Physiotherapy and Biokinetics Activity for 2015

Transcription

1 Physiotherapy and Biokinetics Activity for 2015 Activity No: D6 (15) General Topic: Fibromyalgia Topics: Fibromyalgia Guidelines Trigger Changes for FPs Resistance, Aerobic Training May Reduce Pain in Fibromyalgia Approved for (1) Clinical Continuing Educational Units (CEU) 1

2 Fibromyalgia Guidelines Trigger Changes for FPs Janis C. Kelly May 11, 2013 New guidelines published online May 6 in the Canadian Medical Association Journal have codified a number of major changes in fibromyalgia (FM) diagnosis and treatment. The authors of the new guidelines note that FM diagnosis and care have largely shifted to primary care physicians and away from rheumatologists and other specialists. Mary-Ann Fitzcharles, MB ChB, from the Division of Rheumatology, McGill University, Montreal, Quebec, Canada, and colleagues writing for the Canadian Fibromyalgia Guidelines Committee said that physicians "must rely on the time-honoured art of medicine" in diagnosing FM, as there are no reliable physical findings or laboratory tests, and that the main treatment goal should be to improve function by relieving the most troublesome symptoms, particularly pain, as they arise. "The diagnosis of [FM] no longer focuses on counting tender points. Pain in FM is viewed as the chief symptom, with greater acknowledgement of fatigue, unrefreshing sleep, and cognitive symptoms as often part of the clinical presentation," senior author John Pereira, MD, told Medscape Medical News. The authors said laboratory tests for suspected FM generally should include only complete blood count, erythrocyte sedimentation rate, C-reactive protein level, thyroid function, and creatine kinase level. The authors emphasized that FM remains a clinical diagnosis without reliable confirmatory clinical or laboratory tests; that the most important FM symptom is pain that sometimes can be associated with fatigue, disordered sleep, cognitive changes, or mood disorders; that FM can be diagnosed by primary care physicians without specialist confirmation; and that management should be multimodal, "with the understanding that fibromyalgia symptoms fluctuate over time and seldom completely disappear," and should include strategies for relieving symptoms during disease flares. Refer Only Difficult Cases "I agree with the fact that [FM] should be routinely diagnosed by [general practitioners (GPs)] and that only difficult cases should be referred to rheumatologists and pain specialists," Serge Perrot, MD, PhD, from the Pain Center, Paris Descartes University, Hotel Dieu Hospital, France, told Medscape Medical News. Dr. Perrot 2

3 was not involved in the study. "If GPs were not so reluctant with this diagnosis, patients would not wait for years to get a diagnosis and would not get so many unuseful investigations. Based on that, in difficult cases, to avoid any misdiagnosis (inflammatory rheumatic disorders like spondyloarthropathies) and any inappropriate treatment, patients should be referred to rheumatologists." Others are more cautious. "The reality is that most rheumatologists do not want to be involved in the routine care of [patients with FM]; they are much more comfortable treating rheumatoid arthritis and other autoimmune disorders, " Robert M. Bennett, MD, professor of medicine and head of the Fibromyalgia Research Group at Oregon Health & Science University in Portland, told Medscape Medical News. He was not involved in the study. "Thus, the care of most [patients with FM] will be done by primary care physicians (some of whom become quite skilled in managing these patients). If a [patient with FM] can find a rheumatologist who has expertise and interest in this condition, this would be, in my opinion, to their advantage." Dr. Pereira, who is from the Chronic Pain Centre in Calgary, Alberta, Canada, also pointed out that treatment options for FM have expanded, partly as a result of the shift from seeing FM as a soft-tissue disorder with pain driven by inflammatory signaling. It is now understood to be a neuropathic disorder that includes defects in pain processing. "For example, there is evidence that certain exercises and cognitive behavioral therapy can help some patients. Also, there are now medications officially approved for the treatment of [FM] in both Canada and the United States. That all said, no single treatment works for every patient, and there is no cure for this condition," Dr. Pereira said. Examination of patients with FM for tender points (also known as trigger points) was dropped from both the Canadian guidelines and the American College of Rheumatology criteria. "It is well known that there is a huge variability in these tender points, according to the physician, the patient, and time point. Tender point count is more related to stress and anxiety. However, tender point remains a clinical interesting finding, demonstrating that allodynia is a main feature in [FM], related to central sensitization, but not at all specific," Dr. Perrot said. FM symptoms can be faked, and the guidelines authors advised clinicians to be aware of this possibility, particularly when economic factors such as disability insurance payments might create perverse incentives. "Therefore, physicians, particularly those adjudicating disability issues, must remain empathetic, but alert and cautious. In addition, although the cause of fibromyalgia remains uncertain, the legal system has allowed for triggering events to be determined as having caused fibromyalgia. In this context, physicians should be cautious when attributing the cause of fibromyalgia to an injury, particularly in the workplace, because this determination may have socioeconomic consequences. Physicians should evaluate the global presentation of 3

4 the patient, with particular attention to the physical and psychosocial status before the injury," the authors warn. Dr. Fitzcharles has received consulting fees, speaker fees, and honoraria from Janssen, Eli Lilly, Pfizer, Purdue Pharma, and Valeant Pharmaceuticals International. She has provided expert testimony for both plaintiffs and the defence in medicolegal adjudications, including insurance and workers' compensation cases concerning injuries that lead to various pain syndromes. One coauthor is supported by a grant from the Louise and Alan Edwards Foundation. Dr. Pereira has received research support from Pfizer Canada. Dr. Bennett and Perrot have disclosed no relevant financial relationships. CMAJ. Published online May 6,

5 Resistance, Aerobic Training May Reduce Pain in Fibromyalgia Janis C. Kelly January 31, 2014 The trend toward including exercise training in fibromyalgia (FM) treatment programs gained support from a Cochrane Collaboration review published online December 20, The reviewers found that resistance training was both beneficial and safe for women with FM and that aerobic exercise helps reduce FM pain. However, they caution that these conclusions were supported by low-quality evidence, as was the conclusion about the safety of moderate- to high-resistance training in FM. Lead author Angela J. Busch, PhD, associate professor in the School of Physical Therapy at the University of Saskatchewan College of Medicine, Saskatoon, Canada, told Medscape Medical News that the review's key findings were that moderate-intensity and moderate- to high-intensity resistance training improved multidimensional function, pain, tenderness, and muscle strength in women with FM and that aerobic exercise was superior to moderate-intensity resistance training for improving pain in women with FM. "Clinicians often shy away from resistance exercise for this population," Dr. Busch said. "It appears that people with FM can benefit from this form of exercise, but we noted that the programs we examined involved supervised exercise and started low and gradually increased the resistance. There are particular health benefits associated with resistance exercise (eg, increasing bone strength, which is important for preventing osteoporosis), so it is good to know that clinicians can safely use this form of exercise. We are now reviewing literature on aquatic exercise protocols and mixed exercise protocols, which may provide further information for clinicians." Just 5 Randomized Trials Found The authors' main objective was to evaluate the benefits and harms of resistance exercise training in adults with FM. The researchers searched 9 electronic databases and other sources for published studies and screened 1856 citations, 766 abstracts, and 156 full-text articles. They found 5 studies that met their inclusion criteria: randomized clinical trial, FM diagnosis based on published criteria, adults, full-text publication, and between-group data comparing resistance training with a control or other physical activity intervention. 5

6 The studies included 219 women with FM, 95 of whom were assigned to resistance training programs. Three trials compared 16 to 21 weeks of moderate- to high-intensity resistance training with a control group. Two studies compared 8 weeks of progressive resistance training with aerobic training. One study compared 12 weeks of low-intensity resistance training with flexibility exercise. "Although there were 7 separate publications, there were only 5 included studies. In total, there were 241 participants in the included studies, and of these, there were 219 women with [FM]. This is not many people to make major conclusions," said Bryan T. Walitt, MD. Dr. Walitt, who was not involved in this study, is medical director of the Georgetown University Fibromyalgia Center in Washington, DC. However, the analysis showed statistically significant differences favoring resistance training in multidimensional function (measured using the Fibromyalgia Impact Questionnaire), in self-reported physical function, in number of tender points, and in muscle strength (leg extension). There was a statistically significant reduction in pain that favored aerobic exercise over resistance training, but no significant differences between these 2 types of exercise were seen in multidimensional function, selfreported physical function, or tenderness. Resistance training was significantly more effective than flexibility exercise for multidimensional function and pain, but not for tenderness or strength. Dr. Busch agreed there were limitations to the study. "These results are based on a few small studies, so we are somewhat cautious," Dr. Busch said. In addition, she and her colleagues classified the evidence as low quality and noted there was a risk for bias. The mean change in pain using a 0- to 10-cm visual analog scale at 8 weeks' follow-up was 3.57 cm with aerobic training vs 2.7 cm with resistance training. Mean change in pain at 12 weeks' follow-up was 1.01 cm with flexibility exercise vs 1.89 cm with resistance training. Dr. Walitt commented that even the larger changes reported were only slightly greater than the minimally important clinical difference of 2 cm. "These are not 'I'm better' numbers," he noted. Adverse effects were, in general, poorly documented, but there were no serious adverse effects reported for any intervention and no statistically significant differences in attrition rates between the interventions. "We were surprised that women (pre- and postmenopausal) with FM were able to successfully perform resistance exercise. Only a few transient adverse effects were observed," Dr. Busch said. "The data appear to show that these types of exercise can lead to minor to moderate improvements in how people perceive their bodies. It does not show that exercise makes people better," Dr. Walitt concluded. The authors and Dr. Walitt have disclosed no relevant financial relationships. 6

7 INSTRUCTIONS Cochrane Read through Database the Syst article Rev. and Published answer online the December multiple choice 20, questions Abstract provided at the back of the article. Please note that some questions may have more than one answer; in the case of the latter please tick every correct answer. When done only fax through your answer sheet to the fax number given on the answer sheet. QUESTIONNAIRE D6 (15) CLINICAL GENERAL TOPIC: FIBROMYALGIA (FM) FIBROMYALGIA GUIDELINERS TRIGGER CHANGES FOR FPS Question 1: Are there reliable physical findings or laboratory tests in diagnosing FM? A: YES B: NO Question 2: Laboratory tests for suspected FM generally should include which of the following? A: Only complete blood count B: Erythrocyte sedimentation rate C: C-reactive protein level D: Thyroid function E: Creatine kinase level Question 3: Which one of the following is the most important symptom of FM? A: Disordered sleep B: Mood disorders C: Pain D: Fatigue E: Cognitive changes Question 4: Should patients in difficult cases, to avoid any misdiagnosis and any inappropriate treatment, be referred to rheumatologists? A: YES B: NO Question 5: Currently FM is understood to be which one of the following: A: A soft-tissue disorder with pain driven by inflammatory signaling B: A neuropathic disorder that includes defects in pain processing C: None of the above Question 6: Is it TRUE that FM symptoms can be faked? A: YES B: NO Question 7: In which cases can a patient benefit from a FM diagnosis? A: In a disability insurance claim B: In a workplace injury where the cause of FM is attributed to the injury C In both the above cases RESISTANCE, AEROBIC TRAINING MAY REDUCE PAIN IN Question 8: According to a Cochrane Collaboration Review the key findings were that moderate-intensity and moderate-to-high intensity resistance training improved which of the following in women with FM? A: Pain B: Tenderness C: Multidimensional function D: Muscle strength E: All of the above Question 9: Which of the following was the superior training method for improving pain in women with FM? A: Moderate-intensity resistance training B: Aerobic exercise C: Low-intensity resistance training D: High intensity resistance training Question 10: Resistance training was significantly more effective than flexibility exercise for which of the following? A: Strength B: Tenderness C: Pain D Multidimensional function 7

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