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FIBROMYALGIA

FIBROMYALGIA. Steven Smith, NP Montgomery, Alabama. CONFLICT OF INTEREST STATEMENT: Steven Smith, NP has in years past been on the speaker bureau for Pfizer Inc though not currently. This CE activity was compiled without the aid of any pharmaceutical company.

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FIBROMYALGIA

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  1. FIBROMYALGIA Steven Smith, NP Montgomery, Alabama

  2. CONFLICT OF INTEREST STATEMENT: Steven Smith, NP has in years past been on the speaker bureau for Pfizer Inc though not currently. This CE activity was compiled without the aid of any pharmaceutical company. The medications and products mentioned in this activity will be presented in a fair and balanced way. No ink pens or coffee cups were received in exchange for endorsement of any pharmaceutical product mentioned in this presentation.

  3. WHAT IS FIBROMYALGIA SYNDROME? Is it a musculo-skeletal disorder?

  4. WHAT IS FIBROMYALGIA SYNDROME? Is it a musculo-skeletal disorder? Is it a mental condition or is it all in their heads?

  5. WHAT IS FIBROMYALGIA SYNDROME? Is it a musculo-skeletal disorder? Is it a mental condition or is it all in their heads? Is it an inflammatory, rheumatologic problem?

  6. WHAT IS FIBROMYALGIA SYNDROME? Is it a musculo-skeletal disorder? Is it a mental condition or is it all in their heads? Is it an inflammatory, rheumatologic problem? Is it an illness of the central nervous system?

  7. FMS is thought to be an illness of the CENTRAL NERVOUS SYSTEM And even more, an illness of the NEURO-ENDOCRINE SYSTEM FMS is thought to be one of the many CENTRAL SENSITIZING SYNDROMES

  8. What is CENTRAL SENSITIZING SYNDROME? Afferent (conducting inward) sensory input into THE DORSAL HORN GANGLION of the spinal column overwhelm the GATED PROTECTIVE MECHANISMS so that you get a WIND-UP PHENOMENON.

  9. What is a WIND-UP PHENOMENON? It is NEURON HYPEREXCITABILITY with a LOW DISCHARGE THRESHOLD that worsens with each sensory input (pain, touch, movement, any sensory input). This creates an EXAGERATED DISCOMFORT in people with CENTRAL SENSITIZATION SYNDROME.

  10. FMS is thought to be one of several CENTRAL SENSITIZING SYNDROMES. Others include: IRRITABLE BOWEL SYNDROME IRRITABLE BLADDER SYNDROME CHRONIC PELVIC PAIN CHRONIC FATIGUE SYNDROME CHRONIC T M J CHRONIC HEADACHE RESTLESS LEG SYNDROME THERE IS OFTEN OVERLAP AMONG THESE CONDITIONS

  11. Also overlapping with FMS are a higher prevalence of coexisting psychopathology: Depression GAD/Panic Disorder (responds best to FMS Tx) PTSD (responds worse to FMS Tx) Bipolar Disorder (responds worse to FMS Tx) Insomnia OCD

  12. Pain pathways are a two-way street. There are AFFERENT, conducting inward, ascending pain pathways, (Pain towards the brain) or (Pain on a train trying to gain toward the brain) AND Ameliorating, inhibitory, descending pain pathways. (Drain the pain from the brain) or (Train the pain to wane)

  13. Some of the neurotransmitters involved in the ASCENDING pain pathways are: Substance P Glutamate and other excitatory amino acids Neurotrophins Nerve Growth Factor Brain Derived Neurotrophic Factor These are found in higher levels in the CEREBRAL SPINAL FLUID of patients with Fibromyalgia

  14. Some of the neurotransmitters involved in the DESCENDING pain pathways that inhibit pain are: Norepinephrine Serotonin The metabolites of these were found to have LOWER levels in the Cerebral Spinal Fluid of patients with Fibromyalgia.

  15. ! WAIT !I THOUGHT PAIN WAS A BRAIN THING In one FMS study, they apply painful stimuli to both FMS patients and a normal control group while performing an MRI observing the increased activity in the areas of the brain related to pain. It took only half of the painful stimuli to light up these brain areas in the FMS patients than the control group. The FMS patients have an increase in the “gain” or sensitivity on their CB radios OR have an increased volume control on their MP3 players of pain.

  16. So, what does this have to do with PHARMACOLOGY? To treat FMS appropriately, you must understand: • The Neurotransmitters you want to increase and decrease. • The Receptors you want to block. • The Neurons that you want to control hyperexcitability. • The ascending, descending, and brain pathophysiology of the CNS of the FMS patient. If you understand this you will also understand what pain ameliorating therapies NOT to use.

  17. TWO GREAT TRUTHS You will not adequately treat what you cannot diagnose. Richard Sobel, MD, mentor If you do not know how to diagnose Fibromyalgia then this pharmacology lecture is useless. Steven Smith, NP, mentee

  18. FIBROMYALGIA is a diagnosis of EXCLUSION. That is why FMS is a “Syndrome” and not a “Disease”. There is no specific test for FMS. Diagnosing FMS take the good old fashioned hard work of a good HISTORY AND PHYSICAL EXAM (i.e.. SOAP)

  19. HISTORY AND PHYSICAL EXAM S. CC, HPI, PMH, SocH, PsychH, FH, ROS O. PHYSICAL EXAM, DIAGNOSTIC TESTS A. ASSESSMENT/DIAGNOSIS P. PLAN

  20. Name: _________Date:_______ Age:_39_Sex: __F__ • FMS affects 3 million to 8 million people in the U.S. • Age is usually between 20 and 60 years old. • Over 80% of those diagnosed with FMS are female. • Mostly occurs in females of reproductive age.

  21. S - SUBJECTIVE CHIEF COMPLAINT: Rarely “I think I have 14/18FMS” More often: “I’m depressed” “I can’t sleep” “I’m tired all the time” AND “I hurt all over” Legitimizing statement: “I’m afraid I’m going to lose my job.” • 20% apply for disability • 50% leave the workforce

  22. HISTORY OF PRESENT ILLNESSFMS Onset/duration: “A while.” >3 mo. Location: “My neck and my back” 4quads Severity: “a 6 out of 10” Quality: “It’s hard to describe, it just hurts.” Modifying factors: “I was in a wreck 2 years ago.” “My friend was killed.”

  23. HISTORY OF PRESENT ILLNESSFMS Modifying factors: “I was in a wreck 2 years ago.” “My friend was killed.” Modifying factors in FMS: • Acute trauma • Improper body mechanics, Abnormal posture • Infection, Inflammation • Psycho-social stressors • Metabolic imbalance

  24. HISTORY OF PRESENT ILLNESS Associated signs and symptoms: “I wake up tired”, “I’m depressed”, “My nerves are shot”, “I don’t sleep well”, “I’m gonna lose my job” Associated signs/symptoms in FMS: Cognitive impairment, poor sleep, fatigue, morning stiffness, anxiety, depression, impaired social function, impaired occupational functioning, sexual dysfunction

  25. HISTORY OF PRESENT ILLNESS Current Treatment: “Goody Powders didn’t help but I took a friends Lortab and it helped.” “I been on Prozac since my 1st marriage ended.” Treatment with FMS: • Will NSAIDs help FMS? • Will SSRIs help FMS? • Will narcotics help FMS?

  26. CURRENT MEDICATIONS: Prozac 10mg qd Xanax 0.5mg BID Goody Powders CoQ 10 Will these help Fibromyalgia pain?

  27. PAST MEDICAL HISTORY: Fatigue, Trauma/MVA, Insomnia, Obesity PSYCH HISTORY: Generalized Anxiety Disorder Depression Abused by 1st husband Common comorbid psychiatric conditions with FMS: GAD, Depression, PTSD, Bipolar Disorder

  28. PAST SURGICAL HISTORY: C-Section x 2 Tubal ligation

  29. FAMILY HISTORY: Father: IBS Mother: Depression, Migraine 2 Children: ADHD There is a strong genetic predisposition for FMS with the other CENTRAL SENSITIZATION SYNDROMES (CSS) in family members.

  30. REVIEW OF SYSTEMS: FMS Constitutional: Fever No Fatigue 70% Sleep apnea Weight change Inactivity Energy level Down

  31. REVIEW OF SYSTEMS: FMS Eyes: r/o inflam, neuro ENT: r/o infection Pulmonary: r/o infection, asthma Cardiovascular: r/o CV disease

  32. REVIEW OF SYSTEMS: FMS GI: Abd pain 40% have IBS symptoms Constipation N/V/D Bleeding

  33. REVIEW OF SYSTEMS: FMS GU: Dysuria/Frequency r/o infection Incontinence I.C. (CSS) Nocturia r/o metabolic Ir. Bladder Sy. (CSS)

  34. REVIEW OF SYSTEMS: FMS Musculoskeletal: Back pain Always Neck pain Always Arthralgias 80% Myalgias 80% Fibromyalgia pain must be AXIAL not peripheral. Fibromyalgia pain must be in ALL 4 QUADRANTS, NOT unilateral, NOT upper or lower.

  35. REVIEW OF SYSTEMS: FMS Skin: Rash Butterfly/malar rash r/o Lupus Psoriasis/psoriatic Arth. Dry Skin r/o Thyroid Dz Lesions r/o cancer

  36. REVIEW OF SYSTEMS: FMS Psychiatric: Depression Highly coexistant Anxiety Highly coexistant Insomnia Highly coexistant Bipolar disorder Highly coexistant With FMS, • 1st degree relatives of FMS patients are twice as likely to have a mood disorder. • 1st degree relatives of FMS patients has an 8 fold risk of FMS or other CSS’s.

  37. REVIEW OF SYSTEMS: FMS Neurological: Headache 53% Paresthesias 35% RLS 15% CVA Seizures

  38. REVIEW OF SYSTEMS: FMS Endocrine: Diabetes Always r/o Thyroid Disease Always r/o Dyslipidemia ? Statins Vasomotor Perimenopausal Symptoms

  39. REVIEW OF SYSTEMS: FMS Hemo/Lymph/Immun: Easy bruising/bleeding r/o cancer Lymphadenopathy r/o cancer infection

  40. REVIEW OF SYSTEMS: FMS GYN: Vag d/c r/o infection Bleeding Pelvic Pain r/o pregnancy Other CSS’s are Chronic Pelvic Pain, Post C-Section Neuropathy, Post Inguinal Repair Neuropathy. Remember, damaged nerves can lead to a “wind-up phenomenum”. What is #1 cause of abd. Pain?

  41. O -OBJECTIVE PHYSICAL EXAM: FMS Vital signs: Weight: 200 Height 62” BMI 37 B/P 138/88 HR 92 RR 16 Temp 98.2 ?fever

  42. PHYSICAL EXAM: FMS Alert & oriented x3 Confused “Fibro fog 20%” ↓ Memory ↓ Attn. Span ↓ Task Switching Clean Depressed ↑ with FMS & Chronic Pain Anxious ↑ Correlation

  43. PHYSICAL EXAM: FMS Eyes: Conjunctiva r/o inflammatory Dz r/o anemia PERRLA r/o MS EMOI r/o neuro problems ENT: r/o infection

  44. PHYSICAL EXAM: FMS Neck: Supple LAD r/o infection r/o cancer Thyroid r/o thyroid dz A GOOD TIME TO CHECK TENDERPOINTS SINCE MOST ARE AROUND THE NECK Bruits

  45. PHYSICAL EXAM: FMS Respiratory: CTAB r/o infection Effort normal Retractions Wheezing Crackles A GOOD TIME TO CHECK TENDERPOINTS AROUND THE BACK

  46. PHYSICAL EXAM: FMS CV: r/o fatigue cause ABD: r/o infection GU: r/o infection GYN: r/o infection RECTAL: (not a fibromyalgia tenderpoint)

  47. PHYSICAL EXAM: FMS Lymph: Cervical r/o infection & cancer Supraclavicular Axillary Inguinal A GOOD OPPORTUNITY TO CHECK TENDERPOINTS WITHOUT BEING TOO OBVIOUS

  48. PHYSICAL EXAM: FMS Neuro: Motor Weakness /?MS Sensory r/o cervical, lumbar spinal stenosis Reflexes r/o hypo/hyperthyroid Gait r/o MS, NPH, Parkinsn

  49. PHYSICAL EXAM: FMS Musculo-skeletal: FROM Joints Check joints for RA/OA Check tenderpoints Swelling Erythema Laxity

  50. PHYSICAL EXAM: FMS Skin: Abnormal lesions Face Trunk Extremities Rule out infection, lupus, psoriasis→(psoriatic arthritis) scleroderma, and other skin manifestations of other rheumatologic diseases that could cause FMS like pain.

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