Posted by MERM on 6/15/2008, 12:44 pm
Fibromyalgia and Chronic Myofascial Pain
Keys to Diagnosis and Treatment
No matter what your specialty or title, if you are a medical care provider or in a related field, you have seen patients or clients with fibromyalgia syndrome (FMS) and/or myofascial trigger points (TrPs). These conditions are real and they are not the same. This means that you need the ability to recognize two distinct medical conditions. Once you grasp the concepts behind these conditions, your life, your job, and the lives of those who come to you for help will be changed. Many of your "problem" patients/clients can look forward to improved health, and you can take great satisfaction in knowing that you can make a greater difference in their lives.
These conditions need not be difficult to diagnose and treat. There are some basic concepts to grasp that will aid you in diagnosing and treating FMS and myofascial TrPs. These conditions often, but not always, occur in the same patients, and it is important that each condition be diagnosed, as their treatment is very different and they may be affecting and/or amplifying and perpetuating each other.
When the standard depiction of fibromyalgia was first introduced, we lacked even basic comprehension of the condition, and had only a guide for researchers who were attempting to deepen this knowledge. Due to increasing research, our understanding has grown from counting tender points and focusing on painful muscles to an evolving concept of a heterogeneous set of subgroups who have central nervous system sensitivity and a countless variety of potential dysfunctional biochemical and metabolic interactions. With this new FM concept comes the need for a depiction that acknowledges the complexity of fibromyalgia.
FMS is not a catch-all, "wastebasket" diagnosis of achy muscles. It is a specific, chronic, non-degenerative, non-progressive, noninflammatory, truly systemic pain condition. The pain and stress response systems are out of balance, and other biochemicals, such as hormones, may be as well. FMS is associated with central sensitization (Staud R, Cannon RC, Mauderli et al. 2003). The central nervous system reacts as if it has been amplified and/or distorted. Patients with FMS can be sensitive to smells, sounds, lights, odors, pressure and temperature fluctuations and vibrations. FMS sensitizes nerve endings as well as the rest of the autonomic nervous system, which means that the ends of the nerve receptors may have changed shape. Bright lights and noises, touch and even smells may be translated as pain. Flickering lights and droning, staccato or repetitive noises may be intolerable to these patients. They can easily go into a state of what can be described as sensory overload.
FMS is a syndrome, but that doesn’t mean it is less serious or potentially disabling than a disease. Rheumatoid arthritis, lupus, and other afflictions are also syndromes. FMS may be present along with other conditions such as those just mentioned. There is no blood test that can accurately identify FMS. FMS patients often look healthy, and others may expect them to act as if they are. FMS may vary in its severity, not only from patient to patient but from hour to hour and day to day. Careful pacing is a skill necessary for optimized function.
The official definition of FMS for patients requires that tender points must be present in all four quadrants of the body. Your patient must have had widespread, more-or-less continuous pain for at least three months to be diagnosed with FMS. The criteria of “11 of 18" specific FMS tender points were originally meant to screen patients for clinical study and not as diagnosis. It may be easier to look for the pattern of widespread diffuse body aches, with central sensitization including hyperalgesia and allodynia, and then check for tender points. Tender points occur in pairs on various parts of the body. Because they occur in pairs, the pain is usually distributed equally on both sides of the body. There are no trigger points in FMS. TrPs are part of myofascial pain syndrome. Localized pain usually indicates a co-existing condition. FMS can occur at any age. Most patients, when questioned carefully, reveal that their symptoms began at an early age. About 25 percent of the FMS patients I meet are men. There may be neurotransmitter-mediated objective signs, such as skin mottling or ridged nails. The latter are recognized signs of endocrine imbalance.
Only about 20% of FMS cases have a known triggering event that caused the first obvious "flare". During a flare, current symptoms become more intense, and new symptoms frequently develop. Much of the management of FMS depends on identifying the perpetuating factors and bringing them under control as much as possible. For example, lack of restorative sleep plays a crucial role in FMS. Its causes may be multifactorial. It is critical that sleep be optimized. Spending eight hours in bed is not sufficient. Your patient must feel refreshed on waking. If TrPs are present as well, they must be treated and prevented from recurring.
Myofascia 101: Take A Fresh Look
I ask specialist clinicians who are not totally at ease in the diagnosis of myofascial TrPs to please read this section even though it may seem basic, because it may help you get an edge in the diagnosing and treating TrPs. If you have already worn out at least one set of the Trigger Point Manuals and have at least 5 other well-read books on myofascial medicine and 5 to 10 years experience in diagnosing and treating TrPs, you may be able to skip this section, but I can’t promise you won’t miss something new.
Myofascial pain is probably the most common cause of musculoskeletal pain in medical practice (Imamura, Fischer, Imamura et al.1997). It is a vital factor in the practice of internists, in physical medicine and rehabilitation, internal medicine, dentistry, anesthesiology, gynecology, rheumatology, neurology, pediatrics, gastroenterology, proctology, psychiatry, cardiology, and about any other specialty you can think of. Myofascial medicine has been largely neglected in medical education, but once you grasp a few concepts and hone your observation and palpation skills, you will find that myofascial dysfunction is amazingly common and may cause or contribute to many of your patients’ symptoms.
A small change in the myofascia can cause great stress to the body. Restriction of one major joint in a lower extremity can increase the energy expenditure of normal walking by as much as 40% (Greenman, 1996). If two major joints are restricted in the same extremity, it can increase by as much as 300%. Multiple minor restrictions of movement, particularly in the maintenance of normal gait, can also have a detrimental effect upon total body function. In "Principles of Manual Medicine" (ibid), the author finds it convenient to separate fascia into three layers, but it is continuous and three dimensional, so please visualize it as such.
Superficial fascia is attached to the underside of the skin. Capillary channels and lymph vessels run through this layer, as do many nerves, and subcutaneous fat is attached to it. If the superficial fascia is healthy, skin moves easily over the surface of the muscles. In FMS and CMP, it can get stuck. There is also a great potential to store excess fluid and metabolites in the superficial fascia. This fascia is often the easiest to palpate, but palpation may be hampered by the presence of excess fluid. The presence of this fluid is a clue that there is something wrong and may also give clues as to the location of the problem.
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