Nonarticular Rheumatism/Regional Pain Syndrome Treatment & Management
- Author: David Rabago, MD; Chief Editor: Herbert S Diamond, MD more...
Patients with fibromyalgia and multiple bursitis-tendonitis syndrome are most likely to benefit from a multicomponent program. The European League Against Rheumatism (EULAR) recently published an evidence-based review of treatment modalities, as follows :
Sedating antidepressant (tricyclic) at night
Activating antidepressant in the morning
Low-level aerobic exercise and physical therapy, including heat or ice
Meditation training (Mindfulness meditation is recommended.)
Subcutaneous tender-point injections
EMG biofeedback and hypnotherapy
Psychotherapy and stress management
Cognitive behavior therapy program
For acute exacerbations (first 24-48 h) of regional and local bursitis and tendonitis, the following treatments are used:
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Antibiotics for infection
Chronic pain treatment
Tennis elbow strap for lateral epicondylitis
Padding for bursa and Achilles tendon
Local injection of bursa or tendon with lidocaine and long-acting steroids for cases resistant to conservative therapy: Infection must be ruled out prior to the use of steroids, especially in patients with olecranon and prepatellar bursitis. Never inject into the Achilles tendon because of the risk of rupture.
Bursal aspiration and sometimes sclerosis with tetracycline
Assessment of home and workplace habits such as posture and repetitive motion
Alterations in sleep position may benefit persons with neurovascular entrapment such as thoracic outlet syndrome (ie, avoiding arm hyperabduction) and carpal tunnel syndromes (avoiding wrist flexion). Women with heavy pendulous breasts may need brassieres with proper support. Exercises to correct postural deficits are necessary. Night wrist splints may be curative in carpal tunnel syndrome. Postural therapies such as Alexander or Feldenkrais might be beneficial.
Proper foot support and orthotics can benefit persons with tarsal tunnel syndrome. NSAIDS can be tried for carpal and tarsal tunnel syndromes. Local long-acting steroid injection can be helpful in carpal and tarsal tunnel syndromes.
Goode et al (2010) estimated the prevalence of chronic neck pain to be 2.2% in North Carolina in 2006. The authors found an overuse of diagnostic testing, narcotics, and unproven modalities in these individuals, as well as an underuse of effective treatments such as therapeutic exercise.
A meta-analysis of the use of corticosteroid injection for tendinopathy showed good short-term outcomes. However, intermediate and long-term outcomes may be better with prolotherapy, botulinum toxin, or platelet-rich injection therapies. Most of these latter studies have been small; studies that are more comprehensive are needed before any firm recommendations can be made.
A 2011 article demonstrates the possibility of using leech therapy for lateral epicondylitis. Such therapy may be helpful, but there will likely be barriers to overcome before patients and practitioners accept this mode of therapy.
See the list below:
No surgical care is necessary for fibromyalgia or multiple bursitis-tendonitis syndrome.
Chronic local bursitis and tendonitis occasionally require bursectomy or excision of the inflamed tissue around the tendon, respectively, if conservative measures fail.
Carpal and tarsal tunnel syndromes may require surgical decompression. Aggressively treat coexisting carpal tunnel syndrome before surgical therapy for thoracic outlet syndrome.
See the list below:
Fibromyalgia or multiple bursitis-tendonitis syndrome - Rheumatologist, psychologist, physical therapist, acupuncturist
Local bursitis and tendonitis - Rheumatologist, general/orthopedic surgeon, podiatrist, acupuncturist
Long-term management of fibromyalgia – Usually, primary care physician
No known benefits or worsening of symptoms are associated with dietary manipulations. No special diet requirements exist.
See the list below:
Fibromyalgia and multiple bursitis-tendonitis syndrome
- Often, patients must have periods of rest alternating with mild-to-moderate aerobic activity to optimize function. Hoffman recently published a detailed program of graded exercise for fibromyalgia.
- Moderate activity over baseline often results in increased pain and fatigue.
Local bursitis and tendonitis
- Rest or immobilization for acute exacerbations
- Moderate muscle strengthening and stretching for chronic syndromes
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