Company
LOGO
Fibromyalgia &
Soft Tissue Rheumatism
Shin-Seok Lee, M.D.
Chonnam National University Medical School
Musculoskeletal Disorder
Articular
Inflammatory
Noninflammatory
Monarticular
Septic arthritis
Gout
Pseudogout
Viral arthritis
Juvenile arthritis
Sarcoid
Fungal
Trauma
Osteonecrosis
Osteoarthritis
Charcot joint
Hemarthrosis
PVNS
Foreign body
Polyarticular
Rheumatoid arthritis
SpA
SLE
Rheumatic fever
Juvenile arthritis
Scleroderma
Lyme
Osteoarthritis
Sickle cell
Hemarthrosis
Hemochromatosis
Hypertrophic
osteoarthropathy
Periarticular
Inflammatory
Noninflammatory
Localized
Bursitis
Tendinitis
Tenosynovitis
Epicondylitis
Periostitis
Costochondritis
Carpal tunnel
Sickle cell
Multiple myeloma
Osteoid Osteoma
Reflex sympathetic
dystrophy
Systemic
PMR
Polymyositis
Periostitis
Enthesitis
Eosinophilic fasciitis
Myasthenia gravis
Polychondritis
Fibromyalgia
Multiple myeloma
Myxedema
Osteoporosis
Pagets
섬유근통 증후군에 관한 설명 중 틀린 설명은?
1. 80-90%가 여성이며, 호발 연령은 25-55세이다.
2. 만성 근골격계의 증후군으로 미만성 통증과 압통점이
특징적이며 이럴 경우 NSAID와 steroid가 도움이 된다.
3. stage 4(non-REM) sleep 장애, serotonin의 결핍, 우울증
등이 이 질환과 관계 있다.
4. 주요 압통 부위는 thumbnail, forehead, distal dorsal
forearm 등이 있다.
가. 1,2,3
나. 1,3
다. 2,4
라. 4
마. 1,2,3,4
Chronic Widespread Pain and Fibromyalgia
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Prevalence of chronic widespread pain
Prevalence of chronic widespread
pain
1. US study – 10.6%, 95% CI (9.5, 12)
2. UK study – 11%
25
Prevalence (%)
20
female
male
15
10
5
0
18-29 30-39 40-49 50-59 60-69 70-79
>80
Prevalence of fibromyalgia
1. Wolfe et al – 2.0% 95% CI (1.4, 2.7)
2. Finland study – 0.8%
Age-group (years)
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Prevalence of CWP and FM in Korea
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 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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Chronic Widespread Pain and Fibromyalgia
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Percentile
Prevalence of fibromyalgia
Individuals with
fibromyalgia
Rheumatology clinics
20%
Internal medicine clinics
6%
Family practice clinics
2%
General medicine inpatients (UK)
5%
General population
1%
Tenderness
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What is Fibromyalgia?
Pressure pain threshold (kg)
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Fibromyalgia
Healthy control
4kg
Allodynia
Hyperalgesia
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1990 ACR Classification Criteria
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I.
History of chronic widespread pain involving all 4 quadrants of the body
II. Pain in 11 of 18 tender points on digital palpation
1.
2.
3.
4.
5.
6.
7.
8.
9.
Occiput: bilateral, at the suboccipital muscle insertions.
Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7.
Trapezius: bilateral, at the midpoint of the upper border.
Supraspinatus: bilateral, at origins, above the scapula spine near the medial border.
Second rib: bilateral, at 2nd costochondral junctions.
Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.
Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
Greater trochanter: bilateral, posterior to the trochanteric prominence.
Knee: bilateral, at the medial fat pad proximal to the joint line.
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.
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Tender Point
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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
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What is Fibromyalgia?
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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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What is Fibromyalgia?
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Tension/migraine headache
Temporomandibular
joint syndrome
Regional musculoskeletal
pain (e.g. chronic cervical
or lumbar pain,
“tendinosis”, repetitive
strain syndrome,
myofascial pain syndrome)
Irritable bowel
syndrome
Chronic sinusitis
Sicca symptoms, vasomotor rhinitis
Non-cardiac chest pain, “Syndrome
X”, costochondritis
Biliary dyskinesia, postcholecystectomy syndrome
Interstitial cystitis,
female urethral syndrome,
vulvar vestibulitis, vulvodynia
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Pathogenesis
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 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
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OA, RA, Inflammation, Neuropathies,
Injuries, Disc disorders, Visceral pain,
Chronic headaches, TMJ, Spinal stenosis,
Repetitive strain, Endometriosis, Myofascial
pain
peripheral
tissues
pain
generators
central
spinal cord
and brain sensitization
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Altered central pain processing
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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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Altered central pain processing
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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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Altered central pain processing
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Mean CSF levels of substance P in
fibromyalgia
50
Normal
FMS
fmole/ml
40
 Threefold higher concentrations of
substance P in CSF of FM patients
 Low levels of norepinephrine and its
metabolite, 3-methoy-4-hydroxy
phenethylene, in CSF of FM patients
30
 Low levels of serotonin and its precursor,
20
L-tryptophan, in the serum and low levels
of the principal metabolite, 5-hydroxy
10
indoleacetic acid in CSF
0
Vaeroy Russell
Welin Bradley
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섬유근통 증후군에 관한 설명 중 틀린 설명은?
1. 80-90%가 여성이며, 호발 연령은 25-55세이다.
2. 만성 근골격계의 증후군으로 미만성 통증과 압통점이
특징적이며 이럴 경우 NSAID와 steroid가 도움이 된다.
3. stage 4(non-REM) sleep 장애, serotonin의 결핍, 우울증
등이 이 질환과 관계 있다.
4. 주요 압통 부위는 thumbnail, forehead, distal dorsal
forearm 등이 있다.
가. 1,2,3
나. 1,3
다. 2,4
라. 4
마. 1,2,3,4
58세 여자환자로 6개월 전부터 지속된 쇠약감과 전신적인 근육통을
주소로 내원하였다. 승모근, 늑골, 늑역골 관절, 내측 무릎 등에 대칭
적인 통점을 가지고 있었다. 환자는 류마티스 인자 및 항핵항체는 음
성이었고 적혈구 침강속도도 정상이었으며 기타 신경학적 검사에서
이상소견은 없었다. 상기 환자에 대한 설명 중 옳은 것은?
1. 주로 여자에게서 발생하며 대부분 연령은30-50대 이다.
2. 대부분의 환자들이 활동성의 정신의학적 질환을 가지고 있다.
3. 류마티스 관절염에 병발할 수 있다.
4. 특징적인 REM sleep의 장애를 동반한다.
가. 1,2,3
나. 1,3
다. 2,4
라. 4
마. 1,2,3,4
45세 여자가 수 년간 지속되는 전신 통증으로 왔다. 관절
의 압통과 종창은 없었고, 전신 근육에 압통점이 뚜렷하게
있었다. 류마티스 인자, 항핵항체는 음성이었고 갑상선 기
능검사는 정상이었으며 다른 특이소견은 없었다. 치료로
적절한 것은?
1. amitriptyline
2. 유산소운동
3. tramadol
4. prednisolone
가. 1,2,3
나. 1,3
다. 2,4
라. 4
마. 1,2,3,4
Management
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 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
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Antidepressant: summary of randomized, controlled trials
Class
Compound(s)
TCA
Amitriptyline
Clomipramine
Doxepin
SSRI
SNRI
MAOI
Pharmacology
5-HT/NE reuptake inhibitor
Cation channel blocker
NMDA antagonist
Anticholinergic
Antihistaminergic
Fluoxetine
5-HT reuptake inhibitor
Citalopram
5-HT reuptake inhibitor
Sertraline
5-HT reuptake inhibitor
Venlafaxine
5-HT > NE reuptake inhibitor
Milnacipran
NE > 5-HT reuptake inhibitor
NMDA antagonist
MoclobemideReversible, MAO inhibitor
Pirlindole
Reversible, MAO inhibitor
Pain Sleep Fatigue
Mood
Treating other FSS
+
+
+
-
IBS
TMJD
CLBP?
CTTH prophylaxis
+
+
+
+
+
-
+
+
+
+
+
CTTH prophylaxis
CTTH prophylaxis
CTTH prophylaxis
CTTH prophylaxis
+
+
+
-
+
+
CTTH prophylaxis, CFS
CTTH prophylaxis
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Pharmacologic therapy
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Summary of randomized, controlled trials
Class
Compound(s)
Muscle
relaxant
Cyclobenzaprine 5-HT2 antagonist
+
Anticholinergic
Antihistaminergic
Pregabalin
Ca channel blocker
+
Zopiclone
BZ receptor agonist
Zolpidem
Ibuprofen
Nonspecific COX inhibitor
Naproxen
Morphine (IV)
Mu agonist
Tramadol
Mu agonist
+
5-HT/NE reuptake inhibitor
Tropisetron
5-HT3 antagonist
+
Growth hormone Growth hormone
+
Anti-epileptics
Sedative
Hypnotics
NSAIDs
Opiates
Other
Pharmacology
Pain
Sleep
Fatigue Mood
+
+/-
+
+
+
-
-
-
-
-
+
+
Other FSS
IBS
CLBP
TMJD
CTTH
CLBP
IBS?
+
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Pharmacologic therapy
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 Antidepressant – rationale
 Alpha-delta NREM sleep abnormality mediated by an abnormality in
central 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
neurotransmitters, particularly serotonin (5-HT) and/or norepinephrine
(NE)
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Pharmacologic therapy
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Treatment of Fibromyalgia with Tricyclic Antidepressants:
A Meta-Analysis
9%
11.6
10.6
rating scale
12
treatment mean*
placebo mean*
10
8
6
5.0
23%
6.5
26%
14%
5.8
5.8
4.3
4
5.0
18%
6.5
5.2
2
0
fatigue
trigger
points
pain
symptoms
sleep
wellbeing
O’Malley PG, et al. J Gen Intern Med 2000;15:659
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Pharmacologic therapy
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Effect Size
(Standard Deviations)
TCA Treatment of Fibromyalgia: A Meta-Analysis
1.5
1.0
0.5
0.0
-0.5
Patient
M.D.
Global
Global
AssessmentAssessment
Pain
Fatigue
Sleep Tenderness Stiffness
Outcome Measure
Arnold LM, et al. Psychosomatics 2000;41:104
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Pharmacologic therapy
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 Recommendations
1.
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
zopiclone may be of benefit.
6.
For pain control, use the tramadol. Limit the use of antiinflammatory agents,
narcotic analgesics, and muscle relaxants.
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45세 여자가 수 년간 지속되는 전신 통증으로 왔다. 관절
의 압통과 종창은 없었고, 전신 근육에 압통점이 뚜렷하게
있었다. 류마티스 인자, 항핵항체는 음성이었고 갑상선 기
능검사는 정상이었으며 다른 특이소견은 없었다. 치료로
적절한 것은?
1. amitriptyline
2. 유산소운동
3. tramadol
4. prednisolone
가. 1,2,3
나. 1,3
다. 2,4
라. 4
마. 1,2,3,4
35세 여자 환자가 전신통증과 피로감을 주소로 내원하였다. 평소
에 만성 근육통과 수면장애가 있었다. 목, 어깨, 하지에 걸치는 전
신적인 통증이 있었고 약간의 움직임에도 악화되었다. 신체검사
에서 뒷목, 양어깨, 허리, 무릎에 대칭적인 압통점이 있었으나 방
사선 검사에서 이상소견은 관찰되지 않았다. 항핵항체와 류마티
스 인자는 음성이었고 ESR은 10 mm/hr였다. 이 환자에서 적절하
지 않은 치료는?
1.
2.
3.
4.
5.
유산소운동
cyclobenzaprine
prednisolone
tricyclic antidepressants
zolpidem
삼환계 항우울제와 플루옥세틴(fluoxetine)으로 증상이 조
절되지 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 신
체검사 두 가지는?
답) Tinel's sign과 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
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
50세 여자가 왼쪽 어깨관절의 통증을 주소로 내원하였다.
환자는 3개월 전부터 왼쪽 어깨의 통증을 느끼기 시작했
으며 최근 들어서는 왼쪽으로는 누워 자기가 힘들 정도로
통증이 심하다고 하였다. 과거력상 당뇨는 없었고 신체검
사에서 왼쪽 어깨의 수동 능동 운동 모두에 제한이 있었고
X선 촬영에서 뚜렷한 이상 소견은 발견되지 않았다. 상기
환자의 가능한 진단은?
답) 유착관절낭염 (adhesive capsulitis)
Differential Diagnosis of Shoulder Pain
Diagnosis
Age Type of Location Night Active
onset of pain pain ROM
Passive Impinge Radia Pares- Weak- InstaRadio- Special
ROM
ment -tion thesia ness
bility
graphic features
sign
changes
Rotator cuff
Any Acute or Deltoid +
↓↓
Normal
+++
Only due Look for In chronic Painful arc of
tendinitis
chronic region
guarding
to pain
cases abduction
Rototor cuff
Over Often Deltoid ++
↓↓↓
Normal
++
++
+
Wasting of
tears (chronic)
40 yr chronic region
cuff muscles
Bicipital
Any Overuse Anterior ↓
Normal
+
Only due Look for None Speed test
±
tendinitis
guarding
to pain
Yergason test
Calcific tendinitis 30- Acute Point of ++
↓↓↓
Normal
+++
Only due
++
Tenderness
60 yr
shoulder
guarding
to pain
++
Adhesive
Over Insidious Deep in ++
↓↓
↓↓
+
Global ROM↓
capsulitis
40 yr
shoulder
Acromioclavicular Any Acute or Over Lying ↓full
Normal
In chronic Local
joint
chronic joint
on elevation
cases tenderness
side
Osteoarthritis of Over Insidious Deep in ++
↓↓
↓↓
May have
+++
Crepitus
glenohumoral jt. 40 yr
shoulder
mild
Glenohumoral
<25 Episodic Ant. or
Only
Only Possible + with + with
+++
Often Stress test
instability
yr
post.
appre- appreacute acute
hension hension
episode episode
Cervical
Over Insidious Supra- Often Normal Normal
++
+++
+
Cervical Pain with
spondylosis
40 yr
scapular
spine neck
movement
Thoracic outlet
Any Usually Neck
Normal Normal
++
++
++
syndrome
with shoulder
activity
arm
55세 여자가 6개월 전부터 서서히 진행하는 우측 어깨의 통증과
운동 장애를 주소로 내원하였다. 신체검사에서 부종이나 종창, 발
적은 동반되지 않았으나 환자 스스로 우측 어깨를 모든 방향으로
움직일 수 없었으며 검사자의 도움으로도 비슷한 정도의 운동 장
애를 보였다. 방사선 촬영에서는 우측 어깨 관절 주위의 골감소 이
외에 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