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  Muscle Pain       Fibromyalgia Syndrome      
 
 
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Introduction
  • Fibromyalgia Syndrome (FMS) is a chronic pain condition, commonly seen in the pain clinic, causing pain, stiffness, and tenderness of the muscles, tendons, and joints, usually in a widespread symmetrical pattern. Fibromyalgia is also characterized by restless sleep, awakening feeling tired, chronic fatigue syndrome, anxiety, depression, and disturbances in bowel function . If left untreated it can lead to profound disability.
  • It's cause is currently unknown. The painful tissues involved are not accompanied by tissue inflammation. Therefore, despite potentially disabling body pain, patients with fibromyalgia do not develop body damage or deformity.
  • Fibromyalgia is different from many other rheumatological conditions such as rheumatoid arthritis, systemic lupus, and polymyositis. In those diseases, tissue inflammation is the major cause of pain, stiffness and tenderness of the joints, tendons and muscles, and it can lead to joint deformity and damage to the internal organs or muscles.
  • Regional Myofascial Pain Syndromes on the other hand, usually occur when a single muscle or group of muscles becomes sprained after an injury. The pain is localised to one area of the body, and discreet trigger points can be found on examination within the muscle bellies.
  • The pain usually responds to physical therapy, acupuncture, Pain Gone Pen, trigger point injections, and Botox etc. Each muscle has it's own pattern of trigger points and referred pain as shown in :-
Causes
  • The cause of fibromyalgia is not known. Patients experience pain in response to stimuli that are normally not perceived as painful. Researchers have found elevated levels of a nerve chemical signal, called substance P, and nerve growth factor in the spinal fluid of fibromyalgia patients. The brain nerve chemical serotonin is also relatively low in these patients.
  • Studies of pain in fibromyalgia have suggested that the central nervous system (brain) may be somehow supersensitive. Also, patients with fibromyalgia have impaired non-REM sleep, which likely explains the common feature of waking up fatigued and unrefreshed. The onset of fibromyalgia has been associated with psychological distress, trauma, and infection.
Population
  • Fibromyalgia affects predominantly women (over 80 percent) between the ages of 35 and 55. Rarely, fibromyalgia can also affect men, children, and the elderly. It can occur independently, or can be associated with another disease, such as systemic lupus or rheumatoid arthritis.
  • The prevalence of fibromyalgia varies in different countries. In Sweden and Britain, 1 percent of the population is affected by fibromyalgia. In the United States, approximately 2 percent of the population have fibromyalgia.
Symptoms
  • The universal symptom of fibromyalgia is pain. As mentioned earlier, the pain in fibromyalgia is not caused by tissue inflammation. Instead, these patients seem to have an increased sensitivity to many different sensory stimuli, and an unusually low pain threshold. Minor sensory stimuli that ordinarily would not cause pain in individuals can cause disabling pain in patients with fibromyalgia. The body pain of fibromyalgia can be aggravated by noise, weather change, and emotional stress.
  • The pain of fibromyalgia is generally widespread, involving both sides of the body symmetrically. Pain usually affects the neck, buttocks, shoulders, arms, the upper back, and the chest. Tender Points are localized tender areas of the body that can bring on widespread pain and muscle spasm when touched. Tender points are commonly found around the elbows, shoulders, knees, hips, back of the head, and the sides of the breast bone.
  • Fatigue occurs in 90 percent of patients. Fatigue may be related to abnormal sleep patterns commonly observed in these patients. Normally, there are several levels of depth of sleep. Getting enough of the deeper levels of sleep may be more important in refreshing a person than the total number of hours of sleep. Patients with fibromyalgia lack the deep, restorative level of sleep, called non-REM sleep. Consequently, patients with fibromyalgia often awaken in the morning without feeling fully rested. Some patients awaken with muscle aches or a sensation of muscle fatigue as if they had been working out all night.
  • Mental and/or emotional disturbances occur in over half of fibromyalgia patients. These symptoms include poor concentration, forgetfulness, mood changes, irritability, depression, and anxiety. Since a firm diagnosis of fibromyalgia is difficult, and no confirmatory laboratory tests are available, patients with fibromyalgia are often misdiagnosed as having depression as their primary underlying problem.
  • Other symptoms of fibromyalgia include migraine and tension headaches, numbness or tingling of different parts of the body, abdominal pain related to irritable bowel syndrome (IBS, spastic colon), and irritable bladder, causing painful and frequent urination.
  • Like fibromyalgia, irritable bowel syndrome can cause chronic abdominal pain and other bowel disturbances without detectable inflammation of the stomach or the intestines.
  • Each patient with fibromyalgia is unique. Any of the above symptoms can occur intermittently and in different combinations.
Diagnosis
  • There is no blood or X-ray test to help the doctor determine whether someone has fibromyalgia. Therefore, the diagnosis of fibromyalgia is made purely on clinical grounds based on the doctor's history and physical examination.
  • In patients with widespread body pain, the diagnosis of fibromyalgia can be made by identifying point tenderness areas (typically, patients will have at least 11 of the 18 classic tender points ), by finding no accompanying tissue swelling or inflammation, and by excluding other medical conditions that can mimic fibromyalgia.
  • Many medical conditions can cause pain in different areas of the body, mimicking fibromyalgia. These conditions include:-
    • Low thyroid hormone level (hypothyroidism)
    • Parathyroid disease (causing elevated blood calcium level)
    • Muscle diseases causing muscle pain (such as polymyositis)
    • Bone diseases causing bone pain (such as Paget's disease)
    • Elevated blood calcium (hypercalcemia)
    • Infectious diseases (such as hepatitis, Epstein Barr virus, AIDS)
    • Cancer
  • Even though there is no blood test for fibromyalgia, blood tests are important to exclude other medical conditions.
    • Thyroid hormone and calcium blood levels are obtained to exclude hypercalcemia, hyperparathyroidism and hypothyroidism.
    • Blood alkaline phosphatase (a bone enzyme) level is often raised in patients with Paget's disease of the bone.
    • Vitamin D levels to exclude deficiency
    • Uric acid levels to exclude gout.
    • CPK (a muscle enzyme) level is often elevated in patients with polymyositis, a disease with diffuse muscle inflammation.
    • A full blood count and liver tests help in the diagnosis of hepatitis and other infections.
  • Fibromyalgia can occur alone, or in association with other systemic rheumatic conditions like systemic lupus erythematosus, rheumatoid arthritis, polymyositis, and polymyalgia rheumatica.
  • The following blood test can be useful in helping to exclude these conditions:-
    • Erythrocyte sedimentation rate (ESR)
    • Serum protein electrophoresis (SPEP)
    • Antinuclear antibody (ANA)
    • Rheumatoid factor (RF).
  • In patients with fibromyalgia without associated systemic illnesses, the ESR, SPEP, ANA, and RF blood tests are usually normal.
Treatment
  • Since the symptoms of fibromyalgia are diverse and vary among patients, pain treatment programs must be individualized for each patient.
  • Treatment programs are most effective when they combine patient education, stress reduction, regular exercise, and medications.
  • Recent studies have verified that the best outcome for each patient results from a combination of approaches that involves the patient in customization of the treatment plan.
  • - Fibromyalgia Information pack courtesy of www.fibromyalgia-associationuk.org.
  • Patient Education
    • Patient education is an important first step in helping patients understand and cope with the diverse symptoms.
    • Unfortunately, in the UK there are very few dedicated treatment centres or pain management programs for patients with fibromyalgia.
  • Stress Reduction
    • It is extremely difficult to measure stress levels in different patients. Therefore, stress reduction in the treatment of fibromyalgia must be individualized. Stress reduction might include simple stress modification at home or work, biofeedback, relaxation tapes, psychological counseling, and/or support among family members, friends, and doctors.
    • Sometimes, changes in environmental factors (such as noise, temperature, and weather exposure) can exacerbate the symptoms of fibromyalgia, and these factors need to be modified.
  • Exercise
    • Low-impact aerobic exercises, such as swimming, cycling, walking and stationary cross-country ski machines can be effective treatments for fibromyalgia.
    • Stretches and exercises are most beneficial when performed on an every-other-day basis, in the morning. How exercise benefits fibromyalgia is unknown. Exercise may exert its beneficial effect by promoting a deep level of sleep (non-REM sleep).
    • Similarly, avoiding alcohol and caffeine before bedtime can also help promote a more restful sleep.
  • Medications
    • The most effective pain relief medications in the treatment of fibromyalgia are the tricyclic antidepressants, medications traditionally used in treating depression.
    • In treating fibromyalgia, tricyclic antidepressants are taken at bedtime in doses that are a fraction of those used for treating depression. Tricyclic antidepressants appear to reduce fatigue, relieve muscle pain and spasm, and promote deep restorative sleep in patients with fibromyalgia.
    • It is thought that tricyclics work by interfering with a nerve transmitter chemical in the brain called "serotonin." Examples of tricyclic antidepressants commonly used in treating fibromyalgia include amitriptyline and dothiepin.
    • Tricyclic medications can cause tiredness, fatigue, and a dry mouth in excessive doses.
    • Article - Duloxetine Reduces Pain Severity in Fibromyalgia Patients.
  • Other Treatments
    • Think about trying the Pain Gone Pen - a low cost simple non-drug self-help pain device for home use.
    • Trigger Point Injections - injections of local anaesthetic +/- low dose steroid into the trigger point areas can also be helpful in relieving painful soft tissues, while breaking cycles of pain and muscle spasm.
    • Tramadol may be a useful analgesic as it helps raise spinal cord levels of serotonin and noradrenaline (beware interactions with duloxetine).
    • NSAIDs while very helpful in treating other rheumatic conditions, have only a limited value in treating fibromyalgia pain. Narcotics and cortisone medications are avoided because they have not been shown to be beneficial and they have potential adverse side effects, including dependency, when used long-term. Also long term steroid medications can contribute to osteoporosis.
    • Both biofeedback and electroacupuncture have been used for relief of symptoms with some success.
The Future
  • The key to unlocking the mystery of fibromyalgia has yet to be found. Research scientists have been studying numerous viruses as potential causes for fibromyalgia. Identification of an infectious agent or toxin which causes the disease may one day lead to a laboratory test which can help doctors diagnose fibromyalgia. Until further research uncovers the exact cause of the disease, specific treatment aimed at a cure remains unattainable.
  • New drugs may be developed that block substance P or nerve growth factor to relieve pain of fibromyalgia. Many fibromyalgia patients can be helped by improved patient education, proper exercise, and medications. With ongoing research, the future will certainly improve for those affected by fibromyalgia.
  • Recent research has suggested that drugs that block more than one brain nerve transmitter, such as duloxetine (Cymbalta), can be effective in treating fibromyalgia. Duloxetine has been effective in treating depression and relieving pain in people with depression. Please note: Duloxitene should not be used together with Tramadol as the combination may precipitate a serotonergic syndrome.
  • Additional research suggests that drugs like gabapentin and pregabalin may be helpful by blocking nerve pain in patients with fibromyalgia. More research is underway to evaluate the potential of these new treatments.
  • For information about the Guaifenesin protocol see Fibromyalgia Treatment Centre

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