Fibromyalgia- the rheumatology perspective. Toby Garrood Consultant Rheumatologist Guy s and St Thomas NHS Foundation Trust
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1 Fibromyalgia- the rheumatology perspective Toby Garrood Consultant Rheumatologist Guy s and St Thomas NHS Foundation Trust
2 No-one has fibromyalgia until it is diagnosed..chronic pain remains chronic pain until a doctor diagnoses fibromyalgia. Then support and advocacy groups aggravate the problem, disability is certified, a hopeless prognosis is offered; and in sophisticated societies some antecedent event is blamed The sooner we abandon the diagnosis, fibromyalgia, disband the patient advocacy organizations, and stop the irresponsible publications, the better we serve the public Ehrlich 2003
3 ..typical treatment acts overlook the compromised coping that causes patients to seek care in the first place.applying neologic diagnostic labels that are but reiterations of the presenting symptoms. All the while the treatment act is plying the patient with intimations as to the pathophysiology of their nociception. That is how a person with persistent widespread pain learns to be a patient with fibromyalgia. Hadler 2003
4 But Patients are seeking our help In distress Not malingering Diagnosis is a useful tool to acknowledge need for treatment Is there a danger in framing a narrow group of symptoms? Does diagnosis encourage adoption of sick role?
5 Regional pain Chronic widespread pain Fibromyalgia
6 Depression Widespread pain Anxiety Allodynia Poor sleep Fibromyalgia Cognitive symptoms Fatigue Poorly refreshing sleep Somatic symptoms
7 Depression Widespread pain Anxiety Allodynia Poor sleep Fibromyalgia Cognitive symptoms Fatigue Poorly refreshing sleep Somatic symptoms
8 Depression Widespread pain Anxiety Allodynia Poor sleep Fibromyalgia Cognitive symptoms Fatigue Poorly refreshing sleep Somatic symptoms
9 Depression Widespread pain Anxiety Allodynia Poor sleep Fibromyalgia Cognitive symptoms Fatigue Poorly refreshing sleep Somatic symptoms
10 Depression Widespread pain Anxiety Allodynia Poor sleep Fibromyalgia Cognitive symptoms Fatigue Poorly refreshing sleep Somatic symptoms
11 Risk factors? Healthy Widespread pain Fibromyalgia
12 Risk factors Poor sleep Psychological distress Physical trauma RTAs Lifestyle Obesity, low physical exercise Family history Physical/sexual abuse
13 Childhood events and CWP Hospitalisation following RTA (OR 1.5) Institutional care (1.7) Maternal death (2.0) Financial hardship (1.6) Jones 2009
14 Red flags? Psychological distress Frequent attendance Work disability
15 Diagnosis-dilemmas and pitfalls Early diagnosis vital But not too early No specific test Repeated referral/investigation. To refer or not to refer? Secondary care does not always take holistic view May only answer specific questions Are diagnostic/classification criteria helpful? Are investigations helpful?
16 Diagnosis Clinical judgement Exclude co-morbidities Traditional definitions unhelpful Classification criteria restrictive
17 Prevalence of anxiety
18 Prevalence of depression
19 Widespread pain index (WPI) Shoulder girdle (L) Shoulder girdle (R) Upper arm (L) Upper arm (R) Lower arm (L) Lower arm (R) Hip (buttock, trochanter) (L) Hip (buttock, trochanter) (R) Upper leg (L) Upper leg (R) Lower leg (L) Lower leg (R) Jaw (L) Jaw (R) Chest Abdomen Upper back Lower back Neck Score (0-19) Score (1 for each tick) ACR preliminary diagnostic criteria 2010 Symptom severity score (SSS) Fatigue Waking unrefreshed Cognitive symptoms Number of somatic symptoms Score Total (0-12) No problem No problem No problem No problem Mild Moderate Severe Mild Moderate Severe Mild Moderate Severe Mild Moderate Severe Criteria 1-3 are required for the diagnosis of fibromyalgia syndrome. 1. Either WPI >7 and SSS >5, or WPI 3-6 and SSS >9 2. Symptoms present at a similar level for > 3 months 3. No alternative explanation for the pain Wolfe 2010
20 Are investigations helpful? Limited investigations useful Inflammatory markers Avoid immunology unless specific indication XRs unlikely to be helpful Psychological screening Vitamin D?
21 Is diagnosis useful? Descriptive rather than pathophysiological Provides explanation for disparate symptoms Draws a line under need for further referral/ investigation Helps to focus treatment Hughes 2006
22 What is the role of rheumatology? Confirm diagnosis Find/treat co-morbid musculoskeletal conditions Draw a line under investigation/referral Management plan Is hypermobility relevant?
23 Management Medication Adjunctive Avoid strong opiates Physiotherapy/exercise Psychological Other
24 Medication Patients often intolerant of multiple drugs Do not use in isolation Antidepressants Tricyclics Amitryptiline SSRIs SNRIs Duloxetine Calcium channel modulators Gabapentin/pregabalin
25 Pain efficacy Amitryiptiline Pregabalin Milnacipran Duloxetine Mian and Garrood 2013
26 Locus of control
27 Treatment-exercise Post-exertional fatigue Aerobic exercise Light-moderate intensity Land or pool-based Graded approach minutes, 2-3x/wk Effective for multiple symptom domains High attrition rate in clinical trials Hassett 2011 Hauser 2010
28 Treatment-CBT Behavioural therapy E.g. avoidance Cognitive therapy Thoughts, beliefs, expectations Approaches Self-directed Web-based Group Individual
29 Treatment-other
30 Nuesch 2012 Which is better?
31 Future directions Earlier intervention Optimal CBT approaches Multicomponent therapy Medication Novel agents Combination therapy Personalised medicine
32 Summary Fibromyalgia is a complex multi-symptom condition Early recognition is important Often best managed in primary care Secondary care referral can help to clarify diagnosis and treatment plan Requires multidisciplinary assessment and treatment
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