Fibromyalgia: "What we should know about" - Hospital ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
MSK FOCUS: FIBROMYALGIA 53
Fibromyalgia: “What we should know about”
Fibromyalgia is a common and include genes involved in the
chronic disorder of unknown serotonin and catecholamine Written by Professor Fahim Khan,
aetiology characterised by pathways. Alterations in either of Consultant Rheumatologist, Aut
widespread pain and tenderness, these pathways could alter pain Even Hospital, Kilkenny/Beacon
abnormal pain processing, sleep sensitivity. Additional genetic Hospital Dublin
disturbance, fatigue, and, often, markers have been identified
psychological distress, as well through genome-wide scans.
as other symptoms. Although
fibromyalgia is frequently grouped A biopsychosocial model of
with arthritis-related conditions, fibromyalgia provides a useful
there is no apparent inflammation framework for organisation. A
or damage to the joints, muscles, number of biologic variables
or other tissues. have been identified, including
genetics, female sex, age, poor
Data regarding the exact sleep, trauma, deconditioning,
prevalence of fibromyalgia in the
autonomic dysregulation,
United States are limited. The
chronic infection, abnormal
estimated prevalence is 2%,
nociceptive processing, and
affecting roughly 5 million adults
stress. Identifiable psychological
(age ≥18 years), with women
having a higher prevalence (3.4%) variables include hypervigilance,
and incidence (80-90%) of this feelings of helplessness, poor
condition than men (0.5% and coping strategies, depression, The pathophysiologic sequence usually yields normal findings. A
10-20%, respectively). Although anxiety, certain personality traits of events that leads to the tender-point examination should
fibromyalgia most typically and styles (eg, neuroticism, development of fibromyalgia is be performed at the start of the
presents to physicians in women perfectionism, or compulsive not well elucidated; however, a physical examination.
of middle age, the onset of various behaviour), and excessive pain number of discrete cellular and
pain symptoms often occurs behaviours. Environmental and biochemical abnormalities have Fibromyalgia is a diagnosis of
early in life, and the condition sociocultural variables associated been identified. The volume exclusion and patients must
can present in either sex at any with fibromyalgia include of abnormalities discovered in be thoroughly evaluated for the
age. Multiple epidemiologic family support, job satisfaction, patients with fibromyalgia is presence of other disorders that
studies have demonstrated a childhood abuse, and family high enough to substantiate the could be the cause of symptoms
strong genetic association with members or friends with claim that it is not a subjective before a diagnosis of fibromyalgia
fibromyalgia. Implicated genes chronic pain. pain condition. When viewed is made. Patients must also
collectively, these abnormalities undergo a thorough clinical and
suggest that fibromyalgia is a laboratory evaluation to identify
disorder of central sensitization alternative or coexisting diagnoses
or abnormal central processing of for chronic pain.
nociceptive pain input.
Although patients with fibromyalgia
The pain associated with do not have characteristic
fibromyalgia is typically described or consistent abnormalities
as radiating diffusely from the on laboratory testing, routine
axial skeleton over large areas laboratory and imaging studies
of the body, predominantly
can help to rule out diseases
involving the muscles and joints.
with similar manifestations
Patients also present with various
and to assist in diagnosis of
additional complaints. Fatigue and
certain inflammatory diseases
poor sleep are nearly universal.
Cognitive problems ("fibro fog") that frequently coexist with
produce impairments in memory fibromyalgia. Such tests include
and thinking. Patients with the following:
fibromyalgia typically suffer for
many years before diagnosis and • Complete blood count with
sometimes receive unnecessary, differential
expensive, or needlessly invasive • Metabolic panel
procedures or medication before
fibromyalgia is recognized. • Urinalysis
A history of more than 3 months • Thyroid-stimulating hormone
of diffuse musculoskeletal level
pain, along with the other • 25-hydroxy vitamin D level
symptoms like tiredness, fatigue,
headaches, memory fog, restless • Vitamin B12 level
legs syndrome, irritable bowel
syndrome, poor sleep, pins • Iron studies, including iron level,
and needles etc suggests total iron binding capacity,
fibromyalgia. Physical examination percent saturation, and serum
is helpful in confirming the ferritin level
diagnosis. Except for heightened • Magnesium level
tenderness and evidence of
deconditioning, the examination • Erythrocyte sedimentation rate
HOSPITALPROFESSIONALNEWS.IE | HPN • MAY - 2021
54 MSK FOCUS: FIBROMYALGIA
Table 1. The Evolution of ACR Classification of Fibromyalgia
Antipolymer antibody assay:, The ACR 1990 Criteria
May provide conclusive evidence
for a subgroup of people with
fibromyalgia; about 50% of Widespread pain in combination with:
fibromyalgia patients have
antipolymer antibodies Tenderness at –> 11 out of 18 specific tender points
Management Digital palpation should be done with about 4kg of force
The patient must state that the palpation was painful for the tender point to
There is no cure for fibromyalgia,
but education, lifestyle changes,
be considered positive
and proper medications can help Concomitant radiographic or laboratory abnormalities do not lead to exclu-
the individual to regain control and sions
achieve significant improvement.
Models of pain behaviour that In terms of diagnosis or classification, there is no distinction between primary
interrelate biologic, cognitive, fibromyalgia and secondary (or concomitant) fibromyalgia
emotional, and behavioural
variables form the basis for
cognitive-behavioural and The ACR 2020 Criteria:
operant-behavioural approaches
to adult pain management. Tender-point examination eliminated and patient questionnaire with 2 scales:
Fibromyalgia in children
responds to a combination widespread pain index (WPI) and the symptom severity score (SSS) were added.
of psychotherapy, exercise,
relaxation techniques, and Numerical score was created – the diagnosis of fibromyalgia syndrome was sup-
education. Pharmacotherapy is
generally not indicated in children.
ported when:
Patient Education WPI >_7 and SSS >_5 or
Education is an essential element
WPI 3-6 and SSS >_9
in fibromyalgia management. It
begins with an empathetic manner The ACR 2011 Criteria Modification
on the part of the physician, who
must affirm the patient's pain,
explore social and behavioural
Physician-estimate of somatic symptoms eliminated and the WPI and expanded.
variables (both in childhood and The new 0-31 FM symptom scale (FS) include:
current) that influence the illness,
and explain to the patient how 19 pain locations
stress and distress can amplify the
severity of symptoms. Scheduling 6 self-reported symptoms, including difficulty sleeping, fatigue, poor cognition,
time to provide this education headache, depression and abdominal pain
at early visits can save time in
subsequent visits. An FS >_13 best separated criteria + and criteria – patients
Nonpharmacotherapy
ACR American College of Rheumatology
The patient should be encouraged
to foster self-efficacy, and
healthcare providers should work
to diminish dependence over time. Patients should avoid prolonged, • Low-impact aerobic exercise at include the following:
Providers can help by teaching overly strenuous physical least 3 times weekly
patients about the following: exercise before reconditioning • Analgesics (eg, simple pain
is established. • Target exercise regimen: 4-5 killers like Acetaminophen or
• Diet (eg, promote good nutrition, times a week for at least 20-30 tramadol)
vitamin supplementation, bone Aerobic and flexibility regimens minutes each time; may take
health, weight loss) months to achieve • Antianxiety/hypnotic agents
• Stress management Daily aerobic and flexibility (eg, alprazolam, clonazepam,
exercises may be an essential For patients who may never
zolpidem, zaleplon, trazodone,
• Aerobic exercise (eg, low- component of the fibromyalgia achieve the level of the target
buspirone, temazepam, sodium
impact aerobics, walking, water rehabilitation program. The goal of exercise regimen, encourage them
oxybate)
aerobics, stationary bicycle) these exercises is for the patient to exercise at the highest level
to exercise safely without possible without worsening • Skeletal muscle relaxants (eg,
• Sleep therapy (eg, education/ increased pain. their symptoms. cyclobenzaprine)
instruction on sleep hygiene)
An exercise regimen should Pharmacotherapy • Antidepressants (eg,
• Psychologic/behavioral therapy amitriptyline, duloxetine,
(eg, cognitive-behavioural, include the following
considerations: Always combine pharmacologic milnacipran, venlafaxine,
operant-behavioural)
and nonpharmacologic therapy desvenlafaxine)
Physical Therapy/Physical • Always start at low levels of in the treatment of fibromyalgia.
exercise and progress slowly: Aggressively treat comorbid • Anticonvulsants (eg, pregabalin,
Modalities
Begin with gentle warm-up, depression. gabapentin, tiagabine)
Exercise programs should start flexibility exercises; progress • Alpha 2 agonists (eg, clonidine)
gently and progress gradually to to stretching all of the major Medications used in the
endurance and strength training. muscle groups management of fibromyalgia • Low dose Naltrexone
MAY - 2021 • HPN | HOSPITALPROFESSIONALNEWS.IE
55
Sleep
Managing Flare-ups in
Poor sleep worsens and Fibromyalgia Calmare Pain Therapy is a U.S.
perpetuates symptoms, so Patients should learn to identify FDA 510(k)-cleared and European
intensive treatment is indicated. the factors that trigger flare- CE mark-certified pain therapy
Most patients understand university Indianapolis IN USA ,
ups (although, on occasion, no medical device to treat pain
little about the nature of sleep; Board certified in Rheumatology
trigger can be identified) and what without the use of drugs, a non- and is a fellow of the American
therefore, instruct them on the measures to take to decrease their invasive, biophysical approach to
basics of sleep and proper sleep College of Physicians.
symptoms. Tips for avoiding and chronic pain relief by transmitting
hygiene. Providing this education managing flare-ups include the a 'no-pain' message to the pain-
is one of the most helpful Prof.Khan has extensive
following: producing nerve/s via painless experience in Rheumatology
interventions. surface electrodes applied to the including Fibromyalgia and Soft
• Treat infections quickly skin consistently over a period of
Medications that may prove helpful tissue Rheumatism, Osteoarthritis,
• Avoid changes in diet time and has been found to be Rheumatoid arthritis, Psoriatic
for sleep problems that do not very effective pain relief therapy
respond to nonpharmacotherapy arthritis, Spondyloarthritis, early
• Exercise as prescribed (ask in Fibromyalgia without the use of arthritis clinics and rheumatology
include the following: patients not to increase their drugs or medications and in many related pain management
routine without consulting other pain conditions including disorders including back pain
• Antidepressants (eg, trazodone,
a physician) neuropathic pain. and has extensive experience
SSRIs, SNRIs, tricyclic
antidepressants) • Moderate changes in activity in musculoskeletal ultrasound
Professor Fahim Khan in rheumatology and ultrasound
• Anticonvulsants (eg, • Avoid unnecessary life changes (MBBS,MD,MRCP London,, guided joint injections and for
clonazepam, gabapentin, MRCP Rheumatology RCP-UK, back pain.
tiagabine) • Treat changes in mood or sleep FRCP London, FRCP Edin, FACP,
early and aggressively Diplomat American Board of Prof. Khan has extensive
• Nonbenzodiazepine hypnotics Rheumatology ,is a consultant experience in the use of Scrmbler
(eg, zolpidem, zaleplon, • Always start new medications at
Rheumatologist at the Aut Even therapy,“Calmare Therapy” for
eszopiclone) the lowest possible dose
Hospital Freshford Road Kilkenny pain management which is a
• Muscle relaxants (eg, • Prepare for unavoidable and Beacon Hospital Dublin. Prof U.S. FDA 510(k)-cleared and
cyclobenzaprine, tizanidine) situations that have caused Khan also works as a visiting European CE mark-certified pain
flare-ups in the past (eg, Rheumatologist at the Orlando therapy medical device for pain
• Dopamine agonists (eg, arrange for an increase in sleep Health, Fibromyalgia Center management without the use
pramipexole) medication or for help with in USA. of drugs, in Rheumatological
housework and child care) conditions like Fibromyalgia,
Other agents used in fibromyalgia Prof.Khan completed his higher Myofascial pain syndrome,
may include the following: • Encourage patients to pace their postgraduate qualifications from neuropathic pain back pain and
activities and know their limits Ireland, UK and USA. and qualified is the sole provider of Calmare
• Vitamins and minerals the membership examination of
Any latest treatments in therapy in Ireland for over 10 years
• Malic acid and magnesium Fibromyalgia? the Royal College of Physicians with excellent results.
combination of London UK, Fellowship from
Scrambler therapy “Calmare the Royal college of Physicians Prof. Khan is the author of many
• Antioxidants Therapy” in Fibromyalgia is of London and Edinburgh UK medical and rheumatology
• Amino acids widely used in the USA and it is ,Fellowship in Rheumatology articles/publications in the
also available in Ireland as a non and research experience in knee leading international medical/
• Herbs and supplements drug treatment for pain relief. Osteoarthritis from the Indiana rheumatology journals.
MSK FOCUS: NEWS
Impact of Arthritis on Mental Health
Arthritis Ireland is highlighting “The disruptive and destructive health. They also aired a series of
the impact that arthritis can have nature of arthritis impacts people’s online daily mindfulness sessions
on people’s mental health and relationships, their careers and their with mindfulness practitioner,
wellbeing during National Arthritis capacity to enjoy life. The burden of Susan Barrett.
Week, which took place 12-18 April. living with chronic pain and fatigue
How sleep, diet and exercise affect
affects mental, as well as physical
According to the national patient inflammation was the theme of
health, with the most common
organisation, arthritis is associated an online symposium to be held
with poor mental health, including psychological comorbidities being in conjunction with the molecular
depression and anxiety. Research depression and anxiety. rheumatology unit at Trinity College
has shown that up to 20% of “However, these are poorly Dublin, which took place on
rheumatoid arthritis patients recognised within the health Thursday 15 April.
experience depression, with 30% system, and there is too little
developing depression within five The charity also launched a
psychological support for people nationwide survey looking to gain
years of diagnosis. to help them deal with the mental a better understanding of how
Arthritis is the biggest cause of health aspects of living with a arthritis affects mental health, and it
disability in the country and affects chronic disease like arthritis,” announced a new six-week mental
one million people in Ireland. O’Leary said. health online course, called Behind
the Pain.
According to Gráinne O’Leary, Chief As part of National Arthritis
Executive of Arthritis Ireland, “While Week, the charity held an online Further information about
the physical symptoms of arthritis, information event on Tuesday National Arthritis Week is
like fatigue and joint damage, are 13 April with Dr Jennifer available on the charity’s website at
well recognised, there is much less Wilson-O’Raghallaigh, Chief Clinical www.arthritisireland.ie.
awareness of the drastic effect Psychologist at Beaumont Hospital Grainne O’Leary, Chief Executive,
the condition can have on mental to discuss the relationship Arthritis Ireland
health and well-being. between arthritis and mental
HOSPITALPROFESSIONALNEWS.IE | HPN • MAY - 2021You can also read
