Disclosure

2. Disclosure This program was developed from an educational grant from Pfizer to the University of Calgary and Université de Sherbrooke. Faculty disclosure F-S

3. Core Development Committee F • Dr. Christian Cloutier, Neurosurgeon, Quebec • Dr. MaryAnn Fitzcharles, Rheumatologist, Quebec • Dr. Algis Jovaisas, Rheumatologist, Ontario • Ms. Christal Lacombe, Pharmacist, Alberta • Dr. Rhonda Shuckett, Rheumatologist, British Columbia • Dr. Richard Ward, Family Physician, Alberta

4. National Family Physician Committee Dr. Brian Craig, Family Physician, New Brunswick Dr. Alan Kaplan, Family Physician, Ontario Dr. Bernard Martineau, Family Physician, Quebec Dr. Kenneth Stakiw, Family Physician, Saskatchewan F

5. Overall Learning Objectives F Following this program, participants will • Describe the diagnosis and core symptoms of fibromyalgia (FM) • Have an approach to explaining the diagnosis of FM to patients • Prescribe appropriate pharmacologic and non-pharmacologic interventions based on predominant symptoms

6. Menu (all related to fibromyalgia) F Management of Pain Depression 1 4 Fatigue Making the Diagnosis 2 5 Sleep Disturbance “Selling” the Diagnosis 3 6 Non-pharmacologic Interventions Choice of Medical Therapy 7 8 Incomplete Treatment Response 9 Click on the name of the module you want to access

7. F

8. F Objectives • Following this module, participants will be able to: • Explain the basis of increased pain in patients with fibromyalgia (FM) • Discuss the relationship between pain, fatigue and sleep disturbance in FM • Suggest non-pharmacologic therapies for pain • Prescribe medications that improve pain in FM • Recognize the role of an interdisciplinary team in FM management

9. Core Clinical Features of Fibromyalgia Widespread Pain • Chronic, widespread pain is the defining feature of fibromyalgia • Patient descriptors of pain include: aching, exhausting, nagging, and hurting • Presence of tender points F Neurocognitive Impairment (“FibroFog”) • Characterized by confusion, slowed processing of information and reaction time, difficulty in word retrieval or speaking, concentration, attention, short-term memory consolidation, disorientation Widespread Pain • Chronic, widespread pain is the defining feature of fibromyalgia • Patient descriptors of pain include: aching, exhausting, nagging, and hurting • Presence of tender points Sleep Disturbance • Characterized by nonrestorative sleep and increased awakenings • Abnormalities in the continuity of sleep and sleep architecture Fatigue • Patients describe it as physically or emotionally draining Stiffness • Stiffness in the morning is a common characteristic of Fibromyalgia ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci. 1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum. 2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.

10. Case study Patty is a 32-year-old patient in your practice who was diagnosed with fibromyalgia that appeared to start after she slipped on some ice. Patty was advised to attend a local yoga studio which has a special FM class. She was given a morning medication that targeted mood. As well, she was referred to a local FM support group. F

11. Video 1 F

12. Questions Why do patients with FM have pain? What non-medication approach would you take with Patty? What medical FM therapies improve pain? How could an interdisciplinary team (your own team or resources in your community) assist in the management of patients with FM? F Take the time to answer each of the questions

13. Symptoms of Fibromyalgia Pain, fatigue, and sleep disturbance are present in at least 86% of patients* S 100% 96% 100 86% 72% 80 60% 56% 52% 60 46% 42% 41% 32% 40 20% 20 0 Muscularpain Fatigue Insomnia Joint pains Head-aches Restless legs Numbness and tingling Impairedmemory Leg cramps Impaired Concen-tration Nervous-ness Major depression * US data ACR 1990 Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site http://www.nfra.net/Diagnost.htm.

14. Pathophysiological observations in FM Despite extensive research, the exact cause of pain in fibromyalgia is not clearly understood Peripheral Peripheral sensitization Temporal summation (windup) (short-term) Spine and brain Central sensitization (long-term) Change in grey matter volume Descending inhibition Other factors Hypothalamic-pituitary-adrenal axis dysregulation Sleep disturbance Cognitive effects S Staud et al. Nat Clin Pract Rheumatol. 2006;2:90-98; Henriksson. J Rehabil Med. 2003;41(suppl 41):89-94; Crofford et al. Arthritis Rheum. 2002;46:1136-1138; Vaerøy et al. Pain. 1988;32:21-26; Staud. Arthritis Res.Ther. 2006;8:208.

15. Key Messages for Pain Principles in FM There is no “cure” for the pain Active patient involvement: activity and non-medication approaches Important to manage patient’s expectations Normalize sleep Normalize mood Start with medical interventions for pain that have evidence for efficacy in FM Start low, go slow! S Target pain control that allows functionality

16. Non-pharmacologic Treatments Patient education Conflicting evidence but some studies have shown improvements in pain, sleep, fatigue, and quality of life Cognitive-behavioural therapy Positive effects on coping with and control over pain Not proven to improve pain Proven to improve physical function Should be done by a trained professional Aerobic and strengthening exercises Reduce pain, increase self-efficacy, improve quality of life, and reduce depression Aerobic exercise should be of low to moderateintensity, two to five times/week S Goldenberg et al. JAMA. 2004;292:2388-2395 .Brosseau et al.; Ottawa Panel Members. Phys Ther. 2008;88:873-86.Brosseau et al.; Ottawa Panel Members. Phys Ther. 2008;88:857-871.

17. Modulating Factors of FM Syndrome Pain S Wallace et al. Fibromyalgia and Other Central Pain Syndromes. Lippincott Williams & Wilkins; 2005:126.

18. Sleep interference can directly result from and/or contribute to FM Interrelationship Among Pain, Sleep Disturbance and Psychological Symptoms S Management strategy for FM patients is to improve overall patient functionality Pain Functional Impairment and Fatigue Psychological symptoms are strongly associated with FM Pain Related Sleep interference Psychological symptoms Paradigm of pain FM: fibromyalgiaAdapted from Argoff. Clin J Pain. 2007;23:15-22.

19. Sleep Deprivation and Pain Activates, maintains CNS areas responsible for awake state Dampens areas responsible for initiation and maintenance of sleep May impair healing, leading directly to pain Affects CNS areas responsible for coping mechanisms useful for dampening pain experience S Chronic pain Lack of sleep • Sleep disturbances may lead directly to more pain, and indirectly to a heightening of the pain experience through impairment of usual adaptive mechanisms. Call-Schmidt, Richardson. Pain Manag Nurs. 2003;4:124-133.

20. Best Evidence: FM Pain Medication S (alphabetical order) +++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy Abbreviations: GABA, γ-aminobutyric acid; NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant

21. No/poor Evidence: FM Pain Medication S (alphabetical order) +++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy Abbreviations: GABA, γ-aminobutyric acid; NSAID, nonsteroidal anti-inflammatory drug

22. Video 2 F

23. Video de-brief F

24. Summary Pain is the most common symptom of FM Set realistic treatment goals Use non-pharmacologic treatments first Use medical therapies that target pain and have evidence for efficacy in FM as first- line pharmacotherapy Balance medication side effects and risk with optimizing function F Menu

25. F

26. F Objectives • Following this module, participants will be able to: • Provide a differential diagnosis of fatigue in patients with fibromyalgia (FM) • Prescribe therapies that will improve fatigue in FM • Assist patients in establishing reasonable treatment goals • Recognize the role of an interdisciplinary team in FM management

27. Core Clinical Features of Fibromyalgia Fatigue • Patients describe it as physically or emotionally draining F Neurocognitive Impairment (“FibroFog”) • Characterized by confusion, slowed processing of information and reaction time, difficulty in word retrieval or speaking, concentration, attention, short-term memory consolidation, disorientation Widespread Pain • Chronic, widespread pain is the defining feature of fibromyalgia • Patient descriptors of pain include: aching, exhausting, nagging, and hurting • Presence of tender points Sleep Disturbance • Characterized by nonrestorative sleep and increased awakenings • Abnormalities in the continuity of sleep and sleep architecture Fatigue • Patients describe it as physically or emotionally draining Stiffness • Stiffness in the morning is a common characteristic of Fibromyalgia ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci. 1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum. 2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.

28. Case study Patty is a 32-year-old patient in your practice who was diagnosed with fibromyalgia that appeared to start after she slipped on some ice. Patty signed up at a local gym to take aerobic exercise classes at your suggestion. She was given a bedtime medication to improve her sleep and referred to a website that provides information for patients with FM. F

29. Video 1 F

30. Questions In patients with an established diagnosis of FM, what factors should be considered when evaluating fatigue? What nonmedication approach would you take with Patty? What FM medications target fatigue? How could an interdisciplinary team (your own team or resources in your community) assist in the management of patients with FM? What other HCP could help? F Take the time to answer each of the questions

31. Symptoms of Fibromyalgia Pain, fatigue, and sleep disturbance are present in at least 86% of patients.* S 100% 96% 100 86% 72% 80 60% 56% 52% 60 46% 42% 41% 32% 40 20% 20 0 Muscularpain Fatigue Insomnia Joint pains Head-aches Restless legs Numbness and tingling Impairedmemory Leg cramps Impaired Concen-tration Nervous-ness Major depression * US data ACR 1990 Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site http://www.nfra.net/Diagnost.htm.

32. Things to consider when FM patients complain of fatigue Sleep disturbance Uncontrolled pain Depression Unrealistic expectations “Stress” caused by illness Medication side effects (especially polypharmacy) Deconditioning Unrecognized new illness* * Avoid the trap of re-investigating the patient with firmly diagnosed FM, but remember: eventually all FM patients will get another disease! S

33. Fatigue in primary care – one-year follow-up 1. Musculoskeletal (19.4%) Psychosocial (16.5%) Gastrointestinal (8.1%) Neurological (6.7%) General (4.9%) Respiratory (4.9%) Endocrine (2.8%) Cardiovascular (1.9%) Menopause (1.1%) Malignancy (.7%) 46.9% of those with the initial presentation of fatigue and with no diagnosis made at the time of presentation had, at the end of one year, one or more of these diagnoses that could possibly be the cause of their fatigue. S Note that of musculoskeletal complaints, most were deemed non-specific. Documentation at initiation of study indicated that 24.1% of patients had depressive symptoms. Diagnosis of depression was made in 4.9% of subjects at one year. Nijrolder et al. CMAJ. 2009;181:683-687.

34. Sleep interference can directly result from and/or contribute to FM Interrelationship Among Pain, Sleep Disturbance and Psychological Symptoms S Management strategy for FM patients is to improve overall patient functionality Pain Functional Impairment and Fatigue Psychological symptoms are strongly associated with FM Pain Related Sleep interference Psychological symptoms Paradigm of pain FM: fibromyalgiaAdapted from Argoff. Clin J Pain. 2007;23:15-22

35. Sleep Deprivation and Pain Activates, maintains CNS areas responsible for awake state Dampens areas responsible for initiation and maintenance of sleep May impair healing, leading directly to pain Affects CNS areas responsible for coping mechanisms useful for dampening pain experience S Chronic pain Lack of sleep • Sleep disturbances may lead directly to more pain, and indirectly to a heightening of the pain experience through impairment of usual adaptive mechanisms. Call-Schmidt, Richardson. Pain Manag Nurs. 2003;4:124-133

36. Utility of FM medications targeting fatigue There are no generally accepted, on-label medications that improve the fatigue associated with FM Physical activity is the only non-pharmacologic strategy proven to reduce fatigue S

37. What is helpful for complaints of fatigue? Improvement of sleep hygiene Moderate physical activity Pacing Realistic goal setting Healthy eating Cognitive behavioral therapy (CBT) S Lera et al.J Psychosom Res. 2009;67:433-441. Rossy et al. Ann Behav Med. 1999;21:180-191. Williams DA. Best Pract Res Clin Rheumatol. 2003;17:649-665.

38. Medications With Anti-fatigue Properties S (alphabetical order) +++: strong evidence for use/efficacy; ++: moderate evidence use/efficacy; +: some evidence use/efficacy; -: no evidence for use/efficacy

39. Video 2 F

40. Video de-brief F

41. Summary When fatigue is the primary complaint, evaluate sleep and pain control, and rule out depression. Use of medications may improve fatigue. Help patients set realistic goals for improvement of fatigue. Important role of non-pharmacologic interventions, especially physical activities. F Menu

42. F

43. F Objectives • Following this module, participants will be able to: • Recognize the relationship between sleep restoration and symptom improvement in patients with fibromyalgia (FM) • Provide non-pharmacologic therapies to improve sleep disturbance • Prescribe medications that target sleep and other FM symptoms • Recognize the role of theinterdisciplinary team in FM management

44. Core Clinical Features of Fibromyalgia Sleep Disturbance • Characterized by nonrestorative sleep and increased awakenings • Abnormalities in the continuity of sleep and sleep architecture F Neurocognitive Impairment (“FibroFog”) • Characterized by confusion, slowed processing of information and reaction time, difficulty in word retrieval or speaking, concentration, attention, short-term memory consolidation, disorientation Widespread Pain • Chronic, widespread pain is the defining feature of fibromyalgia • Patient descriptors of pain include: aching, exhausting, nagging, and hurting • Presence of tender points Sleep Disturbance • Characterized by nonrestorative sleep and increased awakenings • Abnormalities in the continuity of sleep and sleep architecture Fatigue • Patients describe it as physically or emotionally draining Stiffness • Stiffness in the morning is a common characteristic of Fibromyalgia ACR Fibromyalgia Diagnostic Criteria. 2010. http://www.nfra.net/Diagnost.htm; Carruthers et al. J Chron Fat Synd. 2003;11:7-115; Harding. Am J Med Sci. 1998;315:367-37; Henriksson. J Rehabil Med. 2003;(suppl 41):89-94; Leavitt et al. Arthritis Rheum. 1986;29:775-781; Roizenblatt et al. Arthritis Rheum. 2001;44:222-2306; Wolfe et al. Arthritis Rheum. 1995;38:19-28.

45. Case study Patty is a 32-year-old patient in your practice who was diagnosed with fibromyalgia that appeared to start after she slippedon some ice. Patty was advised to attend a local yoga studio which has a special FM class. She was given a morning medication that targeted mood and pain. She was encouraged to review a website which provides information for patients with FM. F

46. Video 1 F

47. Questions What elements should you consider when evaluating Patty’s sleep problems? What non medication approach would you take with Patty? What FM medications improve sleep problems? How could an interdisciplinary team (your own team or resources in your community) assist in the management of patients with FM? F Take the time to answer each of the questions

48. Symptoms of Fibromyalgia Pain, fatigue, and sleep disturbance are present in at least 86% of patients.* S 100% 96% 100 86% 72% 80 60% 56% 52% 60 46% 42% 41% 32% 40 20% 20 0 Muscularpain Fatigue Insomnia Joint pains Head-aches Restless legs Numbness and tingling Impairedmemory Leg cramps Impaired Concen-tration Nervous-ness Major depression * US data ACR 1990 Fibromyalgia Diagnostic Criteria. National Fibromyalgia Research Association Web site http://www.nfra.net/Diagnost.htm.

49. Pain Poor sleep hygiene Medication side effects (including caffeine) Anxiety / depression / bipolar disorder Other sleep disorders (restless leg syndrome, obstructive sleep apnea, etc.) S Differential Diagnoses to consider with sleep disorders

50. Sleep interference can directly result from and/or contribute to FM Interrelationship Among Pain, Sleep Disturbance and Psychological Symptoms S Management strategy for FM patients is to improve overall patient functionality Pain Functional Impairment and Fatigue Psychological symptoms are strongly associated with FM Pain Related Sleep interference Psychological symptoms Paradigm of pain FM: fibromyalgiaAdapted from Argoff. Clin J Pain. 2007;23:15-22.