Fibromyalgia Flashcards
Fibromyalgia syndrome
Chronic muscular pain disorder
Female: Male 3:1
Estimated prevalence 1-4%
Age of onset: 35-55
pathophysiology
Not fully understood
Initially was thought to be an inflammatory pain disorder
Now considered to be related to altered Central nervous system (CNS) processing
risk factors
childhood trauma Post traumatic stress disorder Female stress genetics Can be secondary to other auto-immune rheumatology conditions
transmission and perception of pain
amplification of information within the CNS
lots of neurotransmitters involved
glutamate, substance P, serotonin= well known transmitters, amplify the message
central sensitisation
normal - info to CNS - feel pain
bigger injury - eg. burn skin - actual tissue damage - information to CNS, pain takes longer to resolve
pain = warning for potential/ actual tissue damage.
very light touch - into CNS - amplified by CNS sensation is abnormal
central sensitisation will perceive that as pain rather than light touch
widespread pain distribution
features of central sensitisation
Widespread, non-anatomical distribution
Inconsistent response to stimuli & tests. Inconsistent aggravating and easing factors
Allodynia
pain due to a stimulus which is not normally painful e.g. Light touch, pressure
Hyperalgesia
Increased response to a normally painful stimulus i.e feels more painful than normal
Pain seems to have a ‘mind of its own’
other symptoms
Sleep disturbance Chemical Sensitivities Fatigue Depression/Anxiety Headache Morning stiffness Dysmenorrhea Numbness/P+Ns Cognitive dysfunction (fibro fog)
ACR diagnostic criteria
Widespread pain index (WPI) ≥7 and symptom severity (SS) scale score ≥5 or WPI 3–6 and SS scale score ≥9.
SS Scale measures fatigue, Waking unrefreshed, Cognitive symptoms
Symptoms have been present at a similar level for at least 3 months.
The patient does not have a disorder that would otherwise explain the pain.
ACR widespread pain index
Shoulder girdle Hip (buttock, trochanter) Jaw Neck Chest Upper back Upper arm Lower arm Upper leg Lower leg Abdomen
associated central sensitisation conditions
tension headaches migraines PTSP fibromyalgia chronic fatigue syndrome functional gastrointestinal disorders myofascial pain syndrome restless leg syndrome multiple chemical sensitivities primary dysmenorrhea female urethral syndrome temperomandibular disorders functional gastrointestinal disorders
other consequences
20-50% of people with FMS can work few or no days
More sedentary and less physically active than peers
Higher physical fitness associated with lower levels of pain, lower pain-related catastrophizing, and higher chronic pain self-efficacy in women with FM
differential diagnosis
RA
Joint swelling, joint deformities, elevated ESR, CRP, ANA
SLE
Rash, very elevated ESR, CRP
Polymyositis/
Dermatomyositis
Weakness, elevated muscle enzymes
AS
Back and neck immobility, elevated ESR, x-ray changes
Hypothyroidism
Abnormal thyroid function tests
investigations
Blood tests (Normal)
ESR and CRP (inflammatory markers)
Thyroid function tests
CBC (complete blood count)
Avoid screening tests for Rh factor
Avoid extensive x-rays, imaging or neurological investigations… why?
pain fatigue cycle
disease tense muscles poor sleep stress/ anxiety difficult emotions depression metabolic problems
mgmt needs to be integrated
pharmacological stress mgmt lifestyle modification cognitive behavioural therapy exercise
pharm mgmt
Drugs aimed towards the source of the pathology
CNS disorder – centrally acting drugs
Anti-seizure meds: Gabapentin, Pregabalin
Duloxetine acts on CNS, also used for depression (Lunn et al, 2014)
Anti-depressants: Amitryptiline
Improves pain
Elevated mood
NSAIDS/Opioids: no evidence of effect on their own for FMS
physio assessment
Subjective: Pain locations, behaviour Associated symptoms General medical history Activity levels Hobbies/interests Employment Mood
Validated Outcomes
Fibromyalgia Impact Questionnaire
physical Pressure Pain Threshold (PPT) (Pressure algometer) \+ve if pain at approx 4kg/cm2 Posture Active and Passive ROM Strength Functional Ability Cardiovascular fitness
exercise
General Aerobic exercise
ACSM guidelines
Minimum of 30 mins 5 days/week for adults age 18-65
Vigorous exercise for at least 20 minutes 3 days/week (Haskell et al, 2007)
Swimming, cycling, whole body exercise, hydrotherapy
Tai Chi
Strength training
Hydrotherapy
Exercise should be individualised, monitored and progressed slowly
Some evidence for use of Acupuncture +/- exercise (Deare et al, 2013)
evidence for exercise in FM
Supervised aerobic exercise training has beneficial effects on physical capacity, pain, tenderness and overall well-being.
Strength training may also have benefits on some FM symptoms (Busch et al, 2007)
lifestyle modification
Required to address pain, fatigue, mood disturbance Planning the week Reducing length of working day Pacing activity and work Use of activity diaries Allowing time for exercise Energy conservation
cognitive behavioural therapy
Psychological –based intervention Deals with the negative thoughts ( cognitive) and behaviours (actions) associated with chronic pain syndromes such as FMS Negative cognitions Catastrophising ‘Exercise/physio makes me worse’ ‘Nothing can help’ Negative behaviours Resting too much Avoiding exercise
aim of CBT
Aim is not necessarily to relieve pain but to allow patients to cope with it and function, despite the pain
Help them realise it is a manageable condition
Recognise that they are not helpless and passive
Break the vicious cycle
Goal setting
Patients identify triggering events, moods
Positive thought processes
Activity is time-contingent, not pain-contingent
MDT
GP /Rheumatologist
Rheumatology nurse
Physiotherapist
Occupational Therapist
Psychologist
MDT pain mgmt
Should include the following components Physical Activity /Exercise Medications Stress Management Goal-setting Activity pacing Coping Skills training Patient education
prognosis
generally fair
Challenging condition to treat
11 year prospective study (Walitt et al, 2011)
Waxing and waning of symptoms over time
Symptom severity changed little, although the overall trend was for improvement
10% of patients had substantial improvement
15% moderately improved
Pain worsened in 38.6%
conclusion
Complicated pain syndrome
Origins in Central Nervous System
Altered pain processing
Complex myriad of symptoms
Management requires MDT approach
Need to address the physical and psychological aspects of the condition
elements of assessment exam
mood
fatigue
aerobic capacity
functional activities
