Medical Care
Fibromyalgia
Patients with fibromyalgia and multiple bursitis-tendonitis syndrome are most likely to benefit from a multicomponent program. [23] An evidence-based review of treatment modalities by the European League Against Rheumatism (EULAR) listed the following treatment options [24] :
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Sedating antidepressant (tricyclic) at night
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Activating antidepressant in the morning
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Low-level aerobic exercise and physical therapy, including heat or ice
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Meditation training (Mindfulness meditation is recommended.)
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Subcutaneous tender-point injections
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Electromyography biofeedback and hypnotherapy
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Psychotherapy and stress management
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Cognitive behavior therapy program
Physical therapy for 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. [25] Transcutaneous electrical nerve stimulation (TENS) may provide symptomatic relief in some cases. [26]
Meditation has been shown to be helpful. [27] 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. [28]
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. Electromyography and hypnotherapy have been helpful in controlled studies. [29, 30]
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. [31] Stress reduction combined with cognitive-behavioral therapy may be helpful. [32]
Eye movement desensitization and reprocessing (EMDR) has been found to be useful in patients with posttraumatic stress disorder (PTSD). [33] Because the pathophysiology of fibromyalgia is similar to that of PTSD [34] , some practitioners have been using EMDR with anecdotal success.
Transcranial direct current stimulation (tDCS) has emerged as a potential treatment for fibromyalgia. Although tDCS can alter functional connectivity (FC) in brain regions underneath and distant to the stimulating electrode, the analgesic mechanisms of repetitive tDCS remain unknown. Despite promising preliminary results in treating fibromyalgia pain, no neuromodulation technique has been adopted in clinical practice because of limited efficacy, low response rate, or poor tolerability. [35, 36, 37]
Complementary and alternative methods of treatment
Acupuncture has been shown to be helpful in some trials. [38, 39] However, one study found acupuncture to be no better than placebo. [40]
Few controlled trials of herbal or homeopathic treatments have been performed. [41, 42] 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. [42] A recent trial of individualized homeopathic treatment showed modest benefits. [41]
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. [43]
A 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. [44]
For further information on integrative treatment, see the chapter “Fibromyalgia Syndrome” by Muller and Selfridge in Integrative Medicine (2007). [45]
Regional and local bursitis and tendonitis
For acute exacerbations (first 24-48 h) of regional and local bursitis and tendonitis, the following treatments are used:
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Rest
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Immobilization
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Ice
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Nonsteroidal anti-inflammatory drugs (NSAIDs)
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Physical therapy
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Antibiotics for infection
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Chronic pain treatment
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Local heat
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Tennis elbow strap for lateral epicondylitis
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Padding for bursa and Achilles tendon involvement
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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.
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Bursal aspiration and sometimes sclerosis with tetracycline
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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. [46]
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 plasma injection therapies. Most of these latter studies have been small; studies that are more comprehensive are needed before any firm recommendations can be made. [47]
A 2011 article demonstrates the possibility of using leech therapy for lateral epicondylitis. Such therapy might be helpful, but would likely have to overcome barriers before patients and practitioners accept this mode of therapy. [48]
Surgical Care
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.
Consultations
Consultations may be considered for the following:
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Fibromyalgia or multiple bursitis-tendonitis syndrome - Rheumatologist, psychologist, physical therapist, acupuncturist
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Local bursitis and tendonitis - Rheumatologist, general/orthopedic surgeon, podiatrist, acupuncturist
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Long-term management of fibromyalgia – Usually, primary care physician
Diet
No known benefits or worsening of symptoms are associated with dietary manipulations. No special diet requirements exist.
Activity
Fibromyalgia and multiple bursitis-tendonitis syndrome
Patients with fibromyalgia and multiple bursitis-tendonitis syndrome must often have periods of rest alternating with mild-to-moderate aerobic activity to optimize function. Exercise helps decrease the symptoms of fibromyalgia syndrome; however, too much exercise results in increased symptoms that are often severe. Even moderate activity over baseline often results in increased pain and fatigue. This can lead to a cycle of muscle disuse. Hoffman has published a detailed program of graded exercise for fibromyalgia. [49]
Tai chi has been shown to be beneficial in patients with fibromyalgia. In a study comparing Tai chi with aerobic exercise, greater improvement in symptom scores were noted in Tai chi groups. [50] Aerobic therapy in a warm-water pool may be helpful, particularly for severe cases. [51]
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, and 4 years later, none of those patients fulfilled criteria for fibromyalgia. [31]
The efficacy of programs that combine aerobic, strengthening and flexibility were analyzed in a meta-analysis of 29 randomized controlled trials that compared mixed exercise interventions with other or no exercise interventions. The analysis found moderate evidence of improvement in health-related quality of life, physical function, and fatigue. However, the authors cautioned that improvements may be small and clinically unimportant for some participants, as the studies included in the analysis were small trials with possible selection bias. [52]
Regional and local bursitis and tendonitis
Local bursitis and tendonitis require rest or immobilization for acute exacerbations and moderate muscle strengthening and stretching for chronic syndromes.
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.
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The spectrum of nonarticular myofascial pain syndromes.
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Possible factors that lead to myofascial pain syndromes.
