Post on 09-May-2017
Fibromyalgia & Myofascial Pain Sydrome
Paul F. Pasquina, MDPhysical Medicine & Rehabilitation
Historical Perspective
• Hippocrates• “Muskelharten”• “Fibrositis”• “Psychogenic Rheumatism”• “Fibromyalgia”
Introduction
• Incidence / Prevelence• Primary / Secondary• Economic Effects• Sex• Age
MFPS Importance
• Important due to significant source of disability and pain
• Treatments generally effective• Often confused with other conditions• Extremely common and often patients are
undiagnosed for years
Myofascial Pain Syndromes Prevalence
Unselected and Control Groups
• Danish study of 1504 people, aged 30 - 60, 37% of males and 65% of females had localized myofascial pain.
• 100 male and 100 female airforce personnel (Av. Age 19): 45% of males and 54% females had focal neck muscle tenderness (latent trigger points).
• 269 female student nurses. 45% had TrPs in masseter, 35% had TrPs in trapezius. 28% had myofascial pain at the time of examination.
Myofascial Pain Syndromes Prevalence
Comprehensive pain center
283 consecutive admissions to a comprehensive pain center: The diagnosis made independently by a Neurosurgeon and a Physiatrist based on physical examination as described by Travell and Simons assigned a primary diagnosis ofmyofascial pain syndrome in 83% of the cases.
Making the diagnosis: Taking a good history
• Active Listening• Three Major Symtoms:
– Pain– Stiffness– Fatigue
• Sleep Disturbance• Modulating Factors• Associated Conditions
Physical Exam
• Hallmark Finding• Tender / Trigger Points• Other Common Musculoskeletal Disorders• Control Points• Thermography / Dolorimetry
Fibromyalgia Tender Points
Features of Myofascial Pain Syndrome
Anatomic Trigger PointTrapeziusSternocleidomastoidLevator scapulaeScaleneSupraspinatus,
Infraspinatus
SymptomsHeadache (temporal, occipital)Headache, stiff neckStiff neckPain in shoulder and armPain in shouler and arm
Definitions and Language of Myofascial Pain
Myofascial Trigger Points:
• Active Trigger points
• Latent Trigger points
• Secondary Trigger Points
Definitions and Language of Myofascial Pain
An active Myofascial trigger point • Causes pain and tenderness at rest or with motion
that stretches or loads the muscle.• Causes shortening of the muscle, as well as fatigue
and decreased strength.• Pressure on an active TrPt induces / reproduces
some of the patient’s pain complaint and is recognised by the patient as being some or all of his or her pain.
Definitions and Language of Myofascial Pain
A Latent Myofascial Trigger Point: does not cause pain during normal activities. It is locally tender, but causes pain only when palpated, will refer pain on pressure, can be associated with a weakened shortened moreeasily fatigued muscle.
Secondary trigger points develop when a muscle is substituted for the primary muscle with a trigger point with diminished function. Satellite TrPs develop when a muscle is in a referred pain zone of another TrP. Without proper intervention, and with perpetuating factors, the TrPs can lead to severe and widespread chronic myofascial pain (CMP).
Myofascial Trigger Points Clinical Features
Palpable Band.A cord like band of fibers is present in the involved muscle.
This can be difficult to identify when there are overlying muscles or thick subcutaneous tissue.
INJURY
Myofascial Trigger Points Clinical Features
Spot TendernessA very tender small spot which is found in a Taut Band.
The sensitivity of this spot (TrPs) can be increased by increasing the tension on the muscle fibers of the taut band.
Myofascial Trigger Points Clinical Features
Twitch ResponseIs a transient contraction of the muscle fibers of thetaut band containing the trigger point.The twitch response can be elicited by “snapping” palpation of the trigger point.
Or more commonly by precise needling of the trigger point, which results the most effective treatment of a triggerpoint
Referral Pattern of Selected Muscles
• Serratus posterior superior can mimic a C8 radiculopathy or ulnar neuropathy
Referral Pattern of Selected Muscles
• Sternocleidomastoid (sternal portion) can cause frontal headaches, TMJ pain, occipital headaches.
Referral Pattern of Selected Muscles
• Gluteus minimus trigger point mimics L5-S1 radiculopathy
Referral Patterns of Selected Muscles
• Scalene Trigger Points Mimic C6 radiculopathy
Differential Diagnosis
• Somatoform / Psychogenic• Polymyalgia Rheumatica (PMR nor PM&R)• Rheumatoid Arthritis, SLE• Polymyositis / Dermatomyositis
– other myopathic process• Other more common musculoskeletal disorders
– bursitis / tendinitis• Hypothyroid / Hyperparathyroid
Manifestations of common bursitis and tendinitis syndromes
Affected Area or Condition• Shoulder Impingement• Epicondylitis• Wrist Tendinitis
– De Quervain’s• Trochanteric Bursitis• Pes Anserine Bursitis• Achilles Tendinitis
Diagnostic Tests
• CBC, P1, P2, P3, UA• ESR, RF, ANA• TFT, PTH (CA?)• CPK• Lyme, HIV• Syphillis, TB• MRI (Chiari, Syringomyelia,
Spinal Stenosis)
Pathophysiology
• Muscle Abnormality• Central Neuro-Chemical Abnormality
– Sleep Disturbance– Serotonin– Norepinephrine– Substance P– Endorphins
• Hormonal / Immune System– GH, ACTH, Cortisol
Treatment
• No specific treatment• Starts during first encounter• Establish diagnosis• Reassurance• Education• Identify major contributing factors
Medications
• NSAIDs• Avoid Narcotics• Topicals• Tramadol (25mg qhs –
100 mg tid)• TCA’s• Flexeril• Ambien• Klonopin (1.0 mg qhs)
• Sinemet• SSRI’s• Buspar• Clonidine• Anticonvulsants
– Neurontin 300 qhs to 600 tid
• Xanax (.25 – 1.0 mg qhs)
TP Injecitions
• < 25 gage needle• Lidocaine• Steroids• Dry Needle• Phynoxibenzamine
Behavioral Modification
• Focus on well behavior
• Decrease sick role / behavior
Exercise Prescription
• Aerobic conditioning
• Water therapy• Too much vs.
Too Little