Fibromyalgia and Chronic Fatigue - PowerPoint PPT Presentation

About This Presentation
Title:

Fibromyalgia and Chronic Fatigue

Description:

Fibromyalgia and Chronic Fatigue Tory Davis PA-C – PowerPoint PPT presentation

Number of Views:312
Avg rating:3.0/5.0
Slides: 39
Provided by: Bria4345
Category:

less

Transcript and Presenter's Notes

Title: Fibromyalgia and Chronic Fatigue


1
Fibromyalgiaand 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/cm2)

4
Tender Points

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

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
    its 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.
  • FibromyalgiapainCFSlassitude

22
CFS- Who?
  • Female gt male (31)
  • 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 symptomsThese 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 dont 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 dont 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 theyre using.
  • Natural ? good
Write a Comment
User Comments (0)
About PowerShow.com