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Fibromyalgia (FM) definition
multi-symptom condition with chronic widespread pain
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Onset age FM
20-55 years (increases with age)
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FM gender prevalence
more common in females (F for Female) 9:1
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4 types of pathophysiology for FM
- 1. dysregulation of pain pathways
- 2. neuroendocrine abnormalities
- 3. autonomic nervous system abnormalities
- 4. environmental factors
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key players of pain pathway (2)
- NMDA/AMPA activation - substance P (bind to NK-1) and glutamate
- Anti-nociceptive - GABA, serotonin, norepinephrine
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dysregulation of pain pathway: deficiency
- serotonin - regulates sleep, pain control, concentration and memory
- norepinephrine - pain modulation
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dysregulation of pain pathway: enhanced
release of substance P
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neuroendocrine abnormalities
- HPA axis is altered
- - inability to suppress cortisol
- -normally controls reactions to stress and other functions (circadian rhythm, digestion, body temperature).
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autonomic nervous system: components (2)
- growth hormone (GH)
- insulin-like growth factors-1 (IGF-1)
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process of autonomic nervous system normal and FM
- normal: slow wave sleep (SWS) produces GH --> GH produces IGF-1 --> repair of muscle microtrauma
- FM: decreased
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environmental factors FM
- physical stressors
- psychosocial stressors
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genetic influences for FM
- first degree relative 8x
- affects the transport and metabolism of serotonin and norEPI
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Increased pain sensitivity: decrease of
- 1. serotonin
- 2. norepinephrine
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Increased pain sensitivity: increase of
1. substance P
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Implications of FM due to autonomic nervous system dysfunction
- 1. impaired exercise tolerance
- 2. HYPER arousal (affects sleep)
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Most associated symptom with FM
- 1. Muscular pain (makes sense for this class)
- 2. Fatigue
- 3. sleep abnormalities
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pain characteristics of FM (3)
- 1. chronic widespread pain
- ≥3 months, ALL 4 QUADRANTS, not localized in joints (arthritis)
- 2. pain waxes and wanes
- 3. tenderness
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pain characteristics of FM: allodynia
pain from something that shouldn't hurt
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pain characteristics of FM: HYPER algesia
super sensitive
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diagnosis
- difficult and delayed
- and impacts costs and function of life
- 4 quadrants
- 3 months or longer
- 11/18 tender points
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disadvantages of American College of Rheumatology (ACR) Criteria for Classification of FM (4)
- 1. focuses on pain and disregards other sx
- 2. tenderness is subjective
- 3. depends on examiner's strength of palpitation
- 4. many believe 11/18 is arbitrary
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t/f treatment is often trial and error
true
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Strong evidence medications for FM (4)
- 1. TCA (amitriptyline)
- 2. Cyclobenzaprine
- 3. SNRI's (duloxetine, milnacipran, venlafaxine)
- 4. Gabapentin, pregabalin
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Modest evidence medications for FM (3)
- 1. Dopamine agonist
- 2. SSRI's
- 3. Tramadol
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No evidence medications for FM (4)
- 1. opioids
- 2. NSAIDs
- 3. Benzos
- 4. Hypnotics
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FDA approved medications for FM (3)
- 1. Pregabalin (Lyrica)
- 2. duloxetine (Cymbalta)
- 3. Milnacipran (Savella)
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MOA: analogue GABA reduce Ca2+ = DECREASE release glutamate, substance P
hint: FDA approved
pregabalin (Lyrica)
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dose: 75 mg PO twice daily --> 150 mg PO bid (within 1 week) --> max 450 mg/day
hint: FDA approved
pregabalin (Lyrica)
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SE of Lyrica
dose-related drowsiness and dizziness
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MOA: SNRI - inhibits reuptake of both serotonin and norepinephrine (2)
hint: FDA approved
- duloxetine (Cymbalta)
- milnacipram (Savella)
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dose: 30 mg PO QD 1 week --> 60 mg PO QD --> max 60 mg/day
hint: FDA approved
duloxetine (Cymbalta)
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Amitriptyline: benefits and disadvantages
- benefits: pain relief, improved sleep, decreased AM stiffness
- disadvantages: intolerance, long term effectiveness questionable
- not FDA approved
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cyclobenzaprine information
- muscle relaxant
- mixes results in literature
- short-term
- pain relief and improved sleep
- not FDA approved
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tramadol information
- mu-opioid receptor agonist
- serotonin and norepinephrine reuptake inhibitor
- pain relief of FM
- not FDA approved
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SSRI's information
- relief depressive symptoms
- lack of efficacy for pain - use TCA's and SNRI's instead
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symptom management: depression (2)
- 1. SNRI - duloxetine, milnacipram, others
- 2. TCA's
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symptom management: insomnia (4)
- 1. health sleep regimen
- 2. non-benzo hypnotics
- 3. sedating antidepressants
- 4. cyclobenzaprine
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nonpharm management FM (4)
- 1. education
- 2. exercise
- 3. CBT
- 4. complementary therapy
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