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Ortho/Rheumatology > Chronic Fatigue + Fibromyalgia > Flashcards

Chronic Fatigue + Fibromyalgia Flashcards

1
Q

A state of exhaustion, lack of energy, listlessness, unable to participate in ADLs?

A

Fatigue

*7 million office visits per year.

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2
Q

What is defined as Chronic Fatigue?

A

Fatigue lasting more than ONE MONTH.

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3
Q

What other conditions are assoc. w/Chronic Fatigue?

A
  • 67% depression and/or assoc. conditions.
  • 25% idiopathic (meet some CFS criteria).
  • 5% meet CFS criteria.
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4
Q

Clinically evaluated medically unexplained fatigue of “at least 6 months duration, mod-severe intensity at least half the time?”

A

Chronic Fatigue Syndrome (CFS).

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5
Q

Diagnostic Criteria for CFS?

A
  • *Must have the following 3 Sx:
    1. Substantial reduction or impairment in the ability to engage in pre-illness levels of ADLs.
    2. Post-exertional malaise.
    3. Unrefreshing sleep.
  • *At least 1 of 2 of the following manifestations:
    1. Cognitive impairment.
    2. Orthostatic intolerance or the worsening of symptoms upon assuming and maintaining upright posture.
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6
Q

Etiology of Chronic Fatigue Syndrome?

A

**Etiology unknown, multiple hypotheses:

  • -Infection (EBV, Retrovirus, Lyme).
  • -Immune System Differences.
  • -Endo-Metabolic Dysfunction.
  • -Neurally mediated hypotension.
  • -Sleep deficiency.
  • -Gene/DNA differences.
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7
Q

Common symptoms of CFS?

A
  • -post-exertional malaise.
  • -Unrefreshing sleep.
  • -Brain fog.
  • -Muscle/Joint pain, headache.
  • -Light sensitivity and chills.
  • -Stomach pain, bloating, nausea.
  • -Sinus problems, swollen glands, tender LN, ST.
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8
Q

Differential Diagnosis of CFS and Fibromyalgia?

A
  1. Psychological disorders (depression, anxiety, personality disorders).
  2. Pharmacologic (AE of drowsiness, sedation, etc).
  3. Endo-Metabolic.
  4. Neoplastic - Hematologic.
  5. Infectious.
  6. Cardiopulmonary.
  7. IMID/CTD.
  8. Disturbed sleep (Nocturnal Myoclonus, RLS, OSA).
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9
Q

What is extremely important in evaluation of a patient for possible CFS?

A

Complete H and P!!!

**Objective findings are NOT found in CFS; if you do find them, explore them.

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10
Q

Laboratory Studies for CFS?

A

**NO diagnostic tests for CFS!!

  • -Do a full work-up, CFS is a diagnosis of exclusion.
  • -CBC, CMP, ESR/CRP, TSH, CK, UA, HIV/Hep, Mono/Lyme/RMSF.
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11
Q

Treatment options for a patient with CFS?

A

**Validate your pt – this is a real illness.

  • *Symptomatic Treatment:
    1. Sleep – address sleep hygiene, OTC products, low-dose TCAs.
    2. Pain – NSAIDs, TCAs (NO Narcotics).
    3. Depression – counseling, CBT, meds (SSRI, SNRI).
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12
Q

Non-Pharmacologic Treatments for CFS?

A
  1. Massage therapy.
  2. Acupunture.
  3. Self-Hypnosis.
  4. MODEST Regular Exercise.
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13
Q

A disorder of pain regulation or altered pain processing in the CNS?

A

Fibromyalgia

**Pain is nonarticular, chronic MSK pain.

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14
Q

What is Central Sensitization?

A

“Wind up” of the NS into a persistent state of high reactivity.

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15
Q

What are the 2 characteristics of central sensitization?

A

Allodynia – pain from a stimuli that does not normally cause pain (light feather touch).

Hyperalgesia – an enhanced sensitivity to pain.

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16
Q

Etiology of Fibromyalgia?

A
  1. Unknown; but possibly related to:
    - -increased life stress.
    - -alteration of NT metabolism.
    - -abnormal levels of….serotonin, norepi, substance P found, mitochondria in muscle biopsies.
    - -disturbances in stage 4 sleep.
    - -neuroendo changes.
17
Q

Risk factors associated with Fibromyalgia?

A
  • -Stressful or traumatic events (PTSD).
  • -Repetitive injuries.
  • -Illness (eg, viral infections).
  • -Certain diseases (Lupus, RA, CFS).
  • -Genetic predisposition.
  • -Obesity.
18
Q

Epidemiology of Fibromyalgia?

A
  • -Women account for 80-90% of cases.
  • -Occurs in 5% of primary care pt’s.
  • -Age of onset usually 20s-60s.
  • -2dry Fibro occurs in up to 15% of all pt’s w/Rheumatic diseases (RA, Lupus, Sjogren’s).
19
Q

Signs/Symptoms of Fibromyalgia?

A
  • -MSK aches and pains.
  • -Fatigue.
  • -Stiffness.
  • -Anxiety/Mental distress.
  • -Poor sleep.
  • -Headaches.
  • -IBS.
  • -Paresthesias.
  • -Sensation of swelling (subjective).
20
Q

Aggravating/Triggering Factors and Alleviating factors of Fibromyalgia?

A

Aggravating/Triggering:

  • anxiety or stress.
  • cold or humid weather.
  • inflammatory or infectious disorders.
  • nonrestorative sleep.
  • physical inactivity or excess physical activity.
  • physical/mental fatigue or trauma.

Alleviating Factors:

  • warm or dry weather.
  • restful sleep.
  • moderate activity.
  • hot showers or baths.
21
Q

A chronic pain condition that affects the MSK system and is associated with degenerative disc disease?

A

Myofascial Pain Syndrome.

**DDx of Fibromyalgia.

22
Q

Common characteristics of Myofascial Pain Syndrome?

A
  • -Localized pain.
  • *TRIGGER POINTS…unilateral, local tender points.
  • -Pain resolves but often recurs.
  • -Fatigue uncommon.
  • -Morning stiffness uncommon.
23
Q

What are some questions to ask a pt you are evaluating for Fibromyalgia?

A
  • Location of the pain?
  • Fatigue?
  • Alleviating or aggravating factors?
  • Stiffness?
  • Current stress? Abuse?
  • Non-refreshing sleep?
  • Difficulty falling asleep? Staying asleep? Frequent awakenings? How much sleep per night?
24
Q

What is the goal of a PE in evaluating Fibromyalgia?

A

To r/o systemic disease and confirm the diagnosis.

  • Let your pt’s Sx guide the extent of your PE.
  • Very least, complete a full MSK and brief Neuro exam; but if complaint is fatigue…complete PE is necessary.
25
Q

Laboratory studies in Fibromyalgia?

A

No lab will diagnose fibromyalgia; labs are completed to r/o something more serious.

*CBC, CMP, UA, ESR/CRP, Muscle enzymes (CK, Aldolase), Rheumatoid factor, ANA, XR, Bone scan.

26
Q

Treatment strategy for Fibromyalgia?

A

**Education and Reassurance.

  • Chronic, but not life-threatening.
  • Syndrome and not a disease.
  • Treatment is available.
  • PAIN IS REAL!
27
Q

What is the stepwise approach to treatment of Fibromyalgia?

A
  1. Correct sleep disruption first.
    - -If sleep improved but daytime fatigue persists, work on fatigue next.
  2. Local Trigger-point injections.
  3. Exercise – MANDATORY!
  4. Your pt MUST be an ACTIVE participant in their own care!
28
Q

“It is important to realize that sleep affects daytime functioning and daytime functioning can affect sleep.”

A

Remember!

29
Q

Correcting Sleep Disorder?

A
  1. Sleep hygiene.
  2. Is a sleep study needed?
  3. Sleep Aids:
    - -TCAs (Amitriptyline).
    - -Trazodone (sleep and depression).
    - -Muscle Relaxers.
    - -GABA/Benzos (eg, Ambien).
    - -Melatonin.
30
Q
  1. Treat Depression (SSRIs, SNRIs).
  2. Exercise/PT (mod. activity, water aerobics).
  3. Psychotherapy, relaxation, stress mgmt, hypnosis.
  4. acupunture.
  5. massage.
  6. Trigger point injections.
A

Further treatment strategies for Fibromyalgia.

  1. Medications:
    - -NSAIDs.
    - -Tramadol (Ultram or Ultracet).
    - -Lyrica (Pregabalin).
31
Q

Has great data in decreasing fatigue and pain in fibromyalgia; also used for Diabetic Neuropathy and post herpetic neuralgia.

A

Lyrica (Pregabalin).

32
Q

Other medications used to treat Fibromyalgia? What do we want to avoid?

A
  1. Neurontin (Gabapentin) – anti seizure med used to treat nerve related pain; somnolence and dizziness is common.
  2. Duloxetine (Cymbalta) - SNRI.
  3. Milnacipran (Savella) - SNRI.

**AVOID Narcotics and Benzos!

Ortho/Rheumatology (15 decks)

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