1. 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.

2. 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

3. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

4. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4

5. Myofascial Pain Syndrome  Patients complain of the pain as Deep and aching Accompanied by a sensation of  Burning  Stinging  Stiffness Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5

6. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6

7. Myofascial Pain Syndrome VariableFibromyalgiaMyofascial Pain LocationGeneralizedRegional ExaminationTender pointsTrigger points Response to local therapy Not sustainedCurative GenderFemale/male ratio—10:1 Equal or unknown Systemic featuresCharacteristicUnknown Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7

8. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8

9. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9

10. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10

11. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11

12. Fibromyalgia Syndrome (FMS) Commonalities between FMS and Chronic Fatigue Syndrome (CFS) OccurrencePrevious healthy, young and middle-aged women EtiologyInfectious 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 diseaseVariable intensity of symptoms, fluctuates over time Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12

13. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13

14. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14

15. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15

16. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16

17. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17

18. Tender Points in Fibromyalgia Syndrome Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18 Fig. 65-14. Tender points in fibromyalgia syndrome.

19. Fibromyalgia Syndrome (FMS) Clinical Manifestations and Complications  Cognitive effects Range from difficulty concentrating to memory lapses Feelings of being overwhelmed when dealing with multiple tasks  Migraine headaches  Depression and anxiety Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19

20. Fibromyalgia Syndrome (FMS) Clinical Manifestations and Complications  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

21. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21

22. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22

23. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23

24. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24

25. 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) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25

26. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26

27. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27

28. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28

29. Chronic Fatigue Syndrome (CFS)  Also called chronic fatigue and immune dysfunction  Characterized by Debilitating fatigue Variety of associated complaints Immune abnormalities Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

30. 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

31. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31

32. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32

33. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33

34. Chronic Fatigue Syndrome Clinical Manifestations  Incapacitating fatigue Is the most common symptom Problem that causes patient to seek health care  Associated symptoms fluctuate in intensity over time. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34

35. Chronic Fatigue Syndrome Clinical Manifestations  Patient may become angry and frustrated with inability to diagnose the problem.  Disorder can have a major impact on work and family responsibilities. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35

36. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 36

37. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37

38. Chronic Fatigue Syndrome Nursing and Collaborative Management  Many CFS patients have allergies and sinusitis. Antihistamines Decongestants  Tricyclic antidepressants improve Mood Sleep Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 38

39. Chronic Fatigue Syndrome Nursing and Collaborative Management  Clonazepam (Klonopin) for Sleep disturbances Panic disorders  Low-dose hydrocortisone is being studied. Decreases fatigue and disability Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 39

40. Chronic Fatigue Syndrome Nursing and Collaborative Management  Total rest is not advised.  Important to plan a graduated exercise program Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 40

41. Chronic Fatigue Syndrome Nursing and Collaborative Management  Well-balanced diet Fiber Dark-colored fruits and vegetables  Behavioral therapy  Financial instability Major problem facing CFS patients Cannot work or decreased time working Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 41

42. Chronic Fatigue Syndrome Nursing and Collaborative Management  CFS does not progress. Most patients recover or gradually improve over time. Some do not show ample improvement. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 42

43. Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 43

44. Case Study 1  32-year-old woman visits her physician complaining of severe fatigue.  Her symptoms began about 3 months ago. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 44

45. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 45

46. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 46

47. Case Study 1  Physical examination reveals a positive response for tender cervical nodes and joint pain.  She is suspected of having chronic fatigue syndrome. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 47

48. Case Study 1 Discussion Questions 1.What symptoms of chronic fatigue syndrome does she display? 2.What patient teaching should you do with her? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 48

49. Case Study 1 Discussion Questions 3.What classes of medication may help? 4.What emotional and psychosocial issues may you need to address with her? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 49

50. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 50

51. Case Study 2  She has tried getting massages and doing yoga and obtained only slight relief of the pain. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 51

52. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 52

53. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 53

54. Case Study 2 Discussion Questions 1.What are the likely causes of her symptoms? 2.What is the difference between fibromyalgia syndrome and chronic fatigue syndrome? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 54

55. Case Study 2 Discussion Questions 3.What drug treatments are available? 4.What essential patient teaching should you do with her? 5.What nutritional counseling can you provide? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 55