Company LOGO Fibromyalgia & Soft Tissue Rheumatism Shin-Seok Lee, M.D. Chonnam National University Medical School

Company

LOGO

Fibromyalgia & Soft Tissue Rheumatism

Fibromyalgia & Soft Tissue Rheumatism

Shin-Seok Lee, M.D.Chonnam National University Medical School

Musculoskeletal DisorderMusculoskeletal Disorder

ArticularArticular PeriarticularPeriarticular

Septic arthritis Trauma Bursitis Carpal tunnel

Gout Osteonecrosis Tendinitis Sickle cellPseudogout Osteoarthritis Tenosynovitis Multiple myelomaViral arthritis Charcot joint Epicondylitis Osteoid OsteomaJuvenile arthritis Hemarthrosis Periostitis Reflex sympatheticSarcoid PVNS Costochondritis dystrophyFungal Foreign body

InflammatoryInflammatory NoninflammatoryNoninflammatory InflammatoryInflammatory NoninflammatoryNoninflammatory Monarticular Localized

Rheumatoid arthritis Osteoarthritis PMR FibromyalgiaSpA Sickle cell Polymyositis Multiple myelomaSLE Hemarthrosis Periostitis MyxedemaRheumatic fever Hemochromatosis Enthesitis OsteoporosisJuvenile arthritis Hypertrophic Eosinophilic fasciitis PagetsScleroderma osteoarthropathy Myasthenia gravisLyme Polychondritis

Polyarticular Systemic

섬유근통 증후군에 관한 설명 중 틀린 설명은 ?

1. 80-90% 가 여성이며 , 호발 연령은 25-55 세이다 .

2.만성 근골격계의 증후군으로 미만성 통증과 압통점이 특징적이며 이럴 경우 NSAID 와 steroid 가 도움이 된다 .

3. stage 4(non-REM) sleep 장애 , serotonin 의 결핍 ,

우울증 등이 이 질환과 관계 있다 .

4.주요 압통 부위는 thumbnail, forehead, distal dorsal forea

rm 등이 있다 .

가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4

www.themegalllery.com

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Chronic Widespread Pain and Fibromyalgia

Age-group (years)

18-29 30-39 40-49 50-59 60-69 70-79 >80

Prev

alen

ce (%

)

0

5

10

15

20

25

femalemale

Prevalence of chronic widespread pain

Prevalence of chronic widespread pain

1. US study – 10.6%, 95% CI (9.5, 12)2. UK study – 11%

Prevalence of fibromyalgia1. Wolfe et al – 2.0% 95% CI (1.4, 2.7)2. Finland study – 0.8%


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Prevalence of CWP and FM in Korea

Uljin and Pohang, Kyongsangbuk-do 1028 participants in 2004 Prevalence of chronic widespread pain

144/1028 cases (14.0%) F:M = 103:14 Increasing trend in older age

Prevalence of fibromyalgia 23/1028 cases (2.2%) F:M = 21:2 Increasing trend in older age

Kim S, et al. JKRA 2005;12:S71


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Per

cen

tile

Tenderness

Individuals withfibromyalgia

Prevalence of fibromyalgiaRheumatology clinics 20%

Internal medicine clinics 6%

Family practice clinics 2%

General medicine inpatients (UK) 5%

General population 1%

Chronic Widespread Pain and Fibromyalgia


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Pre

ssur

e p

ain

thre

shol

d (k

g)4kg

Allodynia

Fibromyalgia

Healthy control

Hyperalgesia

What is Fibromyalgia?


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1990 ACR Classification Criteria

I. History of chronic widespread pain involving all 4 quadrants of the body

II. Pain in 11 of 18 tender points on digital palpation

Wolfe F, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee. Arthritis Rheum 1990;33:160-172.

1. Occiput: bilateral, at the suboccipital muscle insertions.2. Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7.3. Trapezius: bilateral, at the midpoint of the upper border.4. Supraspinatus: bilateral, at origins, above the scapula spine near the medial border.5. Second rib: bilateral, at 2nd costochondral junctions.6. Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.7. Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.8. Greater trochanter: bilateral, posterior to the trochanteric prominence.9. Knee: bilateral, at the medial fat pad proximal to the joint line.


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Tender Point


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Control anatomic sites Thumbnail, mid forearm, forehead Processus styloideus on the right side In the middle of os sacrum Fold of the skin on the dorsal side of the right antebrachium Fold of the skin over m. gluteus maximum on the right side

Tender Point


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Definition of fibromyalgia Chronic widespread pain with a reduced threshold for pain, generally

identified by an increased sensitivity to pressure at particular points on

the body Associated subjective symptoms such as fatigue, sleep disturbance,

headache, migraine, variable bowel habits, diffuse abdominal pain, and

urinary frequency. One third of patients experience significant minor depression or

anxiety.


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Tension/migraine headache

Temporomandibularjoint syndrome

Regional musculoskeletalpain (e.g. chronic cervical

or lumbar pain,“tendinosis”, repetitive

strain syndrome,myofascial pain syndrome)

Irritable bowelsyndrome

Chronic sinusitis

Sicca symptoms, vasomotor rhinitis

Non-cardiac chest pain, “SyndromeX”, costochondritis

Biliary dyskinesia, post-cholecystectomy syndrome

Interstitial cystitis,female urethral syndrome,vulvar vestibulitis, vulvodynia



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Pathogenesis

Increased nociception Deficiency of stage II/IV sleep

– Alpha EEG NREM sleep anomaly Aberrant CNS function

– Abnormalities in sensory processing

– Hypothalamic-pituitary axis dysfunction

– Autonomic dysfunction

– Psychobehavioral factor Cytokines


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The pain–brain–pain loop

paingenerators

central sensitization

peripheraltissues

spinal cordand brain

OA, RA, Inflammation, Neuropathies, Injuries, Disc disorders, Visceral pain,

Chronic headaches, TMJ, Spinal stenosis, Repetitive strain, Endometriosis,

Myofascial pain


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Altered central pain processing

Lower rCBF in the Thalamus and the Caudate Nucleus by SPECT

Normal Control Fibromyalgia

Mountz JM, et al, Arthritis Rheum 1995;38:926-38


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fMRI Imaging Evidence of Augmented Pain Processing in Fibromyalgia

Gracely RH, et al. Arthritis Rheum 2002;46:1333-43


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Vaeroy Russell Welin Bradley

fmol

e/m

l

0

10

20

30

40

50

Normal FMS

Mean CSF levels of substance P in fibromyalgia

Threefold higher concentrations of substa

nce P in CSF of FM patients Low levels of norepinephrine and its met

abolite, 3-methoy-4-hydroxy phenethyle

ne, in CSF of FM patientsLow levels of serotonin and its precursor,

L-tryptophan, in the serum and low levels

of the principal metabolite, 5-hydroxy ind

oleacetic acid in CSF

섬유근통 증후군에 관한 설명 중 틀린 설명은 ?

1. 80-90% 가 여성이며 , 호발 연령은 25-55 세이다 .

2.만성 근골격계의 증후군으로 미만성 통증과 압통점이 특징적이며 이럴 경우 NSAID 와 steroid 가 도움이 된다 .

3. stage 4(non-REM) sleep 장애 , serotonin 의 결핍 ,

우울증 등이 이 질환과 관계 있다 .

4.주요 압통 부위는 thumbnail, forehead, distal dorsal forea

rm 등이 있다 .

가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4

58 세 여자환자로 6 개월 전부터 지속된 쇠약감과 전신적인 근육통을 주소로 내원하였다 . 승모근 , 늑골 , 늑역골 관절 , 내측 무릎 등에 대칭적인 통점을 가지고 있었다 . 환자는 류마티스 인자 및 항핵항체는 음성이었고 적혈구 침강속도도 정상이었으며 기타 신경학적 검사에서 이상소견은 없었다 . 상기 환자에 대한 설명 중 옳은 것은 ?

1. 주로 여자에게서 발생하며 대부분 연령은 30-50 대 이다 .

2. 대부분의 환자들이 활동성의 정신의학적 질환을 가지고 있다 .

3. 류마티스 관절염에 병발할 수 있다 .

4. 특징적인 REM sleep 의 장애를 동반한다 .

가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4

45 세 여자가 수 년간 지속되는 전신 통증으로 왔다 .

관절의 압통과 종창은 없었고 , 전신 근육에 압통점이 뚜렷하게 있었다 . 류마티스 인자 , 항핵항체는 음성이었고 갑상선 기능검사는 정상이었으며 다른 특이소견은 없었다 . 치료로 적절한 것은 ?

1. amitriptyline2. 유산소운동3. tramadol4. prednisolone 가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4


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Management

Education Nonprogressive condition that is not causing damage or inflammation Not focusing on symptoms. All symptoms are from the same

underlying condition. Existential crisis from denial, searching for ‘the cure’, to eventual

acceptance Pharmacologic therapy

Antidepressants (TCA, SSRI, SNRI, MAOI) Analgesics, sedative hypnotics, muscle relaxant

Nonpharmacologic therapy Exercise, cognitive behavioral therapy


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Pharmacologic therapy

Antidepressant: summary of randomized, controlled trials

Class Compound(s) Pharmacology Pain Sleep Fatigue Mood Treating other FSS

TCA Amitriptyline 5-HT/NE reuptake inhibitor + + + - IBSClomipramine Cation channel blocker TMJDDoxepin NMDA antagonist CLBP?

Anticholinergic CTTH prophylaxisAntihistaminergic

SSRI Fluoxetine 5-HT reuptake inhibitor + + + + CTTH prophylaxisCitalopram 5-HT reuptake inhibitor - - - + CTTH prophylaxisSertraline 5-HT reuptake inhibitor + + + CTTH prophylaxis

SNRI Venlafaxine 5-HT > NE reuptake inhibitor - - - - CTTH prophylaxisMilnacipran NE > 5-HT reuptake inhibitor + - + +

NMDA antagonistMAOI Moclobemide Reversible, MAO inhibitor - - - - CTTH prophylaxis, CFS

Pirlindole Reversible, MAO inhibitor + + + + CTTH prophylaxis


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Summary of randomized, controlled trials

Class Compound(s) Pharmacology Pain Sleep Fatigue Mood Other FSS

Muscle Cyclobenzaprine 5-HT2 antagonist + + +/-

IBSrelaxant Anticholinergic

AntihistaminergicAnti-epileptics Pregabalin Ca channel blocker + + +Sedative Zopiclone BZ receptor agonist - + - -Hypnotics Zolpidem

NSAIDs Ibuprofen Nonspecific COX inhibitor - - - -CLBP

Naproxen

TMJD Opiates Morphine (IV) Mu agonist -

Tramadol Mu agonist +CTTH

5-HT/NE reuptake inhibitorCLBP

Other Tropisetron 5-HT3 antagonist + +

IBS?Growth hormone Growth hormone + + +


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Antidepressant – rationale Alpha-delta NREM sleep abnormality mediated by an abnormality in cen

tral serotonergic neurotransmission Personal and family history of depression in FM patients TCA studies on chronic pain syndromes

Antidepressant – mechanism Increase neurotransmission mediated by the monoamine neurotransmit

ters, particularly serotonin (5-HT) and/or norepinephrine (NE)


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Treatment of Fibromyalgia with Tricyclic Antidepressants: A Meta-Analysis

O’Malley PG, et al. J Gen Intern Med 2000;15:659

4.35.2

5.86.5

10.6

5.05.0

11.6

6.55.8

0

2

4

6

8

10

12

fatigue triggerpoints

pain sleep well-being

symptoms

rati

ng

scale

treatment mean*placebo mean*

14%

9%

26% 23% 18%


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TCA Treatment of Fibromyalgia: A Meta-Analysis

Arnold LM, et al. Psychosomatics 2000;41:104

Eff

ect

Siz

e

(Sta

nd

ard

Devia

tion

s) 1.5

1.0

0.5

0.0

-0.5

Outcome Measure

PatientGlobal

Assessment

M.D.Global

Assessment

Pain Fatigue Sleep Tenderness Stiffness


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Recommendations1. Start with amitriptyline at a dose 5 mg 1-2h before bedtime. The dose can be

gradually increased to a maximum of 50 mg/day

2. If these are ineffective, institute trials of SSRI such as fluoxetine.

3. Consider the combination of SSRI and low dose TCA.

4. If ineffective, substitute SNRI such as venlafaxine for SSRI.

5. For insomnia in patients intolerant of TCA, bedtime doses of zolpidem and z

opiclone may be of benefit.

6. For pain control, use the tramadol. Limit the use of antiinflammatory agents,

narcotic analgesics, and muscle relaxants.

45 세 여자가 수 년간 지속되는 전신 통증으로 왔다 .

관절의 압통과 종창은 없었고 , 전신 근육에 압통점이 뚜렷하게 있었다 . 류마티스 인자 , 항핵항체는 음성이었고 갑상선 기능검사는 정상이었으며 다른 특이소견은 없었다 . 치료로 적절한 것은 ?

1. amitriptyline2. 유산소운동3. tramadol4. prednisolone 가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4

35 세 여자 환자가 전신통증과 피로감을 주소로 내원하였다 .

평소에 만성 근육통과 수면장애가 있었다 . 목 , 어깨 , 하지에 걸치는 전신적인 통증이 있었고 약간의 움직임에도 악화되었다 .

신체검사에서 뒷목 , 양어깨 , 허리 , 무릎에 대칭적인 압통점이 있었으나 방사선 검사에서 이상소견은 관찰되지 않았다 .

항핵항체와 류마티스 인자는 음성이었고 ESR 은 10 mm/hr 였다 .

이 환자에서 적절하지 않은 치료는 ?

1. 유산소운동 2. cyclobenzaprine

3. prednisolone

4. tricyclic antidepressants

5. zolpidem

삼환계 항우울제와 플루옥세틴 (fluoxetine) 으로 증상이 조절되지 않는 섬유근통 환자에서 다음 단계로 투여해 볼 수 있는 약제로 옳은 것은 ?

1. 플루옥세틴 대신 벤라팍신 (venlafaxine) 을 투여한다 .2. 트라마돌 (tramadol) 을 추가한다 .3. 플루옥세틴을 둘록세틴 (duloxetine) 으로 교체한다 .4. 저용량의 프레드니솔론을 추가한다 .

가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4

손목굴증후군 (carpal tunnel syndrome) 을 진단하기 위한 신체검사 두 가지는 ?

답 ) Tinel's sign 과 Phalen's sign

Tinel’s sign percussion of median nerve at the flexor retinaculum (just radial to the palmaris longus tendon at the distal wrist crease) produces paresthesia in the median nerve distribution: thumb, index and middle fingers and the radial half of the ring finger

Phalen’s sign sustained palmar flexion of the wrist for 30-60 seconds induces finger paresthesia

http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Caaem%5Cimages%5CLarge%5C282Phalens.jpg&template=izoom2

http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=%5Cwebsites%5Cemedicine%5Caaem%5Cimages%5CLarge%5C283Tinels.jpg&template=izoom2

다음 사진에서 보이는 검사는 어떤 질병을 진단하기 위한 것인가 ?

답 ) de Quervain's tenosynovitis

de Quervain’s stenosing tenosynovitis tenosynovitis of abductor pollicis longus and extensor pollicis brevis

Finkelstein test passive ulnar deviation of the wrist with the fingers flexed over the thumb placed in the palm

50 세 여자가 왼쪽 어깨관절의 통증을 주소로 내원하였다 .

환자는 3 개월 전부터 왼쪽 어깨의 통증을 느끼기 시작했으며 최근 들어서는 왼쪽으로는 누워 자기가 힘들 정도로 통증이 심하다고 하였다 . 과거력상 당뇨는 없었고 신체검사에서 왼쪽 어깨의 수동 능동 운동 모두에 제한이 있었고 X 선 촬영에서 뚜렷한 이상 소견은 발견되지 않았다 . 상기 환자의 가능한 진단은 ?

답 ) 유착관절낭염 (adhesive capsulitis)

Diagnosis Age Type of onset

Location of pain

Night pain

Active ROM

Passive ROM

Impingement sign

Radia-tion

Pares-thesia

Weak-ness

Insta-bility

Radio-graphic changes

Special features

Rotator cufftendinitis

Any Acute or chronic

Deltoid region

+ ↓↓guarding

Normal +++ - - Only due to pain

Look for In chronic cases

Painful arc of abduction

Rototor cufftears (chronic)

Over 40 yr

Often chronic

Deltoid region

++ ↓↓↓ Normal ++ - - ++ - + Wasting of cuff muscles

Bicipital tendinitis

Any Overuse Anterior - ↓guarding

Normal + ± - Only due to pain

Look for None Speed testYergason test

Calcific tendinitis 30-60 yr

Acute Point of shoulder

++ ↓↓↓guarding

Normal +++ - - Only due to pain

- ++ Tenderness ++

Adhesive capsulitis

Over 40 yr

Insidious Deep in shoulder

++ ↓↓ ↓↓ + - - - - - Global ROM↓

Acromioclavicular joint

Any Acute or chronic

Over joint

Lying on

side

↓full elevation

Normal - - - - - In chronic cases

Local tenderness

Osteoarthritis of glenohumoral jt.

Over 40 yr

Insidious Deep in shoulder

++ ↓↓ ↓↓ - - - May have mild

- +++ Crepitus

Glenohumoral instability

<25 yr

Episodic Ant. or post.

- Only appre-hensio

n

Only appre-hensio

n

Possible - + with acute

episode

+ with acute

episode

+++ Often Stress test

Cervical spondylosis

Over 40 yr

Insidious Supra-scapular

Often Normal Normal - ++ +++ + - Cervical spine

Pain with neck movement

Thoracic outlet syndrome

Any Usually with

activity

Neck shoulder

arm

- Normal Normal - ++ ++ ++ - -

Differential Diagnosis of Shoulder Pain

55 세 여자가 6 개월 전부터 서서히 진행하는 우측 어깨의 통증과 운동 장애를 주소로 내원하였다 . 신체검사에서 부종이나 종창 , 발적은 동반되지 않았으나 환자 스스로 우측 어깨를 모든 방향으로 움직일 수 없었으며 검사자의 도움으로도 비슷한 정도의 운동 장애를 보였다 . 방사선 촬영에서는 우측 어깨 관절 주위의 골감소 이외에 특이 소견은 없었다 . 이 환자에 맞는 소견은 ?

1. 관절의 진행성 미란을 동반한다 . 2. 당뇨병 , 갑상선 질환 , 폐질환에 동반되기도 한다 .3. 진단을 위해 관절경 검사가 필수적이다 .4. 관절강내 코르티코스테로이드 주사가 증상 개선에 도움이 된다 .

가 . 1,2,3 나 . 1,3 다 . 2,4 라 . 4 마 . 1,2,3,4

Documents

Company LOGO Fibromyalgia & Soft Tissue Rheumatism Shin-Seok Lee, M.D. Chonnam National University Medical School