1. Prof. Dr. Şansın Tüzün

2.  Chronic musculoskeletal syndrome characterized by diffuse pain and tender points  No evidence that synovitis or myositis are causes  Occurs in the context of unrevealing physical examination, labaratory and radiologic examination  % 80-90 of patients are women, peak age is 30- 50 years

3.  Generalized chronic musculoskeletal pain  Diffuse tenderness at discrete anatomic locations termed tender points  Other features, diagnostic utility but not essential for classification of fibromyalgia are; fatique, sleep disturbances, headaches, irritable bowel syndrome, paresthesias, Raynaud’s-like syndromes, depression and anxiety

4.  For classification criteria, patients must have pain for at least 3 months involving the upper and lower body, right and left sides, as well as axial skeleton, and pain at least 11 of 18 tender points on digital examination

5. Syndrome Relationship with Fibromyalgia Depression Irritable bowel Migraine Chronic fatiqe Syndrome Myofascial pain 25-60 % of FM cases 50-80 % of FM cases 50 % of FM cases 70 % of CFS cases meet FM May be localized form of FM

6.  Classify as CFS or idiopathic Chronic Fatique if; Fatique persists or relapse for > 6 months History, physical examination and appropriate laboratory tests exclude any other cause for the chronic fatique

7.  Classify as CFS if along with fatique, four or more of the following are present for >6 months; Impaired memory of concentration, sore throat, tender cervical or axillary lymph nodes,muscle pain, multijoint pain, new headaches,unrefreshing sleep, postexertion malaise

8.  Presence of trigger points, which include a localized area of deep muscle tenderness, located in a taut band in the muscle, and a characteristic reference zone of the perceived pain that is aggravated by the palpation of the trigger point

9. VariableFibromyalgia Myofascial pain Examination Tender points Trigger points LocationGeneralized Regional Regional Response to local therapy Not sustained Curative Curative SexFemales;males 10:1 10:1 Equal Equal Systemic features characteristic characteristic ?

10.  NSAID  Tricyclic antidepresants ( i.e. amitriptyline, desipramine 1-3h before bedtime)  Cardiovasculer fitness training  Biofeedback  Hypnotherapy  Cognitive behavioral therapy  Educating patient

11.  Results from incresed pressure on a nerve as it passes through an enclosed space  Knowledge of anatomy is essential for understanding of the clinical manifestations of these syndromes  Splinting, NSAIDs and local corticosteroid injections usually suffice when symptoms are mild and of short time.  Surgical procedures to decompress the nerve are indicated in more severe cases

12.  Results from compression of one or more of the neurovasculer elements that pass through the superior thoracic aperture  Anatomic abnormalities and trauma to the shoulder girdle region play a far more pivotal role

13.  Between the scalenius anterior and scalenius medius  Costoclavicular space  Under the coracoid process and beneath the pectoralis minor tendon

14.  Paresthesias  Aching pain, radiating to the neck, shoulder and arm  Motor weakness  Atrophy of thenar, hypotenar and intrinsic muscles of the hand  Vasomotor disturbances

15.  Neurologic examination  Certain clinical stress tests (Adson and hyperabduction maneuvers)  A radiograph of cervicothoracic region (cervical rib, elongated transverse process of C7)

16.  Exercise designed to improve posture by strengthening the rhomboid and trapezius muscles  Avoidance of hyperabduction  Surgical intervention if; muscle wasting, intermittent fleeting paresthesias replaced by continous sensory loss, incapacitating pain,worsening of circulatory impairment

17.  Compression neuropathy of the ulnar nerve as it transverses the elbow  Causes are; history of a trauma, chronic pressure by occupational stress or from unusual elbow positioning  Arthritic conditions that results in synovitis  Osteophyte production

18.  Paresthesias in the distribution of the ulnar nerve  Aggrevated by prolonged use of the elbow in flexed position  (+) Tinel’s sign  Atrophy of intrinsic muscles and weakness in pinch and grasp  Wasting of the hypothenar muscles and slight clawing of the 4th and 5th fingers  Weakness in adduction of the 5th finger

19.  Physical examination (Tinel’s sign, Wartenberg’s sign i.e.)  Radiographs  Electrodiagnosis

20.  Avoidance of prolonged elbow flexion  Local steroid injection along the ulnar groove  Surgical procedures to decompress the nerve

21.  Entrapment of the ulnar nerve in Guyon’s canal at the wrist  Compression is due to ganglia  Causes are; Aberrant muscles, Dupuytren’s disease, RA, OA  Chronic trauma due to certain tools and occupations

22.  Combined sensory and motor deficits  Hypoesthesia in the hypothenar region and 4th and 5th fingers  Weakness of the intrinsic muscles of the hand

23.  Pyhsical examination  Electrodiagnosis is helpful in determining the site of the entrapmant Treatment  Avoidance of trauma  Physical therapy  Surgical decompression

24.  Most common entrapment neuroropathy  Compression of the median nerve at the wrist  Causes are; occupation, crystal-induced rheumatic disorders  Complication of connective tissue disorders  Uremia, metabolic and endocrine diseases, infections, familial occurrance, during pregnancy

25.  Sensory loss in the radial three finger and one- half of the ring finger  Burning, pins-and-needles sensations, numbness and tingling in the fingers  Pain may radiate to the antecubital region or to the lateral shoulder area  Awaken at night by abnormal sensation

26.  (+)Tinel’s sign  (+) Phalen’s sign (wrist flexion)  Thenar atrophy

27.  History and physical examination  Radiographs  Electrodiagnosis

28.  Splints  Local corticosteroid injection  NSAIDs  Physical therapy  Surgery ; patients with progressive increases in distal motor latency times