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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #12

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LEARNING OBJECTIVES

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Learning Objectives

  • Know the distinguishing elements of the history and physical examination for older adults with fibromyalgia as compared with myofascial pain.

  • Describe the three-pronged approach to treating myofascial pain syndromes.

  • List the nonpharmacologic and pharmacologic treatments for fibromyalgia that are supported by strong evidence and have an acceptable safety profile for older adults.

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Key Clinical Points

  1. Fibromyalgia and myofascial pain are distinct syndromes that may occur independently or coexist.

  2. Myofascial pain syndromes are diagnosed by eliciting a characteristic history coupled with identification of active trigger points on physical examination.

  3. Myofascial pain syndromes may present with neuropathic symptoms such as paresthesias and burning and can mimic radiculopathy. As they are treated best using nonpharmacologic strategies, their diagnosis can prevent exposing frail older adults to multiple potential adverse drug effects and unnecessary procedures.

  4. Older adults presenting with widespread pain should undergo a comprehensive history and physical examination including careful review of their medications. If a potential cause is not elicited, fibromyalgia screening should ensue. The 2010 Revised Fibromyalgia Criteria allow for disease screening without the need for a tender point examination.

  5. Fibromyalgia syndrome (FMS) is common in older adults and may be the sole cause of pain or a key pain comorbidity. Axial pain is common in FMS, and in older adults with neck, upper, or low back pain, FMS should be screened routinely.

  6. FMS is associated with a number of nonpharmacologic and pharmacologic treatments with strong efficacy evidence. Older adults should be encouraged about the wide range of effective treatments that are available.

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Fibromyalgia and myofascial pain syndromes (MPSs) are among the most common musculoskeletal disorders from which older adults suffer. These disorders represent opposite ends of the pain spectrum with the discrete character of MPS at one extreme and the widespread symptoms of fibromyalgia at the other. It should be noted that these disorders may coexist in the same patient. Because MPS are so commonplace, patients with fibromyalgia often have coexisting MPS and the converse occurs less frequently. MPS may be acute or chronic, and is associated with taut muscle bands and hypersensitive areas called trigger points. Fibromyalgia syndrome includes symptoms of sleep disruption, fatigue, and psychological distress in addition to widespread pain. Both fibromyalgia and MPS may result in significant functional impairment and cause suffering and disability comparable to that of rheumatoid arthritis and osteoarthritis. Diagnosis of these disorders is grounded in appropriately targeted history and physical examination; these are the tools required to avoid unnecessary ordering of “diagnostic” tests and foster implementation of appropriate management strategies.

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FIBROMYALGIA SYNDROME

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Definition and Epidemiology

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The gold standard for diagnosing fibromyalgia is clinical evaluation by a specialist. In 1990, the American College of Rheumatology (ACR) developed criteria to help distinguish FM from other rheumatologic disorders associated with widespread pain (eg, systemic lupus ...

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