Transcript Assessing Muscle Power, Fibromyalgia Tender Sites and Joint

Fibromyalgia
Fibromyalgia






What do you know about fibromyalgia?
Who gets it?
What is the cause?
What are the symptoms?
How many of the tender sites can you
identify?
How is it treated?
Who gets Fibromyalgia?







Lack of good population based studies
Prevalence ~0.5 - 4%
70 – 90% female
90% Caucasian
Average age of onset = 30 – 55 yrs
Can start > 55 yrs old but usually due to
underlying disease (infection, neoplasm etc)
Up to 30% of patients in gen med OPD
Prevalence of Fibromyalgia
Population
900
randomly
selected
individuals, aged 50-70
years
200 consecutive general
medical patients
Hospitalized patients
General medical clinic
Family practice clinic
Rheumatology clinic
Prevalence (%)
1.0
5.0
7.5
5.7
2.1
14.0 - 20.0
Aetiology


Unknown
Reports of preceding illnesses:






Viral (parvovirus, hep C)
Lyme disease
Physical trauma (whiplash injury)
Emotional trauma
Localised pain disorder
Drug withdrawal (glucocorticoids)
Aetiology

Pain amplification:



? Sleep disturbance
? Disordered endorphin / enkephalin response
in descending analgesic pathway ( serotonin)
 Substance P in CSF
Fibromyalgia – ACR Criteria for
classification 1990



History - widespread pain at lease 3/12
affecting both sides of body
+
above and below waist
+
axial skeletal pain
Examination – Characteristic tender points
Otherwise unremarkable
Laboratory tests – all normal
Tender Points

18 points (9 pairs)

>11/18 required for
> 3 months

Pressure = 4kg/cm2
Other symptoms often present
or reported in history








Morning stiffness
Fatigue
Sleep disturbance
Depression
Anxiety
Headache
Parasthesia
Impaired memory/concentration
Symptoms

Fatigue:




Worse in morning / on minimal exertion
Due to disturbed sleep
(cf inflammatory disorders in which fatigue
is due to pro-inflammatory cytokines)
Paraesthesia:



50%
Assos with subjective weakness
No neurological abnormalities
Symptoms

50%:
Subjective joint swelling
(no swelling on examn)




33%:
15%:
10%:
Also:
Depression (50-70% PMH depression)
Dry eyes & mouth
Raynaud’s Phenomenon
Migraine / Tension headache
Irritable bowel syndrome
Dysmenorrhoea
Anxiety
Differential Diagnosis
Differential Diagnosis
Helpful Differential Features
Rheumatoid Arthritis
Synovitis, acute phase
response
Dermatitis, serositis, renal
disease
 ESR, elderly, steroid
responsive
muscle enzymes,
weakness > pain
Abnormal TFT’s
Clinical and EMG evidence
of neuropathy
SLE
PMR
Myositis
Hypothyroidism
Neuropathies
Concomitant Conditions
Concomitant Conditions
Depression
IBS
Migraine
Chronic fatigue syndrome
Myofascial pain
Relationship with
Fibromyalgia
25-60% fibromyalgia
patients
50-80% fibromyalgia
patients
50% fibromyalgia
patients
70% of CFS cases meet
criteria for fibromyalgia
? localised form of
fibromyalgia
Management
“Multidisciplinary Approach”






Patient education
Correction of sleep disturbance
Graded aerobic exercise
Physical therapy / education
Treatment of associated disorders
Psychological behavioural councelling
Education
1.
FMS symptoms are real
2.
There is no sinister underlying pathology
3.
The patient has control over many
components that may modulate the
symptoms
Pain and sleep disturbance cycle
Life crisis, anxiety
Disease, illness,
Sleep disturbance
Functional
disturbance, fatigue,
widespread muscular
pain and tenderness
Insufficient,
deep, non-REM
sleep
Graded Exercise







Improves muscle conditioning
Interrupts feedback loop
Can improve sleep
Releases endorphins
Needs to be sustainable (be a tortoise not a
hare)
Aerobic / non-impact
Physio can help design regime for patient
Medications






NSAID (Ibuprofen and Naproxen) of no benefit
Prednisolone no benefit
Amitriptyline and Cyclobenzaprine significantly
better than placebo
Amitriptyline 25 mg-50 mg benefit seen 25-45%
patients
Fluoxetene comparable effect Amitriptyline single
trial
Fluoxetene plus Amitriptyline better than either
alone single study
Medications

Amitriptyline




Taken at night (1 – 3 hrs before sleep)
10 – 25 mg initially increasing up to 100mg
Onset of relief of symptoms suggests that
the mechanism is not anti-depressant
Fluoxetine

One study showed better results with 20mg
od in conjunction with TCA than alone
Prognosis

Tertiary care centres:


Community based study:



majority continue to experience symptoms despite
therapy
25% asymptomatic and 25% improved after Rx
Better results with a sympathetic patient –
physician relationship and organised approach
to Rx
25% of FMS pts in USA on disability allowance
Take-home messages
1.
FMS is part of a spectrum of pain &
fatigue disorders
2.
Can occur as a secondary feature of
chronic disease and make management
decisions difficult (e.g RA)
3.
Difficult to treat but better results with an
organised sympathetic approach