By Richard H. Adler
Myofascial pain is a common muscular pain disorder characterized by regional pain and associated localized muscle tenderness. In clinical studies, it has been reported as the most common diagnosis responsible for chronic pain syndromes and related disability. However, “chronic pain syndrome” is regarded by some health care providers as a “kitchen sink” term for disposing of all soft tissue complaints. One observer notes that part of this confusion stems from the high variability in case definitions and the lack of diagnostic criteria or objective methods of assessment.
Recently, however, researchers and clinicians found it useful to formulate the “fibromyalgia” diagnosis in order to promote research, evaluate treatment programs, and improve patient management. The World Health Organization, in developing the International Classification of Disease (ICD), has incorporated fibromyalgia in the tenth revision of ICD; fibromyalgia is number M79.0.
A consensus conference on fibromyalgia took place in Copenhagen on August 20, 1992, as part of the Second World Congress on Myofascial Pain and Fibromyalgia. Fibromyalgia is defined as
Definition. Pain is considered widespread when all of the following are present: pain in both sides of the body, pain above and below the waist. In addition, axial skeletal pain (see cervical spine, anterior chest, thoracic spine or low back) must be present. Low back pain is considered lower segment pain.
Definition. Pain, on digital palpation, must be present in at least 11 of the following 18 tender point sites.
Occiput: at the suboccipital muscle insertions.
Low cervical: at the anterior aspects of the intertransverse spaces at C5-C7.
Trapezius: at the mid-point of the upper border.
Supraspinatus: at origins, above the scapular spine near the medial border.
Upper Rib: upper lateral aspects of the second costochondral junction.
Lateral Epicondyle: two cm distal to the epicondyles.
Gluteal: in upper outer quadrants of buttocks in anterior fold of muscle.
Greater Trochanter: posterior to the trochanter at the prominence.
The Knees: at the medial fat pad proximal to the joint line.
History of widespread pain.
Pain in 11 of 18 tender point sites on digital palpation.
Digital palpation should be performed with the approximate force of 4 kg. A tender point has to be painful at palpation, not just “tender.”
A review of current literature indicates that fibromyalgia is, in fact, a distinctive syndrome which can be diagnosed with clinical precision by first understanding the definition of fibromyalgia and how to detect it.
From the clinical perspective, the diagnosis is often present when the patient presents with unexplained widespread pain or aching, persistent fatigue, generalized stiffness, non-refreshing sleep, and multiple tender points. Since these pain complaints may somewhat mirror several of the pain complaints of myofascial pain, there is a potential cause of confusion in the diagnosis. However, myofascial pain syndrome patients have localized pain distribution and a limited number of tender points. Fibromyalgia patients often have the profile of persistent fatigue, widespread stiffness, and non-restorative sleep. Additionally, myofascial pain syndrome patients are usually responsive to specific fascial therapy and fibromyalgia patients are not.
ETIOLOGY OF FIBROMYALGIA
The etiology of fibromyalgia has not been conclusively established within the scientific community. However, contemporary studies do provide support for the following assertions.
A. Psychological Factors: There is no basis for the statement that the pain and tenderness in fibromyalgia patients are primarily caused by emotional stress, depression or anxieties. However, there is agreement that these factors may, on occasion, increase or exacerbate the intensity of pain.
B. Sleep Disturbance: It is well known that fibromyalgia patients often wake up feeling unrefreshed. Testing has revealed that this sleep disturbance is connected with an abnormal reading on EEG. There appears to be a disturbance of the deeper stages of sleep, often characterized by an arousal pattern.
C. Muscle Studies: Biopsy of muscle tissues in fibromyalgia patients has failed to reveal any changes that are characteristic or diagnostic of the condition. Testing of these muscles have included looking at the serum levels of muscle enzymes, electromyography studies, exercise testing, and nuclear magnetic resonance have failed to show any global defect of muscle metabolism in fibromyalgia patients.
D. Pain: Contemporary research indicates there is evidence that fibromyalgia patients have a centrally enhanced perception of pain that appears to be organically based.
E. Increased Sympathetic Activity: Fibromyalgia patients appear to have an increase in sympathetic activity as a result of an enhanced responsiveness to physiologically normal stimulation of their sympathetic system. Most fibromyalgia patients complain of cold sensitivity; some 20-40% have the primary form of Raynaud’s phenomenon. Other complaints suggestive of increased sympathetic activity are dry eyes, dry mouth, fluid retention and bladder irritability.
WHO GETS FIBROMYALGIA?
According to the 1992 Copenhagen Consensus document, health surveys in various countries point to a prevalence of 0.7-3.2% in the general adult population. Nearly all cases were found in women, yielding a female prevalence of at least 1.3% to 6% or more. Onset of symptoms is most frequent from the ages of 20 to 40 years, but has been reported to occur at all ages, even in childhood. A study recently published indicates the following profile:
Studies indicate up to 20% of the patients in a rheumatologic clinic have fibromyalgia. Caucasian women between ages 40 and 60 are more likely to present with the syndrome, although 28% indicated they were age 9-15 at onset… Of the 10-20% of cases of fibromyalgia in males, the presentation is no different than that for women.
At least 2% of the general U.S. adult population has fibromyalgia. The prevalence varies with the precise definition of fibromyalgia used. Sixty percent of individuals having the fibromyalgia tender points do not have the chronic, diffuse pain characteristic of the syndrome.
…Most symptoms begin gradually. Onset after trauma, surgery, overactivity, a viral infection, or a period of emotional or physical stress has been reported.
THE EFFECTS OF FIBROMYALGIA ON QUALITY OF LIFE
A. Localized muscle pain: Fibromyalgia may begin as localized muscle pain. It may also evolve into the whole body when fibromyalgia pain is fully developed. Fibromyalgia patients may also have subjective joint pain without evidence of arthritis. The muscle and joint stiffness will be seen in 9 out of 10 patients, with the worst pain occurring in the morning and lasting 2 to 4 hours.
B. Functional disability: Fibromyalgia patients will have problems with activities of daily living that include mobility, arm function, grip strength, and household tasks that are comparable to rheumatoid arthritis patients. Clearly, the fibromyalgia patient has reduced work capacity, which is usually due to pain which limits movement. The functional disability appears to remain stable over time.
C. Poor physical fitness: Most individuals with fibromyalgia appear to exercise very little. On average, maximum muscle strength is lower in fibromyalgia patients than when compared to age-matched healthy subjects.
D. Work disability: According to the Copenhagen Consensus document:
Many patients feel unable to cope with housework. Many have quit work outside the home, changed jobs, or work only part time as a consequence of their fibromyalgia. There is a strong negative impact of fibromyalgia on work performance. When employed, individuals with fibromyalgia have a higher number of sick days, have more difficulty performing work accurately and completing work tasks efficiently compared to individuals with rheumatoid arthritis. They also report the need for more frequent rest periods and within-job modifications. Overall, having fibromyalgia makes it difficult for patients to be competitively employed.
E. Psychological distress: Contemporary research cautions and warns that there is no “fibromyalgia personality.” Persons diagnosed with fibromyalgia respond in very individualized ways and cannot be stereotyped. When fibromyalgia is full-blown, many individuals will present with depression, anxiety and phobia. The psychological distress, however, is more a consequence of pain rather than a cause of it. Psychological distress compounds the situation but is not the primary cause of their symptoms.
F. Decreased quality of life: Patients diagnosed with fibromyalgia will often perceive their quality of life to be significantly different and lower than healthy persons or those with just a diagnosis of rheumatic diseases such as rheumatoid arthritis. All parts of the person’s life are affected, including health, relationships, and ability to engage in recreational pursuits.
TREATMENT OF FIBROMYALGIA PATIENTS
Fibromyalgia affects individuals physically, psychologically, and socially. Treatment programs must be individualized and draw from a multi-disciplinary approach. Management programs must focus on modalities to reduce pain, provide instruction on posture, manipulation to restore proper biomechanics, stretching and exercise, stress reduction, life style changes to improve sleep and appropriate pharmaceuticals. The most successful programs emphasize the patient’s active participation. It is also critical that the patient’s doctor be able to diagnose fibromyalgia correctly and early, as well as understand its consequences. Patient education is important so that the patient knows they have a chronic disorder that will require long-term treatment.
A. Exercise and physical therapy: There is a limited number of studies in this area and the best that can be said is that a low-impact, low-load exercise training program, such as brisk walking, biking or swimming, with some psychological intervention, is recommended. The idea is to advise fibromyalgia patients to avoid the effects of inactivity on muscles, to increase endorphin secretion, and to provide the patient with some control over their activity level.
B. Education: The Copenhagen Document strongly advises that one way to decrease patient anxiety and lead to better treatment compliance is for the fibromyalgia patient to have a clear diagnosis of their condition. Many fibromyalgia patients may be dealing with their pain problems and have a physician who does not believe or understand the diagnosis at all.
C. Medications: A variety of pharmalogic agents have been tried. Several authors doubt the utility of pharmaceuticals because of the overall poor performance and significant side effects. There is little evidence that pharmacologic treatment results in prolonged pain relief. However, there are some clinical therapeutic trials demonstrating that low dosage of trycylic medications are more effective than placebo in the treatment of fibromyalgia. The largest controlled studies have been with Amitriptyline and Cyclobenzaprine.
D. Homeopathy: Tincture of poison oak diluted in ethanol was the most commonly indicated homeopathic medicine for 42% of fibromyalgia patients. In a double blind-placebo controlled, crossover design trial, the treatment group did better in all variables compared to placebo. The number of tender spots reduced by about a quarter. A significant improvement in pain and sleep was reported.
E. Manipulation: Though manipulation does not appear to “cure” the condition, fibromyalgia patients frequently report 1 to 2 hours of pain relief following manipulation, but a return of symptoms thereafter. One author has theorized that relief may be due to a reduction of muscle tension, a release of endorphins, a reduction of stress, a correction of postural dysfunction, or other unknown mechanisms. More research is underway in this area.
Fibromyalgia is now recognized as one of the more common chronic pain syndromes, and its diagnosis has proven to be equally frustrating as its treatment. The most promising result for the patient afflicted with this condition appears to be an individualized multi-disciplinary long-term approach to treatment that incorporates a combination of education, aerobic conditioning, myofascial therapy, a very low dose anti-depressant drugs and manipulation. Achieving a better understanding of the fibromyalgia diagnosis may help patients avoid having to undergo extensive and time-consuming workups only to learn that they have been misdiagnosed and have a chronic condition.
Very truly yours,
ADLER GIERSCH, P.S.
Richard H. Adler
Attorney at Law
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D. A. Fishbain, M. Goldberg, B. R. Meagher, R. Steele, H. Rosomoff, “Male and Female Chronic Pain Patients Categorized by DSM III,” Psychiatric Diagnosis Criteria, Pain, 1986, Vol. 26, pp. 181-197.
S. A. Skootsky, B. Jaeger, R. K. Oye, “Prevalence of Myofascial Pain in General Internal Medicine Practice,” West J Med, 1989, Vol. 151, pp. 157-160.
Rosomoff, et al., “Physical Findings in Patients with Chronic Intractable Benign Pain of the Neck and/or Back,” Pain, 1988, Vol. 26, pp. 181-197.
2 James Fricton, D.D.S., M.S., “Myofascial Pain: Clinical Characteristics and Diagnostic Criteria,” Journal of Neuromuscular Pain, 1988, Vol. 1, No. 34, p. 38.
3 “Consensus Document on Fibromyalgia: The Copenhagen Declaration,” Journal of Musculoskeletal Pain, Vol. 2, No. 3, pp. 295-312.
4 Ibid., p. 299.
6 M. B. Yunus, et al., “Relationship of Clinical Features with Psychological Status and Primary Fibromyalgia,” Arthritis and Rheumatism, 1991, Vol. 34(1), pp. 15-21.
7 “Consensus Document on Fibromyalgia: The Copenhagen Declaration,” Journal of Musculoskeletal Pain, Vol. 2, No. 3, p. 300.
9 Ibid., pp. 300-301.
10 St. Claire, D.C., M.S., “Diagnosis and Treatment of Fibromyalgia Syndrome,” Journal of the Neuromusculoskeletal System, 1994, Vol. 2, No. 3, p. 101.
11 “Consensus Document on Fibromyalgia: The Copenhagen Declaration,” Journal of Musculoskeletal Pain, Vol. 2, No. 3, p. 302.
13 Ibid., p. 303.
14 St. Claire, D.C., M.S., “Diagnosis and Treatment of Fibromyalgia Syndrome,” Journal of the Neuromusculoskeletal System, Fall 1994, Vol. 2, No. 3, pp. 101, 106.
17 Goldenberg, M.D., “Fibromyalgia: Treatment Programs,” Journal of Musculoskeletal Pain, Vol. 2, No. 3, p. 73.
18 St. Claire, D.C., M.S., “Diagnosis and Treatment of Fibromyalgia Syndrome,” Journal of the Neuromusculoskeletal System, Fall 1994, Vol. 2, No. 3, p. 101, 106.
19 M. I. Gatterman, Chiropractic Management of Spine-Related Disorders, 1st ed., Baltimore: Williams & Wilkins, 1990, pp. 285-329.
20 St. Claire, D.C., M.S., “Diagnosis and Treatment of Fibromyalgia Syndrome,” Journal of the Neuromusculoskeletal System, Fall 1994, Vol. 2, No. 3, p. 101, 106.
21 D. L. Goldenberg, “Fibromyalgia Syndrome: An Emerging But Controversial Condition,” JAMA, 1987, Vol. 257, pp. 2782-2787.