Transcript SERONEGATIVE SPONDARTHRITIS 2

Assistant Professor
Dr.Khudair Al-bedri
Consultant Rheumatology & Internal
Medicine .
Fibromyalgia
• Fibromyalgia is a syndrome of chronic pain
and the presence of hyperalgesic points at
specific anatomical sites ,as well as a range of
other physical and psychological symptoms
with no identifiable organic cause .
FAST FACTS
. Fibromyalgia affects two to four percent of people ,
mostly women .
.Doctors diagnose fibromyagia based on all the patients
relevants symptoms (what you feel ), no longer just on the
number of tender points .
. There is no test to detect this disease , but you may need
lab tests or X-ray to rule out other health problems.
.Though there is no cure ,medications can relieve
symptoms.
.Patients also may feel better with proper self-care ,such
as exercise and getting enough sleep.
Aetiology
• Two abnormalities have consistently been
reported:
• 1-Sleep abnormality: Delta waves are
distruption ( characteristic of the deep
stage (4) of non-rapid eye movement
(non-REM) sleep, which usually occurs in
the first few hours and is thought to have
primarily a restorative function..
• People with fibromyalgia have reduced
delta sleep.
Aetiology
• 2-Abnormal pain processing
• A reduced threshold to pain perception
and tolerance at characteristic sites
throughout the body is a central feature of
fibromyalgia
Aetiology
Affected people also have:1-Abnormal levels of neurotransmitters :A- Substance P is increase .
B- Nerve growth factor is increase .
C- Serotonin is low .
All above in neurotransmitters changes
reducing pain threshold.
Aetiology
2- fibromyalgia have reducing hypothalamic pituitary
adrenal axis (HPA) response to stress
The main HPA abnormalities in FMS are:-Low free cortisol levels in 24 h urine samples.
-Loss of the normal circadian rhythm with elevated evening
cortisol level.
-Insulin-induced hypoglycaemia associated with an
overproduction of pituitary ACTH.
-Low levels of growth hormone .
-Reduce adrenal release of glucocorticoids in response to ACTH
stimulation.
Pathophysiology
• The cause of fibromyalgia is poorly
understood but abnormal central and
peripheral pain processing is thought to be
responsible for reduced pain threshold ,
hyperalgesia (amplification of pain ) and
allodynia (pain produced by a non-noxious
stimulus).
Epidemiology and risk factors
• The prevalence of fibromyalgia in the general
population is approximately 2-4%,but it is a
condition that is underdiagnosed.
• The incidence of fibromyalgia in primary care
in the UK is approximately 14 700 new cases
per year .
• There are recognized risk factors for
fibromyalgia but they only contribute
approximately 5-10% to disease development
(Table 1).
Risk factors for fibromyalgia
• Table 1
Gender
10 x more common in women than
men .
Age
More common in individuals aged 20-50
.
Physical trauma
For example whiplash type injuries to
the neck and trunk.
Psychological trauma
Stress , anxiety and depression .
Viral infections
May occur as a post-viral syndrome.
Diagnosis
A full social ,personal ,family and psychological history should be
taken to reveal any past physical disturbance .
• FMS PAIN IS NOT ARTICULAR.
• The most widely accepted set of classification
criteria for Dx of FMS, the ACR 1990, define
fibromyalgia according to the presence of the
following criteria:
 A history of widespread pain lasting more than
three months.
 Tender points—there are 18 designated possible
tender points
Diagnosis
•
Tender points .
Examination disclosed
• Widespread pain ,above and below the waist
as well as the axial skeletal system ,for at least
3 months.
• The presence of 11/18 tender points .
• Digital palpation using the thumb to assess
tender points. The pressure applied should be
just enough to blanch the examiner’s thumb
nail . In the absence of fibromyalgia , the
palpation would not be enough to cause pain .
Diagnosis of FMS
• ACR 2010 replace the tender point count Widespread Pain
Index(WPI) and Symptom Severity Scale(SSS).
• In the WPI patients asked to indicate the regions (maximum
19 regions ) of the body has been experience during the past
week,and each positive regions given a Score of 1(WPI rangs
from 0-19).
• SSS is the sum of the severity of the three symptoms (fatigue
,waking unrefreshed ,cognitive symptoms) plus the extent
(severity) of somatic symptoms in general, SSS Score 0-3(0
=no problem ,1= mild, 2=moderate ,3= severe problem ) .
• A patient satisfies the criteria for FMS if the following
conditions are met. WPI>7 and SSS>5 , or WPI 3-6 and SSS >9.
Investigation revealed
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Blood test
normal
Haematology .
Biochemistry.
Immunology.
Imaging
normal
Differenational diagnosis
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Hypothyroidism.
Polymyalgia rheumatic.
Polymyositis.
RA .
SLE.
Osteomalacia.
Management
General points :
• Pain and function should be assessed in a
psychosocial context.
• Access to a multidisciplinary team with
treatments taking into account the patient’s
needs including pain intensity , function
,depression , fatigue and sleep disturbance.
Non-pharmacological treatment
Heated pool treatment
Can improve pain and function with or without
exercise.
Exercise programmes
Individually tailored exercise programmes which include
aerobic training and muscle strengthening.
Cognitive behavioural
Therapy (CBT)
A form of psychotherapy that is based on scientific
principles that help people change the way they think ,
feel and behave.
Others
Relaxation , rehabilitation , physiotherapy and
psychological support.
Pharmacological treatment
Tramadol
A moderate opioid which is recommended for
pain management.
Mild pain relief
Paracetamol and weak opioids such as codeine
can also be considered .
Antidepressants
Reduce pain and improve function e.g. fluoxetine ,
amitriptyline and duloxetine.
Serotonin
norepinephrine reuptake
inhibitors
Duloxetine and Minaciprans .
α2 agonists eg
,gabapentin
Pregabalin
Relatively new treatment which reduce pain.
Thank you