Myofascial Pain & Fibromyalgia

17/11/54
Myofascial Pain & Fibromyalgia

Pradit Prateepavanich, Assoc Prof
Department of PM&R, Siriraj Hospital,
Faculty of Medicine Mahidol University, Bangkok, Thailand President IAS p (Thai Chapter)
Musculoskeletal Pain
Articular
– Disc Herniation
Soft Tissue Rheumatism
Acute
■ Muscle strain, Ligament Sprain
Chronic
■ Localize Pain : enthesopathy
■ Regional Pain : Myofascial Pain
■ Widespread Pain ะ Fibromyalgia
Concept
Acute ST Injury

Strain Sprain
Knowledge
Chronic
[Microrepetitive Injury] Central Sensitization
Local Regional <-—> Widespread

Refractory
Enthesopathy
Skill
MPS
Fibromyalgia
Attitude
Clinical Diagnosis

QuickTimi TIFF (บทcompresse are needed to se *8

LBI

Diagnostic
Symptom(s): History
Sign(s): Physical Examination
Laboratory: Ix

Age & OA Humanized Medicine

40 60
Age
20
80
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17/11/54

— —. Mis-Diagnosis
I False-positive rates for HNP with various imaging modalities.
JD, ed. Bonica’s Management of Pain, 3rd ed. 2001

Treatment

Common Soft Tissue Pain
เท Clinical Practice
jma
[Common Cause ะ Common Sense
V
Ac LI is
ACUTE

Sport Injury [Acute ~ r
RICE Ti ,=5,. r
□ Rest [AbsoI ute/RelatiVe] w^SS3fdto?2ฟ้รรรรร””
□ Ice
□ Compression -•“รร่ะ”
□ Elevation ■.^.-.=:…. ‘—t
Chronic Sprain
QuickTirre™and a TIFF (ษไ c oppressed) decorrpressor . 1— . 1 — are needed to see this picture. NSAIDS
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17/11/54
Enthesopathy

Myofascial Pain Syndrome
Traditionally defined Regional pain derived from myofascial trigger point
MPS the chronicle

^ Epidemiology: most common chronic pain in clinical practice (NOW) ^ Pathophysiology : exactly unknown: overload principle is favorable เ^ Diagnosis ะ High Touch R/l & High Tech RIO ^ Treatment: TrP eradication (No single standard of the treatment)
Find
&FixPPF
^ Prognosis: Best of all in chronic pain syndrome
Clinical Pictures
Myofascial Pain Syndrome & Dysfunction
‘ร Pain (Bizarre referred pain but specific to each TrP) ‘ร Autonomic Symptom(s)
‘ร Associated neurologic symptom(s)
Essential RP

Diagnostic Criteria (R/O And R/l)
Hx : Regional Pain Syndrome PE : Palpable Trigger Point

High touch is important as High technology
Common characteristic of the TrP ะ
1. Hyperirritable Spot
2. Reproducible referred symptom
3. Palpable of Taut band or nodule
Etiology of Myofascial
Trigger Points (Overload Principle)
• Acute Overuse : Traumatic and/or sport-related
• Chronic Overuse : poor posture with microrepetitive trauma

Field Work Office Syndrome WWW
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17/11/54
Regress tdDHtomdAcute strain]
Su^”!รแ
TIFF (บทcompresse<
โRepetl
Self-sustained Cycle
protective mechanism

1. Motor end-plate Concept 2. Muscle fiber concept 3. ANS concept 4. Central Sensitization
Pathophysiology Trigger Point

Sikdar ร, Shah JP, Gebread T, et al. Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Arch Phys Med Rehabil Vo I 90, November 2009; 1829-38.

Myofascial Pain Syndrome

Regional myofascial pain and medical specialists.

4

17/11/54
MPS Management
เท practice MPS is The largest cross-road of conventional and alternative medicine
c c 77

Q_
IS
ร,’
~ <
jIo
6) ร o
■ LU _|

Trigger Point Eradication : Short-term goal Correct Perpetuating Factor : Long-term goal

Mechanic
^stretching
Jtz Massage
.jgS’Dry Needling
And Acupuncture
^Trigger Point Injection!
Selected of the patient For the Rx. Of choice
Patient preference & compliance
Contraindication
Skill of the Therapist
are needed to see this picture.
No Single standard of the Treatment Combine is common in practice(Mix & Match)
How long does it last?
เ^

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Please Wait
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17/11/54

Q. Psychological Factor
Anxiety and depression increase when related to medical symptoms without identified pathology (Katon etal. 2001)
MPS •«—► Stress & Depress ««—► MPS

Shall I cure? When?
are needed to see this picture.

J’JJach’jnJG’jJ Bysisnjj ช Psych 0.๒ cjj ช:ฟ
Multifactor
6

17/11/54
What shall I do?
CWP with associated symptoms
Characterized by increase pain sensitivity ะ the extreme end of a spectrum of abnormal pain sensation/processing [Wolfe F, etal. Arthritis Rheum 1995;38:19-28.]
[IGD M?9.0 : ttofcspmific rheumatic condition]
Treatment
MTrPs Eradication
PPF Correction
Stretch Massage Dry Needling Acupuncture MTrPs Injection PT
<=> ะ
Postural Correction Stress Reduction Nutritional & Hormonal Correction
Symptomatic <^n) Palliative (n) Curative Rx
BeAiste3teiptegi-%lrmptifrtt<8)pam

QuickTiire™ and a FF (บทCO Impressed) decorrpressor are needed to see this picture.
^Psychologic symptoms
^Rheumatic symptoms JOrthopedic symptoms ^Neurologic symptoms ‘รGynecologic symptoms ^Urologic symptoms ‘ร And etc
QuickTime™ and compressed) deco ledea to see this pi
Palliat Caie 2008 2121:122-7.
FIBROMYALGIA Attitude Scientific Data
Axis I and Axis II Diagnosis
in Fibromyalgia Patients and Control Groups [N : 103/83]
Axis I: Mental Disorder
MDD 14.6 :4.8% Anxiety Disorders
32 ะ 10%
c_\ smell a spy in here ‘^^^H jgg
Axis II ะ Personality Disorder OCPD ะ 23.3/3.6%
Any Axis II disorders
31.1 ะ 13.3%
Axis III ะ IV|edical/Physica(l Disorder [Chronic Pain]
F Uguz et al. Axis I and Axis II psychiatric di^enrtess in patients fibromyalgia. General Hospital Psych iatry2010;^: 105-07.
Curr coin SuDDOit Palliat Care 2008:2121:122-7.
State of the Science
Gracelyet al. Arthritis Rh’eum^002^6:1333-1343.
fMRlin Fibromyalgia Syndrome15

IPL Sll STS. Inula. Putimen Curnhnllnm
fMRUfunctional magnetic resonance imaging; Sl=primary somatosensory cor¬tex; STG=superior temporal gyri; SII=secondary somatosensory cortex.
20% of chronic MPS
M
Peri
5 : Physical
Tra
crorepetitive T raurm.
jheranHglffiffierators
5 : P^PcfiM§Jical
Trauma
4 : Concomitant I
ร,’: MDD
nd th
LAS) (|fetaransi
3: Environmental “spf1
I ‘ Piwlknngitinn iJJIj
พ นุ (MCS)
Etiology ะ Multifactors
Update on Fibromyalgia Syndrome.
Pain Clintal Updates (IASP), Volume XVI, Issue 4, June 2008
_ ralgia: pain in fibromyalgia syndrome. Arthritis Research & Therapy 2006,8:208.
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17/11/54
Pathophysiology
Central Sensitization (Imbalanced of Nociception)

Hybrid
[Common]

StaudR. Biology and therapy of fibromyalgia: pain in fibromyalgia syndrome. Arthritis Res Ther 2006:8:208-14.

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http ะ//พww. pri m aryp sych iatry.com/aspx/articledetail.aspx?articleid=2484

[Outcome of Mixed Result] Common phenomena in Heterogenous Condition
I; KPV swmntnm^^ II- PPfi Ill’Cnninn skill
QuickTime™ and a TIFF (บท com pressed) decompressor are needed to see this picture.
jS’VsiUuusnj DJJ
;al Updates (IASP) 2008 Junrl6(4).
8

17/11/54
Evaluation coping skills
[Subgroup classification] All subgroups are similar in pain severity
Coper
Stress
Fear
Adaptive Coper <=> Distressed <=> Dysfunction
Predominant
Evaluation Key Symptom(s)
NSAIDs Clinical-Based
Acetaminophen
Weak-Opioid
(Reacutization)
Pain TIFF I’Uncomniessffd’ujecomDtessot
Opioids
Glutamate Substance p
/
A
DOSE
TCAs
%
^heum 2003 ;4b
Serotonin
NE
Insomnia/Anxiety
Hypnotics
Anxiety/Depress
SSRIs
ษoldenberg UL, et ai. Arthritis Rheum 1986:29:1371-7
Evaluation PPG
Peripheral pain generator(s) treatment
Glutamate Substance p
27% Of Total Pain Serotonin
NE

Acupuncture Massage Relaxation

Update on Fibromyalgia Syndrome. Pain Clinical Updates {ASP), VolumeXVI, Issue 4, June 2008 Simon DJ. Fibrositis/fibro myalgia: a form of myofascial trigger points? Am JMed. 1986 Sep29;81(3A):93-98. staud R. Biology and therapy of fibromyalgia: pain in fibromyalgia syndrome. Arthritis Research & Therapy 2006,8:208.
Prognosis

Langford CA, GiIIilan BC. Fibromyalgia. เท: Fauci AS, Braunwald E, Kasper DL, edร. Harrison’s Principles of Internal Medicine. UWi eu. N^wYork: McGrawHill Medical; { 2008. pplal 75-76.
Community Hospital NB : 2 years follow up, Go slow, Nature of the disease
Interesting Found [Thailand] £0
c
Dosage of medications is less than in the text from บ, western (O
v^Genetic Polymorphism [CYP2D6] in difference form Q ‘/Culture of/in Pain [Accept] £
■๐ ๐ 3i
(D

Lasch KE. Culture and Pain. Pain Clinical Updates (IASP) 2002;10:1-9

Vietnamese
American
Consumption Mo equi
Inadequate pain control reported 92% Acception
20%
Lasch KE. Culture and Pain. Pain Clinical Updates. 2002;10(5):1-9.
Carragee EJ, Kim D, van derVlugtT,et al. Pain control and cultural norms and expectations after closed femoral shaft fractures. Am J Orthop 1999;28(2):97-102.
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17/11/54
Conclusion
Sudden ST Injury
Acute –
Strain Sprain
Knowledge

Skill

Attitude
10

Foot Patch มีอย. ต้อง Mamae

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