Chronic Fatigue + Fibromyalgia Flashcards
A state of exhaustion, lack of energy, listlessness, unable to participate in ADLs?
Fatigue
*7 million office visits per year.
What is defined as Chronic Fatigue?
Fatigue lasting more than ONE MONTH.
What other conditions are assoc. w/Chronic Fatigue?
- 67% depression and/or assoc. conditions.
- 25% idiopathic (meet some CFS criteria).
- 5% meet CFS criteria.
Clinically evaluated medically unexplained fatigue of “at least 6 months duration, mod-severe intensity at least half the time?”
Chronic Fatigue Syndrome (CFS).
Diagnostic Criteria for CFS?
- *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.
Etiology of Chronic Fatigue Syndrome?
**Etiology unknown, multiple hypotheses:
- -Infection (EBV, Retrovirus, Lyme).
- -Immune System Differences.
- -Endo-Metabolic Dysfunction.
- -Neurally mediated hypotension.
- -Sleep deficiency.
- -Gene/DNA differences.
Common symptoms of CFS?
- -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.
Differential Diagnosis of CFS and Fibromyalgia?
- Psychological disorders (depression, anxiety, personality disorders).
- Pharmacologic (AE of drowsiness, sedation, etc).
- Endo-Metabolic.
- Neoplastic - Hematologic.
- Infectious.
- Cardiopulmonary.
- IMID/CTD.
- Disturbed sleep (Nocturnal Myoclonus, RLS, OSA).
What is extremely important in evaluation of a patient for possible CFS?
Complete H and P!!!
**Objective findings are NOT found in CFS; if you do find them, explore them.
Laboratory Studies for CFS?
**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.
Treatment options for a patient with CFS?
**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).
Non-Pharmacologic Treatments for CFS?
- Massage therapy.
- Acupunture.
- Self-Hypnosis.
- MODEST Regular Exercise.
A disorder of pain regulation or altered pain processing in the CNS?
Fibromyalgia
**Pain is nonarticular, chronic MSK pain.
What is Central Sensitization?
“Wind up” of the NS into a persistent state of high reactivity.
What are the 2 characteristics of central sensitization?
Allodynia – pain from a stimuli that does not normally cause pain (light feather touch).
Hyperalgesia – an enhanced sensitivity to pain.
Etiology of Fibromyalgia?
- 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.
Risk factors associated with Fibromyalgia?
- -Stressful or traumatic events (PTSD).
- -Repetitive injuries.
- -Illness (eg, viral infections).
- -Certain diseases (Lupus, RA, CFS).
- -Genetic predisposition.
- -Obesity.
Epidemiology of Fibromyalgia?
- -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).
Signs/Symptoms of Fibromyalgia?
- -MSK aches and pains.
- -Fatigue.
- -Stiffness.
- -Anxiety/Mental distress.
- -Poor sleep.
- -Headaches.
- -IBS.
- -Paresthesias.
- -Sensation of swelling (subjective).
Aggravating/Triggering Factors and Alleviating factors of Fibromyalgia?
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.
A chronic pain condition that affects the MSK system and is associated with degenerative disc disease?
Myofascial Pain Syndrome.
**DDx of Fibromyalgia.
Common characteristics of Myofascial Pain Syndrome?
- -Localized pain.
- *TRIGGER POINTS…unilateral, local tender points.
- -Pain resolves but often recurs.
- -Fatigue uncommon.
- -Morning stiffness uncommon.
What are some questions to ask a pt you are evaluating for Fibromyalgia?
- 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?
What is the goal of a PE in evaluating Fibromyalgia?
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.
Laboratory studies in Fibromyalgia?
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.
Treatment strategy for Fibromyalgia?
**Education and Reassurance.
- Chronic, but not life-threatening.
- Syndrome and not a disease.
- Treatment is available.
- PAIN IS REAL!
What is the stepwise approach to treatment of Fibromyalgia?
- Correct sleep disruption first.
- -If sleep improved but daytime fatigue persists, work on fatigue next. - Local Trigger-point injections.
- Exercise – MANDATORY!
- Your pt MUST be an ACTIVE participant in their own care!
“It is important to realize that sleep affects daytime functioning and daytime functioning can affect sleep.”
Remember!
Correcting Sleep Disorder?
- Sleep hygiene.
- Is a sleep study needed?
- Sleep Aids:
- -TCAs (Amitriptyline).
- -Trazodone (sleep and depression).
- -Muscle Relaxers.
- -GABA/Benzos (eg, Ambien).
- -Melatonin.
- Treat Depression (SSRIs, SNRIs).
- Exercise/PT (mod. activity, water aerobics).
- Psychotherapy, relaxation, stress mgmt, hypnosis.
- acupunture.
- massage.
- Trigger point injections.
Further treatment strategies for Fibromyalgia.
- Medications:
- -NSAIDs.
- -Tramadol (Ultram or Ultracet).
- -Lyrica (Pregabalin).
Has great data in decreasing fatigue and pain in fibromyalgia; also used for Diabetic Neuropathy and post herpetic neuralgia.
Lyrica (Pregabalin).
Other medications used to treat Fibromyalgia? What do we want to avoid?
- Neurontin (Gabapentin) – anti seizure med used to treat nerve related pain; somnolence and dizziness is common.
- Duloxetine (Cymbalta) - SNRI.
- Milnacipran (Savella) - SNRI.
**AVOID Narcotics and Benzos!
