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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.

19 19 POINTS OF TENDERNESS

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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