Fibromyalgia: A Practical Clinical Guide

265 Pages·2011·3.545 MB·English

by  Atul Deodhar, Dawn A. Marcus (auth.)

Fibromyalgia
·
Dawn A. Marcus Atul Deodhar
Fibromyalgia
A Practical Clinical Guide
123
DawnA.Marcus AtulDeodhar,MD
DepartmentofAnesthesiology DivisionofArthritis&Rheumatic
UniversityofPittsburgh Diseases(OP09)
3550TerraceSt. OregonHealth&ScienceUniversity
A-1305ScaifeHall 3181SWSamJacksonParkRoad
Pittsburgh,PA15261,USA Portland,OR97239,USA
[email protected] [email protected]
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Preface
Fibromyalgia affects about 2–3% of adults worldwide, with women affected three
tosixtimesasoftenasmen.Whilefibromyalgiaisachronicpaindisorder,patients
with fibromyalgia typically present with a complicated constellation of painful
and non-painful complaints, including disabling fatigue, sleep disturbance, and
neuropsychological symptoms. Anxiety, mental distress, and cognitive dysfunc-
tion are reported by nearly two in every three fibromyalgia patients. One in three
fibromyalgia sufferers reports current depression, with a history of depression in
over half. Headaches are also common. Evaluating fibromyalgia patients requires
an understanding of the complex nature of this condition and the myriad of likely
fibromyalgia-relatedcomplaints.
Fibromyalgia is often poorly understood and unrecognized. Failure to identify
and treat fibromyalgia patients effectively can lead patients to feel misunderstood,
confused, and frustrated that their symptoms are not believed by their healthcare
providers, and discouraged about leading a full and rewarding life. Fibromyalgia
typicallyaffectsadultsduringwhatshouldbefulfillingandproductiveyears,when
theyarecaringforfamilies,developingcareers,andmakingastrongimpactontheir
communities. The good news for our patients is that fibromyalgia is straightfor-
wardtodiagnose,withsymptomseffectivelyreducedusingawiderangeofproven
medication,non-medication,andnon-traditionaltreatments.
WhenItoldafriendwhoisalsoafibromyalgiapatientaboutthisnewbook,
sheresponded,WhenIwasdiagnosedwithfibromyalgiaalmost10yearsago,
therewasn’tasmuchinformationastherehasbeeninthelastfewyears.I’m
glad to see that the medical community is finally recognizing this condition
andtreatingfibromyalgiamoreseriouslyandwithmorecompassion.
Fibromyalgia: A Practical Clinical Guide consolidates years of experience in
identifying and treating fibromyalgia from pain management and rheumatology
perspectives. The authors’ wealth of clinical practice and research has been com-
bined to provide easy-to-understand and practical tips for clinicians caring for
v
vi Preface
fibromyalgia patients. Case presentations and quotations from active fibromyal-
gia patients help highlight complaints and concerns commonly experienced by
fibromyalgiasufferers.Dr.DawnA.Marcusisaneurologist,painmanagementspe-
cialist, and professor at the University of Pittsburgh, with expertise treating and
researching fibromyalgia. She is an active writer and lecturer on topics related
to chronic pain and fibromyalgia and has authored several practical books for
both healthcare providers and lay audiences. Dr. Atul Deodhar is a rheumatolo-
gist,associateprofessorofmedicineattheOregonHealthandScienceUniversity,
and director of Rheumatology Clinics at Oregon Health and Science University.
Drs. Marcus and Deodhar previously collaborated to produce Chronic Pain: An
AtlasofInvestigationandManagement.
Fibromyalgia: A Practical Clinical Guide is designed to cut through the
hype about fibromyalgia and provide clinicians with up-to-date information about
fibromyalgiapathogenesisandclinicalevaluation,aswellasevidence-basedguide-
lines for effective treatment. This book includes fully referenced, cutting-edge
information on this fast-growing field and provides practical pointers for effec-
tively managing fibromyalgia patients. Treatment recommendations focus on tar-
geting symptoms most likely to respond to therapy and prescribing medication,
non-medication, and alternative/complementary treatments that have been proven
to reduce fibromyalgia symptoms. Boxes, tables, and figures are used widely
throughoutthetexttoprovidequickreferenceforthebusyclinicianseekinginfor-
mation. Clinically proven tools to help evaluate and treat fibromyalgia patients
include handouts for recording and monitoring fibromyalgia symptoms and sever-
ity, exercise instructions, and self-help guides for psychological pain management
techniques. Additional materials may be accessed through Dr. Marcus’ Web site
www.dawnmarcusmd.com. Both authors are eager to receive comments and sug-
gestionsforadditionsandimprovementstothebookthroughalinkavailableatthis
Website.
Pittsburgh,Pennsylvania DawnA.Marcus
Portland,Oregon AtulDeodhar
Contents
PartI Background
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
FibromyalgiaDefinitionandEpidemiology . . . . . . . . . . . . . . . . 9
DefiningFibromyalgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
EpidemiologyofFibromyalgia . . . . . . . . . . . . . . . . . . . . . . . . 12
Co-morbidConditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
FibromyalgiaBurden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
PathophysiologyofFibromyalgia . . . . . . . . . . . . . . . . . . . . . . 23
NerveAbnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
StructuralChanges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
FunctionalChanges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Neurotransmitters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
MusculoskeletalAbnormalities . . . . . . . . . . . . . . . . . . . . . . . . 28
MuscleDysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
CervicalSpineAbnormalities . . . . . . . . . . . . . . . . . . . . . . . 30
HormonalFactors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
GrowthHormone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
ThyroidFunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
NeuroendocrineAbnormalities . . . . . . . . . . . . . . . . . . . . . . . 32
InflammatoryMarkers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Genetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
FreeRadicalsandAntioxidants . . . . . . . . . . . . . . . . . . . . . . . . 34
Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
PredictiveFactors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
vii
viii Contents
AssessmentandDiagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . 41
AssessmentofFibromyalgia . . . . . . . . . . . . . . . . . . . . . . . . . 42
PainAssessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
AssessmentofTreatableCo-morbidSymptoms . . . . . . . . . . . . . . 45
DiagnosisofFibromyalgia . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
PartII CommonCo-morbiditiesandFibromyalgia
Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
PathophysiologyofHeadacheandFibromyalgia . . . . . . . . . . . . . . . 56
EvaluationandDiagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
AcuteTreatmentforMigraineandTension-TypeHeadache . . . . . . . . 65
PreventionTreatmentforFrequentMigraineorTension-TypeHeadache . 67
InjectionsandAlternativeTreatments . . . . . . . . . . . . . . . . . . . 68
ClusterHeadacheTreatment . . . . . . . . . . . . . . . . . . . . . . . . 70
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
ChronicFatigueSyndrome . . . . . . . . . . . . . . . . . . . . . . . . . 75
DefiningChronicFatigueSyndrome . . . . . . . . . . . . . . . . . . . . . 76
EpidemiologyofChronicFatigueSyndrome . . . . . . . . . . . . . . . . . 78
Co-morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
PathophysiologyofChronicFatigueSyndrome . . . . . . . . . . . . . . . 79
RoleofImmuneDeficiencyinChronicFatigueSyndrome . . . . . . . . 81
AssessmentofChronicFatigueSyndrome . . . . . . . . . . . . . . . . . . 82
TreatmentofChronicFatigueSyndrome . . . . . . . . . . . . . . . . . . . 83
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
IrritableBowelSyndrome . . . . . . . . . . . . . . . . . . . . . . . . . . 89
IrritableBowelSyndrome(IBS) . . . . . . . . . . . . . . . . . . . . . . . 92
DefinitionandEpidemiology . . . . . . . . . . . . . . . . . . . . . . . . 92
EvaluationandDiagnosis . . . . . . . . . . . . . . . . . . . . . . . . . 93
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
SleepDisturbance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
ConsequencesofSleepDisturbance . . . . . . . . . . . . . . . . . . . . . 103
CardiovascularDisease . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
PainSensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Contents ix
SleepDisturbanceinFibromyalgia . . . . . . . . . . . . . . . . . . . . . . 106
MeasuringSleepDysfunctioninFibromyalgiaPatients . . . . . . . . . . 107
TreatingSleepDisturbanceinFibromyalgia . . . . . . . . . . . . . . . . . 108
Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
BehavioralInventions . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
SleepHygieneMeasures . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Cognitive-BehavioralTherapy . . . . . . . . . . . . . . . . . . . . . . . 111
NaturalRemedies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
DepressionandAnxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
EvaluationandDiagnosisofCo-morbidMoodDisorders . . . . . . . . . . 118
Self-EfficacyandLocusofControl . . . . . . . . . . . . . . . . . . . . 119
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
ObesityandMetabolicSyndrome . . . . . . . . . . . . . . . . . . . . . 123
Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
ObesityinFibromyalgia . . . . . . . . . . . . . . . . . . . . . . . . . . 125
ConsequencesofObesity . . . . . . . . . . . . . . . . . . . . . . . . . . 125
TreatmentofObesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
MetabolicSyndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
MetabolicSyndromeinFibromyalgia . . . . . . . . . . . . . . . . . . . 130
TreatmentofMetabolicSyndrome . . . . . . . . . . . . . . . . . . . . . 130
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
PartIIITreatment
PublishedRecommendations . . . . . . . . . . . . . . . . . . . . . . . . 135
OttawaPanelEvidence-BasedExerciseGuidelines . . . . . . . . . . . . . 136
EuropeanLeagueAgainstRheumatism(EULAR) . . . . . . . . . . . . . . 137
GermanInterdisciplinaryAssociationofPainTherapy. . . . . . . . . . . . 139
LimitationsofCurrentGuidelines . . . . . . . . . . . . . . . . . . . . . . 139
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
MedicationTreatments . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
EffectiveMedications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Antiepileptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
SleepTherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
ModerateEfficacyMedications . . . . . . . . . . . . . . . . . . . . . . . . 151
x Contents
MinimalEfficacyMedications . . . . . . . . . . . . . . . . . . . . . . . . 152
GeneralFibromyalgiaMedicationRecommendations . . . . . . . . . . . . 152
EmergingTherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Non-medicationTreatments . . . . . . . . . . . . . . . . . . . . . . . . . 159
PhysicalTreatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Hydrotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
ManualTherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Yoga . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
WorkSimplificationandPacing . . . . . . . . . . . . . . . . . . . . . . 164
Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
PsychologicalTreatments . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Cognitive-BehavioralTherapyandOperant-BehavioralTherapy . . . . . 166
LifestyleModifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
SmokingCessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
SleepHygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
WeightManagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
DevelopingaTreatmentProgram . . . . . . . . . . . . . . . . . . . . . . . 171
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
NutritionalSupplements . . . . . . . . . . . . . . . . . . . . . . . . . . 175
IntravenousNutrientTherapy . . . . . . . . . . . . . . . . . . . . . . . . . 177
ChlorellaPyrenoidosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Methionine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Melatonin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
VitaminC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
VitaminD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Minerals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
CoenzymeQ10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Carnitine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Omega-3FattyAcids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
ClinicalHandouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
ChartingAssessmentandTreatmentDocumentationForms . . . . . . . . . 187
ChartingDocumentationForm1:FibromyalgiaTenderPoint
Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Charting Documentation Form 2: Fibromyalgia Patient
AssessmentRecordingSheet . . . . . . . . . . . . . . . . . . . . . . . . 189
Contents xi
ChartingDocumentationForm3:RevisedFibromyalgiaImpact
Questionnaire[FIQR] . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
ChartingDocumentationForm4:ScreeningforPsychologicalDistress . 191
ChartingDocumentationForm5:ScreenforLocusofControl . . . . . . 192
PatientEducationalHandouts . . . . . . . . . . . . . . . . . . . . . . . . . 194
PatientHandout1:UnderstandingFibromyalgia . . . . . . . . . . . . . 195
PatientHandout2:WholeBodyStretchesforFibromyalgia . . . . . . . 197
PatientHandout3:ExerciseforFibromyalgia . . . . . . . . . . . . . . . 203
PatientHandout4:PainManagementTechniques . . . . . . . . . . . . . 205
PatientHandout5:RelaxationTechniques . . . . . . . . . . . . . . . . . 207
PatientHandout6:SleepManagementforFibromyalgiaPatients . . . . . 208
PatientHandout7:NutritionalSupplementsforFibromyalgia . . . . . . 210
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
PartIV SpecialPopulations
FibromyalgiaandPregnancy . . . . . . . . . . . . . . . . . . . . . . . . 215
EpidemiologyofFibromyalgiaDuringPregnancy . . . . . . . . . . . . . . 216
FibromyalgiaandPregnancy . . . . . . . . . . . . . . . . . . . . . . . . 216
FibromyalgiaPost-partum . . . . . . . . . . . . . . . . . . . . . . . . . 218
FibromyalgiaandBreastfeeding . . . . . . . . . . . . . . . . . . . . . . 218
TreatingFibromyalgiaThroughoutPregnancy . . . . . . . . . . . . . . . . 218
Pre-conceptionPlanning . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
ModifyingNon-medicationTreatmentsDuringPregnancy . . . . . . . . 221
SafetyRatingSystems . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Antiepileptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
SodiumOxybate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Anti-emetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
LaborandDelivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
SafetyDeterminationswithBreastfeeding . . . . . . . . . . . . . . . . . . 229
Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
SodiumOxybate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Antiepileptics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
PlanningforNursingSuccess . . . . . . . . . . . . . . . . . . . . . . . . . 231
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
FibromyalgiainSeniors . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
FibromyalgiaAssessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
FibromyalgiaTreatmentinSeniors . . . . . . . . . . . . . . . . . . . . . . 241
Non-medicationTherapy . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244