Myofascial Pain Fibromyalgia and Chronic Fatigue Syndrome Chapter
Myofascial Pain, Fibromyalgia, and Chronic Fatigue Syndrome Chapter 65 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Myofascial Pain Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Myofascial Pain Syndrome § Chronic § Musculoskeletal pain and tenderness § § § Chest Neck Shoulders Hips Lower back Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Myofascial Pain Syndrome § Referred pain to: § Buttock § Hand § Head § Can cause temporomandibular joint pain (TMJ) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Myofascial Pain Syndrome § Pain within taut bands and fascia of skeletal muscles § Trigger points § Activated by pressure § Worsens with activity or stress § Pain deep and aching, accompanied by burning, stinging, stiffness Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Myofascial Pain Syndrome § Treatment § Physical therapy § “Spray and stretch” method § Painful area is iced or sprayed with a coolant and then stretched § Topical patches § Trigger point injections § Massage, acupuncture, biofeedback, ultrasound Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia § Chronic disorder § Widespread, nonarticular musculoskeletal pain and fatigue § Multiple tender points § May also have § § Nonrestorative sleep Morning stiffness Irritable bowel syndrome Anxiety Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia § § Commonly misdiagnosed Major cause of disability Affects 5 million Americans 75%– 90% are women Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia Etiology and Pathophysiology § Area of active research § Neuroendocrine/neurotransmitter dysregulation § Abnormal sensory processing in CNS Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia Etiology and Pathophysiology § Multiple physiologic abnormalities § ↑ Levels of substance P in spinal fluid § Low levels of blood flow to thalamus § Dysfunction of hypothalamic-pituitaryadrenal (HPA) axis § Low levels of serotonin and tryptophan § Abnormalities in cytokine function § Genetics § Recent illness or trauma Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia Clinical Manifestations and Complications § Widespread burning pain § Worsens and improves throughout day § Difficult to discriminate if pain is in muscles, joints, or soft tissues § Can accompany TMJ dysfunction Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study 1 Purestock/Thinkstock • A. S. , a 45 -year-old female, comes to the clinic complaining of widespread burning pain that worsens and improves throughout the day. • She also complains of being very tired. • Her medical history is negative except for irritable bowel syndrome. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study • What factor(s) in A. S. ’s initial presentation suggest(s) she may be suffering from fibromyalgia instead of myofascial pain syndrome? Purestock/Thinkstock Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study Purestock/Thinkstock • What specific areas will you palpate for point tenderness in A. S. ? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Tender Points in Fibromyalgia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study Purestock/Thinkstock • What other clinical manifestations will you ask A. S. about? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia Clinical Manifestations and Complications § Cognitive effects § Difficulty concentrating/memory lapses § Feelings of being overwhelmed when dealing with multiple tasks § Migraine headaches Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia Clinical Manifestations and Complications § § § Depression and anxiety Stiffness Nonrefreshing sleep Fatigue Paresthesia Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia Clinical Manifestations and Complications Restless legs syndrome Irritable bowel syndrome Difficulty swallowing ↑ Frequency of urination and urinary urgency § For women, difficult menstruation § § Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study • What diagnostic studies would you anticipate the health care provider to order? Purestock/Thinkstock Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia Diagnostic Studies § Difficult to establish a definitive diagnosis § Laboratory results rule out other suspected disorders § Low ANA titer but not diagnostic § Muscle biopsy § Nonspecific moth-eaten appearance § Fiber atrophy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study Purestock/Thinkstock • A. S. ’s lab work results are all within normal limits. • The health care provider diagnoses her with fibromyalgia. • What criteria would the health care provider use to support the diagnosis of fibromyalgia? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia Diagnostic Studies § Fibromyalgia if two criteria are met § Pain is experienced in 11 of 18 tender points on palpation § History of widespread pain is noted for at least 3 months § Fatigue, cognitive symptoms, somatic symptoms help establish diagnosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia Collaborative Care § Symptomatic treatment § Requires high level of patient motivation § Patient teaching § Rest Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study Purestock/Thinkstock • A. S. tells you she is glad that she finally knows what is wrong with her. • She is anxious to begin her medications to help her feel better. • What drug treatments might you anticipate the health care provider ordering for A. S. ? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia Collaborative Care § Drug therapy for chronic pain § Pregabalin (Lyrica) § Duloxetine (Cymbalta) § Milnacipin (Savella) § Low-dose tricyclic antidepressants, SSRIs, or benzodiazepines § Muscle relaxants § Nonopioid analgesics § Zolpidem (Ambien) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study • What other treatments and/or interventions would you teach A. S. about? Copyright © 2014 by Mosby, an imprint of Elsevier Inc. Purestock/Thinkstock
Fibromyalgia Nursing Management § Supportive care § Massage combined with ultrasound § Application of alternating heat and cold packs § PT (gentle stretching) § Yoga/ tai chi § Low impact aerobic exercise Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Fibromyalgia Nursing Management § Limit intake of known muscle irritants § Sugar, caffeine, alcohol § Vitamin and mineral supplements § Relaxation strategies § Biofeedback, guided imagery, autogenic training § Psychologic counseling Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Chronic Fatigue Syndrome Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Chronic Fatigue Syndrome (CFS) § Also called chronic fatigue and immune dysfunction or myalgic encephalomyelitis § Characterized by debilitating fatigue and associated complaints § Affects 1 million people in U. S. § Women more than men Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Chronic Fatigue Syndrome Etiology and Pathophysiology § Precise mechanisms remain unknown § Many theories about cause § Neuroendocrine abnormalities involving a hypofunction of HPA axis and HPG (hypothalamic-pituitary-gonadal) axis § Several microorganisms § Changes in CNS Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study 2 Thomas Northcut/Photodisc/Thinkstock • D. L. is a 32 -year-old female who visits her health care provider complaining of severe fatigue for the past 6 months. • She states that rest does not help. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study 2 Thomas Northcut/Photodisc/Thinkstock • She also complains of general malaise and an inability to concentrate. • She has needed to ask her sister to help her around the house and drive her kids to school. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study Thomas Northcut/Photodisc/Thinkstock • What clinical manifestations of chronic fatigue syndrome does D. L. display? • What other clinical manifestations will you question her about? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Chronic Fatigue Syndrome Clinical Manifestations § Difficult to distinguish between CFS and fibromyalgia § Onset insidious, intermittent, or sudden § Incapacitating fatigue most common § Associated symptoms may fluctuate Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study Thomas Northcut/Photodisc/Thinkstock • D. L. ’s HCP suspects CFS. • Are there any diagnostic studies useful for confirming CFS? • How will the HCP establish this diagnosis? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Chronic Fatigue Syndrome Diagnostic Studies § Physical examination and diagnostic studies rule out other possibilities § In general, a diagnosis of exclusion § CDC algorithm § Major criterion + four or more of minor criteria for 6 months or more § Major criterion = fatigue § Minor criteria = specific associated symptoms Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study Thomas Northcut/Photodisc/Thinkstock • The HCP prescribes treatment for CFS for A. L. • What treatments and other interventions appropriate for CFS will you plan to teach A. L. about? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Chronic Fatigue Syndrome Nursing and Collaborative Management § Supportive care § Patient teaching § Drug therapy § § § NSAIDs Antihistamines/decongestants Tricyclic antidepressants Clonazepam (Klonopin) Low-dose hydrocortisone Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Chronic Fatigue Syndrome Nursing and Collaborative Management § § § Activity Diet Behavioral therapy Financial instability/disability Occupational/psychosocial needs Prognosis variable Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
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 © 2014 by Mosby, an imprint of Elsevier Inc.
Chronic Fatigue Syndrome Nursing and Collaborative Management § CFS does not progress § Most patients recover or gradually improve over time § Some do not show significant improvement Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
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