Chapter 2.20 - Myofascial Pain & Fibromyalgia
In this chapter, Dr. Donache presents Complementary/Alternative Medical (C.A.M.) Therapies for the prevention and treatment of myofascial pain and fibromyalgia.
The chapter includes an overview of the disease's symptoms, conventional treatment methods, and alternative therapies, including Bio-Energetic therapies, Bodywork and Movement therapies, and Mental / Emotional treatments.
This chapter is taken from Dr. Donache's upcoming book, Finding Balance - Integrating Complementary/Alternative Medical (C.A.M.) Therapies for the Prevention of the Top 30 Diseases in America. Each section of chapter 2, which describes alternative treatments for each of the top diseases, is available for download on this website.
Table of Contents
Glossary of Terms Used in this Chapter
Additional Disease Descriptions and Treatments Available for Download
Table of Contents
- ABOUT THIS DOCUMENT
- MYOFASCIAL PAIN & FIBROMYALGIA
- CHRONIC MYOFASCIAL PAIN
- What Fibromyalgia Is
- What Fibromyalgia Isn't
- Fibromyalgia Tender Points
- Fibromyalgia Initiating Events
- Medication Treatment Options
- Side Effects
- Nonprescription Medications
- Prescription Medications
- BIO-ENERGETIC THERAPIES
BODYWORK AND MOVEMENT THERAPIES
- Nutrition and Supplements
- Enzymatic Therapies
- Rainforest and Western Herbs
- Rainforest Herbs
- Western Herbs
- Homeopathic Remedies
- Essential Oils
MENTAL AND EMOTIONAL SUPPORT
- Therapeutic Bodywork and Massage
- Traditional Chinese Medicine
- Hatha Yoga Postures
- PRODUCT ORDERING INFORMATION
- GLOSSARY OF TERMS
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THIS DOCUMENT CONSIDERS MYOFASCIAL PAIN A CHRONIC CONDITION AND A TRUE DISEASE, NOT A SYNDROME. FIBROMYALGIA IS A SPECIFIC AND NON-DEGENERATIVE SYNDROME THAT CAN OCCUR WITH CHRONIC MYOFASCIAL PAIN.
Chronic noncancer pain costs the American economy $40 billion a year. One main reason for the high cost is that most doctors are untrained in the diagnosis and treatment of fibromyalgia and chronic myofascial pain. Thus, many people are put through many unnecessary tests and procedures all of which exhaust them physically, emotionally, and financially. Some of these inappropriate treatments may even worsen their conditions.
Chronic pain is exhausting is every way: physically, mentally, emotionally, spiritually, and financially. It robs the sufferers of their families, friends, jobs, and relationships, even their life force. Pain is supposed to be a warning to tell our brains that there is a problem needing to be corrected. Chronic pain, however, becomes the problem in and of itself. Acute pain protects life - chronic pain destroys it. FMS has a major effect on direct health costs. It is in the interest of many insurers, at least in the short term, to deny patients the health care they need. "It's All In Your Head" is a cheaper diagnosis for the insurance companies and HMOs. In the long term, this attitude costs the health care system more by creating sicker patients who require more extensive services, further stressing medical resources.
Note: The author would like to thank Devin Starlanyl and Mary Ellen Copeland for the substantial contribution to this section, based on their well documented and researched book: Fibromyalgia and Chronic Myofascial Pain - A Survival Manual, 2nd edition, published by New Harbinger Publications, Inc., ISBN # 1-57224-238-8. For more specific information on these two conditions, consult their book.
Chronic Myofascial Pain
The human body comprises a complex web of muscles, tendons, ligaments, bones, joints and nerves. Where muscles and tendons, bones and ligaments come together - are areas of attachment. The cellular membranes in these attachment areas can become extremely convoluted, which increases the surface area and changes the angle of force. This increases the potential for tissue to get stuck together, and causes the tissue there to become more easily torn.
Trigger points (TrPs) are extremely sore points that can occur in the myofascia as taut, ropy bands throughout the body. They also can be felt as painful lumps or nodules. When you have a TrP in your muscle, it causes pain at the end of your range of motion when you attempt to stretch that muscle. The TrP weakens that muscle. You begin to avoid stretching that muscle because it hurts when you do. Your muscles are designed to work their best when they move freely, so as you move the TrP-laden muscle less frequently, it becomes less healthy. Circulation in your smallest capillaries, the microcirculation, becomes impaired in the area of the TrP. Nutrients and oxygen cannot reach the area easily, and wastes cannot easily be removed. Your lymph system depends on the movement of the muscles to move the lymph fluid, so that system begins to stagnate as well. Finally, because some of your other muscles have to do the work of the muscle that is weak, these overworked muscles start developing TrPs.
Trigger points can occur in the myofascia, skin, ligaments and tendons, bone lining, and other tissues. It is important to know why these trigger points are causing you pain before you can understand how to relieve each symptom. Until recently, we had no scientific and understandable cause for the existence of TrPs, and they had no officially recognized diagnostic criteria. Because of this, physicians and therapists for the most part, have not been trained to recognize and treat them. Lack of understanding on the part of insurance carriers and the Social Security Administration has made some lives even more difficult. We now have facts that cannot be disputed. Myofascial pain caused by TrPs is a true disease. They were identified and have been documented by characteristic spontaneous electrical activity (SEA). Doctor Robert Gerwin made an ultrasound video of a TrP local twitch response. Biopsies of myofascial TrPs show contraction knots and giant rounded muscle fibers. The structure of the cells changes microscopically, forming contraction knots - the lumps and bumps we know only too well.
A small change in myofascia can cause great stress to other parts of your body. Restriction of one major joint in a lower extremity can increase the energy expenditure of normal walking by as much as 40 percent, and if two major joints are restricted in the same extremity, in can increase by as much as 300 percent.
Consider differences in the following practitioner types, their areas of training, and treatment programs. The information in this report should help you choose a team that can bring the appropriate relief for your particular condition:
- Massage Therapists work with muscles and tendons, using different techniques like muscle kneading and compression to lessen tension in the muscles. This increases circulation and helps the body flush out cellular debris, which speeds tissue repair and aids in healing back problems. Massage Therapists who are trained in Neuro-Muscular Therapy, Myofascial Release and Manual Lymphatic Drainage provide the most relief for chronic myofascial pain and fibromyalgia. Refer to the section on Massage Therapy for detail information about these modalities.
- Occupational Therapists may recommend other specialists and may supervise lifestyle changes in the home and work environment. O.T.'s often recommend devices designed to ease the burden of living with a recovery from back pain.
- Physical Therapists specialize in improving joint and spine mobility and muscle strength. They are not medical doctors and are strictly limited to physical therapy.
- Physiatrists, also known as doctors of physical rehabilitation medicine, are medical doctors who treat pain by the use of various physical therapies, lifestyle changes, and back braces, which promote healing by reducing the load on the spine. Physiatrists are not licensed to perform surgery, and are less likely than other M.D.'s to hospitalize their patients.
Note: Because bodywork and other therapies move toxins and wastes out of the intercellular fluids and into the bloodstream, it is not uncommon for nausea or headaches to result. This movement is a necessary step in ridding yourself of these chemical toxins and wastes, so it is a good sign, even though it doesn't feel good at the time.
The next time your physician, your insurance company, or other care provider tries to deny the importance of bodywork, especially fascial work, to the state of your health, teach them what they need to know. Bodywork can affect your health at the cellular level. John Barnes, master of Myofascial Release, explains the continuity and pervasiveness of the myofascia in the following way:
"Every muscle of the body is surrounded by a smooth fascial sheath, every muscular bundle of fibrils is surrounded by fascia, every fibril is surrounded by fascia, and every microfibril down to the cellular level is surrounded by fascia. Malfunction due to trauma, poor posture, or inflammation can bind down the fascia. Restrictions of the fascia can create pain or malfunction throughout the body, sometimes with bizarre side effects and seemingly unrelated symptoms. At the cellular level, fascia creates the interstitial spaces. It has extremely important functions in support, protection, separation, cellular respiration, elimination, metabolism and fluid and lymphatic flow. It can have profound influence on cellular health and the immune system
If fascia is restricted at the time of trauma, the forces cannot be dispersed properly and areas of the body are then subjected to an intolerable impact. The forces do not have to be enormous; a person who just does not have enough "give" can be severely injured. Fascia reorganizes along the lines of tension imposed on the body, adding support to misalignment and contracting to protect the individual from further trauma (real or imagined). This has the potential to alter organ and tissue physiology significantly. Over time, the tightness spreads like a pull in a sweater or stocking. Flexibility and spontaneity of movement are lost, setting the body up for more trauma, pain, and limitation of movement."
In the myofascia, there is a material called ground substance. This material can change its form from liquid to solid and back again. When you are healthy, your ground substance has a gelatinous consistency so that it can absorb the forces that are created when you move. It is also a shock absorber if you are involved in trauma. The ground substance can resemble gelatin that has not yet set, or seem like a firm gelatinous slurry, or even harder, like sprayed-on Styrofoam insulation. When the ground substance hardens, it is as if it has turned to glue or cement. When ground substance changes from a liquid to a gel, and then into its more solid form, the myofascia tightens. It won't reverse to its previously more liquid state without outside intervention.
What Fibromyalgia Is
- Fibromyalgia is real. Research supports FMS as a "distinct clinical syndrome deserving of informed medical care and continued research to better understand chronic widespread pain."
- Fibromyalgia can be a source of substantial disability. This is especially true if you have had it for a long period of time without adequate medical support.
- Fibromyalgia is a complex syndrome characterized by pain amplification, musculoskeletal discomfort, and systemic symptoms. In FMS, there is a generalized disturbance of the way in which pain is processed by the body. The definition put forth in American Journal of Medical Science by I.J. Russell in 1998 describes and defines FMS as widespread allodynia and hyperalgesia. "Allodynia" means ordinary nonpainful sensations are experienced as pain sensations. "Hyperalgesia" means that pain sensations are intensified and amplified. The combination can be disastrous. If there is a physically traumatic initiating event, these changes in the way your central nervous system processes pain seem to worsen.
- Fibromyalgia is a central nervous system sensitization. Travell and Simons: Myofascial Pain and Dysfunction - The Trigger Point Manual states: "It is now firmly established that a central nervous system (CNS) dysfunction is primarily responsible for the increased pain sensitivity of fibromyalgia."
What Fibromyalgia Isn't
- Fibromyalgia is not a musculoskeletal disorder. It should have been called "Central Nervous System-myalgia". That is where the dysfunction is located. It has nothing to do with the fibers of your muscles. In FMS, muscle fibers are not causing the problem, although there may be cellular changes caused by the biochemical FMS dysfunction. Fibromyalgia is a biochemical disorder, and these biochemicals affect the whole body.
- Fibromyalgia is not progressive. If your illness becomes significantly worse over time, then there is some perpetuating or aggravating factor or some coexisting condition that has not been addressed.
- Fibromyalgia is not a catchall, wastebasket diagnosis. It is a specific, chronic non-degenerative, noninflammatory syndrome. Rheumatoid arthritis, lupus, and many other serious conditions are also classified as syndromes.
- Fibromyalgia is not the same as chronic myofascial pain. It is fundamentally different in an important way. There is no such thing as a fibromyalgia trigger point.
- Fibromyalgia is not the same as Chronic Fatigue Immune Deficiency syndrome (CFIDS), although they may be part of the same family of central nervous system dysfunctions. Most patients with FMS show increased amounts of substance P in their cerebrospinal fluid. Studies have shown that some of the biochemical levels in the cerebrospinal fluid of patients with FMS are not normal.
- Fibromyalgia is not a homogenous condition. The cause of muscle pain and allodynia may not be the same in all persons fulfilling the ACR criteria for FMS.
- Fibromyalgia is not an autoimmune condition. The presence of antinuclear antibodies and other connective tissue disease features is similar in patients with fibromyalgia and healthy control subjects.
- Fibromyalgia is not a mental illness and must not be categorized as such. Some people with FMS also have mental illness. Some people with flu have mental illness, too, but that doesn't mean that flu is caused by mental illness.
- Fibromyalgia is not infectious. Infection from many causes can start the neurochemical cascade of FMS. This does not mean that FMS is infectious. Both FMS and CMP can be brought on by specific triggers, such as stress, infections, pollutions, and diet.
Fibromyalgia Tender Points
In Fibromyalgia, tender points occur in pairs, so pain is usually distributed equally on both sides of the body. Widespread hypersensitivity and allodynia can be present with fewer than eleven tender points.
On the back of your body, tender points are present in the following places:
- Along the spine in the neck, where the head and neck meet;
- On the upper line of the shoulder, a little less than halfway from the shoulder to the neck;
- About three finger widths, on a diagonal, inward from the last points;
- On the back fairly close to the dimples above the buttocks, a little less than halfway in toward the spine;
- Below the buttocks, very close to the outside edge of the thigh, about three finger widths.
On the front of your body, tender points are present in the following places:
- On the neck, just above the inner edge of the collarbone;
- On the neck, a little farther out from the last points, about four finger widths down;
- On the inner (palm) side of the lower arm, about three finger widths below the elbow crease;
- On the inner side of the knee, in the fat pad.
The tender point count may decrease with proper medical treatment and self-care, but that doesn't mean that the FMS has been cured. It simply means that you have learned to deal with the perpetuating factors and coexisting conditions and have them under control.
Fibromyalgia Initiating Events
Many patients, when questioned carefully, reveal that their symptoms began at an early age. Pain is often the most obvious symptom of FMS, but there are other symptoms too. There are no common specific diagnostic tests for FMS, but demonstrable biochemical differences do exist.
- There are reduced high-energy phosphate levels in the muscles of patients with primary fibromyalgia.
- Levels of phosphocreatine and adenosine triphosphate (ATP) are lower at rest as well as during exercise. ATP is the prime source of cellular energy.
- Fibromyalgia is associated with metabolic abnormalities.
- Increased concentrations of homocysteine and nerve growth factor are found in the cerebrospinal fluid of FMS patients.
- Fibromyalgia may be due to dysfunctional thyroid regulation of the genetic code information transfer between types of nucleic acids. This may be due to mutation of the c-erbaA beta gene, as well as to thyroid deficiency. The result would be tissue-specific hypothyroid-like symptoms despite normal circulating thyroid hormone levels, and thus normal thyroid test results.
- A subset of FMS patients have low levels of insulin-like growth factor 1 (IGF-I)
- Abnormal cerebral blood flow in the caudate nucleus and thalamus have been found in FMS.
- In FMS there is dysfunction at least at the brain stem level. The cerebrospinal fluid showed discrete changes in cell differential count.
TO SUM UP: Myofascial TrPs need to be treated locally, and their perpetuating factors need to be addressed. Chronic myofascial pain is a condition that is potentially curable, unless there is a fixed, uncorrectable underlying cause. Fibromyalgia needs to be treated systemically, and its perpetuating factors need to be addressed. It is a chronic illness that can be controlled.
It is definitely possible to have both. Any treatment tried will be both more complicated and less successful than if the patient had only one of the two conditions.
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Glossary of Terms
- Cerebrospinal Fluid
- A clear, colorless fluid that contains small quantities of glucose and protein. Cerebrospinal fluid fills the ventricles of the brain and the central canal of the spinal cord.
- Licensed health care providers trained in the maintenance and restoration of health primarily through specific hand-on manipulation of the musculoskeletal system and spine.
- Chronic Pain
- Pain persisting over a long period of time.
- The flat layers of fibrous tissue that separate different layers of tissue.
- Cordlike Tissues that connect the bones within or around a joint; if overstretched, they may be a source of pain.
- Lumbar Spine
- The lower spinal region that normally curves inward; the five vertebrae above the pelvis.
- Lymph System
- The tissues and organs (including the bone marrow, spleen, thymus and lymph nodes) that produce and store cells that fight infection and the network of vessels that carry lymph.
- Muscle Spasm
- A painful, involuntary contraction of muscle tissue.
- Of or relating to the fascia surrounding and separating muscle tissue.
- Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
- A class of inflammation-relieving medicine that includes aspirin, ibuprofen and naproxen; available over the counter and by prescription.
- Pain that radiates to the leg or buttocks, as a result of compression of the nerve roots in the spine that join to form sciatic nerves.
- Trigger Point
- A specific point or area where, if stimulated by touch, pain, or pressure, a painful response will be induced.
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