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“I Hurt Everywhere” Beginning the Fibromyalgia (FM) Journey?

“I Hurt Everywhere” Beginning the Fibromyalgia (FM) Journey?. Steven S. Overman MD MPH Medical Director, Northwest Hospital Rheumatology and Musculoskeletal Development Clinical Associate Professor of Medicine University of Washington. Chronic Widespread Pain (CWP).

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“I Hurt Everywhere” Beginning the Fibromyalgia (FM) Journey?

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  1. “I Hurt Everywhere”Beginning the Fibromyalgia (FM) Journey? Steven S. Overman MD MPH Medical Director, Northwest Hospital Rheumatology and Musculoskeletal Development Clinical Associate Professor of Medicine University of Washington

  2. Chronic Widespread Pain (CWP) • Prevalence: 10 – 13% of western populations • Incidence: 5.5%/year of new cases of CWP • 2% in persons without any pain • 8% in persons with chronic regional pain • Outcomes: at one year of CWP persons • 56% still had CWP (more somatic symptoms increased likelihood) • 33% had regional pain • 11% had no pain Croft J of MS Pain 2002;10:191-199

  3. Predictors of CWP • 2x prevalence in women ( FM is 4x ) • Persons with CWP more commonly have - • Anxiety and depression • Fatigue and other somatic complaints • Anxieties about health • Features of somatization • Dissatisfaction with health care and work • Absolute differences not large • Psychiatric diagnoses 16.9% in CWP vs 11.9% pop Croft J of MS Pain 2002;10:191-199

  4. Relevance of CWP and Tender Points (TPs) • 40% of CWP have FM (> 11 TPs) • Some patients with no pain (5%) and regional pain (20%) had > 11 TPs • Local TPs associate with segmental pain • Depression, fatigue and sleep disorders increased as TPs rose, independent of pain complaints. Thomas BMJ 1999:318: 1662-7 Croft BMJ 1994; 309: 696-9

  5. FM is a Syndrome of Pain and TendernessACR Classification - 1990 • Pain for 3 months • Generalized pain – at least 3 quadrants • At least 11 out of 18 tender points painful with 4 kg of pressure ------------------------------------------- • FM is at the severe end of a spectrum of pain and tenderness disorders • Not a diagnosis of exclusion. • FM tenderness is not limited to the 18 points. • Many feel multi-system symptoms should be present to diagnose FM.

  6. Multi-system Symptoms Found in > 50% of FM patients from the ACR 1990 Criteria for Classification Study • Neck pain 85% • Back pain 79% • Fatigue 78% • Sleep disturbance 76% • Morning stiffness 76% • Paresthesias 67% • Skin fold tender, trapezius 60% • Headaches 54% Wolfe A&R 1990; 33: 160-172

  7. Multi-system SymptomsFound in < 50% of ACR FM Study patients • Anxiety 45% • Sicca or dry eye symptoms 36% • Prior depression 31% • Irritable bowel syndrome 30% • Urinary urgency 26% • Raynaud’s phenomenon 17%

  8. Syndromes That Overlap With Fibromyalgia The neurologist sees chronic headache, the gastroenterologist sees IBS, the otolaryngologist sees TMJ syndrome, the cardiologist sees costochondritis, the rheumatologist sees fibromyalgia, and the gynecologist sees PMS.

  9. Objectives • To define Fibromyalgia (FM) and discuss FM as a patient label • Discuss the medical evaluation of FM in relationship to pathophysiologic insights • Review evidence that can guide individual treatment decisions for patients with FM

  10. Disclosures • I have no pharmaceutical grants or consulting for any FM medication. • I am not an Expert, just a Rheumatologist. “A successfully trained rheumatologist is someone who can look patients in the eye all day long and say ‘I don’t know.’” • I am not recruiting more FM patients, but I have not closed my practice either.

  11. Definition Fibromyalgia syndrome is a chronic pain disorder with widespread tenderness. It is commonly associated with symptoms common to the “affective spectrum” disorders. Dysregulation is found in the nervous, immune and adrenal stress systems. A combination of “bio-psycho-social” factors contribute to FMS pathophysiology and influence outcomes.

  12. Liz 40 year-old Caucasian woman with neck, back and generalized pain. Liz is an office manager and had been an avid water skier until 2 yrs. ago when she fell very hard water skiing, twisting her neck, and “laying her up” for several weeks. She actually never recovered – noting episodes of low back pain, fatigue and increased difficulty sleeping. She started having panic episodes 1 year agon which were initially controlled with Paxil. Work is more and more difficult due to fatigue and problems with concentration. Screening Exam – 14/18 tender points are positive, worse around her neck and shoulders.

  13. #1 – What do you say to Liz? • Tell her she has Fibromyalgia disease, which has no cures and with varying impacts on different individuals. Suggest a book or web site for her to learn about FM and return prn. • Tell her she a generalized pain syndrome of unclear etiology and that she will have to learn to live with it. Offer a referral to your pain psychologist and come back in 2 months. • Describe your findings as consistent with Fibromylagia syndrome and suggest further investigation and symptom management.

  14. Answer to #1 • Tell her she has Fibromyalgia disease that no cures and with varying impacts on different individuals. Suggest a book or web site for her to learn about FM. • Tell her she a generalized pain syndrome of unclear etiology and that she will have to learn to live with it. Offer a referral to your pain psychologist. • Describe your findings as consistent with Fibromylagia syndrome and suggest further investigation and symptom management.

  15. Is Labeling someone with FM a BAD idea?It depends ……………… • A population study showed that providing the label Fibromyalgia did not result in an increase prevalence, nor increase illness behavior. (White A&R (AC&R), 2002;47:260-5) • The FM associated disability did not change after a claim or suit was closed. (Moldofsky J Rheum 1993:20:1935-40) • Labeling promotes categorization for scientific evaluation, e.g. Lupus spectrum of illness “FM is not the cause, but rather the result of a variety of interacting factors.” Dr O

  16. #2 – What areas need to be considered for investigation? • Causes of peripheral pain • Causes of nervous system sensitization • Disorders resulting from chronic distress • Risks for pain associated disability • All of the above.

  17. Answer to #2 – ALL THE ABOVE Directed by further history and exam, evaluate: • Causes of peripheral pain • Causes of nervous system sensitization • Disorders resulting from chronic distress • Risks for pain associated disability

  18. Neck Injury is associated with the development of FMS • Israel study showing 21.6% of neck injury patient developed FM compared to 1.7% of leg fracture patients. (Buskila A&R 2002; 4:450-3)) • UW study – Two months after whiplash injury, 80% had TPs of FM, while 20% also had widespread pain to meet FMS classification criteria. (Robinson, World Conference on Pain, 2003)

  19. “The Over-diagnosis of FM Syndrome” • 321 new rheumatology referrals • 35 (11%) were diagnosed with FM 11 (~ 34% of all FM patients) were newly diagnosed with a spondyloarthropathy MA Fitzcharles, Am J Med, 1997;103:44-50

  20. Enthesiopathies • Disease Association: Spondyloarthritis, Reiter’s syndrome, Reactive arthritis, Psoriasis arthritis, Crohn’s and Celiac associated arthritis • Anatomic Locations: epicondylitis, rotator cuff capsulitis, dactylitis, trochanteric tendinitis, ilio-lumbar ligament “itis”, plantar fasciitis, Achilles tendinitis and SI joint, AC and costochondral joints, facet and ribs articulations

  21. Pain Response in Fibromyalgia RELATIVE PAIN

  22. What are Clinical features of Nervous System Sensitization? • Abnormal ‘Wind-up’ – repetitive stimulation with identical stimuli cause progressive increase in pain intensity. • FM patients this lasts longer (up to 2 minutes) and with more burning, stinging, and sometimes numbness, than controls • Central sensitization refers to the changes that occur in the nervous system (neuroplasticity). High stimulus frequency and intensity AND reduced descending pain inhibition from the brain lead to permanent “wind-up” through gene transcription changes. The same stimulus registers at a much greater intensity when compared to a normal person.

  23. Evidence of Nervous System Sensitization in FM In FM patients compared to controls: • Functional MRI has shown enhanced sensory receptive areas and expanded fields of reception to the same pain stimulus. (Cook J Rheum 2004;31:364-78) • Laser-evoked potentials in the CNS have demonstrated increased amplitudes proportional to the subjective response to skin stimulation . (Gibson Pain 1994;58:185-93)

  24. Peripheral Sensitization in Fibromyalgia Syndrome • Trigger Points (TPs) correlate with levels of CSF substance P • Epidural blocks remove pain and tenderness of TPs (Bengtsson Pain 1989; 39:171-180)

  25. Triggers of Central Sensitization Cytokines • Il-1 and IL-6 induces hyperalgesia • IL-8 promotes sympathetic pain • TNF alpha stimulates macrophages and microglia cells which sensitize neurons • Elevation found in cases of FM cases less than 2 years duration. • Cytokines maybe stimulated by stress, injury or inflammatory diseases. (Wallace Rheum 2001;40:743-749)

  26. Triggers Central Pain Sensitization • Functional polymorphism in the promoter region of the serotonin transporter gene • Smokers have have higher levels of substance P in the CSF. • Patients with Restless Leg Syndrome have increased hyperalgesia that resolves with treatment.

  27. Modulators of Sensitization • CSF pain modulators affected by wind-up • NMDA receptors help induce sensitization. After IV infusion Ketamine, an NMDA blocker, FM patients noted pain reduction and improved muscle endurance for 2-7. (Sorensen Scand J Rheum 1995; 24: 360-365) • Substance P are 3-4 times increased in spinal fluid • Serum and platelet serotonin levels are reduced in FM patients. (Wolfe J Rheum 1997; 24:555-9 )

  28. Disorders of Distress • Chronic stress causes initial increase of corticotropin releasing factor (CRF). This may lead to reduction in CRF-1 receptors and a reduction of ACTH and the cortisol response. CRF increases somatostatin causing a reduction in GH secretion.

  29. Disorders of Distress • Sleep dysregulation may induce reduced growth hormone secretion and lower IGF-1 levels. Tender points develop for unclear reasons. • Other conditions with impaired cortisol secretion: chronic pelvic pain, Chronic fatigue, PTSD, overtraining syndrome

  30. What are Predictors of Disability? • PTSD like symptoms hyper-vigilance, catastrophizing, low self-efficacy, harm avoidance, active coping (56%) • Limited exercise • Physical Function at presentation • Depression, anxiety – psychologic distress • Pending litigation • Level of education

  31. #3 – Is FM primarily a Psychiatric Disorder? • YES It shares similar pathophysiology as the anxiety-depression spectrum of disorders. • NO FM is like other diseases that are made worse by or lead to stress-depression. • MAYBE There are studies that suggest FM is in the group of affective spectrum disorders.

  32. #3 – Primarily a Psychiatric Disorder? • YES It shares similar pathophysiology as the anxiety-depression spectrum of disorders. • NO FM is like other diseases that are made worse by or lead to stress-depression. BUT Stress factors may be necessary perpetuators to develop the full FM syndrome of pain, tenderness and somatic symptoms.

  33. Psych Literature and FM • FM “non-patients” had no greater number of psych diagnoses than population controls • Past & current depressive disorders higher • 20% of FM persons who seek any care • 90% of FM patients at UW university rheum clinic had a past history of psychiatric diagnoses

  34. Melzack’s Neuromatrix Endocrine, immune, and autonomic system activity Afferent input Medullary descending inhibition Pain Perception Pathologic Input Neuromatrix Brain areas that underlie pain experience and behavior Pain Behavior Central Nervous System Plasticity Attention Psychosocial and health status factors Melzak, Pain 1999, 82 (supplement 6): S121-126

  35. What is the Menu of Evaluations? • Spine disorders • Inflammatory disorders • Infectious disorders • Psych disorders • Sleep dysfunction • Endocrine dysfunction • Autonomic dysfunction

  36. Evaluation of Peripheral Pain Generators • Neck, back, pelvis pain Entheseopathy or sacroiilits routine x-rays Degenerative disc or facets routine x-rays Chiari or cervical stenosis MRI if long-tract findings Spinal stenosis or radiculopathy MRI Myofascial trigger point evaluation Ligaments, etc. injection blockade

  37. Evaluation of Peripheral and CentralPain Generators and Sensitizers • Inflammatory disorders General CRP, ESR, U/A Bowel Endomesial (tTG) & Gliaden Abs, ASCA Arthralgias ANA, ENA, RF, ACE Sicca Schirmer’s test, thyoid antibodies, ANA, ENA Raynaud’s ? cryoglobulins, Phospholipid Ab screen, ANCA, nail fold eval., complements • Infection disorders Pelvic symptoms Prostatitis, PID, endometriosis , sacroiilitis (xray) Pharyngitis ASO titer, strept screen Hep C risk Hep C antibody (Sjogren’s syndrome presentation) HIV risk HIV screen (multiple rheumatic presentations) Lyme risk Lyme ELISA

  38. MANY conditions can present with as FMS • RA - 14 - 54% of patients • Lupus - 22 – 65%% of patients • Sjogren’s Syndrome - 47% • Hep C - 16-18% (3x controls) • HIV - 29% of patients • Crohn’s disease - 49% of patients attending a university clinic in Israel butno difference in Norwegian population sample.

  39. Evaluation of Central Pain Sensitizers and Behavioral Amplifiers • Psych screen and concerns All rheum new patients – Screening questionnaires (depression, anxiety, panic, stressful events, past trauma or abuse, alcohol screen, function, pain, fatigue, sleep) FM patients – Screen questionnaires (ADD, PTSD, Bipolar, addiction risks, personality traits and coping styles) Screen (+) patient and management problem – Psychologist referral and possible MMPI, etc. (poor compliance, “yes, but …”, controlling, marital or job distress) • Sleep Standard questionnaires - apnea, restless legs, day-time sleepiness, fatigue  refer for sleep consult / study

  40. Evaluation Distress Disorders and Secondary Dysfunctions • Endocrine evaluation General CBC, Full chemistry Thyroid disorder TSH, antibodies Menopausal status FSH HPA axis (adrenal fatigue) AM cortisol Testosterone status Free testosterone Other – muscle pain DHEA-S, IGF-1, Mg, vit D • Autonomic Dysfunction Postural hypotension or ^ HR Trial of salt and stockings Tilt table test (Geenen Rheum Dis Clinics May 2002)

  41. “FM Syndrome pain clearly depends on peripheral nociceptive input as well as abnormal central pain processing.”

  42. Liz PMH: • Divorced 8 years ago and remarried 3 years ago. Had an abusive marriage. • History of childhood non-sexual abuse • Intermittent ‘pelvic’ pain since late teenager. • Diagnosed with hypothyroidism and started on treatment 6 months ago.

  43. Liz ROS: Several years of night sweats and increasing fatigue Morning stiffness in her feet without swelling Constipation and energy are improved on thyroid Non-restorative sleep since her ski injury Dry, gritty eyes

  44. Liz Complete PE: • Very tense, but engaging and personal • Skin – no psoriatic pits, no rashes • Thyroid - slightly enlarged • CV/Pul/GI - negative • MSK – Peripheral joints – negative SC and SI joints more tender than nearby “tender points” Neck - reduced ROM; dorsal spines tender FM tenderness - 14/18 areas + others • Neuro – normal strength & sensation a; no clonus; no reflex abn

  45. #4 - What is the appropriate work-up for Liz? (1 or more) • CBC, Chem Screen, ESR, CRP, ANA TSH, FSH, pelvis x-ray, psychologist referral • LP for substance P level in CSF • MRI cervical spine and functional brain imaging • Sleep study • An exercise growth hormone stimulation test

  46. #4 - The appropriate work-upStep-wise Screening • CBC, Chem Screen, ESR, CRP, ANA TSH, FSH, pelvis x-ray, psychologist referral • LP for substance P level in CSF • MRI cervical spine and functional brain imaging • Sleep study • An exercise growth hormone stimulation test

  47. Liz’s Evaluation Results • X-ray – mild SI sclerosis and tendon calcifications • Labs – CRP = Nl, ESR = 22, thyroid Abs (+), TSH – 5.3 • Other labs negative • Psychologist notes significant family relationship stresses

  48. What is in our bag of treatment tricks? • Counseling • Exercise • Nutritional • Sleep • Peripheral pain rx • Central agents • Endocrine

  49. A Clinical Approach • Patient centered • Unique clinical issues • Negotiated illness model - to develop confidence in program • Understand personal values and goals • Time awareness • Chronological assessment of illness factors, symptoms and patient’s response to these issues • Chronicity may lead to irreversibility • Rehabilitation Model • Positive, hopeful, and “can-do” attitude • Treat local impairments, monitor total function, build on individual resources and social support to limit handicap

  50. “Stuck Car Illness Model”(ATime-dependent Psycho-biologic Illness Model ) • Pre-morbid – Are underlying problems that will cause FM or complicate recovery? • Trigger events – Are there recurrent triggers? • Perpetuating factors – Are there patient behaviors that will impair healing? • Secondary conditions – Are physiologic dysfunctions that may be due to the illness experience?

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