Fibromyalgia & Myofascial Pain Sydrome

1. Fibromyalgia & Myofascial Pain Sydrome Paul F. Pasquina, MD Physical Medicine & Rehabilitation

2. Historical Perspective • Hippocrates • “Muskelharten” • “Fibrositis” • “Psychogenic Rheumatism” • “Fibromyalgia”

3. Introduction • Incidence / Prevelence • Primary / Secondary • Economic Effects • Sex • Age

4. 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

5. 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.

6. 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.

7. Making the diagnosis:Taking a good history • Active Listening • Three Major Symtoms: • Pain • Stiffness • Fatigue • Sleep Disturbance • Modulating Factors • Associated Conditions

8. Physical Exam • Hallmark Finding • Tender / Trigger Points • Other Common Musculoskeletal Disorders • Control Points • Thermography / Dolorimetry

9. Fibromyalgia Tender Points

10. Anatomic Trigger Point Trapezius Sternocleidomastoid Levator scapulae Scalene Supraspinatus, Infraspinatus Symptoms Headache (temporal, occipital) Headache, stiff neck Stiff neck Pain in shoulder and arm Pain in shouler and arm Features of Myofascial Pain Syndrome

11. Definitions and Language of Myofascial Pain Myofascial Trigger Points: • Active Trigger points • Latent Trigger points • Secondary Trigger Points

12. 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.

13. 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).

14. 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

15. Myofascial Trigger Points Clinical Features Spot Tenderness A 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.

16. Myofascial Trigger Points Clinical Features Twitch Response Is a transient contraction of the muscle fibers of the taut 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 trigger point

18. Referral Pattern of Selected Muscles • Serratus posterior superior can mimic a C8 radiculopathy or ulnar neuropathy

19. Sternocleidomastoid (sternal portion) can cause frontal headaches, TMJ pain, occipital headaches. Referral Pattern of Selected Muscles

20. Referral Pattern of Selected Muscles • Gluteus minimus trigger point mimics L5-S1 radiculopathy

21. Referral Patterns of Selected Muscles • Scalene Trigger Points Mimic C6 radiculopathy

22. 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

23. Affected Area or Condition Shoulder Impingement Epicondylitis Wrist Tendinitis De Quervain’s Trochanteric Bursitis Pes Anserine Bursitis Achilles Tendinitis Manifestations of common bursitis and tendinitis syndromes

24. Diagnostic Tests • CBC, P1, P2, P3, UA • ESR, RF, ANA • TFT, PTH (CA?) • CPK • Lyme, HIV • Syphillis, TB • MRI (Chiari, Syringomyelia, Spinal Stenosis)

25. Pathophysiology • Muscle Abnormality • Central Neuro-Chemical Abnormality • Sleep Disturbance • Serotonin • Norepinephrine • Substance P • Endorphins • Hormonal / Immune System • GH, ACTH, Cortisol

26. Treatment • No specific treatment • Starts during first encounter • Establish diagnosis • Reassurance • Education • Identify major contributing factors

28. 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) Medications

30. TP Injecitions • < 25 gage needle • Lidocaine • Steroids • Dry Needle • Phynoxibenzamine

31. Behavioral Modification • Focus on well behavior • Decrease sick role / behavior

32. Exercise Prescription • Aerobic conditioning • Water therapy • Too much vs. Too Little