Nonarticular Rheumatism/Regional Pain Syndrome Treatment & Management

Updated: Apr 04, 2018
  • Author: T P Sudha Rao, MD; Chief Editor: Herbert S Diamond, MD  more...
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Treatment

Medical Care

Patients with fibromyalgia and multiple bursitis-tendonitis syndrome are most likely to benefit from a multicomponent program. [20]  An evidence-based review of treatment modalities by the European League Against Rheumatism (EULAR) listed the following treatment options [21] :

  • 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
  • Electromyography biofeedback and hypnotherapy
  • Psychotherapy and stress management
  • Cognitive behavior therapy program

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. [22, 23, 24]

For acute exacerbations (first 24-48 h) of regional and local bursitis and tendonitis, the following treatments are used:

  • Rest
  • Immobilization
  • Ice
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Physical therapy
  • Antibiotics for infection
  • Chronic pain treatment
  • Local heat
  • Tennis elbow strap for lateral epicondylitis
  • Padding for bursa and Achilles tendon involvement
  • 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. [25]

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. [26]

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. [27]

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Surgical Care

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.

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Consultations

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

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Diet

No known benefits or worsening of symptoms are associated with dietary manipulations. No special diet requirements exist.

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Activity

 

Fibromyalgia and multiple bursitis-tendonitis syndrome activity recommendations are as follows:

  • Often, patients must have periods of rest alternating with mild-to-moderate aerobic activity to optimize function. Hoffman has published a detailed program of graded exercise for fibromyalgia. [28]

  • Moderate activity over baseline often results in increased pain and fatigue.

Local bursitis and tendonitis activity recommendations are as follows:

  • Rest or immobilization for acute exacerbations

  • Moderate muscle strengthening and stretching for chronic syndromes

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