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Fibromyalgia & Soft Tissue Rheumatism
Fibromyalgia & Soft Tissue Rheumatism
Shin-Seok Lee, M.D.Chonnam National University Medical School
Musculoskeletal DisorderMusculoskeletal Disorder
ArticularArticular PeriarticularPeriarticular
Septic arthritis Trauma Bursitis Carpal tunnel
Gout Osteonecrosis Tendinitis Sickle cellPseudogout Osteoarthritis Tenosynovitis Multiple myelomaViral arthritis Charcot joint Epicondylitis Osteoid OsteomaJuvenile arthritis Hemarthrosis Periostitis Reflex sympatheticSarcoid PVNS Costochondritis dystrophyFungal Foreign body
InflammatoryInflammatory NoninflammatoryNoninflammatory InflammatoryInflammatory NoninflammatoryNoninflammatory Monarticular Localized
Rheumatoid arthritis Osteoarthritis PMR FibromyalgiaSpA Sickle cell Polymyositis Multiple myelomaSLE Hemarthrosis Periostitis MyxedemaRheumatic fever Hemochromatosis Enthesitis OsteoporosisJuvenile arthritis Hypertrophic Eosinophilic fasciitis PagetsScleroderma osteoarthropathy Myasthenia gravisLyme Polychondritis
Polyarticular Systemic
섬유근통 증후군에 관한 설명 중 틀린 설명은 ?
1. 80-90% 가 여성이며 , 호발 연령은 25-55 세이다 .
2.만성 근골격계의 증후군으로 미만성 통증과 압통점이 특징적이며 이럴 경우 NSAID 와 steroid 가 도움이 된다 .
3. stage 4(non-REM) sleep 장애 , serotonin 의 결핍 ,
우울증 등이 이 질환과 관계 있다 .
4.주요 압통 부위는 thumbnail, forehead, distal dorsal forea
rm 등이 있다 .
가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4
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Chronic Widespread Pain and Fibromyalgia
Age-group (years)
18-29 30-39 40-49 50-59 60-69 70-79 >80
Prev
alen
ce (%
)
0
5
10
15
20
25
femalemale
Prevalence of chronic widespread pain
Prevalence of chronic widespread pain
1. US study – 10.6%, 95% CI (9.5, 12)2. UK study – 11%
Prevalence of fibromyalgia1. Wolfe et al – 2.0% 95% CI (1.4, 2.7)2. Finland study – 0.8%
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Prevalence of CWP and FM in Korea
Uljin and Pohang, Kyongsangbuk-do 1028 participants in 2004 Prevalence of chronic widespread pain
144/1028 cases (14.0%) F:M = 103:14 Increasing trend in older age
Prevalence of fibromyalgia 23/1028 cases (2.2%) F:M = 21:2 Increasing trend in older age
Kim S, et al. JKRA 2005;12:S71
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Per
cen
tile
Tenderness
Individuals withfibromyalgia
Prevalence of fibromyalgiaRheumatology clinics 20%
Internal medicine clinics 6%
Family practice clinics 2%
General medicine inpatients (UK) 5%
General population 1%
Chronic Widespread Pain and Fibromyalgia
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Pre
ssur
e p
ain
thre
shol
d (k
g)4kg
Allodynia
Fibromyalgia
Healthy control
Hyperalgesia
What is Fibromyalgia?
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1990 ACR Classification Criteria
I. History of chronic widespread pain involving all 4 quadrants of the body
II. Pain in 11 of 18 tender points on digital palpation
Wolfe F, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee. Arthritis Rheum 1990;33:160-172.
1. Occiput: bilateral, at the suboccipital muscle insertions.2. Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7.3. Trapezius: bilateral, at the midpoint of the upper border.4. Supraspinatus: bilateral, at origins, above the scapula spine near the medial border.5. Second rib: bilateral, at 2nd costochondral junctions.6. Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.7. Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.8. Greater trochanter: bilateral, posterior to the trochanteric prominence.9. Knee: bilateral, at the medial fat pad proximal to the joint line.
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Tender Point
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Control anatomic sites Thumbnail, mid forearm, forehead Processus styloideus on the right side In the middle of os sacrum Fold of the skin on the dorsal side of the right antebrachium Fold of the skin over m. gluteus maximum on the right side
Tender Point
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What is Fibromyalgia?
Definition of fibromyalgia Chronic widespread pain with a reduced threshold for pain, generally
identified by an increased sensitivity to pressure at particular points on
the body Associated subjective symptoms such as fatigue, sleep disturbance,
headache, migraine, variable bowel habits, diffuse abdominal pain, and
urinary frequency. One third of patients experience significant minor depression or
anxiety.
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Tension/migraine headache
Temporomandibularjoint syndrome
Regional musculoskeletalpain (e.g. chronic cervical
or lumbar pain,“tendinosis”, repetitive
strain syndrome,myofascial pain syndrome)
Irritable bowelsyndrome
Chronic sinusitis
Sicca symptoms, vasomotor rhinitis
Non-cardiac chest pain, “SyndromeX”, costochondritis
Biliary dyskinesia, post-cholecystectomy syndrome
Interstitial cystitis,female urethral syndrome,vulvar vestibulitis, vulvodynia
What is Fibromyalgia?
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Pathogenesis
Increased nociception Deficiency of stage II/IV sleep
– Alpha EEG NREM sleep anomaly Aberrant CNS function
– Abnormalities in sensory processing
– Hypothalamic-pituitary axis dysfunction
– Autonomic dysfunction
– Psychobehavioral factor Cytokines
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The pain–brain–pain loop
paingenerators
central sensitization
peripheraltissues
spinal cordand brain
OA, RA, Inflammation, Neuropathies, Injuries, Disc disorders, Visceral pain,
Chronic headaches, TMJ, Spinal stenosis, Repetitive strain, Endometriosis,
Myofascial pain
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Altered central pain processing
Lower rCBF in the Thalamus and the Caudate Nucleus by SPECT
Normal Control Fibromyalgia
Mountz JM, et al, Arthritis Rheum 1995;38:926-38
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Altered central pain processing
fMRI Imaging Evidence of Augmented Pain Processing in Fibromyalgia
Gracely RH, et al. Arthritis Rheum 2002;46:1333-43
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Altered central pain processing
Vaeroy Russell Welin Bradley
fmol
e/m
l
0
10
20
30
40
50
Normal FMS
Mean CSF levels of substance P in fibromyalgia
Threefold higher concentrations of substa
nce P in CSF of FM patients Low levels of norepinephrine and its met
abolite, 3-methoy-4-hydroxy phenethyle
ne, in CSF of FM patientsLow levels of serotonin and its precursor,
L-tryptophan, in the serum and low levels
of the principal metabolite, 5-hydroxy ind
oleacetic acid in CSF
섬유근통 증후군에 관한 설명 중 틀린 설명은 ?
1. 80-90% 가 여성이며 , 호발 연령은 25-55 세이다 .
2.만성 근골격계의 증후군으로 미만성 통증과 압통점이 특징적이며 이럴 경우 NSAID 와 steroid 가 도움이 된다 .
3. stage 4(non-REM) sleep 장애 , serotonin 의 결핍 ,
우울증 등이 이 질환과 관계 있다 .
4.주요 압통 부위는 thumbnail, forehead, distal dorsal forea
rm 등이 있다 .
가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4
58 세 여자환자로 6 개월 전부터 지속된 쇠약감과 전신적인 근육통을 주소로 내원하였다 . 승모근 , 늑골 , 늑역골 관절 , 내측 무릎 등에 대칭적인 통점을 가지고 있었다 . 환자는 류마티스 인자 및 항핵항체는 음성이었고 적혈구 침강속도도 정상이었으며 기타 신경학적 검사에서 이상소견은 없었다 . 상기 환자에 대한 설명 중 옳은 것은 ?
1. 주로 여자에게서 발생하며 대부분 연령은 30-50 대 이다 .
2. 대부분의 환자들이 활동성의 정신의학적 질환을 가지고 있다 .
3. 류마티스 관절염에 병발할 수 있다 .
4. 특징적인 REM sleep 의 장애를 동반한다 .
가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4
45 세 여자가 수 년간 지속되는 전신 통증으로 왔다 .
관절의 압통과 종창은 없었고 , 전신 근육에 압통점이 뚜렷하게 있었다 . 류마티스 인자 , 항핵항체는 음성이었고 갑상선 기능검사는 정상이었으며 다른 특이소견은 없었다 . 치료로 적절한 것은 ?
1. amitriptyline2. 유산소운동3. tramadol4. prednisolone 가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4
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Management
Education Nonprogressive condition that is not causing damage or inflammation Not focusing on symptoms. All symptoms are from the same
underlying condition. Existential crisis from denial, searching for ‘the cure’, to eventual
acceptance Pharmacologic therapy
Antidepressants (TCA, SSRI, SNRI, MAOI) Analgesics, sedative hypnotics, muscle relaxant
Nonpharmacologic therapy Exercise, cognitive behavioral therapy
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Pharmacologic therapy
Antidepressant: summary of randomized, controlled trials
Class Compound(s) Pharmacology Pain Sleep Fatigue Mood Treating other FSS
TCA Amitriptyline 5-HT/NE reuptake inhibitor + + + - IBSClomipramine Cation channel blocker TMJDDoxepin NMDA antagonist CLBP?
Anticholinergic CTTH prophylaxisAntihistaminergic
SSRI Fluoxetine 5-HT reuptake inhibitor + + + + CTTH prophylaxisCitalopram 5-HT reuptake inhibitor - - - + CTTH prophylaxisSertraline 5-HT reuptake inhibitor + + + CTTH prophylaxis
SNRI Venlafaxine 5-HT > NE reuptake inhibitor - - - - CTTH prophylaxisMilnacipran NE > 5-HT reuptake inhibitor + - + +
NMDA antagonistMAOI Moclobemide Reversible, MAO inhibitor - - - - CTTH prophylaxis, CFS
Pirlindole Reversible, MAO inhibitor + + + + CTTH prophylaxis
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Pharmacologic therapy
Summary of randomized, controlled trials
Class Compound(s) Pharmacology Pain Sleep Fatigue Mood Other FSS
Muscle Cyclobenzaprine 5-HT2 antagonist + + +/-
IBSrelaxant Anticholinergic
AntihistaminergicAnti-epileptics Pregabalin Ca channel blocker + + +Sedative Zopiclone BZ receptor agonist - + - -Hypnotics Zolpidem
NSAIDs Ibuprofen Nonspecific COX inhibitor - - - -CLBP
Naproxen
TMJD Opiates Morphine (IV) Mu agonist -
Tramadol Mu agonist +CTTH
5-HT/NE reuptake inhibitorCLBP
Other Tropisetron 5-HT3 antagonist + +
IBS?Growth hormone Growth hormone + + +
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Pharmacologic therapy
Antidepressant – rationale Alpha-delta NREM sleep abnormality mediated by an abnormality in cen
tral serotonergic neurotransmission Personal and family history of depression in FM patients TCA studies on chronic pain syndromes
Antidepressant – mechanism Increase neurotransmission mediated by the monoamine neurotransmit
ters, particularly serotonin (5-HT) and/or norepinephrine (NE)
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Pharmacologic therapy
Treatment of Fibromyalgia with Tricyclic Antidepressants: A Meta-Analysis
O’Malley PG, et al. J Gen Intern Med 2000;15:659
4.35.2
5.86.5
10.6
5.05.0
11.6
6.55.8
0
2
4
6
8
10
12
fatigue triggerpoints
pain sleep well-being
symptoms
rati
ng
scale
treatment mean*placebo mean*
14%
9%
26% 23% 18%
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Pharmacologic therapy
TCA Treatment of Fibromyalgia: A Meta-Analysis
Arnold LM, et al. Psychosomatics 2000;41:104
Eff
ect
Siz
e
(Sta
nd
ard
Devia
tion
s) 1.5
1.0
0.5
0.0
-0.5
Outcome Measure
PatientGlobal
Assessment
M.D.Global
Assessment
Pain Fatigue Sleep Tenderness Stiffness
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Pharmacologic therapy
Recommendations1. Start with amitriptyline at a dose 5 mg 1-2h before bedtime. The dose can be
gradually increased to a maximum of 50 mg/day
2. If these are ineffective, institute trials of SSRI such as fluoxetine.
3. Consider the combination of SSRI and low dose TCA.
4. If ineffective, substitute SNRI such as venlafaxine for SSRI.
5. For insomnia in patients intolerant of TCA, bedtime doses of zolpidem and z
opiclone may be of benefit.
6. For pain control, use the tramadol. Limit the use of antiinflammatory agents,
narcotic analgesics, and muscle relaxants.
45 세 여자가 수 년간 지속되는 전신 통증으로 왔다 .
관절의 압통과 종창은 없었고 , 전신 근육에 압통점이 뚜렷하게 있었다 . 류마티스 인자 , 항핵항체는 음성이었고 갑상선 기능검사는 정상이었으며 다른 특이소견은 없었다 . 치료로 적절한 것은 ?
1. amitriptyline2. 유산소운동3. tramadol4. prednisolone 가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4
35 세 여자 환자가 전신통증과 피로감을 주소로 내원하였다 .
평소에 만성 근육통과 수면장애가 있었다 . 목 , 어깨 , 하지에 걸치는 전신적인 통증이 있었고 약간의 움직임에도 악화되었다 .
신체검사에서 뒷목 , 양어깨 , 허리 , 무릎에 대칭적인 압통점이 있었으나 방사선 검사에서 이상소견은 관찰되지 않았다 .
항핵항체와 류마티스 인자는 음성이었고 ESR 은 10 mm/hr 였다 .
이 환자에서 적절하지 않은 치료는 ?
1. 유산소운동 2. cyclobenzaprine
3. prednisolone
4. tricyclic antidepressants
5. zolpidem
삼환계 항우울제와 플루옥세틴 (fluoxetine) 으로 증상이 조절되지 않는 섬유근통 환자에서 다음 단계로 투여해 볼 수 있는 약제로 옳은 것은 ?
1. 플루옥세틴 대신 벤라팍신 (venlafaxine) 을 투여한다 .2. 트라마돌 (tramadol) 을 추가한다 .3. 플루옥세틴을 둘록세틴 (duloxetine) 으로 교체한다 .4. 저용량의 프레드니솔론을 추가한다 .
가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4
손목굴증후군 (carpal tunnel syndrome) 을 진단하기 위한 신체검사 두 가지는 ?
답 ) Tinel's sign 과 Phalen's sign
Tinel’s sign percussion of median nerve at the flexor retinaculum (just radial to the palmaris longus tendon at the distal wrist crease) produces paresthesia in the median nerve distribution: thumb, index and middle fingers and the radial half of the ring finger
Phalen’s sign sustained palmar flexion of the wrist for 30-60 seconds induces finger paresthesia
다음 사진에서 보이는 검사는 어떤 질병을 진단하기 위한 것인가 ?
답 ) de Quervain's tenosynovitis
de Quervain’s stenosing tenosynovitis tenosynovitis of abductor pollicis longus and extensor pollicis brevis
Finkelstein test passive ulnar deviation of the wrist with the fingers flexed over the thumb placed in the palm
50 세 여자가 왼쪽 어깨관절의 통증을 주소로 내원하였다 .
환자는 3 개월 전부터 왼쪽 어깨의 통증을 느끼기 시작했으며 최근 들어서는 왼쪽으로는 누워 자기가 힘들 정도로 통증이 심하다고 하였다 . 과거력상 당뇨는 없었고 신체검사에서 왼쪽 어깨의 수동 능동 운동 모두에 제한이 있었고 X 선 촬영에서 뚜렷한 이상 소견은 발견되지 않았다 . 상기 환자의 가능한 진단은 ?
답 ) 유착관절낭염 (adhesive capsulitis)
Diagnosis Age Type of onset
Location of pain
Night pain
Active ROM
Passive ROM
Impingement sign
Radia-tion
Pares-thesia
Weak-ness
Insta-bility
Radio-graphic changes
Special features
Rotator cufftendinitis
Any Acute or chronic
Deltoid region
+ ↓↓guarding
Normal +++ - - Only due to pain
Look for In chronic cases
Painful arc of abduction
Rototor cufftears (chronic)
Over 40 yr
Often chronic
Deltoid region
++ ↓↓↓ Normal ++ - - ++ - + Wasting of cuff muscles
Bicipital tendinitis
Any Overuse Anterior - ↓guarding
Normal + ± - Only due to pain
Look for None Speed testYergason test
Calcific tendinitis 30-60 yr
Acute Point of shoulder
++ ↓↓↓guarding
Normal +++ - - Only due to pain
- ++ Tenderness ++
Adhesive capsulitis
Over 40 yr
Insidious Deep in shoulder
++ ↓↓ ↓↓ + - - - - - Global ROM↓
Acromioclavicular joint
Any Acute or chronic
Over joint
Lying on
side
↓full elevation
Normal - - - - - In chronic cases
Local tenderness
Osteoarthritis of glenohumoral jt.
Over 40 yr
Insidious Deep in shoulder
++ ↓↓ ↓↓ - - - May have mild
- +++ Crepitus
Glenohumoral instability
<25 yr
Episodic Ant. or post.
- Only appre-hensio
n
Only appre-hensio
n
Possible - + with acute
episode
+ with acute
episode
+++ Often Stress test
Cervical spondylosis
Over 40 yr
Insidious Supra-scapular
Often Normal Normal - ++ +++ + - Cervical spine
Pain with neck movement
Thoracic outlet syndrome
Any Usually with
activity
Neck shoulder
arm
- Normal Normal - ++ ++ ++ - -
Differential Diagnosis of Shoulder Pain
55 세 여자가 6 개월 전부터 서서히 진행하는 우측 어깨의 통증과 운동 장애를 주소로 내원하였다 . 신체검사에서 부종이나 종창 , 발적은 동반되지 않았으나 환자 스스로 우측 어깨를 모든 방향으로 움직일 수 없었으며 검사자의 도움으로도 비슷한 정도의 운동 장애를 보였다 . 방사선 촬영에서는 우측 어깨 관절 주위의 골감소 이외에 특이 소견은 없었다 . 이 환자에 맞는 소견은 ?
1. 관절의 진행성 미란을 동반한다 . 2. 당뇨병 , 갑상선 질환 , 폐질환에 동반되기도 한다 .3. 진단을 위해 관절경 검사가 필수적이다 .4. 관절강내 코르티코스테로이드 주사가 증상 개선에 도움이 된다 .
가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4