Fibromyalgia Flashcards
What are common chronic pain syndromes in children and adults?
Kids- amplified musculoskeletal pain syndrome
Adults- fibromyalgia
What are characteristics of chronic pain syndromes?
there are common characteristics among syndromes.
syndromes may move from one symptom complex to another or have characteristics of multiple syndromes
What is cause of AMPS?
unknown etiology
can be related to injury, illness, or psychological distress
What are hallmark signs of AMPS?
increasing pain over time, heightened pain intensity, absence of other causes
Pain may be diffuse or localized to one body part
What patient populations get AMPS?
pre to adolescent girls (mean age 12-13 yrs)
higher socioeconomic status
presence of psychological distress
What is presentation of AMPS during assessment?
Pain is not restricted to dermatome or peripheral nerve can have autonomic dysfunction multiple joints/muscles involved multiple painful points report numbness or weakness normal neurological exam normal blood work and radiographs
What is fibromyalgia?
chronic musculoskeletal pain syndrome of unknown etiology
Who gets fibromyalgia?
prevalence 2-10%
female to male ratio 8:1
Mean age is 30-60 years
What are hallmark signs of fibromyalgia?
widespread pain over 3 months with tender points
some characteristics of associated symptoms
Where are the tender points for fibromyalgia?
Lower cervical Second rib Occiput Trapezius Supraspinatus Lateral epicondyle Gluteal Greater trochanter Knee
What are some associated symptoms of fibromyalgia?
fatigue, anxiety, depression, sleep, concentration, morning stiffness, headache, numbness/tingling, temperature sensitivity
What was the old diagnostic criteria for fibromyalgia?
American college of rheumatology (1990) History of widespread pain over 3 months presence of tender points (11 out of 18) Bilateral side pain, involving upper and lower body No standard labs Rule out other conditions
What is the new diagnostic criteria for fibromyalgia?
Part 1: widespread pain index (WPI)
Part 2: symptom severity (SS)
What is the WPI?
scored from 0-19
check each area you feel pain in over the past week
What do SS scores mean?
2a: score for fatigue, waking unrefreshed and cognitive symptoms, 0-no problem, 3=severe problem
2b: other symptoms, no symptoms=0, 1-10=1, 11-24=2, >25=3
How do you get diagnosed with FM?
WPI >7 and SS >5 OR WPI 3-6 and SS >9 Presence of symptoms for 3 months R/O other pain conditions
What is difference between the two criteria from American college of rheumatology?
Tender points have been removed and replaced by a symptom checklist
inclusive of comprehensive assessment
What is pathology behind FM?
Unknown etiology
What are predisposing factors for FM?
rheumatic conditions
hereditary
environmental factors
traumatic events
What is a possible pathophysiologic model of FM?
muscles, CNS, endocrine
What happens with the muscles in FM?
Abnormalities in muscle fibers: decreased type1, atrophy in type 2, muscle tetany
Abnormalities in muscle energy metabolism: low oxidative enzymes
What happens with the CNS in FM?
Altered endogenous opioid activity: decreased opioid receptors in pain inhibitory pathways
Altered neurotransmitters and neuropeptides: decreased serotonin, increased substance P and glutamate
What happens with the endocrine system in FM?
Imbalance of many hormones: growth hormone cortisol, important for muscle healing
Immune system: elevated immune markers
What occurs in neuroendocrine system with FM?
abnormality in hypothalamus-pituitary-adrenal gland axis (HPA)
fatigue and sleep disturbance
What is the psychological aspect of chronic pain?
patient focuses on pain
patient presents with emotional distress and verbalizes anxiety, depression and frustration
suffering of pain is present in absence of pain severity
demonstrate avoidance of physical activity due to fear of injury/harm
What is the biopsychological model of chronic pain?
Dynamic interaction between physiological, psychological, and social factors that propagates clinical pain presentation
What is part of PT eval for chronic pain?
Patient profile: female, middle age, recreational
Body chart and location
Agg/Easing factors
24 hour behavior: sleep
Special questions
Current and past history: trauma, psychological
Family history: genetics
Associated signs and symptoms: sleep issues
What are parts of objective assessment for chronic pain?
Pain assessment: VAS, body posture, facial expression, motor behavior, standard pain questionnaires
Joint assessment
Muscle palpation
Tender point assessment
Neurological examination
Psychological assessment: depression and anxiety questionnaire
Functional tests: short form 36, fibromyalgia impact questionnaire
What are goals for PT interventions for chronic pain?
Goal is to improve function
Less focus on pain assessment
Create patient-centered achievable functional goals
Acknowledge small gains
Have open discussion about discharge planning with patient
Recognize need for other health care providers
Be empathetic
What treatment is best for chronic pain?
Interdisciplinary treatment approach is best: combination of medications, physical activity, and cognitive behavior therapy
What is first line of treatment for medical interventions?
Medications: NSAIDS, antidepressants, simple analgesics
Education
Exercise: low impact
What is second line of treatment for medical interventions?
Medications: Cognitive behavioral program Structured exercise program Physical medicine and rehab program Trigger point injections Pain management program acupuncture
What types of exercise do chronic patients need to do?
Aerobic exercise: low impact, gradual increase to moderate intensity, 30 minutes
Strengthening: low reps, low weight, concentric exercises
Flexibility: not effective when done alone
What are the principles behind exercise for chronic pain?
Minimize muscle microtrauma Minimize central pain Emphasize on low-moderate intensity exercise and consistency Exercise program must be individualized Encourage self-efficacy
What can we educate our patients on for chronic pain?
FM condition Life-style changes Importance of exercises Pain education/neuroscience education Self-management: improve sleep, reduce pain and stress, energy consumption
What are alternative therapies for chronic pain?
yoga, acupuncture, energy therapies, body mind relaxation, quigong movement therapy, tai chi
These have mixed results
What treatments have strong evidence for treating FM?
Amitriptyline, cyclobenzaprine, aerobic exercises, CBT, pt education, multidisciplinary treatment
What treatments have moderate evidence for FM treatment?
tramadol, serotonin inhibitors, pregabalin, strength training, acupuncture, biofeedback
What are weak evidences for FM?
growth hormone, serotonin, massage, e-stim, US
What treatments have no evidence for treating FM?
opioids, corticosteroids, NSAIDs, benzodiazepine, trigger points, flexibility exercises
What is prognosis for people with FM?
Negative predictors: depression, pain related anxiety, kinesiophobia or movement avoidance
Positive predictors: acceptance of condition, lack of anxiety and depression
What is a simple explanation of chronic pain you can give your patient?
Painful signals go from pain nerves to SC to the brain
Abnormal reflex in SC to neurovascular nerves
Nerves make blood vessels smaller causing lack of oxygen and build up of acid that causes intense pain
Pain goes back to the SC across abnormal reflexes back to neurovascular nerves resulting in viscous cycle of pain
