1. FIBROMYALGIA Rheumatology Module Anna Mae Smith, MPAS, PA-C

2. Myofascial pain Minor tear in muscle that causes a localized irritation - trigger point Fibromyalgia - widespread myofascial (soft tissue) pain

3. Fibromyalgia Syndrome Most common rheumatic cause of chronic diffuse pain Generalized pain & symptom pain amplification syndrome Extremely common pain phenomenon occurring in a defined pattern & reproduced by pressure on "trigger points"

4. EPIDEMIOLOGY Incidence/Prevalence in USA: 3 in 100 Predominant age: 18-70 Predominant sex: Female > Male

5. DIfferential Hypothyroidism Psychogenic rheumatism Muscle strain/sprain Muscle disease Polymyalgia rheumatica Temporal arteritis

6. SIGNS & SYMPTOMS Typically insidious in onset Diffuse soft tissue pain Pain is increased in the morning, with weather changes, anxiety, stress Pain improved by mild physical activity or vacations (stress-relieving situations) Non-restorative sleep, with early morning awakening in an unrefreshed state.

7. SIGNS & SYMPTOMS Abnormal non-rapid eye movement (non- REM) stage IV sleep Generalized fatigue or tiredness Anxiety Chronic headache Irritable bowel syndrome Tension headaches

8. SIGNS & SYMPTOMS Subjective, non-confirmable complaints of swelling or numbness, not associated with objective neurologic findings Depression Reduced physical endurance Decreased social interaction Paresthesias – normal nerve studies Sensation of swollen hands!

10. Trigger Points Temporalis - above the ear Anterior to tragus of ear Scalenus capitis Sternocleidomastoid Low anterior neck Pectoralis minor

11. Trigger Points Manubriosternal Anterior and posterior axillary folds Trapezius ridge Upper rhomboids Lower rhomboids

12. Trigger Points Iliac crest Mid-buttocks Mid-rectus femoris Mid-vastus lateralis Quadriceps insertion - at the patella Humeral epicondyles

13. LABS ESR CBC TFT

14. TREATMENT Modify/discontinue inciting activity or disease NSAIDS Ultram Local hot or cold ultrasound Local steroid injections

15. Treatment Electroprobe Electrical stimulation ultrasound conditioning

16. TREATMENT Amitriptyline (Elavil) 10 mg 2 po hs prn, increased gradually to 50 mg Cyclobenzaprine (Flexeril) 10 mg tid prn Zolpidem (Ambien) 5 mg po hs prn, increased to 10 mg Temazepam (Restoril) 15 mg po hs prn, increased to 30 mg

17. Ttreatment Flurazepam (Dalmane) 15 mg po hs prn, increased to 30 mg (note Significant "hangover" potential secondary to long half-life) Triazolam (Halcion) 0.125 mg po hs prn increased gradually to 0.5 mg (use is controversial)

18. Prognosis With resolution of sleep disturbance, may resolve totally Aggressive physical therapy is critical in those who do not respond Approximately 5% do not respond to any form of therapeutic intervention. Hypnosis may be attempted in that group.