1. Fibromyalgia and Chronic Fatigue Tory Davis PA-C

2. Fibromyalgia  One of the most common rheumatic syndromes in ambulatory medicine  3-10% of the population  10-20% of pts seeing rheumatologists  Annual cost for direct care about $20 billion or $2300/pt  More common in females, ages 20-50  No objective findings  No diagnostic labs or imaging

3. Diagnostic Criteria  History of widespread pain for at least 3 months –Achy and stiff –Bilateral symptoms –Above and below waist –Worse at neck, shoulders, low back, hips  11 of 18 tender points (elicited by pressure of 4 kg/cm 2)

4. Tender Points

5. Other common symptoms  Fatigue  Sleep disorder  Headache  IBS (irritable bowel syndrome)  Irritable bladder  “Fibro fog” - haze  Low back pain  Mood disorder  Multiple chemical sensitivities  Sexual dysfunction  TMJ dysfunction  Bruxism – grinding teeth at night

6. …and the list goes on  Pelvic pain  Dysmenorrhea  Restless leg syndrome  Subjective numbness – feels numb, but can sense on neuro test  Exercise-induced pain and fatigue

7. Central Sensitization  Pathophysiologic abnormality of CNS  Sensory impulses amplified at spinal cord level –In dorsal horn nocioceptive neurons

8. Proposed Causes  Serotonin (much lower levels in women compared to men)  Substance P- aberrant pain perception?  Sleep disturbance  Injury/trauma  Infection  Psychological stressors- may increase pro-inflammatory cytokines via impaired cortisol response  Hormones- ?neuroendocrine dysfunction

9. DDx  Polymyalgia rheumatica – proximal weaknesss  Rheumatoid arthritis  Sleep apnea  Lupus  Multiple sclerosis  Thyroid disorder (hypo, usually)  Neuropathies  Mental illness

10. DDx continued  Substance abuse  Cancer  Infection  Medication side effects  Malingering – people use it to get other benefits

11. Work-up  Dx of exclusion – must exclude!  TSH (thyroid stimulating hormone)  ESR (erythrocyte sedimentation rate)  CBC (complete blood count)  ANA (antinuclear antibody)  RF (rheumatoid factor)  Sleep study  Psych screening tools

12. Physical Exam:  Normal, except:  Pain is present at multiple FM points when pressure is applied. –Interestingly, it can felt virtually anywhere pressure is applied, including control areas (forehead, thumbnail), which are relatively insensitive to pain in normal subjects.  Allodynia – “other pain” –Pain from stimuli that are not normally painful

13. Risk factors  Sex (female, that is)  Family history (nature/nurture?)  Age- early/mid adulthood  Other rheumatic dz: lupus, RA, ankylosing spondylitis  Disturbed sleep: OSA, RLS

14. Treatment  This is a chronic disease. Requires more than a Rx pad.  Pt self-management  Meds- only treating the symptoms. Not curative nor disease-modifying except as they improve pt ability to self-manage and improve QOL

15. Self-Management  Pts unwilling to engage in proactive self care have poorer prognosis  Regular low-impact exercise  Regular sleep- no naps, limit caffeine  Education about the dx and about self  Support groups

16. Prognosis  Better if ongoing stressors are relieved and self-efficacy for pain control can be achieved.  Worse for patients who are highly distressed and have longstanding FM, major psych disease, or ingrained pattern of work avoidance.

17. Complementary and alternative treatment  Massage  Acupuncture/ acupressure  Myofascial release therapy  Chiropractic treatment or OMT  Cognitive behavioral therapy (CBT)

18. CBT  Cognitive Behavioral Therapy  Purpose: to redefine illness beliefs and learn symptom reduction skills to change behavioral response to pain.  Need to sell this idea- not therapy “because it’s all in your head” but as a tool to improve prognosis.  Tools: gate control, relaxation, reframing

19. Pharm Tx  TCAs: amitriptyline (Elavil)  SNRIs: duloxetine (Cymbalta), milnacipran (Savella) venlafaxine (Effexor)  SSRIs: (paroxetine, fluoxetine, et al)  Muscle relaxants: cyclobenzaprine  Antiseizure meds: gabapentin (Neurontin), pregabalin (Lyrica)  Sleep aids- eszolpiclone (Lunesta), zolpidem (Ambien)

20. Just say NO  No narcotics  No benzodiazepines  To treat the pain use tramadol (Ultram) –better proven efficacy than acetominophen or OTC NSAIDS

21. CFS  Profound fatigue not improved by rest, worsened by physical or mental activity.  No clear cause. No definitive work-up. No good tx.  Fibromyalgia:pain::CFS:lassitude

22. CFS- Who?  Female > male (3:1)  Usually not pediatric patients, but otherwise, any age, racial, ethnic or SES group

23. CFS Diagnostic Criteria  Severe chronic fatigue ≥ 6 months with other medical conditions excluded AND…

24. AT LEAST 4 OF THESE  ↓ STM or concentration  Sore throat  Tender cervical or axillary lymph nodes  Muscle pain  Headache (new type, pattern or severity)  Unrefreshing sleep  Post-exertional malaise lasting ≥ 24 hours  Multi-joint pain without swelling or redness

25. Associated symptoms These are NOT diagnostic criteria  Abd pain  Etoh intolerance  Bloating  Chest pain  Chronic cough  Diarrhea  Dizzy  Dry eyes/mouth  Paresthesias  Otalgia  Palpitations  Jaw pain  Morning stiffness  Nausea  Night sweats  Dyspnea  Wt loss  Etc etc etc etc etc etc etc etc etc…

26. Course  Sx can remit and recur, or can fluctuate in severity.  Some pts will recover 100%, but when?  Some pts have progressively worsening sx  Can be lifelong

27. Causes  A sampling of proposed, not proven etiologies:  Iron deficiency anemia  Hypoglycemia  Hx allergies  Viral infection  Immune system dysfunction  Mild chronic hypotension  Alteration in HPA axis function  Sleep dysfunction  Other

28. Risk factors  What is a risk factor? –A condition or value that alters the likelihood of the occurrence of a disease  Females more likely to be affected  Gulf War veterans have 10-fold increased incidence vs non-deployed vets  Other?  We don’t know.

29. Role of Sleep  Diagnosable sleep disorder present in 40-80% of CFS cases, but tx of sleep d/o only results in modest improvement of CFS sx.  ? Effect rather than cause?

30. Differential diagnosis  Fibromyalgia  Multiple chemical sensitivities  Chronic mono  Thyroid dysfunction  Sleep apnea  Narcolepsy  Mental illness  Cancer  Eating disorder  Obesity  Substance abuse  Medication side effect  Somatization d/o  Malingering

31. Work up  Complete Hx  Complete PE  Psych screening tools  Labs: Exclusionary, not confirmatory!

32. Labs/Work-up  CBC  CMP  TSH  ESR  ANA  RF  UA  PPD  HIV  Lyme serology in endemic areas  ?CXR or other imaging  MRI may show non- diagnostic subcortical frontal lobe punctate hyperintensities

33. CFS Complications  Deconditioning  Med side fx  Social isolation  Loss of job  Lifestyle restrictions  Depression (from sx or lack of dx)

34. CFS Treatment  Tx is directed at sx- Goal is to regain some level of previous function and well-being.  Try NOT to aggravate existing sx or to create new ones.  Limit cost

35. CFS Tx- Non Pharm  Physical activity- “Know thyself.” Pace thyself. Avoid push-crash phenom  Massage  Acupuncture  Acupressure  Chiropractic tx  OMT  Yoga, tai chi  Meditation

36. More non-pharm tx  Education- knowledge is power.  CBT  Colonics?! Go ahead and Google it.  Strive for health, but don’t grasp at straws.

37. CFS Treatment- Meds  Pts with CFS seems very sensitive to meds, so START LOW, GO SLOW  NSAIDS for pain- *these work for CFS, not for fibromyalgia –Remember fibromyalgia pain responds better to tramadol  Low dose TCAs to improve sleep, decrease pain  Antidepressants/anxiolytics

38. More meds  Stimulants: modafinil (Provigil)  Antimicrobials- NO. Not unless proven concurrent infection.  Gamma globulin, Ampligen, antifungals, corticosteroids- no evidence of efficacy  Vitamins/herbals- many claim benefit, few prove it. ASK what they’re using. –Natural ≠ good