Fibromyalgia

1. Fibromyalgia Improving the consultation

2. “What do you think about Fibromyalgia?”

3. Informal survey 30 GPs in Wales • 'Nightmare consultation' • Clinical entity - but difficult to diagnose • I am dubious about its existence as a distinct clinical entity. Most patients that I have seen who do or might have it as a diagnosis have a complex mixture of "somatopsychosocial" symptoms, with generalised sadness distress and misery • I think it probably comes under the umbrella of psychosomatic. I have no problem with this. I feel, with no justification, that patients are fearing pain in areas which tend to be painful..... • It exists

4. Informal survey 30 GPs in Wales • It is a symptom description that has evolved into a spurious diagnosis although probably multifactorial • Made up disease • Very useful concept, which allows the clinician to promote beneficial lifestyle changes (and psychological techniques such as CBT) to patients who appear to have lost their 'pain filter', and who would otherwise resist such initiatives • I try and make it a positive decision to diagnose fm and move the patient forward in coping with their symptoms • If you mean do I think it's a "real" disease - then I do as if patients perceive pain or fatigue then we, as their doctors, should accept this even if we don't have a "test" to confirm the diagnosis. I do think it's tricky to manage and each treatment has to be tailored to the patient

5. “What characteristics do patients with Fibromyalgia exhibit?”

6. Informal survey 30 GPs in Wales • Chronic fatigue. Easy irritability with localised tender spots. Often much worse after a "viral illness" • Female, neurotic, slim • Frequent attendance and poor coping skills • Global pain causing significant debility. Lack of response to analgesia. Psychological distress and helplessness • Mad

7. How do patients with Fibromyalgia make you feel?

8. Informal survey 30 GPs in Wales • Challenged, although usually I just go along with their understandings. I don' t know if it is helpful to label it apart from rheumatologists being able to discharge them! • Depressed, as condition is chronic and these patients need a lot of input • Difficult to treat and I would like more time to take a history examine them and formulate a plan • Frustrated and irritated • Good, because at last I can do something for this sizeable group of patients: mainly along the lines of getting THEM to make changes

9. Informal survey 30 GPs in Wales • Gut reaction is Powerless / Heartsink... but try and make myself see them as a challenge as to how my relationship with them can be therapeutic • Heartsink • I get immensely satisfied when a patient with fibromyalgia comes into my consulting room smiling! • Oh no! A 30-minutes consultation in a 10-minutes slot... • Wish I had something better to offer in terms of diagnostic certainty and therapeutic effectiveness

10. Fibromyalgia

11. Fibromyalgia • Fibromyalgia is a chronic centralised pain syndrome that affects 2-5% of the population • It is associated with sleep disturbance, chronic fatigue and mood disorders • There is a female:male incidence ratio of 2:1 • There is a waxing and waning pattern to the condition • There is scepticism in the medical profession as to the validity of the diagnosis

12. What is fibromyalgia? • Fibromyalgia is a diagnostic term for a chronic widespread centralised pain syndrome with attendant features. There is no diagnostic laboratory test or imaging. It is characterised by chronic widespread pain for which no physical explanation can be given. There are accompanying symptoms, which may or may not be present in an individual and will usually vary over time

13. What are the symptoms of fibromyalgia? • Pain – chronic (3 months +) widespread and unexplained (central symptom) • Mood disturbance • Cognitive impairment • Fatigue • Other associated conditions/symptoms

14. Other associated conditions/symptoms • Irritable bowel syndrome • Migraine • Severe menstrual pain • Lower urinary tract symptoms • Facial and tempromandibularjoint pain • Somatic symptoms • Sexual dysfunction (up to 97% of sufferers)

15. Is fibromyalgia a clinical entity? • The pathogenesis of fibromyalgic pain is multifactorial. There is no practical diagnostic test and imaging is only helpful to rule out underlying pathology. However in research studies, where more invasive testing and specialised imaging is available, physiological changes have been identified in fibromyalgia.

16. Is fibromyalgia a clinical entity? • The underlying problem in fibromyalgia is an enhancement of the neurophysiologic sensory response. This is evidenced by abnormal activity in pain centres in response to touch and heat, increased neuropeptides both peripherally in the nociceptors and centrally in the cerebrospinal fluid (notably Substance P) and is manifest in the allodynia experienced by fibromyalgia sufferers.

17. Is fibromyalgia a clinical entity? • The increased concentration of neuropeptides and other substances related to the excitation of the pain pathways in the CSF may be linked to the fatigue, mood disturbance and cognitive impairment seen in fibromyalgia. Patients with fibromyalgia often have other symptoms that could be considered as "visceral allodynia" e.g. irritable bowel, pelvic pain, lower urinary tract symptoms etc. These conditions could be considered as sensory attenuation based.

18. Is fibromyalgia a clinical entity? • There is sufficient research evidence to demonstrate an abnormality in sensory perception and to explain the symptom complex seen in fibromyalgia

19. Making a diagnosis • Fibromyalgia should be suspected in patients presenting with chronic (greater than 3 months), multifocal pain that cannot be explained by an obvious pathological process – e.g. inflammation, infection, degeneration or neoplasm. Once fibromyalgia is suspected simple laboratory tests should be performed to exclude conditions that can present in the same way as fibromyalgia.

20. Making a diagnosis • Inflammatory rheumatic conditions • Early rheumatoid arthritis • Polymyalgia rheumatic • Giant cell arteritis • Systemic vasculitis • Inflammatory spondyloarthritis • Systemic lupus erythematosus • Myositis • Hypothyroidism • Depression • Neuropathies (tend to be more localised) • Multiple sclerosis (tend to have motor and sensory defects) • Vitamin d deficiency

21. Making a diagnosis Laboratory tests should be tailored to the patient’s symptoms, however if a diagnosis of fibromyalgia is suspected the following would be considered a baseline set of investigations:- • Full blood count • Erythrocyte sedimentation rate • C-reactive protein • Thyroid function • Creatine kinase

22. Making a diagnosis • 1990 ACR criteria were never intended to be used as diagnostic criteria • Relied on tender point examination • Superseded by 2010 criteria • May use self reported scale

23. 2010 criteria

24. 2010 criteria

25. 2010 criteria A patient satisfies diagnostic criteria for fibromyalgia if all the following 3 conditions are met: 1) Widespread pain index (WPI) 7 and symptom severity (SS) scale score 5 or WPI 3–6 and SS scale score 9. 2) Symptoms have been present at a similar level for at least 3 months. 3) The patient does not have a disorder that would otherwise explain the pain.

26. Management The management of fibromyalgia has 4 main components:- • Patient education • Physical therapy • Psychological therapy/support • Drug treatment

28. Patient education • Clear diagnosis • Education about their condition • Patient information leaflets • Adjuvant to face-to-face explanation • Chronic nature of the condition • Interventions, at best, provide partial symptomatic relief • A condition that waxes and wanes • They are part of the treatment • Adherence to treatment regimes

29. Physical therapy • Stress reduction • Sleep hygiene • Weight reduction (if overweight) • Remain in work if possible • Graduated exercise regime • Little or no evidence for massage or physiotherapy • Adherence to exercise regimes is poor • Directed or group exercise has greater adherence

30. Psychological therapy/support • CBT • Try to stay positive • Not to focus on the pain • Catastrophising and stopping moving are poor prognostic indicators

31. Drug treatment • Drug treatment should be tailored to the patient and the choice of medication should take in to account the additional symptoms affecting the patient

32. Drug treatment • A meta analysis published in 2011 estimated treatment differences vs. placebo, separately, for duloxetine, fluoxetine, gabapentin, milnacipran, pramipexole, pregabalin, either of two tricyclic antidepressants, and tramadol plus paracetamol • The analysis examined pain response and did not report on other symptoms. The response was measured as a 30% reduction and a 50% reduction in reported pain from baseline

33. Drug treatment • when compared with placebo, statistically significant pain responses (improvement of 30% and 50%) were observed for patients treated with duloxetine, milnacipran 200 mg/day, pregabalin 300 or 450 mg/day, and tramadol plus paracetamol. Treatment with fluoxetine, gabapentin, or milnacipran 100 mg/day resulted in significant findings for the 30% improvement in pain response

34. Drug treatment • All eight active treatments displayed evidence suggesting improvement over placebo in the treatment of pain in patients suffering from fibromyalgia. Indirect comparison of active treatments found no strong differences • Seven of the eight regimens had increased discontinuation due to side effects when compared to placebo (the exception being fluoxetine)

35. Drug treatment • Severe adverse effects were statically significant for milnacipran (a serotonin–norepinephrine reuptake inhibitor (SNRI) licensed specifically for fibromyalgia but currently only available in the US and Russia) and pregabalin

36. Summary • Fibromyalgia is a chronic centralised pain syndrome that affects 2-5% of the population • It is associated with sleep disturbance, chronic fatigue and mood disorders • There is a female:male incidence ratio of 2:1 • Use the 2010 ARC diagnostic criteria • A stepwise approach to treatment is advised • Patient education is the first step and the patient needs to be an active participant

37. Summary • The aim is to reduce symptoms and increase patient function • There is a waxing and waning pattern to the condition • There is scepticism in the medical profession as to the validity of the diagnosis • There are measurable (research) biochemical changes in fibromyalgia • There is an evidence base to treatment which must be tailored to the patient’s symptoms

38. Summary • The management of fibromyalgia has 4 main components:- • Patient education • Physical therapy • Psychological therapy/support • Drug treatment • Do not (or with caution) use long term opiates

39. And finally • Patients with fibromyalgia will need a long term relationship with their primary care physician – and this is best built on trust, mutual respect and an understanding of the condition