focus on myofascial pain, fibromyalgia, and chronic fatigue syndromes (relates to chapter 65,...
TRANSCRIPT
Focus on Myofascial Pain, Fibromyalgia, and Chronic Fatigue Syndromes
(Relates to Chapter 65, “Nursing Management: Arthritis and Connective Tissue Diseases,” in the textbook)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Soft Tissue Rheumatic Syndromes Three soft tissue disease
syndromes that have many commonalities and may be related Myofascial pain syndrome Fibromyalgia syndrome (FMS) Chronic fatigue syndrome
(CFS)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2
Myofascial Pain Syndrome Characterized by
musculoskeletal pain and tenderness in one anatomic region of the body
Pain has been shown to originate in anterior and posterior trigger points. Muscle trauma Chronically strained muscles
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3
Myofascial Pain Syndrome Regions of pain are often
within taut bands and fascia of skeletal muscles.
Trigger points are thought to Activate a characteristic
pattern of pain when activated by pressure
Worsen with activity or stress
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4
Myofascial Pain Syndrome Patients complain of the
pain as Deep and aching Accompanied by a sensation
of Burning Stinging Stiffness
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5
Myofascial Pain Syndrome Diagnosis is done by palpation
of trigger points. Reveals induration and frequently
a muscle twitch in area of a trigger point
Once a trigger point is palpated, pain will be felt locally. May also be referred to a region
often at some distance
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6
Myofascial Pain Syndrome
Variable Fibromyalgia Myofascial Pain
Location Generalized Regional
Examination Tender points Trigger points
Response to local therapy
Not sustained Curative
Gender Female/male ratio—10:1
Equal or unknown
Systemic features Characteristic Unknown
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7
Myofascial Pain Syndrome Treatments
Physical therapy “Spray and stretch” method
Painful area is iced or sprayed with a coolant and then stretched.
Injecting trigger points with a local anesthetic
Massage
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8
Myofascial Pain Syndrome Treatments (cont’d)
Acupuncture Biofeedback Ultrasound
Patient and family teaching is important nursing responsibility. Instruction should focus on
prevention of muscle tension.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9
Fibromyalgia Syndrome (FMS) Chronic disorder characterized by
Widespread, nonarticular musculoskeletal pain and fatigue
Multiple tender points FMS patients may also have
Nonrestorative sleep and morning stiffness
Anxiety Irritable bowel syndrome
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10
Fibromyalgia Syndrome (FMS) Commonly misdiagnosed
musculoskeletal disorder Major cause of disability Affects 2% to 5% of the U.S.
population Occurs 6 times more
frequently in women than in men
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11
Fibromyalgia Syndrome (FMS)
Commonalities between FMS and Chronic Fatigue Syndrome (CFS)
Occurrence Previous healthy, young and middle-aged women
Etiology Infectious trigger, dysfunction in HPA axis, alteration in CNS
Clinical manifestations
Malaise and fatigue, cognitive dysfunction, headaches, sleep disturbances, depression, anxiety, fever, generalized musculoskeletal pain
Course of disease Variable intensity of symptoms, fluctuates over time
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12
Fibromyalgia Syndrome (FMS)
Commonalities between FMS and Chronic Fatigue Syndrome (CFS) (cont’d)
Diagnosis No definitive laboratory tests or joint and muscle examinations, mainly a diagnosis of exclusion
Collaborative care
Treatment is symptomatic and may include antidepressant drugs
Other measures are heat, massage, regular stretching, biofeedback, stress management, and relaxation training
Patient and family teaching is essential
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13
Fibromyalgia Syndrome (FMS)Etiology and Pathophysiology Research continues to focus on
identifying underlying causes and pathophysiologic mechanisms.
General agreement that FMS is a disorder of central processing with neuroendocrine/neurotransmitter dysregulation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14
Fibromyalgia Syndrome (FMS)Etiology and Pathophysiology Multiple physiologic abnormalities
↑ levels of blood flow to thalamus Dysfunction of hypothalamic-
pituitary-adrenal (HPA) axis Low levels of serotonin and
tryptophan Abnormalities in cytokine function
May be a genetic susceptibility
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15
Fibromyalgia Syndrome (FMS)Clinical Manifestations and Complications Clinical manifestations of
FMS overlap those of CFS. Complaints
Widespread burning pain Pain worsens and improves
throughout day. Difficult to discriminate pain
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16
Fibromyalgia Syndrome (FMS)Clinical Manifestations and Complications
Complaints (cont’d) Head or facial pain originates from
stiff or painful neck and shoulder muscles.
Nonrestorative sleep Fatigue Temporomandibular joint dysfunction
Affects approximately one third of FMS patients
Point tenderness varies.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17
Tender Points in Fibromyalgia Syndrome
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18
Fig. 65-14. Tender points in fibromyalgia syndrome.
Fibromyalgia Syndrome (FMS)Clinical Manifestations and Complications
Cognitive effects Range from difficulty
concentrating to memory lapses Feelings of being overwhelmed
when dealing with multiple tasks
Migraine headaches Depression and anxiety
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19
Fibromyalgia Syndrome (FMS)Clinical Manifestations and Complications
Numbness and tingling in hands or feet
Restless leg syndrome Irritable bowel syndrome Difficulty swallowing ↑ frequency of urination and
urinary urgency For women, difficult
menstruation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20
Fibromyalgia Syndrome (FMS)Diagnostic Studies
Difficult to establish a definitive diagnosis
Laboratory results rule out other suspected disorders.
Occasionally a low ANA titer is seen. Not considered diagnostic
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21
Fibromyalgia Syndrome (FMS)Diagnostic Studies
Muscle biopsy may reveal a nonspecific moth-eaten look or fiber atrophy.
FMS if two criteria are met Pain is experienced in 11 of 18
tender points on palpation. History of widespread pain for
at least 3 months is noted.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22
Fibromyalgia Syndrome (FMS)Collaborative Care
Treatment is symptomatic and requires a high level of patient motivation.
Teach patient to be an active participant in therapeutic regimen.
Pain, aching, and tenderness can be helped by rest.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23
Fibromyalgia Syndrome (FMS)Collaborative Care Analgesics are effective for some.
Acetaminophen (Tylenol), NSAIDs Low-dose tricyclic antidepressants
Stress, fatigue, sleep disturbances Serotonin reuptake inhibitor (SSRI)
antidepressants Reserved for those with depression
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24
Fibromyalgia Syndrome (FMS)Collaborative Care
Benzodiazepines prescribed with low doses of ibuprofen Anxiety, muscle spasms
Zolpidem (Ambien) for severe sleep disturbances
Gabapentin (Neurontin) Pregabalin (Lyrica)
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25
Fibromyalgia Syndrome (FMS)Nursing Management FMS patients need consistent
support. The nurse Other members of health care team
Massage combined with ultrasound Application of alternating heat and
cold packs Soothes tense, sore muscles Increases blood circulation
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26
Fibromyalgia Syndrome (FMS)Nursing Management
Gentle stretching to relieve muscle tension and spasm
Yoga and Tai Chi Low-impact aerobic exercise
helps prevent muscle atrophy.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27
Fibromyalgia Syndrome (FMS)Nursing Management
Limited intake of known muscle irritants Sugar, caffeine, alcohol
Vitamin and mineral supplements
Relaxation strategies Biofeedback, guided imagery,
autogenic training Psychologic counseling
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28
Chronic Fatigue Syndrome (CFS) Also called chronic fatigue
and immune dysfunction Characterized by
Debilitating fatigue Variety of associated
complaints Immune abnormalities
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29
Chronic Fatigue Syndrome (CFS) Difficult to establish
prevalence Lack of validated diagnostic
tests Women more often than men Occurs in all ethnic groups and
socioeconomic groups CFS and FMS share common
features. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30
Chronic Fatigue Syndrome Etiology and Pathophysiology
Precise mechanisms remain unknown.
Many theories about cause Neuroendocrine abnormalities
involving hypofunction of HPA axis and HPG (hypothalamic-pituitary-gonadal) axis have been implicated.
Together regulate stress response and reproductive hormone levels
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31
Chronic Fatigue Syndrome Etiology and Pathophysiology
Several microorganisms have been investigated. Herpesviruses
Epstein-Barr (EBV) Cytomegalovirus (CMV)
Because cognitive deficits occur in many CFS patients, CNS changes are also proposed.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32
Chronic Fatigue Syndrome Clinical Manifestations
Difficult to distinguish between CFS and FMS
CFS develops insidiously in approximately half of cases. Or patient may have
intermittent episodes that gradually become chronic
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33
Chronic Fatigue Syndrome Clinical Manifestations
Incapacitating fatigue Is the most common symptom Problem that causes patient to
seek health care Associated symptoms
fluctuate in intensity over time.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34
Chronic Fatigue Syndrome Clinical Manifestations
Patient may become angry and frustrated with inability to diagnose the problem.
Disorder can have a major impact on work and family responsibilities.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35
Chronic Fatigue Syndrome Diagnostic Studies
Physical examination and diagnostic studies rule out other possibilities.
No laboratory test can diagnose CFS or measure its severity.
In general, a diagnosis of exclusion
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 36
Chronic Fatigue Syndrome Nursing and Collaborative Management
Supportive management is essential.
Inform patient about disease. All complaints should be taken
seriously. NSAIDs can be used to treat
Headaches Muscle and joint aches Fever
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37
Chronic Fatigue Syndrome Nursing and Collaborative Management
Many CFS patients have allergies and sinusitis. Antihistamines Decongestants
Tricyclic antidepressants improve Mood Sleep
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 38
Chronic Fatigue Syndrome Nursing and Collaborative Management
Clonazepam (Klonopin) for Sleep disturbances Panic disorders
Low-dose hydrocortisone is being studied. Decreases fatigue and
disability
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 39
Chronic Fatigue Syndrome Nursing and Collaborative Management
Total rest is not advised.
Important to plan a graduated exercise program
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 40
Chronic Fatigue Syndrome Nursing and Collaborative Management
Well-balanced diet Fiber Dark-colored fruits and vegetables
Behavioral therapy Financial instability
Major problem facing CFS patients Cannot work or decreased time
working
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 41
Chronic Fatigue Syndrome Nursing and Collaborative Management
CFS does not progress. Most patients recover or
gradually improve over time. Some do not show ample
improvement.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 42
Case Study
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 43
Case Study 1 32-year-old woman visits her
physician complaining of severe fatigue.
Her symptoms began about 3 months ago.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 44
Case Study 1 She states that she does not
feel better despite resting during the past week.
She also complains of general malaise and an inability to concentrate.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 45
Case Study 1 Because of the fatigue, she
has needed to ask her sister to help her around the house and to drive her kids to activities.
She had a mononucleosis infection approximately 6 months ago.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 46
Case Study 1 Physical examination reveals
a positive response for tender cervical nodes and joint pain.
She is suspected of having chronic fatigue syndrome.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 47
Case Study 1Discussion Questions1.What symptoms of chronic
fatigue syndrome does she display?
2.What patient teaching should you do with her?
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 48
Case Study 1Discussion Questions3. What classes of medication
may help?
4. What emotional and psychosocial issues may you need to address with her?
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 49
Case Study 2 45-year-old woman calls a
nurse hotline to ask for advice.
She is experiencing burning pain throughout her body that comes/goes and overwhelming fatigue.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 50
Case Study 2 She has tried getting
massages and doing yoga and obtained only slight relief of the pain.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 51
Case Study 2 She is concerned that she
might have some widespread infection.
She also states she has insomnia and feels tired in the morning.
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 52
Case Study 2 She has a history of irritable
bowel syndrome.
Admits she also has urge to move legs when recumbent and occasionally has numbness in hands and feet
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 53
Case Study 2Discussion Questions1.What are the likely causes of
her symptoms?
2.What is the difference between fibromyalgia syndrome and chronic fatigue syndrome?
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 54
Case Study 2Discussion Questions3. What drug treatments are
available?
4. What essential patient teaching should you do with her?
5. What nutritional counseling can you provide?
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 55