Fibromyalgia and Myofascial Pain

CHAPTER 24 FIBROMYALGIA AND MYOFASCIAL PAIN



Mark A. Thomas, MD, Ronald Kanner, MD, FAAN, FACP




1. What are the chronic pain syndromes that involve muscle and fascia?


Myofascial pain syndrome and fibromyalgia are chronic pain syndromes that involve the muscle and soft tissues. Myofascial pain syndrome is regional in distribution whereas fibromyalgia involves the entire body. These diagnoses may represent two points in a spectrum of disease, as subgroups of fibromyalgia have been identified on the basis of differing clinical findings and prognoses.



2. Describe the myofascial pain syndrome


The myofascial pain syndrome is a chronic, regional pain syndrome that involves muscle and soft tissues. It is characterized by trigger points and taut bands (see Questions 7 and 8). Originally described by Travell and later elaborated on by Travell and Simons, myofascial pain syndrome occurs in most body areas, most commonly in the cervical and lumbar regions.



3. What is fibromyalgia?


Fibromyalgia is a clinical syndrome characterized by chronic, diffuse pain and multiple tender points at defined points in muscle and other soft tissues. Periosteal tender points are frequently present. Widespread pain can be felt both above and below the waist and bilaterally. Other characteristic features of the syndrome include fatigue, sleep disturbance, irritable bowel syndrome, interstitial cystitis, stiffness, paresthesias, headaches, depression, anxiety, and decreased memory and vocabulary.



4. What are the American College of Rheumatology 1990 criteria for the classification of fibromyalgia?




image History of widespread pain


image Pain in 11 of 18 tender point sites


Pain is widespread when it is present both in the left and right sides of the body, and both above and below the waist. In addition, axial skeletal pain (cervical spine, anterior chest, thoracic spine, or low back) must be present. Low back pain is considered lower segment pain.


Pain must be present in at least 11 of the following 18 trigger point sites (9 pairs) on digital palpation:



Occiput—bilateral, at suboccipital muscle insertions


Low cervical—bilateral, at anterior intertransverse spaces C5–C7


Trapezius—bilateral, at midpoint of upper border of muscle


Supraspinatus—bilateral, above scapular spine near medial border


Second rib—bilateral, at second osteochondral junctions


Lateral epicondyle—bilateral, 2 cm distal to epicondyles


Gluteal—bilateral, in upper outer quadrants of buttocks


Greater trochanter—bilateral, posterior to trochanteric prominence


Knee—bilateral, at medial fat pad proximal to joint line


Digital palpation should be performed with an approximate force of 4 kg/1 cm2. For a trigger point to be considered “positive,” the subject must state that the palpation is painful. “Tender” is not to be equated with “painful.”



5. Do all fibromyalgia patients have the same symptoms?


No. There is a high degree of variability in the presentation of fibromyalgia. Subgroups of the syndrome have been identified based on the number of active tender points, sleep quality, and cold pain threshold. These subgroups have different prognoses. Patients may also be grouped according to related disease. Of patients with irritable bowel syndrome (IBS), 20% demonstrate findings consistent with fibromyalgia. Fibromyalgia is more common in diabetics than in the general population, and the severity of pain correlates with the duration of diabetes. These may constitute additional subgroups of fibromyalgia.



6. Name syndromes that are associated with fibromyalgia




image Chronic fatigue syndrome


image Irritable bowel syndrome


image Restless leg syndrome


image Interstitial cystitis


image Temporomandibular joint dysfunction


image Sicca syndrome


image Raynaud’s phenomenon


image Autonomic dysregulation with orthostatic hypotension


image Mood disorder



7. What are trigger points?


Trigger points are sites in muscle or tendon that, when palpated, produce pain at a distant site. These occur in consistent locations with predictable patterns of pain referral. Trigger points are often associated with prior trauma, “near falls,” or degenerative osteoarthritis.



8. What are “taut bands”? How are they associated with trigger points?


In patients with myofascial pain, deep palpation of muscle may reveal areas that feel tight and bandlike. Stretching this band of muscle produces pain. This is a taut band. Trigger points are characteristically found within taut bands of muscle. Despite the muscle tension, taut bands are electrophysiologically silent (i.e., the electromyogram [EMG] is normal). Rolling the taut band under the fingertip at the trigger point (snapping palpation), may produce a local “twitch” response. This shortening of the band of muscle is one of the cardinal signs of fibromyalgia.



9. What are some of the most common sites of tender points in fibromyalgia?




image Midtrapezius


image Lower part of sternocleidomastoid muscle


image Lateral part of pectoralis major muscle


image Midsupraspinatus muscle


image Upper outer quadrant of gluteal region


image Trochanteric region


image Medial fat pad of knee



10. Describe the prevalence and typical demographics of the fibromyalgia patient

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Jun 14, 2016 | Posted by in PAIN MEDICINE | Comments Off on Fibromyalgia and Myofascial Pain

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