Chronic pain is at epidemic levels and has become the highest-cost condition in health care. This course uses evidence-based science with creative and experiential learning to better understand chronic pain conditions and how they can be prevented through self-management in our cognitive, behavioral, physical, emotional, spiritual, social, and environmental realms. The goal of this course is to blend creative, experiential, and evidence-based teaching strategies to help participants understand chronic pain conditions and how a human systems approach can be applied to self-management strategies to reduce risk factors, enhance protective factors, and prevent chronic pain. There are four major objectives to the course; 1. Describe the prevalence, personal impact, and health care dilemma associated with chronic pain. 2. Recognize the clinical characteristics and underlying etiology of several common pain conditions and the peripheral, central, and genetic mechanisms of chronic pain 3. Based on the literature associated with risk and protective factors in the seven realms of our lives, learn specific strategies in each realm that can be employed daily to prevent chronic pain and enhance wellness. 4. Appreciate the value of a human systems approach to health care and how it can provide a basis for integrative, interdisciplinary, and individualized care to preventing pain and enhancing wellness. CONTINUING EDUCATION CREDIT OPTION Accreditation Statement: University of Minnesota, Interprofessional Continuing Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. American Medical Association (AMA) The University of Minnesota, Interprofessional Continuing Education designates this enduring material for a maximum of 24.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. American Nurses Credentialing Center (ANCC) This activity is awarded up to 24.0 ANCC contact hours. Other Health Care Professionals Other health care professionals who participate in this CE activity may submit this certificate statement of participation to their appropriate accrediting organizations or state boards for consideration of credit. The participant is responsible for determining whether this activity meets the requirements for acceptable continuing education. Registration and disclosure information is available here at http://z.umn.edu/chronicpain and pay the additional fee. Then, email your Coursera certificate statement of completion to cme@umn.edu.
2 Diagnosis
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En provenance du cours de University of Minnesota
Preventing Chronic Pain: A Human Systems Approach
89 notes
À partir de la leçon
Common Pain Conditions and their Mechanisms (Week 4)
Rencontrer les enseignants
Dr. James Fricton, DDS, MSProfessor and Pain Specialist
University of Minnesota, HealthPartners Institute, and Minnesota Head and Neck Pain Clinic
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Hello.
Welcome to the MOOC presentation on Fibromyalgia.
I'm Doctor Russell.
I'm speaking to you from the video studio in the University of Texas
Health Science Center, where I was a faculty member for 32
years, but then retired in 2010 and am now Medical Director of a research
organization called Fibromyalgia Research and Consulting here in San Antonio.
This slide shows the big picture of the presentations on fibromyalgia.
You can see that they're divided into
three main segments or three main chapters.
What is it?
What is wrong with people with people with fibromyalgia?
And what can be done for them.
And so, for this segment, we're going
to be talking about the diagnosis of fibromyalgia.
Diagnosis means, to identify the medical condition by name
and by a standard name that, physicians and medical
dictionaries and medical information on the Internet will recognize.
Again, we would point to the state-of-the-art descriptions and
the state-of-the-art description that is important to our presentation today
is, a common, fibromyalgia is a common chronically painful soft tissue pain
condition which is characterized by persistent,
widespread pain, tenderness, and multisystem comorbidities.
In an earlier lecture on the presentation of
fibromyalgia we talked about comorbidities and what they were.
But we will be talking more about that.
So, in this presentation, we'll ask where does fibromyalgia fit in medicine?
How is fibromyalgia diagnosed?
Is making the diagnosis of fibromyalgia a good thing or bad thing?
And, the final question is, who cares?
The who cares sounds like a flippant statement, like, maybe, no one would,
or implying that maybe no one did, but it's a play on words.
Who cares is who provides the care.
We refer to medical care by the word care.
And so, this is a play on words regarding who
the physician should be that one with fibromyalgia should turn to.
So in this slide, we see two columns.
On the left hand side are symptoms
that can be experienced by people with fibromyalgia.
And on the right side, the kinds
of medical conditions that that symptom might suggest.
And so, you can see that this is
a diagnostic challenge for physicians, because patients can, with
fibromyalgia can present with symptoms that are, in
many ways, like the symptoms of other medical conditions.
And as a result, there may be confusion about the diagnosis for a period of time.
For example, symptom number one, pain all over.
That could present in a person with metastatic cancer,
meaning cancer that is spread all over the body.
It could recu, result from a spinal cord injury.
Neck and shoulder pain could be due to a
pinched nerve in the neck, or due to widespread osteoarthritis.
Chest wall pain could mimic angina, which is heart pain
because of lack of oxygen or blood flow to the heart.
It could represent esophageal spasm, spasm of the
tube that we use to swallow our food.
It could result it could be confused with gall bladder disease in
which there is a gall stone or inflammation of the gall bladder.
Hip and area, hip area pain could be confused
with arthritis or piriformis syndrome or iliopsoas muscle pain.
Low back pain could be confused with sciatica or spinal stenosis.
Severe headache could be confused with migraine or tumor or pseudo tumor cerebri.
Somatic fatigue could be confused, chronic fatigue
syndrome, hypothyroidism and depression and so forth.
Dizzy and syncope or fainting could be confused with acoustic
neuroma or heart rhythm disturbance or something of that nature.
So, this is, does represent a diagnostic challenge, and one
must take all the information and put it together, and try to
figure out what the patient is presenting.
One of the early findings in the understanding of fibromyalgia was a
finding that, if you give patients a pain diagram, a body diagram
to mark the locations of their pain, they mark pain all over.
Notice that, in this case, there's an area in which
the patient didn't mark any pain on the right back area.
But on the front, the, the same area,
on the right front is affected in this patient.
Notice that it can be in the hands and it can be in the feet a little bit.
It can be over the whole body.
And some patients marked the areas in which
they experienced pain, very darkly and very intensely.
Others marked it more lightly.
And that's a style, but what they're all telling us, these
four patients, are telling us is that their pain is widespread.
In this slide we see, an attempt to try to classify fibromyalgia syndrome.
Notice that we're using the example of arthritis to
see where fibromyalgia fits into the classification of medicine.
Arthritis can be characterized as having a single joint involved.
In that case, it's referred to as monoarticular arthritis.
And is exhibited by or exemplified by gout or by infection in a joint.
Oligoarticular arthritis means that there are a few joints
involved and that is the characteristic in ankylosing spondylitis.
Polyarticular means that there are many joints
involved and it implies that they're symmetrically placed.
That is, both shoulders would hurt and be swollen, both elbows,
both hands and the same fingers, both knees, and so forth.
A symmetric, poly, multiple joint arthritis,
and that is exemplified by rheumatoid arthritis.
Now, if we take the same pattern and talk about
soft tissue pain, we could see that there could be localized
soft tissue pain which would be presented by a diagnosis of tendonitis
with inflammation of tendons or inflammation of bursa, bursitis.
On the other hand, the problem could be sort of
regional, involving an area of the body but not the
whole body and that is exemplified by myofascial pain syndrome,
complex regional pain syndrome, referred pain disorders, and so forth.
And finally, there is the generalized soft tissue pain conditions and fibromyalgia
is the mast head for that category, but also chronic fatigue
syndrome, when it's painful, is often involves multiple areas of the body, and a
disorder called hypermobility syndrome can be painful and exhibit double-jointedness.
So, here we see that a classification of that is used in medicine
is entirely compatible with a place for fibromyalgia in this classification.
Now, when we talk about clinical diagnosis, how do we go about that?
And this was the question that many physicians had early
in the time when fibromyalgia was being studied and being evaluated.
And many approaches were proposed to come
about with a diagnosis for fibromyalgia patients.
But it turns out that the most appropriate and
valuable approach is one that will be accepted by many.
And that is referred to as an expert consensus,
that is, people who know the disorder quite well would
get together and use some means to come to
consensus about what should be included in the diagnostic criteria.
And in the case of fibromyalgia, that was
done on two different occasions using very extensive research
study to try to determine what the characteristics, what
characteristics of fibromyalgia should be included in diagnostic criteria.
There are two me, methods that have now achieved widespread use.
The first one to achieve widespread use was
the 1990 American College of Rheumatology research classification criteria.
You'll notice, down below here, the abbreviations for those words, are spelled
out so that there is no confusion about what the abbreviations mean.
But it's easier to use an abbreviation because it
fits in the mouth better and it's easier to say.
Then, later in 2010, almost exactly 20 years later, there were
new criteria developed called the American
College of Rheumatology Fibromyalgia Diagnostic Criteria.
And so, we'll learn more about these two different criteria in just a moment.
The first one involved doing research at 20
different centers in the United States and Canada.
Studies done by experts in the field and all of them
coordinated to try to find out what the criteria should be.
Eventually, after many collections of data at
many centers the and, and statistical analysis, it was decided that
widespread pain for three months would be one of those important criteria.
And the second criteria, only two criteria, very
easy to think about and learn and remember
was that there were tender places around the
body that were unusually tender in people with fibromyalgia.
And that 18 of them were very characteristic and contributed nicely
to the validity of the diagnosis, and if 11 or more of those
18 criteria were present in a given patient then the diagnosis would be made.
There was quite a bit of interest in these tender locations.
And so it was, important to think about
developing an illustration which could show the location of these places.
They were described anatomically in the research papers, but it was
nice to be able to see them on a body diagram.
And see that in fact, if, if many or all
of them were present, this clearly would be widespread tenderness.
So, what was shown here in this slide
was the original illustration that was associated with fibromyalgia.
It comes from the three graces.
Who were said to represent mythologic daughters of Zeus.
And you see at the bottom of this slide there, the names
of each of these beauties and what they were suppose to represent.
But, on the bodies of these, women, are the
locations of the tender points or areas of unusual tenderness
or low pain threshold that can be experienced in
people with fibromyalgia, and were helpful in making the diagnosis.
And then, a educational program referred to as
ADAM, which exists mainly on the Internet to my knowledge, used a different
kind of diagram and it only required the front and back
of one individual to show the location of the tender points.
And then I got involved in the, pursuit of illustrating
this and painted a painting of a woman, and showed
on the body the tender points location and were able
to do it from a single person showing a single view.
And I even included in the illustration the hand of god bursting through the back
of the painting and showing, pointing to
the tender point at the lateral upper condyle.
And, in essence, saying that the good lord intended us
as physicians to know how to do this tender point examination.
But there were certainly very important values
in developing these criteria and having satisfactory criteria.
This graph shows on the, vertical axis,
the number of publications referenced
in med line in a given
year.
And this was showing five showing the graph of the number
of publications if we just take every five years to illustrate the data.
And you can see that when we come to 1990, when the 1990, American
College of Rheumatology Fibromyalgia, the
research classification criteria were, were published.
There was a dramatic increase from about 10 to 15
articles per year up to, over a 100, very quickly.
And then, on to very progressive and
dramatic increase in the number of publications.
So, this is a soft tissue pain condition which exhibited
growth in research, very dramatically impacted by
the, agreement of the experts in the field
that they now could share diagnostic
criteria and knew that each of the patients in their research studies would
meet the criteria that other physicians were using.
And, I might show that this did not occur in non-specifically.
That is, the brown line, down at, toward the bottom, all the way across the graph,
is showing the number of publications in another
medical condition, myofascial pain syndrome, a regional pain disorder.
And the number of articles in that category did not increase
dramatically in 1990 as the publications about fibromyalgia did.
One other interesting thing here is that some people are trying
to avoid the, the affiliation with the name fibromyalgia
syndrome and would rather call this disorder chronic widespread pain.
And so, I also graphed the frequency of publications about
chronic widespread pain which seemed to increase around 2005 and 2010.
And then, I also added those to the graph of fibromyalgia
because I think they are essentially fibromyalgia being described as
chronic widespread pain, and so you can see the pattern
here which fits very nicely the pattern already established for fibromyalgia.
So then the 1990 American College of
Rheumatology Research Classification Criteria came under attack.
It had already been maybe 15 years and someone said
that the tender point examination was just too hard to learn.
There was another problem and that was that epidemiology studies looking for
the frequency of fibromyalgia in the
community, once a person was identified, perhaps
by phone call or by a questionnaire, it was necessary to examine that person
for tenderness to determine whether they really met criteria for fibromyalgia.
And so that was inconvenient, and then there is a
subgroup of psychiatrists who have decided that their profession
would be better served by not making physical contact with patients.
And so, they prefer not to touch a patient.
And so psychiatrists, in this, in this pursuit would
not be able to make a diagnosis of fibromyalgia
for lack of being able to touch the patient
and, and determine the tenderness at the anatomic tender points.
Another problem was that the original 1990 criteria
were never validated for use in community care, and
so, some said we should not be using
these criteria in diagnosing fibromyalgia in the doctor's office.
It's really only set up to be used
in defining people for, with fibromyalgia for research study.
And it was true.
Another criticism that these criteria addressed only the pain
and tenderness of fibromyalgia, so-called allodynia very well.
But they did not include any of the other comorbidities.
And there was a move to pay more attention to the other
comorbidities in fibromyalgia, so we needed
an, a diagnostic criteria that addressed comorbidities.
And then, the question was, if we're going to include
comorbidities, we may not be able to include them all.
How do we choose which comorbidities should be included?
And so, after a long, process of discussion
and consideration, the slide that you see here
lists, is, is a list of comorbidities in fibromyalgia.
And you'll notice the, blue colored,
words were the ones that were chosen to be included in a new set of criteria
that were established, again, by research study and they were
tiredness, cognitive dysfunction and persistent somatic fatigue.
So tiredness, memory trouble, short term
memory trouble and persistent fatigue, fatigue where
the comorbidities included in the 2010
American College of Rheumatology fibromyalgia diagnostic criteria.
And then, these criteria where subjected, not only to large number
of patients being evaluated and interviewed by clinicians,
but also they were subjected to evaluations
so that they would be validated for clinical use in the doctor's office.
And so, all of that was done and the information about the research studies
was published and this criteria where again, quite simple.
That is, the patient would have assessed their
widespread pain index or established the widespread index.
And that index can range from 0 to 19.
And there would also be an assessment of the
symptom severity scale that could range from 0 to 12.
The widespread pain index would have to do with parts of the body that the
patient had experienced pain within, the last short period of time.
And the Symptom Severity Scale would include
the comorbidities that were associated with it.
And then it was discovered that if,
rather than having the fit, physician interview the
patient, that the same information could be
obtained by providing the patient a self-report questionnaire.
And so, now that can be done.
And I show you here the questionnaire for the 2010 American College of Rheumatology
criteria that we use in our research studies.
You can see that a person might say, yes, check right here,
I've had pain during the last two weeks in the right jaw.
Or the right upper arm, or the right lower arm, or
the right shoulder, and here would be the balance for that in
the left jaw, or the left upper arm, or the left lower
arm, and the left shoulder, and so forth, as we go down.
And for every check in the Yes column, there would be a
a, a single digit added to the widespread pain index.
So, if a person filled out yes on ten of
these areas here, the the widespread index would be ten.
And then, in addition to that, the symptom severity
scale is included here and ranging from zero to three.
So none would be zero, slight, mild would be
one, moderate would be two and severe would be three.
And so, for tiredness or fatigue or discognition, forgetfulness,
trouble concentrating over the past two weeks, the person would
mark which of these categories and then a number would be associated with that.
And finally, somatic symptoms within the past week could be any of these.
The patient would just check them and the clinician would look at the number of
items that were checked, and the value here would be zero to three as well.
And then the sum of each of these
would make the somatic, the symptom severity score.
And then the total score for the 2010 criteria would be the sum of
the widespread pain index and the symptom
severity score, and that would be recorded here.
So, is there value in making the diagnosis of fibromyalgia?
Many had argued, many critics had argued, that making the diagnosis
of fibromyalgia only hurt or harmed patients
by giving them something to focus on, and to
foment about, and to cry about and to worry about.
But others felt that it was likely
that patients were reassured by having a diagnosis.
And they felt better about themselves because they now
knew what their, what their risk prognosis was on a
long term basis and they also could start working
to make themselves better by following good instruction about treatment.
And so, here we see a study that was done in England by Hughes and other authors,
and we see on the vertical axis the rate per 100 person years.
So, you would say, for, for every 100 years of patient follow up,
these values would show how often there were visits to the doctor,
treatments of some sort taken by the patient, or given by the doctor.
Tri-cyclic anti-depressant drugs were administered,
or non steroidal inflammatory analgesic
drugs were administered, so all three of these fit this pattern.
And you can see that fibromyalgia patients got
more and more visits, more and more treatments, more
and more until finally the diagnosis was made
and finally the patients could take a deep breath.
And the number of visits decreased substantially, significantly.
The number of treatments taken by the patient decreased and so forth.
And that did not happen for a controlled group with
another diagnosis which was made at this point in time.
So, this data shows that there is value to not only the patient, but also to
society in reduction of medical care costs associated
with fibromyalgia when the diagnosis is properly made.
Now, something else that I need to share
with you that is important to understand is
that fibromyalgia while, moving from one patient to
the next, the pattern is very, very similar.
There are, in fact, are subgroups of people with fibromyalgia, and so
we need to understand a little bit about how that comes about.
First of all, it's somewhat complex.
It does need understanding.
It's a convoluted topic.
It's perhaps something like taking your cranberry juice,
which you, which is so sour you just can't quite get it down, and adding
strawberry juice, or grape juice to it, which maybe is a little
sweeter and softens it a little bit, so it changes the flavor.
So, we talked about various comorbidities in fibromyalgia, and a person
with fibromyalgia could have developed or inherited
five of those criteria, but another person who lives next door with
fibromyalgia might have inherited some of the same and a few different.
And so, the actual character of the fibromyalgia will depend
a little bit on which of the comorbidities are present.
There were several papers with subgroups of fibromyalgia in the title.
Subgroups of primary fibromyalgia
exist with different proportions of the key
comorbidities such as pain, sleep, mood, etc.
And, there are sub groups in
which fibromyalgia overlaps with other conditions, such
as inflammatory or auto immune disorders like
rheumatoid arthritis, systemic lupus and chronic infections.
There is also subgrouping that has been accomplished by response to medications.
And it turns out that some patients respond to
one medication, whereas others respond better to other medications.
And so that also has been, the
subject of discussion about subgroups of fibromyalgia.
So, finally we get to our, somewhat flippant statement, who cares?
It's, it seems flippant because it implies that no one cares.
But, in fact, care is the term that is used by medical
care physicians, to say we're providing care for this patient.
So who cares for the patient?
What kind of physician should be sought?
What kind of healthcare provider would be helpful?
And the first thing is that primary care physicians that we
abbreviate as PCP should always be the captain of the team.
That should be the person that the physician that the
patient with fibromyalgia, or other medical conditions, should turn to.
Primary care physicians typically are family practice
doctors, pediatricians or specialists in internal medicine.
It's my particular bias that fibromyalgia patients who are adults
should seek the care of a specialist in internal medicine
for their general medical care or to be their primary care physician.
And I have done so myself.
Another person that might in care
for people with fibromyalgia would be rheumatologists.
Rheumatologists actually led in the search to understand fibromyalgia,
and patients came to them because they had pain and were sent to
them, becau, by their physicians because this pain and other symptoms of aching
and stiffness resembled the inflammatory disorders that rheumatologists care for.
On the other hand, it is now, fibromyalgia is now known to be a disorder of
the central nervous system, with pain amplification due
to substance P, a chemical in the spinal fluid.
So, that is one of the reigning theories about how, fibromyalgia
works and we'll be talking more about that in a future session.
Rehabilitation physicians are skilled at helping people, who have lost
the ability to be physically active, to regain that ability.
And they often worked through physic, physical therapists or massage therapists.
Sleep physiologists are very important to the care of
fibromyalgia because they have the technology to evaluate sleep.
When we sleep we're not just unconscious for a period of hours.
There are many things going on during that time.
And sleep physiologists are trained to
understand those activities of the sleep period.
Finally, psychiatrists, psychologists and counselors can be very helpful
in helping patience to find new guidance in their life.
And to deal with emotional, troubles, that can find
themselves in the manifestations of depression, anxiety, panic, and otherwise.
I, we would say that orthopedic or general surgeons would be
involved in the care of a person with fibromyalgia only for surgery.
And so, hopefully those specialists, those surgical specialists,
will recognize fibromyalgia when it shows up on their doorstep, but
they would refer patients to one of the, physicians who
has the skills to evaluate and care for those patients.
And so, in conclusion, we would say that the clinical
diagnosis of fibromyalgia is now possible by two different methodologies.
The 1990 ACR Research Classification Criteria, and the
2010 American College of Rheumatology Fibromyalgia Diagnostic Criteria.
The first is seen as facilitating research study, and
the more the newer criteria as being validated for community
healthcare but in my evaluation of patients I use
both criteria, and I'm very pleased when I see that they essentially
always identify the same individuals
with fibromyalgia.
Making a diagnosis has value in a number of respects,
not only to the person with fibromyalgia, but to society.
There are subgroups, fibromyalgia can be
classified as a chronic, widespread pain syndrome.
And we believe that primary care physicians are the decision
makers and should be the instructors of patients with fibromyalgia.
So finally, we would say, we all should care and again, we get back
to our happy dog painting in which our dog friend is
saying, I'm happy because now fibromyalgia can be diagnosed with confidence.
And the patient can be relieved of the
anxiety and worry about what is happening to them.
Thank you.
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