Fibromyalgia. Resident School December 2013 Mary Lemon

Transcription

1 Fibromyalgia Resident School December 2013 Mary Lemon

2 The Basics Condition that causes people to feel pain in the muscles all over their body No one knows what causes it; appears to be a combo of genetic & environmental triggers (infection, emotional or physical trauma) leading to CNS super-sensitization The most common cause of gen l m-s pain in women Prevalence ~2-10%

3 Basics, cont d Often ass d w/ cognitive ( fibro-fog trouble w/attn or tasks that require rapid thought changes) and mood disturbances and significant fatigue, and HA s, depression, anxiety, irritable bowel, spastic bladder, TMJ syndrome Tend to have tender points in particular places No test for it (usually check CBC, CRP/ESR and prn TSH/CK to r/o similar syndromes Often sx s last a lifetime, though most work & live full life

4 Basics, cont d Tx = pt.ed., PT to learn exercises/stretches, exercise of choice (walking, swimming, yoga, tai chi) min 3 d/wk, counseling for CBT/coping help, meds to help pain/sleep/mood. Positive outlook and regular exercise are the most important things pts can do Pt.Ed. Is the most important thing clinicians can do

5 Is this really for real? Hx debate of validity of dx psychogenic/psychosomatic? just a lot of depressed women? (women>>men, typically ages 20-55, 60-75% will be depressed &/or anxious at some point w/this dx) are they just wimps? (my bias as well as bias of many other doctors) (8 x likelihood in fam.membs, sim. genetic factors noted in people w/irrit.bowel, depr., migraine; strong correlation w/chronic fatigue syndr.) Story from 15 yrs ago referrals poured in! My own story 5 yrs ago Dr. Heffron, please just press on those 18 points!

6 JM s story Aug 2013 My hx with her my 15 min of fame! 42 yo female w/widespread soft tissue pain x sevl yrs still tired after 10 hrs sleep, tired all the time, sleep disrupted avg 4x/night, wants power nap mid-aft, wakes up with jaws really clenched, mouth guards no help, irritable bowel, migraine, victim of abuse at home betw age 8-15, hypothyroid, rheum tests all neg except TSH 4 and CRP 0.8 Already tried pregabalin, duloxetine, milnacipran no help Currently helping: doxepin, gabapentin, tramadol, naproxen, stretching and exercising 5d/wk but still tired all day and gained 15# in 3 mo (since starting doxepin and upping gabap. dose)

7 How to diagnose? Before 2010: 1) bilat widespread m. pain above and below waist >3 mo steady, 2) 11/18 tender points, 3) nothing else to explain sx s (CBC, ESR/CRP; prn TSH, CK; avoid RF, ANA; nl neuro exam, sleep & mood eval.) Since 2010: can opt out of the tender pt exam, instead use sx severity index: 1) widespread pain index 7 or more + sx severity scale score 5 or more or 2) WPI 3-6 & SSS 9 or more See hand-out for these details

8 What causes it? Genetic predisposition tog w/trigger or aggravator (viral infection, Lyme disease, emotional or physical trauma) leads to CNS sensitization. There is lots of research on possible candidate genes. We can see diff s in CNS in fmri, PET scans, actual pain perception & processing, opioid receptors, substance P levels, neurotransmitter diff s (dopamine, GABA, glutamate) Some data suggest disordered sleep patterns (increase in cyclic alternating patterns of sleep) precede dev. of pain

9 Causes, cont d Altererd HPA axis -> hyperactivity of stress response, often linked to childhood trauma, esp. physical abuse. Changes in AM cortisol, CSF CRF, perhaps growth hormone Autonomic NS changes: orthostatic hypotension, increased pain w/tilt table testing, lower urinary and plasma catechols, nocturnal ht rate variability NO immune system diff s NO muscles diff s on bx that are primary (inactivity & pain can cause secondary changes)

10 How to tx? Pt Ed what is this disease? How do we treat it in gen l? Need to address sleep and mood as well. Dx -> fewer sx s and medical costs, better self-management and long-term prognosis Exercise start slow and build to goal: 30 min or more tiw aerobic conditioning are most successful (bicycling, rapid walking, swimming, water aerobics) plus stretching & strengthening (simple routine, Tai Chi, Yoga). Fatigue & pain may be exacerbated at first.

11 Tx - Meds Amitriptyline (or other TCA: doxepin, nortriptyline, desipramine-less studied). Cyclobenzaprine is sort of TCA, even low dose (1-4mg qhs) seems to restore sleep well SNRI (duloxetine/cymbalta, milnacipran/savella, NOT venlafaxine little evidence & lots w/d sx s in rapid release form). Very small help > placebo in pain & sleep sx s, no help w/fatigue or quality of life. Only a minority are helped, many have adverse side effects. Add pregabalin or gabapentin (target dose /d) esp if need more help w/sleep

12 Tx meds, cont d Tramadol is most recommended for addt l pain (2-6 tabs/d) Standard opioids NOT indicated (lack of evidence that they help, addiction, up-regulation). Acetaminophen + tramadol combo has strong evidence for help but nausea more common (from the tramadol). Tramadol activates mu opioid receptors and also inhibits reuptake of serotonin and norepinephrine. NSAID s help only in that they seem to have a synergistic effect with anti-dep s or anti-convulsants, or if they have concomitant arthritis

13 Tx - other TPI s Counseling helps pts have increased sense of control, increased belief one is not disabled, increased belief that pain is not a sign of damage

14 Review JM as example 42 yo woman w/widespread soft tissue pain all over x yrs, still tired after 10 hrs of sleep, tired all the time, sleep disrupted avg 4x/night, wants power nap in mid-aft, wakes up w/jaws really clenched, mouth guards don t help, irritable bowel, migraine, victim of abuse at home betw. ages 8-15, c/o fibro fog, hypothyroid. Pregabalin, duloxetine, milnacipran no help. Doxepin 25 x last 3 mo helping w/sleep, gabapentin 300/300/600 helping some, tramadol 4/day gives great help, naproxen 550 bid, stretching/exercising 5d/wk. Still tired, gained 15# last 3 mo

15 Don t blame the victim Summary Simple to dx w/either 11/18 tender pts or SSS/WPI Make sure to address sleep and mood Education & exercise work better than meds Expect 2/3 to be able to work full-time & have it interfere only modestly w/lives