FIBROMYALGIA

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FIBROMYALGIA

• Rheumatology Module
• Anna Mae Smith, MPAS, PA-C

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Myofascial pain

• Minor tear in muscle that causes a localized
  irritation - trigger point
• Fibromyalgia - widespread myofascial (soft
  tissue) pain

Diffuse aching, stiffness fatigue
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Fibromyalgia Syndrome

• Most common rheumatic cause of chronic diffuse
  pain
• Generalized pain symptom pain amplification
  syndrome
• Extremely common pain phenomenon occurring in a
  defined pattern reproduced by pressure on
  "trigger points"

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EPIDEMIOLOGY

• Incidence/Prevalence in USA 3 in 100
• Predominant age 18-70
• Predominant sex Female Male

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DIfferential

• Hypothyroidism
• Psychogenic rheumatism
• Muscle strain/sprain
• Muscle disease
• Polymyalgia rheumatica
• Temporal arteritis

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SIGNS SYMPTOMS

• Typically insidious in onset
• Diffuse soft tissue pain
• Pain is increased in the morning, with weather
  changes, anxiety, stress
• Pain improved by mild physical activity or
  vacations (stress-relieving situations)
• Non-restorative sleep, with early morning
  awakening in an unrefreshed state.

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SIGNS SYMPTOMS

• Abnormal non-rapid eye movement (non-REM) stage
  IV sleep
• Generalized fatigue or tiredness
• Anxiety
• Chronic headache
• Irritable bowel syndrome
• Tension headaches

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SIGNS SYMPTOMS

• Subjective, non-confirmable complaints of
  swelling or numbness, not associated with
  objective neurologic findings
• Depression
• Reduced physical endurance
• Decreased social interaction
• Paresthesias normal nerve studies
• Sensation of swollen hands!

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Trigger Points

• Temporalis - above the ear
• Anterior to tragus of ear
• Scalenus capitis
• Sternocleidomastoid
• Low anterior neck
• Pectoralis minor

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Trigger Points

• Manubriosternal
• Anterior and posterior axillary folds
• Trapezius ridge
• Upper rhomboids
• Lower rhomboids

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Trigger Points

• Iliac crest
• Mid-buttocks
• Mid-rectus femoris
• Mid-vastus lateralis
• Quadriceps insertion - at the patella
• Humeral epicondyles

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LABS

• ESR
• CBC
• TFT

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TREATMENT

• Modify/discontinue inciting activity or disease
• NSAIDS
• Ultram
• Local hot or cold
• ultrasound
• Local steroid injections

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Treatment

• Electroprobe
• Electrical stimulation
• ultrasound
• conditioning

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TREATMENT

• Amitriptyline (Elavil) 10 mg 2 po hs prn,
  increased gradually to 50 mg
• Cyclobenzaprine (Flexeril) 10 mg tid prn
• Zolpidem (Ambien) 5 mg po hs prn, increased to 10
  mg
• Temazepam (Restoril) 15 mg po hs prn, increased
  to 30 mg

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Ttreatment

• Flurazepam (Dalmane) 15 mg po hs prn, increased
  to 30 mg (note Significant "hangover" potential
  secondary to long half-life)
• Triazolam (Halcion) 0.125 mg po hs prn increased
  gradually to 0.5 mg (use is controversial)

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Prognosis

• With resolution of sleep disturbance, may resolve
  totally
• Aggressive physical therapy is critical in those
  who do not respond
• Approximately 5 do not respond to any form of
  therapeutic intervention.
• Hypnosis may be attempted in that group.