eMedicine Specialties > Rheumatology > Soft Tissue and Regional Rheumatic Disease

Nonarticular Rheumatism/Regional Pain Syndrome: Follow-up

Author: Daniel Muller, MD, PhD, Department of Internal Medicine, Section of Rheumatology, Associate Professor, University of Wisconsin at Madison
Contributor Information and Disclosures

Updated: Nov 5, 2007

Follow-up

Further Outpatient Care

  • Aerobic exercise
    • Exercise helps decrease the symptoms of fibromyalgia syndrome; however, too much exercise results in increased symptoms that are often severe. This can lead to a cycle of muscle disuse.
    • In one study, 9 of 16 patients worsened or reported no change after a 14-week aerobic training intervention; however, 3 of the 16 patients were able to maintain a program of aerobic exercise; 4 years later, none of these patients fulfilled criteria for fibromyalgia.12
    • Aerobic therapy in a warm-water pool may be helpful, particularly for severe cases.13  
    • Hoffman recently published a detailed program of graded exercise for fibromyalgia.5  
  • Physical therapy
    • Restoration of muscle balance, stretching, and local therapy with heat and cold can be helpful. In 1996, Sheon et al published an excellent discussion of physical treatment modalities for fibromyalgia syndrome, tendonitis, and bursitis.14
    • Transcutaneous electrical nerve stimulation (TENS) may provide symptomatic relief in some cases.15
  • Subcutaneous tender-point injections of lidocaine may be mildly helpful, although dry needling or sodium chloride solution may also work. Corticosteroids should be avoided in fibromyalgia.
  • EMG biofeedback and hypnotherapy have been helpful in controlled studies.16,17
  • Psychotherapy: Fibromyalgia and all chronic tendonitis-bursitis disorders (tension-myalgia syndromes) may be conditions in which patients substitute physical pain for emotional pain, as advocated in the book by John Sarno, MD, The Mindbody Prescription: Healing the Body, Healing the Pain. Nancy Selfridge, MD, and Franklynn Peterson wrote Freedom from Fibromyalgia: The 5-Week Program Proven to Conquer Pain, a book using Dr. Sarno's and other techniques that some patients have found helpful.
  • Stress management: In one study, 10 of 15 patients responded to a 14-week cognitive-behavioral and relaxation-training intervention; however, none remained improved after a 4-year follow-up.12
  • Eye movement desensitization and reprocessing (EMDR) has been found to be useful in patients with posttraumatic stress disorder (PTSD).18 Because the pathophysiology of fibromyalgia is similar to that of PTSD19 , some practitioners have been using EMDR with anecdotal success.
  • Meditation has been shown to be helpful.20 Recommended is a mindfulness meditation program developed by Jon Kabat-Zinn, PhD, Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness.21
  • Complementary and alternative methods of treatment include the following:
    • Acupuncture has been shown to be helpful in some trials.22 However, a recent study found acupuncture to be no better than placebo.23
    • Few controlled trials of herbal or homeopathic treatments have been performed.24,25 Many anecdotal cases report short-term benefit that wanes with time.
    • A controversial placebo-controlled trial of a homeopathic treatment (Rhus toxicodendron 6c) decreased tender points.25 A recent trial of individualized homeopathic treatment showed modest benefits.24
    • A combination of malic acid (200 mg) and magnesium (50 mg) (Super Malic) in high doses did not have an effect in the controlled portion of the trial but was found to be useful in the subsequent open-label study.26
    • A recent multicenter trial showed modest salutary effects of acetyl L-carnitine using a combination of daily oral (1000 mg/d) and intramuscular (500 mg/d) treatment for 2 weeks, followed by oral treatment (1500 mg/d) for 8 weeks.27  
    • For further information on integrative treatment, see the chapter “Fibromyalgia Syndrome” by Muller and Selfridge in Integrative Medicine (2007).28

Deterrence/Prevention

  • Prevention of bursitis and tendonitis depends on proper body mechanics at work and at play. Avoiding overuse and gradual increases in exercise is the best means for prevention. Warm-up and cool-down exercises and stretching are recommended. Balancing aerobics with strength training and stretching, particularly yoga, can be helpful.
  • No methods have been proven to prevent fibromyalgia. An overall program of stress reduction that combines mindfulness, meditation, and vigorous exercise, as well as avoiding injury, may offer the best chance for prevention.

Prognosis

  • Fibromyalgia and multiple bursitis-tendonitis syndrome
    • In one study, 65% of patients improved with therapy. A similar percentage reported feeling poor or fair 3 years after diagnosis.
    • About 10-30% of patients are disabled because of fibromyalgia. Most patients function well but continue to report chronic pain.
    • Better response to treatment is observed in patients of younger age with continued employment, supportive families, an absence of affective disorders, and without involvement in litigation.29
    • One study showed that the level of disease activity did not change significantly over an average of 6.4 years that patients were studied. These findings suggest that current conventional medical treatment is unsatisfactory and does not alter the prognosis in fibromyalgia.
    • Complete remissions are uncommon.
  • Regional and local bursitis, tendonitis, neurovascular entrapment, and structural syndromes
    • Most patients do well with therapy.
    • Exacerbations are common but respond well to treatment.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Fibromyalgia, multiple bursitis-tendonitis syndrome
    • Failure to diagnose concomitant autoimmune, infectious, or neoplastic disease can result in medicolegal issues.
    • Disability can occur in 10-30% of cases, with few objective findings on physical examination or laboratory testing.  Disability is significantly related to measures of psychological well-being.30  
    • Litigation may follow an injury at work or in a motor vehicle.
  • Regional and local bursitis and tendonitis - Failure to diagnose septic bursitis or tendonitis
 


More on Nonarticular Rheumatism/Regional Pain Syndrome

Overview: Nonarticular Rheumatism/Regional Pain Syndrome
Differential Diagnoses & Workup: Nonarticular Rheumatism/Regional Pain Syndrome
Treatment & Medication: Nonarticular Rheumatism/Regional Pain Syndrome
Follow-up: Nonarticular Rheumatism/Regional Pain Syndrome
Multimedia: Nonarticular Rheumatism/Regional Pain Syndrome
References
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References

  1. Schur EA, Afari N, Furberg H, Olarte M, Goldberg J, Sullivan PF. Feeling bad in more ways than one: comorbidity patterns of medically unexplained and psychiatric conditions. J Gen Intern Med. Jun 2007;22(6):818-21. [Medline].

  2. Abeles AM, Pillinger MH, Solitar BM, Abeles M. Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med. May 15 2007;146(10):726-34. [Medline].

  3. Wolfe F, Ross K, Anderson J, et al. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum. Jan 1995;38(1):19-28. [Medline].

  4. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. Feb 1990;33(2):160-72. [Medline].

  5. Hoffman JH. Guidelines for Beneficial Group Exercise for Fibromyalgia. Practical Pain Management. 2007/06;7:50-57.

  6. Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. Nov 17 2004;292(19):2388-95. [Medline].

  7. Gendreau R, Mease P, Rao S, et al. Milnacipran: A potential new treatment of fibromyalgia. Arthritis Rheum. 2003;48:S616.

  8. Arnold LM, Lu Y, Crofford LJ, et al. A double-blind, multicenter trial comparing duloxetine with placebo in the treatment of fibromyalgia patients with or without major depressive disorder. Arthritis Rheum. Sep 2004;50(9):2974-84. [Medline].

  9. Arnold LM, Goldenberg DL, Stanford SB, Lalonde JK, Sandhu HS, Keck PE Jr. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. Apr 2007;56(4):1336-44. [Medline].

  10. Crofford LJ, Rowbotham MC, Mease PJ, et al. Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. Apr 2005;52(4):1264-73. [Medline].

  11. Russell IJ, Kamin M, Bennett RM, et al. Efficacy of tramadol in treatment of pain in fibromyalgia. J Clin Rheumatol. 2000;6:250-257.

  12. Wigers SH, Stiles TC, Vogel PA. Effects of aerobic exercise versus stress management treatment in fibromyalgia. A 4.5 year prospective study. Scand J Rheumatol. 1996;25(2):77-86. [Medline].

  13. Jentoft ES, Kvalvik AG, Mengshoel AM. Effects of pool-based and land-based aerobic exercise on women with fibromyalgia/chronic widespread muscle pain. Arthritis Rheum. Feb 2001;45(1):42-7. [Medline].

  14. Sheon RP, Moskowitz RW, Goldberg VM. Soft Tissue Rheumatic Pain: Recognition, Management, and Prevention. 3rd ed. Baltimore, Md: Williams and Wilkins; 1996.

  15. Sunshine W, Field TM, Quintino O, et al. Fibromyalgia benefits from massage therapy and transcutaneous electrical stimulation. J Clin Rheumatol. 1996;2:18-22.

  16. Ferraccioli G, Ghirelli L, Scita F, et al. EMG-biofeedback training in fibromyalgia syndrome. J Rheumatol. Aug 1987;14(4):820-5. [Medline].

  17. Haanen HC, Hoenderdos HT, van Romunde LK, et al. Controlled trial of hypnotherapy in the treatment of refractory fibromyalgia. J Rheumatol. Jan 1991;18(1):72-5. [Medline].

  18. Taylor S, Thordarson DS, Maxfield L, et al. Comparative efficacy, speed, and adverse effects of three PTSD treatments: exposure therapy, EMDR, and relaxation training. J Consult Clin Psychol. Apr 2003;71(2):330-8. [Medline].

  19. Cohen H, Neumann L, Haiman Y, et al. Prevalence of post-traumatic stress disorder in fibromyalgia patients: overlapping syndromes or post-traumatic fibromyalgia syndrome?. Semin Arthritis Rheum. Aug 2002;32(1):38-50. [Medline].

  20. Kaplan KH, Goldenberg DL, Galvin-Nadeau M. The impact of a meditation-based stress reduction program on fibromyalgia. Gen Hosp Psychiatry. Sep 1993;15(5):284-9. [Medline].

  21. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Dell Publishing; 1990.

  22. Deluze C, Bosia L, Zirbs A, et al. Electroacupuncture in fibromyalgia: results of a controlled trial. BMJ. Nov 21 1992;305(6864):1249-52. [Medline].

  23. Assefi NP, Sherman KJ, Jacobsen C, et al. A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia. Ann Intern Med. Jul 5 2005;143(1):10-9. [Medline].

  24. Bell IR, Lewis DA, Brooks AJ, et al. Improved clinical status in fibromyalgia patients treated with individualized homeopathic remedies versus placebo. Rheumatology (Oxford). May 2004;43(5):577-82. [Medline].

  25. Fisher P, Greenwood A, Huskisson EC, et al. Effect of homeopathic treatment on fibrositis (primary fibromyalgia). BMJ. Aug 5 1989;299(6695):365-6. [Medline].

  26. Russell IJ, Michalek JE, Flechas JD, Abraham GE. Treatment of fibromyalgia syndrome with Super Malic: a randomized, double blind, placebo controlled, crossover pilot study. J Rheumatol. May 1995;22(5):953-8. [Medline].

  27. Rossini M, Di Munno O, Valentini G, Bianchi G, Biasi G, Cacace E. Double-blind, multicenter trial comparing acetyl l-carnitine with placebo in the treatment of fibromyalgia patients. Clin Exp Rheumatol. Mar-Apr 2007;25(2):182-8. [Medline].

  28. Muller D, Selfridge N. Fibromyalgia syndrome. In: Rakel D, ed. Integrative Medicine. 2nd ed. Philadelphia, PA: Saunders; 2007:509-18.

  29. Turk DC, Okifuji A, Sinclair JD, Starz TW. Pain, disability, and physical functioning in subgroups of patients with fibromyalgia. J Rheumatol. Jul 1996;23(7):1255-62. [Medline].

  30. Schleicher H, Alonso C, Shirtcliff EA, Muller D, Loevinger BL, Coe CL. In the face of pain: the relationship between psychological well-being and disability in women with fibromyalgia. Psychother Psychosom. 2005;74(4):231-9. [Medline].

  31. Goldenberg DL, Kaplan KH, Nadeau MG. A controlled study of a stress-reduction, cognitive-behavioral treatment program in fibromyalgia. J Musculoskel Pain. 1994;2:53-66.

  32. Goldenberg D, Mayskiy M, Mossey C, et al. A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia. Arthritis Rheum. Nov 1996;39(11):1852-9. [Medline].

  33. Hadler NM. Medical Management of the Regional Musculoskeletal Diseases: Backache, Neck Pain, Disorders of the Upper and Lower Extremities. Orlando, Fla: Grune & Stratton, Inc; 1984.

  34. McCain GA. A cost-effective approach to the diagnosis and treatment of fibromyalgia. Rheum Dis Clin North Am. May 1996;22(2):323-49. [Medline].

  35. Mountz JM, Bradley LA, Modell JG, et al. Fibromyalgia in women. Abnormalities of regional cerebral blood flow in the thalamus and the caudate nucleus are associated with low pain threshold levels. Arthritis Rheum. Jul 1995;38(7):926-38. [Medline].

  36. Ostuni PA, Cassisi GA, Ianniello A. Acupuncture vs. low dose myanserine in primary fibromyalgia. J Musculoskel Pain. 1995;3:88.

  37. Russell IJ. Fibromyalgia syndrome: Formulating a strategy for relief. J Musculoskel Med. 1998;15:4-21.

  38. Simms RW. Fibromyalgia syndrome: current concepts in pathophysiology, clinical features, and management. Arthritis Care Res. Aug 1996;9(4):315-28. [Medline].

  39. Wolfe F, Anderson J, Harkness D, et al. Health status and disease severity in fibromyalgia: results of a six-center longitudinal study. Arthritis Rheum. Sep 1997;40(9):1571-9. [Medline].

  40. Wolfe F, Ross K, Anderson J, Russell IJ. Aspects of fibromyalgia in the general population: sex, pain threshold, and fibromyalgia symptoms. J Rheumatol. Jan 1995;22(1):151-6. [Medline].

  41. Wolfe F, Russell IJ, Vipraio G, et al. Serotonin levels, pain threshold, and fibromyalgia symptoms in the general population. J Rheumatol. Mar 1997;24(3):555-9. [Medline].

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Further Reading

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Keywords

nonarticular rheumatism, regional pain syndrome, soft tissue rheumatic pain syndrome, myofascial pain syndrome, repetitive strain injury, cumulative movement disorders, tendonitis, bursitis, neurovascular entrapment, multiple tendonitis and bursitis syndrome, fibromyalgia, fibrositis, FMS, temporomandibular joint syndrome, flatfoot, hypermobility syndrome, lateral epicondylitis, tennis elbow, carpal tunnel syndrome, thoracic outlet syndrome, regional myofascial pain syndrome, temporomandibular joint syndrome, multiple bursitis-tendonitis syndrome, enthesitis, golfer's elbow, entrapment syndrome, meralgia paresthetica, tarsal tunnel syndrome

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Contributor Information and Disclosures

Author

Daniel Muller, MD, PhD, Department of Internal Medicine, Section of Rheumatology, Associate Professor, University of Wisconsin at Madison
Daniel Muller, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American College of Rheumatology, and American Holistic Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Robert E Wolf, MD, PhD, Professor Emeritus, Department of Medicine, Louisiana State University Health Sciences Center at Shreveport; Chief, Rheumatology Section, Medical Service, Overton Brooks Veterans Administration Medical Center of Shreveport
Robert E Wolf, MD, PhD is a member of the following medical societies: American College of Rheumatology, Arthritis Foundation, and Society for Leukocyte Biology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Elliot Goldberg, MD, Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Temple University School of Medicine
Elliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, and American College of Rheumatology
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; West Penn Allegheny Health System None Board membership

 
 
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