Rheumatic Disorders Part IV

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Fibromyalgia (FM), Spondyloarthropathies (Polymyositis, Dermatomyositis), Bursitis, Vasculitis, Polymyalgia rheumatica, Giant cell arteritis , Mixed connective tissue disease, Lyme disease

Text of Rheumatic Disorders Part IV

Diapositiva 1

Rheumatic Disorders Part IV:

Maria Carmela L. Domocmat, RN, MSN

Instructor, School of Nursing

Northern Luzon Adventist College

Fibromyalgia, Spondyloarthropathies

(Polymyositis, Dermatomyositis), Bursitis,

Vasculitis, Polymyalgia rheumatica, Giant cell

arteritis , Mixed connective tissue disease,

Lyme disease

Fibromyalgia (FM)

Idiopathic inflammatory myopathy

Bursitis

Vasculitis

Polymyalgia rheumatica

Giant cell arteritis

Lyme disease

Sarcoidosis

Maria Carmela L. Domocmat, RN, MSN

Fibromyalgia (FM)

is a disorder of chronic widespread pain with associated fatigue, poor sleep, stiffness, cognitive difficulties,

multiple somatic symptoms, and, not infrequently, anxiety and/or

depression.

Maria Carmela L. Domocmat, RN, MSN

Fibromyalgia (FM)

Pain - radiates diffusely from the axial skeleton

over large areas of the body, predominantly involving muscles and musculoskeletal

junctions,

but also in joints (arthralgia without actual synovitis)

described as exhausting, burning, miserable, or unbearable.

may also be multifocal and can wax and wane in a migratory

fashion.

Described as "pain all over."

However, multifocal pain or recurrent episodes of regional pain are

essentially equivalent to the classic "pain all over" description.

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Algometer or dolorimeter

A useful device

for rough

quantitation of

pain sensitivity

is a pressure

algometer, or

dolorimeter.

Maria Carmela L. Domocmat, RN, MSN

Tender points in fibromyalgia.

Maria Carmela L. Domocmat, RN, MSN

Fibromyalgia (FM)

Fatigue and poor sleep Most patients with fibromyalgia also meet the classification criteria

for chronic fatigue syndrome.

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Fibromyalgia (FM)

Cognitive problems

(known as "fibrofog") - primary symptom of

fibromyalgia,

reflecting impairments in working, episodic, and

semantic memory that are roughly equivalent to 20

years of aging.

Cognitive symptoms associated with

fibromyalgia are exacerbated by pain, mood

and anxiety disorders, and poor sleep.

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Other common symptoms

Weight fluctuations

Allergic symptoms (eg, nasal congestion) and

hypersensitivity to environmental stimuli (eg, odors, bright

lights, loud noises) and medications

Regional pains, including noncardiac chest pain,

dyspepsia, headache, abdominal cramping (irritable bowel

syndrome), temporomandibular pain, chronic pelvic pain,

and others (Patients with fibromyalgia may meet criteria for

3 or more central sensitivity syndromes.)

Maria Carmela L. Domocmat, RN, MSN

Other common symptoms

Syncope or dizziness

Shortness of breath

Urinary frequency and urgency (female urethral syndrome,

interstitial cystitis)

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Causes

multifactorial.

Engel's biopsychosocial model of chronic illness

(ie, health status and outcomes in chronic illness

are influenced by the interaction of biologic,

psychologic, and sociologic factors) provides a

useful way to conceptualize fibromyalgia

Maria Carmela L. Domocmat, RN, MSN

Maria Carmela L. Domocmat, RN, MSN

Laboratory Studies

do not have characteristic or consistent abnormalities as

determined by laboratory test results.

Laboratory studies - important to help rule out diseases

with similar manifestations

Maria Carmela L. Domocmat, RN, MSN

Laboratory Studies

Thyroid-stimulating hormone:

hypothyroidism shares many clinical features with fibromyalgia,

especially diffuse muscle pain and fatigue.

Creatinine phosphokinase (CPK)

to exclude inflammatory myopathies

Erythrocyte sedimentation rate (ESR):

The normal ESR in patients with fibromyalgia contrasts with the

high ESR in elderly patients with polymyalgia rheumatica.

Obtaining an ESR can assist in identifying an underlying

inflammatory disorder or occult malignancy.

Maria Carmela L. Domocmat, RN, MSN

Laboratory Studies

Antinuclear antibodies (ANAs):

Many patients with SLE have comorbid fibromyalgia. A low-titer

ANA is common in the general population and may be of no clinical

significance if diagnostic features of SLE or related autoimmune

disorders are absent.

Rheumatoid factor:

Many patients with RA have comorbid fibromyalgia. However, a

positive result for rheumatoid factor does not support a diagnosis of

RA in the absence of objective evidence of characteristic joint

inflammation. A positive result for rheumatoid factor is

diagnostically nonspecific in other clinical settings.

Maria Carmela L. Domocmat, RN, MSN

Treatment

validation of the patients illness

empathetic listening and acknowledgment that the

patient is indeed experiencing pain

first crucial element in the treatment of pain, fatigue,

and other diverse symptomatology in patients with

fibromyalgia (FM) I

Maria Carmela L. Domocmat, RN, MSN

Treatment

Accurately assess possible causal or perpetuating

factors,

including attention to psychologic and sociocultural

factors

and identification of specific regional sources of ongoing

nociceptive pain (eg, degenerative spondylosis,

bursitis).

Maria Carmela L. Domocmat, RN, MSN

Comments such as "its all in your mind" or "I cannot find anything wrong with you" only add to

the patient's frustration.

Maria Carmela L. Domocmat, RN, MSN

Psychologic and behavioral

approaches Depression must be treated aggressively.

Depression, anxiety, stress, sleep disturbance, pain

beliefs and coping strategies, and self-efficacy all are

central to the pain experience in many patients and

frequently determine the outcome of chronic pain.

Unless psychosocial and behavioral variables are

recognized and approached, strictly

pharmacologic interventions are of limited benefit.

Maria Carmela L. Domocmat, RN, MSN

Psychologic and behavioral

approaches Cognitive-behavioral therapy (CBT) and operant-

behavioral therapy (OBT)

both effect clinically meaningful improvements in pain

intensity and physical impairment in approximately one

third to on half of patients with fibromyalgia.

Maria Carmela L. Domocmat, RN, MSN

Patient Education

Education is an essential element in therapy for

fibromyalgia.

It begins with an empathetic manner on the part of

the nurse/physician, who must affirm the patient's

pain, explore social and behavioral variables (both

in childhood and current) that influence this

illness, and explain to the patient how stress and

distress can amplify pain and fatigue.

Maria Carmela L. Domocmat, RN, MSN

Medication

Anxiolytics/hypnotics

Antidepressants

Tricyclics antidepressants

Selective Serotonin-reuptake Inhibitors (SSRIs)

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Central Nervous System Depressants

Opioids

Anticonvulsants

Analgesics

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Maria Carmela L. Domocmat, RN, MSN

Anxiolytics/hypnotics

often used in combination with antidepressants

and anticonvulsant drugs (both of which also have

efficacy for anxiety and insomnia)

Benzodiazepines

alprazolam [Xanax]

temazepam [Restoril

clonazepam [Klonopin]

buspirone [BuSpar]

trazodone [Desyrel])

Maria Carmela L. Domocmat, RN, MSN

Anxiolytics/hypnotics

Maria Carmela L. Domocmat, RN, MSN

Tricyclic antidepressant

Amitriptyline (Elavil)

Desipramine (Norpramin)

Doxepin (Sinequan)

Imipramine (Tofranil)

Trazodone (Desyrel)

Nortriptyline (Pamelor)

Maria Carmela L. Domocmat, RN, MSN

Selective Serotonin-reuptake

Inhibitors (SSRIs)

Fluoxetine (Prozac)

Sertraline (Zoloft)

Paroxetine (Paxil)

Fluvoxamine (Luvox)

Citalopram (Celexa)

Maria Carmela L. Domocmat, RN, MSN

Serotonin Norepinephrine

Reuptake Inhibitors (SNRIs)

Milnacipran (Savella)

Duloxetine (Cymbalta)

Maria Carmela L. Domocmat, RN, MSN

Central Nervous System

Depressants

Zolpidem (Ambien)

Zaleplon (Sonata)

Sodium oxybate (Xyrem)

Maria Carmela L. Domocmat, RN, MSN

Opioids

Morphine

Oxycodone (OxyContin)

Hydrocodone (Vicodin, Percocet)

Hydromorphon