Clinical Approach to Fibromyalgia. Allen Steverman, MD, CCFP Clinique Antidouleur CHUM Jewish Rehabilitation Hospital

Transcription

1 Clinical Approach to Fibromyalgia Allen Steverman, MD, CCFP Clinique Antidouleur CHUM Jewish Rehabilitation Hospital

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3 Disclosure Speaker: Purdue Advisory Board: Purdue, Paladin, Knight Therapeutic

4 Objectives As a result of attending this session, participants will be able to: q Assess a patient with symptoms suggestive of fibromyalgia q Diagnose fibromyalgia q Initiate a management and follow up plan for patients with fibromyalgia

5 Chronic pain condition True syndrome Diffuse pain Fatigue Cognitive dysfunction Mood disorder Other somatic symptoms Fibromyalgia

6 Fibromyalgia Described in medical literature for over a century Many different names Fibrosis Soft tissue rheumatism Chronic Widespread Pain (CWP) Fashionable diagnosis for psychological distress?

7 Pathophysiology Cause unknown No muscle anomaly No biological marker Genetics Trigger Dysregulation HPA Axis Pain regulation mechanisms altered

8 Pathophysiology Sensitisation of central and peripheral nervous system Central amplification of peripheral sensory signals Endogenous system for pain regulation Descending system - DNIC (Descending Nociceptive Inhibitory Control) Deficit of DNIC in fibromyalgia patients Amplified input + Decreased Inhibition Normal sensations perceived as painful

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10 Epidemiology Prevalence in Canada 2% to 3% Affects woman 6 to 9 times more often than men Increases with age McNally JD, Matheson DA, Bakowsky VS. Chronic Dis Can 2006; 27:9-16 Heterogeneous condition Symptom presentation will vary Severity will vary Functional impact will vary

11 Diagnosis to consider if: Chronic diffuse pain Fatigue Disrupted sleep How to make the diagnosis Clinical Diagnosis History Physical exam Limited investigation

12 History Diffuse Pain for at least 3 months Like always having the flu Pain location and intensity can vary Can be increased by: Physical activity Stress Cold Lack of sleep Emotional distress

13 History Fatigue (> 90%) Nonrestorative Sleep Cognitive Dysfunction Mood Disorder (depression, anxiety) Serotonin and Noradrenalin involved in pain No DNIC deficit in major depression So Fibromyalgia is not masked depression

14 Pain related somatic symptoms associated with FM Migraines Severe menstrual pain Lower urinary tract symptoms Myofascial facial pain Temporomandibular pain Irritable bowel syndrome * 30% patients with IBS have fibromyalgia 30% to 70% patients with fibromyalgia have IBS * Kim SE, Chang L. Neurogastroenterol Motil. 2012;24(10):

15 Sexual dysfunction Non-pain related symptoms May be more vulnerable to PTSD Clinical Picture in Fibromyalgia Not static Symptom intensity will fluctuate over time

16 Physical exam Tender points 11 out of 18 points ACR classification criteria 1990 Research criteria not clinical Eliminated in the ACR 2010 version Therefore not necessary to confirm diagnosis

17 Physical exam Exclude other pathology Neurological exam Joint exam Normal exam Except for tenderness of soft tissues

18 Investigations There is no test to confirm the diagnosis Limit laboratory testing For ruling out other diseases with similar presentations CBC Erythrocyte sedimentation rate CRP TSH Creatine kinase

19 Other testing Investigations Depends on clinical evaluation Serological biomarkers ANA RF Only if clinical evaluation suggests an inflammatory disease Avoid extensive workup aiming to rule out all causes of pain and fatigue Fibromyalgia is Not a diagnosis of exclusion

20 2010 American College of Rheumatology diagnostic criteria for fibromyalgia

21 2010 American College of Rheumatology diagnostic criteria for fibromyalgia A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met: Widespread pain index (WPI) 7 and symptom severity (SS) scale score 5 or WPI 3-6 and SS scale score 9. 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.

22 2010 American College of Rheumatology diagnostic criteria for fibromyalgia Can help validate clinical diagnosis But symptoms will fluctuate over time Focus on symptoms Not tender points Diagnosis remain a clinical diagnosis

23 *White KP et al. Arthritis Rheum. 2002;47(3): Recommended patient trajectory No need for rheumatologist consultation to confirm diagnosis Specialist consultation if atypical symptoms Minimize delay to make diagnosis Establishing + explaining the diagnosis essential to management * Increased health satisfaction Decrease in symptoms long term Decrease in health care utilisation

24 Management Treatment goals to define Reframe what success will look like Not a cure Symptom management addressed early on Reduction in pain intensity Hurt Harm Target functional improvement

25 Management Focus on progress Set treatment goals and adjust as condition evolves Set specific goals (SMART) Specific Measurable Achievable / Action Oriented Realistic / Relevant Time-bound

26 Management Education +++ True syndrome Reassurance Kinesiophobia Catastrophizing Lots of listening, validation, and empathy

27 Chronic pain s vicious cycle Adapted from Cooper R G et al. Rheumatology 2003;42

28 Management Medication not a panacea Bio-psycho-social approach Multimodal Potential comorbidities to identify and treat

29 Biopsychosocial model

30 Management Pharmacological options Non pharmacological options Active participation from the patient

31 Education Non pharmacological treatment Real condition Benign Chronic condition but outcome usually favourable for function Fluctuating Physical activity not dangerous Role of stress and mood Sleep hygiene

32 Physical activity Enjoyable Affordable Easy to follow Non pharmacological treatment Psychological interventions (depression, anxiety, ptsd) Cognitive-behavioural therapy Group therapy Motivational Interviewing

33 Non pharmacological treatment Multidisciplinary treatments (educational or psychological component AND a physical activity component) Self-management Chronic pain self-management programs Acupuncture Mindfulness

34 Mindfulness for pain Patients with chronic pain are often given the message that you will have to live with this pain Traditional approaches come up short on teaching patients how to live with the pain Mindfulness : moment-to-moment non-judgmental awareness, being fully present with what is happening right now. (Kabat-Zinn, J., 1990)

35 Mindfulness for pain Goal is not to change the content of one s experience, but rather altering the way in which it is experienced Suffering caused by chronic pain comes from the combination of the pain sensation and what it means to the sufferer how it is interpreted. Example: pain in extreme sport may be tolerated better than as a result of a MVA

36 Mindfulness and Fibromyalgia Decrease in depressive symptoms Sephton et al Decreased pain scores Better pain coping Improvement in anxiety, depression, and somatic complaints Improvement in quality of life Benefits sustained for 3 years Grossman et al. 2007

37 Mindfulness for pain Mindfulness-Based Chronic Pain Management (MBCPM ) Program developed by Dr. Jackie Gardner-Nix, a physician and chronic pain consultant at St Michael s Hospital, Toronto, Canada Based on the Mindfulness-Based Stress Reduction Program (MBSR) originated by Jon Kabat-Zinn Developed into a program more customized to the needs of those dealing with chronic pain Patient courses (groups) are usually once a week for 12 to 13 weeks, for 2 and a half to 3 hours per session

38 Pharmacological treatments Not always necessary Target symptoms causing most significant impairment Low doses to start Start low Go slow Combining medications (different mechanisms of action) Caution with side effects that can be mistaken for fibromyalgia symptoms

39 Acetaminophen Pharmacological treatments Helpful in some patients Caution with hepatotoxicity NSAIDS Little rationale since action mostly in periphery Treatment of associated condition (osteoarthritis)

40 Pharmacological treatments Anticonvulsivants Gabapentinoids: pregabalin and gabapentin Shown clinical efficacy but modest Reduced pain Improved sleep Improved quality of life

41 Pharmacological treatments Antidepressants Effect on pain independent of effect on mood - Pain modulators Variable beneficial effects on pain, sleep, fatigue Tricyclics SSRIs SNRIs Duloxetine the only antidepressant approved by Health Canada for the treatment of fibromyalgia Cyclobenzaprine Moderate benefit on global improvement, sleep physiology, fatigue, depression

42 Opioids Controversial Pharmacological treatments May be useful in carefully selected patients Caution Tramadol only opioid studied in FM Monitor efficacy, side effects, aberrant drug behaviours Cannabinoids Controversial May be considered particularly if sleep disturbance

43 Follow up Dictated by clinical judgement More frequent visits in the beginning New symptomà evaluation Follow symptoms Functional capacity Therapeutic goals Favourable outcome in many patients

44 Outcome measurement tools Can be used in global clinical context FIQ (Fibromyalgia Impact Questionnaire) (research tool) PGIC (Global Impression of Change) BPI (Brief Pain Inventory)

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46 Brief Pain Inventory

47 *Wolfe, F., et al. Journal of Rheumatology, (6): p Often contentious Work In the US up to 35% of patients receive work disability benefits* Work stoppage sometimes necessary But can lead to isolation, loss of role The longer off work, the harder it is to return Patients with FM who are working: Have less severe symptoms Have a better quality of life But no evidence that remaining in the workforce positively affects health status

48 Work Encourage remaining in the workforce Factors that facilitate continued work and obstacles See algorithme de prise en charge de la fibromyalgie (MSSS) Identify and act on modifiable factors Reasonable workplace adjustments if necessary If have been off work: Progressive return to work Modification of work tasks Modification of work schedule Modification of work station

49 Resources for Professionals (2012) Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome (2012) Algorithme de prise en charge de la fibromyalgie (MSSS)

50 Resources for patients AQDC (Association Québécoise de la Douleur Chronique) Regional fibromyalgia associations L association de la fibromyalgie région Ile-De-Montréal 5 minutes video Comprendre la douleur Hunter New England local health district NSW Australia (english) (french)

51 Resources for patients Faire équipe face à la douleur chronique Un ouvrage conçu pour les patients et écrit par leurs professionnels de la sante. O Donnell- Jasmin, L. (2010). Practical guide for fibromyalgia patients - Associations de la fibromyalgie de Laval et I le-de Montréal

52 Programs in Rehabilitation Centres Association des établissements de réadaption en déficience physique du Quebec AERDPQ Constance-Lethbridge rehabilitation centre Chronic pain self management program - fibromyalgia Jewish rehabilitation hospital (Laval) Adaptation to chronic pain program (PADoC) Fibromyalgia program Centre de réadaptation Lucie-Bruneau Clinique d'adaptation à la douleur chronique

53 Take home Key points Fibromyalgia: Diagnosis made based on history, physical exam, limited investigation Not a diagnosis of exclusion Treatment goals to define, aiming for reduction in pain intensity, symptom improvement and improved function Multimodal approach, including education, reassurance, lots of empathy and listening

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