Fibromyalgia

The pain of FM is profound, widespread and chronic. It knows no boundaries, migrating to all parts of the body and varying in intensity. FM pain has been described as stabbing and shooting pain and deep muscular aching, throbbing, and twitching. Neurological complaints such as numbness, tingling, and burning are often present and add to the discomfort of the patient. The severity of the pain and stiffness is often worse in the morning. Aggravating factors that affect pain include cold/humid weather, non-restorative sleep, physical and mental fatigue, excessive physical activity, physical inactivity, anxiety and stress.

In today's world many people complain of fatigue; however, the fatigue of FM is much more than being tired. It is an all-encompassing exhaustion that interferes with even the simplest daily activities. It feels like every drop of energy has been drained from the body, which at times can leave the patient with a limited ability to function both mentally and physically

Many fibromyalgia patients have an associated sleep disorder that prevents them from getting deep, restful, restorative sleep. Medical researchers have documented specific and distinctive abnormalities in the deep sleep stage of FM patients. During sleep, individuals with FM are constantly interrupted by bursts of awake-like brain activity, limiting the amount of time they spend in deep sleep.

Temporomandibular Joint Dysfunction Syndrome (TMJ) causes tremendous jaw-related face and head pain in one-quarter of fibromyalgia patients. However, a 1997 published report indicated that close to 75% of fibromyalgia patients has jaw discomfort. Typically, the problems are related to the muscles and ligaments surrounding the jaw joint and not necessarily the joint itself.

Additional symptoms may include: irritable bowel and bladder, headaches and migraines, restless legs syndrome (periodic limb movement disorder), impaired memory and concentration, skin sensitivities and rashes, dry eyes and mouth, anxiety, depression, ringing in the ears, dizziness, vision problems, Reynaud's Syndrome, neurological symptoms, impaired coordination, premenstrual syndrome and painful periods, chest pain, morning stiffness, numbness and tingling sensations, muscle twitching and the feeling of swollen extremities. Fibromyalgia patients are often sensitive to odors, loud noises and bright lights.

While many chronic pain syndromes display symptoms that overlap with fibromyalgia, the 1990 American College of Rheumatology (ACR) multi-center criteria study (published in the February 1990 issue of Arthritis and Rheumatism) evaluated a total of 558 patients, of which 265 were classified as controls. These control individuals weren't your typical healthy "normals." They were age and sex matched patients with neck pain syndrome, low back pain, local tendonitis, trauma-related pain syndromes, rheumatoid arthritis, lupus, osteoarthritis of the knee or hand, and other painful disorders. These patients all had some symptoms that mimic fibromyalgia, but the trained examiners were able to hand-pick the fibromyalgia patients out of the "chronically ill" melting pot with an accuracy of 88%. Fibromyalgia is not a wastebasket diagnosis!

To receive a diagnosis of FM, the patient must have widespread pain in all four quadrants of the body for a minimum duration of three months. Tenderness or pain must be present in at least 11 of the 18 specified tender points when pressure is applied. The 18 sites used for the fibromyalgia diagnosis cluster around the neck, shoulder, chest, hip, knee, and elbow regions. The finger pressure that must be applied to these areas during a "palpation" exam is roughly equivalent to the amount that causes the finger nail bed to blanch or start to become white. It has been reported that voluntary skeletal muscle is the largest organ of the human body and accounts for 40% or more of body mass. This muscle mass contains 696 individual muscles in the human body. Any one of these muscles can develop Myofascial trigger points and refer pain to distant locations. Finding the trigger point is most important to relieving the referred pain. Fibromyalgia pain in the back, hip and knee can be the result of referred pain from trigger points in the muscles of the back, hip and thigh (contraction knots). A trigger point is a small knot in a muscle. The trigger point pulls the muscle to put pressure on the connecting tissue. This knot can be as big as a thumb or as small as a pea. It can be also be buried deep in the muscle and difficult to locate.

Even when the muscle has suffered a physical injury, trigger points can be associated with other muscles and contribute a major part of the pain. Referred pain can be every bit as intense as a physical injury from a damaged joint.

Some researchers suspect that trigger points may actually be the root cause of fibromyalgia and other kinds of joint deterioration. This is because muscles afflicted with trigger points become shortened and stiff. When this happens, even normal movement puts undue strain on muscle attachments at the joints, which can eventually result in damage to connective tissue, bone and distortion of the joints themselves.

In addition, a trigger point can be as small as the tip of the finger or the pain can radiate several inches from the trigger point origin. In addition, trigger points can cause referred pain. In fact, each trigger point needs to be assessed individually to ascertain the pain presentation for each individual patient. Over 75 other tender points have been found to exist, but are not used for diagnostic purposes.

Tender points of fibromyalgia exist at these nine muscle locations on both sides of the body:

• Front Neck Area: the muscles on the front lower part of the neck above the collarbone
• Front chest: muscles just below the collarbone near where the upper ribs meet the center of the chest
• Back of the neck: muscles on the back of the neck at the base of the skull
• Top and back of the upper shoulder: halfway between the shoulder joint and the neck on the top of the shoulder .
• Shoulder blade area: halfway between the shoulder joint and the neck on the back of upper shoulder
• Elbow area: inside of arm just below elbow joint.
• Upper buttocks: back upper area of buttocks near the hip
• Lower buttocks: just below the cheek of the buttocks about 2 inches in from the side of the hip
• Knee: inside of knee joint alongside the kneecap

While the underlying cause or causes of FM still remain a mystery, new research findings continue to bring us closer to understanding the basic mechanisms of fibromyalgia. Most researchers agree that FM is a disorder of central processing with neuroendocrine/neurotransmitter dysregulation. The FM patient experiences pain amplification due to abnormal sensory processing in the central nervous system. An increasing number of scientific studies now show multiple physiological abnormalities in the FM patient, including increased levels of substance P in the spinal cord, low levels of blood flow to the thalamus region of the brain, HPA axis hypofunction, low levels of serotonin and tryptophan and abnormalities in cytokine function.

Many of those already suffering from the pain of fibromyalgia also suffer from Myofascial Pain Syndrome, (MPS) another form of chronic pain that can affect the entire body, particularly the face and jaw. Myofascial pain can add to the already annoying symptoms of fibromyalgia, and can contribute to disability and a poor quality of life if not diagnosed properly.

Myofascial syndrome is a pain disorder that affects the muscles and fascia throughout the body. Fascia is like a web that surrounds the bones, tissues, organs, and blood vessels throughout the body. MPS can attack and cause degeneration of certain areas of the fascia, resulting in chronic pain and a variety of other symptoms. Pain usually originates in specific areas of the body, called myofascial trigger points (TrPs), which feel like tiny nodules under the skin. These trigger points commonly develop throughout the body, typically where the fascia comes into contact with a muscle.

MPS is a very common illness, and most people will develop at least one trigger point in their body at some point in their lives. The majority of these people will not develop severe symptoms and will be able to continue with their normal routines. However, about 14 percent of the population will develop a chronic form of the syndrome, resulting in persistent pain and discomfort.

MPS is very common in fibromyalgia sufferers. It was once thought that MPS was actually a kind of fibromyalgia. However, this is now known not to be the case. It is possible to have both fibromyalgia and MPS, and therefore it is important to be diligent when analyzing the symptoms. The most common sign of myofascial pain is the presence of palpable trigger points in the muscles. Trigger points are areas of extreme tenderness and sensitivity, and usually form in bands of muscle underneath the skin. They are similar to the tender points caused by fibromyalgia, only trigger points can be felt beneath the skin. When touched, trigger points will produce pain and twitching in the muscles. Often, pain is felt in an area distinct from the trigger point that is actually affected which is called referred pain.

The pain of MPS is typically a dull ache, but can also produce a throbbing, stabbing, or burning sensation. Pain is often located in the jaw area, though any part of the body can be affected. One-third of myofascial pain sufferers report localized pain, while two-thirds report having pain all over their bodies. Myofascial pain can also produce a variety of other symptoms, many of which may appear unrelated. These include numbness in the extremities, popping or clicking of the joints, limited movement of joints, particularly the jaw, muscle weakness (manifested in dropping things,) migraine or headache, disturbed sleep, balance problems, tinnitus and ear pain, double vision or blurred vision, problems with memory as well as unexplained nausea, dizziness, and sweating.

The causes of MPS can be numerous and depend upon the individual. Generally, myofascial pain is caused by some sort of trauma to the muscles and skeleton in the body. Overworking of the muscles can cause damage to certain areas resulting in the development of a trigger point. Poor posture can also trigger myofascial pain in certain individuals. Skeletal abnormalities, such as having different sized feet, toes, or legs, can also contribute to the development of myofascial pains. Frequent exposure to cold weather may also increase the risk of developing MPS.

People with fibromyalgia may get MPS as a result of their fibromyalgia pain. Compensating for pain can often cause reduced movement or an unhealthy posture, leading to the formation of trigger points. The severe pain caused by fibromyalgia also causes muscle contractions around tender points, referred to as guarding. Eventually these muscle contractions cause trigger points to form in addition to the tender points of fibromyalgia. The depression associated with fibromyalgia may also cause myofascial pain to develop. At least 30 percent of fibromyalgia patients suffer from depression, which causes low levels of serotonin in the brain. Serotonin is a neurotransmitter responsible for regulating mood and pain in the body. Depression may interfere with the process of regulating pain, causing MPS.

Having both MPS and fibromyalgia can be quite trying at times. Symptoms of MPS and fibromyalgia are very similar, making it difficult for medical professionals to properly diagnose many people. Without proper diagnosis, a patient may not receive appropriate treatment, causing his or her symptoms to become even worse. In addition, myofascial pain can often contribute to the pain caused by fibromyalgia, making life much more difficult to enjoy.

An empathetic physician who is knowledgeable about the diagnosis and treatment of FM and MPS and who will listen to and work with the patient is an important component of treatment. It may be a family practitioner, an internist, or a specialist (rheumatologist or neurologist, for example). Conventional medical intervention may be only part of a potential treatment program. Alternative treatments, nutrition, relaxation techniques, and exercise play an important role in FM and MPS treatment as well. Each patient should, with the input of a health care practitioner, establish a multifaceted and individualized approach that works for them. An important aspect of FM and MPS pain management is a regular program of gentle exercise and stretching, which helps maintain muscle tone and reduces pain and stiffness.

Improved sleep can be obtained by implementing a healthy sleep regimen such as going to bed and getting up at the same time every day; making sure that the sleeping environment is conducive to sleep (i.e. quiet, free from distractions, a comfortable room temperature, a supportive bed); avoiding caffeine, sugar, and alcohol before bed; doing some type of light exercise during the day; avoiding eating immediately before bedtime; and practicing relaxation exercises to fall asleep. When necessary, there are new sleep medications that can be prescribed, some of which can be especially helpful if the patient's sleep is disturbed by restless legs or periodic limb movement disorder.

Other conventional pain management techniques include over-the-counter pain medications, such as acetaminophen or ibuprofen, or one of the newer non-narcotic pain relievers (e.g. tramadol) or low doses of antidepressants (e.g. tricyclic antidepressants, serotonin reuptake inhibitors) or benzodiazepines. Many medical professionals also prescribe stronger narcotic pain relievers to manage the pain of these syndromes however, over time, the individual usually requires higher doses to achieve the same pain relief. As a result, addiction and physical dependency are critical issues that must be paid attention to. In addition, narcotic pain relievers can cause negative affects in the body including elevated liver enzymes and compromised kidney function. Long term narcotic use also stimulates the body's pain neurotransmitters to fire even more, creating more pain.

Trigger point injection (TPI) is a procedure also used to treat both FM and MPS. In the TPI procedure, a health care professional inserts a small needle into the patients trigger point. The injection contains a local anesthetic that sometimes includes a corticosteroid. With the injection, the trigger point can be made inactive and the pain is alleviated. Usually, a brief course of treatment will result in sustained relief. Injections are given in a doctors office and usually take just a few minutes. TPI is used to treat many muscle groups, especially those in the arms, legs, lower back, and neck. The effectiveness of TPI for treating myofascial pain is still under study however.

Complementary therapies can be very beneficial. These include: physical therapy, therapeutic massage, myofascial release therapy, water therapy, light aerobics, acupressure, application of heat or cold, acupuncture, yoga, relaxation exercises, breathing techniques, aromatherapy, cognitive therapy, biofeedback, herbs, nutritional supplements, and osteopathic or chiropractic manipulation.