Fibromyalgia K. Mukhida Department of Anesthesiology, Pain - PowerPoint PPT Presentation

Fibromyalgia K. Mukhida Department of Anesthesiology, Pain Management and Perioperative Medicine Dalhousie University February 2019

Disclosures • None

Objectives At the end of this session you will be able to: • Assess a patient with CWP and know the diagnostic criteria for fibromyalgia • Come up with a differential diagnosis for CWP • Come up with management options for the patient with fibromyalgia

• Nociceptive: damage (trauma, inflammation) • Neuropathic: nerves • Centralized: neuronal dysregulation, overactive pain pathways, deficiency of descending inhibitory pain pathways Hauser W and Fitzcharles M-A (2018). Dialogues Clin Neurosci 20: 53-61. Atzeni F et al. (2017). Expert Opinion on Emerging Drugs 22: 357-367.

CL is a 56 year old woman who is new to your practice. She tells you that she is coming to see you because she has pain “all over.”

History PMH FMH Social Physical examination Investigations

Arnold LM et al. (2018). The Journal of Pain https://doi.org/10.1016/j.pain.2018.10.008.

PAIN FATIGUE SLEEP DISTURBANCES COGNITIVE PROBLEMS

Clauw DJ (2014). JAMA 311: 1547-1555.

• Widespread pain index: at least 7 AND Symptom severity score: at least 5 OR WPI 4-6 AND SSS over 9 • Diagnosis is valid irrespective of other diagnoses Wolfe F et al. (2016). Seminars in Arthritis and Rheumatism 46: 319-329.

What is in your differential diagnosis for CL’s pain?

Inflammatory rheumatic diseases Nonrheumatic msk conditions Nonrheumatic medical conditions Neurological conditions Mental health disorders Medication-induced pain conditions Hauser W et al. (2018). Pain Reports e958.

Inflammatory rheumatic diseases Symptoms: joint swelling Examples: SLE, RA, Sjogren, scleroderma, inflammatory polyarthritis, PMR, inflammatory spondyloarthritis Red flags: FHx, am stiffness > 1 hr, severe constitutional symptoms Hauser W et al. (2018). Pain Reports e958.

Inflammatory rheumatic diseases Nonrheumatic msk conditions Symptoms: trigger points Examples: myofascial pain syndrome, CTDs Red flags: pronounced neck and shoulders Hauser W et al. (2018). Pain Reports e958.

Inflammatory rheumatic diseases Nonrheumatic msk conditions Nonrheumatic medical conditions Endocrine / metabolic: hypothyroidism, hyperparathyroidism, acromegaly GI: celiac disease ID: Lyme disease, hepatitis C, HIV Hauser W et al. (2018). Pain Reports e958.

Inflammatory rheumatic diseases Nonrheumatic msk conditions Nonrheumatic medical conditions Neurological conditions Examples: MS, PD, peripheral neuropathies, myelopathy, myopathies Hauser W et al. (2018). Pain Reports e958.

Medication-induced pain conditions Statins Opioids Chemotherapy Aromatase inhibitors bisphosphonates Hauser W et al. (2018). Pain Reports e958.

P P * Physical Pharmacological P P Pins Psychological

• Exercise • Meditative movement therapies • Dance Arnold LM & Clauw DJ (2017). Postgraduate Medicine 129: 709-714. Bidonde J et al. (2017). Cochrane Database of Systematic Reviews 6: CD012700. Gota CE (2018). Cleveland Clinic Journal of Medicine 85: 367-376. Honda Y et al. (2018). Pain Research & Management https://doi.org/10.1155/2018/2930632. Murillo-García et al. (2018). Evidence-based Complementary and Alternative Medicine 8709748. Sosa-Reina MD et al. (2017). BioMed Research International 2356346. Sawynok J & Lynch M (2017). Medicines 4: 37.

Overview of recommended treatment strategies: Pharmacological management Level of evidence Strength of recommendation Amitriptyline 1 (weak for) A Anticonvulsants 1 (weak for) A Muscle relaxant - - SNRIs 1 (weak for) A SSRIs 1 (weak for) A multicomponent therapy 5 D Arnold LM & Clauw DJ (2017). Postgraduate Medicine 129: 709-714. Fitzcharles MA et al. (2012). Pain Research and Management 18: 119-126. Macfarlane GJ et al. (2017). Annals of Rheumatologic Disease 76: 318-328.

• Not responsive to injections

• CBT Aman MM et al. (2018). Current Pain and Headache Reports 22: 33. Bernardy K et al. (2017). European Journal of Pain 22: 242-260. Bernardy K et al. (2018). European Journal of Pain doi: 10.1002/ejp.1284. Mehta S et al. (2018). Journal of Behavioral Medicine https://doi.org/10/1007/s10865-018-9984-x

Overview of recommended treatment strategies: Nonpharmacological management Level of evidence Strength of recommendation Aerobic exercise 1 (strong for) A Balneotherapy - - Cognitive behavioural therapy 1 (weak for) A Defined physical therapies 1 (weak for) A Meditative movement therapies 1 (weak for) A Mindfulness-based stress reduction - - Strengthening exercise 1 (strong for) A Arnold LM & Clauw DJ (2017). Postgraduate Medicine 129: 709-714. Fitzcharles MA et al. (2012). Pain Research and Management 18: 119-126. Macfarlane GJ et al. (2017). Annals of Rheumatologic Disease 76: 318-328.

Confirm diagnosis: - ID important symptom domains / level of function - Evaluate for comorbid medical / psychiatric disorders - Assess psychosocial stressors, level of fitness, barriers to treatment - Provide education about FM Recommend individualized treatment Pharmacological therapy: Nonpharmacological therapy: - CBT - Exercise Depression Sleep Partial response ⍺ 2d ligand - SNRI - monotherapy ⍺ 2d ligand +/- SNRI +/- TCA - Arnold LM & Clauw DJ (2017). Postgraduate Medicine 129: 709-714.