Malady Wise

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Fibromyalgia

References

Epidemiology

  • Common chronic widespread musculoskeletal pain

  • Women between 20 and 55 years

  • Prevalence 2 to 3 percent - increases with age

  • F>M = 6:1

  • Under diagnosed

  • Chronic widespread pain = 10 to 15% of population

Pathogenesis

  • Genetics

    • First degree relates = 8.5 more likely to have FM than relatives of patients with Rheumatoid Arthritis

    • Significant differences in alleles between FM and control

    • Serotonin and opioid pathways - SSRI SNRI improve symptoms

  • CNS altered pain processing

    • FM = greater than normal increases in perceived intensity of pain

    • Decreased endogenous analgesics

    • Changes in opioid receptors

    • Central hypersensitivity

  • Pathophysiologic Studies

    • FMRI = Greater neuronal uptake in pain processing pathways

    • Increased catastrophising

  • Brain morphology

    • Reduced total gray matter suggesting premature brain aging

  • Altered neurotransmitter function

    • Higher glutamine in posterior insula = lower pain thresholds

    • Deficits in GABAergic and Glutamergic mechanisms

    • Higher inositol in right amygdala and right thalamus

    • Low GABA in right insula

  • Sleep

    • Phasic alpha sleep

    • Suggestions that sleep disturbance precedes FM development

    • Study Norway Women = Sleep disturbance = RR 3.3 of developing FM

  • Stress HPAA

    • Correlation with cortisol and pain on waking in FM vs control

  • Peripheral Pain Mechanisms

    • Small fibre neuropathy

  • Immune Abnormalities

    • Different cytokines

    • Not pro or anti-inflammatory

Clinical

  • Fatigue

  • Cognitive Disturbance

  • Psychiatric symptoms

  • Somatic symptoms

Symptoms

  • Widespread MSK pain

  • Fatigue and sleep disturbance

    • Moderate to severe

    • Minor activities aggravate pain and fatigue

    • Prolonged inactivity heightens symptoms

    • Stiff in the morning

  • Sleep

    • Unrefreshed despite 8 to 10 hours

    • Sleep light

    • Wake frequently

    • Difficulty getting back to sleep

  • Cognition

    • Brain fog

    • Difficulty with attention and tasks requiring rapid thought change

  • Psychiatric

    • Anxiety / Depression in 30 to 50% of patients

    • 30% had a lifetime history of Bipolar, Panic Disorder or PTSD

  • Headache

    • 50% including migraine and TTH

  • Paraesthesia

    • Numbness, tingling, burning, creeping, crawling in both arms and legs

    • NCS usually normal

    • Sensation of leg oedema without objective findings = small fibre neuropathy

  • Other

    • Variety of poorly understood pain

      • Chest wall

      • Abdominal

      • IBS symptoms

      • Pelvic pain

      • Bladder pain and frequency

    • Reflux

    • Autonomic dysfunction

    • Dry eyes (1.4x more common in FM)

    • Raynaud’s Phenomenon

    • Orthostatic hypotension

    • Hearing loss (4-5x more reported in FM)

    • Weather changes may aggravate symptoms

    • Environmental hypersensitivity

      • Lights and sounds

Examination

  • Universal findings is tenderness

    • Often marked

    • Modest palpation

    • Multiple soft tissue sites

    • Particularly sites listed in ACT Classification Crtieria

  • Neuro exam can reveal minor sensory or motor abnormalities

Tests

  • No changes

  • FBC, ESR, CRP = normal

  • Some changes noted on functional MRI scans

  • Skin biopsy can show small-fibre neuropathy

Diagnosis

ACR - Preliminary Diagnostic Crtieria for FM - 2010

Diagnostic criteria 2016

  • History

    • Widespread pain

    • > 3 months

    • Fatigue, sleep disturbances

    • Other symptoms such as cognitive disturbance, headaches, bowel irritability

  • Physical

    • Widesprad tenderness

    • Absence of joint swelling and inflammation

  • Investigations

    • Normal FBC, ESR, CRP

    • Normal CK + TFT if indicated

Differential

  • Inflammatory Arthritis

    • ANA, RF

  • Non-inflammatory arthritis

  • Localised pain syndromes

  • Thyroid disease

    • TFT

  • Inflammatory and metabolic myopathies

    • CK

  • Statin myopathy

  • Myalgias

  • Infections

    • HIV, Hep, Chik, Long COVID

  • Endocrine

    • Cushings’s

    • Addisons

  • Neuro

    • MS and MG

  • Myofascial pain syndrome

  • CRPS

Work up

  • FBC, ESR,CRP

Additional evaluation

  • Sleep study if history of OSA or RLS or PLMD

  • Work up psychiatric diagnoses

Co-existing Disorders

  • Functional Somatic Syndromes and Related Disorders

    • 30 to 70%

      • IBS

      • CFS

    • 20 to 50%

      • Migraines / TTH

      • Chronic bladder and pelvic pain syndromes

      • TMJ disorders

  • Psychiatric

    • Anxiety, Depression (50%)

    • PTSD

    • Personality disorder (13%)

    • Sexual dysfunction (50%)

    • Bipolar (15%)

  • Sleep Disorders

    • Sleep disturbances common

    • Non-specific stage 4 sleep disturbance

    • Lower sleep quality and sleep efficiency

    • OSA, RLS and PLMD

  • Inflammatory Arthritis

    • RA

    • SLE

    • Sjogren’s

    • OA

    • Psoriatic arthritis

Management

Individualised approach

  • Prominent symptoms including pain, fatigue, sleep, depression

  • Past experiencing with or contrindiciations to medications

  • Comorbid conditions

  • Levels of physical fitness and barriers to exercise

  • Social determinants

  • Finances

Explanation

  • No persistent tissue damage or infection

  • Central pain

    • Nociception (peripheral pain) can be caused by inflammation or tissue damage

    • Nociplastic (central pain) results from issue with processing pain signals in the brain and spine

    • Fibromyalgia is a central pain syndrome

      • Widespread hypersensitivity

      • Lower threshold to pain

      • Like a guitar amplifier exaggerating the sound of a normal guitar

    • Pain is bidirectional

      • Local pain can aggravate FM and vice versa

  • Realistic expectations

    • Discuss concrete, achievable, short and long-term goals

    • Goals related to meaningful tasks in patient’s lives

    • Goals that are measurable and important

    • e.g. Number of times per week they can do a particular activity

    • No drug cure or highly effective treatment

    • Multimodal approach to make incremental improves in life

    • Symptoms wax and wane

Goals of FM treatment

  • Reduce major symptoms

  • Increase self-efficacy

  • Tailored medication and non-medication strategies

  • Treat comorbid disorders

Initial treatment algo

Core non-drug treatments

  • Education

  • Psychological therapy

  • Increased activity and exercise

Education

  • Explanation

    • Central pain

    • Not inflammatory

    • Not damage

    • Limited role drugs

  • Treat co-morbid = Important

    • Bi-directional relationship

    • Pain > depression > pain

  • Sleep disturbance

    • Common

    • Sleep in a dark, quiet, cool room

    • Avoid stimulants

      • Blue light

      • Caffeine

      • Social media

      • Alcohol

    • Avoid adverse factors

      • Disruptive pets

      • Co-Sleepers

      • Medical conditions

Physical activity

  • Benefit from various forms of exercise

    • Cardiovascular training

    • Resistance training

    • Movement therapies such as Tai Chi

  • Exercise may increase physical function and restorative sleep

  • May improve pain and fatigue

  • Always include low-impact aerobic exercise

  • Individualise therapy

    • Current level of activity and tolerance

    • Co-morbid

  • Optimal cardiovascular fitness

    • 30 minutes of aerobic exercise three times a week

    • Patients may not achieve but encouraged to exercise regularly at what level they can

  • Most evidence

    • Low-impact aerobic exercise and strength training

Cognitive Therapy

  • CBT

  • Mindfulness-based stress reduction

  • Meditation and / or relaxation

Medication

  • Start when moderate to severe symptoms

    • TCA - Endep

    • SNRI - Cymbalta

    • Alpha-2-ligants - Pregabalin

Endep / Amitryptiline

  • Diffuse, widespread pain without major mood disturbance or sleep issues

  • Start at 5 to 10 taken 1 to 3 hours before bedtime

  • Increase by no more than 5mg every 2 weeks

  • Use the lowest dose possible, generally between 20 and 30mg

  • Continue lowest dose that achieves a response for at least 12 months

  • Can stay on indefinitely or wean

  • Side effects: anticholinergic effects (eg, dry mouth, constipation, urinary retention), central nervous system (CNS) depression (eg, drowsiness, confusion, fatigue), serotonin syndrome, cardiac conduction abnormalities, increased bleeding, hyponatremia, fluid retention, and weight gain.

  • Improvement in 25 to 45 % of patients

Cymbalta / Duloxetine

  • Severe fatigue and/or depression

  • Start at 20 to 30mg in the morning with food

  • Increase by 20mg every few weeks to 60mg daily as toelrated

  • Doses as low as 20 to 30mg can be effective

  • Side effects - Potential adverse effects of SNRIs include hepatotoxicity, bleeding, fragility fractures, hyponatremia, orthostatic hypotension, and serotonin syndrome. Patients may also experience withdrawal symptoms, such as fatigue, anxiety, and insomnia, either with gradual or abrupt discontinuation, usually within 1 to 10 days of stopping.

  • Improvement by reducing pain by 50%

  • Side effects lead to stopping medication in 12%

Pregabalin / Lyrica

  • Prominent sleep disturbance

  • Start at 25 to 50mg at bedtdime

  • Increase by 25mg to 50mg every 2 to 4 weeks

  • Up to 300 to 450mg daily in 1 or 2 divided doses as tolerated

  • Side effects - Potential adverse effects of pregabalin include CNS and respiratory depression, dizziness, blurred vision, peripheral oedema, weight gain, and suicidal ideation.

  • Effect - 10% reduction in pain

Medication efficacy

  • At best, modestly effective in less than 50 percent of patients

  • One study showed 50% of patient continued medication for more than 20% of the year

  • All were effective for pain

  • Similar effects for sleep, depression and fatigue

  • Endep most improvement QoL

Combination

  • Low dose Cymbalta AM = 30mg + Low dose Endep nocte = 10 to 20mg OR Lyrica at night

Other Medications

  • SSRI

  • Analgesia

  • NSAID

Low Dose Naltrexone

  • Thought to enhance endogenous opioid system

  • Options for 2nd or 3rd line option

Nutrition and Diet

  • BMI correlates with developing FM and severity of symptoms

  • Caloric restriction and weight loss may improve FM symptoms

  • Study of 123 obest FM patients, 12 weeks on 3500kJ diet,

    • Improvement in symptoms severity, pain and depression

    • Effect more noticable in those that lost 10% BW

    • Follow up study showed improvement by 3 weeks despite no weight loss

  • Some diets including plant based seem to improve symptoms

Other treatments

  • Acupuncture has been show to improve FM

  • Massage and manual therapy can help

  • TENS = mixed results

  • rTMS = possible reduction in depression and fatigue

Prognosis

  • Study of 500 patients in hospital setting

    • Pain, fatigue, sleep disturbance and depression were unchangedo ver 8 years

    • 2/3 reported working full time and FM only interfered modestly with their lives




PsA vs Fibro

Podcast - Link

Management

  • Address sleep patterns

    • Avoid screen time

    • Bedroom cool and dark and quiet

    • Medication

      • Amitryptiline

  • Aerobic exercise

    • Walking 15 to 30 minutes absolutely every day

    • Changes abnormal neural pathways that cause fibromyalgia

  • Stretching programs

  • Medication

    • Endep

    • SNRI / Cymbalta

      • Allows more NA / Serotonin

      • Suppresses pain pathways

    • No narcotics - make things worse

  • Physiotherapy

    • Stretching

    • Relaxation exercise

  • Psychologist

    • CBT

  • Stress reduction

  • Meditation