chapter 10 fibromyalgia syndrome 2013 myofascial trigger points

7/21/2019 Chapter 10 Fibromyalgia Syndrome 2013 Myofascial Trigger Points

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Chapter | 10 |

Fibromyalgia syndromeMartin Offenba cher

10.1 EPIDEMIOLOGY

Fibromyalgia syndrome and mTrP frequently exist to-gether. The principles, diagnosis and therapy of fibromyal-gia syndrome are also known to any trigger point therapist.

Population studies have shown that 2025% of thepopulation suffers from regional musculoskeletal pain.

Chronic widespread pain (or chronic multilocular musculoskeletal pain) has a frequency of 1011%.

Both forms of pain are more commonly found in women (ratio 1.5:1).

The prevalence of fibromyalgia according to the criteria(chronic widespread pain plus 11 out of 18 positivetenderpoints) of the American College of Rheumatology (ACR) of 1990 is reported to be about 2% of the population.

Fibromyalgia affects mainly women (ratio about 8:1). In general medical practice up to 4% are fibromyalgia

patients, in rheumatological practices almost one infive patients suffers from fibromyalgia.

Fibromyalgia and chronic widespread pain have an effect oncapacity to function, state of health and a patients capacityfor work, as well as making high demands on the healthservices.

10.2 THE PATIENTS PATTERNOF SYMPTOMS

Symptoms of fibromyalgia are:

pain, sleep disorder, tiredness, muscle stiffness, psychological symptoms.Other commonly occurring symptoms are:

sensory disorders such as a burning sensation, tingling or the feeling that the limbs are swollen(differential diagnosis of neuropathy),

problems with concentration or capacity for awareness, headaches (differential diagnosis of tension

headaches/migraine), irritable bowel (differential diagnosis of irritable

colon), irritable bladder, tendency to hypertension, high resting pulse, reduced ability to withstand stress.

10.2.1 Investigation Pain: changing location throughout the locomotor

apparatus; made worse by physical exercise,

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monotonous or forced postures (even sitting, lying down, standing) and other factors (e.g. stress, cold weather); relieved by warmth and a good nights sleep.

Sleep disorder: difficulty getting to sleep or sleeping through (waking several times because of pain andrestlessness), not refreshed in the morning.

Tiredness: tiredness during the day, state of exhaustion(is often felt to be more stressful than pain).

Muscle stiffness: persisting for minutes up to hours(also after sitting for a long time).

Psychological symptoms: depressive mood, anxiety,stressful life events, psychosocial stress factors.

10.2.2 Inspection and physicalexamination The inspection is unproductive. The clinical evaluation should include the whole

locomotor apparatus and a basic medical andneurological examination.

Patients with fibromyalgia exhibit positive, i.e. painful,tenderpoints on palpation of typical sites (according tothe ACR criteria) (see Fig. 10.1, Table 10.1 ).

Muscle shortening and incorrect posture as well asexcessive dermographism/dermatographic urticaria arefrequent clinical findings.

Besides the positive tenderpoints, fibromyalgia patientsusually have a lowered tenderness threshold, i.e. patientsreport pain as a result of light pressure on palpation even

away fromthe tenderpoints. This phenomenon does not ruleout the diagnosis of fibromyalgia.

10.2.3 Laboratory tests A standard medical rheumatological laboratory test will givethe first indications of the presence of possible differentialdiagnoses (erythrocyte sedimentation rate (ESR), bloodcount, thyroid hormones, electrolytes, parathormones, an-tinuclear antibodies, C-reactive protein, rheumatoid factor and creatinine kinase).

The laboratory chemistry and machine-aided diagnosisis normal if fibromyalgia syndrome is present. At the begin-ning of the disease this serves for further investigation of adifferential diagnosis or to rule out or find comorbidities inlater stages of fibromyalgia as well.

Peripheral pain generators shouldbe identified both clin-ically and from the history. These include arthritis (e.g. cox-arthritis and gonarthritis), vertebral column syndrome (e.g.scoliosis, spinalcanal stenosis, lumbar spinesyndrome withor without radiculopathy), mTrP, inflammatory joint dis-ease, neuropathy, hypermobility, migraine, enthesopathy,irritable colon.

Some 1525% of patients have sleep apnoea syndrome. An even higher percentage exhibit restless leg syndrome. If there is any suspicion, appropriate investigations and ther-apy should be carried out.

10.3 DIAGNOSIS

The diagnosis of fibromyalgia is based on the ACR criteriaof 1990. These are as follows.

History of generalised pain. Definition: spontaneouspain in the muscles, along the tendons and tendoninsertions typically located on the trunk and/or theextremities or the jaw region which have been present for at least 3 months at three or more different parts of the body above and below the waist.

Evidence of pain at 11 out of 18 tenderpoints onmanual palpation. Definition: palpation with the

Fig. 10.1 Localisation of tenderpoints in fibromyalgia accordingto the criteria of the ACR (from Wolfe et al. 1992) visualised byusing The Three Graces by Jean Baptiste Reynault (1793),Louvre, Paris.

Section | 1 | Introductory overview

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fingers should be performed with a strength of about 4 kg/cm 2 . A tenderpoint is assessed as positive if thepatient reports thatpalpation is painful. Sensitive doesnot necessarily mean painful. The tenderpoints can befound at defined symmetrical anatomical locations(see Table 10.1 ).

10.3.1 Differential diagnosisIf there is any clinical suspicion of a number of other dis-eases, these must be ruled out to exclude any differential di-agnoses. These include:

inflammatory diseases caused by pathogens(particularly hepatitis, borreliosis (Lyme disease),human immunodeficiency virus),

inflammatory rheumatic disease (e.g. chronicpolyarthritis, seronegative spondyloarthropathy,collagenosis, myositis, vasculitis, polymyalgiarheumatica),

non-inflammatory diseases, particularly thyroidfunction disorders, neoplasia or myopathy.

Overlapping/features in common with fibromyalgia:symptoms with depression, chronic fatigue syndrome,somatoform pain disorders, irritable colon and multiplechemical sensitivity. The demarcation is often difficult.

10.4 TREATMENT

10.4.1 General The guidelines for fibromyalgia syndrome were adopted in2008 with the cooperation of some of the authors of thisbook (M. Offenbacher, D. Irnich, A. Winkelmann) and ac-cepted by the Association of the Scientific Medical Societies(AWMF) in Germany. They can be found on the AWMF website ( www.awmf.org/ ).

Effective treatment of patients with fibromyalgia requires abiopsychosocial approach. It is the physicians job to arrangemanagement with the patient based on this approach.

Successful long-term management of this chronic diseaserequires:

building a workable partnership between patient andphysician/therapist,

support for the patient in becoming an expert in the

daily management of his/her symptoms, support for the patient in understanding his/her symptoms. Symptoms often have several causes so thetherapy is variable as well.

Another important factor is that both patient and doctor agree on a therapeutic course of action (shared decision-making).

There are general guidelines which should be taken intoaccount in the treatment of fibromyalgia:

safe diagnosis and identification of concomitant diseases,

thedisease must be explained to thepatient and his/her family,

individual treatment of each patient as there is nospecific therapy which will help each person to thesame extent,

avoidance of unnecessary diagnostic measures or operations.

Advice for the patient plays an important role in treatment.Important aspects of an education programme are:

explanation about the non-destructive nature of thedisease,

focus on improvement of function and not on healing, formulation of realistic treatment aims as patients often

have expectations that are too high,

discussion of medical and non-medical therapeuticoptions,

introduction to self-help (e.g. instructions on the use of physical measures),

evidence of a significant connection between somapsyche (e.g. instruction in meditation and/or relaxation techniques),

instruction on sleep hygiene, explanation of the need for lifelong gentle physical

stamina training,

Table 10.1 Tenderpoints in fibromyalgia

Occiput Insertion sites of the suboccipitalmuscles

Lower neck Intertransversal spaces C5C7

M. trapezius In the middle between the insertion ofthe neck and the acromion

M. supraspinatus Middle part over the spina scapulae

Second rib Cartilage bone border

Lateralepicondyle

2 cm distal from the epicondyle

Gluteal region Upper lateral quadrant of the glutealregion (over the lateral margin of thegluteus maximus muscle)

Greater

trochanter

Posterior to the trochanteric

prominenceKnee Medial fat pad proximal to the medial

knee joint space

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emphasis on the importance of the active role of thepatient in the management of treatment,

advice on planning a balanced day (alternating phasesof exercise and relaxation).

10.4.2 Medical treatment The medical treatment possibilities for fibromyalgia arelimited.

Low-dose tricyclic antidepressants (e.g. amitriptyline25 mg at night); aim: improved sleep and influence onthe pain threshold, side effects even at low dosage; theeffect is often lost after a year.

Analgesics: simple analgesics (favourable riskbenefit profile); NSAIDs are of limited clinical benefit.

10.4.3 Non-medical treatment

Stamina trainingEighty per cent of fibromyalgia patients are physically unfit,83% do not carry out any regular physical exercise, 29% donot reach the anaerobic threshold. It is a vicious circle of paininactivitydeconditioning. Regular endurance/staminatrainingisassociatedwith a positiveoutcomeforfibromyalgia.

Practical considerations/instructions on performing en-durance training:

the aim should be to improve function, not to reducepain,

at the beginning, there is often an increase in pain andtiredness as possible evidence of training too hard,

begin with gentle interval training in order to keep theincrease in pain low after training, the patient shouldfeel: I could have done more,

patients should increase training slowly up to three tofour times a week; the aim should be achieved in612 months,

training should involve little stress on the joints (e.g.ergometer training, walking or aquarobics),

minimisation of eccentric muscle work during training in order to reduce microtrauma in the muscles andnociceptive stimulation,

group training stimulates compliance and providespositive feedback,

additional regular exercise programme at home isnecessary, including muscle extension/stretching, light strength and endurance training,

regular training should become part of life.

PhysiotherapyPractical instruction/aspects of physiotherapy

avoid strain at work and in everyday life, look out for incorrect posture and hypermobility; this

leads to muscle strain, increase in tiredness andmyofascial pain,

a strained muscle system leads to further pain andstiffness,

economic sittingstandinglying down, poor sleeping position (e.g. hyperflexion of the neck)

can trigger pain in the shoulder and neck girdle;recommendation: anatomically shaped neck pillow,

strengthen deconditioned muscles: ideally as part of cardiovascular fitness training,

instructing the patient with regard to eccentric andconcentrated muscle work,

muscle extension: daily programme for all large musclegroups and particularly shortened muscles, 515 min,

use of heat application when necessary (tense muscles)using, e.g., hot bath, shower, volcanic mud,

avoidance of inactivity and planning of regular rest breaks in the course of the day.

Physical measures Massage and underwater massage: some patients react

with an increase in pain at too high an intensity (lymphdrainage is then better).

Heat therapy in any form (e.g. mudpacks, sauna, steambath).

Other procedures: Stanger (hydroelectric) bath,carbonated baths and Kneipp (cold water) drench.

Cold chamber exposure: some patients feel some painreduction in the short term.

The patient can carry out many of these procedures byhimself/herself. Warning: avoid creating a passiverole for the

patient!

Psychotherapeutic procedures/relaxationtechniques Psychotherapeutic procedures for overcoming pain

and disease with appropriate stress. Use of relaxation techniques (e.g. autogenic training or

progressive Jacobsen relaxation); see also Ch. 24 .

10.4.4 Other possibilities fortreatment

Acupuncture There is a lack of quality studies. However, it appears that acupuncture has a significant

effect on pain and the pain threshold. The long-term effect and type of optimum treatment

(point combination and frequency) are unclear.

Tai chi and Qigong Tai chi or Qigong with the aim of increasing body

awareness.

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Trigger point injections Fibromyalgia patients have a number of

predominantly inactive mTrPs. Few have symptomatic mTrPs requiring treatment. The reaction to an mTrP injection is delayed in

fibromyalgia patients and pronounced and morepersistent than in patients with MPS, especially withdry needling.

No more than three to four trigger points should betreated per session.

Follow-up treatment programme (e.g. muscleextension, heat applications, massage) is important.

Transcutaneous electrical nerve stimulation(TENS) An attempt at treatment is sensible for localised pain.

Multidisciplinary therapy integrating the abovemeasures in abalanced programme is most likely to be successful in thetreatment of fibromyalgia.

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Fibromyalgia syndrome Chapter | 10 |

chapter 10 fibromyalgia syndrome 2013 myofascial trigger points

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