Rational management of fibromyalgia:
Gespeichert in:
| Format: | Buch |
|---|---|
| Sprache: | English |
| Veröffentlicht: |
Philadelphia [u.a.]
Saunders
2002
|
| Schriftenreihe: | Rheumatic disease clinics of North America
28,2 |
| Schlagworte: | |
| Online-Zugang: | Inhaltsverzeichnis |
| Beschreibung: | XV S., S. 182 - 460 Ill., graph. Darst. |
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CONTENTS
Preface xiii
Robert M. Bennett
The Rational Management of Fibromyalgia Patients 181
Robert M. Bennett
The exponential increase in pain research over the last 10 years has
established fibromyalgia (FM) as a common chronic pain syn¬
drome with similar neurophysiologic aberrations to other chronic
pain states. As such, the pathogenesis is considered to involve an
interaction of augmented sensory processing (central sensitization)
and peripheral pain generators. The notion, that FM symptoma¬
tology results from an amplification of incoming sensory impulses,
has revolutionized the contemporary understanding of this enig¬
matic problem and provided a more rational approach to treat¬
ment. To date, the management of FM has been mainly palliative,
with the aims of reducing pain, improving sleep, maintaining
function, treating psychologic distress and diminishing the impact
of associated syndromes. The rapidly evolving neurophysiologic,
psychophysiologic and molecular biologic basis for chronic pain
states has already opened up new avenues for management which
should be applicable to this difficult group of patients. Indeed, it is
now possible to think about a rational approach to managing FM
patients that was unthinkable just a few years ago.
A Comprehensive Medical Evaluation of Patients with
Fibromyalgia Syndrome 201
Muhammad B. Yunus
Fibromyalgia syndrome (FMS) is a common and distressful condi¬
tion. It is imperative that all physicians do their best to help these
suffering patients with understanding and respect, since the pri¬
mary responsibility of a physician is to ameliorate suffering of a
patient, irrespective of the type of the disease or the illness. (The
authors use the terms disease and illness synonymously, since
any distinction between these two terms are really pointless
because the word disease means lack of ease or presence of
VOLUME 28 • NUMBER 2 • MAY 2002 v
suffering.) It is clear that a physician cannot optimize management
of a patient with FMS without a thorough medical and psycho¬
logic evaluation. A good evaluation helps to make a proper diag¬
nosis, assess severity, recognize aggravating and relieving
factors of symptoms, appraise psychologic factors, evaluate relevant
associated or concomitant conditions, document individualized
problems in a given patient, and subsequently formulate proper
and individualized management. This article focuses on the major
elements of a comprehensive medical evaluation, with some refer¬
ence to psychologic aspects are covered in detail in the article by
Turk et al in this issue.
Psychological Evaluation of Patients Diagnosed with
Fibromyalgia Syndrome: A Comprehensive Approach 219
Dennis C. Turk, Elena S. Monarch, and Arthur D. Williams
The conventional way of thinking about pain assumes that it
always results from the presence of underlying organic pathology.
In the absence of objective pathology, reports of pain and other
unexplained symptoms may be ascribed to psychological causes.
However, pain is a complex perceptual phenomenon and is always
determined by organic, behavioral, and psychosocial factors.
Somatogenic and psychogenic factors alone are insufficient to
explain individual differences in the experience of pain. Conse¬
quently, assessment of pain symptoms requires an integrated
rather than dualistic approach. In addition to obtaining informa¬
tion about patients pain difficulties through physicals, history, and
laboratory and imaging tests, all patients with fibromyalgia should
routinely receive a psychological screening by the healthcare
provider. An integrated assessment allows health professionals to
identify, and treat, the various factors in a patient s life that con¬
tribute to their unique experience of pain. This article provides
recommendations about what information to obtain in routine
psychological screenings through a patient s self report and the
healthcare provider s observations of the patient s behaviors.
Based on information gathered from the screening, a subset of
patients may be referred for comprehensive psychological assess¬
ments. This article describes the essential components of a com¬
prehensive psychological assessment for patients with fibromyal¬
gia, including the content of a psychological interview and illus¬
trative self report measures. Finally, an example of how informa¬
tion gathered from comprehensive evaluation can contribute to
treatment planning is presented.
The Neuropharmacology of Centrally acting Analgesic
Medications in Fibromyalgia 235
Srinivas G. Rao
Chronic widespread pain is the sine qua non of the fibromyalgia
syndrome, differentiating this disorder from other related condi¬
tions such as chronic fatigue syndrome. Several lines of experi¬
mental data suggest that aspects of the pain of fibromyalgia (FM)
are the result of changes in pain processing at the level of the
central nervous system. In this article, an overview of the pharma¬
cology of the central nervous system pain pathways is presented,
focusing on both ascending and descending systems from the
periphery to the level of the midbrain. The central sites of analgesic
action of medications commonly used to treat the pain of FM are
then reviewed.
Rational and Targeted Pharmacologic Treatment of
Fibromyalgia 261
Andre Barkhuizen
Despite disappointing results when subjected to randomized clini¬
cal trials, pharmacologic agents remain an important component of
fibromyalgia (FM) management. Addressing the main symptoms
of pain, disturbed sleep, mood disturbances, fatigue and associated
conditions are essential to improve patient functioning and
enhanced quality of life. However, much work remains to design
clinical trials that address the complexity of FM, while satisfying
evidence based medicine paradigms.
Nonpharmacologic Management Strategies in Fibromyalgia 291
Carol S. Burckhardt
Clinicians using the results of the extant research base can take an
optimistic view of the role of nonpharmacologic treatment strate¬
gies for fibromyalgia. There were no negative outcomes in any of
the reviewed studies, although in a few studies the experimental
treatment did not prove to be more effective than the attention con¬
trol. Rather than viewing this negatively, one could look more
closely at the attention control groups and attempt to better under¬
stand what they contained that worked as an active treatment. A
number of trials included a follow up component and all but one
of them found maintenance of at least one outcome change.
Maintenance of changes is more likely to occur when the patient
continues to participate in the experimental activity long term.
Patients especially need strategies that help them continue in exer¬
cise regimens. Unlike cognitive skills strategies that once learned
are likely to become part of a person s coping repertoire, both exer¬
cise and behavioral strategies, like progressive muscle relaxation,
need to be performed on a consistent basis in order to have their
effect. The goals of increased self efficacy, symptom reduction,
increased functional status and quality of life along with decreased
inappropriate use of health care resources are realistic when
patients persevere in their use of strategy combinations and receive
support from their providers.
Management of Peripheral Pain Generators in Fibromyalgia 305
Joanne Borg Stein
Fibromyalgia (FM) is a widespread chronic pain disorder that is
characterized in part by central sensitization and increased pain
response to peripheral nociceptive and non nociceptive stimuli.
rv *xrn:xrrc vii
Part of the comprehensive pain management of patients with FM
should include a thoughtful evaluation and search for peripheral
pain generators that either are associated with FM or are coinci
dentally present. The identification and treatment of these pain
generators lessens the total pain burden, facilitates rehabilitation
and decreases the stimuli for ongoing central sensitization.
Current Experience with 5 HT3 Receptor Antagonists in
Fibromyalgia 319
Michael Spath
Serotonin (5 HT) and its receptors play a crucial role for pain per¬
ception, pain transmission, pain processing and pain modulation.
Despite partly contradictory study results concerning nociceptice
and antinociceptive properties of 5 HT3 receptor antagonists, their
antinociceptive effect was investigated in fibromyalgia (FM)
patients. The data from the preliminary studies indicate a benefit in
a subgroup of FM patients.
The Promise of Substance P Inhibitors in Fibromyalgia 329
I. Jon Russell
The fibromyalgia syndrome (FMS) is a chronic pain disorder that
exhibits elevated levels of cerebrospinal fluid (CSF) substance P
(SP). Because SP is known to influence the normal process of pain
perception, there is reason to address its role in the pain of FMS.
The discovery and characterization of the SP receptor (neurokinin
1 receptor, NKlr) for the action of SP have disclosed new opportu¬
nities to understand a wide variety of conditions that are mediated,
at least in part, by SP. Knowledge about the receptor prompted an
aggressive search for agonists and antagonists that might be useful
in mimicking (modeling) or in treating the relevant conditions. This
article will draw heavily from the descriptions of the pioneers in
the field, as they have summarized their years of careful study;
it will then briefly summarize the results of a study designed
to examine the response of FMS patients to an NK1 antagonist;
and finally, it will attempt to forecast some ways in which this
technology may be used in the future to more effectively manage
FMS.
The Promise of N methyl D aspartate Receptor Antagonists
in Fibromyalgia 343
Karl G. Henriksson and Jan Sorensen
In fibromyalgia an NMDA receptor antagonist (ketamine) has been
used for diagnosis of central sensitization of the nociceptive central
nervous system in patients with fibromyalgia. The combination of
another NMDA receptor antagonist (dextromethorphan) and a
weak opioid (tramadol) has been studied with respect to pain
relief. A subset of patients may benefit from this treatment.
Management of Sleep Disorders in Fibromyalgia 353
Harvey Moldofsky
The studies of sleep physiology show that nonrestorative sleep is
important in the pathogenesis of fibromyalgia (FM). More than
90% of patients with FM describe disturbed sleep. The sleep is usu¬
ally perceived to be light and unrefreshing, irrespective of its dura¬
tion. On the rare occasion that there is a night of restful sleep, the
patient often finds that pain and fatigue are substantially improved
on the following day. Some patients may be aware of restlessness
with kicking and involuntary leg movements, which may delay or
disrupt sleep. Sometimes the bed partner may complain that the
loud snoring is disturbing his sleep. There may be pauses in the
snoring with the appearance of interruptions to breathing during
sleep, or the patient may awaken with choking, gasping or a sense
of suffocation. Some patients complain of difficulty keeping awake
and have uncontrollable sleepiness during the day that is interfer¬
ing with their social life, work, and their ability to drive safely. This
article describes the methods for assessing these various sleep dis¬
orders and how they might be managed as part of the comprehen¬
sive approach in treating FM patients.
Treatment of Fatigue in Fibromyalgia 367
Emma K. Guymer and Daniel J. Clauw
Fatigue is a major problem for sufferers of fibromyalgia (FM), and
it contributes significantly to disability and impairment of the syn¬
drome. The fatigue needs to be evaluated carefully for reversible
causes, remembering especially that some medications used to
treat FM can contribute to this symptom. The treatment of fatigue
is best managed by a multimodal approach. This includes patient
education, nonpharmacologic therapies such as aerobic exercise
and cognitive behavioral therapy, and adjunctive medications such
as some antidepressants and CNS stimulants.
Management of Dysautonomia in Fibromyalgia 379
Manuel Martlnez Lavin
Recent evidence coming from different groups of investigators
suggests that sympathetic nervous system dysfunction is frequent
in patients with fibromyalgia (FM). This new knowledge has led to
the proposal that FM is a sympathetically maintained pain syn¬
drome. Dysautonomia may cause its remaining multisystem mani¬
festations. This article discusses evidence of autonomic dysfunc¬
tion in FM as well as theoretical nonpharmacologic approaches
(avoidance of sympathomimetic products, aerobic exercises,
biofeedback, fitted stockings, mineral water) and pharmacologic
therapies (benzodiazepines, adrenergic blocking agents, serotonin
receptor antagonists, and antineuropathic compounds) that could
improve FM symptoms through autonomic nervous system
manipulation.
Evaluation and Management of Endocrine Dysfunction
in Fibromyalgia 389
Rinie Geenen, Johannes W.G. Jacobs, and Johannes W.J. Bijlsma
Fibromyalgia like symptoms such as muscle pain and tenderness,
exhaustion, reduced exercise capacity, and cold intolerance,
resemble symptoms associated with endocrine dysfunction like
hypothyroidism, and adrenal or growth hormone insufficiency. To
investigate the potential of management of endocrine abnorma¬
lities for relief of symptoms of patients with fibromyalgia (FM),
we reviewed experimental and clinical studies of endocrine
functioning and endocrine treatment. Serum GH, androgen, and
24 hour urinary cortisol levels of patients with FM tend to be in the
lower part of the normal range, while serum levels of thyroid hor¬
mone, female sex hormones, prolactin, and melatonin are normal.
With exception of GH, these conclusions are based on studies in
small samples. With respect to dynamic responsiveness of the
hypothalamic pituitary adrenal (HPA) axis, the dexamethasone
suppression test and stimulation with ACTH show normal results,
while patients show marked ACTH hypersecretion in response to
severe acute stressors, perhaps indicative of chronic CRH hypose
cretion. This finding and slightly altered responsiveness of growth
hormone, thyroid hormone, and prolactin in pharmacologic stimu¬
lation tests suggest a central rather than peripheral origin of
endocrine deviations. Because hormone level deviations were not
severe, occurred in subgroups of patients only, and few controlled
clinical trials were performed, there is—unless future research
shows otherwise—little support for hormone supplementation as a
general therapy in the common patient with FM. In patients with
clinically overt hormone deficiency, hormonal supplementation is
an option. In patients with hormone levels that are in the lower
part of the normal range, interventions aimed at pain, fatigue, sleep
or mood disturbance, and physical deconditioning may indirectly
improve endocrine functioning.
The Management of Fibromyalgia Associated Syndromes 405
David S. Silver and Daniel J. Wallace
Ten independently recognized syndromes are statistically more
prevalent in fibromyalgia (FM) patients than in healthy individuals.
Linked by a common feature of central sensitization abnormalities
in chronic pain perception, only some result in chronic neuromus
cular pain. This article reviews these associated syndromes and
presents a rational template for managing them in individuals who
also have FM.
Individualizing the Exercise Prescription for Persons with
Fibromyalgia 419
Kim Dupree Jones and Sharon R. Clark
Exercise is good for you; you must exercise, and just do it are
common admonitions to fibromyalgia (FM) patients by health pro¬
fessionals. I can t exercise; I hurt too much to exercise; and, I don t
have enough energy to exercise are equally common responses
from patients with FM. Such exchanges can lead to frustration for
both patient and provider. The factor that neither participant in the
dialogue is addressing is that exercise carries both risks and bene¬
fits for persons with FM. Although for decades exercise has been
acknowledged to be a key component of the treatment of FM, the
majority of FM patients remain aerobically unfit, with poor muscle
strength and limited flexibility. Unfit muscle is theoretically more
prone to muscle microtrauma, which causes localized pain and
may trigger widespread pain through disordered central process¬
ing. The purpose of this article is to provide practicing health care
providers with guidelines for prescribing exercise to FM patients
that take into account the risk/benefit ratio. A sample exercise pre¬
scription is included.
Office Management of Fibromyalgia 437
Don L. Goldenberg
The office management of fibromyalgia (FM) is best determined by
two variables: (1) the severity and complexity of each patient s
symptoms, and (2) the specialization and interest of the treating
physician. Because there are 6 to 10 million Americans with FM,
most patient visits will be to the primary care physician.
Rheumatologists, physiatrists, and other musculoskeletal specialists
must work with primary care physicians to foster the early diag¬
nosis and appropriate treatment of FM. Primary care physicians are
faced with enormous challenges in caring for patients with chronic
pain disorders like FM. Our managed health care system insists
that patient encounters be brief. Specialty referrals are often dis¬
couraged. There is little if any reimbursement for patient education.
FM treatment is labor intensive. Therefore, optimal planning and
use of precious office time and resources are most important. Rheu¬
matologists should train our primary care colleagues to recognize
FM. Many patients still go months or years before this common
syndrome is diagnosed. Rheumatologists should also spearhead
teaching primary care physicians the basic treatment principles of
FM. If the diagnosis is made early, patients with FM in community
practice do very well with simple management techniques. As
consultants, rheumatologists should confirm the diagnosis of FM
and suggest basic FM management. Some primary care providers or
other specialists will be fully capable of bypassing this consulta¬
tion, especially if the patient responds to simple management
suggestions. Manpower surveys have not studied the cost
effectiveness of specialty care in FM. Rheumatologists should also
assume the responsibility for the management of FM patients who
have not responded to basic FM management. Additionally, some
rheumatologists may wish to subspecialize in FM, a major career
commitment to this perplexing disorder. These situations consti¬
tute advanced FM management.
Index 447
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| spelling | Rational management of fibromyalgia Robert M. Bennett, guest ed. Philadelphia [u.a.] Saunders 2002 XV S., S. 182 - 460 Ill., graph. Darst. txt rdacontent n rdamedia nc rdacarrier Rheumatic disease clinics of North America 28,2 Fibromyalgie gtt Fibromyalgia complications Fibromyalgia drug therapy Fibromyalgia therapy Fibromyalgie (DE-588)4184710-6 gnd rswk-swf Therapie (DE-588)4059798-2 gnd rswk-swf (DE-588)4143413-4 Aufsatzsammlung gnd-content Fibromyalgie (DE-588)4184710-6 s Therapie (DE-588)4059798-2 s DE-604 Bennett, Robert M. 1940- Sonstige (DE-588)124848826 oth Rheumatic disease clinics of North America 28,2 (DE-604)BV000625464 28,2 HBZ Datenaustausch application/pdf http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=009932578&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA Inhaltsverzeichnis |
| spellingShingle | Rational management of fibromyalgia Rheumatic disease clinics of North America Fibromyalgie gtt Fibromyalgia complications Fibromyalgia drug therapy Fibromyalgia therapy Fibromyalgie (DE-588)4184710-6 gnd Therapie (DE-588)4059798-2 gnd |
| subject_GND | (DE-588)4184710-6 (DE-588)4059798-2 (DE-588)4143413-4 |
| title | Rational management of fibromyalgia |
| title_auth | Rational management of fibromyalgia |
| title_exact_search | Rational management of fibromyalgia |
| title_full | Rational management of fibromyalgia Robert M. Bennett, guest ed. |
| title_fullStr | Rational management of fibromyalgia Robert M. Bennett, guest ed. |
| title_full_unstemmed | Rational management of fibromyalgia Robert M. Bennett, guest ed. |
| title_short | Rational management of fibromyalgia |
| title_sort | rational management of fibromyalgia |
| topic | Fibromyalgie gtt Fibromyalgia complications Fibromyalgia drug therapy Fibromyalgia therapy Fibromyalgie (DE-588)4184710-6 gnd Therapie (DE-588)4059798-2 gnd |
| topic_facet | Fibromyalgie Fibromyalgia complications Fibromyalgia drug therapy Fibromyalgia therapy Therapie Aufsatzsammlung |
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