fibromyalgia criteria

[PinchandBurn]

hey guys-

someone that went to a recent course stated that apparently for "board purposes' the American College of Rheumatology changed the criteria for dx of FM. Instead of having 11 out of 18 tender points, reportedly now a patient just has to 'say they have 11 tender points".

Which sounds a little strange as it avoid 'objective' evidence.

Is this true? Any updated info? I tried googling w/o any success.

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[Ducttape]

nowadays, all a patient has to do is say "i have fibro"...

 

[lobelsteve]

And they get access to Lyrica, Cymblata, Savella, a muscle relaxant, and PT.

OK, I'll throw in naloxone 5mg compounded for the severe folks, and have no problem with Ultram. But not other meds, no procedures. Finding out about who beat them, insulted them, or the crazy uncle in a clown suit is just so much fun. Then I can add in counseling.

FMS is the easiest thing I treat. It is 99% the patient's treatment and I provide a little guidance..



http://www.rheumatology.org/practic...lgia/2010_Preliminary_Diagnostic_Criteria.pdf

 

[Ducttape]

i push the exercise routine. some patients seem kinda upset i spend more time talking about exercise and even occasionally tell them to remember "no pain, no gain" kind of philosophy.

course, these are the same fibro patients that develop excruciating pain pushing away from the dinner table ("and thats why i stay at the dinner table so long")

 

[facetguy]

Do you guys find many of your FM patients also have IBS or other functional GI problems? There is increasing interest in small intestinal bacterial overgrowth (SIBO) in various conditions, particularly IBS. It would be nice to see a good sized study of FM patients treated with rifaximin, for example, to see if they make any significant improvement. Perhaps the gut will become a therapeutic target for FM patients in the future.

 

[Apollyon]

Irritable bowel, fibromyalgia, interstitial cystitis, chronic fatigue - all somatic representations of psychological problems. Something is affirmatively there (the uros can see it on scope), but it is somatic representations of psychological problems.

I had an episode of depression after being diagnosed with diabetes. I had all these aches and pains, and I said that I would be DAMNED before I had the "fiber". My doc told me the aches and pains would go away with resolution of the depression, and, you know what? He was right!

 

[facetguy]

Irritable bowel, fibromyalgia, interstitial cystitis, chronic fatigue - all somatic representations of psychological problems. Something is affirmatively there (the uros can see it on scope), but it is somatic representations of psychological problems.

I had an episode of depression after being diagnosed with diabetes. I had all these aches and pains, and I said that I would be DAMNED before I had the "fiber". My doc told me the aches and pains would go away with resolution of the depression, and, you know what? He was right!

I think we'll find that gut flora have a lot to do with the very neuroendocrinology and psychological problems you mention. The so-called gut-brain axis. It's an active area of research.

 

[bedrock]

I think we'll find that gut flora have a lot to do with the very neuroendocrinology and psychological problems you mention. The so-called gut-brain axis. It's an active area of research.

All possibilities. All I know is that none of these people need opioids.

Which mess up your bowels anyway, right......?

 

[PMR 4 MSK]

Irritable bowel, fibromyalgia, interstitial cystitis, chronic fatigue - all somatic representations of psychological problems. Something is affirmatively there (the uros can see it on scope), but it is somatic representations of psychological problems.

I like to ask Gyns this question - "When you do routine surgery, such as hysterectomy, tubals and similar, what % of the time do you see endometriosis in a patient who does not have symptoms of it?" Most have said > 50%.

Irritable bowel appears to be a purely functional disorder - no real pathology known.

I have seen very few fibro pts who don't have at least 1-2 other somatic disorders or complaints.

 

[painstop]

All possibilities. All I know is that none of these people need opioids.

Which mess up your bowels anyway, right......?

Agreed. I don't even prescribe tramadol for these folks (the evidence for its efficacy in this population is poor as well...one could argue about the serotonin aspect but I think there are better ways to accomplish this without the opiod effects and possible opioid-induced hyperalgesia).

Neurontin/Lyrica (often max or near-max dose)
Cymbalta/Savella (insurance), Elavil/Pamelor/Doxepin/favorite SSRI (no insurance)
Warm water therapy (insurance), exercise and hot baths (no insurance)
Good sleep hygiene
Yoga/acupuncture/tai-chi/massage
CBT/pain coping support group/psychological therapy for various past and present issues

Off-label stuff like naloxone, ketamine infusions, diet changes, etc. are intriguing

 

[powermd]

I'm unaware of any law of nature that says a patient with FMS can't also have focal, treatable pain generators as well.

 

[olivercall]

And they get access to Lyrica, Cymblata, Savella, a muscle relaxant, and PT.

OK, I'll throw in naloxone 5mg compounded for the severe folks, and have no problem with Ultram. But not other meds, no procedures. Finding out about who beat them, insulted them, or the crazy uncle in a clown suit is just so much fun. Then I can add in counseling.

FMS is the easiest thing I treat. It is 99% the patient's treatment and I provide a little guidance..



http://www.rheumatology.org/practic...lgia/2010_Preliminary_Diagnostic_Criteria.pdf

Wow. That is a really mean, selfish, and unprofessional thing to say. Espically coming from a "doctor". I pray your children are never physically abused by anyone in their lifetime. Maybe then you would have more compassion for others.

Yes I am new (been lurking for almost a year now). Will post an introduction later.

 

[facets]

Look deeper, that type of comment is from frustration and helplessnesss, not meaness, we all have done that when overwhelmed with the misery of what we see

 

[Dr. Ice]

Wow. That is a really mean, selfish, and unprofessional thing to say. Espically coming from a "doctor". I pray your children are never physically abused by anyone in their lifetime. Maybe then you would have more compassion for others.

Yes I am new (been lurking for almost a year now). Will post an introduction later.

Perhaps a "student" should pass some type of board exam and get some real world experience before calling practicing physicians "mean, selfish and unprofessional."

 

[Ducttape]

Wow. That is a really mean, selfish, and unprofessional thing to say. Espically coming from a "doctor". I pray your children are never physically abused by anyone in their lifetime. Maybe then you would have more compassion for others.

Yes I am new (been lurking for almost a year now). Will post an introduction later.

you obviously misinterpreted his comment. he is not saying that it is fun/good/etc that someone has been abused. only that finding out such information is necessary and helpful, and then therapy directed at the root cause can be initiated.

 

[ampaphb]

I'm unaware of any law of nature that says a patient with FMS can't also have focal, treatable pain generators as well.

Completely agree, but you have to address the supra-tentorial issues prior to parsing specific pain generators. Otherwise way too much "noise" gets in the way.

 

[powermd]

Completely agree, but you have to address the supra-tentorial issues prior to parsing specific pain generators. Otherwise way too much "noise" gets in the way.

I find that a lot of my patients with FMS have accepted that as part of their life, and understand there is no specific medical treatment likely to make a huge difference. I suspect that our no-opioid policy likely tends to select for this. I explain the concept of the focal, treatable pain generator, versus the untreatable (not with injections anyway), central pain generator, and they generally understand this. I explain to them that injecting for FMS symptoms tends to cause greater pain than it treats, and local anesthetic doesn't produce the expected "numbness in the area that was previously painful" for a focal pain generator. They seem to appreciate that as well, as I ham up my disappointment that a particular injection didn't work out.

As for addressing the supratentorial issues, I find it's a waste of time at best, and at worst the patient turns on you with hatred since you think "it's all in her head". In very select cases, I refer for psych coping skills, counseling, and biofeedback. My spidey sense for who will appreciate the referral seems pretty good. In fellowship I was taught you have to address the head first in FMS before doing anything with the body. In PP I've discovered that's not necessarily true. I've had lots of success treating focal pain generators in patients with CWPS.

 

[SSdoc33]

Wow. That is a really mean, selfish, and unprofessional thing to say. Espically coming from a "doctor". I pray your children are never physically abused by anyone in their lifetime. Maybe then you would have more compassion for others.

Yes I am new (been lurking for almost a year now). Will post an introduction later.

its not about a lack of compassion. animals don't have to deal with their parents beating them up or their stepfathers doing unspeakable things. we have all seen so much of this in our practice that we can usually tell that something isnt quite right in these patients.

but thats not the sort of experience i would expect you to see while squeezing a dog's butt-gland all day.

 

[giddyup]

I have had fairly good results with infusion therapy for widespread body pain like in fibro. Ketamine, lidocaine, etc. It may be partially a placebo effect, but If the patient thinks it helps I'm happy to offer it.

 

[facetguy]

I have had fairly good results with infusion therapy for widespread body pain like in fibro. Ketamine, lidocaine, etc. It may be partially a placebo effect, but If the patient thinks it helps I'm happy to offer it.

Is that treatment typically reimbursed by insurances in these FM cases?

 

[lobelsteve]

I have had fairly good results with infusion therapy for widespread body pain like in fibro. Ketamine, lidocaine, etc. It may be partially a placebo effect, but If the patient thinks it helps I'm happy to offer it.

And this is scientifically validated and without much risk?

Sounds nutty to me.

Hang out in Phila much?

 

[Ducttape]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC126218/

i dont do it. ill consider lidocaine infusion for central neuropathic pain due to post-thalamic stroke pain, not myofascial pain. but there is a review for what little it is worth.


when i have done it for post-stroke pain, generally speaking you bill for the office visit and bill for an infusion, by the hour. even for somewhat more approved conditions, its not that much, and generally speaking not financially beneficial.

 

[giddyup]

Well i try to stay away from nutty stuff. I have had very reliable patients tell me it works so I think they are a nice supplementary thing I can offer. You bill it with an infusion code and a visit code, I don't know it off the top of my head. It doesn't pay great but sometimes it's the only thing that helps. They can also be of assistance when trying to wean narcs. There have been studies to validate ketamine, lidocaine, magnesium, and DHEA infusions for various chronic pain syndromes:


Limdi, NA, Faught, E. (2000) The safety of rapid valproic acid infusion. Epilepsia. 41(10):1342-5.
Lipton, RB, Diamond, S, Reed, M, O’Quinn, S, Stewart, WF. (2000) American Migraine StudyII: prevalence, burden and health care utilization for migraine in the United States. Headache. 40:416.
Mathew, NT, Kailasam, J, Meadors L, Chernyschev O, Gentry, P, (2000) Intravenous valproate sodium (depacon)aborts migraine reapidly: a preliminary report, Headache: The journal of head and face pain, Oct:40(9): 720-3
National Institute of Neurological Disorders and Stroke http://www.ninds.nih.gov/health_and_medical/disorders/headache.htm
Robbins, LD. (2000) Intravenous valproate for prolonged migraine headache. Headache. 40:427
Sethi, PK (2003)Sodium valproate in migraine therapy. *Neurosciences Today 7(2): 118-20.
Silberstein, SD. (1996) Divalproex sodium in headache: literature review and clinical guidelines. 36:547-555.
Dihydroergotamine (DHEA) references:
Colman, I, Brown, M, Grant, I, Grafstein, E, Roberts, T, Rowe, B. (2005) Parenteral dihydroergotamine for acute migraine headache: asystematic review of the literature. *Annals of Emergency Medicine. (4)45: 393-341
Levetiracetem (Keppra) references:
Micromedex Healthcare series: DRUGDEX Drug Point 2008
Ketamine references:
Baranowski, P, Adamczyk, A, (2007) The implementation of continuous ketamine infusions in neuropathic pain syndrome. *Advances in Palliative Medicine 6: 87-92.
Chung, W, Pharo, G (2007) Successful use of ketamine infusion in the treatment of intractable cancer pain in an outpatient. Journal of Pain and Symptom Management 33(1): 2-5.
Cohen, SP, DeJesus, M. (2004) Ketamine patient-controlled analgesia for dysesthetic central pain. Spinal Cord 42: 425-428.
Edmonds, P. { (1998) The role of ketamine in the management of chronic pain CME Bulletin Palliative Medicine 1(1): 3-6.
Fitzgibbon, E. et al. (2002). Low dose ketamine as an analgesic adjuvant in different pain syndromes: a strategy for conversion form parental to oral ketamine. *Journal of Pain and Symptom Management, 23 (2), 165-170.e
Hocking, G, Cousins, M. (2003) Ketamine in chronic pain management: an evidence-based review. *Anesthesia *Analogue 97:1730-9.
Kronenberg, R (2002). Ketamine as an analgesic: parenteral, oral, rectal, subcutaneous, transdermal and intranasal administration. *Journal of Pain and Palliative Care Pharmacotherapy. 16(3):27-35.
Pasero, C (2005) Ketamine: low doses may p[rovide relief for some painful conditions American Journal of Nursing 105(4):60-64.Rauch, D (1998)Use of ketamine in a pain management protocol for repetitive procedures *Pediatrics: Official journal of the American Academy of Pediatrics. 102(2):404.
Subramaniam, K, et al. (2004). *Ketamine as adjuvant analgesic to opioids: a quantitative and qualitative systematic review. *Anesthesia Analogue. 99: 482-95.
Visser and Schug -The role of ketamine in pain management. Biomed Pharmacother 2006; 60:341-8
Lidocaine references:
Attal, N, Gaude, V, Brasseur, L, Dupuy, M, Guirimand, F, Parkter, F, Bouhassira, d. (2000) Intravenous lidocaine in central pain: a double-blind, placebo-controlled, psychophysical study. Neurology 54: 564
Ferrini, R, Paice, J (2004) How to initiate and monitor infusional lidocaine for severe and/or neuropathic pain *The Journal of Supportive Oncology 2: 90-94
Baranowski, A ( 1999) A Trial of intravenous lidocaine on the pain and allodynia of postherpetic neuralgia. *Journal of Pain and Symptom Management 17(6): 429-433.
Magnesium references:
Efficacy of intravenous magnesium in neuropathic pain Bril et al British Journal of Anesthesia 89(5)711-14.
Propofol references:
Anwar, MM, Rahman, A (1998) Effect of propofol on perception of pain in mice: mechanisms of action Comp-Biochem-Physiol-A-Mol-Integr-Physuiik, 120(2):249-53.
Bloomstone, J (2007) Propofol: A Novel Treatment for Breaking Migraine Headache (Correspondence). Anesthesiology: 106(2): 405-406.
*
Bostrom, B, Grund, E, Sommers, N, Haase, M, Mill, B (1999) Propofol for Management of Hospice Patients with Cancer Pain. American Society of Clinical Oncology Annual Meeting abstract no. 2300
*
Canavero, S, Bonicalzi, V, Pagni, CA, Castellano, G, Merante, R, Gentile, S, Bradac, GB, Bergui, M, Benna P, Vighetti, S, et al. (1995) *Propofol analgesia in central pain: preliminary clinical observations. *Journal Neurology, 242 (9):561-7.
*
Canavero S, Bonicalzi, V. (2004) *Intravenous subhypnotic propofol in central pain: *A double-blind, placebo-controlled, crossover study. *Clinical Neuropharmacology 27(4): 182-186.
*
Heins, A (2005) Focus On: *Effective Acute Pain Management. American College of Emergency Physicians: Advancing Emergency Care. October: 1-4.
Simmonds, M, (2007) *Propofol Injection for Daily Headache, University of Alberta study. *Clinical Trials.gov
*
Oda, Y, Hamaoka, N, Hiroi, T, Imaoka, S, Hase, I, Tanaka, K, Funae, Y, Ishizaki, T, and Asada, A. (2001). Involvement of human liver cytochrome P4502B6 in the metabolism of propofol. British Journal of Clinical Pharmacology, 51 (3): 281-285.
Zaccheo, M, Bucher, D (2008) Propofol Infusion syndrome Critial Care Nurse. 28(3): 18-25.
*

 

[Mister Mxyzptlk]

" gut-brain axis" = head up their azzz?

 

[Apollyon]

" gut-brain axis" = head up their azzz?

Apparently, it is an active area of research.

 

[ghost dog]

hey guys-

someone that went to a recent course stated that apparently for "board purposes' the American College of Rheumatology changed the criteria for dx of FM. Instead of having 11 out of 18 tender points, reportedly now a patient just has to 'say they have 11 tender points".

Which sounds a little strange as it avoid 'objective' evidence.

Is this true? Any updated info? I tried googling w/o any success.

Yes, there has been an update on the Dx criteria for FM:

http://www.fmnetnews.com/docs/NewFibroCriteriaSurvey.pdf

However, the old criteria still apply.

I don't bother with this crap, as it is too time consuming, and stick with the old criteria.

 

[Ducttape]

Yes, there has been an update on the Dx criteria for FM:

http://www.fmnetnews.com/docs/NewFibroCriteriaSurvey.pdf

However, the old criteria still apply.

I don't bother with this crap, as it is too time consuming, and stick with the old criteria.

dang, i have fibro! i fit the criteria.

wait, maybe taking care of a 2 year old accounts for 70% of my test results...

its a self-administered test and, not to say that the power of suggestion is strong, but everyone who takes the test will get a positive diagnosis.

 

[facetguy]

dang, i have fibro! i fit the criteria.

wait, maybe taking care of a 2 year old accounts for 70% of my test results...

its a self-administered test and, not to say that the power of suggestion is strong, but everyone who takes the test will get a positive diagnosis.

...and be put on meds for life. Coincidence?

 

[jettavr6]

Simple...
11 points gets them percocet and norco
A well earned 15 points wins them some LA's even Duragesic patches
18 gets them all of the above + a medical marijuana card and free refills!

I love the lectures that some fibro patients try to give me about the virtues of high dose opiates and marijuana in the treatment of fibromyalgia.... Lyrica and Neurontin are far too toxic...

 

[clubdeac]

Steve whats the mech of action or thought behind low dose naloxone?

 

[lobelsteve]

Steve whats the mech of action or thought behind low dose naloxone?

Layman's page:

http://wiki.medpedia.com/Low_Dose_Naltrexone_for_the_Treatment_of_Fibromyalgia

Doc level blurb in Practical Pain Mgmt, work by Younger et al.

 

[clubdeac]

Layman's page:

http://wiki.medpedia.com/Low_Dose_Naltrexone_for_the_Treatment_of_Fibromyalgia

Doc level blurb in Practical Pain Mgmt, work by Younger et al.

Ahh I see.. thanks Steve

 

[Mister Mxyzptlk]

No Mrs Jones, you don't need narcotics. In fact you need the OPPOSITE!

I love it.

 

[lobelsteve]

No Mrs Jones, you don't need narcotics. In fact you need the OPPOSITE!

I love it.

Mrs. Jones, you need a pain medicine so strong it works on the morphine receptor in the brain. But since FMS is known yo have insensitivity to opiates, we can sneak in naloxone to target the. Same receptor

 

[ghost dog]

Mrs. Jones, you need a pain medicine so strong it works on the morphine receptor in the brain. But since FMS is known yo have insensitivity to opiates, we can sneak in naloxone to target the. Same receptor

When I asked my friendly neighbourhood pharnacist about the above, she wasn't able to locate compounded Naloxone.

Maybe it's not available in Canadia.

 

[lobelsteve]

When I asked my friendly neighbourhood pharnacist about the above, she wasn't able to locate compounded Naloxone.

Maybe it's not available in Canadia.

Oops. It's Naltrexone.

50mg tabs.

Compounded to make dosing:

5mg po QD. #30

Side effects include vivid dreams.

 

[onechance]

This drug is also being used in multiple sclerosis related fatigue, with good outcome.

 

[giddyup]

How much does the compounded naltrexone cost them? Is insurance covering this? I spend half my time in rural areas so cost is often an issue for me but this therapy does sound interesting.

 

[mille125]

How much does the compounded naltrexone cost them? Is insurance covering this? I spend half my time in rural areas so cost is often an issue for me but this therapy does sound interesting.

I have a compounding pharmacy. My pharmacist said that it is very cheap. He charges about $30 for a month supply private pay. Some insurance plans cover it but even if they dont $30 does not break the bank.

 

[ghost dog]

Oops. It's Naltrexone.

50mg tabs.

Compounded to make dosing:

5mg po QD. #30

Side effects include vivid dreams.

I should have figured this out - if not me - the pharmacist should have.

Anyways, I will definitely be giving this a try on FM pts.

 

[melancholy]

Curious after two years if more people have trialed low dose naltrexone on patients with FMS or other pain conditions (who are off opioids) and what the anecdotal evidence has been.

 

[Aether2000]

I tell these patients the term means the same as "I hurt all over and my doctors don't have a clue why". I do not use the term and prefer "undifferentiated widespread longstanding pain".

 

[clubdeac]

I tell these patients the term means the same as "I hurt all over and my doctors don't have a clue why". I do not use the term and prefer "undifferentiated widespread longstanding pain".

Kind of like how the rheumatologists use UCTD. I like it

 

[Dr. Ice]

i push the exercise routine. some patients seem kinda upset i spend more time talking about exercise and even occasionally tell them to remember "no pain, no gain" kind of philosophy.

course, these are the same fibro patients that develop excruciating pain pushing away from the dinner table ("and thats why i stay at the dinner table so long")

"that doctor had nothing to offer..he basically told me to live with the pain.." says the disgruntled fms patient expecting a cure and a little trigger happy on healthgrades.com...good times..