Fibromyalgia : What Primary Care Providers Need to Know Learning - PDF document

Fibromyalgia : What Primary Care Providers Need to Know Learning Objectives  Evaluate a patient with fibromyalgia complaints using the American College of Rheumatology (ACR) Fibrom yalgia: Diagnostic Criteria W hat Prim ary Care Providers  Construct a comprehensive and effective treatment Need to Know plan for the patient with fibromyalgia taking into account current FDA approved medications and non- Susan Hutchinson, MD Director, Orange County Migraine & Headache Center pharmacologic intervention strategies Volunteer Clinical Faculty, UC I rvine Department of Family Medicine I rvine, CA Fibrom yalgia: A Controversial Diagnosis The Mystery & Burden of Fibrom yalgia Delay in Diagnosis The Burden of Fibrom yalgia  On average, takes 5 years for diagnosis 1  FM patients’ average annual direct healthcare costs $9,573*  Only 1 out of every 4 patients with fibromyalgia (FM) are diagnosed accurately 1  Indirect costs include the effect on work, relationships, physical, and emotional health  FM patients visit their HCP’s 2 times as much as non-FM prior to diagnosis 2  FM patients receive an average of 11 prescriptions in the year prior to diagnosis compared to 4.5 in the control group* 1 Arnold LM, et al. Mayo Clin Proc . 2011;86:457-464. 2 Berger A, et al. Int J Clin Pract . 2007;61:1498-1508. *Berger A, et al. Int J Clin Pract . 2007;61:1498-1508. 1

Fibromyalgia: What Primary Care Providers Need to Know Prevalence  Fibromyalgia - one of most common, chronic, widespread pain conditions in US How Com m on is  Affects 2%-5% of adult population in US Fibrom yalgia? (5-10 million Americans)  Prevalence in women 3.4%  Prevalence in men .5% Wolfe F, et al. Arthritis Rheum . 1995;38:19-28. National Fibromyalgia & Chronic Pain Association. What is Fibromyalgia? http://www.fmcpaware.org/fibromyalgia/prevalence.html Dem ographics  Age of onset 35-55 years  Prevalence increases with age, reaching 7%-8% in women age 60-80 Patient Video  50% patients no precipitating event Susanne  50% attribute to physical or emotional trauma or an infection (Lyme disease or often nonspecific viral infections) Goldenberg DL. Clinical Management of Fibromyalgia. 1 st Edition. West Ipslip, NY: Professional Communications, Inc.;2009. Fibrom yalgia - General Definition  Chronic widespread pain and fatigue  Pain is predominately described in muscles  Joint swelling does not occur unless other conditions Diagnosis such as RA or OA are present  Must be present for at least 3 months  History and examination are keys to diagnosis RA, rheumatoid arthritis, OA, osteoarthritis 2

Fibromyalgia: What Primary Care Providers Need to Know Blood W ork for Fibrom yalgia History  ESR or CRP  How and when symptoms began  CBC  Assess level of disability  Thyroid function  Ask about mood, sleep, stress  Review medications  In select cases: Liver function tests, CPK, ANA, RF  Exercise & lifestyle questions  Key Point: ESR or CRP should be normal in FM patient unless another condition co-exists  Current treatment including non-pharmacological Com m on Com orbid Conditions  Depression  Migraine/Tension headaches  Sleep disorders Patient Video  IBS Susanne  Temporomandibular joint disorder  Interstitial cystitis/ chronic prostatitis  Idiopathic low back pain ACR 1 9 9 0 Diagnostic Criteria Physical Exam ination  Chronic widespread pain ≥ 3 months  Tender-point examination of the nine pair of tender points used for ACR Criteria of FM  Pain is bilateral and both above and below waist  Use pressure of 4 kg/cm 2 or enough to whiten examiner’s  At least 11 out of 18 tender points on exam fingernail; apply pressure gradually using finger or thumb; endpoint is pain; compare with joint tenderness  Control locations include thumb, mid forearm or forehead (palpate in same fashion; FM patients should not be as tender in these locations) Wolfe F, et al. Arthritis Rheum . 1990;33:160-172. 3

Fibromyalgia: What Primary Care Providers Need to Know Tender-Point Exam ination 1. Insertion suboccipital muscle 2. Under the lower sternomastoid muscle 3. Mid upper trapezius muscle 4. Second costochrondal junction 5. Origin supraspinatus muscle 6. 2 cm distal lateral epicondyle 7. Upper outer quadrant buttock 8. Prominence of greater trochanter 9. Medial fat pad of knee W hat Do Tender Points Represent?  Heightened pain perception as opposed to areas of tissue damage  Dysfunctional sensory processing in the CNS involving Patient Video both ascending and descending pain pathways has Susanne been shown to occur in studies of FM resulting in “central amplification” of pain signals Alternatives to ACR Tender-Point ACR 2 0 1 0 Prelim inary Diagnostic Exam ination for Diagnosis Criteria for Fibrom yalgia*  CWP ≥ 3 months and a patient-completed pain diagram 1  Presentation of widespread pain and symptoms for ≥ 3 months  CWP ≥ 3 months and Symptom Criteria (at least 4 out of the following 6): 2  Calculation of Widespread Pain Index (WPI) by HCP 1. Generalized fatigue  Measurement of Symptom Severity (fatigue, waking 2. Headaches unrefreshed, cognitive, and other somatic symptoms) 3. Sleep disturbance 4. Neuropsychiatric complaints  Can be used to diagnose and track progress 5. Numbness or tingling sensations 6. Irritable bowel 1 Katz RS, et al. Arthritis Rheum . 2006;54:169-176. 2 Hudson JI, et al. Baillieres Clin Rheumatol . 1994;8:839-856. CWP, Chronic Widespread Pain *www.FibroKnowledge.com. Accessed June 2, 2015. 4

Fibromyalgia: What Primary Care Providers Need to Know Wolfe F, et al. Arthritis Wolfe F, et al. Arthritis Care Res . 2010;62:600-610. Care Res . 2010;62:600-610. Wolfe F, et al. Arthritis Wolfe F, et al. Arthritis Care Res . 2010;62:600-610. Care Res . 2010;62:600-610. Assessm ent of Sym ptom Severity  Revised Fibromyalgia Impact Questionnaire (FIQR) 1  Modified Visual Analogue Scale of the Fibromyalgia Impact Questionnaire (mVASFIQ) 2  Numeric Rating Scales for Symptoms and Function in Fibromyalgia  ACR Preliminary Diagnostic Criteria for Fibromyalgia 3 1 Bennett RM, et al. Arthritis Res Therap . 2009;R120. 2 Boomershine C, et al. Nat Rev Rheum . 2009;5:191-199. Bennett RM, et al. 3 Wolfe et al. Arthritis Care Res . 2010;62:600-610. Arthritis Res Therap . 2009;R120. 5

Fibromyalgia: What Primary Care Providers Need to Know Boomershine C, et al. Nat Rev Rheum . 2009;5:191-199. Diagnosis Sum m ary Diagnosis Sum m ary  The American College of Rheumatology (ACR)  ACR Provisional Diagnostic Criteria were adopted in published classification criteria for Fibromyalgia in 1990 2010 and eliminate the need for tender-point and includes a history of chronic widespread pain for examination for the diagnosis ≥ 3 months and the physical finding of at least 11 of 18  Criteria include calculation of the patient’s widespread tender points. These criteria can be applied to help pain index (WPI) and Symptom Severity Scale diagnose FM in a busy primary care setting  Can be used to diagnose and track progress of the FM patient in clinical practice  Available on www.FibroKnowledge.com Treatm ent of FM - 4 Core Principles 1. Explain the condition 2. Set treatment goals in collaboration with the patient Treatm ent 3. Implement a comprehensive, multimodal treatment approach 4. Track progress (physical, social, emotional/cognitive, work/activity) Arnold LM, et al. Mayo Clin Proc . 2012;87:488-496. 6

Fibromyalgia: What Primary Care Providers Need to Know Explain the Condition Patient Education Tools  Chronic medical condition  National Fibromyalgia Association  Cannot be cured, but can be treated  www.fmaware.org  National Fibromyalgia Research Association  Set realistic expectations  www.nfra.net  Patient must be an active participant in his/her care including taking responsibility for lifestyle changes and  Fibrocenter adhering to a treatment plan  www.fibrocenter.com  Informational brochures and handouts Professional Resources Treatm ent Goals  Assess impact of FM across multiple domains of a  FibroKnowledge patient’s life  www.FibroKnowledge.com  Focus treatment on areas of most concern to the patient  Information on diagnosis including both the 1990 and 2010 ACR criteria, treatment, patient resources  Prioritization and goal-setting critical to avoid being too aggressive, falling short of meeting goals, and frustration for patient and provider Dom ains Affected by FM* Treatm ent Team for FM Patient  Patient Domain Impact  Family Physical Pain, Fatigue, Disturbed Sleep  Primary Care Provider Loss of career/reduced work hours Work/Activity Reduced activities of daily living  Specialists when appropriate Avoidance exercise/physical activity Disrupted family and friend relationships  Mid-level professionals Social Missed social/family outings Social isolation  Allied health professionals Depression, Anxiety Cognitive impairment (“fibro pain”) Emotional/Cognitive  Community resources Memory problems *Adapted from: Arnold LM, et al. Patient Educ Couns . 2008;73:114-120. 7