FIBROMIÀLGIA UPDATE MUTUAM

FIBROMIÀLGIA UPDATE
MUTUAM
Jordi Carbonell Abelló MD, PhD
Parc de Salut Mar
Universitat Autónoma
Fundació FFC
Barcelona
[email protected]
Dr. Jaime Rotés Querol
Síndrome de Hiperlaxitud Articular
Fibromialgia
Gota, Hiperostosis Anquilosante Vertebral Senil, Artritis Reumatoide,
Espondilitis Anquilosante, etc
FIBROSITIS
• Smyte and Moldofsky
• Asociacion constante de dolor crónico, sueño no reparador, rigidez matutina y fatiga a:
- dolor a la presión en 12/14 puntos prederfinidos
- ondas alfa fase REM del sueño
• no cumplen criterios:
- dolor post-ejercicio
- mialgias virales
- polimialgia
These criteria may also help to differentiate
"fibrositic" pain from pain which is purely
malingering pretense, or neurotically symboli
Two Contributions to Understanding of the "Fibrositis" Syndrome. Smythe HA, Moldofsky H. Bulletin of the
Rheumatic Diseases. 1977-78. 28-1; 928-931
Hench, P. (1976). Nonarticular Rheumatism, Twenty-Second Rheumatism
Review: Review of the American and English Literature for the Years 1973
and 1974. Arthritis and Rheumatism, 19 (suppl),1081–1089.
• Dr. Jaime Rotés Querol. 25 años de Reumatismo psicógeno.
Med Clin (Barc). 1988 Mar 19;90(11):456-8
• Rotes Querol J. Fibromialgia.Rev Esp Reumatol. 2005;32:77-81
Yunus M, Masi AT, Calabro JJ, Miler KA, Feigenbaun SL. Primary
Fibromyalgia (Fibrositis): Clinical Study of 50 Patients with Matched
Healthy Controls. Arthritis Rheum. 1981. 11-1: 151-171
Hipermovilidad Articular o Laxitud Articular es un entidad caracterizada por
distensibilidad de las articulaciones ante movimientos pasivos e hipermovilidad en
movimientos activos en ausencia de enfermedad reumatológica sistémica
Association Between Joint Hypermobility Syndrome and Panic Disorder. Rocío Martín-Santos, M.D.;
Antonio Bulbena, M.D., M.Sc.(Cantab.); Miquel Porta, M.D., M.P.H.; Jordi Gago, M.D.; Lluís Molina,
M.D.; Juan C. Duró, M.D, The American Journal of Psichiatry. 1998
Joint Hypermobility and Anxiety: The State of the Art. Javier Garcia-Campayo & Elena Asso & Marta Alda.
Curr Psychiatry Rep. 2010
Síndrome de hipermovilidad es el conjunto de síntomas esqueléticos en presencia de
hipermovilidad articular en pacientes sin otra patología
Kirk JH, Ansell B, Bywaters EGL: The hypermobility syndrome. Ann Rheum Dis 1967, 26:419–
425
Sutro J: Hypermobility of knees due to overlengthed capsular and ligamentous tissues.
Surgery 1947, 21:67–76.
La hipermovilidad aislada puede considerarse como un trastorno del desarrollo
mesenquimal* en un extremo del conjunto de enfermedades hereditarias del tejido
conectivo como el Ehler-Danlos o el Síndrome de Marfan, etc.
*Mesenquima: tejido embrionario que se diferencia en tejido conectivo
Es un trastorno común, benigno y hereditarios del tejido conectivos que dar lugar a
mayor elasticidad de tendones y cápsulas articulares. Puede considerarse una forma
clínica de la enfermedad de Ehler-Danlos en la que solo se presenta hipermovilidad
articular
Hiperelasticidad cutánea
Pectus excavatus
Aracnodactilia
Escleròticas azules
Fragikidad ósea
La hipermovilidad aislada es importante porqué se asocia a:
Dolor generalizado
Patología degenerativa articular
Su prevalencia en poblaciones europeas se sitúa en el 10%
La relación hombre/mujer es de 1/3
Más frecuente en niños y adolescentes
Disminuye de prevalencia con la edad (mujer 5 década y varón 3 década)
¡El punto de corte en 4/9 criterios de Beighton deberían modificarse en relación a
la edad y el sexo!
Diagnostic Associations with Hypermobility in Rheumatology patients. Hudson N, Starr MR, Esdaile
JM, Fitzcharles MA. British Journal of Rheumatology 1995; 34: 1157-1161
Diagnostic Associations with Hypermobility in Rheumatology patients. Hudson N, Starr
MR, Esdaile JM, Fitzcharles MA. British Journal of Rheumatology 1995; 34: 1157-1161
Prolapso de valvula mitral 3% población general
Asociación entre prolapso mitral y trastorno de pánico
Asociación entre pànico y laxitud sin prolapso
Association between joint hypermobility syndrome and panic disorder Martin-Santos, Rocio;Bulbena,
Antonio;Porta, Miquel;Gago, Jordi;et al The American Journal of Psychiatry; Nov 1998; 155, 11
Association between joint hypermobility syndrome and panic disorder Martin-Santos,
Rocio;Bulbena, Antonio;Porta, Miquel;Gago, Jordi;et al The American Journal of Psychiatry;
Nov 1998; 155, 11
Epidemiology of General Joint Hypermobility and Basis for the Proposed Criteria for Benign Joint
Hypermobility Syndrome: Review of the Literature. LARS REMVIG, DORTE V. JENSEN, and ROBERT C.
WARD. J Rheumatol 2007;34;804-809
Epidemiology of General Joint Hypermobility and Basis for the Proposed Criteria for Benign Joint
Hypermobility Syndrome: Review of the Literature. LARS REMVIG, DORTE V. JENSEN, and ROBERT C.
WARD. J Rheumatol 2007;34;804-809
DOLOR MUSCULOESQUELETICO Y LAXITUD ARTICULAR
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Las artralgias son claramente más comunes en laxos
La raquialgia es más común en adultos laxos y también lo es la raquialgia laboral
Existe una clara relación con los esguinces, especialmente de tobillo
Probable relación con dislocación de codo y dolor temporomandibular
Mayor prevalencia de osteoartritis (artrosis rodillas)
Laxitud articular: otras patologías asociadas posibles
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Prolapso mitral
Elasticidad cutánea
Cicatrices hipertróficas
Hernias
Prolapsos uterino y rectal
Venas varicosas
Hemorroides
New American College of Rheumatology Criteria
for Fibromyalgia: A Twenty-Year Journey
FREDERICK WOLFE
• Sacan la hipersensibilidad al dolor por el recuento de puntos del centro de la enfermedad
• Refuerzan la medida de la severidad del dolor por el WPI
• Incorporan otros síntomas en los criterios
• Conceptualización alternativa para los escépticos
• Muestra como el dolor y la escala de severidad sintomática son un único factor (correlación
0.733)
• No deben entenderse como una legitimación de la FM
• No se han resuelto los problemas filosóficos, existenciales y/o sociales sobre la FM
• Los nuevos criterios no eliminan la exploración física ni el interrogatorio. El rol del médico
permanece y se profundiza al extenderse a los síntomas somáticos
Arthritis Care & Research. Vol. 62, No. 5, May 2010, pp 583–584
INSTRUMENTS DIAGNOSTIC I MESURA FM
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ENTREVISTA CLINICA ESTRUCTURADA
PERFIL BIÒLOGIC
IMATGE
FIQ
ACR TRIGGER PONITS
WPI
SIMPTOM SEVERITY ESCALE (AI B)
ENTREVISTA PSIQUIATRICA ESTRUCTURADA
ESCALES DEPRESSIO I ANSIETAT
ESTUDI COGNITIU
QUEESI
CRITERIS FUKUDA
FIBROFOG
Definition
A small fiber neuropathy occurs when damage to the peripheral nerves predominantly
or entirely affects the small myelinated (Aδ) fibers or unmyelinated C fibers.
The specific fiber types involved in this process include both small somatic and
autonomic fibers. The sensory functions of these fibers include thermal perception and
nociception. These fibers also are involved in a number of autonomic and enteric
functions.
Etiology
• Idiopathic (50%)
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• diabetes and other glucose dysregulation •
syndromes (eg, impaired glucose
tolerance and metabolic syndrome)
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• thyroid dysfunction
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• sarcoidosis,
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• vitamin B12 deficiency
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• HIV
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• neurotoxic medications (including many
chemotherapeutic agents and
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antiretroviral agents)
celiac disease
paraneoplastic syndromes, and
paraproteinemias
Guilleain-Barre
Restless Leg Syndrome
Amyloidosis
Utoimmune Diseases
Hereditary neropathies sensory and
autonomic
Fabry
Symptoms
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Disestesia in socs
Burning pain that often is persistent
Electric shock–like painl
Allodynia and hyperesthesia (bedsheets are exquisitely painful)
Autonomic and enteric dysfunction
Dry eyes and dry mouth
Postural lightheadedness
Presyncope, syncope
Abnormal sweating
Erectile dysfunction
Nausea, vomiting, diarrhea, constipation
Difficulty with urinary frequency, nocturia, and/or voiding
Diagnostic
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Quantitative Sensory Testing (QST)
EMG (CHEPS)
Quantitative Sudoromotor Axon Reflex Testing (QSASRT)
Skin Biopsy
EMG and Nerve-conduction studies
The clinical approach to small fibre neuropathy and painful channelopathy.
Themistocleous AC, Ramirez JD, Serra J, Bennett DL. Pract Neurol. 2014 Apr 28.
Hyperexcitable C nociceptors in fibromyalgia. Serra J, Collado A, Solà R, Antonelli F,
Torres X, Salgueiro M, Quiles C, Bostock H. Ann Neurol. 2014 Feb;75(2):196-208. doi:
10.1002/ana.24065. Epub 2014 Feb 12.
Double and triple spikes in C-nociceptors in neuropathic pain states: an additional
peripheral mechanism of hyperalgesia. Serra J, Solà R, Aleu J, Quiles C, Navarro X,
Bostock H. Pain. 2011 Feb;152(2):343-53
C-nociceptors sensitized to cold in a patient with small-fiber neuropathy and cold
allodynia. Serra J, Solà R, Quiles C, Casanova-Molla J, Pascual V, Bostock H, Valls-Solé J.
Pain. 2009 Dec 15;147(1-3):46-53.
Hyperexcitable polymodal and insensitive nociceptors in painful human neuropathy.
Ochoa JL, Campero M, Serra J, Bostock H. Muscle Nerve. 2005
• Small fibres are small narrow diameter myelinated (Aδ) and unmyelinated (C) nerve
fibres of the peripheral nervous system6
• Somatosensory Aδ-fibres and C-fibres innervating skin pass through the dermis where
they innervate cutaneous structures; both groups of fibres end as free nerve endings in
the epidermis (the Aδ-fibres lose their myelin sheath as they cross the dermoepidermal junction). Aδ-fibres are responsible for conveying cold input and nociceptive
input
• C-fibres convey innocuous warm sensations and possibly innocuous cold sensations,
and noxious input from a variety of high threshold mechanical, thermal and chemical
stimuli.
• Small fibres play an important role in the autonomic nervous system, because thin
myelinated fibres contribute to preganglionic fibres and C-fibres contribute to postganglionic fibres, innervating structures such as sweat glands, blood vessels and the
heart
▸ Possible—length-dependent symptoms and/or clinical
signs (pinprick and thermal sensory loss and/or allodynia/hyperalgesia).
▸ Probable—length-dependent symptoms, clinical signs
ofsmall fibre damage and normal nerve conduction
studies.
▸ Definite—length-dependent symptoms, clinical signs
of small fibre damage, normal nerve conduction
studies, and altered intra-epidermal nerve fibre density
at the ankle and/or abnormal quantitative sensory
testing of thermal thresholds at the foot.
Small fibre pathology in patients with fibromyalgia syndrome
Nurcan U ̈ c ̧eyler,1 Daniel Zeller,1 Ann-Kathrin Kahn,1 Susanne Kewenig,1 Sarah Kittel-Schneider,2 Annina Schmid,1 Jordi CasanovaMolla,1 Karlheinz Reiners1 and Claudia Sommer1
Brain 2013: 136; 1857–1867
We hypothesized that pain in fibromyalgia syndrome is related to small fibre
dysfunction
Method
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case-control study
25 patients with fibromyalgia syndrome (23 females, two males; median
age: 59 years, range: 50–70 years) diagnosed according to the 1990
American College of Rheumatology criteria (Wolfe et al., 1990)
Inclusion criteria were: confirmed diagnosis of fibro- myalgia syndrome
according to the American College of Rheumatology criteria
Exclusion criteria included: other differential diagnoses explaining the
pain. Abnormalities in routine blood tests. After the telephone interview,
20/47 patients either were not willing to take part in the study or were
excluded.
Methods
• Clinnical consultation by the same physician
• Lab determinations
• EMG, QST, Skin biopsy, Pain related evoked potencials
Demographics and clinical data of patients with fibromyalgia syndrome and depression
The boxplots give (A) the NPSI-G discriminative score
for the assessment of neuropathic pain and (B) the
ADS assessing depressive symptoms
Sensory profiles measured with QSTat the left foot of
patients with fibromyalgia syndrome (A) and
depression (B) compared with age- and gendermatched control subjects
PREP measurements in patients and controls
PREP in patients with fibromyalgia syndrome, depression and in healthy control subjects. (A, C and E)
N1 and P1 latencies of patients with fibromyalgia syndrome are not different after eliciting PREP at
the face and the hand; N1 latencies are prolonged in patients with fibromyalgia syndrome compared
with patients with depression and to healthy control subjects when elicited at the foot. (B, D and F)
Peak-to-peak amplitudes of PREP are reduced in patients with fibromyalgia syndrome when PREP is
elicited at the face, the hand, or the feet. ***P 5 0.001; **P 5 0.01; *P 5 0.05. FMS = fibromyalgia
syndrome.
ENFD at the lower leg(A)and the proximal thigh(B)of patients with fibromyalgia syndrome,
depression, and of healthy control subjects investigated with the pan-axonal marker PGP9.5
PGP9.5 stained skin punch biopsies of a patient with fibromyalgia syndrome (A and
D), a patient with depression (B and E), and of a healthy control subject (C and F).
Replay to Dr. Martinez Lavin
• We would like to point out that our study did not reveal a small fibre neuropathy
in patients with fibromyalgia syndrome, but small fibre pathology (U¨ c¸ eyler et
al., 2013). It is essential to make this distinction. The term ‘small fibre
neuropathies’ is reserved for a distinct subgroup of sensory neuropathies that has
a substantially different clinical presentation from that in fibromyalgia syndrome
• Whereas patients with fibromyalgia syndrome suffer from deep and generalized
musculoskeletal pain that is regularly associated with additional symptoms like
sleep disturbance and fatigue (Wolfe et al., 1990), patients with small fibre
neuropathies report superficial acral burning pain that is typically located at toes
and feet. Symptom spread over the entire body is possible, but is an exception,
and additional symptoms are usually missing
• Dysautonomic symptoms in patients with fibromyalgia syndrome (mostly
orthostatic dysregulation, loss of heart rate variability) are also different from
those usually reported by patients with small fibre neuropathy (mostly abnormal
acral sweating or thermal dysregulation). Thus, this obvious difference in clinical
presentation underscores that small fibre pathology in patients with small fibre
neuropathies and in patients with fibromyalgia syndrome may emerge from
different pathophysiological backgrounds
Reply: Small fibre neuropathy, fibromyalgia and dorsal root ganglia sodium channels
Nurcan Uceyler and Claudia Sommer. Brain 2013: 136; 1 |
Amurallar el propio sufrimiento es arriesgarte a que te devore desde el interior
Intenté ahogar mis dolores, pero ellos aprendieron a nadar