9.08 Fibromyalgia (Trigger Points)
The patient, generally between 25 and 50 years old, will be
troubled with the gradual onset of fibromuscular pain that
at times can be immobilizing. There may be a previous history of acute strain, muscle spasm or nerve root irritation (e.g., whiplash injury of the neck or low back strain). The areas most commonly affected include the posterior muscles of the neck and
scapula, the soft tissues lateral to the thoracic and lumbar
spine, and the sacroiliac joints. The patient is often
depressed or under emotional or physical stress and often has associated fatigue with disturbed sleep as well as sensations of numbness or swelling in the hands and feet. Cold weather may be one of the precipitating causes of pain.
There should be no swelling, erythema or heat over the
painful areas, but applying pressure over the site with an
examining finger will cause the patient to wince with pain .
This tender " trigger pont" is usually no larger than your
finger tip and when pressed will cause local pain, referred
pain, or both.
What to do:
- When you find a trigger point, map out its exact location
(point of maximum tenderness) and place an X over the site
with a marker or ball point pen. If the trigger point is
diffuse there is no need to outline its location.
- Obtain a careful history and perform a general physical
exam to help exclude the possibility of a serious underlying
disorder such as rheumatoid arthritis or cancer.
- With any suspicion that an underlying problem exists,
obtain an x ray or an erythrocyte sedimentation rate. These
studies should both be normal in fibromyalgia.
- Where trigger points are diffuse, prescribe a nonsteroidal
anti-inflammatory such as naprosen (Anaprox) 275mg two tablets
stat then one qid or ibuprofen (Motril) 800mg stat then 600mg qid x 5 days. A muscle relaxant like cyclobenzaprine (Flexaril) may also be helpful.
- When a focal trigger point is present you can suggest to
the patient that he may get immediate relief with an
injection. Inject 2-5ml of l% xylocaine or loger-acting 0.5% bupivacaine along with 20-40mg of methylprednisolone (Depomedrol) or 2-5mg of triamcinolone (Aristospan) through the mark you placed on the skin, directly into the painful site. Be sure you are
not in a vessel and then "fan" the needle in all directions
while injecting the trigger point. In addition, to insure
total coverage, massage the area after the injection is
complete. The patient will often get complete or near-complete pain relief, which helps to confirm the diagnosis of fibromyalgia. The beneficial effect of this injection may last for weeks or months. A supplementary five day course of non-steroidal anti-inflammatories is optional.
- Moist hot compresses and massage may also be comforting to
the patient after discharge.
- Inform the patient that after trigger point injection there
may be a transient painful rebound. Anti-inflammatory
analgesics will help to reduce this potential discomfort.
- Provide followup care for patients in the event their
symptoms do not clear and they require further diagnostic
evaluation and therapy. For example, hypothyroidism and polymalgia rheumatica coexist with or predispose to fibromyalgia, or the patient may develop dermatomyositis.
What not to do:
- Do not attempt to inject a very diffuse trigger point (more than one square centimeter). Results are generally unsatisfactory.
- Do not prescribe narcotic analgesics or systemic steroids. They are no more effective and add side effects and the risk of dependence.
Although the pathophysiology of fibromyalgia is unknown it is a very real syndrome. Treatment may provide only partial symptomatic relief. True fibromyalgia syndrome is a chronic conditio requiring long term management that may include physical therapy, exercise, patient education and reassurance along with sleep-enhancing medications like low dose tricyclic antidepressants.
Emergency physicians often see trigger points associated with simple self-limiting regional myofascial pain syndromes which appear to arise from muscles, muscle-tendon junctions, or tendon-bone junctions. Myofascial disease can result in severe pain, but typically in a limited distribution and without the systemic feature of fatigue. When symptoms recur or persist after the basic therapy above, or are accompanied by generalized complaints, refer the patient to a rheumatologist or primary care physician.
When the quadratus lumborum muscle is involved there is
often confusion as to whether or not the patient has a
renal, abdominal, or pulmonary ailment. The reason for this
is the muscle's proximity to the flank and abdomen as well
as its attachment to the 12th rib, which when tender, can
create pleuritic symptoms. A careful physical exam, with
palpation, active contraction, and passive stretching of
this muscle reproducing symptoms, can save this patient from
a multitude of laboratory and x ray studies.
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD