1. FIBROMYALGIA Rosamund Vallings MB BS

2. FIBROMYALGIA Is it a symptom or a disease? CENTRAL SENSITISATION SYNDROME

3. Tired and achy all the time

4. Fatigue/Pain The commonest symptoms seen in general practice

5. FATIGUE Common symptom in GP consultation Normal fatigue Disease related fatigue: acute or chronic Fatigue in CFS/FM: – Unrelieved by rest – Worsened by exercise – Delayed recovery

6. What is CFS?

7. CFS/FM Most people with CFS have FM Most people with FM have chronic fatigue Common features: – Myalgia – Headaches – Generalised pain – Sleep disorder – Cognitive difficulties

8. PREDISPOSING FACTORS GENETIC VIRAL STRESS: Physical/Mental SLEEP DEFICIT SEX PERSONALITY OVEREXERCISE/INJURY

9. Who gets CFS/FM

10. IMMUNOLOGICAL CHANGES INCREASED CYTOKINES (Klimas) DECREASED NK CELLS (Klimas) ABNORMAL R-NaseL (Suhadolnik) Raised NPY (Fletcher) etc

11. Associated Conditions Irritable bowel syndrome Irritable bladder Migraine Endometriosis Orthostatic intolerance Hypersensitivity/allergies ?Autoimmune

12. ORTHOSTATIC INTOLERANCE LOW BLOOD VOLUME (Bell) LOW BP (Rowe) POOR BRAIN PERFUSION (Mena, Kuratsune) PALPITATIONS Symptoms: postural dizziness brain fog cold extremities bloatedness

13. DIAGNOSIS OF FM EXCLUSION OF OTHER DISORDERS ASSOCIATION WITH OTHER ILLNESS (eg IBS,CFS,PPS,SLE,LYME etc) STAND ALONE CONDITION CHRONIC PAIN SYNDROME VALIDITY OF PRESSURE POINTS

14. PAIN History(M Fitzgerald) Genetic predisposition Pain is a CNS problem (microglia) Background of trauma Neonates Bad experiences associated with pain Conditioning (original site reactivation)

15. Diagnostic Criteria FM A. Widespread pain in all four quadrants of the body, for a minimum of three months B. At least 11 of the 18 specified tender points

17. Laboratory Findings in CFS/FM Typically normal except for… – Immune abnormalities – Atypical lymphs – Autoantibodies Anti-nuclear (ANA) Thyroid Komaroff et alia, Arch IM, 155, Jan 1995

18. MANAGEMENT CORRECT DIAGNOSIS ACKNOWLEDGEMENT/SUPPORT EDUCATION LIFESTYLE

19. GENERAL MEASURES Stress management Gentle exercise (breathing, sunshine) Diet (salt, frequency, balance) Supplements (B12, Mg, CoQ10, omega 3) Hormones Sleep management Pain management

20. CBT/Psychotherapy Useful for stress management Understanding of sleep disorder Change in negative thinking A focus on what is possible

21. Relaxation strategies Music Physical relaxation/deep breathing Creative visualisation Meditation Prayer Self hypnosis

22. EXERCISE NONE LEADS TO POOR OUTCOME TOO MUCH LEADS TO RELAPSE NEEDS TO BE REGULAR/OUTSIDE START AT LOW LEVEL (?lie down) LITTLE and OFTEN PREPARATION and REST BUILD SLOWLY AVOID CRASH and BURN

23. NUTRITION BALANCED DIET/VARIETY SMALL REGULAR MEALS MINIMISE ALCOHOL, CAFFEINE AVOID RICH FATTY FOODS PLENTIFUL FLUIDS (not excess) SALT/potassium SUNSHINE

24. SUPPLEMENTS BETTER ABSORBED VIA FOOD DEFICIENCIES IN BLOOD DEFICIENCIES IN DIET TREATMENT OF CONDITION POSSIBILITIES: OMEGA 3/OMEGA 6 OILS B VITAMINS (B12 INJECTIONS) MAGNESIUM (MALIC ACID) COENZYME Q-10 D-RIBOSE AVOID VIT C EXCESS

25. Sleep Sleep is our natural restorative phase Sleep restores, replenishes and heals Stress, pain etc lead to disturbed sleep FM, CFS lead to loss of sleep quality Until sleep is corrected nothing will come right

27. Levels of Sleep Deep level 4 sleep needed for restoration of body, healing, hormone release etc REM sleep required for restoration of brain, memory, etc - associated with dreams. Body functions continue and use energy

28. Causes of abnormal sleep Illness – acute/chronic Anxiety/depression Environmental Body clock disturbances Hormonal Drugs/caffeine/alcohol Sleep disorders Bad habit PAIN

29. Management of Sleep Lifestyle Sleep hygiene Treatment of underlying disorders Relaxation strategies Sleep deprivation CBT/psychotherapy Herbal preparations Medication

31. Herbal Preparations Tend to be mild in effect Maybe useful for physical symptom control Valerian Kava 5HTP Lavender Herbal may not mean “natural” Watch costs/charlatans NB Magnetic mattresses

32. Medication Benzodiazepines Muscle relaxants Tricyclics Antihistamines Melatonin Gabapentin Antipsychotics Stimulants

33. Restless legs/cramps Supplements – magnesium, calcium, salt Relaxation ?Co enzyme Q10 Quinine Ropinarole

34. Pain Pain is exhausting Pain creates stress Pain disturbs sleep Pain in FM resistant to normal treatments Central sensitization

35. Kids’ website http://faculty.washington.edu/chudler/pain.html

36. Management of Fibropain Non-pharmacologic – Aerobic exercise – Cognitive therapy (CBT) – Physical therapy – Acupuncture – Biofeedback – Balneotherapy – Hypnotherapy – Massage Pharmacologic – Sleep – Antidepressants – Analgesics – Antiepileptics – Naltrexone – Hormones

37. Realistic Goals Complete pain relief is rarely achieved Common goals include: – Pain reduction – Improvement in functional ability – Improved concentration – Improved mood – Improved sleep

38. ONGOING ISSUES Surveillance Report new symptoms Multidisciplinary team Future research Avoidance of relapse Balanced lifestyle

39. BALANCE

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