“Doc, I hurt everywhere!” How to approach Fibromyalgia in 2011

1. “Doc, I hurt everywhere!”How to approach Fibromyalgia in 2011 Deborah Jane Power, D.O., MS, FACR, FACOI Catalina Pointe Arthritis & Rheumatology Specialists, P.C. Assistant Professor of Clinical Medicine, The University of Arizona Health Sciences Center October 1, 2011

2. Goals Recognize the diagnostic features of Fibromyalgia Syndrome and become more comfortable making the diagnosis Understand current thinking regarding pain processes in Fibromyalgia Syndrome Implement use of evidence-based treatment approaches for Fibromyalgia Syndrome

3. “Doc, I hurt everywhere!” • Chronic, widespread pain • Pain waxes and wanes, may be migratory • Some patients – aching all over; others – chronic, regional pain • Tenderness all over, not just at tender point sites • Many patients report high lifetime and current prevalence of variety nonspecific symptoms that defy current organic explanation

4. Fibromyalgia: Today’s Perspective B. Available at: http://www.medscape.com/viewarticle/737800_2.

5. Fibromyalgia Epidemiology • 2% of the general population • Affects as many as 10 million Americans • More common in women • Most commonly occurs in people aged 35-60 • 6% of patients in internists’ offices • 15% of patients in rheumatologists’ offices

6. No “gold standard” for diagnosis 1Wolfe F, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 1990;33:160-72. 2Turk DC, et al. Managing fibromyalgia: An update on diagnosis. Available at: http://www.musculoskeletalnetwork.com/fibromyalgia/content/article/1145622/1476015. 3Wolfe F, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010;62(5):600-10. • No laboratory tests specific for fibromyalgia • American College of Rheumatolgy (ACR) classification criterianot ideal • Criteria felt to under-diagnose fibromyalgia • Many physicians not familiar or comfortable with the tender point exam • Usefulness of the tender point exam being questioned • Difficult to distinguish between fibromyalgia and other central pain disorders

7. Differential Diagnosis of Diffuse Pain and/or Fatigue • Mechanical overuse • Drugs – statins, fibrates, antimalarias • Endocrinopathies – hypo/hyperthyroidism, Cushing’s, diabetes, Vitamin D deficiency • Neurological – MS, MG, polyneuropathy • Malignancy • Infections – Hep C, HIV, Lyme disease • Rheumatologic causes – RA, SLE, Sjogren’s, AS, PMR, inflammatory myopathies • Metabolic myopathy • Osteomalacia • Tapering of steroids • Regional pain syndromes

8. Fibromyalgia (FM) • Patient History – • Onset and character of the pain • Accompanying symptoms • “Exposures” that could cause symptoms • Especially prescription and OTC medications • Red Flags • Family history of myopathies, personal history of cancer, unexplained, systemic symptoms, symptoms suggesting inflammation – true morning stiffness, swelling, redness or warmth of joints

9. Clinical presentation:The typical patient • Widespread pain • Characteristic total body pain • Generalized, deep, aching pain • Present for at least 3 months • Both sides of body AND above and below the waist • From the top of the head to the tip of the toes • Fluctuation over the course of a day • Aggravating factors • Gradual onset of pain, symptoms • Imperceptible • Report being out of sorts for a number of weeks or months, followed by pain et al. Glenview (IL): American Pain Society (APS); 2

10. Clinical presentation:The typical patient • Trouble sleeping, fatigue • Characteristic pattern: Sleep 2 hours, wake up, go back to sleep around 3:00-4:00 AM, wake up exhausted • Sleep disturbance present in >75% of patients with FM • Mood disorder • Sadness • ~40% depression • ~40% anxiety • Possibly due topain and fatigue • It is a myth that ALL fibromyalgia patients are depressed • J Med 1986:81 Supp:85-9.

11. Clinical presentation:The typical patient • Other Somatic Symptoms • Chronic headache • Symptoms of IBS • Irritable bladder • Dyscognition (Fibro Fog) • Temporomandibular joint disorder (30%) • Sensitivity to bright light, loud sounds • Precipitating Factors • Physical trauma • Psychological trauma • Influenza or other viral infections • No evidence to support causality • Reported by some patients The time frame from onset of symptoms to diagnosis is dropping, but it still more than 2 years and almost 4 different physicians, according to a recent survey1 et al. Arthritis Rheum. 1990;33:160–72.

12. Laboratory Studies in FM • Minimum evaluation • CBC • Liver function studies • Renal function • TSH • ESR • CRP • Vitamin D 25-OH level • X-rays, EMG, bone scan and NCV - use sparingly • Avoid checking ANA or RF unless strong evidence for an autoimmune disorder

13. ACR criteria for Fibromyalgia • History of chronic, widespread pain involving all four quadrants of the body, above and below the waist and the axial skeleton • Plus, presence of 11 of the 18 described tender points on physical examination with 4 kg of pressure (enough to blanch examiner’s nail)

14. Tender points Wolfe et al. Arthritis Rheum. 1990;33:160–72.

15. Occiput At suboccipital muscle insertions Low cervical Anterior aspects of intertransverse spaces at C5-C7 Trapezius Midpoint of upper border Supraspinatus Above scapula spine near the medial border Second rib At 2ndcostochondral junctions Lateral epicondyle 2 cm distal to epicondyles Gluteal Upper, outer quandrants of buttocks in anterior fold of muscle Greater trochanter Posterior to trochanteric prominence Knee At the medial fat pad of the joint line ACR Tender Points All bilateral

16. New Diagnostic Criteria for FM Wolfe et al 2010 • Preliminary acceptance by the ACR • Under the new criteria, a patient has fibromyalgia if they meet 3 conditions: • 1. Widespread pain index (WPI) >7 and the symptom severity (SS) scale score > 5 or WPI 3-6 and SS scale score >9 • 2. Symptoms present at a similar level for at least 3 months • 3. Patient does not have a disorder that would otherwise explain the pain

17. Diagnosis of fibromyalgia: Multiple options ACR criteria, including tender points exam Widespread Pain Index/ Symptom Severity3 Bypasses the need for tender point exam Creation of a 0 – 31 FM symptom scale by adding Widespread Pain Index (WPI) and the modified Symptom Severity (SS) scale Score of ≥13 meets the criteria for FM When tested, it correctly identified 93% of FM patients • 11/18 tender points typically required, but <11 tender points acceptable if rigorous TP exam performed • An alternative to the 18-point exam uses 3 points: • Lateral border of the trapezium • Lateral epicondyle or lateral upper arm • Anterior thigh • Tender points reflect overall increased sensitivity to pain

18. Tension/migraine HA Cognitive difficulties Multiple chemical sensitivity, allergic symptoms TMJ syndrome Irritable bowel syndrome Nondermatomal paresthesias Vulvar vestibulitis, vulvodynia ENT complaints Vestibular complaints Esophageal dysmotility Nerually mediated hypotension, mitral valve prolapse Non-cardiac chest pain, dyspnea due to respiratory muscle dysfunction Interstitial cystitis, female urethral syndrome Overlapping Regional Syndromes and Symptoms

19. Overlap with Autoimmune Disorders • Symptoms in FM that can mislead practioner to consider autoimmune disorders • Arthralgias, myalgias, fatigue • Morning stiffness • History of subjective swelling of the hands/feet • Symptoms suggestive of Raynaud’s phenomenon (rather than true Raynaud’s) – paleness or erythema of the entire hand rather than only specific digits • Malar flushing (rather than fixed, malar rash) • Livedo reticularis

20. Overlap with Autoimmune Disorders • Patients with established autoimmune disorders • 25% patients with autoimmune disease have “secondary FM” • Consider when autoimmune disease well controlled but patient has persistent complaints or when symptoms unresponsive to anti-inflammatory therapy • Especially common when tapering down on corticosteroid dose

21. Etiology and Pathogenesis • Genetic and environmental influences • Increasing evidence for genetic predisposition • 1st degree relative, 8 fold increased risk of developing FM • Polymorphisms of receptors involved in the metabolism or transport of monoamines that have central role in sensory processing and human stress response

22. Etiology and Pathogenesis • Abnormalities in pain and sensory processing • Lower threshold for electrical, pressure or thermal stimuli cause pain or unpleasantness • Cause likely multifactorial – but key factor central pain or enhanced nociceptive sensation due to augmentation of central pain processing • Four studies have shown increased levels of substance P in CSF of FM patients versus controls • Substance P – pronociceptive peptide stored in secretory granules of sensory nerves, released upon axonal stimulation

23. Pathophysiology of Chronic Pain:Exact mechanism not completely known, but neurological changes have been identified • Central sensitization • Increased sensitivity to stimuli of varying intensities, both painful and painless • Brain changes • Changes in cerebral blood flow (SPECT, fMRI) • Gray matter volume changes • Hypervigilance • Defective descending inhibition of pain Abeles et al. Ann Am. 2009;35:421-35.

24. Theory of Central Sensitization • Impulses from afferents depolarize dorsal horn neurons • Then, extracellular calcium and nitric oxide diffuse into neurons and cause exaggerated release of substance P and glutamate – causes neuronal hyperexcitability • Finally, pain signal is sent to the brain from dorsal horn • Dorsal horn neurons become hyperresponsive to nociceptive and nonnociceptive somatic stimuli – felt to lead to hyperalgesia and allodynia

25. Hypothalamic-Pituitary and Autonomic Dysfunction • Substantial data demonstrates alterations in hypothalamic-pituitary axis and ANS in patients with FM • Seems to suggest changes which allow for somatic symptoms to occur rather than causing the symptoms

26. Pathophysiology…Important Molecules Abeles et al. Ann Intern Med. 2007;146(10):726;8(3):208-14.

27. Psychological and Behavioral Factors • Longstanding debate – role of psychiatric, psychological and behavioral factors • Distress can lead to pain, pain can lead to distress • Pain and other symptoms of FM can cause patients to function less well in various roles - work, family • Maladaptive behaviors can develop • Focus on disability and compensation systems • Typically ensures patient will not improve

28. Psychological and Behavioral Factors • Positive psychological and cognitive factors may be able to buffer neurobiological factors • Internal locus of control • Patients feel they are empowered to do something about their pain • Low catasrophizing (negative, pessimistic view of their pain) • Value of positive coping responses • Cognitive Behavioral Therapy efficacious

29. FM Treatment • Progress in understanding FM has led to improved treatment options • Clinic based evidence – multifactorial program directed at patient education, certain medications, cognitive behavioral therapy and exercise • Consider before given diagnostic label of FM • Some beneficial to have diagnosis for symptoms • Others – diagnostic label may prove detrimental • Upfront time with patient extremely useful for both patient and practioner

30. FM Treatment • Education • Critical • Address nature of FM – benign, nonprogressive condition • National Fibromyalgia Association • American Fibromyalgia Syndrome Association • Arthritis Foundation • Local/national support groups, reliable web sites

31. FM Treatment • Pharmacologic • Tricyclic antidepressants (TCA) • Amitriptyline, cyclobenzaprine • Serotonin reuptake inhibitors (SSRI’s) • fluoxetine • Serotonin-norepinephrine reuptake inhibitors (SNRI’s) • Venlafaxine, duloxetine (Cymbalta)*, milnacipran (Savella)* • Anticonvulsant medication • Pregabalin (Lyrica)* * FDA approved for treatment of Fibromyalgia

32. FM Treatment: Pharmacology Use caution in all medications! Use lowest dose possible Consider side effect profile relative to patient Abeles et al. Am J Med. 2008;121(7):555-61;; Russell. Primary Psychiatry. 2006;13(9):76-84; Wolfe et al. Arthritis Rheum. 1990;33:160–72.

33. Management of fibromyalgia:Combine from both categories Arnold Psychiatry. 2006;13(9):76-84; Wolfe et al. Arthritis Rheum. 1990;33:160–172.

34. FM Treatment • Cognitive Behavioral Therapy • Structured educational program focusing on skill training • Skills that address pain and coping mechanisms: • Relaxation training • Activity pacing • Visual imagery techniques • Distraction stragies • Problem solving • Goal setting

35. FM Treatment • Aerobic Exercise • Studies show improves outcomes, especially in function • Carefully plan for tolerability and to ensure long term compliance • Low impact exercise • Aquatic exercise, walking, swimming, stationary cycling • “Start low, go slow”

36. FM Treatment • Complimentary Therapies • Physical modalities – have some data to support • Trigger point injections • Myofascial release therapy • Other hands-on techniques (acupuncture) • Others – no current data to support • Nutritional supplements • Diets • Devices

37. References Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010;62(5):600-610 Wolfe, F. New American College of Rheumatology criteria for fibromyalgia: a twenty-year journey. Arthritis Care Res (Hoboken). 2010;62(5):583-584 ClauwDJ. Fibromyalgia: update on mechanisms and management. J ClinRheumatol. 2007;13(2):102-109 Arnold LM. Biology and therapy of fibromyalgia. New therapies in fibromyalgia. Arthritis Res Ther. 2006;8(4): 212

38. Internet Resources for Patients FamilyDoctor.org (AAFP) Athritis.org (Arthritis Foundation) FMNetNews.com (Fibromyalgia Network) FibromyalgiaSupport.com (ProHealth)