PDF Format - American Nurse Today


PDF Format - American Nurse Today

BE Amyth-buster:STOP THE MISCONCEPTIONSABOUT FIBROMYALGIAThe truth about fibromyalgiawill help you help patients ease their pain.By Jennifer FitzGibbons, MSN, APN,CSOME HEALTHCARE professionalsdismiss the very real, very complex,and very painful condition of fibromyalgia(FM) as a wastebasketdiagnosis. And some view FM patientsas malingerers—and worse. Insuch an atmosphere, these patients,about 6 million in the United States,must meet the challenge of copingwith extensive pain and fatigue andtrying to find adequate treatment fora perplexing condition.As a nurse, you can help bylearning about FM, educating patientsand colleagues, and providingpatients with supportive, holisticcare. (See Fibromyalgia:Fiction and fact.)What is fibromyalgia?FM is a continuum of pain andsomatic syndromes that oftenevades diagnosis and effectivetreatment. Less than half of thepeople with FM report adequaterelief or improved functional status.Many go years before beingproperly diagnosed.The complex symptoms of FMinclude:• widespread pain in all four quadrants(above and below the waistand both sides of the body), includingthe axial chest and backfor three months or more• fatigue• concentration and memorylapses, called fibro-fog• sleep dysfunction• muscle stiffness and reducedexercise tolerance• increased sensitivity to temperature,light, and sound• hyperalgesia (increased sensitivityto painful stimuli)• allodynia (increased sensitivityto nonnoxious stimuli).CE: 1.6 contacthoursCERxRx: 0.5 contacthoursL E A R N I N G O B J E C T I V E S1. Identify factors that can makediagnosing fibromyalgia achallenge.2. Describe the pharmacologicmanagement of fibromyalgia.3. Discuss the nonpharmacologicmanagement of fibromyalgia.Patients often describe minortypes of touch, such as handshakesand gentle pats on theback, as painful.FM often exists with other conditions,including chronic fatigue syndrome,myalgic encephalopathy, irritablebowel syndrome, migraineheadache, multiple chemical sensitivity,depression, and temperomandibularsyndrome. FM andthese conditions are called centralpain syndromes. The symptoms ofFM may appear before or afterthese other central pain syndromes.A patient with any central pain syndromeshould be screened for FM.Subjective and extensivecomplaintsThe symptoms of FM have beenknown for thousands of years, butthe American College of Rheumatologyfirst announced diagnosticcriteria for the condition just 20years ago. Unfortunately, becauseFM is so poorly understood, somecontinue to question its existence,despite the many reports establishingits legitimacy. Patients continueto be dismissed and stigmatized40 American Nurse Today Volume 2, Issue 9

ecause the condition producesmany symptoms but no obvioussigns. Most patients with FM appearperfectly normal. And because theircomplaints are subjective and extensive,clinicians often consider patientsto be malingering or seekingdrugs.Experts now agree that FM is adiffuse condition in which abnormalpain (and probably sensory)processing in the central nervoussystem (CNS) causes symptoms thataffect the entire body. The problemis thought to be in the CNS, thoughperipheral factors—such as muscle,skin, and blood abnormalities—possibly play a role. Patients canhave FM which is secondary to otherconditions such as rheumatoidarthritis, inflammatory/viral disease,and trauma to the spine.Psychological and behavioral factorsplay a role in some peoplewith this condition. Clearly, depressionexacerbates pain, and pain exacerbatesdepression because theyshare common pathways and neurotransmitters.But despite substantialoverlap between depressionand FM, most patients with FMaren’t clinically depressed. FM is anindependent condition.What causes fibromyalgia?The 18 tender points described in somany articles about FM have noanatomic abnormalities. These pointsare simply areas that are significantlymore tender in people with FM. Inmany well-controlled studies, FM patientshave lower pain thresholdseverywhere, not just at the 18 tenderpoints.The abnormal processing of painin the CNS is thought to result frommechanisms such as central sensitization,blunting of inhibitory painpathways, changes in neurotransmitters,and psychiatric conditions. Theexact mechanisms aren’t known.But studies show that the cerebrospinalfluid (CSF) of those withFM contains three times as muchneuropeptide substance P and fourFibromyalgia: Fiction and factFiction Fibromyalgia doesn’t exist.Fact Fibromyalgia is a complicated condition, with diagnostic criteria establishedby the American College of Rheumatology.Fiction Fibromyalgia is a symptom of depression.Fact Fibromyalgia can be associated with depression, but fibromyalgia is an independentphysiologic condition, and most patients don’t suffer from clinical depression.Fiction Fibromyalgia occurs only in middle-aged women.Fact Fibromyalgia occurs in men, women, and children, though it’s three timesmore prevalent in women.Fiction Patients who complain of fibromyalgia pain despite treatment are seeking drugs.Fact Less than half of the patients with fibromyalgia achieve adequate reliefwith medication.times as much nerve growth factoras the CSF of those without FM.Both substances are involved in initiatingand perpetuating painfulsymptoms. Reduced levels of thebiogenic amines dopamine, norepinephrine,and serotonin in thespinal cord are thought to impairthe effect of endogenous painkillingendorphins and significantlyamplify pain sensitivity.The sleep patterns of those withFM also suggest underlying physiologic,not psychological, causes. Asearly as 1975, FM patients undergoingelectroencephal-ography (EEG)showed alpha and delta sleep wavechanges, known as alpha-EEG sleepdisorder. When healthy control subjectswere deprived of sleep to simulatethis disorder, they reportedmuscle pain and fatigue. Alpha-EEGsleep disorder isn’t unique to FM; itoccurs in other conditions characterizedby chronic nonrestorativesleep, pain, and fatigue, such asrheumatoid arthritis and systemiclupus erythematosus.FM patients have decreased deepsleep (stage 4 sleep) and bursts ofawake-like brain activity, preventingsound sleep. A 2006 study suggeststhat patients with FM haveimpaired parasympathetic nervoussystem activity that prevents restorativesleep. And chronic, severesleep dysfunction and pain, ofcourse, perpetuate more sleep dysfunctionand pain.A strong genetic predispositionto FM may exist. Anxiety, depression,physical and psychologicaltrauma, and viral infection may beonly contributing factors.Who does fibromyalgia strike?FM most commonly strikes middleagedwomen. But it also strikes menand children.The condition appears to be threetimes more prevalent in women, butit’s likely that a significant number ofmen with FM are incorrectly diagnosedas having regional pain syndromessuch as osteoarthritis. Menwith FM typically report fewer symptoms,less fatigue, and fewer tenderpoints than women. Men also have alower incidence of concurrent irritablebowel syndrome.Diagnosing fibromyalgiaThe hallmark of FM is widespreadand chronic pain in all four quadrantsof the body and specificallyin the axial chest, neck, and back.Marked fatigue, disturbed sleep,and difficulty concentrating compoundthe pain.A diagnosis is based on a thoroughhistory, physical examinationfindings, and tests used to rule outconditions with symptoms similar tothose of FM. (See Mimicking fibromyalgia.)The onset of FM symptomsmay be linked to physical trauma.The patient history may revealthat the initial pain of an injury nev-September 2007 American Nurse Today 41

er healed and, in fact, became morewidespread.The physical examination of a patientwith widespread pain shouldinclude a tender-point examination.A tender-point examination is performedby applying 4kg of pressure(enough to blanche the clinician’sfingertip) to 18 specific areas of thebody. In the past, a total of 11 ormore tender points was used as a diagnosticcriterion. Experts now thinkthat a person with fewer than 11 tenderpoints can have FM becausesymptoms are cyclical, and the numberof tender points and the intensityof pain can vary over time. The criterionof 11 points was established forresearch trials; it shouldn’t be usedas an absolute for diagnosis.The initial tests should be limitedto a complete blood count, chemistryprofile, thyroid-stimulating hormonelevel, Lyme titer, and C-reactiveprotein level. Depending on thepatient’s history and signs andsymptoms, a clinician may order anantinuclear antibody level and rheumatoidfactor assays. Keep in mindthat antinuclear antibody levels arecommonly false-positive.Unfortunately, no test or procedurecan confirm the diagnosis: only clinicalknowledge and experience can.MimickingfibromyalgiaBefore making a diagnosis of fibromyalgia,a clinician must considerthese conditions in the differentialdiagnosis:• rheumatoid arthritis• hypothyroidism• hepatitis C• polymyalgia rheumatica• cervical and low-back degenerativedisease• endocrine disorders• Lyme disease• chronic fatigue syndrome (myalgicencephalopathy)• sleep disorders• depression• cancer• Human immunodeficiency virusinfection.Keep in mind that fibromyalgia cancoexist with these and other painfulconditions.Managing fibromyalgiaTreatment is becoming more uniformand progressive, though thesuccess rates are far from ideal. Despitetherapy, patients have inadequatepain relief, increased workdisability, and increased need forhealth care. Inadequate responseand intolerance to the treatment ofFM symptoms cause greater disabilityand economic concerns.Because drug therapy producesonly limited relief, patients need amultidimensional therapeutic approach.Ideally, a patient with FMreceives an early diagnosis and anearly start with holistic therapy.Greater awareness of the variedsymptoms seen with FM and centralpain syndromes is crucial. Remember,a holistic approach includes acknowledginga patient’s pain, regardlessof its cause.Drug therapy for fibromyalgiaRecent studies increasingly supportthe use of two classes of medicationsfor the treatment of FM. Theyinclude serotonin/norepinepherinereuptake inhibitors (SNRI’s) and alpha-2delta ligands. SNRI’s arethought to help correct the functionallylow levels of circulating serotoninand norephinepherine in theCNS, thereby improving the abnormalpain-inhibiting pathways whichexist in FM patients. The SNRI’smost commonly used are tricyclicantidepressant amytriptyline (25 mgat bedtime) used with cyclobenzaprine(a muscle relaxant). This combinationof medications is well-studiedin clinical trials, with modestimprovement seen in FM symptoms,particularly sleep quality. Nevertheless,the anticholinergic side effectsof these medications make tolerabilityand adherence a significant problemfor patients. (See Examples ofdrug therapy for fibromyalgia.)Duloxetine (60-120 mg daily) andMilnacipran (50-100 mg twice daily)are potent SNRI’s recently FDA-approvedfor the treatment of FM. Inclinical trials, these drugs werefound to reduce widespread pain,improve mood, and lessen concentrationproblems with better tolerabilitythan tricyclic medications.Alpha-2 delta ligands seem tohave more of an analgesic effect onFM by reducing the release of neurotransmittersinvolved in pain processing.By blunting the over-activityof these neuronal synapses,central pain is reduced. Also FDAapproved,Pregabalin (150-225 mgtwice daily) was found in clinicaltrials to reduce pain and improvesleep dysfunction in FM patients.Gabapentin (1200-2,400 mg/day),while not FDA-approved for FM, isoften used for the treatment of neurologicpain syndromes. It is anotheralpha-2 delta ligand found to reducepain and improve sleep in clinicaltrials, but its use is decreasing sincethe approval of pregabalin.Drugs for specific symptomsAntiepileptics can reduce burningpain, especially in patients with migraineheadaches; their effects areless predictable for dull and widespreadpain. Tramadol hydrochloride(Ultram) disrupts pain messagesfrom the spinal cord to theperiphery and increases serotoninand norepinephrine levels. Andstimulants such as modafinil(Provigil) ease fatigue and cognitiveimpairment.Corticosteroids and nonsteroidalanti-inflammatory drugs (NSAIDs)may be prescribed to treat a concurrentinflammatory condition,such as osteoarthritis or rheumatoidarthritis, or to provide synergisticdrug effects. However, NSAIDsaren’t effective as monotherapy forFM. A prescriber should order anopioid only after all other pharmacologicand nonpharmacologic optionshave failed.42 American Nurse Today Volume 2, Issue 9

SExamples of drug therapy for fibromyalgiaDrug class Commonly used drugs ConsiderationsTricyclic antidepressants amitriptyline • Used to manage pain and sleep disorders.cyclobenzaprine (Flexeril) • Administer 1-2 hours before bedtime.doxepin (Sinequan)nortriptyline (Pamelor)Dual serotonin duloxetine (Cymbalta) • Used to manage symptoms related to pain, sleep, and mood.norepinephrine reuptake venlafaxine (Effexor XR) • Venlafaxine also used for fatigue and cognitive impairment.inhibitorsAntiepileptics gabapentin (Neurontin) • Used to manage symptoms related to pain and sleep.lamotrigine (Lamictal)pregabalin (Lyrica)oxcarbazepine (Trileptal)5-HT selective serotonin citalopram (Celexa) • Used to manage symptoms related to mood.reuptake inhibitors fluoxetine (Prozac)paroxetine (Paxil)sertraline (Zoloft)Other antidepressants bupropion (Wellbutrin SR) • Used to manage symptoms related to mood.mirtazapine (Remeron) • Mirtazapine and trazodone also used to improve sleep.nefazodone• Nefazodone also used for pain.trazodone (Desyrel)• Bupropion also used for fatigue and cognitive impairment.Nonsteroidal ibuprofen • Used to manage pain.anti-inflammatory drugs naproxen • Typically not used as monotherapy.aspirin• May provide added analgesia when used with other drugs,especially if patient also has mechanical or inflammatory condition.Sedative hypnotics sodium oxybate (Xyrem) • Used to improve sleep.zaleplon (Sonata)• Use sodium oxybate cautiously. It can only be obtained from onezolpidem (Ambien)pharmacy in the United States because of its potential use as adate rape drug.Other drugs clonazepam (Klonopin) • Clonazepam is used to improve sleep and relax painful muscles.tramadol (Ultram)• Tramadol is used to manage pain.Stimulants amphetamine • Used to manage fatigue and cognitive impairment.(Adderall or Dexadrine)methylphenidate(Concerta or Ritalin)modafinil (Provigil)Opiates codeine • Should be used sparingly.morphineoxycodoneSome patients with FM experienceorthostatic palpitations, weakness,or dizziness. Small doses ofbeta blockers or increased fluid intakeand sodium and potassiumsupplementation can reduce thesesymptoms.Keep in mind that adverse effectsof and sensitivity to thesedrugs pose a significant problem ofdrug intolerance for patients. SevereFM symptoms and desperation convincemany patients and theirproviders to use antidepressants,antiepileptics, and opioids, despitelittle or no therapeutic effect. Continuedfailure of multiple (and oftencostly) treatment regimens commonlyfrustrates providers and patientsalike. As a nurse, you canplay a crucial role in reinforcing appropriatedosing regimens, teachingpatients about adverse effects, assessingtheir response to treatments,and following up when prescriptionschange.Adjunctive therapyMany adjunctive, nonpharmacologictreatments and strategies can improvea patient’s outcome. Part ofyour role is teaching patients aboutthese other therapies. (See Vagusnerve stimulation for fibromyalgia?)The loss of physical function, demandsof chronic unexplained ill-September 2007 American Nurse Today 43

Vagus nerve stimulation for fibromyalgia?Because of the challenges of drug tolerance and effectiveness, our study group atthe Pain and Fatigue Study Center received funding to conduct a pilot study of vagusnerve stimulation for fibromyalgia patients.The vagus nerve is involved in central pain processing. And clinical research trialsin refractory epilepsy and depression suggest improvements in pain thresholdsand mood when the afferent pathways of the vagus nerve are stimulated by a surgicallyimplanted, wristwatch-size device.Our study is the first to research the safety and tolerability of vagus nerve stimulationto treat severe fibromyalgia pain. We hope that our data will show promisingresults for this individually programmable device.ness, and strained personal andwork relationships can overwhelma person struggling to feel better.Accurately identifying the psychologicalinfluences on FM symptomsand incorporating the patient’semotional status into the treatmentplan improve outcomes. As withany troubling illness, patients dobest with supportive, well-informedproviders who can help them copeand remain in control.The best adjunctive therapies includecognitive behavior therapy(CBT), patient education, low-impactexercise and stretching, and acupuncture.Many patients also use complementaryand alternative medicine totreat their symptoms.Initially developed as a treatmentfor conditions such as depressionand anxiety, CBT is now used forFM with and without drug therapy.In CBT, a patient focuses on understandinghis or her condition andusing pragmatic coping strategies toimprove the emotional and physicalresponse to it. The goals are tofunction despite pain and disability,eliminate destructive attitudes andbehaviors, and adapt a positivemindset. The patient uses CBT toconserve mental and physical energyand minimize pain. The relaxationtechniques help effectivelymanage chronic pain and sleep difficulties.As a nurse, you can teachCBT techniques and work with patientsto find effective options thatthey prefer.Acupuncture may also alleviatesymptoms and improve outcomes.However, a person may need 8 to10 sessions before this option is effective,and for some, the cost maybe prohibitive.Other adjunctive therapies includeelectromyography biofeedback, aquatherapy, and hypnotherapy.Motivating patients to remain active,intellectually busy, and engagedin enjoyable activities also helps. Encouragesleep hygiene strategies,such as establishing consistent bedtimes,taking short naps (less than 15minutes), pacing physical activityconsistently, and avoiding caffeineand alcohol, to minimize sleep dysfunctionand fatigue. Any exercisemust be gentle, very gradual, andeasy on the joints. Be careful not tominimize a patient’s symptoms or assumethat any new symptom resultsfrom his or her FM.Be familiar with the results ofclinical trials and explain them topatients with FM so they can tailortheir regimens to target their symptoms.You can also encourage patientsto participate in clinical researchtrials (www.clinicaltrials.gov).Referring patients to organizationssuch as The American FibromyalgiaSyndrome Association (www.afsafund.org)and the National FibromyalgiaAssociation (www.fmaware.org)can help them better understandtheir condition and the latest treatmentoptions.Just the factsPeople with FM suffer from disablingsymptoms. They don’t needhealthcare providers who thinktheir condition is a mental health issue.To help these patients, learnthe facts, dispel the myths and,above all, provide supportive, holisticnursing care.✯Selected referencesAbeles AM, Pillinger MH, Solitar BM, AbelesM. Narrative review: the pathophysiology offibromyalgia. Ann Intern Med. 2007;146(10):726-734.Arnold LM, Hudson JL, Hess EV, et al. Familystudy of fibromyalgia. Arthritis Rheum.CE POST-TEST — Be a myth-buster: Stop the misconceptions about fibromyalgiaInstructionsTo take the post-test for this article and earn contact hour credit, pleasego to www.AmericanNurseToday.com. Simply use your Visa or Master-Card to pay the processing fee. (Online: ANA members $15; nonmembers$20.) Once you’ve successfully passed the post-test and completed theevaluation form, you’ll be able to print out your certificate immediately.If you are unable to take the post-test online, complete the print formand mail it to the address at the bottom of the next page. (Mail-in testfee: ANA members $20; nonmembers $25.)Provider accreditationThe American Nurses Association Center for Continuing Education and ProfessionalDevelopment is accredited as a provider of l continuing nursing education by theAmerican Nurses Credentialing Center’s Commission on Accreditation.ANA is approved by the California Board of Registered Nursing, ProviderNumber 6178.Contact hours: 1.6 Rx contact hours: 0.5Expiration: 12/31/12 Post-test passing score is 75%.ANA Center for Continuing Education and Professional Development’s accreditedprovider status refers only to CNE activities and does not imply that there is real orimplied endorsement of any product, service, or company referred to in this activitynor of any company subsidizing costs related to the activity. This CNE activitydoes not include any unannounced information about off-label use of a productfor a purpose other than that for which it was approved by the Food and DrugAdministration (FDA).44 American Nurse Today Volume 2, Issue 9

2004;50:944-952.Clauw DJ. Fibromyalgia: correcting the misconceptions.J Musculoskel Med. 2003;20:467-472.Clauw DJ. Fibromyalgia: update on mechanismsand management. J Clin Rheum.2007;13(2):102-109.Longley K. Fibromyalgia: aetiology, diagnosis,symptoms, and management. Br J Nurs.2006;15(13):729-733.Wallace DJ, Clauw DJ, eds. Fibromyalgia andOther Central Pain Syndromes. Philadelphia,Pa: Lippincott Williams & Wilkins; 2005.Wolfe F, Ross K, Anderson J, et al. Theprevalence and characteristics of fibromyalgiain the general population. ArthritisRheum. 1995;38(1):19-28.For a complete list of selected references, visitwww.AmericanNurseToday.com.Jennifer FitzGibbons, MSN, APN,C, is the ClinicalResearch Coordinator at the Pain and FatigueStudy Center at the University of Medicine andDentistry of New Jersey in Newark. The plannersand authors of this CNE activity have disclosed norelevant financial relationships with any commercialcompanies pertaining to this activity.September 2007 American Nurse Today 45

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