Myofacial Pain Syndrome 

Fibromyalgia Syndrome (FMS) encompasses a generalized pain syndrome of the muscles, ligaments and tendons, in other words the fibrous connective tissues of the body.  Fibromyalgia is a specific, chronic non-degenerative, non-progressive, non-inflammatory, truly systemic pain condition.  Many patients with fibromyalgia describe it as an overall constant ache and fatigue where their muscles feel like they have been overworked.  Sometimes the muscles may twitch and at other times they burn.

Fibromyalgia is described as widespread musculoskeletal pain with fatigue due to an unknown cause.  There may be several triggering events that could precipitate its onset like an infection (viral or bacterial), an automobile accident or some chronic disorder – rheumatoid arthritis, lupus, or hypothyroidism.  The triggering event is probably not the cause in most causes, but may make an underlying physiological abnormality that is already present be expressed.  There are several lines of evidence to suggest that the pain of fibromyalgia may be due in part to the result of disordered sensory processing at a central level.    

Alterations could have occurred in neurotransmitter regulation of serotonin, norepinephrine, and substance P (pain neurotransmitter).  Several studies have shown a dysregulation present in how the brain operates in an individual suffering from fibromyalgia.  Some studies have shown that a change in the myofacial (muscles and tissue around structures) system of the body causing great stress in other parts of the body.  These minor restrictions in a joint or muscle can increase the energy needed to move the body up to 300%.

Many researchers believe that fibromyalgia results from a combination of the above causes and that is why each individual with fibromyalgia may need different treatments.  Since each cause and resulting stimulating event is different, each presentation may be a little different.

Most individuals suffering with fibromyalgia have pain.  The pain is described as a deep muscular aching, burning, throbbing, shooting, and/or stabbing that can be worse in the morning.  There can also be periods that the pain gets better and then will worsen if aggravated by something as simple as a lack of sleep or increased exertion.  Along with this pain, many also complain of fatigue.  This is a feeling of totally drained of energy and unable to concentrate.  Many individuals with fibromyalgia describe there limbs feeling like they were tied to concrete blocks.

Most of the patients with fibromyalgia also have an accompanying sleep disorder.  Many can fall asleep fine, but will be unable to reach deep sleep known as stage 4 sleep.  This is the restorative sleep the body needs to repair, fight infections, and function well.  Individuals with fibromyalgia will have stage 4 sleep interrupted with bursts of awake-like brain activity so that they never spend any time in stage 4 sleep.  As a result, they wake feeling like they did not sleep at all or very little through the night even though they may have got eight to ten hours.

The other multitude of symptoms associated with fibromyalgia can range from irritable bowel syndrome to chronic headaches.  The different presenting symptoms can vary with the individual and the underlying issue.  There are also the aggravating factors that can cause flare-ups such as changes in the weather, cold, hormonal fluctuations, stress, mood issues, and over-exertion.

Fibromyalgia is many times difficult to diagnosis.  For a long time it was not considered an actual diagnosis or a fabrication that was made up to appease patients.  Research has shown that fibromyalgia does exist and has given doctors more information about the syndrome and how to treat.  In 1994 the CDC published diagnostic guidelines in the Annuals of Internal Medicine {121(12):953-959} that included the presence of severe, unexplained fatigue that is not relieved by rest that has been lasting for at least six consecutive months with four of the following symptoms: impaired memory or concentration; tender cervical or axillary lymph nodes; sore throat without signs of infection; muscle or multi joint pain; new onset of headaches; unrefreshing sleep; and post-exertional fatigue.

Trigger Points of Myofascial Pain versus Tender Points

The medical literature contains many references to myofascial pain as a regional syndrome whereas fibromyalgia is a widespread syndrome.  The difference between the two versions is the definition between a trigger point and a tender point.  Trigger points are found as extremely sore points along a ropy muscle.  These points are typically felt as an area of hardening fascia causing a palpable lump.  The underlying muscle can be ropy and hard.  Each trigger point also has a referred pain that is caused when it is stimulated.  This means that when it is pressed it causes pain at the site and pain elsewhere, typically along the muscle it is found in.

There are also “latent” trigger points.  A latent trigger point does not hurt until it is pressed, unlike a trigger point which can ache with motion and stress.  This latent trigger point can still restrict movement, weakens, and prevents full lengthening of the affected muscle.  Latent trigger points are generally found in individuals who get little exercise.  The latent trigger point becomes activated by overstretching, overuse, or chilling the affected muscle.

Tender points are specific paired points on the body that occur in a distinct pattern.  There are typically eighteen paired points described in the literature associated with fibromyalgia.  These tender points do not cause referred pain elsewhere in the body typically.  They can be very tender in someone suffering from fibromyalgia.  Fibromyalgia can contain both of these points, but myofascial pain only has trigger points.

Treatments

Treatments of fibromyalgia should focus on four major areas – pain, exercise, sleep, and psyche.  Not treating all of these can make a great treatment plan fail.  Since the body is a dynamic being, so should the treatment.  Most doctors familiar in treating fibromyalgia will try to treat all of these aspects because they understand the basic underlying physiology going on.

Relieving even part of the pain can significantly improve the psychological distress, cognitive abilities, sleep, and functional capacity of fibromyalgia patients.  There are several medications available to treat pain, but few do more than a band-aid approach and need to be used sparingly.  The use of opiate medication can lead to other issues such as dependence and causing rebound pain.

There are also some treatments that do not involve medications in the treatment of trigger points and stressed muscles.  Massage done carefully can be very beneficial, but can also aggravate pain issues if done poorly or too strongly.  Other therapies such as trigger point injections, acupuncture, TENS units, or osteopathic manipulations can be helpful depending on the situation and type of pain.

A gentle stretching and active cardio routine is essential to keep the muscle from becoming more dysfunction in fibromyalgia if left to little to no use.  Stretching to the point of resistance and then holding the stretch allows for a signal to the muscle fibers to relax, whereas stretching to the point of increased pain will cause additional muscle fibers to contract instead of relax.  Active cardio is showing that it is more beneficial in helping to keep muscles functional and slowing the progression of the fibromyalgia.

The sleep issues in fibromyalgia can be multifactorial and should be addressed so that these issues are resolved.  Stage 4 deep sleep is critical in the body’s ability to heal itself, immune system is most active, and it is a time of regulating various neurotransmitters and hormones.  The various issues can range from sleep apnea, pain, or to psychological distress.  A medication may aid sleep, but it may not help a person really deal with the actual issue causing the disturbed sleep.

Any individual dealing with chronic pain can have feelings of depression, anger, fear, withdrawal, or anxiety.  It is a natural occurrence and nothing to be afraid of.  These strong emotions can become debilitating in of themselves and end up worsening the condition in many cases by decreasing an individual’s ability to function normally to stay competitively employed or continue working at the level they use to work at.  This can then lead to further worsening of the overwhelming feelings that are occurring and then lead to more stress.