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FIBROMYALGIA or MYOFASCIAL PAIN Othon Molina, Ph.d.c, LMT First of all I want to make it clear that this information is not to diagnose nor prescribe, and it should not take the place of the advice of your doctor. This is intended to complement conventional medicine, not to replace it. What is Fibromyalgia? Often called other names, has led to further confusion as it use to be called Fibrositis, fibromyositis, or syndrome, psychogenic rheumatism, myofasciitis, tensionmyalgia, or psychological muscle disorder, myofascial pain. It has gotten confused with CMFS chronic muscular fatigue syndrome, these are all terms that have been associated with fibromyalgia. Many people think it’s a very new disease but has been around some 100 years or more. Only recently have we used the terms Fibromyalgia or Myofascial Pain Syndrome as the most acceptable definition. Fibromyalgia syndrome is the most common term due to the many associated symptoms found with this disorder. Chronic muscular pain is just one small facet of this syndrome as it runs much deeper than just sore and aching muscles or joints. Just living with gravity and our modern day stress, can cause many of the soreness and muscle tension that most people experience. However when we have the condition of Fibromyalgia, or myofascial pain syndrome all of the stress, tension and pain is exasperated ten fold. Whether chronic pain is regional (myofascial {in the connective tissue} or muscle pain syndrome) or widespread (fibromyalgia- overall aches and pains with neurological and other problems), the condition can be more severe and has many faces. There is a lot of controversy surrounding Fibromyalgia, mainly because it’s so hard to diagnose. As well as the fact that every person with this said condition, has slightly different symptoms and pain. My theory is that the weak link in any body will determine the type of symptoms the patient shows, as well as the severity of the condition. This is critical to understand the person as a whole individual and lifestyle to determine what to do, how to approach their wellness, as well as the best treatment. Our approach is to treat each individual Holistically and work with the whole person and not just the symptoms. What happens with fibromyalgia and myofascial pain syndrome? Since mostly women suffer from fibromyalgia, most experts think it is connected to the hormone Estrogen. It could be an estrogen deficiency or certain hormonal changes that may affect muscle pain, it’s usually found in women over thirty. So it’s interesting that the disease of fibromyalgia is mostly a female disease, and most experts suspect someday we may find an underlying hormonal relationship. I have never heard of males with this condition, in my thirty years of practice. I have only had s small amount of women that actually where diagnosed with this condition anyway. It probably is not just a high or low level of hormones, but how the nervous system and muscle tissue is affected by these hormonal imbalances. It could be heredity but there is not sufficient research in this area yet. Some of the common symptoms with FMS Intense Pain - The pain of fibromyalgia has no limits and is as different as the individual; sometimes dull other times sharp. It can be surface like in the skin, numbness or deep muscular aching; dull, shooting, burning, throbbing or stabbing sharp pain. Most often, the pain and stiffness are worse in the morning and it’s not unusual to hurt in the muscle groups that are used more often; Upper neck, shoulders, low back, hips, legs, in fact often every joint may hurt at some time or another. Here again it varies with the person, their activities or jobs as well as their mechanical postures, as that can dictate where they will suffer most. Chronic Fatigue - This symptom can be mild in some patients and yet totally incapacitating for others. The fatigue has been described as “Feeling unmotivated” or "mental fatigue" some patients told me if they could get the strength to get out of bed, then they could deal with the rest of the day. But just getting out of bed is a challenge (see sleep disorders). Often they feel totally drained of energy. Some patients feel like their arms and legs are heavy, movement takes great effort and often they have difficulty concentrating as their minds are fatigued as well as their body. Chronic headaches - Recurrent migraine or tension-type headaches are seen in about 50-60% of fibromyalgia patients and can pose a major problem. Just dealing with the daily activities of life can be a struggle for these patients. Sleep disorders - Most fibromyalgia patients have a sleep disorder called the alpha-EEG anomaly. This means that they don’t get to the deeper levels of sleep, and they are constantly interrupted by awaken brain activity. Thus, when they wake up they feel that they didn’t get any rest, and the body did not get a chance to recover. This condition creates added stress, which keeps them in the vicious cycle. One of my patients said she felt like she was run over by a truck when she gets up in the morning. Everything hurts and many days she just doesn’t want to get out of bed. Temperomandibular Joint Dysfunction Syndrome (TMJ) - This syndrome, is connected with the headaches or face pain in 25-30% of FMS patients. Some of the research indicates that as many as 90% of fibromyalgia patients may have jaw and facial tenderness that could produce the same symptoms as TMJ. So we assume that most of the problems associated with this condition, are related to the muscles and ligaments holding the jaw. Irritable Bowel Syndrome (IBS) – It’s common for many of these women to have bowel problems; Constipation, diarrhea, or frequent abdominal or chest pain is not uncommon. These symptoms are found in 60% to 70% of fibromyalgia patients according to the research. PMS Painful menstrual periods (dysmenorrhea) is another common complaint. Some patients with chronic fatigue syndrome (CFS) have the same alpha-EEG sleep pattern disorder and some fibromyalgia-diagnosed patients have been found to have other sleep disorders, as well. Most common Myoclonus or PLMS (nighttime jerking of the arms and legs), restless leg syndrome and Bruxism (teeth grinding). The sleep pattern for clinically depressed patients is distinctly different from that found in FMS or CFS. Other common symptoms - Muscle numbness and or tingling sensations in the hands or feet, dry skin or skin sensitivity, muscle twitching, swollen extremities, dry eyes and mouth, dizziness, and impaired coordination. Often sensitive to weather or wind, rain and cold changes, hormonal fluctuations (premenstrual and menopausal states),depression, anxiety and over-exertion can all contribute to symptom flare-ups. Many of these women are usually high strung professionals with much stress or extremely active people. There are four main components, that we see in most of these patients. They are all are important understand to optimize healing and approach it on all levels: Recurring injury in the form of micro-trauma and bio-mechanical imbalances that perpetuate muscle strain. This means that if your body is out of alignment, along with having this condition, you are setting up micro-injuries, by stressing the muscle and connective tissue constantly. This pain, stress cycle can create overuse syndrome which will tax the bodies ability to deal with pain. 1. Pain sensitivity is turned way up: The central nervous system changes induced by constant muscle strains, that “turn up” the pain sensitivity creates heightened stress chemically as well as neurologically. This condition is often called Allodynia. This usually makes normal people react abnormally to low levels of painful stimuli that would not previously have caused much stress. The body can normally handle this even though many people have sore and tense muscles. These changes are physical, as well as physiological. The body has to release more histamines, endorphins as well as other anti-inflammatory chemicals to just keep the balance. Eventually the body gives up, as it cannot keep up with the unusual demand, and intensity. 2. Nerve propreoceptive tissue increases in size: The nerve propreoceptive cells that carry pain messages from the muscles to the spine and eventually the brain are said to actually increase in size as chronic pain persists. This is some of the latest research being done, if not in actual size the irritation caused to the nerves creates this hyper-sensitivity, not only on the skin, and muscles but all the way into the joints and organs. Serotonin (A soothing chemical in the body) in the central nervous system falls, this can increased Substance P, which is an inflammatory neurochemical, and causes more pain when it’s released. Thus a physiological (Chemical) change as well starts to happen in the body. Some of the brain imaging tests with highly sophisticated equipment, such as fluoroscopes, show pain pathways “lighting up” at just moderate levels of pressure on skin and muscle that would not normally show before the allodynia process has set in. Which means what is mild pressure on a normal subject is much more intense on a person with this condition. Thus we advocate very gentle massage, for soothing relief but more importantly balancing the body mechanics to reduce the stress and get to the deeper cause of muscle irritability. 3. Increased vulnerability to other disorders: Naturally a body that is under severe stress and constantly fighting with pain is more susceptible, as the immune system weakens from over-exertion. Neurochemical, metabolic and hormonal overload causes the increase vulnerability to other diseases and conditions especially any biochemical abnormalities that could overlap with the myofascial pain and fibromyalgia. This is where it becomes difficult to understand, as the body weakens from the overload, the weakest link is the first to create a problem. Just as many viral flues hit people in different places, some get the throat soreness, some cough in the lungs and others get the stomach disorder, all arising from the same virus. 4. This chronic pain undermines health: This constant pain, puts the body on full alert and over a prolonged period of time due to the complications of chronic pain that it will undermine both physical and mental health in most people. Mostly causing the body to stress would come from; disrupted sleep, weakened immune resistance, inadequate exercise, increased craving for sugar, discouragement and depression. All of these factors can all lead the body to not function at it’s optimum level. Holistic Treatment The Holistic approach seeks to approach it on all levels; mental, nutritional and physical. Each aspect of these problems needs a specific modality or therapy. We recommend the use of conventional medicine with holistic nutritional, herbal, biochemical-nutrients, as well as Bio-mechanical-body-therapy and mind-body methods designed to enhance the body’s own natural healing. Nutritional, and herbal treatments: We know that the only way to approach a vague disease is to use conventional holistic practices such as good nutrition; lower fat intake, especially the saturated fats, sugar and junk foods. Increase; water intake for flushing the system, increase intake of antioxidants; vitamin C, E, Beta carotene, a good multi-vitamin, with increased doses of cell salts, and selenium. Some medical experts say Phosphatigylserine which is a lipid (fat processor) and Gingko Biloba can also help ease the condition. From a natural perspective GABA itself is available from the health food stores over the counter, I just want to caution anyone self-medicating even with natural substances. Magnesium-Calcium and Selenium supplements also may help by acting on some of the same neural and muscle receptor sites that GABA also influences. About 80% of our chronic pain patients are deficient in magnesium. That’s because physical pain (and also mental anguish) as well as the muscles overworking causes the body to use up much more Magnesium than normal. This is other reason many athletes need extra Magnesium as well. Ironically the muscles really need that magnesium to function and not having enough of it increases muscle spasm and pain. As well as general vulnerability to stressful stimuli such as laud noises, chemicals, and emotional distress. So this hyper-sensitivity puts people in that vicious cycle. Many of these patients have hypoglycemia or blood sugar control problems as well. This is normally due to the stress of their illness on the glucose/insulin system being taxed. Excess stress causes the body to be on high alert. Consequently the dietary guidelines described above and further with a few quick and helpful nutritional tricks such as small supplementation of olive oil, chromium or glutamine, can usually help this common complication. Be sure to not just approach the symptom but work with the whole person. Of course we know that sleep is crucial for natural healing. The latest studies show that fibromyalgia pain can be produced in just a single night. When the sleeping person is just jostled at a specific sector of the EEG dream cycle–even if they continue to sleep without being awakened they will not get the deep rest they need to heal. Natural herbs to help sleep are; valerian root, skullcap, 5-hydroxy tryptophan, passion flower, GABA, Melatonin (amino acid), relaxation or meditation training and other natural approaches can do much to restore good sleep. This is a bit more complicated than it sounds, we advise that you consult with a professional. Of course some medicines can also help with sleep as long as we are careful to not create habit or dependence on these drugs. Reducing alcohol drinking as well as reducing caffeine and sugar will help the body sleep better. Conventional Medicines: The most interesting recent research is that the kinds of medicine that seem to work best for fibromyalgia and myofascial pain are not the traditional narcotic pain suppressors, such as vicodine, codeine, or the highly potent non-steroidal anti-inflammatory medicines such as Celebrex or muscle relaxers such as Flexeril. The best medicines instead are those that act on our nervous system and neurochemistry to reduce and reverse allodynia, the body’s abnormal increased sensitivity to that pain. None of these new medicines is a cure by itself, as it does not always get to the original cause, which we really don’t know anyway. As we mentioned before every individual is different there is no magic pill that will work for everyone. Many of the drugs do have some potential side-effects. However, with a clear approach to strengthening the patient using the holistic approach the body can heal much more that we give it credit. The key is patience by both patient and doctor that you are working with. Especially keeping an open mind and looking at all that is available. We can almost always find one, two, or three safe tools as well as effective drugs or nutrients that can help reduce the pain and the vulnerability to further problems. Hopefully without undue side effects and increased stress. If we catch it early enough many things help, the problem is most people don’t seek medical help until they have had it for a year or more. The most surprising news is that many of the best new medicines are actually old-standby’s that where used for many years for other conditions. Because of the complexity of Fibromyalgia we are just re-discovering the beneficial effects for helping the neurochemistry. Some of the common ones used are; Baclofen, Elavil, Flexeril, Gabatril, Klonopin, Neurontin, Paxil, Sinequan, Serzone, Xanax and Zofran Baclofen is commonly used for muscle relaxation with people that have multiple sclerosis. Baclofen enhances the GABA neuro-transmitters that help reduce the central nervous system pain and also relaxes the muscles. Neurontin and Gabatril are two more GABA enhancers that were first used to treat patients with epileptic seizures. It can also can help chronic nervous disorders and muscle pain. Zaniflex is another muscle relaxant first used for multiple sclerosis that can also reduce the body’s vulnerability to pain. Zaniflex works on the sympathetic nervous system pathways in the brain. (Zaniflex is also said to reduce hot flashes on post-menopausal women, and has no estrogen hormone-like side effects) Zofran, is a standard drug used to stop nausea for people taking cancer chemotherapy, it also blocks the release of substance P, a main neurochemical contributor to myofascial and fibromyalgia pain. Studies show that many people with fibromyalgia have improved using Zofran. The top medications of course can cause some side-effects in some people, so see your doctor, for any questions you may have. Biochemistry and Metabolism: Since every body is very individual there are laboratories specializing in diagnosis that can help us detect metabolic imbalances and dysfunctions: 1. Essential fatty acid analysis often shows a deficiency of omega-3 essential fatty acids, or certain Amino Acids analysis often show a deficiency of the chain relationship of amino acids, glutamine, taurine, tryotophan or tyrosine, being the most common. 2. Other theories pertaining to alterations in neurotransmitters like Serotonin and or epinephrine. As mentioned before substance P has an immune system function. Substance P is a pain neurotransmitter that has been found by repeat studies to be elevated threefold in the spinal fluid of fibromyalgia patients. Two hormones that have been shown to be abnormal are cortisol and growth hormone (HGH). 3. A comprehensive digestive and stool analysis can point to digestive enzyme deficiencies, yeast, candida or ebstine bar or other bacterial over-growth, or even parasites, which most people have anyway. The key is your immune system can usually handle it, and when it can’t then you succumb to worse problems. I feel that enhancing or strengthening the immune system is the best way to improve any disease. 4. Food allergies can be tested as well or going on an elimination diet, can at times identify “sensitive” foods allergies that can make pain symptoms worse. Careful with cleansing diets as I have found most people need building foods first, due to poor eating habits in the first place. Urine tests for milk or wheat derived opioid peptides can pin-point digestive abnormalities that can lead to toxic by products. However we have found most people are allergic to dairy products as well as gluten found in wheat products anyway so most patients would do better to avoid them. See Dr. Andrew Wiels books on nutrition. The key once again is everybody is different and no fad diet can help everyone. 5. We use to do hair analysis or DMSA provoked urine testing to detect high levels of toxic metals like; mercury or lead. Now we have many other systems for diagnosing and finding problems of that nature. 6. Checking the liver functions and enzyme levels is another way to find out any problems there, as the liver is a key organ for cleansing the body. 7. Ordering a screening T4/TSH is a good first approach as well. Many of the symptoms of fibromyalgia mimic hypothyroid muscular disease. Your doctor should order a screening thyroid test as part of the initial workup of fibromyalgia. 8. Checking for Hyperthyroid is also done quite easy in the laboratory, so just make sure you are working with someone that takes the time to eliminate other potential problems that could appear as FMS. Body-Therapy and Mind-Body Therapies: Great relief may come with just getting massage, however, it can also aggravate your condition, usually gentle massage is recommended not deep tissue work. Many people with chronic muscle spasms or pain have tiny taut fibrous bands or trigger points within the bellies or the origin and insertion of the muscles. These can be worked on with several techniques. Some of the best techniques for these painful bands are DTF (Deep Transverse Friction) made popular by an Orthopedic Doctor from England named James Cyriax MD. He treated most of his patients with minor soft tissue injuries with this technique. With patients with Fibromyalgia you have to be extremely careful to not create more irritation, you should see a professional massage therapist trained in this technique. Trigger point therapy is another technique that helps reduce the stress in the tissues and also should be done with great care. As you will find within these taut bands of muscle are extraordinarily sensitive pain points. These trigger points will help relive the stress in the nervous system and also act to keep the entire muscle from spasms. The problem with one muscle in spasm is it puts its antagonist or assistant in stress too, and soon all the muscles are over-taxed in turn. This creates the muscle tug-of-war or a vicious cycle of muscle spasm, imbalance and pain, more tension, more pain muscle imbalance etc, etc. It takes professional knowledge to break this cycle, it can sometimes just be balancing the pelvis, neck or back to allow the body proper mechanics. It may take heat or ice and DTF, or trigger point therapy and gentle massage to turn it around. Other times it can take muscle relaxers or even cortosteroid injections. All of these can have value, the key is to know when to use or not use a specific treatment, or medication. By injections we mean trigger point injections, or injections into ligaments or joints. These are called Spinal facet joint injections, or epidurals. Sometimes Acupuncture treatments can be beneficial, as well as the use of herbs. We mentioned massage, in that same body therapy techniques we sometimes use mobilization or manipulations to free up the vertebras or certain joints, these methods are used by Osteopaths, Chiropractors and some manual therapists. I said before working to balance the hips or spine mechanics will often reduce the muscle tug-of-war that then reduces the muscle holding patterns in the body. These are some of the most effective treatments available to these patients. I have to keep telling the reader it’s critical to work with your doctor, and if he is not open to some of these natural modalities share this article with him or her. It’s important to find highly qualified professionals and just because you find a doctor it does not always mean he knows how to treat this condition. God only knows that the human body is a vast universe and no one person can know all there is about the body. That’s why many of us in the medical fields have to specialize, by focusing on some aspects we get to understand it better. Then by working together we can assist all our patients better using the principles of synergy. Most open minded doctors have found this out and have a vast network of health professionals to work in conjunction with, and for the betterment of the patient. Mind-body techniques: There is in the realm of body-mind techniques several that have proven effective in neurological balancing; the most popular and widely used are Traggering and Feldenkrais. These two extraordinary people, where pioneers in body mind therapy. Milton Tragger was an MD, a neurosurgeon that created a movement type of treatment that is gentle and achieves deep levels of relaxation through rocking motions. He was a personal friend and got to know him in Honolulu and experience his work directlym as well as working on him with my methods. Feldenkrais was once associated with Ida Rolf, the mother of Rolfing; He however rather than doing deep body work on the fascia, like Rolfing, worked with certain body postures and movement to free up the patterns in the body, as it often falls into poor posture or pain. Using movement and re-education of the body his theory was to break up the neurological patterns of pain and restrictive movement. Both of these techniques would be highly beneficial for people with fibromyalgia as they are gentle and would be very relaxing as well as assist in reducing the pain and tension. There are a few others that are similar, one is Aston patterning, Alexander Technique and certain types of Polarity Therapy. Of course one of the best mental treatments for chronic pain and chronic illness as it takes a psychological toll on the mind as well as the body is bio-feedback training, or some kind of relaxation or meditation techniques. These systems have been around for thousands of years, and only in the application do we think they are new. Almost everyone in the health field agrees that these are good techniques for pain. With stress being ramped in this modern day we could all benefit from learning how to relax, without that after work martini. There is a very useful technique call Neuro-Lynguistic-Programing or NLP, this is another mental tool to have the person change their physiology by focusing on a positive new pattern rather than on the old problem. Just good old fashioned deep breathing can do wonders for the pain and stress level of any individual. Yoga with this may be helpful, the only advice I give in this area is never push or go into the pain as you will create the vicious cycle. Once again all of the skills and tools mentioned above are all available to us in our network of health professionals. Be sure and check with your doctor first to go into or try some of the natural and holistic practices for your health and well being are what is most important. What to do if you have FMS In the long term the most important thing you need to understand is that the first step is to understanding your fibromyalgia syndrome. We know that it can be chronic, but the symptoms or your episodes may flare up- or mellow out. This we feel can depend on your stress level, as well as what you have been doing to work on improving your condition. The impact that FMS has on your daily living as well as your activities, is going to be different with each individual. It is commonly accepted that FMS can be as serious as rheumatoid arthritis in its disabling people from working full time jobs. On the other hand the Chronic Fatigue syndrome CRS part of this situation indicates that many people can improve but according to most experts; there are few that actually completely recover from it. There are not enough studies done on FMS yet to fully understand it. Many patients have felt helpless, or hopeless, and generally get very little relief or poor results. We must remember the best results come from using all the tools and methods available, it takes knowledgeable people as well as your commitment to getting informed as well as getting better. Being in the health field most of my adult life; I know people with severe pain and frustration from having seen every doctor known to man, can get depressing or even suicidal with this disease or with severe back problems. Know that FMS is not a life-threatening disorder, but we can’t say to these patients that it’s harmless either. Some on the far end of the spectrum may feel like they can’t live like this and on the other side some people can do well and live a good life. The other factor is to get your doctor to do the laboratory tests to rule out other possible maladies that can over-lap or appear as FMS. One is Hypothyroidism it can be over-diagnosed, but most commonly it’s misdiagnosed. Fibromyalgia patients must have a good and thorough clinical diagnosis. Most qualified medical doctors or an Osteopath must make this diagnosis and ideally rule out other possibilities. This disease can be confuse or be similar to MS multiple sclerosis, lupus, osteoarthritis or rheumatoid arthritis, even heart problems. You may have a TMJ temperomandibular joint syndrome, candida, ebstine bar, or CFS chronic fatigue, or even Lou Gehrig's disease, a brain tumor, spine disease or a whole bunch of other problems. The only way to know its FMS is to rule out some of these others and only a qualified medical or osteopathic doctor can do this. Most clinical judgments are based on laboratory tests, as well as the patients history and a physical examination. You need to take the time to be clear that you do have FMS, and the doctor making the diagnosis is experience in it. The best thing that we can suggest as health professionals is to find a doctor that you can work with, that is open minded and can understand the complexity of working with this disorder. Using the information in this article and researching on the web at www.fibromyalgia.com or other sites that are similar will start to give you some hope to improve many of these symptoms. They key is that you have to take control of your own life and health. Understand that to get better takes a whole lifestyle change, and you need to understand what makes you better as well as what makes you worse. Sometimes it takes some experimentation as no human is the same and there is no magic pill. You can start or join a FMS group, also contact Fibromyalgia Network for a listing of patient contacts and physician referrals. The phone number is: (800)853-2929. Other educational materials may be ordered from The Fibromyalgia Network "Newsletter Resources". May health be with you in all ways….. Othon Molina, Ph.d.c, LMT Sources; Most of this work was taken from Dr. Podell who has a clinic for the treatment of Fibromyalgia, as well as the works of, Hans C. Hansen, The Rheumatic Disease Clinics of North America (22(2):219-243, 1996), and Dedra Buchwald, M.D.
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