Fibromyalgia and Chronic Fatigue

1
Fibromyalgiaand Chronic Fatigue

• Tory Davis PA-C

2
Fibromyalgia

• One of the most common rheumatic syndromes in
  ambulatory medicine
• 3-10 of the population
• 10-20 of pts seeing rheumatologists
• Annual cost for direct care about 20 billion or
  2300/pt
• More common in females, ages 20-50
• No objective findings
• No diagnostic labs or imaging

3
Diagnostic Criteria

• History of widespread pain for at least 3 months
• Achy and stiff
• Bilateral symptoms
• Above and below waist
• Worse at neck, shoulders, low back, hips
• 11 of 18 tender points (elicited by pressure of 4
  kg/cm2)

4
Tender Points

5
Other common symptoms

• Low back pain
• Mood disorder
• Multiple chemical sensitivities
• Sexual dysfunction
• TMJ dysfunction
• Bruxism grinding teeth at night

• Fatigue
• Sleep disorder
• Headache
• IBS (irritable bowel syndrome)
• Irritable bladder
• Fibro fog - haze

6
and the list goes on

• Pelvic pain
• Dysmenorrhea
• Restless leg syndrome
• Subjective numbness feels numb, but can sense
  on neuro test
• Exercise-induced pain and fatigue

7
Central Sensitization

• Pathophysiologic abnormality of CNS
• Sensory impulses amplified at spinal cord level
• In dorsal horn nocioceptive neurons

8
Proposed Causes

• Serotonin (much lower levels in women compared to
  men)
• Substance P- aberrant pain perception?
• Sleep disturbance
• Injury/trauma
• Infection
• Psychological stressors- may increase
  pro-inflammatory cytokines via impaired cortisol
  response
• Hormones- ?neuroendocrine dysfunction

9
DDx

• Polymyalgia rheumatica proximal weaknesss
• Rheumatoid arthritis
• Sleep apnea
• Lupus
• Multiple sclerosis
• Thyroid disorder (hypo, usually)
• Neuropathies
• Mental illness

10
DDx continued

• Substance abuse
• Cancer
• Infection
• Medication side effects
• Malingering people use it to get other benefits

11
Work-up

• Dx of exclusion must exclude!
• TSH (thyroid stimulating hormone)
• ESR (erythrocyte sedimentation rate)
• CBC (complete blood count)
• ANA (antinuclear antibody)
• RF (rheumatoid factor)
• Sleep study
• Psych screening tools

12
Physical Exam

• Normal, except
• Pain is present at multiple FM points when
  pressure is applied.
• Interestingly, it can felt virtually anywhere
  pressure is applied, including control areas
  (forehead, thumbnail), which are relatively
  insensitive to pain in normal subjects.
• Allodynia other pain
• Pain from stimuli that are not normally painful

13
Risk factors

• Sex (female, that is)
• Family history (nature/nurture?)
• Age- early/mid adulthood
• Other rheumatic dz lupus, RA, ankylosing
  spondylitis
• Disturbed sleep OSA, RLS

14
Treatment

• This is a chronic disease. Requires more than a
  Rx pad.
• Pt self-management
• Meds- only treating the symptoms. Not curative
  nor disease-modifying except as they improve pt
  ability to self-manage and improve QOL

15
Self-Management

• Pts unwilling to engage in proactive self care
  have poorer prognosis
• Regular low-impact exercise
• Regular sleep- no naps, limit caffeine
• Education about the dx and about self
• Support groups

16
Prognosis

• Better if ongoing stressors are relieved and
  self-efficacy for pain control can be achieved.
• Worse for patients who are highly distressed and
  have longstanding FM, major psych disease, or
  ingrained pattern of work avoidance.

17
Complementary and alternative treatment

• Massage
• Acupuncture/ acupressure
• Myofascial release therapy
• Chiropractic treatment or OMT
• Cognitive behavioral therapy (CBT)

18
CBT

• Cognitive Behavioral Therapy
• Purpose to redefine illness beliefs and learn
  symptom reduction skills to change behavioral
  response to pain.
• Need to sell this idea- not therapy because
  its all in your head but as a tool to improve
  prognosis.
• Tools gate control, relaxation, reframing

19
Pharm Tx

• TCAs amitriptyline (Elavil)
• SNRIs duloxetine (Cymbalta), milnacipran
  (Savella) venlafaxine (Effexor)
• SSRIs (paroxetine, fluoxetine, et al)
• Muscle relaxants cyclobenzaprine
• Antiseizure meds gabapentin (Neurontin),
  pregabalin (Lyrica)
• Sleep aids- eszolpiclone (Lunesta), zolpidem
  (Ambien)

20
Just say NO

• No narcotics
• No benzodiazepines
• To treat the pain use tramadol (Ultram)
• better proven efficacy than acetominophen or OTC
  NSAIDS

21
CFS

• Profound fatigue not improved by rest, worsened
  by physical or mental activity.
• No clear cause. No definitive work-up. No good
  tx.
• FibromyalgiapainCFSlassitude

22
CFS- Who?

• Female gt male (31)
• Usually not pediatric patients, but otherwise,
  any age, racial, ethnic or SES group

23
CFS Diagnostic Criteria

• Severe chronic fatigue 6 months with other
  medical conditions excluded
• AND

24
AT LEAST 4 OF THESE

• ? STM or concentration
• Sore throat
• Tender cervical or axillary lymph nodes
• Muscle pain
• Headache (new type, pattern or severity)
• Unrefreshing sleep
• Post-exertional malaise lasting 24 hours
• Multi-joint pain without swelling or redness
  
  

25
Associated symptomsThese are NOT diagnostic
criteria

• Abd pain
• Etoh intolerance
• Bloating
• Chest pain
• Chronic cough
• Diarrhea
• Dizzy
• Dry eyes/mouth
• Paresthesias

• Otalgia
• Palpitations
• Jaw pain
• Morning stiffness
• Nausea
• Night sweats
• Dyspnea
• Wt loss
• Etc etc etc etc etc etc etc etc etc

26
Course

• Sx can remit and recur, or can fluctuate in
  severity.
• Some pts will recover 100, but when?
• Some pts have progressively worsening sx
• Can be lifelong

27
Causes

• A sampling of proposed, not proven etiologies
• Iron deficiency anemia
• Hypoglycemia
• Hx allergies
• Viral infection
• Immune system dysfunction
• Mild chronic hypotension
• Alteration in HPA axis function
• Sleep dysfunction
• Other

28
Risk factors

• What is a risk factor?
• A condition or value that alters the likelihood
  of the occurrence of a disease
• Females more likely to be affected
• Gulf War veterans have 10-fold increased
  incidence vs non-deployed vets
• Other?
• We dont know.

29
Role of Sleep

• Diagnosable sleep disorder present in 40-80 of
  CFS cases, but tx of sleep d/o only results in
  modest improvement of CFS sx.
• ? Effect rather than cause?

30
Differential diagnosis

• Fibromyalgia
• Multiple chemical sensitivities
• Chronic mono
• Thyroid dysfunction
• Sleep apnea
• Narcolepsy
• Mental illness

• Cancer
• Eating disorder
• Obesity
• Substance abuse
• Medication side effect
• Somatization d/o
• Malingering

31
Work up

• Complete Hx
• Complete PE
• Psych screening tools
• Labs Exclusionary, not confirmatory!

32
Labs/Work-up

• CBC
• CMP
• TSH
• ESR
• ANA
• RF
• UA

• PPD
• HIV
• Lyme serology in endemic areas
• ?CXR or other imaging
• MRI may show non-diagnostic subcortical frontal
  lobe punctate hyperintensities

33
CFS Complications

• Deconditioning
• Med side fx
• Social isolation
• Loss of job
• Lifestyle restrictions
• Depression (from sx or lack of dx)

34
CFS Treatment

• Tx is directed at sx- Goal is to regain some
  level of previous function and well-being.
• Try NOT to aggravate existing sx or to create new
  ones.
• Limit cost

35
CFS Tx- Non Pharm

• Physical activity- Know thyself. Pace thyself.
  Avoid push-crash phenom
• Massage
• Acupuncture
• Acupressure
• Chiropractic tx
• OMT
• Yoga, tai chi
• Meditation

36
More non-pharm tx

• Education- knowledge is power.
• CBT
• Colonics?! Go ahead and Google it.
• Strive for health, but dont grasp at straws.

37
CFS Treatment- Meds

• Pts with CFS seems very sensitive to meds, so
  START LOW, GO SLOW
• NSAIDS for pain- these work for CFS, not for
  fibromyalgia
• Remember fibromyalgia pain responds better to
  tramadol
• Low dose TCAs to improve sleep, decrease pain
• Antidepressants/anxiolytics

38
More meds

• Stimulants modafinil (Provigil)
• Antimicrobials- NO. Not unless proven concurrent
  infection.
• Gamma globulin, Ampligen, antifungals,
  corticosteroids- no evidence of efficacy
• Vitamins/herbals- many claim benefit, few prove
  it. ASK what theyre using.
• Natural ? good