fibromyalgia - dalhousie university · muscle relaxant - - snris 1 (weak for) a ssris 1 (weak for)...
TRANSCRIPT
Fibromyalgia
K. Mukhida Department of Anesthesiology, Pain Management and Perioperative MedicineDalhousie UniversityFebruary 2019
Disclosures• None
ObjectivesAt the end of this session you will be able to:
• Assess a patient with CWP and know the diagnostic criteria for fibromyalgia
• Come up with a differential diagnosis for CWP
• Come up with management options for the patient with fibromyalgia
• Nociceptive: damage (trauma, inflammation)
• Neuropathic: nerves
• Centralized: neuronal dysregulation, overactive pain pathways,deficiency of descending inhibitory pain pathways
Hauser W and Fitzcharles M-A (2018). Dialogues Clin Neurosci 20: 53-61.Atzeni F et al. (2017). Expert Opinion on Emerging Drugs 22: 357-367.
CL is a 56 year old woman who is new to your practice.
She tells you that she is coming to see you because shehas pain “all over.”
History
PMH
FMH
Social
Physical examination
Investigations
Arnold LM et al. (2018). The Journal of Pain https://doi.org/10.1016/j.pain.2018.10.008.
PAIN
FATIGUE
SLEEP DISTURBANCES
COGNITIVE PROBLEMS
Clauw DJ (2014). JAMA 311: 1547-1555.
• Widespread pain index: at least 7
AND
Symptom severity score: at least 5
OR WPI 4-6 AND SSS over 9
• Diagnosis is valid irrespective of other diagnoses
Wolfe F et al. (2016). Seminars in Arthritis and Rheumatism 46: 319-329.
What is in your differential diagnosis for CL’s pain?
Inflammatory rheumatic diseases
Nonrheumatic msk conditions
Nonrheumatic medical conditions
Neurological conditions
Mental health disorders
Medication-induced pain conditions
Hauser W et al. (2018). Pain Reports e958.
Inflammatory rheumatic diseases
Symptoms: joint swelling
Examples: SLE, RA, Sjogren, scleroderma, inflammatory polyarthritis, PMR, inflammatory spondyloarthritis
Red flags: FHx, am stiffness > 1 hr, severe constitutional symptoms
Hauser W et al. (2018). Pain Reports e958.
Inflammatory rheumatic diseases
Nonrheumatic msk conditions
Symptoms: trigger points
Examples: myofascial pain syndrome, CTDs
Red flags: pronounced neck and shoulders
Hauser W et al. (2018). Pain Reports e958.
Inflammatory rheumatic diseases
Nonrheumatic msk conditions
Nonrheumatic medical conditions
Endocrine / metabolic: hypothyroidism, hyperparathyroidism, acromegaly
GI: celiac disease
ID: Lyme disease, hepatitis C, HIV
Hauser W et al. (2018). Pain Reports e958.
Inflammatory rheumatic diseases
Nonrheumatic msk conditions
Nonrheumatic medical conditions
Neurological conditions
Examples: MS, PD, peripheral neuropathies, myelopathy, myopathies
Hauser W et al. (2018). Pain Reports e958.
Medication-induced pain conditions
Statins
Opioids
Chemotherapy
Aromatase inhibitors
bisphosphonates
Hauser W et al. (2018). Pain Reports e958.
P
P
P
P
Physical
PsychologicalPins
Pharmacological
*
• Exercise
• Meditative movement therapies
• Dance
Arnold LM & Clauw DJ (2017). Postgraduate Medicine 129: 709-714.Bidonde J et al. (2017). Cochrane Database of Systematic Reviews 6: CD012700.
Gota CE (2018). Cleveland Clinic Journal of Medicine 85: 367-376. Honda Y et al. (2018). Pain Research & Management https://doi.org/10.1155/2018/2930632.
Murillo-García et al. (2018). Evidence-based Complementary and Alternative Medicine 8709748.Sosa-Reina MD et al. (2017). BioMed Research International 2356346.
Sawynok J & Lynch M (2017). Medicines 4: 37.
Overview of recommended treatment strategies:
Pharmacological managementLevel of evidence Strength of recommendation
Amitriptyline 1 (weak for) AAnticonvulsants 1 (weak for) AMuscle relaxant - -SNRIs 1 (weak for) ASSRIs 1 (weak for) Amulticomponent therapy 5 D
Arnold LM & Clauw DJ (2017). Postgraduate Medicine 129: 709-714.Fitzcharles MA et al. (2012). Pain Research and Management 18: 119-126.
Macfarlane GJ et al. (2017). Annals of Rheumatologic Disease 76: 318-328.
• Not responsive to injections
• CBT
Aman MM et al. (2018). Current Pain and Headache Reports 22: 33. Bernardy K et al. (2017). European Journal of Pain 22: 242-260.
Bernardy K et al. (2018). European Journal of Pain doi: 10.1002/ejp.1284. Mehta S et al. (2018). Journal of Behavioral Medicine https://doi.org/10/1007/s10865-018-9984-x
Overview of recommended treatment strategies:
Nonpharmacological managementLevel of evidence Strength of recommendation
Aerobic exercise 1 (strong for) ABalneotherapy - -Cognitive behavioural therapy 1 (weak for) A Defined physical therapies 1 (weak for) AMeditative movement therapies 1 (weak for) AMindfulness-based stress reduction - -Strengthening exercise 1 (strong for) A
Arnold LM & Clauw DJ (2017). Postgraduate Medicine 129: 709-714.Fitzcharles MA et al. (2012). Pain Research and Management 18: 119-126.
Macfarlane GJ et al. (2017). Annals of Rheumatologic Disease 76: 318-328.
Confirm diagnosis:- ID important symptom domains / level of function- Evaluate for comorbid medical / psychiatric disorders- Assess psychosocial stressors, level of fitness, barriers to treatment- Provide education about FM
Recommend individualized treatment
Nonpharmacological therapy:- CBT - Exercise
Pharmacological therapy:
Depression- SNRI
Sleep- ⍺2d ligand
Partial response monotherapy- ⍺2d ligand +/- SNRI +/- TCA
Arnold LM & Clauw DJ (2017). Postgraduate Medicine 129: 709-714.