[BLANK_AUDIO] Hello, I'm Dr. Russell. Welcome to another MOOC presentation on Fibromyalgia Syndrome. I'm speaking to you from the studio in the University of Texas Health Science Center at San Antonio. Where I was on the faculty for 32 years, retired in 2010 and now I'm medical director of an organization called Fibromyalgia Research and Consulting which does research for fibromyalgia patients here in San Antonio, Texas. We are today going to continue on with the concept of the question. What is fibromyalgia? And in this case we're going to identify fibromyalgia by severity of the symptoms of fibromyalgia. But you can see that this outline, which we call the big picture, indicates what's going to, come, and that is that the next chapter in this. Saga about fibromyalgia, will be about what's wrong with people who have fibromyalgia. Physician speak would say what is the pathogenesis of fibromyalgia and there we'll talk about genetics and a variety of other things that are objective measures that are abnormal in fibromyalgia. And then final chapter will be what can be done for them or, in doctor speak, treatment. Recall that there is a state of the art description for each of these main chapters for fibromyalgia. And the one that pertains to our topic today is that fibromyalgia is a common. Chronically painful, soft tissue pain condition which is characterized by persistent, widespread pain, tenderness, and multisystem comorbidities. So, next we turn to an illustration. About severity, answering the question, how bad is it? The picture is of Saint Sebastian, was painted by Andrea Mantegna in 1480, but he was drawing, painting a picture that was depicting an event that happened back in around 300 AD. In that time, there was a Roman Emperor by the name of Gaius Aurelius Valerius Diocletianus Augustus. Depending on who writes the article, he was either a really good guy. Or he was a bad guy. He and Saint Sebastian had a, disagreement about how things should be going. And the emperor found the, practice of Christianity in the life. Of St. Sebastian to be objectionable, or at least some of his colleagues did. And they went about trying to convince him that he shouldn't practice Christianity any longer. So you can see here that one of their approaches to try to change his mind. Involved shooting arrow, arrows into various parts of his body. And, then as the story goes, they were unsuccessful in convincing him to change his philosophy by these arrows. And some friend helped him to. Remove the arrows, and recover his strength. And eventually, the emperor was so aggravated by the turn of events, that he had him clubbed to death. When Diocletian finished his term, or gave up. His term as emperor of Rome. He went back to his birth city which was split Croatia, and built a castle that is still there called Diocletian Castle. Now the purpose for showing this picture. Is that we're asked to assess the severity of something, and the question is, what should we evaluate? Should we evaluate each part separately. There's clearly a series of arrows going into the right leg. Should we evaluate the right leg for the severity of its pain? Or how about the left leg? Or how about the abdomen where an arrow is piercing the, a least\ the sub-contanious tissue and perhaps the muscle as well. So, should we do each part separately, or should we do all of the parts combined? And that's the same approach that is necessary to evaluating various comorbidities in fibromyalgia. Severity, that is the topic of this session, is the answer to the question how bad is it? So one approach that has been taken in evaluating people with various symptoms, including pain. Is to use a visual analog scale. On several occasions I've tried to get back to where the original publication suggesting the visual analog scale be used for, health assessment. But the closest I've come to it is a paper in 1976. That I have referenced here below and a very good use for it done by Dr. Jim Freese and his colleagues in 1982. You can see that a visual analog scale is characterized by a horizontal line. That is, ends in posts at either end. On the left-hand side is no pain, and on the right side, the post says, pain as bad as it could possibly be. So this is very severe pain. And you can see below the diagram there are designations that perhaps this thing which should be 10 centimeters in length exactly. The, the range from 1 centimeter to 4 centimeters should be considered or below that. Below 4 centimeters should be considered mild whereas in the range of 4 to 6 should be considered moderate severity. And in the range of 7 to 19 should be considered very severe. You can see that a patient could be asked to make a mark across this line. At any point which they think represents this severity of their pain at any point in time. And so if they mark down here, that might be just about the middle, and the severity of their pain would be said to be. 5 on a scale of 10, or 5 over 10. But the same could be used when they have had treatment for a period of time. And we would expect if the treatment is helpful that the place they would mark the line now would be lower. Maybe substantially lower than it was when they marked it the first time, before receiving any treatment. So, here is a research paper, data from a research paper. By Bennet and all which was published in a Musculoskeletal Disorders, journal in 2010. And what the authors show is the severity on a visual analog scale of the morning stiffness at 7.2 centimeters plus or minus 2.5. Fatigue was next at 7.1, pain at 6.4, non restorative sleep at 6.8. So we would say that all of these would be in the range of severe to moderate for each of the categories. And then when we get down into anxiety, depression, headaches, abdominal pain and bladder. Problems. The severity of those symptoms would be less in the mind of the individual's that were completing the questionnaire. This questionnaire bears a fair amount to weight, because it represents the responses of almost 3,000 people in the research study. Now another one of the [UNKNOWN] that we have to think about and find ways to quantify or measure the severity, would be the sleep trouble and a questionnaire. A very brief 4 question questionnaire. I found to be very, very useful for fibromyalgia. It might not be ideal for some other sleep disorders, but for the sleep disorder associated with fibromyalgia, it works very well and it changes. The score changes or decreases with treatment. You'll notice here that the person that is filling out the questionnaire is asked to mark all the boxes with a check mark. Eh, If you answer incorrectly, please fill in the correct box entirely. And so they're asked to put down how often in the past month did you. Have trouble falling asleep. And if that wasn't a problem at all, they would indicate not at all. And the score from that would be 0. If that had happened for 8 to 14 days of this month, or almost a third to a half of the time, then that score would be 3. If in fact it was, they had to mark 22 to 31 days for the month that would say that it's 2/3rds or perhaps the entire month and the score from marking this box would be 5. And then you can see as we down, move down through each of the boxes, we have the potential of having the total score of 20 for fibromyalgia sleep trouble. The other questions, wake up several times at night? Having trouble staying asleep, including waking far too early? Waking up with, after your usual amount of sleep, feeling still tired? And worn out. So, these are questions that are very characteristic and very enlightening for, people with fibromyalgia to understand their sleep function. So let's look at some data. This is a research study that was published in 2011 and shows the Jenkins Sleep score at baseline, when the patients came into the study at 15. And you can see that after a period of time of treatment, the placebo group had a decrease by 2.9. Centimeters it would be or 2.9 score point sorry, 2.9 out of a total of 15 so they decrease down to almost 12 but people receiving the active medication, decreased by 6.1 and 6.2 and so there was a highly significant difference. Between the change associated with treat, active treatment and the change associated with ple, placebo when using the Jenkins Sleep Scale score as the measurement. Another approach to evaluation, we said we could evaluate each of the manifestations separately as we've just seen. With pain and sleep, or we could evaluate the whole package. And so Dr. Bennett and his group at the University of Oregon, Oregon health science center have developed a questionnaire which sort of includes everything about fibromyalgia. A sort of global assessment of fibromyalgia. Not only. Symptom wise but way in which it interferes with their ability to function. And so the patient might be asked here during the past seven days indicate, and this is something like the visual analogue scale except it's divided up into. Boxes, so this is zero and this is 10. And the patient is supposed to mark whether it sort of down toward the no difficulty area or very difficult. And so brushing and combing your hair. So where should that be marked? And the patient would mark it. And if, if they mark it in this one there would be a 10, if here, 9, 8, 7, 6, and so forth, and then the total score can be added up and, that sum is divided by 3 and that number goes into this box. This. Set of two questions. Evaluates the extent to which fibromyalgia has interfered with things over the past seven days. And so that could be marked and there is no modification of the number that is the resultant score. So the patient would mark maybe 9 here and 10 here and the score would be 19 for the subscore would be 19. And here we're looking at a variety of symptoms and those symptoms could be pain on the first level. Your level of energy that would be sort of like fatigue. Your stiffness and so forth. And the subscore that is obtained by adding all these numbers together would be divided by 2. And that would be the subscore here. And then we would just add the subscore from each of these three components, and that makes the total. The total has a range of zero up to 100. And so. A person who has a score on the fibromyalgia impact questionnaire, or FIQ, modified which is presented here. That person, if they had a score of 95, you would say that's quite severe. Fibromyalgia whereas if the score was 22 or 14, we will say that's relatively mild. So here is some data showing that that instrument not only goes score that one can easily detirme. But it also is changes with treatment, and so you can see that the, there was a decrease of 17 here from the baseline of 62, there was a change of, decrease of 17 with placebo treatment. But active treatment decreased by 24, and those changes were very significantly different than the change that occurred with placebo. So, another way of getting information about fibro myalgia comes back to the original fibro myalgia criteria, the 1990. American College of Rheumatology research classification criteria that depended on the examination of tender points. So one could examine the tender points and put the severity of the pain experienced by the patient as well as possible in these and then scores added up. Another way of doing that is to use an instrument called a dolorimeter or algometer, which can assess the pain threshold. And so we're going to see here a dolorimeter being pressed at 90 degrees to the lateral epicondyle which is one of those areas of tenderness or tender points. As was they were called in the 1990 criteria for fibromyalgia. It's interesting that people with fibromyalgia have a, or are found to have a pain threshold. In kilograms between, 0 and 4. Usually between 0 and 3 in fact. Whereas healthy normal people including healthy normal women. A pain threshold in the range of 4 or 5 or 9 or more. And, so there is very little overlap between the pain threshold experience by people with fibromyalgia and those of healthy, normal controls. So the instrument is pushed down. Until the patient says, now I feel the change from pressure to pain. And that would be the pain threshold. Let's look at some numbers that come from an actual patient here of pain threshold values at the low cer, at the sorry, this should have been trapezius right in this location, 1.3 for the lateral border of the trapezius. On the right-hand, 1.4 on the left. For the second rib area, for the lateral epicondyle and for the medial knee. We found in a research study that, including these 4, on each side. For a total of 8 gave us values that were very comparable and correlated highly with doing all of them, examining all of them. So we limited our evaluation to that. We take the average of these eight numbers, which in this case, was 1.6. And the units would be kilograms per centimeter squared. So let's look and see what that kind of data looks like from a research study. Here we see average pain threshold of 2.1 for fibromyalgia and 4.8 for healthy normal controls. And this is compared to the visual analog scale for pain which was 6.8 for these individuals. and only 1.3, so this was up in the moderate almost to the severe range and 1.3 in the healthy normal controls was in the very mild, very low value for the pain visual analog scale, which was associated with a high pain threshold in the normal individuals. So, it's interesting that there are important ways to use this information. We think that in the future, physicians and other healthcare workers responsible for helping their patients will be paid on the basis of outcomes for the patient. That is a much better payment. For an outcome that was good, in which the patient improved considerably. But, the problem is, it has always been difficult to propose a way to assess outcome. From medical records. Because as you look back to a medical record, the physician might say one time patient is much better, next time not so good. And how is the patient really doing and how do you document that? Well, we just talked about some instruments and my preference is the fibromyalgia impact questionnaire because a single score can represent the entire patient. And, and that score could be put into the electronical. Electronic medical records as one of the vital signs, like temperature, and blood pressure, and weight, and so forth. There's always room for expanding that categories of vital signs and the nice thing about vital signs in an electronic medical record is that they can easily be graft. And someone could graph the data when the patient, for the patient at periodic intervals. That comes from this questionnaire, and then one would have documentation that there was improvement of the fibromyalgia impact questionnaire with the treatment the patient was receiving. That would insure payment for effective care and. It would help the physician or the health care worker receive that objective satisfaction of improvement noted by the patient. So in conclusion, we would say that severity can be assessed and it's important to assess the severity. In people with fibromyalgia as well as any other medical condition. It can be focused on specific comorbidities or evaluation could be more global by merging comorbidities in the evaluation instrument. The severity can be assessed by administering questionnaires. Or by using examination measures. And documentation of severity offers the real potential of measuring change that occurs with treatment. And so, when we finish with our Happy Dog who is happy that we're able to. Assess the severity in fibromyalgia and document improvement with our care. Thank you. [BLANK_AUDIO]
