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Dupuytren’s Dupuytren’s ContractureContracture

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Dupuytren’s ContractureDupuytren’s Contracture Fibrous tissue of the palmar fascia to Fibrous tissue of the palmar fascia to

shorten and thicken shorten and thicken Common in men older than 40 years; in Common in men older than 40 years; in

persons of Northern European descent; and persons of Northern European descent; and in persons who smoke, use alcohol, or have in persons who smoke, use alcohol, or have diabetes (3 to 33 %)diabetes (3 to 33 %)

Present with a small, pitted nodule (or Present with a small, pitted nodule (or multiple nodules) on the palm, which slowly multiple nodules) on the palm, which slowly progresses to contracture of the fingers progresses to contracture of the fingers

Progresses' faster in <50 yr oldsProgresses' faster in <50 yr olds Smoking and alcohol use increase the Smoking and alcohol use increase the

chance that surgery will be neededchance that surgery will be needed

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Dupuytren’s Dupuytren’s ContractureContracture

Found on the palm of the Found on the palm of the hand proximal to the hand proximal to the metacarpo-phalangeal metacarpo-phalangeal (MCP) joint. Can be (MCP) joint. Can be bilateralbilateral

Patients usually have Patients usually have difficulty with tasks such difficulty with tasks such as face washing, hair as face washing, hair combing, and putting combing, and putting their hands in their their hands in their pockets. pockets.

Note the site of the Note the site of the nodule and the presence nodule and the presence of contractures; bands; of contractures; bands; and skin pitting, and skin pitting, tenderness, and dimpling.tenderness, and dimpling.

Grade 1 disease presents Grade 1 disease presents as a thickened nodule as a thickened nodule and a band in the palmar and a band in the palmar aponeurosis; this band aponeurosis; this band may progress to skin may progress to skin tethering, puckering, or tethering, puckering, or pitting. pitting.

Grade 2 presents as a Grade 2 presents as a peritendinous band, and peritendinous band, and extension of the affected extension of the affected finger is limited. finger is limited.

Grade 3 presents as Grade 3 presents as flexion contractureflexion contracture

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FibromyalgiaFibromyalgia

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Characteristic features:Characteristic features: Chronic widespread pain for at least Chronic widespread pain for at least

three monthsTender points in 11 of 18 three monthsTender points in 11 of 18 specific anatomic locationsspecific anatomic locations

Associated featuresAssociated features AnxietyAnxiety Cognitive difficultiesCognitive difficulties FatigueFatigue Headache (50%) (migraine)*Headache (50%) (migraine)* Paresthesias, morniing stiffnessParesthesias, morniing stiffness Sleep disturbanceSleep disturbance

*?a defect in the serotonergic and *?a defect in the serotonergic and adrenergic systemsadrenergic systems

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Associated FindingsAssociated Findings History of trauma, History of trauma,

childhood abuse, anxiety, childhood abuse, anxiety, depression, or sleep depression, or sleep disorder (alpha frequency disorder (alpha frequency rhythm, termed alpha-delta rhythm, termed alpha-delta sleep anomaly )sleep anomaly )

Patients with high tender Patients with high tender point counts are more likely point counts are more likely to report adverse childhood to report adverse childhood experiences like loss of a experiences like loss of a parent or abuse parent or abuse

Irritable bowel syndrome Irritable bowel syndrome (IBS)(IBS)

Other disorders commonly Other disorders commonly associated with FM include:associated with FM include:

Irritable bladderIrritable bladder Dysmenorrhea Dysmenorrhea Premenstrual syndrome Premenstrual syndrome Restless leg syndrome Restless leg syndrome Temporomandibular joint Temporomandibular joint

pain pain Noncardiac chest pain Noncardiac chest pain Raynaud's phenomenon Raynaud's phenomenon

and Sicca syndrome and Sicca syndrome (Sjogren’s)(Sjogren’s)

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Other Other Diagnoses/AssociatedDiagnoses/Associated

Myofascial pain syndrome, Myofascial pain syndrome, Chronic fatigue syndrome, and Chronic fatigue syndrome, and Hypothyroidism. Hypothyroidism.

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Myofascial pain syndromeMyofascial pain syndrome Characterized by painful, tender areas in the Characterized by painful, tender areas in the

muscles. muscles. It is a localized disorder without any systemic It is a localized disorder without any systemic

manifestations.manifestations. It commonly affects the axial muscles. It commonly affects the axial muscles. In contrast to the widespread pain of In contrast to the widespread pain of

fibromyalgia, the pain in myofascial pain fibromyalgia, the pain in myofascial pain syndrome arises from trigger points in syndrome arises from trigger points in individual muscles. individual muscles.

On examination, the presence of trigger points On examination, the presence of trigger points is characteristic of myofascial pain syndrome. is characteristic of myofascial pain syndrome.

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Chronic fatigue syndrome Chronic fatigue syndrome (CFS)(CFS)

Chronic pain and fatigue are common to Chronic pain and fatigue are common to chronic fatigue syndrome and fibromyalgia. chronic fatigue syndrome and fibromyalgia.

CFS an ongoing subclinical inflammatory CFS an ongoing subclinical inflammatory process manifested by low-grade fever, process manifested by low-grade fever, lymph gland enlargement, and acute onset lymph gland enlargement, and acute onset of the illness, whereas there is no evidence of the illness, whereas there is no evidence of inflammatory response in fibromyalgia. of inflammatory response in fibromyalgia.

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HypothyroidismHypothyroidism

Manifested by profound fatigue, muscle Manifested by profound fatigue, muscle weakness, and generalized malaise, closely weakness, and generalized malaise, closely resembles fibromyalgia.resembles fibromyalgia.

Patients need to be examined for clinical signs Patients need to be examined for clinical signs of thyroid dysfunction and, if in doubt, thyroid of thyroid dysfunction and, if in doubt, thyroid function tests should be ordered to rule out function tests should be ordered to rule out hypothyroidism.hypothyroidism.

(The differential diagnosis also might include (The differential diagnosis also might include metabolic and inflammatory myopathies metabolic and inflammatory myopathies (especially in patients taking statins), (especially in patients taking statins), polymyalgia rheumatica, and other rheumatic polymyalgia rheumatica, and other rheumatic diseases.diseases. ) )

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optimal intervention is an approach that optimal intervention is an approach that also includes nonpharmacologic also includes nonpharmacologic treatments, specifically exercise and treatments, specifically exercise and cognitive behavior therapy cognitive behavior therapy

education, cognitive behavior strategies, education, cognitive behavior strategies, physical training, and medications for physical training, and medications for treatment of fibromyalgia treatment of fibromyalgia

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FIBROMYALGIA-ReviewFIBROMYALGIA-Review

Multi symptom condition

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Multi symptom conditionMulti symptom conditioncharacterized by chronic widespread characterized by chronic widespread painpain

Muscular pain Fatigue Sleep abnormalities Joint pain Headaches Restless legs

Numbness Impaired memory Leg cramps Impaired

concentration Nervousness Major depression

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Patient-Reported Symptoms at Diagnosis of Fibromyalgia

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FeaturesFeatures3 months or longer in all 4 quadrants of the body, but not centered in the joints

Lower pain threshold: Allodynia-pain from normally non noxious stimuliHyperalgesia-increased response to painful stimuliUnder diagnosed and undertreated (Prevalence:2% to 4%)/

Onset usually at 20 to 55 years/ F:M 9:1First-degree relatives of FM patients have 8 times the risk

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?etiology?etiology

Pain amplificationPain amplificationLower levels of metabolites of serotonin and Lower levels of metabolites of serotonin and norepinephrine in their cerebrospinal fluidnorepinephrine in their cerebrospinal fluid

Increased levels of pro-nociceptiveIncreased levels of pro-nociceptive

transmitters substance P and glutamate thattransmitters substance P and glutamate that

amplify pain impulsesamplify pain impulses

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No objective laboratory test or markerNo objective laboratory test or markerexists, diagnosis is based on history and exists, diagnosis is based on history and

physical examinationphysical examinationChronic Widespread Pain for at least 3 Chronic Widespread Pain for at least 3 months months and pain on at least 11 of 18 and pain on at least 11 of 18 specified specified muscle muscle tendon sites of focal tendon sites of focal tenderness tenderness (“tender (“tender points” 11/18)points” 11/18)Use of a structured interview with questions Use of a structured interview with questions

about generalized fatigue, headache, about generalized fatigue, headache, sleep disturbance, neuropsychiatric complaints,numbness or tingling, and irritable bowel

symptoms.

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POINTS OF TENDERNESSPOINTS OF TENDERNESS

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?TREATMENT Eval Criteria?TREATMENT Eval Criteria

SYMPTOM CRITICAL FOR EVAL%

Pain 100

Fatigue 94

Patient global improvement

94

Multidimensional function 86

Tenderness 7474

Sleep 66

Health-related quality of life

65

Dyscognition 61

Stiffness 6060

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Current Knowledge AboutPharmacotherapies

‘Off label’SNRIs Anticonvulsants Tricyclic antidepressants (TCAs) Muscle relaxants SSRIs OpioidsNonsteroidal anti-inflammatory drugs (NSAIDs) andCyclo-oxygenase (COX2) inhibitors

FDA ‘approved’FDA ‘approved’ Pregabalin(Lyrica) Duloxetine

Hydrochloride (Cymbalta) Milnacipran

Hydrochloride(Savella)

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Pregabalin(Lyrica)

Duloxetine Hydrochloride (Cymbalta)

Milnacipran Hydrochloride(Savella)

Alpha2 receptor SNRI SNRI

150-225 mg bid150-225 mg bid

75 mg bid75 mg bid

May increase to 150 mg May increase to 150 mg bid within 1 wkbid within 1 wk

Maximum dose 225 mg Maximum dose 225 mg bidbid

60 mg/dStart 30 mg/d for 1 wk, increase to 60 mg/d

50 mg bid (start 12.5 mg/d, increase on day 2 to 12.5 mg bid,on day 4 to 25 mg bid, after day 7 to 50 mg bid) Maximum dose 200 mg/d

Angioedema, hypersensitivityreactions, peripheral edema

Suicidality, orthostatic hypotension, serotonin syndrome

Suicidality, orthostatic hypotension, serotonin syndrome

Dizziness, somnolence, dry mouth, edema, blurred vision, weight gain, difficulty with concentration/attention

Nausea, dry mouth, constipation,somnolence, hyperhidrosis,decreased appetite

Nausea, headache, constipation,dizziness, insomnia, hot flush, hyperhidrosis, vomiting, palpitations,heart rate increase, drymouth, hypertension