PMR 4 MSK

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Here's one I'd like to see the residents and fellows chime in on. I know how most the pain attendings would approach it, but they can ring in too.

49 yo female, bipolar, fibromyalgia, 20 + years of "all over pain." Has drifted from one abusive relationship to another, currently trying to help get the boyfriend out of jail for blackening both her eyes last month. Rheumatologist referred for DDD C-Spine (looking for an out?). Pt on Medicare.

Pt on hydrocodone 5/500 QID prn, prednisone taper (which has calmed down most of the neck and back pain). Also on naproxen, pregabalin, cyclobenzaprine, trazadone, lipitor, lupiprostone (had to look that one up - for IBS) and quetiapine (AKA seroquil) and a bunch of asthma meds. Non-smoker, denies alcohol or drug abuse. Surgeries - tonsils, ex lap for endometriosis, hysterectomy, tubal ligation (I assume before the hyst) and hemorrhoidectomy. Allergy to PCN. FH benign. ROS only positive for depression and anxiety symptoms.

On the pain diagram, she draws lines from the neck down both arms, from the back down both legs, and lines all around the body, surrounding it, including the entire head, turnk and extrmeities.

PE - diffuse soft tissue tenderness throughout the neck and back - with minimal pressure. Normal neuro exam all 4 extremities, CNS and mental status.

C-Spine MRI shows DDD with minor bulge, no NF or central stenosis, no nerve impingement/displacement, but sagital shows T2-3, moderate sized left lateral HNP displacing T2 and T3 nerve roots.

Where would you go from here? What would be your treatment plan?
 

Disciple

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I would offer 1 thoracic ESI but set the bar low, i.e. "it might help somewhat for your upper back and lower neck pain, but don't expect it to help your arms/legs, etc."

If the Rheumatologist is writing for her opiates and her doses aren't escalating, no need to change anything.

If her meds start getting out of control, would see the patient in f/u, have the "Fibromyalgia" talk and recommend a wean off of Vicodin or switch to long-acting opiate with Ultram for breakthrough if I thought she had a true component of spinal pain.

I'm assuming a Psychiatrist is treating her Bipolar, prescribing the Seroquel and talking to her about her social situation.
 

lobelsteve

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She will do poorly regardless of treatment plan. Her history assures her of that, and as her doc you must let her know. It may be the fibro, it may be the crazy, it may be the social history.

No injections for FMS patients. Will only make it worse. Get the labs sorted out- if she has all this baggage, then she has some treatable hormonal issues. If PCP, Rheum, or Endocrine won't do it- check free and total testosterone, estradiol, 1,25 OH D. Why was she on oral steroids? Unless the Rheum is hiding something treatable with DMARD's, it makes nothe pool sense. Neither does opioids, NSAIDs. Lyrica, SMR (except Soma), and psych meds from Psych. Get her into the pool. Get her on a recumbent bike. Limit exercise sessions to 2 minutes day/ 4 days week for the first week and increase by 1 minute per week until at 35min per day. Try her on Armour, it's like crack for the thyroid- my Endo would kill me, but the patients dig it and it's not a controlled substance.


You did not get her into this mess, you cannot fix her, but you may be able to raisethe quality of her life marginally. Set the bar lower! Could be worse, could have no psychiatrist and be uninsured. Ask her about the prior sexual abuse, physical abuse, emotional abuse- she needs to be talking with her psych/clinical psychologist to cope with the old baggage.

Your goals of treatment may be to get her to color in the lines on the pain diagram after 2 months (from painful aura to painful person) or maybe to get her to use fewer colors in her pain aura/person. I love this type of patient- if you do nothing except fix the meds to "reasonable" and not make them worse- you've won. If you figure out what is actualy causing their pain and have a treatment for that- it's like creating a new person. Good luck.
 

Disciple

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No injections for FMS patients. Will only make it worse. Get the labs sorted out- if she has all this baggage, then she has some treatable hormonal issues. If PCP, Rheum, or Endocrine won't do it- check free and total testosterone, estradiol, 1,25 OH D. Why was she on oral steroids? Unless the Rheum is hiding something treatable with DMARD's, it makes nothe pool sense.
That is a good idea with the labs. I recently started checking Vit D level on more patients.

Perhaps the Rheum was using the steroids as shot-gun treatment for a possible inflammatory component at T2/3 or the C-Spine.

So you believe in natural hormone replacement Steve? I consider it every now and then in patients like these.
 

Ludicolo

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Did anyone else think to get creative?

Like busting out the Lidoderm body suit?

Or the trigger point injection iron maiden?

Or my favorite - the treadmill PCA system? Secure the patient to a treadmill. After she walks for a half mile or for 15 minutes (your choice) it dispenses her pain meds!

Seriously - I agree with checking the endocrine labs and making sure she has adequate psychiatric follow up and getting her social issues straightened out. You might not be able to fix her, but you can make sure she doesn't get worse.
 
OP
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Here's what I did - I told her the Thoracic HNP could not be causing all her pain, but we'll get a dedicated thoracic MRI to view it axially and to check it more caudally, also get L-Spine MRI to evaluate that as well. Yeah, mainly a CYA, but you knows she's trouble.

I didn't touch the opioids. I didn't start them and don't feel they appropriate for her. In my note, I indicated that if my input regarding the opioids is further desired, I will be happy to wean her off of them over 6-8 weeks.

I am very loathe to touch her with a needle. To me, this is a damaged soul. She's spent her life being abused, likely abusing herself as well. Bipolars are classic for this (chicken or egg?). Patients like this rarely do well with interventional approaches, in my experience. Plus the steroids may precipitate manic episodes.

Before I would Rx an opioids, I would drug test her. If clean, she'd get a 2 week supply at first and begin weaning. This would likely cause her to leave me. I think she needs a "washout" and then re-eval. Odds are she's psychologically dependent on the opioids for both pain relief and life-coping. Bad combo, bad candidate for opioids long-term.

She needs as much psych care as her insurance will cover, weekly or more visits. She needs a PT who does TLC. A sports med or ortho-trained PT will drive her away. Hospital-based PT's used to the elderly may be good at this.

What she really needs is a very good seriously multi-disciplinary pain program, but there are none in my area.

Good ideas on the labs, it's an area I often slack on.
 

SG1

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Not to throw more drugs at her, but we're taught that poor sleep really contributes to FM symptoms, so maybe a little ambien to help with Stage 4 sleep. Also check DHEA levels.

Thanks for presenting this case in such a sensitive manner. It's so easy for us to be jaded when working with patients similar to this one.
 

SSdoc33

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Not to throw more drugs at her, but we're taught that poor sleep really contributes to FM symptoms, so maybe a little ambien to help with Stage 4 sleep.
no medication has been shown to improve overall sleep quality.
 
OP
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Not to throw more drugs at her, but we're taught that poor sleep really contributes to FM symptoms, so maybe a little ambien to help with Stage 4 sleep.
I'm still not convinced Ambien helps fibro patients long term. Some do well for a few weeks on it, but don't seem to long term. But they want it long-term anyway. We have a couple sleep labs here in town, so I usually turf that to them. I tell patients I'm not a sleep doc. I truely feel that if a patient needs a controlled substance for sleep long-term, it should come from a sleep specialist, just like an opioid should come from a pain doc, if used long term. Unless the PCP wants to take it over, but the initiation and titration or at least the blessing should come from the specialist, to protect the PCP if nothing else.
 

SpineBound

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What is your guys experience with tiagabine in fibromyalgia patients? It is supposed to help with stage 3,4 sleep thus releasing more growth hormone and decesasing whole body pain.
 

SSdoc33

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no medication has been shown to improve overall sleep quality.
 
OP
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So an update. MRI T-spine shows the HNP is left paracentral with some nerve root impingment again at T2, some mild DDD mid-thoracic spine, L-Spine MRI is normal.

Pt calls the day before the appt for f/u to tell my nurse she now has increased pain in her neck, back, shoulders, arms, hands, head, back, legs and feet (yes, she named them all). Also having swelling in the face arms and hands. Oh, and the headaches are just killing her. What can I give her? I say pick 2-3 meds and stop them one at a time. Not what she wanted to hear.

At the f/u visitgo over the MRI's with her, show her the pictures. I give her the talk about what we can do to help her and how she can help herself. I specifically recommend PT, as she does not currently exercise and doesn't know what to do.

Then she asks "So what can I do about this pain?" I say PT. She says, "No, what can I take?" I say again to work on reducing meds, not adding in more. Does not compute.

She then specifically asks for Valium "to help my muscles relax." I tell her it's not indicated for this kind of pain. "But my last doctor had me on it." Then go back to him. "He moved." How convienient.

She leaves without new meds, instructions on selective reduction of current meds - starting with hydrocodone and an Rx for PT. Also started a referral for psychiatric consult. From her reaction to that, I can tell you, there's no way in hell she's going to go. On the way out, she must have forgot to make a follow-up appointment :rolleyes:. Nor did she make an appointment in out PT department.

So I didn't pile on more meds, she didn't get what she wanted out of me. How sad.:(

So lets assume she does go to PT, and it doesn't help her or makes her pain worse as I suspect she would report. Anything else you'd do? I still ain't gonna touch her with any sharp pointy objects.
 

ampaphb

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So an update. MRI T-spine shows the HNP is left paracentral with some nerve root impingment again at T2, some mild DDD mid-thoracic spine, L-Spine MRI is normal.

Pt calls the day before the appt for f/u to tell my nurse she now has increased pain in her neck, back, shoulders, arms, hands, head, back, legs and feet (yes, she named them all). Also having swelling in the face arms and hands. Oh, and the headaches are just killing her. What can I give her? I say pick 2-3 meds and stop them one at a time. Not what she wanted to hear.

At the f/u visitgo over the MRI's with her, show her the pictures. I give her the talk about what we can do to help her and how she can help herself. I specifically recommend PT, as she does not currently exercise and doesn't know what to do.

Then she asks "So what can I do about this pain?" I say PT. She says, "No, what can I take?" I say again to work on reducing meds, not adding in more. Does not compute.

She then specifically asks for Valium "to help my muscles relax." I tell her it's not indicated for this kind of pain. "But my last doctor had me on it." Then go back to him. "He moved." How convienient.

She leaves without new meds, instructions on selective reduction of current meds - starting with hydrocodone and an Rx for PT. Also started a referral for psychiatric consult. From her reaction to that, I can tell you, there's no way in hell she's going to go. On the way out, she must have forgot to make a follow-up appointment :rolleyes:. Nor did she make an appointment in out PT department.

So I didn't pile on more meds, she didn't get what she wanted out of me. How sad.:(

So lets assume she does go to PT, and it doesn't help her or makes her pain worse as I suspect she would report. Anything else you'd do? I still ain't gonna touch her with any sharp pointy objects.
He moved? I'm shocked!

I generally let patients know that benzos are anxiolytics, and that, if their anxiety is sufficient to warrant being medicated, it needs to be managed by a specialist in anxiety (i.e psych). That way, it isn't that I think they are crazy, it's that I am sending them to a doc with expertise in the very symptom they are concerned about (rarely works, but it makes me feel better). In the written request for a psych consult, I would ask if, in addition to managing her self-reported anxiety, whether an SSRI might be indicated (as I certainly think it is).
 

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Have you considered using a home TENS or IFC unit to help control pain levels while she is weaning off of meds? (I realize that she can't use it on her entire body, but maybe she could use it for her most painful areas.)

Does the PT dept have access to warm water pool? If so, it probably wouldn't be a bad place to start since most of the patients that I've treated with fibromyalgia/chronic pain seem to tolerate aquatics PT well.
 

Gauss

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Ect
 

Gauss

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Book it as an NCS study - state you're checking blink reflex to r/o myasthenia or whatever, apply the leads and zap - voila unilateral ECT. don't forget the versed!
 

indytravl

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this was a great thread; well-considered psych & clinical factors. learned some things & the ending was hilarious! love that multipurpose ect...one of our psychiatrist put that as a rec for consult on 89year old for "involutional melancholia" along with ngt because pt failing to thrive less than a week before pt died. maybe it was prophylactic defibrillation:D
 

Gauss

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In case anyone thought I had totally lost my marbles:

Usui C, Doi N, Nishioka M, Komatsu H, Yamamoto R, Ohkubo T, Ishizuka T, Shibata N, Hatta K, Miyazaki H, Nishioka K, Arai H.
Electroconvulsive therapy improves severe pain associated with fibromyalgia.
Pain. 2006 Apr;121(3):276-80. Epub 2006 Feb 21.
PMID: 16495009 [PubMed - indexed for MEDLINE]

Huuhka MJ, Haanpää ML, Leinonen EV.
Electroconvulsive therapy in patients with depression and fibromyalgia.
Eur J Pain. 2004 Aug;8(4):371-6.
PMID: 15207518 [PubMed - indexed for MEDLINE]

McDaniel WW.
Electroconvulsive therapy in complex regional pain syndromes.
J ECT. 2003 Dec;19(4):226-9.
PMID: 14657776 [PubMed - indexed for MEDLINE]