FIBROMYALGIA

(Myofacial Pain):

When the Aches are not Arthritis

The term "fibrositis" was used first in 1904 when Sir Williams Gowers described lumbago or nonarticular rheumatism. It is unclear whether he was describing the pain syndrome we know today - but the misnomer stuck firmly. There is still confusion about what to call this condition. "Fibromyalgia" , myofascial pain, or "the syndrome of benign arthralgias and myalgias" are all appropriate alternatives, but "fibromyalgia" is now the preferred term.

A typical primary fibromyalgia patient is a young or middle-aged woman, in otherwise good health, with aches and pains in muscles and around joints. The areas most often affected are around the knees, upper backs, shoulder blades and elbows. Associated features include stiffness, fatigue, sleep difficulties (most commonly awakening in the early hours), depression symptoms (sadness, tearfulness, loss of normal energy and interest in activities) and tension headaches. Because exercise is often painful and tiring, the patient becomes less and less active. In most people, the symptoms have been present for several months, or more. Wet, cold weather, anxiety and stress make the symptoms worse; so does either too much or too little physical activity. Symptoms come and go - this is often a chronic problem.

Secondary fibromyalgia, or myofascial pain, which is much more common, is due to overuse, e.g. repetitious micro-trauma as in athletes or assembly line workers, or following an acute injury, e.g. a sprain or strain, or even just sitting at a desk for long periods of time.

Pain is the main complaint and symptom of fibromyalgia. On physical examination, this is brought out by the examiner pressing a series of "trigger points" located in specific areas in and around joints. Some of the points may be a little tender to most people, but to fibromyalgia patients, slight pressure really hurts. This should be the basic abnormal finding on the exam. Fibromyalgia or myofascial pain is NOT ARTHRITIS. There may be pain and stiffness, but the joints are not warm or swollen, and they usually move normally. Of course, arthritis may also be present.

Diagnosing fibromyalgia means being sure there are no other medical, orthopedic, or psychiatric illnesses present that could cause some of the same symptoms. After all, taken separately, the complaints are common ones. These other conditions are excluded by a careful history, careful physical exam and by doing laboratory tests and x-rays. No single laboratory test or x-ray is specific for fibromyalgia. Thermography is a technique capable of objectifying the presence of trigger points, and may be useful, but is rarely necessary to make the diagnosis. There are no scientific studies proving that a patient with fibromyalgia is more likely than the general population to develop the other diseases mentioned.

The best way to treat any illness is to treat its cause. This is difficult in fibromyalgia since the cause is usually unknown. A specific type of sleep abnormality has been documented, and some authors discuss a pain cycle related to abnormal muscle contraction, while others think there may be abnormalities in the chemical transmitters of pain. An inflammatory cause is unlikely. Treatment should alleviate the symptoms, in the safest way, with the fewest side effects.

Narcotics (or "strong pain pills") don't help this type of pain in the long run and should be avoided. There are many better ways to cope with fibromyalgia. Heat (showers, whirlpool or heat packs), massage, TENS units, galvanic stimulators, and ultrasound, or a combination of these, give relief. It is important to develop a slow, gradually increasing regimen of stretching and other, usually aerobic, exercises. Swimming is particularly good for fibromyalgia. Besides appropriate exercise, learning relaxation is beneficial. This is valuable in easing muscle tightness and putting aside daily stresses. Medications may be used with the exercise program. Aspirin and anti-inflammatory compounds (drugs like Naprosyn, Motrin, Feldene, Indocin, Tolectin, Voltaren) help some patients. Muscle relaxants, especially Flexeril or Zanaflex, may also help alleviate pain in some patients. Shots of small amounts of cortisone-type medication and/or local anesthetics may help especially painful trigger points. An antidepressant, Elavil (or Amitriptyline), Zoloft, etc. often works to correct the sleep problems. Prozac may help some patients. In any individual, the goal is to find which therapy, or combination, works best. Some flares respond differently than others; medications and activities are tailored to the waxing and waning of symptoms.

It is important to remember that fibromyalgia may be painful and it may take time to improve, but current knowledge suggests that it is a benign disorder that usually does not progress to worse problems. Also, if athletic participation is the causative factor, the athlete should decrease the intensity of the next work-out, practice, etc., until there is no further occurrence of any debilitating pain (that which prevents normal participation).

Many diseases, of course, may coexist with fibromyalgia; therefore, they will need to be treated appropriately, also.

DISEASES TO EXCLUDE

I. RHEUMATOLOGIC PROBLEMS

Rheumatoid Arthritis

Ankylosing Spondylitis

Lupus

Sjogrens Syndrome

Polymyalgia Rheumatica

II. "ATHLETIC OVERUSE"

Tennis Elbow

Golfer's Elbow

Muscle Strain and Sprain

III. COMMON INFECTIONS

Influenza

Hepatitis

Mononucleosis

IV. ENDOCRINE (GLAND) DISORDERS

Hypothyroidism("Low Thyroid")

V. PSYCHOLOGICAL PROBLEMS

Depression

Psychogenic Pain Syndromes

VI. MISCELLANEOUS

Neurological Problems

Drug Withdrawal

Bone Diseases

EXERCISES FOR FIBROMYALGIA

Exercise is very important when you have fibromyalgia. When you hurt you usually do less and use your muscles less, so they get out of shape. This can make your pain get even worse. Of course, when you have pain, it is hard to make yourself exercise so you need to work first on pain relief techniques and ease into the exercises slowly. A therapist can teach you specific and safe exercises that would be good for you to do. The spray and stretch technique is a very good form of therapy and can be done at home with the help of a family member after being instructed by a therapist. These are in addition to any work-outs, practice, etc., any athlete may be doing!

"SPRAY-AND-STRETCH" TREATMENT FOR MYOFASCIAL PAIN

Most physicians encounter patients with myofascial pain. But all to often, we fail to recognize and treat it -- or we take easy ways out: aspirin, drugs, or heat. Many patients who don't respond to such treatment are labeled "crocks" or referred to psychiatrists.

You may be properly skeptical of this spray-and-stretch approach if you've been exposed to lectures, demonstrations, or articles dealing with ethyl chloride-spraying of painful areas. Certainly, I was skeptical years ago when I attempted to chill and anesthetize pain-trigger areas in patients. My results with ethyl chloride were poor, and I abandoned the attempts altogether.

Then I learned the special method used by Dr. Janet Travell, former physician to Presidents Kennedy and Johnson -- and I was astonished by the results. Now I use or prescribe this technique almost every day.

Instead of ethyl chloride, the substance used with this technique is a mixture of trichloromonofluoromethane (85 per cent) and dichlorodifluoromethane (15 per cent). It's available -- as Fluori-Methane under light pressure in glass and metal bottles with calibrated nozzles. The metal containers are safer, of course, but usually more expensive.

Pressing the handle produces a continuous jet stream that's directed at the skin from about 18 inches (40 cm) away. The mixture vaporizes almost immediately. On each muscle, use three to six sweeping strokes of one to two seconds each, in one direction. Stretch the muscles in a natural way with a free hand by moving the joints over which they or their tendons pass. For back muscles, rock the back, while sitting, or bend over a chair.

The liquid jet stream, used this way, has only a momentary chilling effect, but it doesn't freeze or anesthetize the flesh, as you might expect. Frosting must be avoided. The proper effect is best described as a light touch on the skin.

The hydrocarbon mixture is far safer to use than ethyl chloride. The hydrocarbon mixture is nonflammable, nonexplosive, and nontoxic in external use, and it ordinarily doesn't put patients to sleep if they inhale it. Shield your mouth and eyes.

Knowing exactly where to direct the liquid is essential. It's not enough to cover the area where you feel pain (which is often referred pain). Nor is it satisfactory to hit only the pain-trigger point. Sweep from the trigger point, or muscle origin, to its insertion and over the region in which the patient tells you he feels pain. For example, if pain is in the infraspinatus muscle (the muscle over the lower part of the scapula or "wing-bone" of the shoulder), spray from the infraspinatus fossa of the scapula to the upper end of the humerus (the bone between your elbow and shoulder). At the same time, gently rotate the humerus medially -- with the patient's hand behind his back -- to stretch the infraspinatus muscle just short of producing pain, or to its resting length.

Ordinarily, you should jet the liquid into the primary-pain area. But if an occasional patient fails to get relief, try sweeping from the trigger point into the referred pain area. Satellite trigger points may have to be treated, too.

How does this combination of hydrocarbon stream and muscle stretching relieve pain? No one knows for sure, but there are rational explanations based on current knowledge about nerve impulses. For physicians who want a scientific hypothesis, here's one I consider logical: Myofascial pain is usually caused by muscle spasm, which probably reflects activity in an irritable trigger area. We can predict these trigger points, locate them, and reproduce the offending pain by palpation.

The jet stream apparently produces impulses that move faster from skin receptor organs along large afferent nerves than do painful impulses traveling from muscle spindles along smaller afferents. Both sets of impulses are relayed by the lateral spinothalamic (spinal cord) tracts to an unknown center, perhaps at the level of the thalamus (brain). Arriving first, the cooling impulses set up a refractory state that blocks reception of the slower pain impulses. This permits the muscle to relax and to be stretched to resting length. Then the muscle is in its normal physiological and pain-free state.

The spray-and-stretch technique has many applications. But there are contraindications, of course. For instance, if a patient has neuropathology causing muscle spasm and pain, you won't be able to help until you diagnose and treat the clinical problem. (In fact, the patient with nerve pain may get worse because stretching hurts the inflamed nerve.) Joint pain won't lessen if the joint is unstable, because the muscle can't rest without leaving the joint ligaments and/or capsule unsupported. If a bone has shortened in postfracture healing, its muscles cannot stretch to normal resting length, only to an adapted resting length.

And certain precautions are necessary. Be careful not to overchill or overstretch muscles, for that can set up painful spasms that will defeat therapy. Occasionally a patient will be able to stretch, but just can't tolerate the cold spray. Also, if one is trying to eliminate (or diminish) hydrocarbons in our atmosphere, you can substitute with an ice cube, or, preferably, ice-on-a-stick (frozen beforehand and kept in the freezer).

These qualifications notwithstanding, I recommend this therapy for selected cases of both chronic and acute pain. It can also temporarily alleviate pain from cramps, abrasions, torn calluses and burns.

Athletes, especially elite athletes, push themselves to the very limit and, therefore, are extremely prone to fibromyalgia. "Weekend warriors" also frequently suffer from fibromyalgia.

When you hurt a lot, begin slowly:

* use heat to painful areas (warm bath or shower, hot water bottle, heating pad, etc.)

* exercise slowly and just to the point of pain. These are usually gentle stretching exercises to begin with such as alternately bending your knees up to your chest while keeping other knee bent or tilting your head from side to side.

* learn and practice good body mechanics and posture at all times.

As you begin to feel better:

* continue using heat if it helps

* continue relaxation techniques

* slowly add more muscle conditioning exercises now. The best would be swimming or a water exercise program. You could also try riding a stationary bike or walking. Remember, begin with just a little and try to do more each day.

When you feel good:

* DO NOT QUIT EXERCISING! Exercising every day and continuing to practice relaxation can keep you feeling good.

For more severe symptoms:

* Learn and regularly do spray and stretch exercises.

* Utilize massage therapy to help you overcome the pain.

Always learn the proper stretching and relaxing technique from an experienced Athletic Trainer, Physiotherapist, Occupational, Physical or Massage Therapist or Physician - D.O., D.C. or M.D., especially a Physiatrist (an M.D. who specializes in Physical Medicine and Rehabilitation) and be sure your massage therapist is certified in the U.S. by the American Massage Therapy Association.

REFERENCES

Barnes, John F.: Five Years of Myofascial Release. Physical Therapy Forum; September 16: 12-14, 1987.

Barnes, John F.: Myofascial/Osseous Integration. Physical Therapy Forum; Holiday Issue: 19-21, 1991.

Barnes, John F.: The Elasto-Collagenous Complex. Physical Therapy Forum; Week of April 25 1988.

Barnes, John F.: Myofascial Release - An Introduction for the Patient. Physical Therapy Forum; Week of October 3, 1988.

Barnes, John et al: Myofascial Release: The Search for Excellence, 1990. MRF Seminars, 10 S. Leopard Rd., Suite 1, Paoli, PA, 19301.

Bennett RM, Campbell S, Burckhardt C, et al: A multidisciplinary approach to fibromyalgia management. J Musculoskel Med; 8(11); 21-32, 1991.

Berges, P.U.: Myofascial pain syndromes. Postgrad Med; 53: 161, 1973.

Boulware DW, Schmid LD, Baron M: The fibromyalgia syndrome: could you recognize and treat it? Postgrad Med; 87(2): 211-214, 1990.

Casey, K.L.: The neurophysiologic basis of pain. Postgrad Med; 53: 58, 1973.

Cutler, P., Rockwood, C.A., Jr., Grant, A.E., et al.: A practical guide to common aches and pains. Hospital Physician; 8: 36, 1972.

Kraus, H.: Clinical Treatment of Back and Neck Pain. New York: McGraw-Hill, 1970.

Kraus, H.: Backache, Stress & Tension. New York: Simon & Schuster, 1965.

McMennel, J.: "Spray-and-stretch" treatment for myofascial pain. Hospital Physician; 12: 1-4, 1973.

Sherman, Carl: Managing Fibromyalgia With Exercise. The Physician and Sports Medicine; 20(10): 166,168 170, 1992.

Travell, J.: Referred pain from skeletal muscle. NY State J Med; 55: 331, 1955.

Travell, J. and Rinzler, S.H.: The myofascial genesis of pain. Postgrad Med; 2: 425, 1952.

Travell, J. and Simons, David: Myofascial pain and dysfunction. The Trigger Point Manual. Williams and Wilkins, 1983.

Travell, J. and Simons, David: Myofascial pain and dysfunction. The Trigger Point Manual, Volume II. Williams and Wilkins, 1992.

Webber, T..: Diagnosis and modification of headache and shoulder-arm-hand syndrome. J Am Osteopath Assoc; 72:697, 1973.

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