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AD_HTT_027_034___SEPT23_05 16/9/05 10:14 AM Page 27 How to Treat Pull-out section www.australiandoctor.com.au EARN CPD POINTS Complete How to Treat quizzes online (www.australiandoctor.com.au/cpd) or in every issue – see page 34. inside 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. www.australiandoctor.com.au 23 September 2005 | Australian Doctor | 27 AD_HTT_027_034___SEPT23_05 16/9/05 from page 27 10:14 AM Page 29 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. www.australiandoctor.com.au 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 23 September 2005 | Australian Doctor | 29 AD_HTT_027_034___SEPT23_05 16/9/05 10:14 AM Page 30 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. 30 | 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 www.australiandoctor.com.au 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). AD_HTT_027_034___SEPT23_05 16/9/05 10:14 AM Page 31 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 www.australiandoctor.com.au 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 cont’d next page 23 September 2005 | Australian Doctor | 31 AD_HTT_027_034___SEPT23_05 16/9/05 10:14 AM Page 32 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. cont’d page 34 AD_HTT_027_034___SEPT23_05 16/9/05 10:14 AM Page 34 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) with an X on this form. Fill in your contact details and return to us by fax or free post. FREE POST Australian Doctor Education Reply Paid 60416 Chatswood DC NSW 2067 ❏ 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 www.australiandoctor.com. au/cpd/ for immediate feedback 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 CONTACT DETAILS Dr: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phone: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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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 www.australiandoctor.com.au