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Fibromyalgia
Polymyalgia
rheumatica
Polymyositis
Myofascial pain
Chronic fatigue
syndrome
Background
MUSCLE pain is ubiquitous in medical practice. Depending on the
cause, it can vary in severity from
mild (for example, secondary to a
minor sprain) to severe (for example,
associated with malignant tumours).
It can also vary in degree and be systemic, iatrogenic (for example, secondary to statin medication) or
caused by trauma.
Skeletal muscle accounts for up
to 50% of body weight, with about
400 muscles performing multiple
functions. Hence it is not surprising
that muscle pain is the reason for a
significant number of medical consultations.
Medical practitioners often see
patients who present with medically unexplained physical symptoms. The challenge is to reach the
correct diagnosis, preferably early,
and then see the patient respond to
treatment, even if a cure is not
attainable.
Patients presenting with tired
and aching muscles that cannot be
explained by trauma, medication
or neurological or endocrine
causes are likely to be experiencing a systemic disorder such as
myofascial pain, fibromyalgia,
polymyalgia rheumatica, chronic
fatigue syndrome or polymyositis.
Although these conditions can be
disabling, it is important to reassure patients that they are not lifethreatening or deforming.
cont’d page 29
The author
ASSOCIATE PROFESSOR
NORM BROADHURST
is associate professor,
department of orthopaedics,
Flinders University, Bedford
Park; senior visiting medical
specialist, rehabilitation, Queen
Elizabeth Hospital, Woodville;
and in private practice in
Glenelg, SA.
Muscle pain
and weakness
*1
BACK IN BUSINESS, FULL-TIME
*IN DEPRESSED PATIENTS, EFEXOR-XR HELPS IMPROVE DAILY FUNCTIONING, INCLUDING HOME OR WORK ACTIVITIES.1
BEFORE PRESCRIBING, PLEASE REVIEW PRODUCT INFORMATION AND PBS INFORMATION IN THE PRIMARY ADVERTISEMENT IN THIS PUBLICATION. Reference: 1. Lenderking WR,
et al. J Clin Psychiatry 1999; 60: 157-163. Further information is available from Wyeth Australia Pty Limited. ABN 16 000 296 211. 17-19 Solent Circuit, Norwest Business Park, Baulkham Hills NSW 2153.
®Registered Trademark. WP2005123. McCann Healthcare WYE0307/7. 07/05.
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Are there any previous episodes of
similar symptoms? If so, how were
they treated?
n Is there any morning pain and stiffness?
n Is inflammation present?
n Does the pain get worse with activity?
n What makes the pain worse and
what eases it (such as position, activity, other treatments)?
n Has any medication (prescription or
over-the-counter) helped?
n Does the pain start in the morning
or with activity (inflammation vs
degenerative changes)?
n
Musculoskeletal examination
Always take a thorough history and
combine this information with your
knowledge of anatomy and biomechanics, if applicable. For example, a
fall on an outstretched hand can lead
to wrist, elbow and/or shoulder pain.
When assessing a patient, consider:
n What caused the pain. Was it
trauma? If so, what were the biomechanics involved?
n If there was no trauma, was the onset
gradual or sudden (weeks or
months)?
Most patients describe muscle pain,
fatigue and/or joint stiffness at various times in their lives and usually
such symptoms have a simple explanation.
Protracted muscle pain and tiredness that cannot be explained by
identifiable factors, including stress,
can be a puzzling presentation for
the GP.
Systemic disorders such as myofascial pain, fibromyalgia, polymyalgia
rheumatica, chronic fatigue syndrome
and polymyositis should be considered in the differential diagnosis.
Fibromyalgia
DURING the past three
decades, research has supported widespread muscle
pain and fatigue as the cardinal feature of fibromyalgia, previously known as
fibrositis, soft tissue rheumatism, tension myalgia or
chronic muscle pain syndrome.
In general, patients with
fibromyalgia have less disability but more pain than
patients with rheumatoid
arthritis.
Fibromyalgia is not an
inflammatory condition and
can now be differentiated
from other rheumatological
disease with an accuracy of
about 85% because of the
absence of inflammatory
markers or radiological
changes.
The diagnosis of fibromyalgia is made on the basis
of degree and constancy of
symptoms in the absence of
definable pathology. Critics
of the existence of this syndrome complain about the
absence of known physical
pathology but it should be
noted that conditions such
as irritable bowel syndrome
also have no demonstrable
pathology.
Low cervical
(anterior
aspects of
intertransverse
spaces of
C5-C7)
Occiput
(suboccipital
muscle
insertions)
Trapezius
(midpoint of
upper border)
Risk factors
Second rib
(second
costochondral
junctions)
Supraspinatus
(above medial
border of
scapular spine)
Lateral
epicondyle
(2cm distal to
epicondyles)
Gluteal
(upper outer
quadrant of
buttock)
Knee
(medial fat pad
proximal to
joint line)
Greater
trochanter
(posterior to
trochanteric
prominence)
Signs and symptoms
Patients’ symptoms vary
greatly from day to day and
over a single day.
Variation in symptoms
can be associated with
changes in stress, weather
conditions and physical and
mental activity.
Muscle pain and fatigue
wax and wane at the beginning of the illness and it
usually takes several months
for these symptoms to
become a constant part of
life.
Although light palpation
Females constitute 80-90%
of patients and the condition
is known to occur in close
relatives of affected patients.
In most cases age of onset
ranges from early to middle
adulthood.
All socioeconomic classes
can be affected and the condition may occur more often
in well-educated and motivated people.
It is difficult to know
whether sleeping difficulties
are a cause or a result of
fibromyalgia — people with
sleep disorders are known to
develop this condition.
Making the diagnosis
Prevalence
Fibromyalgia is estimated to
affect about 2% of the general population, but the incidence in patients presenting
to medical clinics can be as
high as 20%. Up to 90% of
patients with fibromyalgia
are female.
The condition also
appears to be more common
in patients with rheumatoid
and other autoimmune disorders (as a comorbidity)
than in the general population.
Low levels of serotonin and
tryptophan.
n Abnormalities in cytokine
function.
The usual search for a
cause related to a virus or
bacterium is generally illfounded, although fibromyalgia seems to occur more often
in patients with HIV and
hepatitis C infections than in
the general population.
n
Figure 1: Specific tender points in fibromyalgia.
of all muscles is likely to
elicit pain, diagnosis requires
identification of at least 11
out of 18 identified tender
points (figure 1).
Characteristic findings in
fibromyalgia include:
n Pain — neck, shoulder and
pelvic girdle musculature
are affected, as well as
upper and lower limbs.
Algometry, which measures pressure over an area
2
of 1cm , will produce pain
at pressures as low as
1-2kg.
n Fatigue — this is thought
to be partly due to sleep
disturbance that interrupts
non-REM sleep, causing
the patient to miss out on
deep restorative sleep.
n Stiffness — generally stiffness is greatest in the morning, but this does not worry
the patient as much as
fatigue and pain.
n Other symptoms — headaches; irritable bowel and
bladder; temporomandibular joint dysfunction; rest-
less legs; numbness and
tingling in hands and feet;
dry eyes, skin and mouth;
dizziness; and anxiety and
depression (this is common
and possibly related to
hormonal changes relating
to the hypothalamic-pituitary-adrenal axis). The
rate of depression is similar
to that seen in rheumatoid
arthritis.
Pathophysiology
A specific cause for fibromyalgia has not been discovered, but the pain in part
relates to central neural pain
pathway sensitisation as
well as the multiple factors
that govern central processing.
Patients with fibromyalgia
have been shown to have:
n Increased levels of substance P, a neurotransmitter in the CSF.
n Low levels of blood flow to
the thalamic region.
n Hypothalamic-pituitary axis
hypofunction.
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Because there is no single or
specific diagnostic test for
fibromyalgia, the diagnosis
is one of exclusion.
The condition can occur
with other diseases, making
diagnosis more difficult.
Symptoms of pain, fatigue
and stiffness as well as sleep
disturbance are known to
occur in several diseases that
can be given a definitive
diagnosis, including:
n Hypothyroidism.
n Polymyalgia rheumatica.
n Peripheral neuropathy.
n SLE.
n Multiple sclerosis.
n Rheumatoid arthritis.
It is important that these
potentially treatable conditions are not overlooked in a
patient presenting with such
symptoms.
If the GP is not confident
of diagnosis, referral to a
specialist may be appropriate to eliminate concurrent
disease. Imaging is of no
value in making the diagnosis but may identify concurrent early rheumatic disease
in some patients.
Fibromyalgia is not a progressive condition, but
patients become frustrated,
anxious and depressed as a
result of not being able to
do what they used to — life
can be a chore rather than a
joy. Many patients are satisfied with an explanation
about their condition and in
some cases join a support
group, but others seek
answers elsewhere.
Treatment
The usual medications for
pain, stiffness and fatigue are
unsuccessful in alleviating
the symptoms of patients
with fibromyalgia. Antidepressants in low doses (for
example, amitriptyline [Endep,
Tryptanol] 10mg at night, or
equivalent doses of doxepin
[Deptran, Sinequan] or nortriptyline [Allegron]) may
help to promote regular
sleep patterns.
Sertraline (Xydep, Zoloft)
and paroxetine (Aropax,
Paroxetine, Oxetine, Paxtine) may help when depression is present.
Tramadol (Tramadol,
Tramal, Zydol), gabapentin
(Gabapentin, Gabahexal,
Gantin, Neurontin, Nupentin, Pendine) and pregablin
(Lyrica) may improve pain
control.
Corticosteroids injected
into the tender muscles have
not been shown to be helpful.
Patients with fibromyalgia
experience significantly
reduced life potential and
enjoyment of life, so they
need social support from
family, friends and colleagues. Ongoing encouragement to pace activities can
help patients to set realistic
goals and participate in a
wide range of profitable pursuits.
A light program of gentle
aerobic exercises and stretching helps maintain flexibility and muscle tone and
should be encouraged.
The presence of very tender
areas in muscle, commonly
called trigger points, can be
treated with dry needling or
local anaesthetics (1% lignocaine) (see Myofascial pain,
‘Treatment’, page 32), followed by massage and
stretching.
Joining a fibromyalgia
support group can help the
patient to develop a greater
understanding of the disease
and also build new friendships.
cont’d next page
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How to treat – muscle pain and weakness
from previous page
Where possible, family and friends
can help by encouraging:
n Stress reduction — reducing activities at home or at work and maintaining as much of their former
functioning as possible.
n Adequate sleep — maintaining a
regular sleeping pattern and ensuring adequate sleep time.
n Gentle regular exercise — this
minimises the pain. Walking,
swimming, cycling and water aerobics are worthwhile pursuits,
provided they are not overdone.
n Other beneficial lifestyle measures
— eating a balanced diet, limiting
caffeine intake and prioritising
enjoyable activities.
Specific medications can help
Characteristics of fibromyalgia
Prognosis
Three months of diffuse muscle pain
and fatigue not related to any
precipitating event.
■ Reproduction of pain by light palpation,
ie, palpation that would not normally be
uncomfortable.
■ Absence of any relevant laboratory or
imaging investigations to explain the
signs and symptoms.
■
Prognosis varies and depends on
the severity of symptoms and the
degree of family and community
support.
Making lifestyle changes and
maintaining a hopeful attitude
improves prognosis.
One study reported that 47% of
patients no longer fulfilled the
diagnostic requirements for
fibromyalgia two years after treatment and 24% went into apparent remission.1
However, another study
reported that 17% of patients
stopped work and 30% had to
change their employment to
remain functional.2
Self-care
The patient should not be allowed
to develop a perpetual ‘sick’ role.
restore normality when there are
complications, such as treating dry
eyes with eye drops and irritable
bowel symptoms with diet and
antispasmodics.
Complementary therapies
Although there is no cure for the
condition, many complementary
therapies are available and some
can help minimise the patient’s
symptoms and improve their quality of life.
Massage can help to improve
patients’ blood flow, relax muscles,
reduce resting heart rate and
improve functioning. Acupressure
or acupuncture may be of value in
some patients.
Polymyalgia rheumatica
POLYMYALGIA rheumatica
is a rheumatic disorder characterised by muscle pain and
joint stiffness. Although it may
appear suddenly, the usual
onset is gradual. Muscle pain
develops in the neck, shoulder
and pelvic girdle musculature,
accompanied by morning stiffness that lasts an hour or so.
Low-grade synovitis in peripheral joints is increasingly
recognised as part of this condition.
Figure 2: Giant cell arteritis. 1. Verhoeff-Van Geison stain showing breakdown of elastin in the
intima. 2. Temporal artery involvement.
L shows the narrowed lumen of the temporal artery with increase of intima involving giant cells
(G), moving out to inflammatory cells and the adventitia (A).
Elastic
Lamina
L
Epidemiology
Polymyalgia rheumatica is
rare under age 50, relatively
common after age 60, and
women are twice as likely as
men to be affected. Incidence
varies from country to country but is about 50 per
100,000 persons, with a
higher incidence in northern
European countries. It is
rarely seen in the AfricanAmerican population.
1
A
L
Pathophysiology
The cause of polymyalgia
rheumatica is unknown. It is
usually a self-limiting disease
of 1-3 years’ duration. A
virus may be implicated
because the prevalence of
antibodies to adenovirus and
respiratory syncytial virus
are higher in patients with
polymyalgia rheumatica
than in the general population. Occurrence in siblings
also suggests a genetic predisposition.
G
2
History
Patients are usually in good
health before the onset of
bilateral shoulder or pelvic
pain or stiffness. Low-grade
fever, mild weight loss,
malaise, fatigue and depression are recognised associations. Difficulties in rising
from a sitting, lying or
squatting position and in
completing the activities of
daily living are frequently
reported.
Patients often complain of
muscle stiffness after periods
of prolonged inactivity, such
as lying down during the
day. They may describe feeling as if they have had an
exhaustive workout, such as
running a marathon.
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| Australian Doctor | 23 September 2005
A
Examination
Patients often have a fatigued
appearance and may have
low-grade fever.
Muscle strength may be
normal when symptoms
begin but there will be pain
and decreased range of
movement on flexion and
abduction of the upper limbs
and hips, mainly due to transient non-reactive synovitis.
The limitation of range of
movement is largely due to
proximal muscle weakness,
and contractures when present. Palpation of shoulder
girdle and pelvic musculature
reveals tenderness and, with
the passage of time, disuse
atrophy of the proximal muscles may be seen.
Synovitis of more peripheral joints can cause diagnostic confusion with rheumatoid arthritis and may mimic
the classic picture of polymyalgia rheumatica in the
elderly.
Investigations
ESR is the most sensitive diagnostic test for polymyalgia
rheumatica but it is not specific. The reading is usually
>40mm/hour, but can be
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normal in fewer than 10% of
patients. C-reactive protein
levels often parallel the ESR,
and an FBC may reveal a mild
normocytic-normochromic anaemia. In the absence of additional symptoms further
blood tests or imaging are
not indicated.
In the elderly an elevated
rheumatoid factor level suggests, but does not prove, that
symptoms thought to be from
polymyalgia rheumatica are in
fact due to rheumatoid arthritis. A small number of patients
with polymyalgia rheumatica
will go on to manifest
rheumatoid arthritis.
When polymyalgia rheumatica is confirmed the patient
needs to be assessed for signs
or symptoms of giant cell
arteritis, which occurs in
about 15% of patients.
Overall, 50% of patients
with giant cell arteritis also
have polymyalgia rheumatica,
and the ESR is higher in
patients with both conditions.
In these cases patients are likely
to complain of headaches as
the predominant symptom.
In rare cases, giant cell
arteritis can be complicated by
ocular involvement, which
may result in permanent
blindness, primarily due to
ischaemic neuritis of the optic
nerve.
The clinician should always
enquire about symptoms that
may indicate temporal artery
involvement. A temporal
artery biopsy is not necessary
in mild cases of polymyalgia
rheumatica, as giant cell
arteritis is unlikely.
However, patients with
moderate to severe polymyalgia rheumatica are more likely
to have involvement of the
temporal artery, and confirmation by biopsy should be
undertaken (figure 2). In some
cases, biopsy may not be conclusive because of segmental
involvement of the artery.
Treatment
Mild cases may respond to
NSAIDs but the usual treatment required for a response
is 15-20mg prednisolone
daily or, if giant cell arteritis
is present, 60mg daily.
The response is usually
dramatic, with significant
relief reported overnight.
When an unrelated tendon
pathology such as supraspinatus tendonitis has complicated
the presentation, the response
may seem to be delayed.
When reviewing the patient
a day or two after treatment
has started, the dose of steroid
should be titrated to the
lowest dose that controls
symptoms. Treatment with
immunosuppressive agents
has no advantage over corticosteroids. However, there
may be specific circumstances
when their use is preferable,
such as in patients with diabetes.
Both polymyalgia rheumatica and giant cell arteritis tend
to run a self-limiting course
lasting 2-3 years, but marginal
symptoms may persist for
many years.
Prognosis
Polymyalgia rheumatica
without temporal artery
involvement has an excellent
prognosis, even though
relapse can occur if corticosteroid dose reduction is too
rapid. Relapse can be treated
by increasing the dose then
resuming a reduction sequence. An ophthalmologist
must be involved in management when giant cell arteritis
is present.
Ongoing care
The long duration of corticosteroid treatment and the preponderance of elderly women
with the condition mean that
clinicians should be alert to
the development of osteoporosis. Bone mineral density
studies should be done 3-6
months after starting steroid
treatment, and calcium and
vitamin D supplementation
initiated early in treatment.
Bisphosphonates can also be
used when there is deterioration in bone density.
The patient should be
encouraged to participate in
regular weight-bearing exercise and have an appropriate
well-balanced diet. Another
complication of prolonged
use of corticosteroids is avascular necrosis (see Author’s
case studies, page 32).
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Polymyositis
POLYMYOSITIS is an idiopathic, autoimmune inflammatory myopathy of unknown cause in which skeletal
muscle is damaged, causing
symmetric proximal muscle
weakness. In the one-third of
patients who also have characteristic skin eruptions in
hands, shoulders and face the
condition is called dermatomyositis.
The variable signs and
symptoms of this disease have
resulted in a classification by
Bohan and Peter3 into:
n Type I — primary idiopathic
polymyositis (about onethird).
n Type II — primary idiopathic dermatomyositis
(about one-third).
n Type III — type I or II associated with malignancy
(<10%).
n Type IV — type I or II in
childhood (about 10%).
n Type V — type I or II associated with collagen and vascular diseases (about 10%).
n Type VI — a miscellaneous
group including inclusionbody myositis. This type
overlaps with connective
tissue diseases such as scleroderma, rheumatoid arthritis and SLE. The more
recently recognised and rare
anti-synthetase syndromes
represent another group.
Interstitial pneumonitis and
aspiration pneumonia.
n Exertional dyspnoea.
n CHF and pericarditis.
n Arthralgias involving knees,
wrists and hands.
The differential diagnoses
include muscular atrophies
(for example, neuropathies,
myasthenia gravis), endocrine
disorders (for example, thyroid and parathyroid dysfunction, electrolyte disorders,
Cushing’s syndrome), metabolic disorders (for example,
McArdle disease, maltose
deficiency) and drug-induced
myopathy (for example,
caused by alcohol, antimalarials, statins, colchicine or
clofibrate).
Investigations should
include:
n FBC, multiple biochemical
analysis (MBA 20) and
rheumatoid screens (usually
within normal limits but
may be marginally raised).
n Creatine kinase — always
significantly elevated.
n Extractable nuclear antigens
(ENA) screen to help
exclude anti-synthetase syndrome.
n An EMG showing the diagnostic triad of:
— polyphasic motor-unit
potential
— spontaneous fibrillations
— bizarre repetitive discharges in the absence of
a neuropathy (figure 3).
n Muscle biopsy — shows
infiltration of inflammatory
cells and muscle fibre
destruction with phagocytosis (figure 4). The muscle
biopsy should be taken from
the opposite side on which
any EMG was measured,
because of possible muscle
injury.
n
Figure 3: Electromyographic activity in normal and myositic muscle.
4
(Adapted from O’Leary PA, et al. )
Normal
Polymyositis
Needle insertion
100 µV
0.1 sec
Resting muscle
50 µV
0.001 sec
Voluntary contraction
500 µV
0.001 sec
Figure 4: Lymphocytic infiltration of muscle, consistent with
polymyositis.
(Image courtesy of Institute of Medical and Veterinary Science, Adelaide.)
Clinical background
Polymyositis is an uncommon
disease occurring in about
one in a million people, with
a lower incidence in the
Japanese population and a
higher incidence in AfricanAmericans. Women are affected more often than men in a
ratio of 2:1, except in type VI,
where males are affected twice
as often as women. Age of
adult onset is generally over
20 years and peaks between
45 and 60 years. Type II is
the main entity in children.
Presentation
The onset of muscle weakness
is usually slow, occurring over
3-6 months. When the hippelvic musculature is affected
the patient notices increasing
difficulty in rising from squatting, kneeling or sitting. When
shoulder girdle muscles are
involved, there is difficulty
reaching to or above head
height for actions such as
washing or combing the hair.
Pharyngeal muscle weak-
ness may cause dysphonia and
difficulty in swallowing. The
systemic nature of the condition produces constitutional
manifestations, including
morning stiffness, fatigue,
anorexia, weight loss and lowgrade fever.
Physical examination
demonstrates a symmetric
weakness of the proximal
muscles, and weakness may
also be seen in neck flexors.
Gait is slow and waddling,
with affected muscles tender
on palpation.
Pain is not a characteristic
feature of polymyositis but
can occur late in a small percentage of patients, providing
a picture confused with
polymyalgia rheumatica. Pain
may be more prominent in
patients with dermatomyositis.
Complications
Other musculoskeletal structures become involved as the
disease progresses. This causes:
n Oesophageal weakness and
dysphagia.
Treatment
Because treatment has not
been subjected to any randomised controlled trials, it
must be empirical and usually
begins with prednisolone
1mg/kg/day until the creatine
kinase level returns to normal.
This takes about 6-8 weeks
on average but may take several months. The paediatric
dose is half the adult dose.
Regular monitoring for corticosteroid side effects is necessary from the time of initial
treatment and during steroid
dose reduction.
In severe cases a cytotoxic
drug can be used in combination with a corticosteroid.
Methotrexate is the drug used
most often, starting with a
dose of 7.5mg/week and
adjusting the dose according
to response.
As the inflammatory condition subsides concurrent
graded exercises help to
restore strength and improve
mobility. As the condition
improves, patients can graduate to aerobic exercises.
Calcium and vitamin D
supplementation is suggested
and, when osteoporosis is present, oral bisphosphonates can
be used. Some experts prefer
to use bisphosphonates to prevent osteoporosis.
Use of proton-pump inhibitors should also be considered if there is evidence of
oesophageal reflux, which
may or may not be secondary
to use of bisphosphonates.
Prognosis
Recent studies report that 7080% of patients with polymyositis have a normal life
span. The death rate from pulmonary, renal or cardiac complications is about four times
that of the unaffected population.
Females, African-Americans,
patients aged ≥45 at onset
and those more severely
affected have a poorer prognosis. Children have a better
prognosis than adults.
Myofascial pain
SOME types of muscle pain have
specific referred pain patterns, which
were substantiated before WWII and
further defined in the latter part of
last century. Muscle pain associated
with tender thickened areas called
taut bands, with specific patterns of
referred pain, is known as myofascial
pain.
It is localised, unilateral, has an
equal sex distribution and is not
associated with fatigue, stiffness or
generalised aching. In patients with
myofascial pain the pain is deep and
aching and can be readily reproduced
by relatively light palpation over the
hypersensitive area of muscle.
Although it is markedly different
from fibromyalgia (table 1), there is
some degree of overlap, which can
cause a diagnostic challenge on first
presentation. This condition can also
be experienced in patients with
chronic fatigue syndrome.
Prevalence
Myofascial pain occurs in about
Table 1: Differential features of fibromyalgia and
myofascial pain*
Feature
Fibromyalgia
Myofascial pain
Pain
Diffuse
Local
Fatigue
Common
Uncommon
Morning stiffness
Common
Uncommon
Tender points
Diffuse
Local
Treatment
Exercise, sleep medication
Local measures
Prognosis
Tends to be chronic
Resolves with treatment
but may recur
5
resistance to an electric current
over the region of the tender trigger
point has also been documented.
In some patients, laboratory
findings show conditions such as
anaemia and low levels of calcium,
potassium, iron and vitamins C, B2,
B6 and B12. Hypothyroidism and
hypoglycaemia may also play a role
occasionally.
Patients with myofascial pain
probably have a reduced threshold
to pain.
*Adapted from Arthritis Foundation USA, 1993
Signs and symptoms
15% of the general population,
with males and females equally
affected. It is most common in the
30-55-year age group and is less
frequent with increasing age.
Pathophysiology
There are no laboratory tests to
confirm the diagnosis of myofascial pain. Attempts to identify pain
morphology using ultrasound
imaging have not been successful,
which means that, as in fibromyalgia, the diagnosis is clinical. The
only role for imaging is to help rule
out other causes for pain such as
joint disease.
In patients with fibromyalgia,
EMG studies have demonstrated
excess electrical activity over the
hyper-irritable areas, probably
related to the motor end-plate
potentials of the affected muscles
firing randomly. Lowered skin
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Patients complain of muscle pain
that may be diffuse or limited to a
specific area. There is often a sensory disturbance, such as numbness
distal to the site of pain.
Onset may be secondary to
injury or related to working environment issues, such as poor posture and muscle overuse. Sleep disturbance is reported, either because
of difficulty finding a comfortable
position or waking during sleep
after rolling onto the painful side
or area.
When examining the painful
muscle, the GP should find:
■ Taut painful band(s) that produce
muscle shortening.
■ A specific tender area within the
taut band, often referred to as a
trigger point. Trigger points have a
70-80% correspondence with classical acupuncture pain points
known as Ah Shi.
■ Pressure over the tender area
reproduces the patient’s pain and
the referred pain pattern. The
sudden tightening of the muscles is
referred to as a ‘jump sign’.
■ Restricted range of motion of the
related joint, due to the tight band.
■ No evidence of atrophy.
■ Occasionally a local twitch
response, caused by the brisk contraction of muscle fibres in or
around the taut band.
A pressure algometer can be used
to identify the specific tender areas
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How to treat – muscle pain and weakness
from previous page
within the taut band. Pressure
responses are similar to those in
patients with fibromyalgia. Patients
with myofascial pain may complain
of associated localised autonomic
dysfunction such as vasoconstriction, pilomotor response, sweating
and temperature changes.
Figure 5: Pneumothorax secondary
to dry needling of the left erector
spinae muscles.
Differential diagnoses
The differential diagnoses of
myofascial pain include:
■ Radicular pain from neck or
shoulder.
■ Z-joint pathology.
■ Fibromyalgia.
■ Rheumatoid arthritis.
■ Thoracic outlet syndrome.
Treatment
NSAIDs and muscle relaxants have
not been shown to be helpful as
the sole treatment but they may be
used as an adjunct to a more active
treatment program. If sleep disturbance is present, a low dose of an
antidepressant such as amitriptyline (10mg at night) for a short
period may help improve the sleep
cycle.
An active physical regimen is
aimed at restoring the balance in
affected and non-affected muscles
working as a functional unit. The
aim of physiotherapy and massage
is to restore normal muscle length
and function.
Needling the trigger point with
an injecting agent such as local
anaesthetic, or dry needling (twiddling an acupuncture needle a few
times after insertion into the trigger
point) helps break up the taut
band. The patient experiences their
pain response for several seconds
before improvement.
Occasionally, when the pain
does not improve, it may be necessary to remove the needle and reinsert it; this gives the muscle time
to relax. Reinsertion is much less
painful and pain usually resolves
subsequently. Needling must be
followed by stretching of the
affected muscle along the line of
muscle fibres.
Local anaesthetic has some
advantage over dry needling because
the pain is reduced immediately, but
the injected material can be more
irritating to the patient than the dry
acupuncture needle. One study
found that pain persisted for 48
hours before relief in all patients
treated with dry needling, compared
with 47% of those received local
anaesthetic.6
Recalcitrant taut bands have been
successfully treated using botulinum
toxin, which blocks the release of
acetylcholine at the neuromuscular
junction. Pain relief with botulinum
toxin may be curative or may
require treatment at eight-week
intervals.
Prognosis
Resolution of myofascial pain is
good when treatment is started in
the acute phase and aggravating
factors are eliminated. Treatment
becomes more difficult as chronicity increases. Attention to massage
and regular stretching improves the
prognosis.
Complications
Complications of needling are rare
and depend on the area being
injected. Local pain and bruising
are to be expected after some treatments. Penetration of an underlying structure in dry needling may
cause a neural irritation or a pneumothorax (figure 5).
Chronic fatigue syndrome
TIREDNESS, or fatigue, is
widespread in the Western
world and many illnesses are
associated with prolonged
periods of lethargy during
the illness and the recovery
period.
Explained fatigue has a
determined endpoint, but
people who suffer from
unexplained fatigue may be
diagnosed as having chronic
fatigue syndrome. This diagnosis should only be made
in the absence of medical
and/or psychiatric causes for
chronic fatigue lasting more
than six months.
No signs, pathognomonic
diagnostic tests or definitive
treatments are available for
the condition. Subgroupings
within chronic fatigue syndrome are suggested but not
widely adopted. The condition can coexist with fibromylagia and in up to two-thirds
of adults experiencing, or
who have experienced, an
episode of major depression.
Prevalence
In the 1980s chronic fatigue
syndrome was considered to
be a condition of well-educated, well-off women in their
30s and 40s. It is now considered to cross all economic
and social groups. The US
Centers for Disease Control
and Prevention estimates the
incidence at one in 600, with
women 2-3 times as likely as
men to have the condition.
Diagnosis
The diagnosis can only be
made after a thorough medical and psychosocial history-
taking and physical examination to confirm or exclude any
disease state. A minimal battery of laboratory tests including ESR, FBC, TSH, MBA 20
and a urinalysis should be
within normal limits.
A patient with chronic
fatigue syndrome will have:
■ Unexplained, persistent or
relapsing chronic fatigue,
with exertion not resolved
by rest, and accompanied
by diminished occupational, educational, social
and personal activities.
■ Concurrent (four or more)
symptoms including loss of
concentration, sore throat,
tender cervical and axillary
lymph nodes, widespread
muscle pain, multiple joint
pain without swelling,
headaches of a new type
and unrefreshing sleep.
Treatment
No definitive treatment is
recommended, but antidepressants can help improve
sleep and relieve generalised
mild muscle pain. Emotional
support from family and
friends, as well as a chronic
fatigue syndrome support
group, can be helpful. Other
aspects of management
include:
■ Eating a balanced diet and
getting adequate rest.
■ Exercising regularly, short of
increasing the fatigue.
■ Pacing activities to accomplish goals.
Prognosis
Few patients with chronic
fatigue syndrome return to
pre-onset activity levels.
Author’s case studies
Long-term muscle pain after a
strain
MS AM, 32 and a registered nurse,
sustained an injury low in the right
lumbosacral area when transferring
a patient. She described a burning
feeling and pointed to the right buttock as the site of pain. Initially, the
pain settled with rest and some nonspecific physiotherapy.
Two later episodes nearly 12
months apart resulted in a constant
low-grade ache. She rated the pain
as 2-3/10, increasing with sporting
activities to 6-7/10. The pain was
accompanied by a diffuse, deep, dull
ache at the back of the leg, extending
to the knee.
With the onset of the referred pain
she consulted a spinal surgeon, who
ordered an MRI of the lumbar spine
that was reported as normal. Lower
lumbar facets were injected, with no
resolution of her pain. In frustration
AM tried chiropractic and physiotherapy treatment on many occasions
but considered the response as variable and of short duration.
Several years after the original
injury, she was seen at a musculoskeletal clinic in a public hospital.
Examination revealed she had good
posture, a BMI of 27, and all lumbar
spine and hip movements within
normal limits, as was straight-leg
raising.
Palpation of buttock structures
32
| Australian Doctor | 23 September 2005
Salient features of disorders involving muscle pain
Disease/
syndrome
Systemic Age
Male:female
ratio
Diagnostic
tests
Onset
Medication
Rehabilitation
regimen
Prognosis
Fibromyalgia
Yes
Young to
middle-aged
1:8
Nil
Gradual, over
several months
Amitriptyline
10mg nocte
Patience, keep
active
Generally poor
Myofascial pain
Yes
35-55
1:1
Nil
Gradual, may be NSAIDs (mild
related to work
cases), dry needling,
injection of trigger
points
Stretching,
mobilising, avoiding
precipitating
causes
Good if treated
early
Polymyalgia
rheumatica
Yes
>50
1:2
ESR >40mm/
hour, response
to steroids
Usually gradual
but can be
sudden
Prednisolone
20mg initially,
tapering down
Prednisolone
Good
(reducing dose);
2-3 years to resolution
Polymyositis
Yes
Usually 45+,
occasionally
in childhood
1:2
Large rise in
creatine kinase
level, specific
EMG pattern,
characteristic
muscle biopsy
Gradual
weakness
Prednisolone
1mg/kg/day, may
need methotrexate
>7.5mg/week
Drug maintenance,
maintain a level
of fitness — up
to three years
Generally good
Chronic fatigue
syndrome
Yes
Any age
1:2
Nil
Sudden onset
of fatigue
Amitriptyline
10mg at night
may help
Keep active, support
and patience
Poor
reproduced low-grade muscle ache
not reflective of her reported symptoms. However, deep palpation at
the right sciatic notch, greater
trochanter and the tissue between
reproduced her pain, and downward
pressure between these two landmarks reproduced her referred pain.
A diagnosis of myofascial pain
within the right piriformis muscle
was made. Ms AM underwent deep
massage, stretching and injection to
the insertions of the piriformis
muscle under image control. She
experienced good relief.
Persisting muscle ache with no
identifiable disease
Ms TM, 22 and previously an active
student, did well at school and
started tertiary studies with enthusiasm. Toward the end of her first
year, after an episode of influenza,
she felt tired and experienced muscle
www.australiandoctor.com.au
aches even with mild exertion. She
thought this was normal so she continued her course but found study
and keeping up with her friends difficult.
Visits to her local GP resulted in a
series of blood investigations, all of
which were normal, as were her vital
signs. Movements of major joints
were a little stiff and uncomfortable,
but she was able to achieve a full
range of movement. The muscles in
her legs and arms were very tender.
At a later visit, a creatine kinase
was done, as well as a repeat of the
ESR and C-reactive protein, all of
which were normal.
On the basis of her history, 18
months of symptoms, which had
plateaued, and the absence of any
identifiable disease, she was diagnosed as having fibromyalgia and
counselled accordingly.
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How to treat – muscle pain and weakness
from page 32
Relief from neck/shoulder pain with
corticosteroids — but at what cost?
Mr AK, 67 and retired, described waking
with morning pain and stiffness that lasted
about an hour. His symptoms, which
began a few years ago, were most noticeable in the upper girdle structures and
neck. Initially he put this down to old age
and thought ‘taking it easy’ would help.
At the first consultation with his local
GP he was told he had a “bit of arthritis”
and was prescribed NSAIDs. Symptoms
persisted unabated so he returned to the
GP, who then ordered an ESR, which
was reported as 65mm/hour, and a
rheumatoid factor test, which was
normal.
On the basis of his symptoms and the
raised ESR, polymyalgia rheumatica was
diagnosed. Mr AK was treated with prednisolone 20mg daily. When reviewed a
few days later he reported an excellent
response. He was managed with a reducing dose until a stable level of 6mg daily
was achieved, and remained stable on this
for about three years, at which point it
was able to be withdrawn.
About eight weeks after withdrawal,
Mr AK complained of right hip pain and
difficulty in dressing, walking and sleeping. X-ray of the hip was normal. When
reviewed six weeks later Mr AK complained of increasing pain and stiffness. A
repeat X-ray showed severe osteoarthritis
and an MRI confirmed avascular necrosis secondary to his corticosteroid treatment (figure 6). Happy endings do not
always occur.
Figure 6: Rapid destruction of a hip joint in an elderly man, due
to avascular necrosis.
Questions for the author
DR ALAN WRIGHT
South Lake, WA
Case study
MRS VC, 49, has had muscle
pain for many years. In 1991
she complained of right
shoulder and upper-limb pain
that showed little response to
NSAIDs, physiotherapy and
exercise. The pain became
more generalised over the
next year and extended to her
shoulder girdle, neck, lower
back and pelvic girdle.
All investigations were
normal apart from mild
degeneration of the left hip
and cervical spine. Referral to
a rheumatologist resulted in
a diagnosis of fibromyalgia
but no subsequent improvement of symptoms, and she
did not return to see him.
Similar outcomes followed
referral to pain management
clinics and clinical psychologists. Whenever Mrs VC is
told that there is no quick fix
and that management will
require patience, exercise,
analgesia and time, she looks
for someone else to resolve
the problem.
She worked for a time as a
library assistant, but found
that carrying books aggravated her symptoms. She was
rehabilitated as a florist but
the long hours and her persistent tiredness made life difficult.
Her tiredness is secondary
to her discomfort and the
stress of running her business:
References
she has been unable to take a
holiday for several years.
She is currently managed
with Tramadol 400mg daily
and Efexor 300mg daily. She
has been encouraged to take
up and persist with a walking program and to lose
weight.
One of the major difficulties of management is that she
will persist with analgesia and
antidepressants but not with
physical activities because of
discomfort. She experiences
physical inertia and finds
comfort in eating.
She also has a stressful
occupation, with periods of
high activity when she cannot
keep up with the demand,
followed by periods of muchreduced activity when it is difficult to pay the bills.
Management of her case
requires patience and sympa-
thy on the part of her GP,
sometimes made difficult by
her lack of compliance and
missed appointments.
Questions for the author
Is there any particular personality type associated with
the development of fibromyalgia?
No.
Mrs VC cannot access gabapentin because of cost and
because she is not a Department of Veterans’ Affairs
patient. Is there any possibility
of a listing soon, or is there an
accessible alternative?
Probably not. Pregablin
may be more specific but is
also expensive. A drug company may give a few weeks
of samples but there is no
proof that membrane stabilisers help all patients.
How To Treat Quiz
INSTRUCTIONS
Muscle pain and weakness
— 23 September 2005
FAX BACK
Photocopy form
and fax to
(02) 9422 2844
1. Claire, 60, presents with pain in her
shoulders and neck of three months’
duration. Which THREE symptoms would
make fibromyalgia a likely diagnosis?
❏ a) Pain that varies from day to day and is
worse when the patient is stressed
❏ b) Pain that began intermittently but has
become more constant
❏ c) Stiffness on waking that worsens during
the day and is the main symptom
❏ d) Tiredness unrelieved by sleep
2. Muscle pain and fatigue are Claire’s
major symptoms and her symptom review
is otherwise unremarkable. Which THREE
illnesses would you be most likely to
consider in the differential diagnosis?
❏ a) Polymyalgia rheumatica
❏ b) Hypothyroidism
❏ c) SLE
❏ d) Polymyositis
3. Which ONE of the following drug
treatments would you be most likely to
recommend for fibromyalgia?
❏ a) Antidepressants
❏ b) Anti-inflammatories
❏ c) Low-dose oral prednisolone titrated to
symptoms
❏ d) Corticosteroid injections into trigger
points
4. Nola, 65, was well until two months ago.
She now complains that she feels “wrung
out” and can’t even hang the washing on
the line. Which THREE symptoms would
make polymyalgia rheumatica the most
likely diagnosis?
❏ a) Weight loss
❏ b) Morning stiffness
❏ c) Wrist stiffness and pain
❏ d) Alternating constipation and diarrhoea
5. Which THREE clinical findings in Nola
would be consistent with a diagnosis of
polymyalgia rheumatica?
❏ a) Bruising
❏ b) Oral temperature of 37.9°C
General questions for the
author
Of the patients with fibromyalgia who go into remission, how many remain in
remission?
This is variable. Some
patients report resolution in
2-3 years; others experience
prolonged disease.
In myofascial pain there
can be an association with
some biochemical disorders, low vitamin levels
and anaemia. If these are
corrected, what happens to
the myofascial pain? What
is the natural history of
myofascial pain if left
untreated?
There are numerous diets
and treatments available on
the Internet for these pain
syndromes, but good efficacy data are lacking.
1. Granges G, et al. Fibromyalgia
syndrome: assessment of the
severity of the condition two years
after diagnosis. Journal of
Rheumatology 1991; 21:523-29.
2. Russell IJ. Fibromyalgia
syndrome. Diagnosis, pathogenesis
and management. Physical
Medicine Rehabilitation Clinics of
North America 1997; 8:213-26.
3. Bohan A, Peter JB. Polymyositis
and dermatomyositis (first of two
parts). New England Journal of
Medicine 1975; 292:344-47.
4. O’Leary PA, et al. Examination
in Neurology. 7th edition. Mayo
Clinic, 1998, p369.
5. Arthritis Foundation USA.
Primer on the Rheumatic
Diseases. 10th edition. Arthritis
Foundation USA, 1993, p227.
6. Esenyl M, et al. Treatment of
myofascial pain. American
Journal of Physical Medicine and
Rehabilitation 2000; 79:48-52.
Further reading
Harris ED Jr, et al (eds). Kelley’s
Textbook of Rheumatology. 7th
edition. Elsevier Saunders, 2005.
Complete this quiz to earn 2 CPD points and/or 2 PDP points by marking the correct answer(s)
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❏ c) Wasting of the shoulder girdle
❏ d) Boggy swelling around the wrists
6. Which ONE of the following tests is most
important in establishing a diagnosis?
❏ a) Antinuclear antibody
❏ b) X-rays of shoulder girdle
❏ c) ESR
❏ d) Electromyography
7. Nola also complains of headaches and
you suspect giant cell arteritis. Which TWO
statements about investigation and
treatment of giant cell arteritis are correct?
❏ a) You should withhold treatment until the
results of temporal artery biopsy are known
❏ b) A very high ESR would increase your
suspicion of the diagnosis
❏ c) You should enquire about jaw
claudication
❏ d) If temporal artery biopsy is negative,
cerebral CT with contrast is indicated
8. Giant cell arteritis is confirmed on Nola’s
ONLINE
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temporal artery biopsy. Which THREE
strategies are appropriate in Nola’s
immediate and long-term management?
❏ a) Prednisolone 20mg daily
❏ b) Bone mineral density studies
❏ c) Calcium and vitamin D supplementation
❏ d) Blood sugar levels
9. Shaun, 58, presents with muscle
weakness that has slowly worsened over
the past three months. Which TWO
symptoms are most typical of
polymyositis?
❏ a) Symmetrical proximal muscle weakness
❏ b) High-stepping gait
❏ c) Difficulty swallowing
❏ d) Pain in the shoulders and hips
10. Which ONE investigation is likely to be
most helpful in diagnosing polymyositis?
❏ a) FBC
❏ b) Multiple biochemical analysis (MBA 20)
❏ c) Creatine kinase
❏ d) C-reactive protein
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HOW TO TREAT Editor: Dr Lynn Buglar
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Quiz: Dr Annette Katelaris
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Your CPD activity will be updated on your RACGP records every January, April, July and October.
NEXT WEEK The next How To Treat focuses on the increasingly prevalent problem of myopia. The author is Dr Kathy Rose, researcher and lecturer at the school of applied vision sciences, faculty of
health sciences, University of Sydney, and a chief investigator and project co-ordinator for the Sydney Myopia Study.
34
| Australian Doctor | 23 September 2005
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