Nonarticular Rheumatism/Regional Pain Syndrome Treatment & Management: Medical Care, Surgical Care, Consultations

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Nonarticular Rheumatism/Regional Pain Syndrome

Sections Nonarticular Rheumatism/Regional Pain Syndrome
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
Questions & Answers
Media Gallery
References

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]

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.

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

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 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

Medication

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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. 1995 Jul. 38(7):926-38. [Medline].
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Light AR, White AT, Hughen RW, Light KC. Moderate exercise increases expression for sensory, adrenergic, and immune genes in chronic fatigue syndrome patients but not in normal subjects. J Pain. 2009 Oct. 10(10):1099-112. [Medline]. [Full Text].
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Wolfe F, Ross K, Anderson J, Russell IJ. Aspects of fibromyalgia in the general population: sex, pain threshold, and fibromyalgia symptoms. J Rheumatol. 1995 Jan. 22(1):151-6. [Medline].
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. 1990 Feb. 33(2):160-72. [Medline].
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Häuser W, Bernardy K, Arnold B, Offenbächer M, Schiltenwolf M. Efficacy of multicomponent treatment in fibromyalgia syndrome: a meta-analysis of randomized controlled clinical trials. Arthritis Rheum. 2009 Feb 15. 61(2):216-24. [Medline].
[Guideline] Carville SF, Arendt-Nielsen S, Bliddal H, Blotman F, Branco JC, Buskila D, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008 Apr. 67(4):536-41. [Medline].
Fagerlund AJ, Hansen OA, Aslaksen PM. Transcranial direct current stimulation as a treatment for patients with fibromyalgia: a randomized controlled trial. Pain. 2015 Jan. 156 (1):62-71. [Medline].
Cummiford CM, Nascimento TD, Foerster BR, Clauw DJ, Zubieta JK, Harris RE, et al. Changes in resting state functional connectivity after repetitive transcranial direct current stimulation applied to motor cortex in fibromyalgia patients. Arthritis Res Ther. 2016 Feb 3. 18:40. [Medline].
Castillo-Saavedra L, Gebodh N, Bikson M, Diaz-Cruz C, Brandao R, Coutinho L, et al. Clinically Effective Treatment of Fibromyalgia Pain With High-Definition Transcranial Direct Current Stimulation: Phase II Open-Label Dose Optimization. J Pain. 2016 Jan. 17 (1):14-26. [Medline].
Goode AP, Freburger J, Carey T. Prevalence, practice patterns, and evidence for chronic neck pain. Arthritis Care Res (Hoboken). 2010 Nov. 62(11):1594-601. [Medline]. [Full Text].
Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010 Nov 20. 376(9754):1751-67. [Medline].
Bäcker M, Lüdtke R, Afra D, et al. Effectiveness of leech therapy in chronic lateral epicondylitis: a randomized controlled trial. Clin J Pain. 2011 Jun. 27(5):442-7. [Medline].
Hoffman JH. Guidelines for Beneficial Group Exercise for Fibromyalgia. Practical Pain Management. 2007/06. 7:50-57.
Living with Fibromyalgia, Drugs Approved to Manage Pain. U.S. Food and Drug Administration. Available at http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm107802.htm#approved. January 31, 2014; Accessed: January 3, 2018.
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. 2005 Apr. 52(4):1264-73. [Medline].
Gendreau R, Mease P, Rao S, et al. Milnacipran: A potential new treatment of fibromyalgia. Arthritis Rheum. 2003. 48:S616.
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. 2004 Sep. 50(9):2974-84. [Medline].
Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17. 292(19):2388-95. [Medline].
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. 1996 Nov. 39(11):1852-9. [Medline].
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. 2007 Apr. 56(4):1336-44. [Medline].
Russell IJ, Kamin M, Bennett RM, Schnitzer TJ, Green JA, Katz WA. Efficacy of Tramadol in Treatment of Pain in Fibromyalgia. J Clin Rheumatol. 2000 Oct. 6(5):250-7. [Medline].
Younger J, Mackey S. Fibromyalgia symptoms are reduced by low-dose naltrexone: a pilot study. Pain Med. 2009 May-Jun. 10(4):663-72. [Medline].
Russell IJ, Perkins AT, Michalek JE,. Sodium oxybate relieves pain and improves function in fibromyalgia syndrome: a randomized, double-blind, placebo-controlled, multicenter clinical trial. Arthritis Rheum. 2009 Jan. 60(1):299-309. [Medline].
Wang C, Schmid CH, Fielding RA, Harvey WF, Reid KF, Price LL, et al. Effect of tai chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial. BMJ. 2018 Mar 21. 360:k851. [Medline]. [Full Text].
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Sheon RP, Moskowitz RW, Goldberg VM. Soft Tissue Rheumatic Pain: Recognition, Management, and Prevention. 3rd ed. Baltimore, Md: Williams and Wilkins; 1996.
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Media Gallery

The spectrum of nonarticular myofascial pain syndromes.
Possible factors that lead to myofascial pain syndromes.

of 2

Author

T P Sudha Rao, MD Associate Professor of Medicine, Virginia Commonwealth University School of Medicine; Chief, Rheumatology Fellowship Coordinator, Department of Rheumatology, McGuire VA Medical Center

T P Sudha Rao, MD is a member of the following medical societies: American College of Rheumatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Elliot Goldberg, MD Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Lewis Katz School of Medicine at Temple University

Elliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; 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, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Daniel Muller, MD, PhD Associate Professor of Medicine, Department of Medicine, Section of Rheumatology, University of Wisconsin School of Medicine and Public Health

Daniel Muller, MD, PhD is a member of the following medical societies: American Holistic Medical Association, American College of Physicians-American Society of Internal Medicine, American College of Rheumatology

Disclosure: Nothing to disclose.

Robert E Wolf, MD, PhD Professor Emeritus, Department of Medicine, Louisiana State University School of Medicine in Shreveport; Chief, Rheumatology Section, Medical Service, Overton Brooks Veterans Affairs Medical Center

Robert E Wolf, MD, PhD is a member of the following medical societies: American College of Rheumatology, Arthritis Foundation, Society for Leukocyte Biology

Disclosure: Nothing to disclose.

David Rabago, MD Assistant Professor, Co-Director, Primary Care Research Fellowship, Associate Research Director, Department of Family Medicine, University of Wisconsin School of Medicine and Public Health

David Rabago, MD is a member of the following medical societies: American Academy of Family Physicians, North American Primary Care Research Group, Society of Teachers of Family Medicine

Disclosure: Nothing to disclose.

Sections Nonarticular Rheumatism/Regional Pain Syndrome
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
Questions & Answers
Media Gallery
References

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