Advanced Practice Rheum: Fibromyalgia Save
Transcription
This is Advanced Practice RheumNow. Hi, I'm Jack Cush, RheumNow. In this review, we're going to discuss fibromyalgia and nonarticular rheumatic complaints.
Patients with fibromyalgia will present in many, many ways. They don't come in saying, "I have fibromyalgia. I have tender points. I have widespread pain and I have a sleep disorder." No, they come in like all other patients with joint complaints. And your job is to figure out whether this is nonarticular or articular. Fibromyalgia patients will have articular and nonarticular. In fact, they'll have more nonarticular complaints than articular. And when you have nonarticular complaints, you have to think about tendonitis, bursitis, tender points, neuropathies, myopathies, etc.
Causes of nonarticular arthralgia myalgia would include postviral algias, endocrinopathies, hypothyroid, Addison's, hyperthyroid disease, PMR in elderly people, especially elderly white people, maybe the earliest onset of a connective tissue disease like RA, lupus, or PsA, and in kids, hypermobility syndrome. But most common amongst these are overuse syndromes as a cause for arthralgia and articular complaints, but also depression, sleep disorders, and fibromyalgia. And those three — depression, sleep disorder, and fibromyalgia — run together. If you find one, ask about the other two.
Fibromyalgia is widespread pain, hypersensitivity to pain. They have a triad of widespread pain, tender trigger points, and a sleep disturbance. They hurt all over, where they have these incredible, impressive histories of motor dysfunction and widespread pain, but on exam you find very little other than that they're tender. You don't find deformities. You don't find contractures. You don't find swelling. The labs are non-revealing or misleading if they were wrongly ordered.
Again, this is the most common cause of aches and pains. The patients describe themselves as having a total body toothache. So they hurt all over. They're bothered by cognitive dysfunction, which is called fatigue or brain fog. These people will show up not with a complaint of widespread pain. They're going to come in with a specific pain — my elbow, my knees, my neck, my low back. There'll be chronic complaints involving the musculoskeletal system. They're never acute. Focal is not unreasonable as a cause for a widespread disorder like fibromyalgia. They have pain and dysfunction more so than clinical abnormalities, and their labs are normal. And stiffness — not helpful. No stiffness, lots of stiffness.
ACR has 1990 criteria and 2010 criteria. The 2010 criteria — Widespread Pain Index and Symptom Severity Scale, WPI greater than seven, SSS greater than five. You don't know what that is. I don't know what that is. I do get that you have to have generalized pain in four out of five body regions, symptoms for more than three months, and no alternative explanation. That's the 2010 guidelines.
I like the 1990 guidelines from Dr. Fred Wolfe. Widespread pain for more than three months on right and left side of the body, above and below the waist, and involves the axial skeleton. That's perfect. And they have to have at least 11 out of 18 tender points.
Fibromyalgia is found alongside many other disorders, and that's because other disorders like OA, lupus, RA, PsA cause pain. Pain causes sleep problems. Sleep problems cause pain amplification and fibromyalgia. So FM is found in 8% of osteoarthritis. It's found in up to 60% — more like 20% — of lupus patients. In RA, it's found in either 10 to 30% or 10 to 57% in different studies. In PsA, it's found in 25%. In Sjögren's, the majority of patients with Sjögren's have fibromyalgia, at least 50%. Chronic fatigue syndrome is fibromyalgia, but studies show they meet criteria 70% of the time. Chronic TMJ — at least a third of them are going to have fibromyalgia. The same can be said for POTS, another name for fibromyalgia or another manifestation of fibromyalgia.
Fibromyalgia's got a lot of new names that people like to call it. The one that's in vogue the most right now is myalgic encephalomyelitis with chronic fatigue syndrome, ME/CFS. I don't really like this because there is no encephalomyelitis. There's just brain abnormalities, and those don't show up, by the way, on most brain imaging.
Also, people wrongly use names for this. Names that should not be used for this include fibrositis, fibromyitis, myofasciitis, or fibromyalgia rheumatica. Just plain wrong. Don't do it.
FM is a largely female disorder — as much as five to one, female to male — all races, all ages. I've seen many, many children. I've seen many, many octogenarians with fibromyalgia. It affects at least 5 million, I think 7 million, people in America. In a rheumatologic practice, at least 20% of your patients will have fibromyalgia. In a general practice, it's 2 to 7%. The prevalence of widespread pain and fibromyalgia is 1 to 2% in the population. Widespread pain in the population is 10 to 20%. Realize that if you have fibromyalgia
up to 35% of patients will be legally disabled. People who are not legally disabled have problems with their jobs. 30% change their job, 17% quit their job.
What causes fibromyalgia? There's a primary insult. The primary insult I think does a reset on central pain and accompanied with that are either sleep disorders and depression or anxiety, and those then give you amplified, magnified pain. What is the primary insult? It can be anything. Trauma, surgery, death, death of a loved one, stress, divorce, uncontrolled arthritis, uncontrolled pain. The net result is it alters pain thresholds. People with fibromyalgia say, "I have a very high pain threshold." And I say, "Oh, no, you don't. If I breathe on you, you're going to hurt. If I just touch you over the shoulder, you're going to jump." They have a sleep disturbance with or without depression. And in all patients with fibromyalgia, less than a third are going to have either real depression or anxiety. Nonetheless, because of an altered pain threshold and hyperalgesia, they get amplified pain and muscle spasm, soft tissue, hypesthesia, deconditioning, weakness, comorbidities, and polypharmacy.
Think about these things that go together. I told you the triad. The triad is widespread pain, problems with sleep, and multiple tender points. The other triads you need to think of that go together is poor sleep, depression, and pain. They run together. Also fibromyalgia is grouped together with other functional disorders that are pain centric. This includes tension headache, irritable bowel syndrome, primary dysmenorrhea. They all run together.
Characteristic features of this include fatigue, non-restorative sleep, stiffness, unexplainable paresthesias and dysesthesias, or plain, you know, hard to describe neurologic manifestations, poor memory, cognitive dysfunction, brain fog. As I said, less than a third have depression or anxiety.
Here are symptoms that are a clue to the diagnosis. They're screaming at you from the page. TMJ pain, atypical chest pain, fatigue, brain fog, memory loss — big one, big one — cognitive dysfunction, paresthesias, dysesthesias. It's non-anatomic, it's intermittent, it has no reproducibility or predictability, unlike carpal tunnel or other entrapment syndromes. Chronic allergic sinusitis and rhinitis is a manifestation of the same fibromyalgia. Bowel syndrome, interstitial cystitis, diagnoses of vulvodynia — any patient that you do metrics on. RAPID 3 — I do a RAPID 3 — when you see a RAPID 3 score of greater than 30, I got a hundred bucks in my pocket that says they also have fibromyalgia. Take that bet. I like handing out money when I'm wrong.
Arty Kavanagh wrote an interesting article and he called fibromyalgia part of a group of disorders that he called multi-organ dysesthesia, meaning fibromyalgia shows up in other clinics — it's just called other things. In ENT clinic it's TMJ syndrome. In neuro clinic it's migraine or unexplained neuropathies. In cardiology it's atypical chest pain, costochondritis, or POTS — postural orthostatic tachycardia syndrome. In GI it's irritable bowel syndrome or mistaken IBD. In OB it's PMS, chronic pelvic pain, or vulvodynia. In ortho it's cervical strain and disc disease. In psychiatry it's depression and somatization disorder. And in allergy it's chronic sinusitis.
Here are my clues to the diagnosis. Number one, suspect fibromyalgia first. In the algorithm of diagnostic things to consider in patients presenting with musculoskeletal complaints, fibromyalgia is at the top of the list, right behind any trauma, because they're more likely to show up and present to you wanting a diagnosis. Second, widespread pain but no physical findings. Third, a globally positive review of systems. If you use the MDQ or any kind of survey form and they check a lot of boxes, I would think fibromyalgia. I have this funny term of "noalgia." That's when the patient brings in so many notes that you hurt. But it means that they don't have a threshold for how abnormal this is in me or not. And they're worried that many of these things are abnormal, and their worry is justified.
Patients who don't like taking medicines but are taking many medicines. Arthritis and musculoskeletal complaints in the setting of anxiety, depression, or ADHD is always going to have fibromyalgia on board. Why ADHD? You're giving them amphetamines and they're going to sleep lousy. It's easy. Patients who have unusual, unlikely diagnoses — someone who comes in and says, "I have Schnitzler syndrome." When I moved to Texas from the Northeast where Lyme disease is very prevalent — Texas, they don't have the right tick, there's almost no Lyme disease — go to a Lyme disease support group, they all had fibromyalgia.
Hyperalgesia. When you touch them, they jerk, jump, fall off the table. It's a hyper reaction, an overly sensitive, minimal sensory response to a
minimal stimulus. Lastly, these people are miserable. They need your help. They are sick and tired of being sick and tired.
What lab should you order? None. Never order an ANA, rheumatoid factor, Lyme disease, or B27. I never do. I never order any labs in someone who I know has fibromyalgia. If they have other features that suggest lupus or spondyloarthritis, I'll order those labs. Sed rates and CRP are not indicated here. Screening labs are generally not indicated here. You want to go on a wild fishing expedition and order a CBC, chem profile, CPK, sed rate, TFTs, and vitamin D levels, go right ahead. You'll be making money for someone who owns a lab because they're not helpful. You can order those if they're clinically indicated by the history and physical exam.
Lastly, how do you treat fibromyalgia? You need to discuss the diagnosis with the patient. Tell them what your role is going to be in their care. Explain the condition. Give them a handout. You can get a handout on fibromyalgia from RheumNow.com. Tell them that this is not a deadly disorder. This is not an autoimmune or arthritic disorder. They're never going to be deformed or disabled if they do the right thing, and then teach them when to seek your help or the help of another doctor.
The pillars of treatment are: do something for pain, improve their sleep, prescribe stretching and pool exercise, and if present, treat depression or anxiety. Of all of those, the one that's going to give them the most amount of relief if they're not depressed or anxious is going to be improving their sleep.
Treat their pain with simple acetaminophen 650 milligrams. I mean long-acting acetaminophen. Tylenol Arthritis. I give them three once a day, two twice a day, three just at bedtime, three twice a day because you're allowed to take up to 4,000 milligrams a day if there's no liver disease and no contraindication. But do not chase pain. Do not give narcotics.
Sleep. Use simple sleep measures. Teach them about good sleep. And if you can't treat them with simple sleep measures like a tricyclic antidepressant or a muscle relaxant that has sleep as a side effect, then refer them to a sleep clinic for a sleep study and a sleep evaluation.
Exercise is important, but they can't do aerobic exercise. Run, walk, jump, jump rope, play tennis — no, they'll be in bed for a week. You've got to get them to stretch. Their problem is spasm. Get them to stretch. You do that with yoga, tai chi, Pilates, or learning how to stretch on YouTube, and then sending them to the pool. And they must do that at least three to five times a week. And as I said, if depression or anxiety is present, refer them or treat them. Mindfulness therapy works great. Cognitive behavioral therapy works great.
I hand all my patients a four-page handout on fibromyalgia and a one-page overview on sleep hygiene. Sleep hygiene — there are 12 steps. Number one, sleep only as much as you need to feel rested. Two, develop and keep a regular schedule and routine. But I have number five memorized in my brain. And number five is: your bed is your special place for sleep only. Do not read or watch TV in bed. Your bed should be free of remote controls. No food, children, pets, snoring spouses, cookies, magazines, or cell phones. Your cell phone is charging in the kitchen or living room and not in your bedroom waking you up at night. They have to live the sleep hygiene rules.
If they don't, I see patients with fibromyalgia twice and I educate them both times, and then I want them to be managed by their primary care or a neurologist or a sleep specialist or a psychiatrist.
To excel at fibromyalgia: number one, do not use narcotics. Number two, use simple sleep aids. And if that doesn't work, they need a sleep study and a sleep consult. As I said, stretching is the way to go along with pool exercise, and physical therapy may be indicated for those that are very weak or for those that are disabled. The mental component is big — anxiety, coping, compliance. Again, mindfulness and CBT is the way to go.
These patients can be disabled. Don't thwart them. Don't send them away saying they're not disabled and whatnot. Of course, that would make sure that they're not going to come back and see you, but they are disabled. They can't work. And I think you should respect their wishes.
The problem with fibromyalgia is that it's 20% of your patients, but it'll take up 80% of your staff time. You need a plan. You need handouts. You need an aftercare plan. For me, it's two visits and done, and then primary care or neurology or sleep or psychiatry.
Tune in for more on rheumatology with advanced care.
Patients with fibromyalgia will present in many, many ways. They don't come in saying, "I have fibromyalgia. I have tender points. I have widespread pain and I have a sleep disorder." No, they come in like all other patients with joint complaints. And your job is to figure out whether this is nonarticular or articular. Fibromyalgia patients will have articular and nonarticular. In fact, they'll have more nonarticular complaints than articular. And when you have nonarticular complaints, you have to think about tendonitis, bursitis, tender points, neuropathies, myopathies, etc.
Causes of nonarticular arthralgia myalgia would include postviral algias, endocrinopathies, hypothyroid, Addison's, hyperthyroid disease, PMR in elderly people, especially elderly white people, maybe the earliest onset of a connective tissue disease like RA, lupus, or PsA, and in kids, hypermobility syndrome. But most common amongst these are overuse syndromes as a cause for arthralgia and articular complaints, but also depression, sleep disorders, and fibromyalgia. And those three — depression, sleep disorder, and fibromyalgia — run together. If you find one, ask about the other two.
Fibromyalgia is widespread pain, hypersensitivity to pain. They have a triad of widespread pain, tender trigger points, and a sleep disturbance. They hurt all over, where they have these incredible, impressive histories of motor dysfunction and widespread pain, but on exam you find very little other than that they're tender. You don't find deformities. You don't find contractures. You don't find swelling. The labs are non-revealing or misleading if they were wrongly ordered.
Again, this is the most common cause of aches and pains. The patients describe themselves as having a total body toothache. So they hurt all over. They're bothered by cognitive dysfunction, which is called fatigue or brain fog. These people will show up not with a complaint of widespread pain. They're going to come in with a specific pain — my elbow, my knees, my neck, my low back. There'll be chronic complaints involving the musculoskeletal system. They're never acute. Focal is not unreasonable as a cause for a widespread disorder like fibromyalgia. They have pain and dysfunction more so than clinical abnormalities, and their labs are normal. And stiffness — not helpful. No stiffness, lots of stiffness.
ACR has 1990 criteria and 2010 criteria. The 2010 criteria — Widespread Pain Index and Symptom Severity Scale, WPI greater than seven, SSS greater than five. You don't know what that is. I don't know what that is. I do get that you have to have generalized pain in four out of five body regions, symptoms for more than three months, and no alternative explanation. That's the 2010 guidelines.
I like the 1990 guidelines from Dr. Fred Wolfe. Widespread pain for more than three months on right and left side of the body, above and below the waist, and involves the axial skeleton. That's perfect. And they have to have at least 11 out of 18 tender points.
Fibromyalgia is found alongside many other disorders, and that's because other disorders like OA, lupus, RA, PsA cause pain. Pain causes sleep problems. Sleep problems cause pain amplification and fibromyalgia. So FM is found in 8% of osteoarthritis. It's found in up to 60% — more like 20% — of lupus patients. In RA, it's found in either 10 to 30% or 10 to 57% in different studies. In PsA, it's found in 25%. In Sjögren's, the majority of patients with Sjögren's have fibromyalgia, at least 50%. Chronic fatigue syndrome is fibromyalgia, but studies show they meet criteria 70% of the time. Chronic TMJ — at least a third of them are going to have fibromyalgia. The same can be said for POTS, another name for fibromyalgia or another manifestation of fibromyalgia.
Fibromyalgia's got a lot of new names that people like to call it. The one that's in vogue the most right now is myalgic encephalomyelitis with chronic fatigue syndrome, ME/CFS. I don't really like this because there is no encephalomyelitis. There's just brain abnormalities, and those don't show up, by the way, on most brain imaging.
Also, people wrongly use names for this. Names that should not be used for this include fibrositis, fibromyitis, myofasciitis, or fibromyalgia rheumatica. Just plain wrong. Don't do it.
FM is a largely female disorder — as much as five to one, female to male — all races, all ages. I've seen many, many children. I've seen many, many octogenarians with fibromyalgia. It affects at least 5 million, I think 7 million, people in America. In a rheumatologic practice, at least 20% of your patients will have fibromyalgia. In a general practice, it's 2 to 7%. The prevalence of widespread pain and fibromyalgia is 1 to 2% in the population. Widespread pain in the population is 10 to 20%. Realize that if you have fibromyalgia
up to 35% of patients will be legally disabled. People who are not legally disabled have problems with their jobs. 30% change their job, 17% quit their job.
What causes fibromyalgia? There's a primary insult. The primary insult I think does a reset on central pain and accompanied with that are either sleep disorders and depression or anxiety, and those then give you amplified, magnified pain. What is the primary insult? It can be anything. Trauma, surgery, death, death of a loved one, stress, divorce, uncontrolled arthritis, uncontrolled pain. The net result is it alters pain thresholds. People with fibromyalgia say, "I have a very high pain threshold." And I say, "Oh, no, you don't. If I breathe on you, you're going to hurt. If I just touch you over the shoulder, you're going to jump." They have a sleep disturbance with or without depression. And in all patients with fibromyalgia, less than a third are going to have either real depression or anxiety. Nonetheless, because of an altered pain threshold and hyperalgesia, they get amplified pain and muscle spasm, soft tissue, hypesthesia, deconditioning, weakness, comorbidities, and polypharmacy.
Think about these things that go together. I told you the triad. The triad is widespread pain, problems with sleep, and multiple tender points. The other triads you need to think of that go together is poor sleep, depression, and pain. They run together. Also fibromyalgia is grouped together with other functional disorders that are pain centric. This includes tension headache, irritable bowel syndrome, primary dysmenorrhea. They all run together.
Characteristic features of this include fatigue, non-restorative sleep, stiffness, unexplainable paresthesias and dysesthesias, or plain, you know, hard to describe neurologic manifestations, poor memory, cognitive dysfunction, brain fog. As I said, less than a third have depression or anxiety.
Here are symptoms that are a clue to the diagnosis. They're screaming at you from the page. TMJ pain, atypical chest pain, fatigue, brain fog, memory loss — big one, big one — cognitive dysfunction, paresthesias, dysesthesias. It's non-anatomic, it's intermittent, it has no reproducibility or predictability, unlike carpal tunnel or other entrapment syndromes. Chronic allergic sinusitis and rhinitis is a manifestation of the same fibromyalgia. Bowel syndrome, interstitial cystitis, diagnoses of vulvodynia — any patient that you do metrics on. RAPID 3 — I do a RAPID 3 — when you see a RAPID 3 score of greater than 30, I got a hundred bucks in my pocket that says they also have fibromyalgia. Take that bet. I like handing out money when I'm wrong.
Arty Kavanagh wrote an interesting article and he called fibromyalgia part of a group of disorders that he called multi-organ dysesthesia, meaning fibromyalgia shows up in other clinics — it's just called other things. In ENT clinic it's TMJ syndrome. In neuro clinic it's migraine or unexplained neuropathies. In cardiology it's atypical chest pain, costochondritis, or POTS — postural orthostatic tachycardia syndrome. In GI it's irritable bowel syndrome or mistaken IBD. In OB it's PMS, chronic pelvic pain, or vulvodynia. In ortho it's cervical strain and disc disease. In psychiatry it's depression and somatization disorder. And in allergy it's chronic sinusitis.
Here are my clues to the diagnosis. Number one, suspect fibromyalgia first. In the algorithm of diagnostic things to consider in patients presenting with musculoskeletal complaints, fibromyalgia is at the top of the list, right behind any trauma, because they're more likely to show up and present to you wanting a diagnosis. Second, widespread pain but no physical findings. Third, a globally positive review of systems. If you use the MDQ or any kind of survey form and they check a lot of boxes, I would think fibromyalgia. I have this funny term of "noalgia." That's when the patient brings in so many notes that you hurt. But it means that they don't have a threshold for how abnormal this is in me or not. And they're worried that many of these things are abnormal, and their worry is justified.
Patients who don't like taking medicines but are taking many medicines. Arthritis and musculoskeletal complaints in the setting of anxiety, depression, or ADHD is always going to have fibromyalgia on board. Why ADHD? You're giving them amphetamines and they're going to sleep lousy. It's easy. Patients who have unusual, unlikely diagnoses — someone who comes in and says, "I have Schnitzler syndrome." When I moved to Texas from the Northeast where Lyme disease is very prevalent — Texas, they don't have the right tick, there's almost no Lyme disease — go to a Lyme disease support group, they all had fibromyalgia.
Hyperalgesia. When you touch them, they jerk, jump, fall off the table. It's a hyper reaction, an overly sensitive, minimal sensory response to a
minimal stimulus. Lastly, these people are miserable. They need your help. They are sick and tired of being sick and tired.
What lab should you order? None. Never order an ANA, rheumatoid factor, Lyme disease, or B27. I never do. I never order any labs in someone who I know has fibromyalgia. If they have other features that suggest lupus or spondyloarthritis, I'll order those labs. Sed rates and CRP are not indicated here. Screening labs are generally not indicated here. You want to go on a wild fishing expedition and order a CBC, chem profile, CPK, sed rate, TFTs, and vitamin D levels, go right ahead. You'll be making money for someone who owns a lab because they're not helpful. You can order those if they're clinically indicated by the history and physical exam.
Lastly, how do you treat fibromyalgia? You need to discuss the diagnosis with the patient. Tell them what your role is going to be in their care. Explain the condition. Give them a handout. You can get a handout on fibromyalgia from RheumNow.com. Tell them that this is not a deadly disorder. This is not an autoimmune or arthritic disorder. They're never going to be deformed or disabled if they do the right thing, and then teach them when to seek your help or the help of another doctor.
The pillars of treatment are: do something for pain, improve their sleep, prescribe stretching and pool exercise, and if present, treat depression or anxiety. Of all of those, the one that's going to give them the most amount of relief if they're not depressed or anxious is going to be improving their sleep.
Treat their pain with simple acetaminophen 650 milligrams. I mean long-acting acetaminophen. Tylenol Arthritis. I give them three once a day, two twice a day, three just at bedtime, three twice a day because you're allowed to take up to 4,000 milligrams a day if there's no liver disease and no contraindication. But do not chase pain. Do not give narcotics.
Sleep. Use simple sleep measures. Teach them about good sleep. And if you can't treat them with simple sleep measures like a tricyclic antidepressant or a muscle relaxant that has sleep as a side effect, then refer them to a sleep clinic for a sleep study and a sleep evaluation.
Exercise is important, but they can't do aerobic exercise. Run, walk, jump, jump rope, play tennis — no, they'll be in bed for a week. You've got to get them to stretch. Their problem is spasm. Get them to stretch. You do that with yoga, tai chi, Pilates, or learning how to stretch on YouTube, and then sending them to the pool. And they must do that at least three to five times a week. And as I said, if depression or anxiety is present, refer them or treat them. Mindfulness therapy works great. Cognitive behavioral therapy works great.
I hand all my patients a four-page handout on fibromyalgia and a one-page overview on sleep hygiene. Sleep hygiene — there are 12 steps. Number one, sleep only as much as you need to feel rested. Two, develop and keep a regular schedule and routine. But I have number five memorized in my brain. And number five is: your bed is your special place for sleep only. Do not read or watch TV in bed. Your bed should be free of remote controls. No food, children, pets, snoring spouses, cookies, magazines, or cell phones. Your cell phone is charging in the kitchen or living room and not in your bedroom waking you up at night. They have to live the sleep hygiene rules.
If they don't, I see patients with fibromyalgia twice and I educate them both times, and then I want them to be managed by their primary care or a neurologist or a sleep specialist or a psychiatrist.
To excel at fibromyalgia: number one, do not use narcotics. Number two, use simple sleep aids. And if that doesn't work, they need a sleep study and a sleep consult. As I said, stretching is the way to go along with pool exercise, and physical therapy may be indicated for those that are very weak or for those that are disabled. The mental component is big — anxiety, coping, compliance. Again, mindfulness and CBT is the way to go.
These patients can be disabled. Don't thwart them. Don't send them away saying they're not disabled and whatnot. Of course, that would make sure that they're not going to come back and see you, but they are disabled. They can't work. And I think you should respect their wishes.
The problem with fibromyalgia is that it's 20% of your patients, but it'll take up 80% of your staff time. You need a plan. You need handouts. You need an aftercare plan. For me, it's two visits and done, and then primary care or neurology or sleep or psychiatry.
Tune in for more on rheumatology with advanced care.
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