FMS article - long but good

Discussion in 'Fibromyalgia Main Forum' started by Applyn59, Jun 3, 2003.

  1. Applyn59

    Applyn59 New Member

    This article touches on many different facts and I found
    it very interesting. I was not too thrilled with the prognosis factors for my case - but it helps me
    to know that there is a reason for being so sick.

    Fibromyalgia Syndrome
    ----------------------------------


    Kathleen D. Johnson, MD


    Volume 2530, No 8, pp. 4391-4455, June 1, 2003


    I. Introduction
    -------------------


    A. Definition

    1. Fibromyalgia syndrome (FMS) is characterized by
    musculoskeletal aching and tenderness on palpation of
    tendinomusculoskeletal sites called tender points.

    2.Frequently associated with a sleep disorder and daytime
    fatigue.

    3.May be associated with several other organ specific
    syndromes.



    B. Classification
    1. Primary - Fibromyalgia syndrome occurring in absence of any
    underlying or concomitant condition.

    2. Concomitant - Fibromyalgia syndrome occurring in
    association with another rheumatic condition.

    a. Concomitant FMS is clinically identical to primary fibromyalgia
    syndrome.

    3. Secondary - FMS caused by rheumatic or other disease.

    4. Localized - pain and tenderness in a few (1-4) contiguous
    anatomic sites.

    a. Usually above the waist, especially around the neck and
    shoulder.

    b. Frequently precipitated by injury or trauma.

    c. Similar to myofascial pain syndromes.

    d. May develop into generalized FMS over time.



    II. Etiology and Pathogenesis
    -----------------------------------------


    A. FMS

    1.Primary FMS - no specific etiology has been identified.

    a. Neurohormonal abnormality.

    (1) Insulin-like growth factor-1 (IGF-1) deficiency?

    (2) Serotonin deficiency.

    (3) Increased substance P in CSF.

    (4) Altered thalamic blood flow.

    (5) Abnormal hypothalamic-pituitary-adrenal axis homeostasis.


    b. Result of initial insult is stage 4 sleep anomaly.

    2. Etiological factors causing stage 4 sleep anomaly leading to
    FMS.

    a. Musculoskeletal pain.

    b. Physical trauma and/or Emotional trauma.

    (1) No cause and effect relationship established.

    (2) Possible relationship to physical and sexual abuse.

    c. Sleep apnea. d. Nocturnal myoclonus/periodic limb movement
    disorder (PLMD).

    e. Drugs.

    f. Exogenous causes of sleep disturbance - noise.

    g. No evidence of infectious cause, ie, Lyme disease, EBV.



    B. Pathogenesis

    1. Stage 4 sleep anomaly.

    a. Normal non-REM/stage 4 (restorative) sleep shows I cps delta
    pattern on EEG.

    b. FMS patients showed baseline delta pattern with 8-10 cps
    alpha intrusion in original investigations.

    c. This is similar to normal healthy sleep with stage 4
    deprivation, ie, noise.

    d. More recent studies have not found any consistent
    abnormalities in sleep EEG.


    2.Stage 4 sleep anomaly in predisposed patient results in a
    positive feedback cycle:

    a. Abnormal neurohormonal homeostasis.

    b. Poor restorative sleep.

    c. Daytime fatigue.

    d. Muscle microtrauma, inactivity, deconditioning.

    e. Musculoskeletal pain.

    3. Final result- FMS.

    4. Patients frequently exhibit depressive symptoms, poor pain
    coping mechanisms.



    C. Spectrum of FMS and related disorders.

    1. Several disorders with similar etiopathogenesis and
    overlapping clinical manifestations.

    2. Stage 4 sleep anomaly unifying underlying pathogenic
    mechanism.

    3. Often associated with musculoskeletal pare and fatigue.

    4. Fibromyalgia Syndrome (FMS)/Chronic Fatigue Syndrome
    (CFS).

    5. Tension headaches, TMJ syndrome, noncardiac chest pain.

    6. Irritable bowel syndrome, chronic cystitis, primary
    dysmenorrhea.

    7. Others:

    a. Periodic limb movement disorder/nocturnal myoclonus
    (PLMD).

    b. Restless leg syndrome (RLS).

    c. Repetitive strain injury (RSI).

    d. Multiple drug sensitivities (MDS).



    III. Clinical manifestations
    ------------------------------------


    A. Epidemiology

    1. Probably the most common rheumatic disease.

    2. Prevalence of FMS in typical rheumatology practice is 20%.

    3. Prevalence of FMS in typical primary care practice is 2-5%.

    4. Prevalence of FMS in general population is probably about 2%.

    a. Females - 3.5%, Males - 0.5%.

    5. Mean age of patients - 44 years.

    a. Increasing prevalence with increasing age.

    6. Female predominance- 90%.

    7. Caucasian predominance - 94% (may be selection bias).

    8. Duration of symptoms before diagnosis - 6 years.



    B. Clinical manifestations.


    1. Musculoskeletal symptoms.
    -------------------------------------------------------
    Pain at multiple sites``````````````````100%
    -------------------------------------------------------
    Morning stiffness > 15 minutes```````78%
    -------------------------------------------------------
    "Pain all over"````````````````````````````64%
    -------------------------------------------------------


    2. Non-musculoskeletal symptoms.
    ------------------------------------------------------
    Fatigue``````````````````````````````````````86%
    ------------------------------------------------------
    Sleep disturbance````````````````````````65%
    -------------------------------------------------------
    Paresthesias````````````````````````````````54%
    ------------------------------------------------------


    3. Associated symptoms.
    -------------------------------------------------------
    Self-assessed anxiety -`````````````````62%
    -------------------------------------------------------
    Headaches -````````````````````````````````53%
    -------------------------------------------------------
    Dysmenorrhea -```````````````````````````43%
    -------------------------------------------------------
    Irritable bowel syndrome -`````````````40%
    -------------------------------------------------------
    Self-assessed depression -`````````````34%
    -------------------------------------------------------
    Urinary urgency -```````````````````````````26%
    -------------------------------------------------------
    Sicca symptoms -``````````````````````````15%
    -------------------------------------------------------
    Raynaud's phenomenon -````````````````13%
    -------------------------------------------------------




    4. Physical findings.

    a. Tenderness to palpation particularly in neck, shoulder and
    lower back area.

    (1) Tender points are reliable and reproducible to a moderate to
    high degree.

    (2) In most patients, tender points are consistent in location.

    b. No synovitis, full range of motion of all joints.

    (1) May be abnormal due to concomitant rheumatic disease.

    c. Normal muscle strength.

    d. Normal neurologic examination.

    5.Females have more tender points and more associated
    symptoms of fatigue, sleep disorder, pain all over, irritable bowel
    syndrome than males.

    6.Laboratory tests are all normal. Laboratory abnormalities are
    not due to FMS.



    IV. Diagnosis
    ------------------


    A. Diagnostic criteria for FMS.

    1. History of widespread pain for at least 3 months.

    2. Pain in 11 of 18 tender sites.

    a. Classic tender points.

    3. Diagnosis also supported by a history of a sleep disorder and
    daytime fatigue.

    4. Differential diagnosis: Must rule out other possible causes of
    symptoms.

    a. Connective tissue disease - prodrome of SLE, Söjgren's
    syndrome, RA.

    b. Hypothyroidism.

    c. Other rheumatic problems - PMR, OA, tendinitis/bursitis,
    overuse syndromes.

    d. Hyperparathyroidism.

    e. Myofascial pain syndrome.

    (1) Regional pain syndromes with local symptoms similar to
    FMS.

    (2) Commonly involve shoulder, neck or low back.

    (3) Some patients evolve into generalized FMS over time.
    (4) Symptoms often begin after injury or trauma.

    (5) Trigger points - muscle areas-tender to palpation with
    referred pain distally.

    (a) Poor scientific evidence for trigger points.

    (6) Unlike FMS, males are equally affected, symptoms of pain
    and stiffness are localized with regional tenderness, fatigue is
    unusual, sleep disorder occurs occasionally secondary to pain,
    response to treatment is generally good.

    f. Psychogenic pain.

    (1) Unlike FMS, pain and tender points are widespread and
    variable.

    (2) Patient response to question are inappropriate.

    (3) Response to therapy inconsistent.

    (4) General demeanor is affected.

    (5) Response to treatment is poor- emotional problems and
    secondary gain.

    5. Helpful to obtain several laboratory tests such as CBC, ESR,
    TSH and occasionally ANA and RF in order to rule out other
    diagnostic possibilities.



    V. Prognosis
    -----------------

    A. Poor prognostic indicators.

    1. Symptoms for long period; >2 years.

    2. Severe symptoms that have resulted in limitation of activities.

    3. Work disability - often related to "non medical" factors.

    4. FMS starting after physical injury; automobile or work related.


    B. FMS generally remains symptomatic for long periods of time.

    1. In many patients, symptoms can be improved modestly with
    treatment.

    2. In occasional patients significant improvement or rarely
    remission is achieved.

    3. Children with FMS appear to have a better outcome than
    adults.



    VI. Management
    ----------------------


    A. Firm diagnosis ruling out other possible causes of symptoms.

    1.Patients are often relieved to learn that their symptoms are not
    caused by a progressive, crippling or fatal disease.

    2.Obtain a panel of laboratory tests to-rule out other diagnostic
    possibilities.

    3.Avoid ordering more tests on subsequent visits; -this will
    increase patient anxiety.



    B. Patient education and support.

    1. Patient cooperation is important for a good therapeutic
    outcome.

    2. FMS is not progressive, is not crippling and is not fatal.

    3. Encourage patient to continue working and keep physically
    active.

    4. Outcome is in patient's hands - try to minimize dependence on
    physician.

    5. Educate patient about the pathophysiology of FMS and its
    treatment.

    a. Importance of restorative sleep.

    b. Understand factors that affect symptoms.

    c. Importance of physical conditioning.

    d. Role of medical therapy - benefits and side effects.



    C. Behavior modification

    1. Avoidance of factors which aggravate symptoms.

    2. Learn to live with chronic pain.

    a. Occasional patient may benefit from input of psychologist or
    psychiatrist.



    D. Physical therapy

    1.Improve physical fitness with mild to moderate regular
    exercises.
    a. Walking, swimming, cardiovascular fitness training program.

    2. Use of heat with stretching exercises.

    3. Periodic rest periods during physical activity.



    E. Medical therapy

    1. Pain

    a. Analgesics - acetaminophen, propoxyphene HCI, NSAIDs.

    b. Local injection of tender points with lidocaine +/-
    corticosteroids.

    2. Sleep disorder.

    a. Tricyclic antidepressants

    (1) Cyclobenzaprine (Flexeril) 10-40 mg po qhs.

    (2) Amitriptyline (Elavil) 10-50 mg po qhs.

    (3) Nortriptyline (Pamelor) 10-50 mg po qhs.

    b. Specific serotonin reuptake inhibitors (SSRIs)

    (1) Sertraline (Zoloft) 50-100 mg po qhs.

    (2) Paroxetine (Paxil) 20-40 mg po qhs.

    (3) Fluoxetine (Prozac) 20-40 mg po q day (not effective alone, ?
    in combination).

    c. Hypnotics

    (1) Alprazolam (Xanax) 0. 5-1 mg po. qhs.

    (2) Zolpidem (Ambien) 10 mg po qhs.


    Reference
    --------------

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    [This Message was Edited on 06/03/2003]
  2. Applyn59

    Applyn59 New Member

  3. Susan07

    Susan07 New Member

    Thank you