1. Dupuytren’s Contracture

2. Dupuytren’s Contracture
Fibrous tissue of the palmar fascia to shorten and thicken
Common in men older than 40 years; in persons of Northern European descent; and in persons who smoke, use alcohol, or have diabetes (3 to 33 %)
Present with a small, pitted nodule (or multiple nodules) on the palm, which slowly progresses to contracture of the fingers
Progresses' faster in <50 yr olds
Smoking and alcohol use increase the chance that surgery will be needed

3. Dupuytren’s Contracture
Found on the palm of the hand proximal to the metacarpo-phalangeal (MCP) joint. Can be bilateral
Patients usually have difficulty with tasks such as face washing, hair combing, and putting their hands in their pockets.
Note the site of the nodule and the presence of contractures; bands; and skin pitting, tenderness, and dimpling.
Grade 1 disease presents as a thickened nodule and a band in the palmar aponeurosis; this band may progress to skin tethering, puckering, or pitting.
Grade 2 presents as a peritendinous band, and extension of the affected finger is limited.
Grade 3 presents as flexion contracture

4. Fibromyalgia

5. Characteristic features:
Chronic widespread pain for at least three monthsTender points in 11 of 18 specific anatomic locations
Associated features
Anxiety
Cognitive difficulties
Fatigue
Headache (50%) (migraine)*
Paresthesias, morniing stiffness
Sleep disturbance
*?a defect in the serotonergic and adrenergic systems

6. Associated Findings
History of trauma, childhood abuse, anxiety, depression, or sleep disorder (alpha frequency rhythm, termed alpha-delta sleep anomaly )
Patients with high tender point counts are more likely to report adverse childhood experiences like loss of a parent or abuse
Irritable bowel syndrome (IBS)
Other disorders commonly associated with FM include:
Irritable bladder
Dysmenorrhea
Premenstrual syndrome
Restless leg syndrome
Temporomandibular joint pain
Noncardiac chest pain
Raynaud's phenomenon and Sicca syndrome (Sjogren’s)

7. Other Diagnoses/Associated
Myofascial pain syndrome,
Chronic fatigue syndrome, and
Hypothyroidism.

8. Myofascial pain syndrome
Characterized by painful, tender areas in the muscles.
It is a localized disorder without any systemic manifestations.
It commonly affects the axial muscles.
In contrast to the widespread pain of fibromyalgia, the pain in myofascial pain syndrome arises from trigger points in individual muscles.
On examination, the presence of trigger points is characteristic of myofascial pain syndrome.

9. Chronic fatigue syndrome (CFS)
Chronic pain and fatigue are common to chronic fatigue syndrome and fibromyalgia.
CFS an ongoing subclinical inflammatory process manifested by low-grade fever, lymph gland enlargement, and acute onset of the illness, whereas there is no evidence of inflammatory response in fibromyalgia.

10. Hypothyroidism
Manifested by profound fatigue, muscle weakness, and generalized malaise, closely resembles fibromyalgia.
Patients need to be examined for clinical signs of thyroid dysfunction and, if in doubt, thyroid function tests should be ordered to rule out hypothyroidism.
(The differential diagnosis also might include metabolic and inflammatory myopathies (especially in patients taking statins), polymyalgia rheumatica, and other rheumatic diseases. )

11. optimal intervention is an approach that also includes nonpharmacologic treatments, specifically exercise and cognitive behavior therapy
education, cognitive behavior strategies, physical training, and medications for treatment of fibromyalgia

12. Multi symptom condition
FIBROMYALGIA-Review
Multi symptom condition

13. Multi symptom condition characterized by chronic widespread pain
Muscular pain
Fatigue
Sleep abnormalities
Joint pain
Headaches
Restless legs
Numbness
Impaired memory
Leg cramps
Impaired concentration
Nervousness
Major depression

14. Patient-Reported Symptoms at Diagnosis of Fibromyalgia

16. Features
3 months or longer in all 4 quadrants of the body, but not centered in the joints
Lower pain threshold:
Allodynia-pain from normally non noxious stimuli
Hyperalgesia-increased response to painful stimuli
Under diagnosed and undertreated
(Prevalence:2% to 4%)/
Onset usually at 20 to 55 years/ F:M 9:1
First-degree relatives of FM patients have 8 times the risk

17. ?etiology Pain amplification
Lower levels of metabolites of serotonin and norepinephrine in their cerebrospinal fluid
Increased levels of pro-nociceptive
transmitters substance P and glutamate that
amplify pain impulses

18. No objective laboratory test or marker
exists, diagnosis is based on history and physical examination
Chronic Widespread Pain for at least 3 months and pain on at least 11 of 18 specified muscle tendon sites of focal tenderness (“tender points” 11/18)
Use of a structured interview with questions about generalized fatigue, headache, sleep disturbance, neuropsychiatric complaints,
numbness or tingling, and irritable bowel symptoms.

19. POINTS OF TENDERNESS

20. ?TREATMENT Eval Criteria
SYMPTOM
CRITICAL FOR EVAL%
Pain
100
Fatigue 94
Patient global improvement
Multidimensional function 86
Tenderness 74
Sleep 66
Health-related quality of life 65
Dyscognition 61
Stiffness 60

21. Current Knowledge About Pharmacotherapies
‘Off label’
SNRIs
Anticonvulsants
Tricyclic antidepressants (TCAs)
Muscle relaxants
SSRIs
Opioids
Nonsteroidal anti- inflammatory drugs (NSAIDs) and
Cyclo-oxygenase (COX2) inhibitors
FDA ‘approved’
Pregabalin(Lyrica)
Duloxetine Hydrochloride (Cymbalta)
Milnacipran Hydrochloride(Savella)

22. Duloxetine Hydrochloride (Cymbalta) Milnacipran Hydrochloride
Pregabalin
(Lyrica)
Duloxetine Hydrochloride (Cymbalta)
Milnacipran Hydrochloride
(Savella)
Alpha2 receptor
SNRI
mg bid
75 mg bid
May increase to 150 mg bid within 1 wk
Maximum dose 225 mg bid
60 mg/d
Start 30 mg/d for 1 wk, increase to 60 mg/d
50 mg bid (start 12.5 mg/d, increase on day 2 to 12.5 mg bid,
on day 4 to 25 mg bid, after day 7 to 50 mg bid) Maximum dose 200 mg/d
Angioedema, hypersensitivity
reactions, peripheral edema
Suicidality, orthostatic hypotension, serotonin syndrome
Dizziness, somnolence, dry mouth, edema, blurred vision, weight gain, difficulty with concentration/attention
Nausea, dry mouth, constipation,
somnolence, hyperhidrosis,
decreased appetite
Nausea, headache, constipation,
dizziness, insomnia, hot flush, hyperhidrosis, vomiting, palpitations,
heart rate increase, dry
mouth, hypertension