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Ancient or Modern Problem? Fibromyalgia and Myofascial Pain Jacqui Leeden
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Known as an invisible illness, many people suffer Fibromyalgia in silence because of the difficulty in determining the syndrome. It is one of more than 130 known arthritic conditions, not fatal, sometimes not progressive, and occasionally going into remission.
Fibromyalgia, this so-called modern disease, was known in biblical times, recognised in the Middle Ages and although Llewellyn and Jones of Bath, England wrote a full volume
(1) in 1914, there are many myths that still exist around it.When exploring historical Osteoarthritis and Rheumatoid Arthritis, we find animal and human skeletal evidence stretching back to the Iceman. Fibromyalgia
(pronounced fibe-roe-my-AL-juh) affects soft tissues, the muscles, tendons and ligaments around a joint and as such, historical evidence is found only in references.Fibromyalgia (often abbreviated to fibro or FM) is recognised as being common, ninety percent of the afflicted being women, and is the second most commonly diagnosed musculo-skeletal disorder in the U.S.A. It now ranks third in arthritic prevalence behind Osteoarthritis and Rheumatoid arthritis and is said to affect 1 in 10 people. Many cases follow a traumatic event involving stress, such as an accident, surgery or a close bereavement, but others have no apparent cause, a minority having fibro from childhood and/or a true familial basis or genetic inheritance.
History
Fibromyalgia (FM) still represents an enigma to modern medicine, and the aethiopathogenesis is far from explored. Formerly known as 'fibrositis' from the first medical references of 1904 (1, 2) , it was 1981 when the term "fibromyalgia" first entered the medical dictionary and not until 1990 that the American College of Rheumatology (ACR) established the Criteria for Fibromyalgia (6).
Early references were confusing, being confined to a particular part of the body. Gradually by 1992, a distinction was made where 'pain all over the body' refers to Fibromyalgia and pain in specific areas of the body is 'Focal Myofascial Pain' - myofascia being fascia, or a thin sheath of fibrous tissue, enclosing a muscle. Healthy myofascia allows for compression and tension, as well as relaxation.
Sir William R. Gowers, in 1904 (2), posed that Fibrositis was 'back pain that did not have a mechanical nature' caused by inflammation in muscle bundles. Later that year, Dr. Stockman of Edinburgh, Scotland, published a picture of an affected muscle and areas of inflammation, certain he had found "…the pathological entity of Fibrositis."
"Fibrositis is the most common form of acute and chronic rheumatism," wrote a leading doctor from the United States Mayo Clinic in 1943, noting the British Ministry of Health (MoH) revelation that 'of 2,500 insurance cases of rheumatic diseases, sixty per cent were based on Fibrositis'. At the same time a Dr Copeman in 1939, found that Fibrositis was a fairly common cause of disability in the British Army when he collaborated on a paper stating that Fibrositis was a form of 'Psychogenic Rheumatism'. His idea that this pain condition was 'psychological' rather than 'physiological' in nature persisted well into the 1970's. Even today, this argument is still accepted by a decreasing number of doctors who continue to give undue attention to 'the inability to cope' of some patients.
Fortunately, in 1975 a major research finding redirected the existing medical opinion. Psychiatrist Harvey Moldofsky of Canada and Hugh Smythe (3, 4) showed that when looking at these patients' electroencephalograms (EEGs), abnormalities in their sleep architecture were apparent, exhibiting a faster rhythm in the deeper stages of sleep. This proved that patients with Fibrositis experienced non-restorative sleep.
This break-through finding and the resulting publication was a turning point, which increased the interest of rheumatologists. Moldofsky's work on non-restorative sleep and Smythe's findings that these patients had specific tender points was extraordinary. For the first time ever, the world became aware of physical abnormalities in these patients. A way for diagnosis of the illness was offered.
In his historic work of 1981, Muhammad Yunus conducted the first control trial on Fibrositis patients (5), and established a new direction in Fibromyalgia research. In his paper, he offered the preferred name of 'Fibromyalgia' (FM) because 'Fibrositis' implied inflammation, when this illness was not of an inflammatory nature. In this historic work, Yunus also found that patients did have the tender points, predominate fatigue and other syndromes such as irritable bowel syndrome (IBS) and restless leg syndrome (RLS), which are now associated with FM.
Definition
Based on the subsequent work of Yunus (8, 9), Moldofsky and Goldenberg, the American College of Rheumatology established a multi-center study to define how to diagnose FM. The result was the ACR - 90 classification criteria for the Diagnosis of Fibromyalgia in 1990 (6), based on two cut-off values, for pain extent and for number of tenderpoints (TP).
Thus, to fulfil the ACR-90 criteria, an individual has to present
- Chronic widespread pain in the muscles
- In all four quadrants of the body
- Of at least three - six months duration and
- At least eleven out of eighteen positive tenderpoints (TP), defined as discomfort when thumbnail or 4 kilograms of pressure is applied to the TP.
- FM may occur alone as in primary fibromyalgia, where there is no other rheumatic condition or
- In secondary FM it may occur as a result of another associated condition or an event (a physical trauma i.e. an accident, injury or severe illness) which appears to act as a trigger in predisposed individuals.
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Fibromyalgia is hard to pinpoint, in part because the criteria defining it are fairly new and many general practitioners haven't been trained and/or have difficulty in recognition. The four criteria do not have to be present at the same time in order for someone to have FM, making diagnosis even more elusive.
However, it is particularly important that the condition is carefully diagnosed as it may be easily confused with several closely allied problems.
The differential diagnosis being Polymyalgia Rheumatica (PMR), inflammatory arthritis (RA), Spondylitic arthritis, anti-immune connective tissue disorder, Sjogrens syndrome, Ehlers Danlos syndrome, Systemic Lupus Erythematosus (SLE), myalgia associated with other conditions and others.
Features in Diagnosis
There is no specific test for Fibromyalgia and as a result, normal investigations of bloods, renal, liver and enzymes are made to exclude other conditions. Additional investigations e.g. MRI, are made according to symptom. In Polymyalgia Rheumatica (PMR), although initial presentation is the same as for FM, it can be excluded by MRI scans, presence of inflammation, positive bloods and by treating successfully with cortico-steroids, usually prescribed as prednisone.
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The warning signs of fibromyalgia are stiffness, especially in the morning; pain in muscles and joints all over the body; trouble sleeping at night and a heavy feeling of being very tired all the time; numbness in muscles and joints; poor memory and concentration; and may include depression, irritable bowel syndrome, tension and migraine headaches, and pain in the jaw.
Clinically, rheumatologists or musculoskeletal specialists look for the number of muscular tender points, fatigue, IBS, migraines, skin sensitization, Raynauds phenomenon,* sicca symptoms,*
photosensitivity,* rashes* and mouth problems.*
Diagnosis must look at the whole picture.
(*also found in systemic lupus erythematosus - SLE)
Common symptoms include
- Pain and swelling in many joints or soft tissues
- Trouble sleeping as a result of the pain and a feeling of fatigue and weakness throughout the day
- Stiffness, particularly in the morning
- Memory and concentration may be poor
- Tingling in feet and some people also experience numbness in joints or muscles.
- Experience heightened sensitivity to cold
- Develop sensitivities to certain foods, medications and/or allergens and eyes may be dry.
- Depression
- Tension and migraine headaches
- Irritable bowel and bladder, characterized by pain in the abdomen and frequent need to go to the bathroom or difficulty in doing so
- Chronic fatigue syndrome (CFS) and
- Temporomandibular joint dysfunction (TMJ), characterized by pain in the jaw.
Non-Restorative Sleep
Fibromyalgics have an abnormal EEG in deep sleep showing Alpha-wave intrusion in the slow-wave delta or rapid eye movement (REM) sleep. Experimentally, fatigue symptoms & muscle pain can be induced in controls and they show similar results to FM patients with a greater consciousness of stimuli. It is well understood that with lack of sleep, certain hormones are not produced in the body including the endorphins, which help guard against depression. This is part of the reason why gentle exercise is important in treatment. Very recent studies are showing that HGH (7, 10), and amino acids are also being successfully used in therapy.
Post Traumatic Pain Disorder (PTPD) can be distinguished from FM because there is always a trigger in PTPD where an injury or an event takes place, and as the healing process occurs the pain recedes, even though nerve endings sometimes continue to transmit pain (Regional Pain Disorder) or patients may develop FM. It is not understood what makes the connection.
Elusive Pain
Pain is defined, by scientific groups that study it, as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.' "That sweeping description is part of the problem," says Michael Clark, a psychiatrist and director of the Chronic Pain Treatment Program at Johns Hopkins University School of Medicine, "There is no 'one-size-fits-all' definition for pain. It's a very personal experience."
People can use the same words to describe different sensations. One man's twinge is another person's agony because pain thresholds vary. Doctors are adept at looking for damage and symptoms, testing a hypothesis and reaching for the right medicine. But when a pain's cause is elusive, doctors in the past too often figured "if we don't know what's wrong with you, you're crazy. If there's no test for it, it doesn't exist," says Jacob Teitelbaum (14), director of an Annapolis Research Center for chronic pain and fatigue. "People with rheumatoid arthritis were once told there was nothing wrong with them, despite having thick, swollen joints," he says. "Chronic pain is finally moving past that point and getting some understanding."
For optimum results, all factors -- tissues, neurology, disease, behavior, psychology and personality -- need to be addressed together. When they are, the diagnosis might be such recently identified pathologies as chronic fatigue syndrome (CFS), fibromyalgia syndrome (FMS), myalgic encephalomyelitis (ME) or myofascial pain syndrome (MPS) -- four incompletely understood conditions that have pain and chronic fatigue as a common denominator.
In Fibromyalgia, we find that there may be a trigger such as repeated stimuli or physical overuse such as in:
- Repetitive strain injury (RSI) or occupational overuse syndrome (OOS)
- An excess of stimulative medications or drinks, such as coffee
- Onset of a serious medical condition
- An event, which may be a physical stress, such as an operation or an accident, or it may be an emotional stress, as in a bereavement. Often the incident may be some years earlier - such as late childhood stress. Management of stress is a key factor in therapy.
- Practitioners do try and seek an association by alluding to cause but often there is no initiating event.
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The field of biotechnology is now looking at the physiology of pain -- the systems that detect something wrong and send a pain message to the brain and the neurotransmitters and receptors involved in that process. Researchers have discovered that one, the mu opioid receptor, comes in hundreds of varieties. Each variety responds to different pain relievers, from morphine to aspirin. "One day, doctors may be able to do a simple test to determine which painkiller will work best for an individual sufferer, a process that until now has been mostly trial and error." -- Frappa
Treatment
The management of FM is mostly based on empirical research, Few controlled studies have been performed. The basic drug therapy rests on the administration of amitriptyline (AMI) and conventional analgesics. Drug therapy is initiated only after careful patient information and delineation of therapeutic goals. It is administered in combination with physical treatment and cognitive behavioural therapy. Due to the appearing contours of pathogenic mechanisms, several new drugs may become available to patients with this complex pain syndrome in the near future.
The broad areas of treatment are:
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Education
Exercise, direct & physical therapy
Medication - a poor third, some medications may help
Cognitive behavioural therapy
Exercise - direct & physical therapy
Recommended are low-impact cardio-vascular type exercises such as walking, exercycling, recreational exercises and hydrotherapy, which is excellent. These form a fundamental part of self-management. Weight-bearing and impact exercises are contra-indicated.Exercises must all start at a low level of activity, gradually increasing over months in small increments. The goal is to aim for 20 to 30 minutes sustained daily exercise. The patient must be prepared for setbacks until an individual balance eventuates. Pilates, Tai Chi, some very gentle forms of Yoga and relaxation exercises may also be considered.
The patient aims to be self-mindful of their condition while improving cardio-vascular and muscle condition. Exercise has pain-modulating qualities. Sleep quality is improved and fatigue reduced as endorphins assist slow-wave delta sleep.
Medical Therapy
Unfortunately, empirical research is rather discouraging, as only a few drugs have proved partly effective and medical therapy becomes a poor third in the list of available therapies. Frequently administered drugs fall into the following groups:- Analgesic therapy
- Pain modulating agents
- Medications for secondary symptoms
- Future medical therapies
Although there is a large body of evidence that fibromyalgia is a central pain state, opioids are only occasionally applied in severe cases. Such drugs should be individualised and avoided where there is a prior history of substance abuse. Systemic glucocorticoids may be employed, usually only for short term use. Conventional medication therapy also comprises triggerpoint injections.
Many medications are very potent in treating FM. Fibromyalgics have an over-sensitivity to medications in general. Patients need to start with an extremely small dose as they can feel very groggy in the morning and fatigued, taking a long time to get moving.
- Analgesics
Paracetamol, Dihydrocodeine (DHC), Tramadol - Tramal
- Non-steroidal anti-inflammatory drugs (NSAIDS)
Voltaren, Naprosyn, Oravail, (Trazadone - overseas, not yet in N.Z.)
Cox-II Inhibitors - Vioxx, Celebrex and Etoricoxib
- Local Preparations
Capsaicin, Gels, Sprays
Adverse effect with transient burning or stinging at application site.
- Low-dose Tricyclic Antidepressant Agents (TCADs)
Amitryptiline (AMI), Nortryptyline, Dothiepin, Doxepin
Tricyclic antidepressant agents inhibit the re-uptake of serotonin and norepinephrine at the neuronal terminals.
The prevailing hypothesis is that mechanisms involving serotonin and norepinephrine mediate clinical analgesia through descending systems originating in the brainstem and influence the dorsal horn of the spinal cord.
Although prescribed for the treatment of depression in much higher dosages, the TCAD amitriptyline is often useful in low doses for Fibromyalgics because it addresses the serotonin deficiency which often accompanies FM and helps control pain and promote sleep. Beneficial short-term effects of Amitryptiline (AMI), significantly improving morning stiffness and pain appear well documented. Long-term studies are warranted before the role of AMI is finally defined. At present AMI represents the drug of choice for FM.
- Selective Serotonin Reuptake Inhibitors (SSRIs)
Fluoxetine - Prozac, Sertraline - Zoloft, Paroxetine - Aropax
- Serotonin/Norephinephrine Reuptake Inhibitors (SNRIs)
Venlafaxine - This drug is expensive, not funded.
- Benzodiazepine Tranquillisers
Temazepam, Tegretol and Clonazepam
Clonazepam is helpful in treating restless legs syndrome. These drugs act as mild tranquilizers and have muscle relaxant properties. They can cause physical dependency and must be administered with care.
- Depression
Regional Neurogenic Symptoms
- Raynauds and Scleroderma (11)
- Irritable Bowel Syndrome (11)
- Fatigue
- B12 injections help about 60 per cent of people with FM. B12 levels often appear normal in blood levels but low in the cerebro-spinal fluid. With regular injections, it is important to take B-complex daily as other B vitamins and particularly folic acid may become unbalanced.
- Multi-vitamin preparations daily. Colostrum may be useful.
(Positive Living stocks highest grade N.Z. Colostrum - Ed.) - B6 (pyridoxine) is indicated daily for pre-menstrual women with worsening symptoms
- Magnesium oxide and malic acid - Fibrodol are well absorbed and may help muscle problems
- Valerian
- Sleep Disturbances
Many doctors and patients find that some antidepressants, including TCADS, help promote deep, restorative sleep when taken at bedtime. However, benzodiazepines may be counterproductive by interfering with Stage four restorative sleep. SSRIs may be taken along with tricyclics to increase energy.
While the aforementioned drugs remain the mainstay of general FM treatment, physicians are utilizing several other new drugs for the treatment of specific symptoms
and syndromes.
They include:
- Guaifenesin (pronounced 'gwhy-fen-es-in') is a tree bark extract called guaiacum, originally used to treat rheumatism as far back as 1530.
- Generally used as an expectorant which thins mucus and helps to loosen phlegm and commonly found in some over the counter cough mixtures.
- Researchers report efficacy in treatment of varied conditions such as fibromyalgia, chronic fatigue syndrome, multiple chemical sensitivities and vulvodynia.
- Pure Guaifenesin (Guai) now manufactured in New Zealand to Dr R. Paul St Amand's specifications with no additives.
- Guaranteed salicylate-free and free from any chemicals known to cause allergic sensitivities including dyes and lactose. Available in 300mg and 600mg gelatin (vege-free) capsules.
- Guaifenesin is unubsidized but low cost and affordable.
- Guaifenesin gives substantial relief of symptom, and is effective in 55 percent to 75 percent of patients using Guai. Requires body mapping by experienced person at regular intervals.
Latest research substantiates work done by R. Paul St Amand,(12). There is an adverse reaction from salicylates in products and plant material touching the skin while using Guaifenesin. (Guaifenesin is readily available from Positive LIving - Ed.)
2. Growth Hormone (HGH)
- Growth Hormone - GH4 - with or without St John's Wort
- Organic ingredients which stimulate the body's anti-aging or Growth Hormone production.
- Replenishes cell growth of all body organs, tissues and blood, thus repairing deep damage from loss of sleep. Also, strengthens immune system, bone growth and hormone production.
- This brand also contains vitamins and minerals, including Selenium, and good quality amino acids (L-Arginine, L-Ornithine, L-Glutamine etc.), which help reduce pain.
- Unsubsidized, moderate cost at present, HGH appears promising for Fibromyalgia.
Bennett et al (10) investigated the possible efficacy of HGH in FM patients with low levels of insulin-like growth factor using the FM Impact Questionnaire, the TP score and the global improvement. Over nine months there was a significant improvement in all the examined parameters.
See also: 'Management of Fibromyalgia: What are the Best Treatment Choices?' (7) Forseth & Gran, Norway and studies at Pain Research Centre, Sydney University, Newcastle.
(Positive Living imports GH4 at cost for Fibromyalgics - Ed.)
3. 5-Hydroxytryptophan (5-HTP)
4. Gamma-hydroxybutyrate (GHB)
Gamma-hydroxybutyrate (GHB) is a naturally occurring metabolite of the human nervous system, with the highest concentrations in the hypothalamus and basal ganglia.
May give significant improvement in both fatigue and pain, with an increase in slow wave sleep and a decrease in the severity of the o-anomaly (the protrusion in slow wave sleep).
This is a drug of interest with a potential place in the treatment of FM. Further studies are needed to establish clinical improvement and polysomnographic changes. Side effects severe
Stress-Management & Complementary Therapies
Management of stress is a key factor in therapy. Most non-pharmacological treatments are associated with significant improvement in coping and also with some pain reduction.
When compared, non-pharmacological treatment appears to be more efficacious in improving self-report of FM symptoms than pharmacological treatment alone.
The optimal intervention for FM would appear to include appropriate medication as needed for sleep and pain, combined with non-pharmacologic treatment such as specific exercise,
instruction in relaxation techniques, attending support groups, including participation in patient education programs and cognitive-behavioural therapy.
Attendance at Regional Clinics, Support Groups and Arthritis N.Z. courses for 'Managing Chronic Conditions' assists in reducing pain when patients learn coping skills and self-management.
The importance of people's attitudes and an understanding from relatives, carers and friends cannot be underestimated. However it is by reducing a patient's dependence on passive treatment or medications,
and increasing their self-management by encouraging healthy illness behaviour and the development of coping skills, which is encouraged.
A number of complementary approaches have proven useful in the management of fibromyalgia: Postural Training, Occupational Therapy, Relaxation Therapy, Massage, Myofascial Release, Hydrotherapy,
Exercise Therapy, Arthritis NZ Exercise Audiotapes & Videotapes, Acupuncture, Trigger-Point Therapy, Nutrition, Craniosacral Therapy, Chiropractic, Osteopathy, Cognitive/Behavioral Therapy, Common Sense and Self-Tolerance.
The many gentle forms of relaxation and stress management, along with patients finding an appropriate therapy for themselves, is the best course of long-term management
Conclusion At present, the pain of Fibromyalgia may be relieved by some medications but by far the most successful treatment is gained through a person's education. Reducing a patient's dependence on passive treatment or medications is encouraged; and at the same time, increasing their self-management skills by developing healthy illness behaviour and coping skills.
Gentle exercise, diet and physical therapy are fundamental and particularly vital to obtaining a good quality of life. Stress management and relaxation, along with patients finding an appropriate exercise therapy for themselves, is the best course of long-term management.
There are many aspects of Fibromyalgia, which go beyond the medical elements. These could only be touched on here. Further reading of references and resources, especially of new advances in knowledge, is encouraged. Newly diagnosed patients need to understand it is not their fault they have Fibromyalgia. It takes enormous energy, as well as courage, to adjust to FM and find treatments that work well without wasting precious energy on guilt, self-deprecation, loneliness and doubt.
Fibromyalgia is not a modern problem. Like Arthritis, Fibromyalgia in one or another of it's guises, has been around for centuries. Hopefully, some of the many myths about Fibromyalgia have been dispelled here and thus a number of misunderstandings, which may exist in the community, have been dismissed. Since 1995, public awareness of FM has been rapidly increasing. Fibromyalgia is a legitimate, medically recognized condition, now being actively researched every day.
Written for
The New Zealand Pharmacy Journal,Written by Jacqui Leeden, Editor Positive Living, Convenor, Auckland Fibro Support,
- Llewellyn, Jones, Fibrositis, Bath, England 1914
- Gowers, Sir William R, Lambago: It's Lessons and Analogues, 1904
- Moldofsky, Harvey, Musculoskeletal Systems and Non-REM Sleep Disturbances in Patients with Fibrositis", Psychosomatic Medicine Journal 1975
- Moldofsky, Harvey, Smythe, H, Two Contributions to the Understanding of Fibrositis Syndrome", Bulletin on the Rheumatic Diseases 1977
- Yunus, Muhammad B, Primary Fibromyalgia (Fibrositis) Clinical Study of 50 Patients with Matched Normal Controls, 1981
- Wolfe, Frederick et al, The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia: Report of a Multicenter Criteria Committee, Arthritis & Rheumatism,
Yunus, Muhammad B, Bethesda, MD., Fibromyalgia and Other Overlapping Syndromes: The Concept of Dysregulation Spectrum Syndrome, Seminar hosted by the National Fibromyalgia Partnership (formerly the Fibromyalgia Association of Greater Washington, Inc.) on 11/10/97,
Yunus, Muhammad B, Dysfunction Spectrum Syndrome: A Unified Concept for Many Common Maladies, Fibromyalgia Frontiers, Vol. 4, No. 4, Fall 1996.