Fibromyalgia

Diagnosis And Treatment Of

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Pathophysiology

Alternative Approaches

Controversies and Case Management

Overview and Etiology

Literature & Evidence

Presentation Timeline

History

Fibromyalgia-like symptoms have been described since the 19th century

The term “fibromyalgia”

was first used by Dr. P. K. Hench in 1976 to

describe the condition

Clinical studies supporting the syndrome first gained traction in the 80s

Overview

Fibromyalgia is a significant chronic pain condition

2-8% of US adult population is affected

Age of onset ranges from 30-55, but children and adolescents may also have it

More common in women than men

Symptoms

Symptoms (Cont.)

Typical Clinical Phases

Previous treatment included diagnostic cervical medial branch blocks which did not provide relief of symptoms

Clinical course: Over time pain has become more widespread, with a concentration in the neck and upper back

Physical exam

Trigger points in the upper trapezius and levator scapulae muscles: Pain at 14/18 paired tender points

Case Presentation

35-year-old woman was rear-ended in a MVA 1 year ago

Initial complaint: Diffuse posterior neck and shoulder girdle pain

No symptoms suggestive of radiculopathy

Cervical MRI scan negative

Etiology - Genetics

There is evidence that FM may run in families: Monozygotic twins with FM have a 15% chance that their twin also has FM. For dizygotic twins, the percentage is 7%

These polymorphisms also cause related chronic pain disorders as well as depression

FM gene polymorphisms affect dopaminergic, serotoninergic, and catecholaminergic systems

Etiology - Lifestyle

Stress is an important factor in developing FM

Smoking, obesity, and no exercise are also risk factors

FM is comorbid with other chronic pain conditions

Anderberg UM, Marteinsdottir I, Theorell T, von Knorring L (August 2000). "The impact of life events in female patients with fibromyalgia and in female healthy controls". Eur Psychiatry 15 (5): 33–41.

Etiology - Psychological Factors

Goldenberg DL (April 1999). "Fibromyalgia syndrome a decade later: what have we learned?". Arch Intern Med. 159 (8): 777–85.

Also linked with hypomanic component of bipolar disorder

Strong evidence that major depression is associated with fibromyalgia

Overview and Etiology

Etiology (Cont.)

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Pathophysiology - Neurochemical

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Pathophysiology - Dopamine

Some people with fibromyalgia respond to pramipexole, a dopamine agonist

“Dopamine hypothesis of fibromyalgia”: insufficient dopamine causes most FM-associated symptoms

Wood PB (2004). "Stress and dopamine: implications for the pathophysiology of chronic widespread pain".Medical Hypothesis 62 (3): 420–424.

Pathophysiology - Serotonin

Serotonin regulates sleep, mood, pain, and concentration

Selective serotonin reuptake inhibitors (SSRIs) have had limited success

Serotonin-norepinephrine reuptake inhibitors (SNRIs) have been more successful

Arnold LM (2006). "Biology and therapy of fibromyalgia. New therapies in fibromyalgia". Arthritis Res Ther. 8 (4): 212.

Overview and Etiology

Pathophysiology - Neuroendocrine

Hormonal imbalances may be important, especially those controlled by GH (growth hormone)

Abnormal sleep pattern may be caused by GH

GH deficiency may also cause delayed healing of muscle microtraumas

Chronic overactivity of neurons could also disrupt the pituitary-adrenal axis

Overactive baseline of the sympathetic nervous system

Sympathetic Hyperactivity

Lower heart rate variability

Sustained hyperactivity is most pronounced at night

Norepinephrine levels in people with fibromyalgia are low

Alternative Approaches

Cerebrospinal Fluid Abnormalities

Russell IJ, Orr MD, Littman B, Vipraio GA, Alboukrek D, Michalek JE, Lopez Y, MacKillip F (November 1994). "Elevated cerebrospinal fluid levels of substance P in patients with the fibromyalgia syndrome". Arthritis Rheum. 37 (11): 1593–601.

Hyperactivation in pain-sensing brain centers

Pathophysiology - Brain Imaging Studies

Accelerated rate of gray matter loss as part of age-related brain atrophy

Decreased blood flow in certain areas like the thalamus

Evidence of hippocampal disruption and reduced availability of mu-opioid receptors

Activation in response to non-painful stimuli as well

Diagnosis

No definitive criteria to diagnose fibromyalgia

Must rule out other diseases, including rheumatoid arthritis, metabolic myopathies and peripheral neuropathies

Fibromyalgia is very similar to Chronic Fatigue Syndrome

Pain is the most common symptom in fibromyalgia, in contrast to fatigue in CFS

Overview and Etiology

Diagnosis - American College of Rheumatology Criteria

History of chronic widespread pain for more than 3 months

18 tender points throughout body

These criteria have since been updated

Diagnosis - ACR Provisional Criteria

Uses a widespread pain index (WPI) and symptom severity (SS) scale

Measures pain in 19 general body areas, as well as fatigue, sleep, and cognitive symptoms

Diagnosis - Central Sensitization Theory

Alternative Approaches

Central Sensitization

Alternative Approaches

Overview and Etiology

Differential Diagnosis

Visceral referred pain

Mechanical Stresses

Nutritional, metabolic & endocrine

Psychological disorders

Infectious Diseases

Chronic Fatigue Syndrome

Joint Disorders

Inflammatory Disorders

Neurological Disorders

Regional Soft Tissue Disorders

Recent Literature Findings

Compounded Medications

Benzodiazepines

Neuropathic

NSAIDS

Non sedating muscle relaxation

Balance training has a beneficial effect on functional levels of patients with fibromyalgia.

Adding upper cervical manipulative therapy to a multimodal program is beneficial in patients with fibromyalgia (Pain Management Review)

Pregabalin provides quick improvements in pain or sleep quality in patients with fibromyalgia (Pain Management Review)

Stimulus-response assessments in patients with fibromyalgia responding to milnacipran reveal antihyperalgesic effects (Pain Management Review)

Muscle strengthening activity is a safe and effective mode of exercise in patients with fibromyalgia (Pain Management Review)

Alternative Approaches

Recent Literature Findings - Cont.

Person

Recent Literature Findings (Cont.)

Gene polymorphisms have been found that contribute to susceptibility to get FM

FM is often comorbid with depression, anxiety, and many other rheumatoid disorders, i.e. arthritis, back pain

Strong Evidence Supports

Amitriptyline, cyclobenzaprine

Cardiovascular exercise

Cognitive behavioral therapy

Patient education

Multidisciplinary therapy

Alternative Approaches

Overview and Etiology

Dual reuptake inhibitors

Moderate Evidence Supports

Fluoxetine

Pregabalin

Tramadol

Acupuncture

Biofeedback

Hypnotherapy

Strength training

Patients

Weak Evidence Supports:

Chiropractic therapy

Electrotherapy

Manual and massage therapy

Ultrasound

Tender (trigger) point injections

Flexibility exercise

Corticosteroids

No Evidence Supports the Following

Melatonin

NSAIDs

Opioids

Thyroid hormone

Controversies

There is debate over whether the cause of fibromyalgia is physical or psychological

There is evidence that fibromyalgia patients have elevated cytokine levels and neurochemical imbalances

It may exist on a continuum

Controversies (Cont.)

Some view fibromyalgia as a “physical response to depression and stress”, i.e., an underlying psychological problem is the cause of the physical symptoms

In many cases there is a lack of physical abnormalities in fibro patients

No objective diagnosis criteria

Viewed by some as an affective or somatoform disorder

Controversies (Cont.)

irritable bowel syndrome

chronic fatigue syndrome

chronic muscular headaches

One problem is that it is a challenge to draw the boundary between fibromyalgia and other similar disorders:

Pathophysiology

i.e. Evidence that the pain has a neurogenic origin

i.e. There is muscle and connective tissue dysfunction

Others view fibromyalgia as a pathology:

Case Management

Patient education

CNS active agent at low doses to help with sleep and pain e. g., cyclobenzaprine

Encourage an active aerobic exercise program

On follow-up, if needed, add daytime antidepressant, dual reuptake inhibitor

On further follow-up, consider local trigger point injection

Refer to PT for education in stretching and strengthening

Facilitate participation in PT

Summary of Approaches

Clinically establish the presence of central sensitization

Identify peripheral pain generators and treat them

Engage in “rational polypharmacy”

Treatment must be individualized

Enroll in a rehabilitation/functional and restoration/ multidisciplinary program

Evaluate for other metabolic, inflammatory, or nutritional causes of bone, joint, and muscle pain

Overview and Etiology

Alternative Approaches

Alternative Approaches (Cont.)

Be prepared to work hard and give your all, knowing that you have chosen a profession where the demands will become more intense

Yoga Approach

References

Häuser W, Eich W, Herrmann M, Nutzinger DO, Schiltenwolf M, Henningsen P (June 2009). "Fibromyalgia syndrome: classification, diagnosis, and treatment". Dtsch Arztebl Int 106(23): 383–91.

Goldenberg DL (January 1995). "Fibromyalgia: why such controversy?". Ann. Rheum. Dis. 54 (1): 3–5.

Wolfe F (2009). "Fibromyalgia wars". J. Rheumatol.36 (4): 671–8.

Goldenberg DL, Burckhardt C, Crofford L (Nov 2004). "Management of fibromyalgia syndrome"(Free full text). Journal of the American Medical Association 292 (19): 2388–2395.

Busch A, Schachter CL, Peloso PM, Bombardier C (2002). Busch, Angela, ed. "Exercise for treating fibromyalgia syndrome". Cochrane database of systematic reviews (Online) (3): CD003786.

Goldenberg DL (2008). "Multidisciplinary modalities in the treatment of fibromyalgia". J Clin Psychiatry 69(2): 30–4.

References (Cont.)

Bernardy K, Klose P, Busch AJ, Choy EH, Häuser W (10 September 2013). "Cognitive behavioral therapies for fibromyalgia.". The Cochrane database of systematic reviews 9: CD009796.

"FDA Approves First Drug for Treating Fibromyalgia"(Press release). U.S. Food and Drug Administration. 21 June 2007. Retrieved 14 January 2008.

Häuser W, Bernardy K, Uçeyler N, Sommer C (January 2009). "Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis". JAMA301 (2): 198–209.

Moore, R Andrew, ed. "Gabapentin for chronic neuropathic pain and fibromyalgia in adults".Cochrane database of systematic reviews (Online) (3): CD007938.

References (Cont.)

Bennett RM, Clark SC, Walczyk J (1998). "A randomized, double-blind, placebo-controlled study of growth hormone in the treatment of fibromyalgia".The American Journal of Medicine 104 (3): 227–231.

Jones KD, Deodhar P, Lorentzen A, Bennett RM, Deodhar AA (2007). "Growth hormone perturbations in fibromyalgia: a review". Seminars in Arthritis and Rheumatism 36 (6): 357–79.

March 2014

Holman AJ (September 2009). "Impulse control disorder behaviors associated with pramipexole used to treat fibromyalgia". J Gambl Stud 25 (3): 425–31.

Wolfe, F et al. (May 2010). "The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity"(PDF). Arthritis Care Res 62 (5): 600–610.

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