Fibro / CRPS Flashcards
** Fibro sx **
Arthralgia/myalgia/stiffness
-Muscle spasm
-Paresthesia
-Fatigue
-Sleep disturbance
-Nonrestorative sleep
-Cognitive problems (Fibrofog)
-Mood disorder
** Prevalence
–Fibro
– SLE w/ Fibro
–Chance of work disability**
3%
~30%
~30%
** Fibro workup **
CBC, ESR, CRP, TSH, 25-hydroxy vitamin D and CK
-Further testing based on clinical assessment.
-No serologies unless objective synovitis or inflamm markers elevated
** FM diagnostic criteria**
ACR 2010
-WPI ≥ 7 + SS ≥ 5 OR WPI 4-6 + SS ≥ 9
-Symptoms >3mo
-No other explanation
-2016 Revision added:
-Generalized pain = at least 4/5 must be present: left/right upper/lower, axial
-(**jaw, chest, abdo NOT included in definition)
-Dx of Fibro valid irrespective of other dx and does not exclude presence of other illness
Items in symptom severity score
Fatigue (0-3 pts)
-Waking unrefreshed (0-3 pts)
-Cognitive sx (0-3 pts)
-Somatic symptoms (H/A, abdo pain/cramps, depression) - 1 pt each
** Co-existing conditions with FM**
-Migraine/Tension H/A
-TMJ d/o
-IBS
-Urinary freq/urg
-Chronic pelvic pain
-RLS
Sleep disturbance assoc/d w/ FM
Alpha delta sleep = disruption of delta wave sleep by frequent alpha wave intrusion (reducing restorative nonREM stage 4 sleep)
** RF Fibro**
Biologic:
-Genetics
-Female
-Lack of exercise
-Sleep abnormalities
-Autonomic dysregulation: POTS
Environmental:
-Sexual/Physical abuse as child
-Job dissatisfaction
-Poor support system
Psych:
-Psych traits: perfectionists, catastrophizing, preoccupation w/ pain, poor coping mech, A&D
** Draw trigger points for fibro**
The 18 tender points for fibromyalgia include:
-Base of the skull in the back of the head
-Lower neck in front
-Back of the neck
-Back of neck/shoulders
-Edge of upper breast
-Lateral epicondyle
-Upper outer buttock
-Hip bone - posterior to greater trochanter
-Knee - medial fat pad proximal to joint line
** FM triggers**
-Early stress (life trauma)
-Acute stress (eg MVA)
-Chronic distress
-Catastrophic events (life/war)
-Sleep apnea
-Joint inflammation
DDx FM
Rheum: RA, SLE, SS, Sjogrens, PMR, AS
Endocrine: hypothyroid, hyperPTH, adrenal insuff
Myopathy (metabolic, statin)
GI: IBD, Hep C, celiac
Infxn: IE, lyme, HIV, parvo
Neuro MS, MG,
Cancer
Sleep apnea
Psych disorders
** Fibro /CRPS pathophys - mechanism of peripheral sensitization**
-Prolonged noxious stimulation (eg whiplash) causes peripheral nociceptors (previously silent polymodal C fibers) to become responsive → spontaneous signalling recognizing non-noxious stimuli as noxious due to lower threshold
-Decreased NE metabolites in CSF affects pain inhibition
-Decreased dopamine in CSF affects pain inhibition
** Fibro /CRPS pathophys - mech of central sensitization**
Wind up
–Following peripheral sensitization, persistent nerve impulses to the dorsal root of the spinal cord cause release of glutamate to act on NMDA and release inflammatory neuropeptides (eg substance P) that decrease threshold for excitability (i.e. windup)
Neuroplasticity
–More neurons transmitting pain signals expands receptive fields in the brain
Changes to brain structure
–Decreased blood flow to the thalamus and caudate nucleus (areas of brain that signal noxious stimuli)
–Increased blood flow to the insula, anterior cingulate cortex and primary/secondary somatosensory cortices (areas involved in pain perceptions, emotional modulation from any cause of chronic pain)
Fibro CNS pathophys evidence
- Increased excitability of dorsal horn nuclei (windup) -
- Expanded receptive fields for central pain perception
- Increased substance P, glutamate, and aspartate in CSF
- Decreased antinociceptive neurotransmitters eg NE, serotonin, and DA
** FM Nonpharm Tx**
Education
-Analgesia
-PT/Aerobic/Strength Training Exercise (endorphins, less microtrauma)
-Treat assoc’d: mood, sleep hyiene, IBS, migraine
-CBT
-Heated pool
** FM Pharm Tx and doses **
SNRI
– Duloxetine (20-60mg/d),
– Milnacipran (12.5mg daily → 50mg BID) for fibrofog/fatigue
– Venlafaxine (37.5mg daily → 75-150mg BID)
– **Tramadol **
– SSRI: fluoxetine, duloxetine
-Anticonvulsant
–Pregabalin (50qhs→ BID→ 75-150BID)
–Gabapentin (300-600TID)
-TCAs:
– Amitriptyline 10-25mg qhs
– Nortryptyline
– Cyclobenzaprine
-Others:
– Modafinil - for fatigue
– Trazodone - for sleep
– Naltrexone - for pain/mood
– Pramipexole
-Trigger point injxn w/ lidocaine +/- GC