Fibromyalgia &

Myofascial Pain Sydrome

Paul F. Pasquina, MD
Physical Medicine & Rehabilitation
Historical Perspective
Hippocrates
Muskelharten
Fibrositis
Psychogenic Rheumatism
Fibromyalgia
Introduction
Incidence / Prevelence
Primary / Secondary
Economic Effects
Sex
Age
MFPS Importance
Important due to significant source of
disability and pain
Treatments generally effective
Often confused with other conditions
Extremely common and often patients are
undiagnosed for years
Myofascial Pain Syndromes Prevalence
Unselected and Control Groups

Danish study of 1504 people, aged 30 - 60, 37% of males and
65% of females had localized myofascial pain.

100 male and 100 female airforce personnel (Av. Age 19): 45%
of males and 54% females had focal neck muscle tenderness
(latent trigger points).

269 female student nurses. 45% had TrPs in masseter, 35% had
TrPs in trapezius. 28% had myofascial pain at the time of
examination.
Myofascial Pain Syndromes Prevalence
Comprehensive pain center

283 consecutive admissions to a comprehensive pain
center: The diagnosis made independently by a
Neurosurgeon and a Physiatrist based on physical
examination as described by Travell and Simons
assigned a primary diagnosis ofmyofascial pain
syndrome in 83% of the cases.
Making the diagnosis:
Taking a good history
Active Listening
Three Major Symtoms:
Pain
Stiffness
Fatigue
Sleep Disturbance
Modulating Factors
Associated Conditions
Physical Exam
Hallmark Finding
Tender / Trigger Points
Other Common Musculoskeletal Disorders
Control Points
Thermography / Dolorimetry
Fibromyalgia Tender Points
Features of
Myofascial Pain Syndrome
Anatomic Trigger Point
Trapezius
Sternocleidomastoid
Levator scapulae
Scalene
Supraspinatus,
Infraspinatus
Symptoms
Headache (temporal, occipital)
Headache, stiff neck
Stiff neck
Pain in shoulder and arm
Pain in shouler and arm
Definitions and Language
of Myofascial Pain
Myofascial Trigger Points:

Active Trigger points

Latent Trigger points

Secondary Trigger Points
Definitions and Language
of Myofascial Pain
An active Myofascial trigger point
Causes pain and tenderness at rest or with motion
that stretches or loads the muscle.
Causes shortening of the muscle, as well as fatigue
and decreased strength.
Pressure on an active TrPt induces / reproduces
some of the patients pain complaint and is
recognised by the patient as being some or all of
his or her pain.
Definitions and Language
of Myofascial Pain
A Latent Myofascial Trigger Point: does not cause pain during
normal activities. It is locally tender, but causes pain only when
palpated, will refer pain on pressure, can be associated with a
weakened shortened moreeasily fatigued muscle.

Secondary trigger points develop when a muscle is substituted for
the primary muscle with a trigger point with diminished function.
Satellite TrPs develop when a muscle is in a referred pain zone of
another TrP. Without proper intervention, and with perpetuating
factors, the TrPs can lead to severe and widespread chronic
myofascial pain (CMP).

Myofascial Trigger Points
Clinical Features
Palpable Band.
A cord like band of fibers is present in the involved
muscle.





This can be difficult to identify when there are overlying
muscles or thick subcutaneous tissue.






INJURY
Myofascial Trigger Points
Clinical Features
Spot Tenderness
A very tender small spot which is found in a Taut
Band.





The sensitivity of this spot (TrPs) can be increased by
increasing the tension on the muscle fibers of the taut
band.

Myofascial Trigger Points
Clinical Features
Twitch Response
Is a transient contraction of the muscle fibers of the
taut band containing the trigger point.
The twitch response can be elicited by snapping
palpation of the trigger point.


Or more commonly by precise needling of the trigger
point, which results the most effective treatment of a trigger
point

Referral Pattern of Selected
Muscles
Serratus posterior superior can mimic a C8
radiculopathy or ulnar neuropathy
Referral Pattern of Selected
Muscles
Sternocleidomastoid
(sternal portion) can
cause frontal
headaches, TMJ
pain, occipital
headaches.
Referral Pattern of Selected
Muscles
Gluteus minimus
trigger point
mimics L5-S1
radiculopathy
Referral Patterns of Selected
Muscles
Scalene
Trigger Points
Mimic C6
radiculopathy
Differential Diagnosis
Somatoform / Psychogenic
Polymyalgia Rheumatica (PMR nor PM&R)
Rheumatoid Arthritis, SLE
Polymyositis / Dermatomyositis
other myopathic process
Other more common musculoskeletal disorders
bursitis / tendinitis
Hypothyroid / Hyperparathyroid
Manifestations of common
bursitis and tendinitis syndromes
Affected Area or Condition
Shoulder Impingement
Epicondylitis
Wrist Tendinitis
De Quervains
Trochanteric Bursitis
Pes Anserine Bursitis
Achilles Tendinitis
Diagnostic Tests
CBC, P1, P2, P3, UA
ESR, RF, ANA
TFT, PTH (CA?)
CPK
Lyme, HIV
Syphillis, TB
MRI (Chiari, Syringomyelia,
Spinal Stenosis)
Pathophysiology
Muscle Abnormality
Central Neuro-Chemical Abnormality
Sleep Disturbance
Serotonin
Norepinephrine
Substance P
Endorphins
Hormonal / Immune System
GH, ACTH, Cortisol
Treatment
No specific treatment
Starts during first encounter
Establish diagnosis
Reassurance
Education
Identify major contributing factors
Medications
NSAIDs
Avoid Narcotics
Topicals
Tramadol (25mg qhs
100 mg tid)
TCAs
Flexeril
Ambien
Klonopin (1.0 mg qhs)
Sinemet
SSRIs
Buspar
Clonidine
Anticonvulsants
Neurontin 300 qhs to
600 tid
Xanax (.25 1.0 mg qhs)
TP Injecitions
< 25 gage needle
Lidocaine
Steroids
Dry Needle
Phynoxibenzamine
Behavioral Modification
Focus on well
behavior
Decrease sick
role / behavior
Exercise Prescription
Aerobic
conditioning
Water therapy
Too much vs.
Too Little