1. FIBROMYALGIA Lisa Rose-Jones, MD April 27 th, 2010

2. Clinical Manifestations Cardinal complaint is diffuse musculoskeletal pain (may initially be localized) Often difficulty distinguishing joint vs. muscle pain Common to report swelling Fatigue reported in more than 90% cases Many pts report HA of the muscular or migraine-type Cognitive difficulty Mood Disturbances

3. Diagnosis (Via American College of Rheumatology Guidelines ) ~widespread Musculoskeletal pain ~excess tenderness in at least 11 of 18 predefined anatomic sites *Requiring both criteria results in 80% sens/specificity from distinguishing this from other chronic painful disorders

5. Proposed Pathophysiology Central Sensitization: Alteration in pain & sensory processing Pts sense discomfort from noxious stimuli at a lower level of physical stimulation than do healthy controls Endogenous analgesic systems appear to be thwarted, reduced brain habituation to somatosensory stimulation Reduction in opioid receptors in brain (narcotics less effective) ?genetic predisposition

6. Treatment 1 st discussing the diagnosis, REASSURANCE! Patient education can have a therapeutic effect www.NFA.com Cognitve Behavior Therapy Aerobic Exercise

7. MEDICATIONS ~recommended 1 st line is TCA like Amitriptyline (avoid if older patient) ~If sleep is an issue: try Pregabalin* qhs (or Gabapentin if $$ is an issue) ~if Fatigue is more prominent: Duloxtine* at breakfast ~Milnacipran (another SNRI) had had good results