Volume 2 Issue 2 February, 2012
Consultation Liaison Psychiatry Focus: Orthopedics
Although among patients reporting at orthopedics outpatient department are more commonly referred to psychiatrist for somatization, somatoform pain disorder and those symptoms where no organic cause could be elicited. Consultation liaison with psychiatry for management of Fibromyalgia can be beneficial to patients and clinician as well. Fibromyalgia is a nonspecific disorder characterized by many diffuse complaints, including pain, stiffness, tender muscles and joints, overwhelming fatigue, distress, and sleep disturbances. The presence of pain in fibromyalgia originates in the muscles and connective tissues of the body. The exact physiological process behind fibromyalgia has not been determined. The American College of Rheumatologists (ACR) defined fibromyalgia in 1990 as the presence of 1) body or joint pain above and below the waist, and on the right and left side of the body, 2) axial skeletal pain and 3) 11 out of 18 possible tender points. Digital palpation must elicit pain in at least 11 of possible 18 tender-point sites. These bilateral sites include occiput, lower cervical, trapezius, supraspinatus, second rib, lateral epicondyle, gluteal, greater trochanter, and knees.
Patients most often have associated fatigue, sleep disorders, irritable bowel syndrome, migraine headaches, and
endocrine system disorders. When examined there is surprisingly little inflammation present and biopsy samples characteristically show no unusual patterns of disease or inflammation. About 2-5% of the general population is considered to have fibromyalgia. The etiology and pathogenesis of fibromyalgia are unknown. Environmental factors, viruses, microbes, injury, or stress have been proposed as Neurophysiological and neuroimaging reveal changes in serotonin and increased substance P this nociceptive neurotransmitter lead to amplified pain sensations. SPECT and PET demonstrated that there is a decrease blood flow in thalamic and caudate nuclei in patients with fibromyalgia.
Diagnosis of fibromyalgia can be difficult. The most common associated symptoms are fatigue, depression, sleep
disturbances, and cognitive problems. Additional features may include complaints of weakness, headaches, cold sensitivity, paresthesia or dysesthesia, swelling, Raynaud’s phenomena, restless legs, exercise intolerance, and irritable bowel and bladder. Psychological abnormalities, especially depression and anxiety, often develop and aggravate the condition .Fibromyalgia should be differentiated with Musculoskeletal disorders Rheumatoid arthritis Polymyalgia rheumatica Polymyositis Metabolic-endocrine myopathies Psychiatric disturbances Dysthymic disorder Generalized anxiety disorder Somatization Chronic pain syndrome. Treatment No single medical or psychiatric intervention has been shown to be uniformly effective.
The current approach combines supportive counseling, cognitive-behavioral therapy, education, physical conditioning like water aerobics, cycling, yoga, and limited pharmacological interventions. muscle relaxants ,tricyclic antidepressants useful in promoting sleep and decreasing pain. Other agents being studied include tramadol ,S-adenosyl-L-methionine,5-hydroxytryptophan,growth hormone,ondansetron ,GABA agonists, sertraline, venlafaxine benzodiazepines.
Assistant Professor of Orthopedics, Adichunchunagiri Institute of Medical Sciences
