Dr Ng Swee Cheng Senior Consultant Khoo Teck Puat Hospital

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1 Dr Ng Swee Cheng Senior Consultant Khoo Teck Puat Hospital

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3 1. Soft Tissue Rheumatism 2. Myofascial Pain 3. Neurovascular compression Syndromes 4. Complex Regional Pain Syndromes

4 Tendinitis, tenosynovitis Enthesitis Bursitis

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9 Regional myofascial pain Generalised myofascial pain - Fibromyalgia

10 Deep aching pain, occasionally with burning or stinging. Often restricted active movement. The pain often in one body region, and may lead to a chronic regional perplexing pain disorder. Trigger points present feel indurated to palpation, and palpation reproduces the pain in the "target zone" The Trigger Point Manual: Upper Half of Body, 2nd edition. Result from acute trauma, repeated minor microtrauma or chronic strain.

11 Of 54 patients whose reason for a visit included pain, 16 (30%) had myofascial pain West J Med. 1989;151(2):157. Myofascial trigger points are very prevalent in patients with chronic tension-type headache Clin J Pain. 2007;23(1):23 Magnetic resonance elastography (MRE) can identify and quantitate asymmetries in the muscle tone of the taut bands of trigger points in patients with myofascial pain. 50% greater muscle tone Arch Phys Med Rehabil. 2007;88(12):1658..

12 Variable Myofascial Pain Fibromyalgia Pain Localized Generalized Examination Trigger points Trigger points Fatigue Data Unknown Prominent Gender Data Unknown 90% Female Course May be self-limiting Chronic

13 History of widespread pain > 3 months, both sides of the body, above and below the waist, axial skeleton Pain in 11 of 18 tender point sites on digital palpation with approximate force of 4 kg. Arthritis Rheum. 1990;33:

14 11/18

15 Severe pain & symptoms WPI >/= 7, SS scale >/= 5 WPI >/= 3-6, SS scale >/= 9 Symptoms > 3 months No disorder that would otherwise explain the pain WPI - Widespread Pain Index SS - Symptom Severity Arthritis Care Res 2010; 62:600.

16 In how many of the 19 areas has the patient had pain last week? Score will be between 0 and 19

17 Fatigue Waking unrefreshed Cognitive Symptoms Somatic Symptoms No symptom (0) Slight or mild(1) Moderate, considerable(2) Severe, pervasive, continuous, life-disturbing problems(3) Somatic Symptoms: muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering problem, muscle weakness, headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud's phenomenon, hives/welts, ringing in ears, vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms

18 Central thoracic outlet syndrome Peripheral carpal tunnel syndrome

19 Neck and shoulder pain referred to inner arm. The triad of numbness, weakness, and a sensation of swelling of the upper limbs. Positive Roos sign (3 minutes of abduction & external rotation of the shoulder causing pain, fatigue and paraesthesiae in the ulnar nerve distribution) Positive Adson's test (diminution of the radial pulse when the arm is abducted, extended backward, the head is turned ipsilaterally, and the patient inspires)

20 Pain or paresthesia (numbness and tingling) Worse at night Patients react to these symptoms by shaking

21 Diagnosis regional pain and sensory changes following a noxious event. Often associated with abnormal skin color, temperature changes, abnormal autonomic activity or edema. Pathogenesis may involve formation of reflex arc aften an inciting event. The arc follows the routes of the sympathetic nervous system and is modulated by cortical centres to produce peripheral vascular disturbances.

22 CRPS is a disorder of the extremities with pain, swelling, limited range of motion, vasomotor instability, skin changes, and patchy bone demineralization.

23 Subacute Reflex sympathetic dystrophy - diffuse edema, erythema, and flexion deformity. In the chronic stage, atrophy of the skin and flexion contractures of the fingers may occur resulting in a useless claw-like limb.

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25 Provide relief from pain (KIV Pain Team, Psychiatrist etc as needed). Provide an explanation to the patient. Recognize and eliminate aggravating factors (possibly work related) PT, OT & self help exercises. Project an expected outcome. Is there anything else??

26 Helliwell

27 Is this just a simple Soft Tissue Rheumatic Disorder? Is there anything else?

28 Systemic diseases diabetes mellitus, hypothyroidism, occult neoplasm, Structural issues hypermobility syndrome other structural deficits Consider screening tests for bilateral CTS, frozen shoulder, or fibromyalgia. These tests include urinalysis, ESR, CRP & appropriate chemistry tests.

29 Uric crystals

30 A 2003 systematic review of CTS found an association with: diabetes (OR2.2) hypothyroidism (OR 1.4) and RA (OR 2.2) Clin Chem. 2003;49(9):1437. One-third of patients with acromegaly have CTS, frequently bilateral. Medicine (Baltimore). 1994;73(5):233.

31 Enthesis is highy vascular and is susceptible to bacterial invasion and antigen deposition

32 Sports injury Infection eg. TB Spondyloarthritis Hyperlipidemia

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35 Not all aches and pains arise from the joint. Recognize the forms of non-articular musculoskeletal pain and manage accordingly. Four categories given here There may be an underlying condition that caused the non-articular musculoskeletal pain. Recurrent soft tissue rheumatism Diabetes Mellitus Enthesitis - Spondyloarthritis

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