FM correctin the misconceptions.LONG,Will help some seeking treat

Discussion in 'Fibromyalgia Main Forum' started by suzetal, Sep 15, 2006.

  1. suzetal

    suzetal New Member

    Don't know if this has been posted.I learned a lot reading it.

    Hope it might help others seeking treatment.

    Fibromyalgia: Correcting the Misconceptions

    Fibromyalgia syndrome (FMS) is the currently preferred term used to describe a musculoskeletal condition characterized by chronic widespread pain and diffuse tenderness.

    According to the American College of Rheumatology (ACR) criteria for classification of FMS, persons are said to have the condition if they have 11 of 18 "tender points" and a history of pain in all quadrants of the body as well as the axial skeleton.

    Using this definition, FMS affects 2% to 4% of the US population as well as persons in several other industrialized countries.

    FMS and other chronic pain and fatigue syndromes are part of a clinical spectrum of overlapping disorders that affect a significant portion of the general population.

    There may be a familial tendency toward having these disorders, and exposure to physical, emotional, or environmental"stressors" may trigger or worsen symptoms. Once the illness develops, most symptoms probably are mediated by CNS mechanisms.

    Overlapping comorbid conditions, such as chronic fatigue syndrome (CFS), multiple chemical sensitivity, irritable bowel syndrome (IBS), and tension and migraine headaches, are common and, in many cases, respond to similar interventions.

    In contrast, mimicking disorders (e.g., hepatitis C, hypothyroidism, and polymyalgia rheumatica (PMR) and, particularly, autoimmune diseases (e.g., rheumatoid arthritis and systemic lupus erythematosus) need to be differentiated because the therapies for inflammatory disorders are not useful in managing FMS.

    To manage chronic illnesses effectively, an empathetic physician should develop a partnership with the patient. Various treatments should be tried, preferably one at a time, and the more effective ones continued.

    In routine clinical practice, nonpharmacologic therapies are typically underutilized. Identifying these conditions earlier and intervening before chronicity leads to dysfunction and disability may lead to having far fewer "difficult" patients.

    FMS is both common and well studied, but a variety of misconceptions persist concerning what causes this condition, how to diagnose it, and how to manage it (See: Fibromyalgia Fact and Fiction). In this article, I attempt to clarify some of these points.

    Neurobiologic mechanisms
    Although ample data suggest a strong familial predisposition for FMS and related conditions, the precise genetic underpinnings of FMS are not known.

    Information, regarding the potential triggers is more extensive. It appears that exposure to a variety of stressors can initiate the development of FMS; these include infections, physical trauma, immune stimulation, and emotional distress.

    Exposure to stressors in a series or to numerous stressors concurrently may increase the likelihood of FMS occurring. Once a person has FMS, exposure to these same stressors can exacerbate symptoms.

    The primary mechanism for symptom expression in patients with FMS involves dysfunction of various components of the CNS. There is increased sensitivity to sensory stimuli in these patients.

    Although the condition is defined on the basis of increased sensitivity to In persons who have fibromyalgia syndrome pressure stimuli, persons with FMS also frequently display hypersensitivity to heat, noise, odors, and bright lights, suggesting a global problem with sensory amplification.

    In persons who have FMS, it appears that the "volume control" in the CNS is set too high. Other components of the CNS function improperly, at least in subsets of patients with FMS. Both the autonomic nervous system and various hypothalamic-pituitary axes have been demonstrated to be abnormal. However, these findings are found only in a subset of patients, and therapies that act directly on these systems are not recommended at this time.

    Psychological and behavioral factors These also playa role in symptom expression in many patients. In a typical pattern, persons function increasingly poorly in their various roles as a result of the pain and other symptoms of FMS.

    Difficulties with spouses, children, and fellow employees may lead to distress, further worsening symptoms. In some instances, concurrent mood disorders develop.

    In others, "maladaptive illness behaviors" develop; these include isolation, cessation of pleasurable activities, and reductions in activity and exercise. Patients may also become involved in disability and compensation systems.

    Tender points and pain
    The ACR criteria were formulated for research purposes and were never intended to be used as strict diagnostic criteria for use in clinical practice. Many persons who clearly have FMS do not have 11 tender points or pain throughout their entire body.

    In fact, a great deal has been learned about tender points since the criteria were published. First, persons with FMS can have tenderness throughout the entire body, not just in regions identified as tender points.

    Even areas that have no associated muscle, such as the fore head or thumbnail, are much more tender in a patient with FMS. Second, tender point counts are not an exact measure of tenderness.

    In population-based studies, the I number of tender points a person has is highly correlated with various measures of distress (some other measures of pain threshold are not correlated with distress}.

    Finally, women are much more likely than men to have 11 tender points but are only slightly more likely to have chronic widespread pain. Thus, the use of the criterion of 11 tender points is partially responsible for FMS disproportionately affecting women who have high levels of distress.

    In clinical practice, it may be most useful to think of FMS whenever a patient has multifocal pain that cannot be explained on the basis of current damage or inflammation in those regions of the body.

    In most cases, musculoskeletal pain is the most prominent feature, but because pain pathways throughout the body are amplified, pain can be felt anywhere. Chronic headaches, sore throats, chest pain, abdominal pain, and pelvic pain are common in persons with FMS, and patients with chronic regional pain in any of these locations are more likely to have FMS.

    When a person has chronic pain in numerous locations, especially when it is accompanied by other symptoms noted below, then FMS is a likely diagnosis.

    Physical examination of patients with FMS is often unremarkable, except for the presence of tenderness. As previously discussed, tenderness may be generalized and present anywhere in the body. Laboratory testing is generally not useful, except for differential diagnosis.

    The length of time the patient has had symptoms can help guide the intensity of the diagnostic workup. If the symptoms have persisted for several years, minimal testing is required; for acute or subacute onset of symptoms, a more aggressive strategy should be employed.

    simple testing should be limited to a complete blood cell count and chemistries along with thyroid-stimulating hormone (TSH) level, erythrocyte sedimentation rate (ESR), or C-reactive protein (CRP) level.

    Unless there are historic features not seen in FMS or abnormalities on physical examination, serologic studies, such as antinuclear antibody (ANA) and rheumatoid factor assays, generally should be avoided.

    The fact that FMS and several autoimmune disorders share overlapping symptomatology becomes a problem in clinical practice. Overlapping symptoms include not only fatigue, arthralgias, and myalgias but also morning stiffness and subjective swelling of the hands and feet.

    Certain dermatologic features commonly seen in FMS (malar flushing, livedo reticularis, and Raynaud-like paling or reddening of the hands) also mimic symptoms of autoimmune disorders; this sometimes results in FMS being misdiagnosed as an autoimmune disorder.

    ANA tests are particularly difficult to interpret in this setting because of the high rate of false-positive test results. If an ANA test is ordered and the result is found to be positive in a patient who has only the findings noted above, several features can help differentiate a true-positive from a false-positive test result. First, the titer of the antibody is important; most false positive results are 1:160 or lower.

    Second, follow-up testing for autoantibodies that are more specific for autoimmunity and have a lower rate of false-positives {e.g., autoantibodies to SS-A/Ro, SS-B/La, Smith, and ribonucleoprotein) can be useful.

    FMS may also present similarly to or concurrently with other disorders that may confuse the diagnosis. Table 2 shows conditions that often mimic or present concurrently with FMS.

    Hypothyroidism can be differentiated from FMS by using TSH levels, and PMR can be differentiated by the older age at onset {usually 60 years) and elevated ESR or CRP level. Sleep apnea and hepatitis C also simulate FMS; they tend to present more often in men.

    Start with patient education Management of FMS should include patient education about the nature and course of the illness. Once the diagnosis of FMS is considered, the physician should schedule a prolonged patient visit or series of visits to avoid the frustration of attempting to manage a new patient in a lO-minute follow-up appointment.

    Also, this "front-loading" of time pays tremendous long-term dividends for both the physician and patient: the physician better understands precisely what is bothering the patient, and the patient better understands the goals of and rationale for treatment. In these visits, it is important to explore the symptoms the patient is experiencing, the impact these symptoms are having on his or her life, the patient's perception of what is causing these symptoms, and the stressors that may be exacerbating the illness.

    Once this has been accomplished, the patient should be informed that the condition is nondestructive and that meaningful improvement rarely occurs without active patient participation.

    Patients with FMS should also be provided a list of resources from which they can learn more about their illness, including the Arthritis Foundation; the many FMS advocacy groups; and reputable Web sites.

    For patients who have mild symptoms, such counseling combined with intermittent pharmacologic therapy is often enough. For patients whose symptoms are pronounced enough that they limit daily function, more aggressive therapy is typically needed. The consensus is that multimodal therapy combing pharmacologic and non- pharmacologic approaches is best.

    Pharmacologic agents
    Central pain not resulting from activation of nociceptors; as occurs in FMS, shows only minimal response to commonly used analgesics, such as NSAIDs and opioids.

    Because FMS is not an inflammatory disorder, corticosteroids are also not effective. Thus, the classes of drugs that physicians most commonly use to treat patients with pain (NSAIDs, opioids, corticosteroids} have limited utility in patients who have FMS.

    The best supported pharmacologic therapy for FMS is low doses of tricyclic compounds. Two such compounds, amitriptyline and cyclobenzaprine, have been effective in managing the pain associated, with FMS, especially when tolerance-promoting strategies are used.

    This class of compounds has also demonstrated effectiveness for comorbid conditions, including tension and migraine headaches, IBS, and noncardiac chest pain. Tricyclic antidepressants provide the added benefit of improved sleep patterns in patients with disrupted sleep.

    Amitriptyline and cyclobenzaprine are the most studied tricyclic agents used in the treatment of patients with FMS. No difference in effectiveness has been found between them. However, the clinical trials performed to date demonstrate only short-term benefits; neither agent has been shown to be superior to placebo at 6 months of study.

    This result could represent tachyphylaxis to these drugs; more likely, this is because the studies are underpowered and not designed to administer the optimal dosage.

    Determining the optimal dosage for each patient has been a major issue concerning the use of tricyclic antidepressants. Because tolerance for these drugs is problematic, it is recommended that treatment be initiated at low dosages of 10 mg/d or less several hours before bedtime and that slow (10 mg/d) increases be implemented every week or two until an optimal dosage is achieved (cyclobenzaprine, 40 mg/d or less; amitriptyline, 70 to 80 mg/d).

    In spite of these tolerancepromoting strategies, anticholinergic side effects are common, as is weight gain, which patients should be specifically counseled about.

    Because they have a better adverse-effect profile, newer antidepressants are used frequently in patients with FMS.

    Although only anecdotal data support their use, many experts on chronic pain say that agents that have greater adrenergic or dopaminergic activity or both, such as venlafaxine or nefazodone, may be of more benefit than purer serotonergic drugs.

    Pain management may also be achieved using tramadol. There also is evidence (again only anecdotal) indicating that high doses of gabapentin or long-acting opioids may be useful for refractory pain.

    For persons who cannot tolerate tricyclic drugs, alternatives that may help improve sleep include trazodone, zolpidem, and clonazepam. A subset of patients with FMS who have features of autonomic dysfunction, including orthostatic hypotension, palpitations, or vasomotor instability, may benefit from the use of low-dose beta-blockers or increased fluid and sodium/potassium intake or both.

    Nonpharmacologic therapies
    These include 2 primary modalities: aerobic exercise and cognitive behavioral therapy. Improved out comes have been shown in a number of studies of aerobic exercise in patients with FMS. In many patients, not only is pain reduced but also the general perception of overall symptoms seems to be improved.

    An exercise program for patients with FMS needs to be designed with the goals of physical tolerance and long-term compliance. Because high-impact exercise frequently is poorly tolerated in these patients, low-impact aerobic activities (e.g., walking, swimming, water aerobics, and stationary cycling) should be recommended, especially at first.

    Post-exertional worsening of symptoms is reduced by using low-impact conditioning programs initiated at a slow pace (sometimes beginning at only 5 minutes per day) and gradually increased over time (e.g., increasing a few minutes per week).

    Cognitive-behavioral therapy has been shown to be effective in a number of chronic pain syndromes, including FMS. The principles of this therapy, outlined originally by Keefe and colleagues are to provide the patient a rationale for treatment, to offer retraining of coping skills, and to teach the patient to apply these skills over the long term.

    A variety of techniques can be used to improve a patient's coping mechanisms, including relaxation training, activity pacing, advance scheduling, cognitive restructuring, problem solving, visual imagery, distraction strategies, and goal setting. The benefits are many: short-term pain management and long-term improved patient response to pain, reduced level of distress, and increased sense of control over the illness.

    Although cognitive-behavioral therapy is effective, problems involving patient acceptance (e.g., "I don't need to see a psychologist!"), reimbursement, and a lack of well trained therapists are common. Because of these problems, lay programs run by groups such as the Arthritis Foundation can be very beneficial alternatives.

    Alternative therapies:
    These have been explored by both health care providers and patients who manage their own illness. There are few controlled trials to support their general use.

    Among the more commonly used modalities, which achieve varying levels of success, are trigger-point injections, chiropractic or osteopathic manipulation, acupuncture, and myofascial release therapy.

    Some evidence suggests that the use of alternative therapies provides patients a greater sense of control over their illness, and when there is an improved clinical state, the decision to use these therapies is made between physicians and patients themselves.

    As with many other conditions, there are many unproven and untested theories regarding the cause of FMS and associated therapies.

    Two current theories are that FMS may be caused by cerebellar/spinal compression resulting from Chiari malformation or cervical stenosis and that FMS is caused by a previously unrecognized infectious agent. Because early tests of these hypotheses have not suggested that they have credence, these avenues cannot be recommended until more supporting data are available.

    FMS is very common and together with other "functional somatic syndromes" leg, IBS, headache, CFS, and chronic idiopathic fatigue) makes up a spectrum of illnesses that are difficult to define and manage. Much has been learned about the mechanisms and most effective treatments, but much more remains unknown.

    Because its frequency is high and no "specialized" care is necessary, FMS is best managed by primary care physicians. Others (e.g.rheumatologists, physiatrists, and pain medicine specialists) can play a role in making the diagnosis and helping design treatment plans.

    permission from Journal of Musculoskel Medicine

  2. suzetal

    suzetal New Member

  3. lenasvn

    lenasvn New Member

    Some of the info here is really useful, I am going to print this out for my doc to see if he is interested in learning about this. The trigger point theory here was a big plus for me, I present much as FM, but also CFS.

    I have hardly any trigger points especially during summer, but many VERY sore muscles. I scream if my daughter bump her head on my arm, or steps on my foot. It is abnormally painful!
  4. painintheeverywhere

    painintheeverywhere New Member

    I to am going to add it to my research folder. I agree with so much of it, but wonder or question a few things about it. Many of us who push ourselves end up paying for it in the days to follow. I am so willing to try to get past that threshold or tolerance if possible. It would be wonderful to feel better!

    I am happy to see them seriously studying this disease and trying more than any other article I have read to bring clarity to the treatment and disease. I think many doctors will be relieved to see this documentation as well. As frustrating as it is for us to try to relate our multitude of ailments to the doc's, it's got to be just as frustrating for them to try to diagnos and treat.

    Thanks so much for sharing this.


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