HOW TO TAME FIBROMYALGIA - Dr Gillick1000+ new patients per year 100 +/- Fibromyalgia – 30 /w Dx . One-third UCSD Work Injuries 350 +/- new injuries per year 25 +/- active fibromyalgics

HOW TO TAME

FIBROMYALGIA

By Dr. John Gillick, MD, MPH, FACP

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Aarrggg!!

Controversies of FIBROMYALGIA jsgillick

FIBROMYALGIA

is the name given to a

CHRONIC PAIN

SYNDROME

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FIBROMYALGIA

FIBROMYALGIA

is

UNDERSTANDABLE

as well as,

readily

TREATABLE

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SUMMARY

Anesthesiology / Internal Medicine

Preventive Medicine: Occupational Medicine Associate Professor of Medicine & Anesthesiology, non-salaried, UCSD

Anesthesia and Pain Medicine (1970-94)

Private (77-94) / Military (70-77)

Army Reserve disability evaluation, fitness for duty, and

Preventive Medicine (1977-present).

Occupational Medicine - Internal Medicine

Comprehensive Disability Evaluation

(1993/4-present)

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BACKGROUND

John S. Gillick, MD, MPH

PRACTICE

Disability Evaluation

Occupational Medicine

Two-thirds

VA

Comprehensive Disability Evaluations

1000+ new patients per year

100 +/- Fibromyalgia – 30 /w Dx

. One-third

UCSD

Work Injuries

350 +/- new injuries per year

25 +/- active fibromyalgics - 5 /w Dx half of these, the fibromyalgia is intertwined with the work injury

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COMMONALITY

1 Heralding trauma(s)

or a history of cumulative traumas

2 Identifiable daily cumulative traumas

Simple traumas which

exceed the individual’s short-term recovery powers (coping) .

3 amplified pain perception

“hyperalgesia”

&

“allodynia”

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FIBROMYALGIA

Demystify

Simplify

Treat

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PURPOSE OF PRESENTATION


CLINICAL PRESENTATION

based upon

MY EXPERIENCE

PAST

THREE+ YEARS

> 300+ Meet ACR criterion

Treat about thirty each year

80% significant improvement


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Zero budget

Clinical or Research

Successful Management --> Premise Theory Seems to explain the condition

No hard Numbers

Burden of proof

requires

PROSPECTIVE SCIENTIFIC STUDY

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WHAT IS FIBROMYALGIA? (ACCEPTED MEDICAL COMMUNITY EXPLAINATION)

Idiopathic

----------------------

Chronic pain disorder – (most frequent)

-----------------

Widespread muscle pains

With associated fatigue, sleep dysfunction

and

Multiple systemic symptoms

------------------

Not a specific disease

nor a diagnosis of exclusion

-------------------

CLINICAL SYNDROME

with similar physical and constitutional manifestations

---------------------

Confirm the diagnosis

by history and clinical exam alone

no specific blood test, scan, etc.

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HISTORY & DEFINITION

a. 440 BC Hypocrites - regional and diffuse muscle pain

b. 1783 Ramizziniz - muscle pain and fatigue with repetitive motion

c. 1816 Balfour - a British surgeon described widespread muscle /

joint pains

d. 1841 Velliex - muscular rheumatism and widespread tender points

e. 1869 Beard - myelasthenia / neurasthenia

f. 1904 Glowers - fibrositis / lumbago

"ladies of blameless habits and abstemious clergymen“

g. 1915 Llewellyn & Jones - Fibrositis, myofibrositis

h. 1927 Albee - myofascitis, mimicry of other disorders

i. 1942 Travell - Myofascial trigger points, idiopathic myalgia

j. 1977 Smythe and Modofsky - Fibrositis syndrome

k. 1981 Yunis - fibromyalgia

l. 1990 American College of Rheumatology - definition (Wolfe, et al)

m. 1993 World Health Organization - recognition

(#2 most frequent Rheumatology diagnosis made) jsgillick

HISTORY:


DEFINING THE

CONDITION

1990

Rheumatologists collaborated, 1986-90

criterion & name

for

fibrositis, neuro-myasthenia, myofascitis, etc.

Fibromyalgia Syndrome

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American College of Rheumatology

(ACR) diagnosis requires

1) Chronic widespread myalgia (>3-6 months)

2) Pain in at least 11 of 18 ACR designated tender areas,

(including axial, above and below the waist,

and right and left sides)

3) Systemic manifestations

- fatigue, sleep dysfunction

- worsening with weather, stiffness

- numbness, tingling

- irritable bowel syndrome

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18 Points

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WHO GETS FIBROMAYALGIA ?

Almost anyone

5 to 10 times more frequent in women

High-functioning, hard-driving, over-achievers

Hereditary vulnerability

Population prevalence across cultures

2 and 8 percent

The US admits to about 2.5%

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VIEWS OF FIBROMYALGIA

General medical community

The lay public

The Fibromyalgic

Myself

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VIEWPOINTS

General Medical Community

Skepticism

Disbelief

Compassion

Suspicion

Frustration

Irritation

Avoidance

Detachment, and even,

Disdain

Arrogance

Dismissal jsgillick

VIEWPOINTS

Mainline explanation:

Growing pains, hysteria, somatization

Mainline treatment:

None specific

Centers on pain alleviation

Physical therapy & exercise

Then to the psychiatrist and/or pain doctor

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VIEWPOINTS

PROF IN A BOX

Who are they?

Practitioners or lecturers who:

--armchair clinicians--

--know about it by lectures/reading--

--see the condition infrequently--

--refuse to deal with it-- --don't get to know their patients with the condition…

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VIEWPOINTS

What do they do?

LABEL

fibromyalgia

as a psychiatric condition and

fibromyalgics

as malingerers -- people short in moral fiber and

those who treat fibromyalgia

as "quacks" jsgillick

VIEWPOINTS

What’s their rationale?

"If we don't understand it

and

If we can't measure it, or cure it with surgery or a pill

then

It doesn't exist in reality

Therefore

The condition is in the mind, a mental disorder,

or the person is faking it.”

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VIEWPOINTS

Lay Community’s View

Curiosity & fear…

The sufferers must be exaggerating, etc.

They are faking

whiners & wimps

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VIEWPOINTS

Fibromyalgic’s View

When active or hyper-active

Hurt all over

All the time, without relief

24 / 7

Afraid to talk about it

No decent sleep, have diarrhea

Social recluses

Snowed by pain meds, that don't work

Basic tasks require great concentration

Mask their feelings

Wonder if they are crazy

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VIEWPOINTS

The rest of the time (low active):

Dread weather changes

Ache and hurt

Smoldering pain: exacerbates and calms

They just "want to be normal."

Only look for help when totally "spent."

What’s beneath:

Fear, anger, blame

Defense, denial, and masking.

Frustration with health specialists

Search alternative medicine

* Call 'em liars or fakes and you anger them

*There's no better way to disable a person than to label

them as faker, liar, malingerer, exaggerator…. jsgillick

VIEWPOINTS

My View

A lot out there

Many more than we like to admit

Real and believable people

Deserve to be heard and helped

Beyond temporary pain alleviation

Real condition

Can be understood

Can be controlled

by the individual …

IEWPOINTVS

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UNDERSTAND

FIBROMYALGIA (FM)

(REMOVE THE MYSTERY) jsgillick

THE MYSTERY

THE KING

WITH MANY COSTUMES

THE MYSTERY

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KING WITHOUT

CLOTHES

THE MYSTERY

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FIVE CONCEPTS

To understand Fibromyalgia (FM)

It is necessary to understand:

I. Vulnerability

II. Cushion & Overload

III. Triggers & Enablers

IV. Active Fibromyalgia

V. Ownership

CONCEPTS

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I. VULNERABILITY

Appears to be familial

Women more vulnerable than men

No significant cultural, ethnic, geographic,

or generational predisposes or protectors

Increased vulnerability for some

Others - same triggers - no signs

(alcohol, nicotine addiction, diabetes)

Trigger anyone with enough trauma

CONCEPTS - I

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II. COPING, CUSHION, OVERLOAD,

OVERWHELM

Healthy coping mechanism rapid recovery from trauma and stress

Normal individuals readily cope with

ongoing traumas of daily life

Exceptional individuals can endure prolonged torture

Chronically stressed individuals (whether from illness, physical/mental stress, sleep depravation)

decreased coping capacity -- recovery can’t keep up

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CONCEPTS - II

Medically

neuro-muscular

restorative system

= coping capability

and

If restoration of neuro-muscular neutrality

cannot keep pace with daily trauma coping capacity

becomes overwhelmed

CONCEPTS - II

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When coping mechanisms are overwhelmed

PAIN AMPLIFICATION

occurs

pain-begets-pain

CONCEPTS - II

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Neurophysiology

of

Chronic Pain

Dickerson (5) & Yaksh(11)

Experimentally induced

Chronic pain In animal experimentation

document reproducible

anatomical / biochemical

central nervous system changes

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CONCEPTS - II

DETOUR

FINDINGS

0n-going hyper-stimulation of

Peripheral nociceptors

Causes anatomical changes spino-thalamic tract

anti-nociceptors & dorsal horn cells

dendritic nerve remodeling

&

inhibition

of the normal

Thalamic down regulation

of pain stimulus transmission

CONCEPTS - II

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DETOUR

CNS mechanism for

neutralizing pain reception

THALAMIC DOWN-REGULATION

= coping

With ongoing hyper-stimulation

anti-nociceptive system

doesn’t recover

&

Dysfunctional thalamic down-regulation

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CONCEPTS - II

DETOUR

With ongoing hyper-stimulation

inter-relationship between dorsal horn dendrites,

the nociceptive and anti-nociceptive receptors doesn’t recover

Nerve remodeling occurs with:

a) dendritic new growth toward the thalamus;

b) sympathetic nerve sprouting; &

c) crossing over of spino-thalamic lamina fibers

Nerve remodeling

dorsal horn hyper-excitability

and

Retrograde activation of nocioceptors by the hyper-active

remodeled anti-nocioceptors,

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CONCEPTS - II

DETOUR

Retrograde activation of nocioceptors,

RENEGADE neuropathic behavior

- perhaps the cause of visceral manifestations-

Also plays a role in the

allodynia and hyperalgesia common to the

chronic pain

syndromes

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CONCEPTS - II

DETOUR

III. T&E's

TRIGGERS AND ENABLERS

Triggers Fibromyalgia (FM)

has a beginning.

The initial cause is its TRIGGER

Enablers Once activated,

FM is kept active by

ongoing irritations or traumas

which I dub ENABLERS

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CONCEPTS - III

Triggers May be single or multiple

Commonly: macro-trauma

May be multiple micro-trauma

Enablers

Usually multiple

Ongoing (micro) traumas **

Residuals of macro-trauma triggers

Both

Macro-trauma

Commonly recognized injuries or

happenings with pain-producing consequences

Micro-trauma

Small traumas, often irritants for many,

the usual daily stuff that the ordinary Joe “sucks-up”

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CONCEPTS - III

Macro-trauma examples:

Multiple-trauma auto accidents; back injuries;

acute into chronic whiplash; difficult pregnancy;

shoulder trauma; non-union fractures; fall injury to

hip,leg, coccyx; arthropathies; etc.

Most commonly associated with TRIGGERS

Micro-trauma examples:

Chronic allergic sinusitis/rhiniitis; recurring

cervical / thoracic subluxations; wallet sciatica; feet:

shoe/arch problems; sleeping position/comfort

dysfunction; exercise/work traumas; gout; automobile

stick-shift, etc.

Most commonly associated with ENABLERS jsgillick

CONCEPTS - III

FIBROMYALGIA IS CATEGORIZED by itsTriggers

“Secondary” FM (10-30%) specific macro=trauma

rapid onset (3 mo)

“Delayed-secondary” FM: (20-30%) (concomitant)

onsets six months to several years

traumatic episode or disease (macro-trauma)

persists as residual on-going micro-trauma

"Primary” FM (50% +/-) "idiopathic" gradual onset

cumulative micro-traumas

no immediately obvious trigger(s)

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CONCEPTS - III

IV. FMS

THE FIBROMYALGIA SYNDROME “THE ULTIMATE CUMULATIVE TRAUMA OVERLOAD SYNDROME”

Systemic condition

“Hyperalgesia” - hypersensitive to noxious stimulus

“Allodynia" - identify non-noxious stimuli as noxious

Widespread neuro-muscular-spasm

"pain-begetting-pain“

“pain-amplification-chamber”

Daily activity trauma amplification

Neuro-physiological basis / explanation jsgillick

CONCEPTS - IV

Fibromyalgia starts:

WHEN :

coping mechanism overwhelmed (dysfunctional thalamic down-regulation)

(dysfunctional anti-nociceptive system)

MANIFESTS:

"pain amplification"

hyperalgesia and allodynia

widespread muscle spasm & pain

Fibromyalgia is kept active by:

ENABLERS:

Amplified by a dysfunctional CNS

“daily activity trauma amplification”

CONTINUES UNTIL:

enablers and triggers

neutralized

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CONCEPTS - IV

V. RESPONSIBILITY

& OWNERSHIP

FMS activity / control: - the individual - not the health professional.

Tools: - education

- behavior modification training

- adjunctive medications

- physical modalities

- emotional support

CONTROL by the individual

TOOLS from the health professional jsgillick

CONCEPTS - V

CONTROL OWNERSHIP

Fibromyalgia controls the individual

dominant factor limiting home and employment activities

Fibromyalgia may co-exists within the individual

temporarily “shut-it-down”

The fibromyalgic owns the condition

“turn-down," then "turn-off”

neutralize the triggers and enablers

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CONCEPTS - V

TREATMENT

(MANAGEMENT)

THREE AVENUES

1. CHANGE VULNERABILITY = ideal

2. PAIN MANAGEMENT = the most common, placation

3. T&E APPROACH = most effective

NEUTRALIZATION OF THE TRIGGERS AND ENABLERS

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TREATMENT SELECTION / EXPECTATIONS

T & E

NEUTRALIZE

the

TRIGGERS & ENABLERS

APPROACH

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T&E APPROACH

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T&E

Approach

Trigger & Enabler

Disabler

T&E APPROACH

REASONABLE GOALS

80%

80% calmed in a month

80% controlled in two months

80% "ownership" within four months

80% 80% TAMED IN SIX MONTHS

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PROVIDED 1. Primary patient agenda rid the condition

2. Knowledgeable healer as a guide

3. Individualized plan

- focused

- comprehensive

4. Educable, fully-committed, co-operative, persistent patient

5. Availability of modest and appropriate

a. pharmacologic tools

b. orthotic devices

c. work-home modifications

d. physical medicine resources

6. Co-operation and co-ordination of health care resources

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T&E APPROACH Control of Triggers and Enablers

1. Diagnosis

2. Selection

3. Educate

4. Identify T & E’s

5. Draft solutions

6. Apply solutions

7. Prevention

T&E APPROACH

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1

T&E #1a - Diagnosis

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DIFFERENTIAL

DIAGNOSIS

R/O other organic condition

differentiate from:

polymyalgia rheumatica

polymyositis

collagen vascular diseases

endcocrinopathies

etc.

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T&E #1b - Diagnosis

SCREENING LABS

CBC, ESR

CRP and CPK

Chemistries:

Include: glucose, BUN, creatinine, electrolytes,

calcium and phosphate, alkaline phosphatase,

ALT, AST, thyroid function screen, ANA, and

Rheumatoid Factor

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T&E #1c - Diagnosis

**PATIENT SELECTION** Attitude, Agenda, Attention - - - 80%

1. Doesn’t need the condition or diagnosis

- income, disability or other secondary gain

2. Is committed to self-control of the condition

- ready to make behavioral change

3. Has realistic expectations

- does not expect a magic pill or surgical / diet cure

4. Does not have a fixed agenda

5. Will use and continue successful adjunctive treatments

- give up problem behaviors

- terminate overload activities

6. Hates the condition more than loves enablers

- (shoes, car, activity)

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T&E #2 - Patient Selection

2

EDUCATION

The patient and the healer must clearly understand

and agree:

It is the healer’s role to:

- diagnose, teach, guide and assist

It is the patient’s role is to:

- make the necessary behavioral modifications

- review and maintain the necessary treatment remedies

- discover other helpful/harmful factors and seek aid for

remedies

- secure/pay for

necessary ancillary services, medicines and devices

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T&E #3a - Education

3

FIVE CONCEPTS

I. Vulnerability

II. Cushion & Overload

III. Triggers & Enablers

IV. Active Fibromyalgia

V. Ownership

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T&E #3b - Education

IDENTIFY T&E's

Fibro-specific exam

History

Physical

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T&E #4a - Identify T&E’s -- examination

4

Common discrete TRIGGERS

Traumas

Whiplash

Back injury

Non-healing fractures

Arthropathies (i.e., osteoarthritis)

Psych stress

Pregnancy

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T&E #4b - Identify T&E’s -- exam

Common ENABLERS

and enabler-triggers

Sinusitis/rhiniitis (breathe 168 hrs/wk)

Sleep -- position (bed – 50 hrs/wk)

Foot and shoe dysfunction (stand /walk –50 hrs/wk)

Repetitive impact loading (exercise – 5+ hrs/wk)

Driving equipment / behaviors (travel 15 hrs/wk)

Sitting (sit / slouch 60 hrs/wk)

Clothing, environment – day & night (clothed 160 hrs/wk)

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T&E #4c

History Fully list the symptoms & conditions :

Sinus or breathing problems

Medical problems

Orthopedic problems

Occupational and Environmental conditions / problems

Current treatments & past Specifically address and ask about:

thoracic and cervical spine low back

neck-shoulder bowel – diarrhea

shoes hip, back, knee

foot, ankle problems occupational injuries

automobile sports, workouts

hobbies second jobs

home work station psychological stressors

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T&E #4d - Identify T&E’s -- exam

Physical

"Fibro-thorough“

“Fibro-specific”

physical examination and observation

Different from standard classical

“physical exam”

Exam of observation and listening start and finish

patient clothed

Understanding and familiarity daily living ergonomics

myofascial trigger

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T&E #4e - Identify T&E’s -- exam

NAME & ID # SYMPTOMS # # #

DATE #1 Sinusitis / rhiniitis

DATE #2 Sleep disorder

DATE #3 Multiple allergies

DATE #4 Fatigue

Headaches

TENDER AREAS Light headednessR L FELT AS PAIN R L R L R L Jaw Pain (TMJ)

1 Occiput Chest pain

2 Low cervical Irregular Heart

3 Trapezius Stiffness

4 Supraspinatus Cold intolerance

5 Second rib Worsen /w weather

6 Lateral epicondyle Anxiety

7 Outer gluteal Numbness & weak

8 Greater Trochanter Raynaud's

9 Knee fat pad Shoulder dysfunction

Feel swollen

Carpal tunnel

#1 Global Function #2 #3 #4 Heartburn

Fibro Functional Level Upset stomach

scale of 0 - 4 Irritable bowel

Standard Pain Scale Diarrhea/Constipation

scale of 1 to 10 Irritable bladder

Ovarian pain

Dysmenorrhea

#1REMEDIES

#

2

#

3

#

4

Endometriosis

Orthotics-shoe change Cervical SpineSleep position Thoracic SpineAutomobile - Stick shift Low backWallet in pocket - Sacro/CoccyxGlasses change Hip painsClothing Radiculopathy / armsSinus medication Radiculopathy / legsAllergy medication Patello-femoralTricyclic Ankle sprain, etc.Analgesic Plantar fasciitisGabapentin Flat feet

Bunions / Morton's

#1 #2 #3 #4

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Documents

HOW TO TAME FIBROMYALGIA - Dr Gillick1000+ new patients per year 100 +/- Fibromyalgia – 30 /w Dx . One-third UCSD Work Injuries 350 +/- new injuries per year 25 +/- active fibromyalgics