1. Fibromyalgia

2. Fibromyalgia What do you know about fibromyalgia? What do you know about fibromyalgia? Who gets it? Who gets it? What is the cause? What is the cause? What are the symptoms? What are the symptoms? How many of the tender sites can you identify? How many of the tender sites can you identify? How is it treated? How is it treated?

3. Who gets Fibromyalgia? Lack of good population based studies Lack of good population based studies Prevalence ~0.5 - 4% Prevalence ~0.5 - 4% 70 – 90% female 70 – 90% female 90% Caucasian 90% Caucasian Average age of onset = 30 – 55 yrs Average age of onset = 30 – 55 yrs Can start > 55 yrs old but usually due to underlying disease (infection, neoplasm etc) Can start > 55 yrs old but usually due to underlying disease (infection, neoplasm etc) Up to 30% of patients in gen med OPD Up to 30% of patients in gen med OPD

4. Prevalence of Fibromyalgia

5. Aetiology Unknown Unknown Reports of preceding illnesses: Reports of preceding illnesses: Viral (parvovirus, hep C) Viral (parvovirus, hep C) Lyme disease Lyme disease Physical trauma (whiplash injury) Physical trauma (whiplash injury) Emotional trauma Emotional trauma Localised pain disorder Localised pain disorder Drug withdrawal (glucocorticoids) Drug withdrawal (glucocorticoids)

6. Aetiology Pain amplification: Pain amplification: ? Sleep disturbance ? Sleep disturbance ? Disordered endorphin / enkephalin response in descending analgesic pathway (  serotonin) ? Disordered endorphin / enkephalin response in descending analgesic pathway (  serotonin)  Substance P in CSF  Substance P in CSF

7. Fibromyalgia – ACR Criteria for classification 1990 History - widespread pain at lease 3/12 History - widespread pain at lease 3/12 affecting both sides of body +above and below waist + axial skeletal pain Examination – Characteristic tender points Examination – Characteristic tender points Otherwise unremarkable Laboratory tests – all normal Laboratory tests – all normal

8. Tender Points 18 points (9 pairs) 18 points (9 pairs) >11/18 required for > 3 months >11/18 required for > 3 months Pressure = 4kg/cm 2 Pressure = 4kg/cm 2

9. Other symptoms often present or reported in history Morning stiffness Morning stiffness Fatigue Fatigue Sleep disturbance Sleep disturbance Depression Depression Anxiety Anxiety Headache Headache Parasthesia Parasthesia Impaired memory/concentration Impaired memory/concentration

10. Symptoms Fatigue: Fatigue: Worse in morning / on minimal exertion Worse in morning / on minimal exertion Due to disturbed sleep Due to disturbed sleep (cf inflammatory disorders in which fatigue is due to pro-inflammatory cytokines) (cf inflammatory disorders in which fatigue is due to pro-inflammatory cytokines) Paraesthesia: Paraesthesia: 50% 50% Assos with subjective weakness Assos with subjective weakness No neurological abnormalities No neurological abnormalities

11. Symptoms 50%: Subjective joint swelling 50%: Subjective joint swelling (no swelling on exam n ) 33%:Depression (50-70% PMH depression) 33%:Depression (50-70% PMH depression) 15%:Dry eyes & mouth 15%:Dry eyes & mouth 10%: Raynaud’s Phenomenon 10%: Raynaud’s Phenomenon Also:Migraine / Tension headache Also:Migraine / Tension headache Irritable bowel syndrome DysmenorrhoeaAnxiety

12. Differential Diagnosis

13. Concomitant Conditions

14. Management “Multidisciplinary Approach” Patient education Patient education Correction of sleep disturbance Correction of sleep disturbance Graded aerobic exercise Graded aerobic exercise Physical therapy / education Physical therapy / education Treatment of associated disorders Treatment of associated disorders Psychological behavioural councelling Psychological behavioural councelling

15. Education 1. FMS symptoms are real 2. There is no sinister underlying pathology 3. The patient has control over many components that may modulate the symptoms

16. Pain and sleep disturbance cycle Disease, illness, Sleep disturbance Insufficient, deep, non-REM sleep Life crisis, anxiety Functional disturbance, fatigue, widespread muscular pain and tenderness

17. Graded Exercise Improves muscle conditioning Improves muscle conditioning Interrupts feedback loop Interrupts feedback loop Can improve sleep Can improve sleep Releases endorphins Releases endorphins Needs to be sustainable (be a tortoise not a hare) Needs to be sustainable (be a tortoise not a hare) Aerobic / non-impact Aerobic / non-impact Physio can help design regime for patient Physio can help design regime for patient

18. Medications NSAID (Ibuprofen and Naproxen) of no benefit NSAID (Ibuprofen and Naproxen) of no benefit Prednisolone no benefit Prednisolone no benefit Amitriptyline and Cyclobenzaprine significantly better than placebo Amitriptyline and Cyclobenzaprine significantly better than placebo Amitriptyline 25 mg-50 mg benefit seen 25-45% patients Amitriptyline 25 mg-50 mg benefit seen 25-45% patients Fluoxetene comparable effect Amitriptyline single trial Fluoxetene comparable effect Amitriptyline single trial Fluoxetene plus Amitriptyline better than either alone single study Fluoxetene plus Amitriptyline better than either alone single study

19. Medications Amitriptyline Amitriptyline Taken at night (1 – 3 hrs before sleep) Taken at night (1 – 3 hrs before sleep) 10 – 25 mg initially increasing up to 100mg 10 – 25 mg initially increasing up to 100mg Onset of relief of symptoms suggests that the mechanism is not anti-depressant Onset of relief of symptoms suggests that the mechanism is not anti-depressant Fluoxetine Fluoxetine One study showed better results with 20mg od in conjunction with TCA than alone One study showed better results with 20mg od in conjunction with TCA than alone

20. Prognosis Tertiary care centres: Tertiary care centres: majority continue to experience symptoms despite therapy majority continue to experience symptoms despite therapy Community based study: Community based study: 25% asymptomatic and 25% improved after Rx 25% asymptomatic and 25% improved after Rx Better results with a sympathetic patient – physician relationship and organised approach to Rx Better results with a sympathetic patient – physician relationship and organised approach to Rx 25% of FMS pts in USA on disability allowance 25% of FMS pts in USA on disability allowance

21. Take-home messages 1. FMS is part of a spectrum of pain & fatigue disorders 2. Can occur as a secondary feature of chronic disease and make management decisions difficult (e.g RA) 3. Difficult to treat but better results with an organised sympathetic approach