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1 Dupuytren’s Contracture. 2  Fibrous tissue of the palmar fascia to shorten and thicken  Common in men older than 40 years; in persons of Northern.

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Presentation on theme: "1 Dupuytren’s Contracture. 2  Fibrous tissue of the palmar fascia to shorten and thicken  Common in men older than 40 years; in persons of Northern."— Presentation transcript:

1 1 Dupuytren’s Contracture

2 2  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 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 4 Fibromyalgia

5 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 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 7 Other Diagnoses/Associated  Myofascial pain syndrome,  Chronic fatigue syndrome, and  Hypothyroidism.

8 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 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 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 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 12 FIBROMYALGIA-Review Multi symptom condition

13 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 14 Patient-Reported Symptoms at Diagnosis of Fibromyalgia

15 15

16 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 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 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,  Use of a structured interview with questions about generalized fatigue, headache, sleep disturbance, neuropsychiatric complaints, numbness or tingling, and irritable bowel symptoms.


20 20 ?TREATMENT Eval Criteria SYMPTOMCRITICAL FOR EVAL% Pain100 Fatigue94 Patient global improvement 94 Multidimensional function86 Tenderness74 Sleep66 Health-related quality of life65 Dyscognition61 Stiffness60

21 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 22 Pregabalin (Lyrica) Duloxetine Hydrochloride (Cymbalta) Milnacipran Hydrochloride (Savella) Alpha2 receptorSNRI 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

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