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FIBROMYALGIA JACK FU MSIII

PATIENT HISTORY Mrs. D.V. is a 37 year old white female with a history of fibromyalgia diagnosed in Holland in 1997, who presented to Dr. Cynthia Sessions’ Plano office on December 28th for follow-up of irritable bowel syndrome medication and fibromyalgia. Mrs. D.V.’s symptoms include: Myalgias Morning stiffness Insomnia Headaches (migraine and muscle contraction type) Postprandial diffuse colicky abdominal pain (part of IBS) Nausea

PATIENT HISTORY Chronic diarrhea Visual disturbances – that are not correctable with glasses.  She has been seen by several opthmologists.  The disturbances do not always accompany headaches. Chronic gait unsteadiness Mid-back pain Poor recent memory Medical History: Hypertension

PATIENT HISTORY Surgical History: 2 foot surgeries in 1986 Allergies: Penicillin Medications: Advil, Naproxen (Alleve), Toradol (Ketorolac), Lotrinex (for IBS), Elavil (Amitriptyline), Family History: Arthritis (uncertain of type) in mother beginning in her 40’s.  Both mother and father had hypertension. Social History: Mrs. D.V. is a married homemaker with two children (1 son & 1 daughter) from an upper middle class family. She denies the use of illegal drugs, tobacco, or alcohol.  She immigrated to Dallas from Holland in July 1999.

PHYSICAL EXAMINATION HEENT: Clear Neck: No thyromegaly or lymphadenopathy. Chest: RRR, CTA B Back: Tender right flank, normal range of motion. Abd: +B/S, diffuse abdominal tenderness GU: Tender vagina, cervix, and uterus. Upper Extremities: No ulnar deviation.  No swollen joints. Lower Extremities: Patient has LE edema.

PHYSICAL EXAMINATION Neuro: trigger points in the medial scapular, iliolumbocostalis, and sacroiliac regions. Previous physical exam revealed over 18 trigger points.  No trigger points in the neck or SCM. Right sided hyperreflexia especially of the right knee Decreased pin of the right upper extremity Decreased Vibration of right toe compared to the right finger

PAST STUDIES For Neurologic Workup MRI of Head: negative (1997 in Holland) EEG: normal (1997 in Holland) LP: normal (1997 in Holland) No ESR, CK, Rheumatoid Factor, or EMG available. For Abdominal Workup UA: Negative, negative pregnancy test (10/00) Colonscopy: two polyps (not cancer) (6/00) CT of abdomen and pelvis: normal (6/00) CBC and electrolytes: normal (6/00)

FIBROMYALGIA DIFFERENTIAL Fibromyalgia Giant Cell Arteritis – can cause headaches but does not usually have joint pain (can have swollen joints). Polymyalgia Rheumatica – responds to NSAID’s, but often has decreased motor ability. Rheumatoid Arthritis – possible positive FH.  Pain at joints only. Dermatomyositis – has decreased motor ability. No headaches.

FIBROMYALGIA DIFFERENTIAL

WHAT IS FIBROMYALGIA? A chronic non life threatening musculoskeletal disorder characterized by widespread pain, exquisite tenderness at specific anatomic sites and other clinical manifestations such as fatigue, sleep disturbance,and irritable bowel syndrome. Source: Koopman: Arthritis and Alllied Conditions, p. 1619

FIBROMYALGIA DIAGNOSTIC CRITERIA ACCORDING TO THE MULTICENTER COMMITTEE OF THE AMERICAN COLLEGE OF RHEUMATOLOGY WIDESPREAD PAIN FOR AT LEAST 3 MONTHS TENDERNESS IN AT LEAST 11 OF 18 ANATOMIC SITES

FIBROMYALGIA DIAGNOSTIC CRITERIA

FIBROMYALGIA MUSCULOSKELETAL SYMPTOMS Other musculoskeletal symptoms that are not part of ACS criteria: Source: Koopman: Arthritis & Allied Conditions, p. 1620

FIBROMYALGIA NON-MUSCULOSKELETAL SYMPTOMS FATIGUE – is not the primary symptoms (unlike chronic fatigue syndrome).’ SLEEP DISTURBANCES – most suffer from insomnia or unrefreshing sleep.  It has been reported that fibromyalgia patients have abnormal EEG patterns during sleep (May and colleagues), while others believe OSA is the factor . OTHER SYMPTOMS Source: Koopman: Arthritis and Allied Conditions, p. 1621

FIBROMYALGIA EPIDEMIOLOGY FIBROMYALGIA IS MOST COMMONLY DIAGNOSED IN: Middle-aged (however can occur in elderly and children) Caucasian (this is controversial) Women Middle and upper socioeconomic strata OVERALL PREVALENCE HAS VARIED FROM STUDY TO STUDY.  THE MOST RECENT POPULATION BASED STUDY FOUND THE PREVALENCE IN WICHITA, KANSAS WAS 2%. 3.4 % among women .5% among men Source: Koopman: Arthritis & Allied Conditions, 1622

FIBROMYALGIA CAUSES The cause of fibromyalgia is unknown.  However, there are several hypothesis about its cause: Genetics – reported 73% of close relatives have fibromyalgia or exhibited clinical evidence of abnormal muscles. Muscular – studies have shown reduced levels of ATP, phosphocreatine, and ragged red fibers. Non-restorative sleep – due to findings of abnormal EEG patterns (fast alpha wave superimposed on a slower delta wave) Neuroendocrine – b/c of findings of lower free-cortisol levels, low CSF serotonin, and high CSF substance P levels. Source: Koopman: Arthritis & Allied Conditions, 1623-1625.

FIBROMYALGIA CAUSES Immunologic – 55% of patients report symptoms during or after a flu-like febrile illness.  76% have deposits of IgG at dermoepidermal junction. Psychological – often times many patients have high levels of psychological distress.  This observation with no other known causes make many come to this conclusion. CNS Structural Abnormalities – some believe the thalamus or caudate nucleus may hold the key to finding the cause of fibromyalgia. Source: Koopman: Arthritis & Allied Conditions, 1623-1625.

FIBROMYALGIA TREATMENT OPTIONS Amitriptyline & Cyclobenzaprine Effects: Increase NREM Stage IV sleep Increase availability of serotonin Decrease muscle spasms Only amitryptline has been shown to decrease pain and tender point counts. Cyclobenzaprine is more efficacious in improving sleep quality than pain. Source: Koopman: Arthritis & Allied Conditions, 1631

FIBROMYALGIA TREATMENT OPTIONS Amitriptyline & Cyclobenzaprine Problems with the Amitryptyline & Cyclobenzaprine: Symptoms generally improve after 1 month of treatment but over time there efficacy decreases. a study showed that 1 year after terminating the study’s end, 69% were still taking the medication These same patients actually reported increases in pain intensity, fatigue, sleep difficulty, and global symptoms despite the fact that continued taking the medication. Source: Koopman: Arthritis & Allied Conditions, 1631

FIBROMYALGIA TREATMENT OPTIONS Psychotropic Medications Anxiety & Depression tend to amplify pain perception. Alprazolam with ibuprofen produced significantly reduced pain and symptoms compared to placebo. SAMe (a drug with antidepressant, anti-inflammatory, and analgesic effects) has been shown to be superior to placebo. SSRI’s – are used because serotonin deficiency has been demonstrated in fibromyalgia patients.  However, studies have shown that although improving depression and fatigue they are not superior to placebos. Source: Koopman: Arthritis & Allied Conditions, 1633

FIBROMYALGIA TREATMENT OPTIONS Other Treatments Growth Hormone – shown to improve symptomology and number of tender points after 9 months of daily therapy. Source: Bennett, 227-231 Gamma-hydroxybutyrate – in healthy volunteers, GHB increases non-REM and REM sleep.  Preliminary data shows decreased fatigue and pain.  Sleep was also improved, but further studies will need to be done. Source: Scharf, 1986-1990 Corticosteroids – It’s effectiveness is controversial.

FIBROMYALGIA TREATMENT OPTIONS Behaviorial Interventions Aerobic Exercise – McCain & Associates showed that patients put on a 20 week cardiovascular fitness training program produced improvements in patient’s subjective ratings of their disease severity. Cognitive Behaviorial Therapy – such as relaxation training, reinforcing healthy behaviors, restructuring maladaptive behaviors about one’s ability to control pain.  Several studies have shown improvements with Cogntive Behaviorial Therapy. EMG biofeedback and hypnotherapy – have been shown to improve patient’s pain intensity ratings. Source: Koopman: Arthritis & Allied Conditions, 1634

FIBROMYALGIA TREATMENT RECOMMENDATIONS There is no generally accepted treatment regimen. Education and reassurance that the disorder is not life-threatening nor imaginary. Pharmacotherapy Amitryptyline and cyclobenzaprine SSRI’s Alprazolam with ibuprofen/NSAID Corticosteroids Source: Koopman: Arthritis & Allied Conditions, 1634

FIBROMYALGIA TREATMENT RECOMMENDATIONS Physical exercise Aerobic exercise led by PT’s. Also may use massage or tender point injections Psychotherapy All patients should be given training in pain management and coping skills.  Have not been studied with fibromyalgia but shown to help in other chronic pain syndromes. Source: Koopman: Arthritis & Allied Conditions, 1635

ASSESSMENT AND PLAN Dr. Session’s Plan d/c lotronex, it has been voluntarily withdrawn by Glaxo-Wellcome. Advil 2 q 4-6 Hours Continue Naproxen, Elavil (amitryptyline). Discuss any questions she may have concerning her condition. F/U in one month. I would like to have TSH, ESR, and CK levels and would recommend PT.

ASSESSMENT AND PLAN  Source: Goroll: Primary Care Medicine, 801 Social Implications: Mrs. D.V. is a homemaker and is not currently employed.  She has few responsibilities except picking up and dropping off her children from work.  Her condition doesn’t permit her from working.  However, she is lucky that her husband has a steady job.  Her family is very supportive. Patient Education:  Mrs. D.V. knows a great deal already about her condition from physicians here in the U.S. as well as Holland.  It is important that all patient’s understand that fibromyalgia is a non life-threatening chronic condition with no known cure.  Very little is known about the cause of fibromyalgia.  It is important to emphasize that it is a real condition. Also let her know the use of amitryptyline is for sleep not depression.

FIBROMYALGIA BIBLIOGRAPHY Bennett, Robert M., Sharon Clark, and Jacqueline Walczyk. “A Randomized, Double-Blind, Placebo-controlled Study of Growth Hormone in the Treatment of Fibromyalgia.”  The American Journal of Medicine. Vol. 104, March 1998, p. 227-231. Giovengo, Susan Liew, I. Russell, and Alice Larson. “Increased Concentrations of Nerve Growth Factor in Cerebrospinal Fluid of Patients with Fibromyalgia.” The Journal of Rheumatology. July 26, 1999.  P. 1564-1569. Goldman: Cecil Textbook of Medicine, 21st edition.  W.B. Saunders Company. 2000. Goroll: Primary Care Medicine, 3rd edition.  Lippincott-Ravens Publishers, 1995. P. 801 Koopman: Arthritis and Allied Conditions: A Textbook of Rheumatology, 13th edition. Williams & Wilkins. 1997 p. 1619-1635 Scharf, Martin B., et. Al. “Effect of Gamma-Hydroxybutyrate on Pain, Fatigue, and the Alpha Sleep Anomaly in Patients with Fibromyalgia. Preliminary Report.” The Journal of Rheumatology. November 25, 1998. P. 1986-1990.

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