MYOFASCIAL PAIN AND FIBROMYALGIA

Rafael Higashi MD

neurologist

www.estimulacaoneurologica.com.br

Define the main components of myofascial pain :

a) Trigger points

b) Tender spots x tender points

c) Taut bands

d) Muscle spasm

Describe the trigger points according to location, chronicity, and latency.

Location(muscle,ligaments,soft tissues, pericapsularar, periosteum)

Acute(hours or days) x chronic(weeks,months,or years)

Active(symptomatic at rest) x latent

What are steps and criteria for diagnosis of Trigger points and tender spots?

a) Ask patient to point where the most intensive pain is.

b) Find the point of maximum tenderness or trigger points, quantify by algometer lower by 2kg/cm2.

c) Reproduction of pain.

Describe an effective palpatory technique for diagnosis of T.S. and spasm in muscles.

a) Position the patient in order to have access to the examined area.

b) Ask the patient to contract the examined muscle.

c) Ask the patient to contract minimally the antagonist of the examined muscles.

Review the etiology and perpetuating factors causing myofascial pain syndrome.

Metabolic

Nutritional

Biomechanical

Overuse of muscles

Endocrine abnormalities

Psychological stress

Infection

List the diagnostic criteria for fibromyalgia.

A) Widespread pain, bilateral ,above and below the waist.

B) Axial pain.

C) Tenderness over at least 11 of the following 18 specified tender points: occiptal,low cervical, trapezius, supraspinatus,second rib,lateral epicondylite,gluteal,greater trochanter,knee. Algometric(4kg/cm2).

How do electrodiagnostic testing,imaging,and laboratory findings contribute to the diagnosis of myofascial pain syndrome and fibromyalgia?

Complete blood count

VHS

Blood chemistry

Thyroid function

If there is evidence of radiculopathy: E.M.G.,C.T, nuclear scans, or M.R.I

When suspicions of systemic connective tissue or Lyme desease sorologic tests.Functional Tests( oxidative stress).

What are peripheral and central sensitization?

Spinal segmental sensitization is a condition characterized by hiperactivity and hyperexcitability of a spinal segment that develops in reaction to a irritative focus.

Peripheral sensitization is characterized by hyperreactivity of sensory nerve fibers to stimuli.

The pentad of discopathy, radiculopathy and paraspinal ligament sprain.

1) Sprained Supraspinous ligament⇨

2) Paraspinal muscle spasm⇨

3) Narrowed space beteween spinous processes and Neural Foramina⇨

4) Nerve root compression⇨

5) Narrowed disc space.

Pentad of radiculopathy:

How is spinal segmental sensitization in clinical pratice?

Spinal segmental sensitization is diagnosed by hyperalgesia and pressure pain sensitivity that extend over the sensory , motor, and skeletal areas suppllied by the involved spinal segment,ie, its dermatome,myotome and sclerotome.

Sensory testing for diagnosis of spinal segmental sensitizastion:

Scratching the skin with the tip of a opened paper clip tests .The sharp object is slowly dragged across the dermatomal borders.

Sensitivity of subcutaneous tissue is tested .It is the most sensitivity test for the diagnosis of sensitization .It is tested by the pinch and roll method.

How to mensured the simpathetic dysfunction ?

Electric skin condutance is a objective test of sympathetic dysfunction and can be measured by a microampere meter.

Quantified diagnosis of microedema.

Motor testing for sensitization :

Deep tissue (muscle )tenderness is assessed by digital pressure and quantified whith a pressure algometer.It is considered abnormal if is lower by 2kg/cm2 compered to normalsensitive control point.

                                          

   Algometer

What consists the sclerotomal involvement?

Bursits

Tendinitis

Enthesopathy (attachment of taut band to bones)

Epicondylitis

What is the relationship between spinal segmental sensitization(S.S.S.) and musculoskeletal pain ?

This is a vicious cycle in which the peripheral sensitized irritative focus cause SSS and the sensitized spinal segment mediates increased peripheral sensitization should be interrupted as soon as possible for effective pain relief.

Describe injection techniques employed in treatment of these conditions.

Dry needling.

Injection of medications:anti-inflammatory injections(ketorolac), botulinum toxin, lidocaine 1%.

Needling and infiltration combine both techniques rendering improved results.

What is the specific treatment for spinal segmental sensitization?

A special injection technique , the paraspinous block,effectively desensitizes the SSS and alleviates the pain in the segment.Paraspinous block achieves this effect by blocking the nociceptive impulses from the sprained interspinous ligament,which acts as a irritative focus.

After B.P.S:

Outline a algorithm for managing musculoskeletal pain with both short- and long term goals.

Phase 1-Identify the immediate cause of pain.

Phase 2-Diagnose the SSS (sensory, motor, sclerotome).

Phase 3-Treatment : injections and physical therapy.

Phase 4-Diagnosis and removal of perpetuating and etiologic factors

How would you treat a patient with fibromyalgia?

Enhancement of peripheral and central analgesia, it can be obtained by central – acting analgesics . Individualized cardiovascular fitness programs allow increased blood flow to muscle and superficial tissues. Patients should be taught relaxation techniques.

Which medications are commonly used to treat fibromyalgia

Amitriptyline doses are 25-50mg,the medication promotes 4 sleep and potentiation of endogenous opioids,brain serotonin and others neurogenic amines.

Cyclobenzaprine,10 to 40mg in divided doses,also improves pain, fadigue,sleep,and tender point count.

Describe the adverse effects of amitriptyline:

Potential adverse effects include the anticholinergic effects: dry mounth, constipation, fluid retention, weight gain, and difficulty concentrating are comun ; even in low doses. Atrioventricular blockage and closed angle glaucoma are contraindications.

Thanks !

Rafael Higashi, MD

www.estimulacaoneurologica.com.br