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Fibromyalgia a n evolving concept Robert M. Bennett, MD, FACP, FRCP, MACR Professor of Medicine and Nursing Oregon Health & Science University.

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Presentation on theme: "Fibromyalgia a n evolving concept Robert M. Bennett, MD, FACP, FRCP, MACR Professor of Medicine and Nursing Oregon Health & Science University."— Presentation transcript:

1 Fibromyalgia a n evolving concept Robert M. Bennett, MD, FACP, FRCP, MACR Professor of Medicine and Nursing Oregon Health & Science University

2 Fibrositis is a misnomer for a very common form of non-articular rheumatism. The name implies an inflammatory process in fibro-connective tissue which has never been verified. 3O years ago: West J Med 134: , May 1981

3 Low back painOsteoarthritisFibromyalgiaGoutRheumatoid arthritis Fibromyalgia is the third commonest cause of chronic pain 1 Rooks DS. Curr Opin Rheumatol. 2007;19: Lawson K. Neuropsychiatr Dis Treat. 2008;4: Bennett RM, et al. BMC Musculoskelet Disord. 2007;8:27. 4 Lawrence RC, et al. Arthritis Rheum. 2008;58: Helmick CG, et al. Arthritis Rheum. 2008;58: Prevalence (%)

4 30 years ago the cause of fibromyalgia was a puzzle Thought to be mainly a disease of muscles

5 The First Reference to Fibrositis Published in the British Medical Journal in 1904 Postulated an inflammation of fibrous tissue between muscle bundles (hence fibrositis)

6 Histologic proof of Gowers hypothesis? Supported Gowers hypothesis regarding inflammation of fibrous tissue Stockman R. Edinburgh Medical Journal, 1904, 15:

7 The first textbook on fibrositis Llewellyn and Jones of Bath All unexplained symptoms were attributed to fibrositis (i.e. a wastebasket diagnosis)

8 Peripheral tissues Nerve impulses Understanding FM 1900 – 1930s A disorder of painful muscles

9 Histologic proof of Gowers hypothesis? Stockmans muscle histology could never be duplicated Stockman R. Edinburgh Medical Journal, 1904, 15:

10 Boland, Annals of the Rheumatic Diseases 1947;6: Psychogenic Rheumatism FM was considered to be a result of psychoneurosis

11 Its all in your head Unexplained symptoms are often still viewed as psychogenic in origin: Somatization Hypochondriasis Masked depression etc.

12 First Scientific Study in FM Moldofsky et al. Psychosomatic Med. 37: , 1975

13 Electroencephalogram (EEG) sleep stages Deep sleep Delta (1- 3cps) Awake/alert Alpha (8-12 cps)

14 Abnormal EEG in sleeping FM patients Fibromyalgia Alpha + delta EEG waves Sleep disruption in healthy subjects caused pain and fatigue

15 First study comparing fibromyalgia patients to healthy individuals Yunus et al. Seminars Arthritis and Rheumatism 1981, 11:

16 FM patients often have: Irritable bowel Irritable bladder Chronic fatigue Restless legs Dizziness Fibro-fog Cold intolerance Multiple sensitivities

17 Arthritis Rheum. 1990;33: American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia: Report of the Multicenter Criteria Committee F Wolfe, HA Smythe, MB Yunus, RM Bennett, C Bombardier, DL Goldenberg, P Tugwell, SM Campbell, M Abeles, and P Clark The ACR Classification Criteria In addition to defining FM, the name was changed from fibrositis to fibromyalgia

18 ACR defined fibromyalgia Widespread pain 11 of 18 tender points +

19 Publication of the ACR criteria led to an explosion of research in fibromyalgia National Library of Medicine references on fibromyalgia in 5-Year Increments

20 What has been found? Sensory impulses are amplified at level of spinal cord and brain in fibromyalgia patients Central sensitization

21 Evidence for central sensitization in FM 1.Hyperalgesia / allodynia 2.Elevated CSF levels of neurotransmitters 3.Temporal summation (wind-up) 4.Enhanced somatosensory potentials 5.Increased activity on fMRI and SPECT scans 6.Impaired DNIC 7.Response to centrally acting drugs

22 First nervous system study in FM Vaeroy et al. Pain 32:21-26, 1988 Found that the CSF of FM patients had elevated levels of substance P This finding focused attention on the nervous system, and away from muscle Lumbar puncture

23 Abnormal sensory processing in FM 1.Hyperalgesia / allodynia 2.Elevated CSF levels of neurotransmitters 3.Temporal summation 4.Enhanced somatosensory potentials 5.Increased activity on fMRI scans 6.Impaired DNIC 7.Response to centrally acting drugs

24 Functional Brain Imaging SPECT MRS PET f MRI

25 SPECT scan in FM patients at rest Increased brain activity in areas that are involved in pain processing Guedj E, European Journal of Nuclear and Molecular Imaging, 2007, 34:130-4.

26 Peripheral tissues Spinal cord Descending inhibition Brain Important new concept: the body has a mechanism for modulating pain This inhibitory pain system is dysfunctional in FM patients

27 PAG Spinal cord This pain dampening system originates in a brain area called the periaqueductal gray Activation of the PAG stimulates the pain inhibitory system

28 Understanding FM Peripheral tissues A disorder of sensory amplification

29 What are tender points Found that FM tender points had the typical features of myofascial trigger points

30 What are myofascial trigger points? There are several hundred myofascial trigger point locations in the body

31 Peripheral tissues Understanding FM present FM now thought to be a disorder of both peripheral pain generators and central sensitization This latest understanding of FM is crucial for planning effective treatment strategies

32 What causes fibromyalgia? Environmental insults Infections Trauma Prolonged stress PTSD Disordered sleep Alpha-delta sleep Sleep apnea Hereditary influences Genes (COMT, serotonin receptor) Epigenetics (changes in gene expression) Not just one gene but many

33 30 years ago the cause of fibromyalgia was a puzzle Thought to be mainly a disease of muscles

34 Environment Genes sensitization Central Pain generators 30 years later - some of the puzzle is now in place

35 Next speaker please

36 Welcome and orientation - Sharon Clark, PhD Fibromyalgia: An Evolving Concept - Robert M Bennett, MD Diagnosis and Mis-diagnosis - Atul Deodhar, MD Guided Stretch Break - Janice Holt Hoffman How Can I Help Myself? - Kim Dupree Jones, PhD How Can Medications Help Me? - Robert M Bennett, MD Roundtable: Questions and Answers - Drs Bennett, Deodhar and Jones, moderated by Dr Sharon Clark Fibromyalgia Information Foundation Spring Conference 2010

37 Diagnosis and Misdiagnosis Atul Deodhar MD, FACR, MRCP Associate Professor of Medicine Medical Director, Rheumatology Clinics Oregon Health & Science University

38 Why do you need a specialist? To make the correct diagnosis To rule out other causes of generalized pain To rule in common problems that go hand-in- hand with fibromyalgia (sleep apnea, restless legs, irritable bowel, depression etc) Fibromyalgia can co-exist with other rheumatic conditions and they shouldnt be missed either To develop a comprehensive treatment plan

39 How do I make the diagnosis of FM? History & Physical Examination is usually enough to make the diagnosis of fibromyalgia Blood tests & other investigations rule out other causes of generalized pain which may have different and effective treatments It is not since they could not find anything else on blood tests, they told me I have FM

40 How do I make the diagnosis of FM? FM patients usually have – Generalized Pain – Tenderness all over – Fatigue – Sleep disturbance – Depression/anxiety – Cognitive dysfunction – Irritable Bowel Syndrome FM patients usually do not have – Weight loss – Joint swelling as seen in rheumatoid arthritis – Major organ (kidney, heart, lungs, brain) dysfunction – Abnormal lab tests

41 Source: National Fibromyalgia Association Survey FM Symptoms

42 Do I have Lupus? Do I have MS? Autoimmune disease affecting multiple organs in a specific fashion – generalized tenderness but nothing else on examination is not lupus! Over-diagnosed with positive anti-nuclear antibody (ANA) test Autoimmune disease that presents with specific neurological deficits – true weakness, sensation loss, visual loss etc. Generalized tenderness but normal neurological examination is not MS!

43 My MRI scan showed Arthritis MRI scans are extremely sensitive and show all sorts of abnormalities which may or may not have any clinical relevance Everyone in this room has spurs, bulging discs, degenerative discs, and arthritis in the spine but not everyone has chronic back pain There is no direct correlation between what you find on the MRI scan and the generalized pain and tenderness as seen in FM

44 Take Home Message After the age of 30, completely normal MRI scan of the spine is as rare as hens teeth There is poor correlation between arthritis changes as seen on the MRI scan and patients symptoms

45 Other common causes of generalized pain Chronic hepatitis C Hypothyroidism, Hyperparathyroidism Metastatic cancer, Multiple myeloma Vitamin D Deficiency Polymyalgia rheumatica OA, RA, Sjögrens syndrome, SLE

46 ACR Classification Criteria for FM Widespread body pain – Pain on both left and right sides of the body – Pain above and below the waist – Axial pain present Pain persisting 3 months 11 of 18 tender points (painful to 4 kg pressure)

47 New ACR Diagnostic Criteria for Fibromyalgia Widespread Pain Index Shoulder girdle, L & R Upper arm L & R Lower arm L & R Hip buttock/trochanter L R Upper leg L & R Lower leg L & R Jaw L & R Chest Abdomen Upper back Lower back Neck Symptom Severity Scale (0-3) Cognitive symptoms Waking Un-refreshed Fatigue Does Pt have somatic symptoms? No symptoms Few symptoms Moderate number Great deal of symptoms 0 to 19 0 to 9 0 to 3 Wolfe F. et al. Arthritis care & Research 2010;62(5):600–610

48 New ACR Diagnostic Criteria for Fibromyalgia Patient can be Diagnosed as FM if they have: 1.Widespread pain index (WPI) 7 & symptom severity (SS) scale score 5 or WPI 3–6 and SS scale score 9 2.Symptoms have been present at a similar level for at least 3 months 3.The patient does not have a disorder that would otherwise explain the pain Wolfe F. et al. Arthritis care & Research 2010;62(5):600–610

49 Take Home Message Your doctor doesnt have to rule out other diseases to diagnose fibromyalgia Fibromyalgia can co-exist with other diseases such as lupus, rheumatoid arthritis etc. Be Aware: Once the diagnosis is made, there is a risk of blaming all symptoms on fibromyalgia

50 What else do I look for every time I see a patient with Fibromyalgia? Sleep disturbance: – Sleep Apnea Syndrome – Restless Leg Syndrome Depression/Anxiety/Stress Functional status, de-conditioning Irritable Bowel Syndrome I also look for signs & symptoms that do not fit

51 Case Report Helen H. is a frustrated 50 year old CEO of a small company who has been treated for fibromyalgia for the past 8 months. I just hate going to see the doctor. Im there for fibromyalgia and instead of focusing on my pain complaints, he makes me answer questions and fill out questionnaires asking about my mood, sleep, bowel habits, and headaches. Why doesnt he just ask about my fibromyalgia?

52 Was Helens doctor justified? FM evaluation includes assessment of pain and other conditions that occur frequently with FM Understanding the full symptom complex & its impact allows the doctor to develop an effective treatment plan Improvement may initially occur with non-pain symptoms e.g. sleep, mood etc Not utilizing non-pain conditions may result in missing the early treatment success & abandoning treatments that might eventually improve both pain & non-pain symptoms

53 Summary In expert hands, FM diagnosis is straight forward, and is based on history & examination Blood tests are not required to make the diagnosis, but they help rule out additional conditions with specific therapies Several other conditions can go hand-in-hand with FM, e.g. sleep, mood, bowel disturbances Be aware: New symptoms may or may not be related to FM: Dont hesitate to ask

54

55 20 minute break and stretching with Janice Hoffmam

56 Welcome and orientation - Sharon Clark, PhD Fibromyalgia: An Evolving Concept - Robert M Bennett, MD Diagnosis and Misdiagnosis - Atul Deodhar, MD Guided Stretch Break - Janice Holt Hoffman How Can I Help Myself? - Kim Dupree Jones, PhD How Can Medications Help Me? - Robert M Bennett, MD Roundtable: Questions and Answers - Drs Bennett, Deodhar and Jones, moderated by Dr Sharon Clark Fibromyalgia Information Foundation Spring Conference 2010

57 What Can I do for Myself? Kim Dupree Jones PhD, FNP-BC Associate Professor School of Nursing Oregon Health & Science University

58 1. Please select the most appropriate option Medications and surgery are the only effective treatments that help fibromyalgia? 1.True 2.False

59 2. Please select the most appropriate option The combination of medications, cognitive behavioral strategies, education, exercise, diet and physical therapy may be used to fully treat fibromyalgia. 1.True 2.False

60 Take Home Message To maximize benefit, treatments should match specific problems or symptoms. One size does not fit all

61 One Size Fits All Myth Ignoring individual differences Treating everyone the same Inconsistent results Providers may have little understanding of which treatments are worth your time

62 Non-pharmacological treatments for FM 024 essential oil Acupuncture Aquatic exercise (deep water running) Aerobic exercise Aloe vera Amitriptyline + Stanger bath Anthocyanidins Autogenic training Balneotherapy Biofeedback Bioresonance therapy CBT Chlorella Connective tissue manipulation + ultrasound Cryotherapy (whole body) Dance/movement therapy Delta wave sleep interruption Diet ECT Education EEG-driven stimulation Electroacupuncture Electromagnetic shielding fabric Feldenkrais Flexibility exercise Guided imagery Homeopathic vellum Hot packs Hydrogalvanic therapy Hyperbaric oxygen Hypnotherapy Laser therapy Light therapy Magnetized mattress Manipulation + ultrasound Marital counseling Massage Meditation Muscle vibration Neck support Omega-3 fatty acid Operant conditioning Peripheral neurostimulation Pool exercise + education Psychomotor therapy Qigong + mindful meditation Relaxation Stress management Stretching exercise Sulphur mud baths Tender point injections TENS Transcranial direct current stimulation Valerian bath Warm water exercise Written emotional expression CBT, cognitive behavioral therapy; ECT, electroconvulsive therapy; EEG, electroencephalogram; TENS, transcutaneous electrical nerve stimulation. 56 published studies

63 Exercise Jones KD & Lipton G. Exercise interventions in fibromyalgia: Clinical applications from the evidence. Rheumatic Disease Clinics of North America. 2009;35 (2), Top 10 Principles: 1.Treat peripheral pain generators to minimize central sensitization 2.Minimize eccentric muscle work 3.Choose low-intensity non-repetitive exercise 4.Recognize the importance of restorative sleep 5.Address obesity and deconditioning 6.Create fibromyalgia-friendly exercise environment 7.Be aware of balance/dizziness problems 8.Conserve energy in daily life 9. Reverse pain postures (stretch anterior chest/strengthen back) 10. Start low and go slow

64 What are Cognitive Behavioral Strategies? Hassett, AL & Gevirtz (2009) Nonpharmacologic treatment for fibromyalgia: patient education, cognitive-behavioral therapy, relaxation techniques and complementary and alternative medicine. Rheumatic Disease Clinics of North America.35 (2), Understanding Treatment Options/Self-Advocacy Time-based Pacing Fatigue Control Realistic Expectation/Boundary Setting Pleasant Activity Scheduling Decreasing Catastrophic Thinking & Distraction

65 Self-Management: Sleep Example Jones, K.D., Kindler, L.L. & Lipton, G. (in press). Self-management strategies in fibromyalgia. Journal of Clinical Outcomes Management. Lifestyle -Regular bed time/wake time - Get in bed when sleepy -Use bed for sleep -Ride the wave of pain -Caffeine in am only (remember meds) Thermal Tips - Lower core temp signals sleep - Exercise, warm bath before bed -Socks, moisture wicking PJs Environment - Steady room temperature -Keep room dark -Silicone ear plugs -No TV or computer -No guilt inducing exercise equipment -No bills/mail -Private room (no pets/spouses…)

66 Diet Holton, K.F., Kindler, L.L. & Jones, K.D., & (2009). Potential dietary links for central sensitization in fibromyalgia: past reports, future directions. Rheumatic Disease Clinics of North America.35 (2),

67 Eat More Fresh Food- Less Processed Foods Some food additives contribute to FM: MSG, aspartame and l-cystine: – most canned soups & stocks – most flavored potato chip products (tortilla chips v Doritos) – many other snack or processed foods including protein shakes – many frozen dinners including diet foods and diet drinks – almost all US-originated fast foods, salad dressings, marinades – boxed meals including a seasoning packet – Hydrolyzed protein, natural flavors/spices on food label – Look for short food labels with words you recognize (flour, oil, salt, sugar…) Kindler, L.L., Jones, K.D., & Holton, K. (2009). Potential dietary links for central sensitization in fibromyalgia: past reports, future directions. Rheumatic Disease Clinics of North America.35 (2),

68 Education & Self-Help REST The End of Stress as We Know It by Bruce McEwen Does Stress Damage the Brain? by Douglas Bremner The Relaxation and Stress Reduction Workbook by Martha Davis Managing Chronic Pain: A CBT Approach by John Otis 30 Scripts for Relaxation Imagery & Inner Healing by Julie T Lusk The Breathing Book, by Donna Farhi EDUCATION / EXERCISE Understanding Fitness How Exercise Fuels Health and Fights Disease by Kim Jones Full-Body Flexibility For Optimal Mobility and Strength by Jay Blahnik Fall Proof! A Comprehensive Balance & Mobility Training Program by Debra J Rose The 10 Best Questions for Living with Fibromyalgia by Dede Bonner Beginners Guide to TaiChi by Andrew Austin

69 Your experiences shared

70 Find Your New Baseline Individual differences requires individualized treatment: Adequate therapy of symptoms – Pain – Sleep disturbances – Depression/anxiety Education – Accessible explanation of pathophysiology Identifying and addressing your unique perpetuating factors Setting realistic objectives- Try one treatment at a time Van Houdenhove, Luyten. Psychosomatics. 2008;49(6): Fibromyalgia is something that you have, not who you are

71 Next speaker please

72 How can medications help me? Robert M. Bennett, MD, FACP, FRCP, MACR Professor of Medicine and Nursing at OHSU

73 HEALTH JOURNAL / By LEILA ABBOUD Staff Reporter of THE WALL STREET JOURNAL August 3,2004 Off-Label Treatments, New Drugs Target Mysterious, Debilitating Fibromyalgia Drug companies are racing to develop drugs for a highly debilitating disease that has confounded doctors and plagued patients for years. The disorder, called fibromyalgia, causes people to feel chronic pain all over their bodies and suffer from a constellation of symptoms, including sleep disturbances, fatigue and headaches. An estimated four to six million Americans have fibromyalgia. Women are seven times as likely as men to develop it. Despite the large number of people afflicted, because of the mysterious nature of the disease, there is currently no drug approved specifically to treat it.

74 Now there are 3 drugs that are FDA approved for the treatment of fibromyalgia

75 Crofford LJ. Curr Opin Rheumatol. 2008;20: Arnold LM, et al. Arthritis Rheum. 2004;50: Arnold LM, et al. Pain. 2005;119:5-15. FDA Approved Medications for Fibromyalgia

76 What does FDA approval mean? The drug has been thoroughly tested and is better than a placebo The adverse events are not generally very severe However, with wider use important adverse events may lead to its being withdrawn from the market As a generalization, the currently approved drugs for FM give about 30% relief of pain to about 30% of patients Approved medications are seldom tested against each other There is usually no evidence that FDA approved medications are any more efficacious than commonly used unapproved medications

77 Gabapentin (Neurontin) Anticonvulsant Should be used in divided doses TID for optimal effect: –Most will require mg/day –Start with lower dose, increase to minimize adverse events –Dizziness and somnolence may limit tolerability Amitriptyline and related compounds Antidepressants SNRIs Multiple actions increase adverse events: –Caution in the elderly and those with heart problems –Additional anticholinergic, antiadrenergic, antihistaminergic, and quinidine-like effects Fluoxetine (Prozac) Antidepressant SSRI More important effects on mood than on pain: –Higher doses may improve analgesic effects –More serotonin-selective agents have not been effective for relief of pain Tramadol (Ultram/Ultracet) Opioid + SNRI Useful dual action: –Usual dose 100 mg / bid –Is not a scheduled drug Crofford LJ. Curr Opin Rheumatol. 2008;20: Additional Pharmacotherapy Options (Off Label in USA)

78 What treatments do FM patients really use?

79 Intervention Effectiveness (0-10 scale) Use Prescription sleep medications6.5± 2.752% Prescription pain medications6.3±2.466% Resting6.3 ±2.586% Heat modalities (warm water, hot packs)6.3 ±2.374% Prescription antidepressants6.2±2.863% Massage/reflexology6.1 ±2.843% Pool therapy6.0 ±3.026% Stretching5.4 ±2.662% Non-aerobic exercise (stretching,yoga)5.1±2.924% Relaxation/meditation5.1 ±5.547% Chiropractic manipulation5.1 ±3.030% Aerobic exercise5.0±3.032% Trigger point injections5.0 ±3.321% NFA internet survey Interventions Bennett et al BMC Musculoskeletal Diseases 2007, 8:27

80 The most helpful drugs were all opioids NFA internet survey Medications

81 Rational use of medications is dependent on understanding mechanisms of their action

82 Neurophysiology of nerve impulse transmission ElectricalChemical Electrical

83 Inhibition of glutamate release Modulation of Glutamate Release Reduced output to brain Mechanism of action of anti-seizure medications

84 PAG Spinal cord The pain dampening system originates in a brain area called the periaqueductal gray and projects down to the spinal cord Activation of the PAG stimulates the pain inhibitory system

85 The inhibitory pain system acts at level of dorsal horn Impulses arise in nuclei of brainstem Reduced output to brain Serotonin and nor- epinephrine are main neurotransmitters From PAG Mechanism of action of antidepressant medications

86 Sleep Disturbance Moldofsky et al. Psychosomatic Med. 37: , 1975

87 Chronic Pain Disturbed sleep Disturbed Sleep Chicken or Egg?

88 PAG Dorsal horn Disturbed sleep promotes pain Disturbed sleep inhibits the activity of the PAG

89 Treating disturbed sleep Practice good sleep hygiene Be evaluated for sleep disorders Medications: Amitryptyline (Elavil) Cyclobenzaprine (Flexeril) Zolpidem (Ambien) Sodium oxybate (Xyrem)

90 Improvements in sleep and fatigue Also improvemed pain, stiffness and FIQ Currently under review by the FDA

91 Contemporary medications are of some help, but seldom reduce pain by more than 30% A basic reality

92 Peripheral tissues Understanding FM present FM now thought to be a disorder of peripheral pain generators and central sensitization

93 Pain Generators Osteoarthritis Inflammation Neuropathies Injuries Disc disorders Visceral pain Chronic headaches TMP syndromes Spinal stenosis Repetitive strain Endometriosis Myofascial pain The effective treatment of peripheral pain generators is an essential component of any fibromyalgia treatment plan

94 Drug side effects (Duloxetine) Arnold LM et al. (2005), Pain 119(1-3):5-15 Placebo (N=120) Duloxetine 60 mg bid (N=116) Duloxetine 60 mg qd (N=118) % of Patients Nausea * * * * Dry Mouth Constipation Diarrhea * Somnolence Decreased Appetite * Nasopharyngitis * Hyperhidrosis * Anorexia * * Feeling Jittery * Nervousness *

95 It must be all the herbal tea you are drinking Everything has side effects

96 N Engl J Med 2005;352: The serotonin syndrome is an adverse drug reaction that results from therapeutic drug use or inadvertent interactions between drugs Too much serotonin

97 Agitation or restlessness Nausea, vomiting and diarrhea Confusion, hallucinations Poor coordination Racing pulse Rapid changes in blood pressure Sweating Hyper-reactive reflexes Fever Seizures Coma Cause: excessive stimulation of serotonin receptors Serotonin syndrome Presentation:

98 SSRIs: citalopram (Celexa), fluoxetine (Prozac) SNRIs: duloxetine (Cymbalta), venlafaxine (Effexor) NDRIs: buproprion (Wellbutrin) MAOIs: isocarboxazid (Marplan) and phenelzine (Nardil) Analgesics: tramadol (Ultram), fentanyl (Sublimaze) Anti-migraine: sumatriptan (Imitrex) and zolmitriptan (Zomig) Anti-nausea: metoclopramide (Reglan) and ondansetron (Zofran) Bipolar: lithium (Lithobid) Cough: dextromethorphan (Robitussin DM) Herbal supplements: St. John's wort and ginseng Serotonin syndrome – implicated drugs In some patients combinations of the following drugs can lead to a serotonin syndrome: This risk depends on genetic make-up (CYP 450 genes)

99 The FDA-approved AmpliChip for analysis of CYP2D6 and CYP2C19, variants of CYP Extensive metabolizers. Can be administered drug in "standard dosages 2. Intermediate metabolizers. Multiple drug therapy can turn in people into poor metabolizers. 3. Poor metabolizers. May develop drug accumulation and adverse reactions 4. Ultrarapid metabolizers. May experience either no effect or less- than-expected effectiveness from their drug therapy Individualize drug dosing based on metabolic profiling of CYP variants

100 What about the placebo effect?

101 Week * * A typical result in a recent treatment trial (Duloxetine) Change from baseline in LS mean pain score Arnold LM et al. (2005), Pain 119(1-3):5-15 Placebo response Drug effect

102 The placebo effect is often maligned Take 2 placebos and call me in the morning Apparently your health insurance only covers placebos

103 The latest research has demonstrated the placebo effects physiology Compared the effects of an opioid and a placebo on activation of brain regions in an experimental model of pain

104 Placebo activation of PAG area Pain + opioid Pain alone Pain + placebo The placebo effect is due to activation of the descending pain system via the PAG A placebo can be the equivalent of taking oxycodone or a similar opioid drug

105 Practice activating your PAG My final piece of advice

106 2 minute stretch break

107 Welcome and orientation - Sharon Clark, PhD Fibromyalgia: An Evolving Concept - Robert M Bennett, MD Diagnosis and Misdiagnosis - Atul Deodhar, MD Guided Stretch Break - Janice Holt Hoffman How Can I Help Myself? - Kim Dupree Jones, PhD How Can Medications Help Me? - Robert M Bennett, MD Roundtable: Questions and Answers - Drs Bennett, Deodhar and Jones, moderated by Dr Sharon Clark Fibromyalgia Information Foundation Spring Conference 2010

108 Dr. Jones Is FM a form of depression?

109 Dr. Deodhar What else could it be?

110 Dr. Bennett Is FM inherited?

111 Dr. Jones Can FM be cured?

112 Dr. Deodhar What vitamins should I take?

113 Dr. Bennett Does the XMRV virus cause FM?

114 Dr. Jones Should I take pain killers?

115 Dr. Deodhar Should I move to Arizona?

116 Dr. Bennett Should I try muscle injections?

117 Dr. Jones Should I change jobs?

118 Dr. Deodhar Should I see a psychologist?

119 Dr. Bennett How should I prepare for surgery?

120 Dr. Jones Why do I hurt more when I exercise?

121 Dr. Deodhar What will happen to me?

122 Dr. Bennett What about drugs that are not FDA approved for fibromyalgia?

123 Thank you for attending this FIF conference These presentations are available on our website at:


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