Posted by Merm on 6/15/2008, 12:46 pm, in reply to "3 : Fibromyalgia and Chronic Myofascial Pain"
People with both FMS and CMP face more than just the two sets of symptoms of both conditions. Today, a few researchers are realizing that FMS and CMP not only occur together – they reinforce each other. The peripheral stimulation of TrPs can perpetuate the central sensitization of FMS, and the central sensitization of FMS can amplify the pain of TrPs. In patients with both of these conditions, to gain control over FMS symptoms you must gain control over the TrPs as well. Unless they understand the magnitude of both of these conditions, care providers tend to underestimate the amount of pain involved.
Bodywork and all other forms of treatment must proceed carefully. Any treatment regimen will be both more complicated and less successful than if the patient had only one of the two conditions. Some of the treatments normally prescribed for FMS patients can cause damage to CMP patients, and the reverse is also true. For example, you cannot strengthen a muscle with a TrP, because it is physiological contractured and already contracting it. Repetitive motion exercises, weight training and “work hardening” are torture for TrP patients and can result in permanent disability. In FMS patients without co-existing TrPs, limited strengthening exercises tailored to the patient’s condition may be appropriate if they are started gently and increased very gradually as the patient improves.
In the context of FMS, many different neurotransmitters are affected to different degrees and in different combinations in each patient. Also, other biochemicals in the body are affected to different degrees. Various hormones may be involved. Standard tests may be meaningless or must be evaluated in context. For example, the standard TSH test depends on a working hypothalamus-pituitary-adrenal axis. In FMS the HPA axis is usually out of balance. Histamine, a neurotransmitter, is often an important factor and easily overlooked. The possible combinations are endless, so this is no place for "cookbook" medicine, especially when you figure in the possible combinations of TrPs. FMS perpetuates CMP and the reverse is also true. The spiral of pain/contraction/pain/contraction continues until it is interrupted by an outside force in some form.
Treatment must be appropriate to the patient’s status and must be done properly. You cannot become an expert in TrP diagnosis and treatment by looking at TrP diagrams. You must understand the nature of the TrP and the proper performance of therapies. Spray and stretch cannot be done well without proper positioning of the patient, palpation, and “spray and stretch” together. It is not appropriate to spray the patient with vapocoolant and tell them to stretch later. The spraying must be done in conjunction with the stretching for full effect, with rewarming of the tissues. TrP injections also must be done according to protocol in order for them to be effective and lasting. Injection without proper positioning, range of motion stretch and attention to perpetuating factors will not bring a lasting result. The Trigger Point Manuals tell you how to inject TrPs most effectively, and training is available. Different treatment methods and medications may work better for specific patients. Every patient will be different. This is a challenge, but be assured that it is a challenge for your patient as well. The body will be constantly finding a new balance, and it will take time.
Chronic pain, all by itself, causes stress and lack of sleep. That's another reason why many cases of FMS are accompanied by CMP. But many things can be done to relieve the patient’s symptoms and return some measure of balance to the biochemistry. The key to management of both FMS and CMP is understanding the concepts of each illness. Then you can proceed with a careful assessment of the perpetuating factors, including chronic pain. Each of these perpetuating factors must be found and brought under control. The patient is an important part of this process. Life style modification – including good sleep hygiene, postural awareness, diet modification, appropriate exercise and stretching, elimination of smoking and excess alcohol, and avoidance of immobility – all lie within the patient’s control. You need to work as a team, enlisting other health care providers as needed. The task may seem daunting for you and your patient, but perseverance will bring rewards.
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