Fibromyagia Medical Presentation

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Slide 1-

Fibromyalgia
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Outline Definition of fibromyalgia Epidemiology of fibromyalgia Possible mechanism of fibromyalgia Signs and symptoms of fibromyalgia Diagnosis of fibromyalgia Management of fibromyalgia
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Case 38 yrs old female presented to the clinic with the complaint of left sided neck, chest, upper back, elbow, lower back, hip pain and accompanying stiffness for about three months. also she complains of tiredness, difficulty in concentration, waking up tired. These symptoms were there for the last 6 months she awakens 3-4 times at night and has difficulty back to sleep recently. ın the last week she also describes frequent urination, dyspnea, dry mouth. she has chronic constipation for years
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Case 38 yrs old female presented to the clinic with the complaint of left sided neck, chest, upper back, elbow, lower back, hip pain and accompanying stiffness for about three months. also she complains of tiredness, difficulty in concentration, waking up tired. These symptoms were there for the last 6 months she awakens 3-4 times at night and has difficulty back to sleep recently. ın the last week she also describes frequent urination, dyspnea, dry mouth. she has chronic constipation for years
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2010 Diagnostric Criteria. The preliminary ACR 2010 criteria for the diagnosis of FMS do not require physical examination but the requirement for the presence of widespread pain for at least three months and that the patient does not have a disorder that would otherwise explain the pain are retained. However, tender point count has been replaced by a symptom checklist which includes Widespread Pain Index (WPI) In the WPI, patients are asked to indicate the regions (maximum 19 regions) of the body in which pain has been experienced during the past week. Each positive region is given a score of 1 (WPI ranges 0 to 19). and Symptom Severity Scale (SSS).
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SSS is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. Each of the 3 symptoms: severity of fatigue, waking unrefreshed and cognitive symptom, is scored between 0-3 (0 = no problem, 1 = slight or mild problems, generally mild or intermittent, 2 = moderate, considerable problems, often present and/or at a moderate level, 3 = severe: pervasive, continuous, life-disturbing problems over the last week). The extent of somatic symptoms is also scored between 0-3 (0 = no symptoms, 1 = few symptoms, 2 = a moderate number of symptoms and 3 = a great deal of symptoms).
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Removing the reliance on tender point count is the major advantage of the survey base criteria for FMS. In addition the SSS includes characteristic features of FMS and may be used to monitor disease activity. These criteria are not intended to replace the ACR 1990 classification criteria, but to represent an alternative method of diagnosis.
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Fibromyalgia chronic (>3 mo), widespread (axial, left- and right-sided, upper and lower segment), non- articular + non-inflammatory + idiopathic pain with characteristic tender points ıt is a multisystem disease characterized by sleep disturbance, fatigue, headache, morning stiffness, paresthesias, and anxiety. Female-2% male-0.5% primarily ages 25-45
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Pathogenesis. There is persuasive evidence that FM pain results from abnormal sensory as central sensitization and results from an amplification of peripheral sensory stimuli and a deficit of descending inhibitory control from the midbrain. The magnification of peripheral sensory input is readily visualized as increased activity in somatosensory areas of the brain on magnetic resonance imaging in FM subjects versus healthy controls.processing within the central nervous system.
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Possible mechanism
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Symptomatology widespread aching, stiffness • easy fatigability • sleep disturbance • symptoms aggravated by physical activity, poor sleep, emotional stress • patient feels that joints are diffusely swollen although joint examination is normal • neurologic symptoms of hyperalgesia, paresthesias • associated with irritable bowel or bladder syndrome, migraines, tension headaches, restless legs syndrome, obesity, depression, and anxiety
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Diagnosis
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WPI Neck jaw chest abdomen Upper arm Lower arm upper leg Lower leg Shoulder girdle Upper back lower back Hips 19
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Pain FM-related pain is usually perceived as arising from muscle; however, many patients also report joint pain but have no objective evidence of arthritis.
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Symptoms severity score 0 = no problem 1 = slight or mild problems 2 = moderate, considerable problems 3 = severe: life-disturbing problems
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Fatique Easy fatigability from physical exertion, mental exertion, and psychological stressors is typical of FM. Patients with CFS and FM share many similarities; about 75% of patients meeting the diagnostic criteria for CFS also meet the criteria for FM.
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SLEEP FM patients have nonrestorative sleep. difficulty falling asleep, and frequent wakening Even if they sleep continuously for 8 to 10 hours, they awake feeling tired. Many exhibit an alpha-delta electroencephalographic pattern that explains their failure to achieve restorative stages 3 and 4 of non–rapid eye movement sleep. A poor night’s sleep is often followed by a worsening of FM symptoms the next day. Restless leg syndrome and the associated periodic limb movement disorder occur in up to 60% of FM patients.
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COGNITIVE DYSFUNTION Cognitive dysfunction is a prominent complaint of many FM patients. They commonly describe difficulties with working memory, semantic memory, concentration, logical analysis, and motivation.
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Clinical features. ■ Morning stiffness ■ Subjective swelling ■ Raynaud-like symptoms ■ Sleep disturbance ■ Headache ■ Dry mouth ■ Paresthesias ■ Irritable bowel
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Most patients with fibromyalgia syndrome are not depressed. There are some depressive symptoms, but it does not usually reach the level of clinical depression. One way of screening/testing for depression and anxiety is to use the Hospital Anxiety and Depression Score, a validated self-completed screening questionnaire for depression and anxiety. It is simple to complete and can quickly assess the Having a chronic, painful disorder for which there is no generally accepted cure often produces an existential crisis.mood of the patient.
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Patients with high tender point count, low pressure pain threshold and mild/no mood disturbance often do well because their coping strategy is often more effective. In 30% of patients has significant depression,anxiety. It is useful to ask sadness,feeling of worthness,or emptiness,lack of pleasure in activities which were previously enjoyable. Poor appetite, and succidal thought.
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EXERCISE. exercise program (walking, aquatic exercises), physical therapy (good posture, stretching, muscle strengthening, massage)
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STRESS REDUCTION stress reduction, CBT
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NO evidence no evidence for alternative medicine such as biofeedback, meditation, acupuncture
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RED FLAG 1-Weight loss, Fever, joint swelling, muscle weakness, abnormal gait, Skin rash, delayed reflexes, lympadenopathy.
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Fibromyalgia It is a diagnosis of exclusion It is a must to rule out other disorders by history and physical exam
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D/D • diagnosis of exclusion • rule out other disorders by history and physical exam (RA, SLE, PMR, myositis, hypothyroidism, hyperparathyroidism, neuropathies)
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Investigations to be considered serology: do not order ANA or RF unless there is clinical suspicion for a connective tissue disease
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Goal of treatment. Decrease pain ■ Decrease distress ■ Increase energy level ■ Improve function ■ Treat associated symptoms, including anxiety and depression
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Management
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Excercise It is important to encourage the patient to stay active and to start graded Classical analgesics (paracetamol) may be helpful before exercises and activity.exercise.
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Warm bath Warm water baths are often helpful
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PREGABLIN,GABAPENTIN Anticonvulsant medications such as gabapentin, pregabalin, and topiramate are increasingly being used in FM and other chronic pain states; they inhibit the presynaptic release of glutamate and thus modulate the Pregabalin has FDA approval for use in FM..activation of NMDA receptors
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Analgesics analgesics may be beneficial for pain that interferes with sleep (NSAIDs, not narcotics)
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PITFALLS in THERAPY. Psychosocial issues not addressed Benefit of exercise undervalued ■ Exercise program too rigorous or advanced too quickly ■ Tricyclic therapy discontinued prematurely ■ Unrealistic expectations for improvement