Rheum E1 -Diffuse & Regional Pain Syndromes

Is fibromyalgia more common in men or women?

Women

When does fibromyalgia usually present?

Early & middle adulthood or childbearing years

What are the 2 types of fibromyalgia?

1. Primary- innate

2. Secondary- associated with AI disease (RA, SLE)

What are the proposed theories for fibromyalgia?

Central sensitization, Abnormal levels of neurotransmitters (substance P & glutamate), Genetics, Stress

What is fibromyalgia?

chronic widespread pain in all 4 quadrants of the body (above and below the waist, left and right sides of the body and in the axial skeleton) of > 3 months duration

How long does widespread pain have to be present to diagnose fibromyalgia?

> 3 months

Where does the pain associated with fibromyalgia have to be located to make the correct diagnosis?

All 4 quadrants of body

______ fibromyalgia is a diagnosis of exclusion

Primary

What are sx associated w/ primary fibromyalgia?

fatigue, HA, IBS, irritable bladder, “fibro fog”, restless leg syndrome, hypersensitivity, anxiety, depression

What are 4 mimickers of fibromyalgia and what should you check?

Hypothyroidism- check TSH

Polymyalgia rheumatica- check ESR

SLE- check ANA

RA- check anti-CCP Abs

What are the 9 trigger points of fibromyalgia?

1. Occipital

2. Lower C-spine

3. Trapezius

4. Rhomboid

5. Pectoralis

6. Lateral condyle of elbow

7. Sacro-iliac

8. Trochanter

9. Medial aspect of knee

What is the tx of Fibromyalgia?

Muscle relaxants (cyclobenzaprine), SSRIs/Tricyclic, TCAs, Antiepileptics, Pregabalin

What should you NOT give to tx fibromyalgia?

pain meds, NSAIDs

True or False: NSAIDs or other pain meds are beneficial to patients with fibromyalgia

False

What is the new term for Chronic Fatigue Syndrome?

Myalgic encephalomyelitis

What is Myalgic encephalomyelitis?

state of chronic fatigue (a reduction in at least 50% of ADLs), which exists without other explanations, for ≥ 6 months and is accompanied by cognitive difficulties

What is the most common virus associated with myalgic encephalomyelitis?

EBV

What is the most characteristic feature of myalgic encephalomyelitis?

Post-exertional malaise

What cognitive dysfunction is mainly present with myalgic encephalomyelitis?

Short-term memory loss

What physical exam findings might be present in a patient with myalgic encephalomyelitis?

Crimson crescents & shotty adenopathy

What are crimson crescents?

purple/crimson discoloration of both anterior tonsillar pillars in the absence of pharyngitis

What disease are crimson crescents associated with?

Myalgic encephalomyelitis

What is the tx of myalgic encephalomyelitis?

Supportive care- CBT, exercise/PT, consider OI tx if dizziness

What is Hypermobility spectrum disorder?

"Double-jointed"

What term is used to describe symptomatic joint hypermobility in the absence of any form of EDS or other HDCT?

Hypermobility spectrum disorder

What is Ehlers-Danlos syndrome?

inherited genetic abnormalities that lead to changes in the structure or function of collagen and allied structural proteins (connective tissue)

What score can be used to measure joint hypermobility and diagnose hypermobility spectrum disorder?

Beighton score

What is the tx for hypermobility spectrum disorder?

Exercise (to strength muscles), aqua therapy, neuro-massage, muscle relaxants

What is the most common cause of tendonitis/bursitis?

repetitive overuse with minor injury

Tendonitis/Bursitis common in:

Tennis players

Lateral epicondylitis

Tendonitis/Bursitis common in:

Baseball pitches

subacromial bursitis

Tendonitis/Bursitis common in:

Golfers

Medial epicondylitis

Tendonitis/Bursitis common in:

Runners

Trochanteric bursitis

Tendonitis/Bursitis common in:

Housemaids/clergyman

Infrapatellar bursitis

Special tests include:

Impingement, Neers, Empty can, Drop arm

Rotator cuff

Special tests include:

Palpable fissure at 4-5th palmar fascia

Dupuytren's contracture

Special tests include:

"Catch" test on digital flexion

Trigger finger

Special tests include:

Finkelstein's test

DeQuervain's tenosynovitis

Special tests include:

Tinel's & Phalen's signs

Carpal tunnel syndrome (median nerve)

Special tests include:

Knee pop, patella pain

Chondromallacia patella

Special tests include:

Palpable pain at antero-medial region below the knee

Anserine bursitis

Special tests include:

Drawer sign

ACL injury

Special tests include:

Popliteal fullness- often associated with OA

Baker's/Popliteal cyst

Deep or Superficial bursae:

Located in the fascia

Deep

Deep or Superficial bursae:

Located in the subcutaneous tissue

Superficial

Deep or Superficial bursae:

Subacromial & Iliopsoas bursae

Deep

Deep or Superficial bursae:

Olecranon & Prepatellar bursae

Superficial

What will be seen on physical exam on tendonitis/bursitis?

Palpable point tenderness

What is the usual tx for Tendonitis/Bursitis?

RICE

Where should you NEVER inject steroid shots?

directly into tendon (inject in tendon sheath/bursa)

*risk of rupture!!

TMJ has a higher correlation with _______

Mood disorders, anxiety, depression

Pt presents with unilateral mouth pain that radiates to the ear and worsens with chewing. States that they feel a locking of their jaw and ear clicking/popping when they eat. Also c/o head, neck, shoulder, and back pain. Most likely dx?

TMJ

What sx are associated with TMJ?

unilateral, locking of jaw, radiates to ear/jaw, bite malalignment, bruxism, psychosocial sx, head/neck/back pain

What imaging may be indicated for TMJ?

Panorex or CT

What is the 1st line tx for TMJ?

NSAIDs and Benzos

What causes CTS?

median nerve entrapment @ wrist

How does Carpal tunnel syndrome present?

Numbness/paresthesias of the fist 3 and 4th half fingers, dec hand grip strenght, + Tinel’s sign

What is the 1st line Tx of Carpal Tunnel Syndrome?

NSAIDs/Acetaminophen, splint, steroid injections, surgery (surgical release)

What is Thoracic outlet syndrome?

Compression of the neurovascular structures in the area just above the 1st rib and behind the clavicle

3 type of thoracic outlet syndrome

1. Neurogenic (nTOS)

2. Venous (vTOS)

3. Arterial (aTOS)

What is the most common facet of thoracic outlet syndrome?

Neurogenic (brachial plexus)

What causes TOS?

bony factors, soft tissue factors, trauma, mechanical stress

Adson maneuver, Wright test, and Roos stress test are tests for ______

Thoracic outlet syndrome

What testing can be done to help dx TOS?

radiography, CT/MRI, venous/duplex, EMG/nerve conduction

What is the tx for TOS?

physiotherapy, medical therapy, surgery

What diseases cause chest wall inflammation and tenderness localized along the costochondral joints/rib (2-5 MC)?

Tietze syndrome and costochondritis

Tietze syndrome vs. Costochondritis:

nonsuppurative edema/swelling

Tietze syndrome

Tietze syndrome vs. Costochondritis:

No palpable edema/swelling

Costochondritis

What diagnostic study can be ordered to confirm Tietze syndrome/Costochondritis?

CXR

Bone (gallium) scans: rarely used

What is the 1st line tx for Tietze syndrome/Costochondritis?

NSAIDs, generally self-limiting

Who is most likely to develop CRPS?

younger (avg. 40), women > men, UE > LE, s/p minor trauma or surgery

*in kids LE > UE

Type 1 or Type 2 CRPS:

An excessive CNS afferent sympathetic reaction of joints and periarticular soft tissues to any insult, traumatic or unknown

Type 1

Type 1 or Type 2 CRPS:

Causalgia due to partial nerve injury

Type 2

What are the sx of CRPS?

pain, edema, stiffness, atrophy, skin changes aggravated by activity extended over a larger region than the primary injury/surgery

What is the best diagnostic study for diagnosis of CRPS?

Bone scan- 3 phase technetium Tc 99m

*no labs, dx of hx and PE

What is the 1st line tx for CRPS?

Analgesics, NSAIDs, Antidepressants, Anticonvulsants

*in this order

What is the 2nd line tx for CRPS?

anesthetics, adrenergic compounds, CCB, corticosteroids, surgical ablation/ sympathectomy

*in this order

What type of fibromyalgia is innate?

Primary

What type of fibromyalgia is associated with autoimmune dx, such as RA or SLE?

Secondary

What neurotransmitters have abnormal levels in patients with fibromyalgia?

Substance P & Glutamate

What are sacs that buffer between bone/muscle or bone/skin?

Bursae

What type of joint is the TMJ?

Synovial

For refractory cases of TMJ, where should you refer the patient to?

ENT/oral surgeon

______ distribution of the brachial plexus is often affected in TOS

Ulnar