Fibromyalgia Syndrome: Rheumatology Notes

• These are study notes on rheumatology and capsule remobilization

Fibromyalgia Syndrome

• Characterized by a diffuse pain index, severity score, symptoms lasting at least 3 months, and exclusion of other pathologies
• Diagnosis is made by ruling out other conditions, no specific marker exists
• It is more frequent in women

Fibromyalgia: Physiopathology

• Painful stimuli sent through nociceptive fibers to the spinal cord, integrates in the posterior horn, then ascends to the thalamus
• Body has pain control systems that can be dysfunctional in fibromyalgia
• Cortex links to behavior, thalamus to intensity/emotions, and there are vegetative reactions and neurotransmitters like dopamine involved.
• “Dysnociception” causes diffuse pain and neuropathic allodynia.
• The syndrome results from a dysregulation in the cerebral and medullary systems, linked to central sensitization and pain memory.

Treating Fibromyalgia

• Involves a thorough assessment of pain, function, and psychosocial factors.
• European League Against Rheumatism recommends a global evaluation.
• Treatment requires a multidisciplinary approach
• Avoid overuse of medication

Pharmacological Treatments

• Antalgics of level 2, include tramadol
• Opioids are to be avoided
• Corticoids are avoided
• Antidepressants such as amitriptyline used for neuropathic pain at low doses.
• Pregabalin can be used through secure prescriptions.

Non-pharmacological Treatments

• Doing physical activity is important
• Balneotherapy can be useful

Other non-pharmacological treatment options

• Relaxation, sophrology, and physiotherapy
• Psycho-corporeal therapies like mindfulness and mediation
• Hypnosis and autohypnosis
• Meditative and movement therapies like yoga

More treatment options

• Music therapy, art therapy, resonance therapy, and mesotherapy
• Thermalism, transcranial magnetic stimulation, and hyperbaric chambers
• Acupuncture or auriculotherapy

Vagus Nerve Stimulation

• Involves electrostimulation to reduce pain
• Noninvasive and can regulate autonomic functions
• Stimulating helps with digestion, anti-inflammation
• Used with migraines, polyarthritis, and face pain

Fibromyalgia conclusion

• A disorder of nociceptive pain pathways caused by physical or psychological stress
• Linked to genetic or acquired predisposition
• Causes central sensitization
• Can lead to exhaustion

Complex Regional Pain Syndrome (CRPS)

• Also known as algoneurodystrophy
• CRPS-1 follows a nociceptive initiating event with symptoms not corresponding to specific nerve territory
• CRPS-2 follows a nerve lesion with immediate effects
• CRPS-1 involves spontaneous pain, allodynia, hyperalgesia, vasomotor, sudomotor, and trophic changes
• CRPS-2 is similar, but distribution can be limited or not, to the injured nerve territory

CRPS: Etiological Circumstances and Predisposing Factors

• Traumatic
• Extra-skeletal factors
• Iatrogenic Factors
• Immobilization, maladapted kinesitherapy, endocrine disruption, and psychological factors are also involved

Clinical manifestations

• Can be regional, spontaneous, and continuous
• Vasomotor, sudomotor, and trophic changes
• Aggravated by movement
• Mechanical or thermal allodynia/hyperalgesia

CRPS: Topographic Forms and Evolution

• hand, shoulder, hip, knee, or foot involvement
• The evolution includes a chronic aspect with trophic disorders
• Can extend the pain to the contralateral side
• Relapses may occur contralaterally

CRPS: Post-traumatic Form

• Initial phase: pseudo-inflammatory with pain, edema, vasomotor issues for weeks
• Cold phase: sclero-atrophic phase for months
• Resolution: symptoms resolve, sometimes with sequelae

Complementary Examinations

• Radiography shows demineralization
• Biology is normal
• MRI shows bone and medullary edema
• Biphosphonates and Vitamin C may be used for bone density

Treatment principles

• Focus on pain relief and functional recovery
• Physical treatments is the cornerstone
• Drug treatments include analgesics, anti-depressants or anti epileptic medicines

Physical treatment methods

• Should avoid pain while in a hot phase
• Hydrokinesitherapy, gentle drainage and assisted active movement is useful in the hot phase
• Hydrokinesitherapy and progressive stretching is useful in the cold phase

Key CRPS messages

• Should suspect especially when initially a pseudo inflammatory picture
• Normal biology
• MRI shows edema
• Bone scan shows hyper fixation in a hot phase
• Scintigraphy and MRI can help with the diagnosis
• Physical management is major

Osteonecrosis

• Can be aseptic or septic
• Aseptic osteonecrosis relates to the cellular death of oss components, such as bone marrow or fatty tissue

Clinical Presentation

• Typically insidious pain with possible but not limited trauma
• Mechanical pain with possible intermittence
• Pain at the extreme movements

Diagnosing Osteonecrosis

• Bloods normal
• Radiography to show any defects
• Also look for lipid or lupus cause
• Can also look for drépanocytose
• Smoking and Corticoids are risk factors

Osteonecrosis Imaging

• Radiography show be slow
• Radiography can be used with the Ficat standard
• Scintigraphy where radio graphic abnormalities are not present
• MRI to see extent of the damage

Osteonecrosis Evolution and Causes

• Corticotherapy, alcohol
• Trauma, accident, radiotherpay
• Can become tumoral
• Genetic

Risk with prosthesis

• Loss of the femoral sphere with subsequent arthrosis
• Primarily depend on the symptoms whether a prosthesis is needed

Treatment

• Retard sinking of the damaged tissue
• Reduced load on the limb
• Take analgesics

Osteochondrosis

• Disorders that affect the epiphyses
• Osteochondritis of the hip affects boys largely and is a necrosis of the femoral epiphysis
• No link to trauma

Clinical

• Mechanical and recurrent pain
• Normal bones

Diagnosing

• X-ray is normal at the beginning
• Will see signs of ossification
• Can see a condensation stage

Treating Osteochondrosis

• Can be prolonged with discharge
• Can do surgery
• Kohler disease causes inflamed feet in kids
• Osgood schlatter causes issues with the knee

Scheuermann's Disease

• It results in a osteochondritis of vertebral plates
• Will see a hunch on the back to compensate

Osteomalacia

• Os that lacks mineralization
• Mal formed bone due to vitamin d deficiency
• The same as rachitisme in kids

Symptoms

• Feeling bad everywhere
• Limping gait

Imaging

• Osseous demineralization
• Shows flou image of the bone
• Need to identify and correct

Tumour Osseuse

• Can be primary of secondary
• Symptom is bone pain and fractures
• Do radiology and imagery to diagnose

Radiology for Tumour diagnosis

• Can also use scanner and scintigraphic views
• A key exam is to have a biopsy

Bone cancer secondary

• Frequent for adults
• Love bone
• Revealing
• Often axial skeleton
• Metastatic origin

Syndromes Canalaires

• Neurological manifestation from a nerve
• Irritation of a nerve when traversing a osteonigamentous
• Clinical is linked with the relevant nerve

The median Nerve

• Compression of the nerve
• High correlation to inflamed rhumatismes
• Sensitivity in the first three digits

Clinical and motor signs

• Motor signs include weakness of the hand
• This disappears with shaking
• The exam is with forced inflection
• Neurology will show deficiency

Treatment

• Night splint
• Injection of corticoids
• Can require surgery

Nerve ulnar

• Parallels the nerve median
• Touches finger mainly
• Often by trauma

Treatment ulnar

• Posture
• Correction
• Orthosis and surgery

Fibrular

• Postural
• External compression

Sensory Symptomatology

• Involving the external side of the leg
• The diagnostic is with percussion
• Can see radi and echo for diagnostics

Sydrome thoraco-bracial

• Rare
• compression of the brachial artery
• Evoked pain must point to this
• Can hear breath

Treatments

• Imagery
• Nerve scan
• Communicate with neuro colleagues

Meraglai Paresthesique

• Face lateral of the cuisse
• compression on the lateral cutaneous fémoro
• diagnostic is by looking at the pain
• there is a high correlation
• can do electro myogram to confirm
• Improve spontaneously

Treatment and causes

• Clothes can trigger it
• Not carry clothes that are tight
• Tarsien-nerve tibial posterior- compression occurs mostly in ankles/feet
• description de douleuurs neuropathiques
• can put tinel if have had zone to trigger.
• Diagnostic clinical
• Can do radiograph for oss
• Electro myogram can confirm
• Corrections statiques via podologue
• Infractions and surgeries are rare