July

 5,  2012   [FIBROMYALGIA]  

 
Fibromyalgia   (FM)   is   characterized   by   chronic   2. Increased  pain  sensitivity  can  be  demonstrated  
widespread   musculoskeletal   pain   and   tenderness.   not  only  for  the  mechanical  pressure-­‐induced  
Although  it  is  defined  primarily  as  a  pain  syndrome,   pain  used  in  the  clinic  but  also  for  non  muscular  
mechanical  pressure,  heat,  cold,  and  other  
FM  patients  commonly  complain  of.   sensory  stimuli.  
1. Neurophysiological  symptoms  of  fatigue.   3. This  reinforces  the  idea  that  the  pathogenic  
2. Unrefreshing  sleep.   mechanisms  of  FM  are  not  related  to  specific  
3. Cognitive  dysfunction,  anxiety,  and  depression.     musculoskeletal  pathology  but  to  altered  pain  
processing.  
FM  patients  have  also  increase  prevalence  of  other  
syndromes  associated  with  pain  and  fatigue  incl.  

1. Chronic  fatigue  syndrome.  

2. Temporomandibular  disorder.  
3. Chronic  headaches  
4. Irritable  bowel  syndrome.  
5. Interstitial  cystitis/painful  bladder  syndrome.  

*FM  is  far  more  common  in  men.  

Clinical  Manifestation  

1. Patient’s  common  complaint  is  “pain  all  over”.  

2. Patients  with  FM  have  pain  that  is  typically  
above  and  below  the  waist  on  both  sides  of  the  
body  and  involves  the  axial  skeleton  (neck,    
back,  or  chest).  
3. Pain  is  poorly  localized,  difficult  to  ignore,   Patients  with  FM  often  have  peripheral  pain  generators  
severe  in  its  intensity  associated  with  reduce   such  as.  
functional  capacity.  
1. Arthritis  
4. Pain  should  have  been  present  most  of  the  day  
2. Bursitis  
on  most  days  for  at  least  3  months.  
3. Tendinitis  
*in  clinical  practice  pain  and  tenderness  is  determine  by   4. Neuropathies  
a  tender  point  examination  in  which  the  examiner  uses   5. Inflammatory  or  degenerative  conditions  
the  thumbnail  to  exert  pressure  of  approximately                        
*More  subtle  pain  generators  may  include  joint  hyper  
4  kg/m2  or  the  pressure  leading  to  blanching  of  the  tip  
mobility  and  scoliosis.  Patients  also  may  have  chronic  
of  the  thumbnail.  
myalgias  triggered  by  infectious,  metabolic,  or  
American  College  of  Rheumatology  classification   psychiatric  conditions  that  can  serve  as  triggers  for  the  
criteria  previously  required  that  11  of  18  sites  be   development  of  FM.  
perceived  as  painful  for  a  diagnosis  of  FM.  

1. Tenderness  is  a  continuous  variable,  and  strict  

application  of  a  categorical  threshold  for  
diagnosis  specifics  is  no  longer  necessary.  
 July  5,  2012   [FIBROMYALGIA]  
 
  Functional  Impairment  

Neuropsychological  symptoms:   It  is  crucial  to  evaluate  the  impact  of  FM  symptoms  on  
function  and  role  fulfilment.  In  defining  the  success  of  a  
1. Fatigue   management  strategy,  improved  function  is  a  key  
2. Stiffness   measure.  Functional  assessment  should  include  
3. Sleep  disturbance   physical,  mental,  and  social  domains.  
4. Cognitive  dysfunction  
5. Anxiety  and  depression   Differential  Diagnosis  

*Fatigue  is  highly  prevalent  in  patients  under  primary   Inflammatory    

care  who  ultimately  are  diagnosed  with  FM.  Pain,  
Polymyalgia  rheumatica  
stiffness,  and  fatigue  often  are  worsened  by  exercise  or  
unaccustomed  activity  (postexertional  malaise).  The   Inflammatory  arthritis:  rheumatoid  arthritis,  
sleep  complaints  include  difficulty  falling  asleep,   spondyloarthritides  
difficulty  staying  asleep,  and  early-­‐morning  awakening.  
Connective  tissues  diseases:  systemic  lupus  
Overlapping  symptoms;   erythematosus,  Sjögren's  syndrome  
 
Chronic  pain  includes  

1. Headaches   Infectious    
2. Facial/jaw  pain   Hepatitis  C  
3. Regional  myofascial  pain  particularly  involving  
the  neck  or  back.   Human  immunodeficiency  virus  (HIV)  
4. Arthritis.  
Lyme  disease  
Visceral  Pain  
Parvovirus  B19  
1. Gastrointestinal  tract  
2. Bladder,  pelvic  and  perineal  pain.   Epstein-­‐Barr  virus  
 
*Patients  may  or  may  not  meet  defined  criteria  for  
specific  syndromes.   Noninflammatory    

Comorbid  Conditon   Degenerative  joint/spine/disk  disease  

1. Chronic  musculoskeletal  pain.   Myofascial  pain  syndromes  

2. Infections  
3. Metabolic  conditions   Bursitis,  tendinitis,  repetitive  strain  injuries  
4. Psychiatric  conditions    

Psychosocial  Condition   Endocrine    

FM  often  has  their  onset  and  is  exacerbated  during   Hypo-­‐  or  hyperthyroidism  
periods  of  high  levels  of  real  or  perceived  stress.  This  
Hyperparathyroidism  
may  reflect  an  interaction  between  central  stress  
physiology,  vigilance  or  anxiety,  and  central  pain-­‐ Neurologic  diseases    
processing  pathways.  
 July  5,  2012   [FIBROMYALGIA]  
 
Multiple  sclerosis   controlling  pain  sensitivity  and  stress  response.  Some  of  
the  genetic  underpinnings  of  FM  are  shared  across  
Neuropathic  pain  syndromes   other  chronic  pain  conditions.  

  Psychophysical  testing  of  patients  with  FM  has  

demonstrated  altered  sensory  afferent  pain  processing  
 
and  impaired  descending  noxious  inhibitory  control  
leading  to  hyperalgesia  and  allodynia.  
Psychiatric  disease    
Major  depressive  disorder   Treatment:  

Drugs    
Non  pharma;  
Statins  
1. The  physician  should  focus  on  improved  
Aromatase  inhibitors   function  and  quality  of  life  rather  than  
  elimination  of  pain.  
2. Physical  conditioning,  with  encouragement  to  
Laboratory  and  radiographic  testing   begin  at  low  levels  of  aerobic  exercise  with  slow  
but  consistent  advancement.  
3. Patients  who  have  been  physically  inactive  or  
Routine    
who  report  post-­‐exertional  malaise  may  do  best  
Erythrocyte  sedimentation  rate  (ESR)  and  C-­‐ in  supervised  or  water-­‐based  programs  to  start.  
reactive  protein  (CRP)   4. Yoga  and  Tai  Chi  may  also  be  helpful.  
5. Strength  training.  
Complete  blood  count  (CBC)   6. Cognitive  behavioural  strategies.  

Complete  metabolic  panel   Pharmacologic;  

Thyroid-­‐stimulating  hormone  (TSH)   Antidepressants:  balanced  serotonin:norepinephrine  

Guided  by  history  and  physical  examination     reuptake  inhibition  

Antinuclear  antibody  (ANA)   Amitryptiline  

Anti-­‐SSA  (anti-­‐Sjögren's  syndrome  A)  and  anti-­‐SSB   Duloxetinea  

Rheumatoid  factor  and  anticyclic  citrullinated   Milnaciprana  

peptide  (anti-­‐CCP)  
Anticonvulsants:  ligands  of  the  alpha-­‐2-­‐delta  subunit  
Creatine  phosphokinase  (CPK)   of  voltage-­‐gated  calcium  channels  

Viral  and  bacterial  serologies   Gabapentin  

Spine  and  joint  radiographs   Pregabalina  

 
   

a
Genetics  and  Physiology    Approved  for  fibromyalgia  by  the  U.S.  Food  and  Drug  
Administration.  
As  in  most  complex  diseases,  it  is  likely  that  a  number  of  
genes  contribute  to  vulnerability  to  the  development  of    
FM.  To  date,  these  genes  appear  to  be  in  pathways  
 July  5,  2012   [FIBROMYALGIA]  
 
Additional  Notes:   Adhesive  capsulitis  

Bursa    Frozen  shoulder  

 Pain  and  restriction  of  motion  
1. Facilitate  movement  of  tendons  and  muscles  
over  bony  prominence.   Plantar  Fasciitis  
2. Thin  walled  sac  lined  by  synovial  tissue.  
 Pain  on  the  first  step  arising  in  the  morning.  
3. Inflammation  may  be  due  to  overuse.  
 Tenderness  
             Bursitis    
 
a. Subarachnoid  arthritis  
b. Trochanteric  bursitis    
c. Olecranon  bursitis    
d. Achilles  bursitis  
e. Retrocalcaneal  bursitis  (weaver’s  bottom)    
f. Ischial  bursitis  
g. Prepatellar  bursitis  (housemaid’s  knee)  

             Rotator  cuff  tendonitis  

 Major  cause  of  shoulder  pain  

 Tendon  of  four  (4)  muscles  insert  on  the  
humeral  tuberosties.  
 Supraspinatus  tendon  commonly  affected.  

           Calcific  tendinitis  

 Deposition  of  calcium  salts  (hydroxyapatite)  

within  a  tendon.  
 Supraspinatus  tendon  frequently  affected.  

               De  Quervain  tenosynovitis    

                   Inflammation   of   the   the   tendons   of   the   abductor                                

pollicis   longus   and   extensor   pollicis   brevis   as   it   pass  
through  a  fibrous  sheath  at  the  radial  styloid  process.  

Etiology:  

 Repetitive  twisting  of  the  wrist.  

 Pregnancy  

s/sx  

Finkelstein  sign