​Kembara Xtra - Medicine - Fibromyalgia

​Kembara Xtra - Medicine - Fibromyalgia 
Multiple system manifestations of chronic, broad, noninflammatory musculoskeletal pain. The exact cause is unknown, although it is assumed to be a disease in which the brain's normal pain-control mechanisms malfunction.
Fibromyalgia syndrome; fibrositis; fibromyositis (incorrectly called)


Incidence in Epidemiology
Seventy to ninety percent of participants are women, whereas only ten to twenty percent are men. 2%-5% of the adult U.S. population have it (1), and 8% of those who see their primary care doctor have. 


Causes and Mechanisms of Illness 
Changes in neuroendocrine, neuromodulatory, neurotransmitter, neurotransporter, biochemical, and neuroreceptor function/physiology Abnormalities in sleep —-wave intrusion Apparent primary disorder of central pain processing (central sensitization) Afferent augmentation of peripheral nociceptive stimuli
Fibromyalgia is not characterized by widespread inflammation, although it may be related to immunologic processes occurring locally in the central nervous system.
The exact mode of inheritance is unclear, but it's likely polygenic.
A first-degree relative of a familial proband has an odds ratio of as high as 8.5. Environmental—several triggers have been described, including: - Extreme illness or a traumatic physical injury
Work, family, unexpected events, and physical or sexual abuse are all examples of stressors. Infections, both bacterial and viral

Low socioeconomic position, negative/stressful life experiences, and being a woman are all risk factors.

Prevention

The absence of effective preventative measures


Related Disorders 
Obesity is prevalent and has been linked to increased symptom severity, and it is frequently co-morbid with other rheumatologic or neurological illnesses.

Diagnosis The original ACR criteria from 1990 are still commonly utilized today. 2010/2011 ACR criteria, amended in 2016 (1) - Based on Widespread Pain Index (WPI) and Symptom Score (SS) - (i) pain in all four quadrants > 3 months, (ii) axial (neck/spine) involvement, and (iii) tender spots 11. For a diagnosis of fibromyalgia, the following criteria must be met: Pain in at least four of the five major body regions Must have WPI 7 + SS 5, or WPI 4 and SS 9 Symptoms lasting at least three months Fibromyalgia may be diagnosed regardless of any active disease entities (i.e., it need not be the only reason for the patient's symptoms).
● Patients' functional level should be evaluated initially and periodically using the Visual Analogue Scale Fibromyalgia Impact Questionnaire (VASFIQ).


History Presenting Symptoms - Chronic widespread pain lasting more than three months, affecting both extremities and the midsection
Frequent occurrence:
Depression, anxiety, and panic attacks are all examples of mood disorders. Disruption of thought processes that is fundamentally distinct from that which is evident in singular mood disorders (also known as "fibro fog"). - A variety of headaches, most frequently tension and migraine
- Small-fiber neuropathies and "nonanatomic" paresthesias - Other regional pain syndromes such irritable bowel syndrome, chronic pelvic discomfort, vulvodynia, and interstitial cystitis
Daily fluctuations in the quality, intensity, and location of symptoms are common, including: - intolerance to exercise, shortness of breath, and palpitations - sexual dysfunction - ocular dryness - "multiple chemical sensitivity" and an increased propensity to report drug reactions - impaired social/occupational functioning.

Medical Diagnosis 
The standard number of fibromyalgia TPs is 9, split evenly between the front and back.
The presence of 11 or more TPs has an 88% disease sensitivity and an 81% disease specificity. 
TPs in fibromyalgia are not therapeutic injection sites, and they differ from "trigger points" in myofascial pain syndromes.
Check for crepitus, cysts, and mass lesions, as well as swelling, discomfort, erythema, restricted range of motion, and crepitus in the joints. Fibromyalgia sufferers rarely experience them.
Synovitis, enthesopathy, dermatologic, and ocular abnormalities should not be present, therefore be sure to note this.
Generalized or "nonanatomic" dysesthesia, hyper- or hypesthesia may be found on a neurological exam.

Differential Diagnosis-Rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, and other inflammatory connective tissue disorders ,Diffuse/advanced osteoarthritis Seronegative spondyloarthropathies (psoriatic arthritis, ankylosing spondylitis, etc.),polymyalgia rheumatica; inherited myopathies; drug-induced and endocrine myopathies; viral/postviral polyarthralgia; anemia and iron deficiency; sickle-cell anemia; electrolyte disturbances (Mg, Na, K, Ca); restless leg syndrome; osteomalacia/vitamin D deficiency; joint hypermobility syndromes (Ehlers-Dan
Myofascial pain syndrome (more physically localized than fibromyalgia, but they may co-occur) and chronic fatigue/immune dysfunction syndrome (CFIDS) .

Research Results 

We recommend beginning with a complete blood count (CBC), electrolyte and inflammatory marker (ESR or CRP), complete metabolic profile (CPK, TSH), and maybe 25-hydroxyvitamin D (25-OH vitamin D), magnesium, vitamin B12, folate, and a urine drug screen.
Unless there is evidence of an inflammatory connective tissue illness, rheumatologic labs such as the antinuclear antibody (ANA) and the rheumatoid factor (RF) are usually unneeded.
Unless ruling out other possible diagnosis, imaging is not necessary.

Tests and Other Methods of Diagnosis

It may be necessary to conduct a sleep study in order to rule out obstructive sleep apnea or narcolepsy.
Think about getting checked out by a psychiatrist or neuropsychiatrist if you've been experiencing emotional or mental instability.

Interventions in management supported by evidence Both pharmacologic and nonpharmacologic approaches are included. Only by making serious adjustments to one's lifestyle, such as engaging in regular exercise, practicing good sleep hygiene, and giving up smoking, can a partial or complete remission be obtained.
Methods that do not involve the use of pharmaceuticals include: Fibromyalgia and chronic pain have a number of online resources available, including those listed below.
VASFIQ for both the initial exam and follow-up assessments during treatment Mood, energy, pain, and functional status can all benefit from cognitive-behavioral therapy (CBT).
Commitment and acceptance treatment (ACT)
Aerobic exercise should be performed at a modest intensity and progressively increased in order to prevent the worsening of symptoms ("start low and slow"). Strength training: light to moderate
- Tai chi: as good as or better than cardio (3)[A]
Aerobic, anaerobic, and flexibility training in one session; losing weight, which may increase the effects of exercise.
Improve your sleep hygiene; reduce or quit using smoke, alcohol, or other drugs.
The FDA has approved three pharmaceutical treatments for PTSD: duloxetine, milnacipran, and pregabalin. Recent research suggests that only a subset of patients benefit from these medications as monotherapy.
Patients with fibromyalgia are often prescribed multiple medications at once, so it's important to keep an eye out for adverse reactions, such as sedation, serotonin syndrome, and anticholinergic reactions.

Treatment with Drugs Initially

Treatment of discomfort, weariness, and sleep problems with amitriptyline (10-50 mg PO before bedtime) (4)[A]. It's possible that other tricyclic antidepressants (TCAs) wouldn't be any less helpful.
Duloxetine 30 mg once day for a week, then up to 60 mg once daily if tolerated. When stopping, reduce gradually.
First day: 12.5 mg; second and third days: 12.5 mg BID; fourth through seventh days: 25 mg BID; eighth through fourteenth days: 50 mg BID; fifteenth through twentieth days: 100 to 200 mg BID; maximum dose: 12.5 mg BID. Reduce gradually if stopping.

Maximum daily dose of 450 mg (other authorities prescribe up to 600 mg daily) of pregabalin, taken as 75 mg BID on Day 1 and Day 2 and Day 3 and Day 5, with food.
As tolerated, increase cyclobenzaprine dosage from 5 mg qHS to 10 mg BID-TID.
Sequence Two

Maximum daily dose of 3,600 mg on gabapentin (recommended starting dose 300 mg HS, increasing to 1,200-2,400 mg BID-TID)
Tramadol 50–100 mg q6h; possibly more effective in combination with acetaminophen; venlafaxine xr 37.5–225 mg; likely as effective as other SNRIs (duloxetine, milnacipran)
Several medicines, including pramipexole, memantine, low-dose naltrexone, medical cannabis, and hyperbaric oxygen therapy, have showed promise of efficacy, albeit little data.

Patients with low 25- OH vitamin D levels may benefit from cholecalciferol.
REFERRAL QUESTIONS
Refer to specialists in rheumatology, neurology, and/or pain management if you are having trouble making a diagnosis or feeling better after treatment.

Added Therapies 
Regional myofascial dysfunction may be alleviated by trigger point (not tender point) injections.
"Multidisciplinary Rehab" means a clinic that offers more than one type of treatment for patients.
Nonsteroidal anti-inflammatory drugs (NSAIDs), full-agonist opioids (except in refractory cases), benzodiazepines, selective serotonin reuptake inhibitors (SSRIs) (although may have efficacy in combination therapy with TCAs or pregabalin), magnesium, guaifenesin, thyroxine, corticosteroids, DHEA, valacyclovir, interferon, calcitonin, (5)
Although NSAIDs, corticosteroids, opioids, and other medicines may help with the pain associated with fibromyalgia, the condition commonly coexists with other pain syndromes.

Different Medical Practices 
Myofascial massage, low-level laser treatment, and mindfulness-based meditation have shown short- to medium-term benefits, as have acupuncture and electroacupuncture, biofeedback, and hypnotherapy.
S-adenosyl-l-methionine and acetyl-L-carnitine supplements have been demonstrated to be useful in small, double-blind studies.
Transcranial direct current and other forms of cranial electrical stimulation have rather flimsy evidence, and chiropractic care, multivitamin therapy, and homeopathy are probably not going to help. 

Constant Patient Supervision
Treatment frequency after initial assessment of response: every 1–6 weeks for the first few months, then every 2–4 weeks as needed.
Exercise should be progressed gradually to prevent intolerance.
HEALTHY CHOICES The patient has to eat well and break bad eating patterns. Obese patients might benefit from cutting back on calories or carbs. Patients who followed hypocaloric, vegan, and low fermentable saccharides and polyols (FODMAP) diets experienced less pain.

Poorer outcomes linked to longer duration and severity of symptoms, depression, obesity, insufficient engagement and "ownership" of the treatment plan, advanced age, and lack of social support. Prognosis 50% with partial remission after 2–3 years of therapy; complete remission possible but rare.