV) is associated with day-time fatigue andday-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 disorderMen and children may also develop the disorder

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

How is FMS diagnosed?How is FMS diagnosed?

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

American College of Rheumatology American College of Rheumatology Classification Criteria for Fibromyalgia (1990)Classification Criteria for Fibromyalgia (1990)…….…….widespread widespread pain for at least 3 months pain for at least 3 months and and pain in pain in 1111 out of out of 1818 tendertender pointpoint sites on digital sites on digital palpationpalpation

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 History of widespread pain for more than 3 months, on

both sides of the body, above and below the waist, and both sides of the body, above and below the waist, and axial skeleton (cervical spine, anterior chest, thoracic axial skeleton (cervical spine, anterior chest, thoracic pain, or low back)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 Presence of second clinical disorder does not exclude diagnosis of fibromyalgia.diagnosis of fibromyalgia.

ACR Diagnostic Criteria for FMSACR Diagnostic Criteria for FMSHistory of widespread pain for at least 3 months History of widespread pain for at least 3 months – Pain on both sides of the body Pain on both sides of the body PLUSPLUS– Pain above and below the waist Pain above and below the waist PLUSPLUS– Axial skeletal painAxial skeletal pain

Pain in at least 11 of 18 tender-point sites on digital Pain in at least 11 of 18 tender-point sites on digital palpationpalpation– Thumb Pressure is Applied to 18 tender-point sitesThumb Pressure is Applied to 18 tender-point sites– Until Nail Bed is Starting to Blanch (~ 4 kg of pressure)Until Nail Bed is Starting to Blanch (~ 4 kg of pressure)

Wolf et al. Arthritis Rheum. 1990;33:160-172.

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

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

General RecommendationsGeneral RecommendationsFibromyalgia should be recognized as a heterogeneous Fibromyalgia should be recognized as a heterogeneous condition comprising of a range of symptoms & featurescondition comprising of a range of symptoms & features

– Effective management should take into account all Effective management should take into account all these factors these factors

Optimal treatment therefore requires a multidisciplinary Optimal treatment therefore requires a multidisciplinary approach withapproach with

– Combination of non-pharmacological and Combination of non-pharmacological and pharmacological treatment modalities pharmacological treatment modalities

– Tailored according to pain intensity, sleep disturbance, Tailored according to pain intensity, sleep disturbance, fatigue & other symptoms, and functionfatigue & other symptoms, and function

– Associated co-morbiditiesAssociated co-morbidities

– In discussion with the patientIn discussion with the patient

Available Treatment ModalitiesAvailable Treatment Modalities

Mease P. J Rheumatol. 2005; 32 (suppl 75): 6.Carville, et al. Ann Rheum Dis. Doi:10.1136/ard.2007.071522.Goldenberg et al. JAMA. 2004; 292: 2388.Clauw DJ, Crofford LJ. Best Pract Res Clin Rheumatol. 2003; 17: 685.Arnold LM, et al. Arthritis Rheum. 2007;56:1336-1344.

Pharmacological ModalitiesPharmacological Modalities

DrugsDrugsShort-Term Short-Term EfficacyEfficacy

Long-Term Long-Term EfficacyEfficacy Safety/ TolerabilitySafety/ Tolerability

AmitriptylineAmitriptyline Multiple Multiple small RCTssmall RCTs

-- Anti-cholinergic, anti-Anti-cholinergic, anti-adrenergic, anti-adrenergic, anti-histaminic, cardiac muscle histaminic, cardiac muscle suppressant effectssuppressant effects

DuloxetineDuloxetine 2 RCTs2 RCTs 1 RCT 1 RCT (Pain)(Pain)

Insomnia, GI & CV effectsInsomnia, GI & CV effects

GabapentinGabapentin 1 RCT1 RCT -- Dizziness, somnolence, Dizziness, somnolence, weight gainweight gain

PregabalinPregabalin 4 RCTs4 RCTs 1 RCT (pain 1 RCT (pain & function)& function)

Dizziness, somnolence, Dizziness, somnolence, weight gainweight gain

TramadolTramadol 1 RCT1 RCT -- Dizziness, somnolence, Dizziness, somnolence, headache, GI effects headache, GI effects

Stepwise Treatment of Stepwise Treatment of FibromyalgiaFibromyalgia

Assess psychosocial stressors, level of fitness, and barriers to treatment

Provide education about fibromyalgia

Review treatment options

Confirm diagnosis

Identify important symptom domains, their severity,and level of patient function

Evaluate for comorbid medical and psychiatric disorders

Arnold LM. Arthritis Res Ther. 2006;8:212. Available online: http://arthritis-research.com/content/8/4/212. Accessed February 28, 2007.

As a first-line approach for patients with moderate to severe pain, trial with evidence-based medications

Stepwise Treatment of Stepwise Treatment of Fibromyalgia (cont’d)Fibromyalgia (cont’d)

Provide additional treatment for comorbid conditions

Encourage exercise according to fitness level

Adjunctive CBT for patients with prominent psychosocial stressors, and/or difficulty coping, and/or difficulty

functioning

Arnold LM. Arthritis Res Ther. 2006;8:212. Available online: http://arthritis-research.com/content/8/4/212. Accessed February 28, 2007.

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 and pharmacologic treatment for treating pain and improving sleep disturbance includes:improving sleep disturbance includes:

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

- Dual reuptake inhibitors such as venlafaxine - Dual reuptake inhibitors such as venlafaxine (EFFEXOR), duloxetine (CYMBALTA) and (EFFEXOR), duloxetine (CYMBALTA) and tramadol (ULTRAM)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) such as - NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen and naproxen are generally ineffectiveibuprofen and naproxen are generally ineffective

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

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

Other Therapies for FMSOther Therapies for FMS

Complementary and alternative therapies have Complementary and alternative therapies have been used although not well studied in FMSbeen used although not well studied in 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 to Eleven (11) out of 18 tender points needed to make the diagnosis of FMS 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 psychologic factors factors including depression may be the major determinant of pain in othersincluding depression 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

Dedicated to my family Dedicated to my family for making everything worthwhilefor making everything worthwhile

MY SINCERE THANKS TO PFIZER

MY SINCERE THANKS TO PFIZER

READ not to contradict or confute

Nor to Believe and Take for Granted

but TO WEIGH AND CONSIDER

THANK YOU