Focus on Myofascial Pain, Fibromyalgia, and Chronic Fatigue Syndromes (Relates to Chapter 65,...

Focus on Myofascial Pain, Fibromyalgia, and Chronic Fatigue Syndromes

(Relates to Chapter 65, “Nursing Management: Arthritis and Connective Tissue Diseases,” in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Soft Tissue Rheumatic Syndromes Three soft tissue disease

syndromes that have many commonalities and may be related Myofascial pain syndrome Fibromyalgia syndrome (FMS) Chronic fatigue syndrome

(CFS)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

Myofascial Pain Syndrome Characterized by

musculoskeletal pain and tenderness in one anatomic region of the body

Pain has been shown to originate in anterior and posterior trigger points. Muscle trauma Chronically strained muscles


Myofascial Pain Syndrome Regions of pain are often

within taut bands and fascia of skeletal muscles.

Trigger points are thought to Activate a characteristic

pattern of pain when activated by pressure

Worsen with activity or stress


Myofascial Pain Syndrome Patients complain of the

pain as Deep and aching Accompanied by a sensation

of Burning Stinging Stiffness


Myofascial Pain Syndrome Diagnosis is done by palpation

of trigger points. Reveals induration and frequently

a muscle twitch in area of a trigger point

Once a trigger point is palpated, pain will be felt locally. May also be referred to a region

often at some distance


Myofascial Pain Syndrome

Variable Fibromyalgia Myofascial Pain

Location Generalized Regional

Examination Tender points Trigger points

Response to local therapy

Not sustained Curative

Gender Female/male ratio—10:1

Equal or unknown

Systemic features Characteristic Unknown


Myofascial Pain Syndrome Treatments

Physical therapy “Spray and stretch” method

Painful area is iced or sprayed with a coolant and then stretched.

Injecting trigger points with a local anesthetic

Massage


Myofascial Pain Syndrome Treatments (cont’d)

Acupuncture Biofeedback Ultrasound

Patient and family teaching is important nursing responsibility. Instruction should focus on

prevention of muscle tension.


Fibromyalgia Syndrome (FMS) Chronic disorder characterized by

Widespread, nonarticular musculoskeletal pain and fatigue

Multiple tender points FMS patients may also have

Nonrestorative sleep and morning stiffness

Anxiety Irritable bowel syndrome


Fibromyalgia Syndrome (FMS) Commonly misdiagnosed

musculoskeletal disorder Major cause of disability Affects 2% to 5% of the U.S.

population Occurs 6 times more

frequently in women than in men


Fibromyalgia Syndrome (FMS)

Commonalities between FMS and Chronic Fatigue Syndrome (CFS)

Occurrence Previous healthy, young and middle-aged women

Etiology Infectious trigger, dysfunction in HPA axis, alteration in CNS

Clinical manifestations

Malaise and fatigue, cognitive dysfunction, headaches, sleep disturbances, depression, anxiety, fever, generalized musculoskeletal pain

Course of disease Variable intensity of symptoms, fluctuates over time


Fibromyalgia Syndrome (FMS)

Commonalities between FMS and Chronic Fatigue Syndrome (CFS) (cont’d)

Diagnosis No definitive laboratory tests or joint and muscle examinations, mainly a diagnosis of exclusion

Collaborative care

Treatment is symptomatic and may include antidepressant drugs

Other measures are heat, massage, regular stretching, biofeedback, stress management, and relaxation training

Patient and family teaching is essential


Fibromyalgia Syndrome (FMS)Etiology and Pathophysiology Research continues to focus on

identifying underlying causes and pathophysiologic mechanisms.

General agreement that FMS is a disorder of central processing with neuroendocrine/neurotransmitter dysregulation


Fibromyalgia Syndrome (FMS)Etiology and Pathophysiology Multiple physiologic abnormalities

↑ levels of blood flow to thalamus Dysfunction of hypothalamic-

pituitary-adrenal (HPA) axis Low levels of serotonin and

tryptophan Abnormalities in cytokine function

May be a genetic susceptibility


Fibromyalgia Syndrome (FMS)Clinical Manifestations and Complications Clinical manifestations of

FMS overlap those of CFS. Complaints

Widespread burning pain Pain worsens and improves

throughout day. Difficult to discriminate pain


Fibromyalgia Syndrome (FMS)Clinical Manifestations and Complications

Complaints (cont’d) Head or facial pain originates from

stiff or painful neck and shoulder muscles.

Nonrestorative sleep Fatigue Temporomandibular joint dysfunction

Affects approximately one third of FMS patients

Point tenderness varies.


Tender Points in Fibromyalgia Syndrome


Fig. 65-14. Tender points in fibromyalgia syndrome.


Cognitive effects Range from difficulty

concentrating to memory lapses Feelings of being overwhelmed

when dealing with multiple tasks

Migraine headaches Depression and anxiety



Numbness and tingling in hands or feet

Restless leg syndrome Irritable bowel syndrome Difficulty swallowing ↑ frequency of urination and

urinary urgency For women, difficult

menstruation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

Fibromyalgia Syndrome (FMS)Diagnostic Studies

Difficult to establish a definitive diagnosis

Laboratory results rule out other suspected disorders.

Occasionally a low ANA titer is seen. Not considered diagnostic


Fibromyalgia Syndrome (FMS)Diagnostic Studies

Muscle biopsy may reveal a nonspecific moth-eaten look or fiber atrophy.

FMS if two criteria are met Pain is experienced in 11 of 18

tender points on palpation. History of widespread pain for

at least 3 months is noted.


Fibromyalgia Syndrome (FMS)Collaborative Care

Treatment is symptomatic and requires a high level of patient motivation.

Teach patient to be an active participant in therapeutic regimen.

Pain, aching, and tenderness can be helped by rest.


Fibromyalgia Syndrome (FMS)Collaborative Care Analgesics are effective for some.

Acetaminophen (Tylenol), NSAIDs Low-dose tricyclic antidepressants

Stress, fatigue, sleep disturbances Serotonin reuptake inhibitor (SSRI)

antidepressants Reserved for those with depression


Fibromyalgia Syndrome (FMS)Collaborative Care

Benzodiazepines prescribed with low doses of ibuprofen Anxiety, muscle spasms

Zolpidem (Ambien) for severe sleep disturbances

Gabapentin (Neurontin) Pregabalin (Lyrica)


Fibromyalgia Syndrome (FMS)Nursing Management FMS patients need consistent

support. The nurse Other members of health care team

Massage combined with ultrasound Application of alternating heat and

cold packs Soothes tense, sore muscles Increases blood circulation


Fibromyalgia Syndrome (FMS)Nursing Management

Gentle stretching to relieve muscle tension and spasm

Yoga and Tai Chi Low-impact aerobic exercise

helps prevent muscle atrophy.


Fibromyalgia Syndrome (FMS)Nursing Management

Limited intake of known muscle irritants Sugar, caffeine, alcohol

Vitamin and mineral supplements

Relaxation strategies Biofeedback, guided imagery,

autogenic training Psychologic counseling


Chronic Fatigue Syndrome (CFS) Also called chronic fatigue

and immune dysfunction Characterized by

Debilitating fatigue Variety of associated

complaints Immune abnormalities


Chronic Fatigue Syndrome (CFS) Difficult to establish

prevalence Lack of validated diagnostic

tests Women more often than men Occurs in all ethnic groups and

socioeconomic groups CFS and FMS share common

features. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30

Chronic Fatigue Syndrome Etiology and Pathophysiology

Precise mechanisms remain unknown.

Many theories about cause Neuroendocrine abnormalities

involving hypofunction of HPA axis and HPG (hypothalamic-pituitary-gonadal) axis have been implicated.

Together regulate stress response and reproductive hormone levels


Chronic Fatigue Syndrome Etiology and Pathophysiology

Several microorganisms have been investigated. Herpesviruses

Epstein-Barr (EBV) Cytomegalovirus (CMV)

Because cognitive deficits occur in many CFS patients, CNS changes are also proposed.


Chronic Fatigue Syndrome Clinical Manifestations

Difficult to distinguish between CFS and FMS

CFS develops insidiously in approximately half of cases. Or patient may have

intermittent episodes that gradually become chronic



Incapacitating fatigue Is the most common symptom Problem that causes patient to

seek health care Associated symptoms

fluctuate in intensity over time.



Patient may become angry and frustrated with inability to diagnose the problem.

Disorder can have a major impact on work and family responsibilities.


Chronic Fatigue Syndrome Diagnostic Studies

Physical examination and diagnostic studies rule out other possibilities.

No laboratory test can diagnose CFS or measure its severity.

In general, a diagnosis of exclusion


Chronic Fatigue Syndrome Nursing and Collaborative Management

Supportive management is essential.

Inform patient about disease. All complaints should be taken

seriously. NSAIDs can be used to treat

Headaches Muscle and joint aches Fever



Many CFS patients have allergies and sinusitis. Antihistamines Decongestants

Tricyclic antidepressants improve Mood Sleep



Clonazepam (Klonopin) for Sleep disturbances Panic disorders

Low-dose hydrocortisone is being studied. Decreases fatigue and

disability



Total rest is not advised.

Important to plan a graduated exercise program



Well-balanced diet Fiber Dark-colored fruits and vegetables

Behavioral therapy Financial instability

Major problem facing CFS patients Cannot work or decreased time

working



CFS does not progress. Most patients recover or

gradually improve over time. Some do not show ample

improvement.


Case Study


Case Study 1 32-year-old woman visits her

physician complaining of severe fatigue.

Her symptoms began about 3 months ago.


Case Study 1 She states that she does not

feel better despite resting during the past week.

She also complains of general malaise and an inability to concentrate.


Case Study 1 Because of the fatigue, she

has needed to ask her sister to help her around the house and to drive her kids to activities.

She had a mononucleosis infection approximately 6 months ago.


Case Study 1 Physical examination reveals

a positive response for tender cervical nodes and joint pain.

She is suspected of having chronic fatigue syndrome.


Case Study 1Discussion Questions1.What symptoms of chronic

fatigue syndrome does she display?

2.What patient teaching should you do with her?


Case Study 1Discussion Questions3. What classes of medication

may help?

4. What emotional and psychosocial issues may you need to address with her?


Case Study 2 45-year-old woman calls a

nurse hotline to ask for advice.

She is experiencing burning pain throughout her body that comes/goes and overwhelming fatigue.


Case Study 2 She has tried getting

massages and doing yoga and obtained only slight relief of the pain.


Case Study 2 She is concerned that she

might have some widespread infection.

She also states she has insomnia and feels tired in the morning.


Case Study 2 She has a history of irritable

bowel syndrome.

Admits she also has urge to move legs when recumbent and occasionally has numbness in hands and feet


Case Study 2Discussion Questions1.What are the likely causes of

her symptoms?

2.What is the difference between fibromyalgia syndrome and chronic fatigue syndrome?


Case Study 2Discussion Questions3. What drug treatments are

available?

4. What essential patient teaching should you do with her?

5. What nutritional counseling can you provide?


Focus on Myofascial Pain, Fibromyalgia, and Chronic Fatigue Syndromes (Relates to Chapter 65,...

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Transcript of Focus on Myofascial Pain, Fibromyalgia, and Chronic Fatigue Syndromes (Relates to Chapter 65,...