fibromyalgia - dalhousie university · muscle relaxant - - snris 1 (weak for) a ssris 1 (weak for)...
TRANSCRIPT
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Fibromyalgia
K. Mukhida Department of Anesthesiology, Pain Management and Perioperative MedicineDalhousie UniversityFebruary 2019
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Disclosures• None
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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
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• 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.
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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.”
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History
PMH
FMH
Social
Physical examination
Investigations
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Arnold LM et al. (2018). The Journal of Pain https://doi.org/10.1016/j.pain.2018.10.008.
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PAIN
FATIGUE
SLEEP DISTURBANCES
COGNITIVE PROBLEMS
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Clauw DJ (2014). JAMA 311: 1547-1555.
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• 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.
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What is in your differential diagnosis for CL’s pain?
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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.
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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.
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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.
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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.
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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.
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Medication-induced pain conditions
Statins
Opioids
Chemotherapy
Aromatase inhibitors
bisphosphonates
Hauser W et al. (2018). Pain Reports e958.
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P
P
P
P
Physical
PsychologicalPins
Pharmacological
*
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• 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.
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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.
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• Not responsive to injections
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• 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
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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.
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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.