Chronic Musculoskeletal Pain
By A.L Shaw, M.D.Do you hurt all over! Does ANY one believe you? Will it EVER end? If you have been hurting for longer than 6 months, feel your doctor can't help you! You and your family "feel" the pain. You're SCARED! You're MAD! And life has become a BEAR! You may have Fibromyalgia or Myofascial Pain.
Myofascial pain generally is in both sexes. Fibromyalgia is in females approximately 4:1 relative to males. Myofascial pain is localized pain, whereas fibromyalgia has generalized pain. All Ages have myofascial pain, whereas fibromyalgia is in the 35-65 age group. Changes in spinal fluid endorphine concentrations are potentially etiological in MPS, whereas, peripheral substance P production and alteration is most important in fibromyalgia. Myofascial pain can be either acute or chronic, but nearly all fibromyalgia patients are chronic, involving months to years of history. Myofascial patients commonly radiate pain from trigger points which are considered to be active, whereas fibromyalgia rarely has radiation. The same trigger points which radiate pain in myofascial pain also have twitch responses; that is, when stimulated the muscle has a rapid jerk. Fibromyalgia patients rarely have twitch responses. Most MPS patients have a good prognosis when treated with appropriate methods; fibromyalgia patients commonly have a reserved prognosis. Most authors agree MPS commonly has a mechanical etiology, whereas fibromyalgia has metabolic, environmental, and neurologic etiologies. MPS patients demonstrate spinal reflexes; but fibromyalgia patients have increased sensory fields in their CNS.
Fibromyalgia has many aliases, among them are Primary Fibromyalgia Syndrome, Fibrositis, Nonarticular rheumatism, Fibromyositis, Primary Fibrositis Syndrome, Diffuse Myofascial Pain Syndrome, and in the UK, Myalgic Encephalomyelitis.
True etiology of fibromyalgia is unknown. Some evidence exists for increased sensory fields in the CNS. Certainly we are aware of associated factors, including stress and fatigue which can exacerbate slow wave non-REM sleep deprivation. Bengtsson, believes sympathetics may be involved in causing vasoconstriction due to chronically heightened muscle tensions.
Commonly associated are a overall high substance P and many patients exhibit the Raynaud's phenomenon. These patients develop chronic overload of many muscle groups, poor posture and work habits which cause heightened tension in dorsal muscle groups most of their waking life. These conditions are exaggerated by ergonomically inappropriate furniture, skeletal asymmetry in the occasional individual. Many patients are diagnosed with dental "malocclusion." Most of these patients have a sedentary life-style, exhibit much myofascial pain, have frequent muscular or mixed headaches and neck pain.
Chronic low back pain, major joint restricted ROM, work-mate rejection because of lack of performance or "carrying one's own load," an over abundance of fear of bodily damage (harm) as opposed to tolerance of some muscular discomfort during mandated muscular exercise (hurt). Nearly all of these patients demonstrate disuse muscular degeneration, proximal extremity and truncal aching, distal swelling, numbness, stiffness, and morning joint stiffness, especially at extremes of ROM, especially stiffness of cervical and lumbar spinal musculature.
The obese patients nearly always exhibit cardio-pulmonary degeneration and are usually clinically depressed, lose lots of sleep and claim loss of appetite. Spousal disapproval and family rejection, combined with poly-pharmacy extend the depression.
Many claim and usually exhibit widespread aching pain which is characteristically poorly localized for >3 months duration, demonstrated by complete muscular morning "exhaustion" after a restless night's sleep. Muscular symptoms are aggravated by cold, damp, stress, to create under/over use of involved muscles, increasing the pain.
Diagnosis is difficult relying on groups of problems, but widespread aching >/= 3 months duration, absence of laboratory evidence of inflammation or muscle damage, and demonstrated bilateral tender areas of >= 6 total are usually utilized criteria for diagnosis. Those areas are mid upper trapezius fold, superio-lateral aspect 2nd costochrondral junction, anterior interspinous spaces, C4-6, long finger extensor muscle belly at lateral epicondyle, interspinous ligament of L4-S1, upper outer buttock over the gluteus medius, and medial knee fat pad over medial collateral ligament proximal to joint line. Other confirmatory criteria are >= 12 trigger points in discrete areas of muscle, skin fold tenderness reactive hyperemia proximal limbs/upper truncal areas, distal limbs and lumbar area devoid of reactive hyperemia, disturbed sleep, and morning fatigue and stiffness. There are no consistent pathologic histologic factors demonstrated. Thermography usually consistent with triggers @ >1-2oC in the region or focal; mean body <1oC.
Therapy must include some exercise with maximum ROM exercises using modest resistance with free weights or elastics. JH Pilates based equipment as manufactured by Current Concepts can help significantly with ROM. Appropriate nutrition involving high carbohydrate, low fat content food to obtain appropriate weight helps tremendously. Common NSAIDs, such as ASA <= 3 gms/24 hrs or ibuprofen <= 1200 mg/24 hrs will help for "normal" pain. For prescriptioned therapy one can look at antidepressants, such as amitriptyline <= 200 mg/24 hrs, doxepin <= 100 mg/24 hrs, or trazadone <=100 mg/24 hrs. Muscle relaxants as cyclobenzaprine <=40 mg/24 hrs, methocarbamol <= 3000 mg/24 hrs, combined with anti-sympathetic therapy such as clonidine <= 300 micrograms/24 hrs, phenoxybenzamine <= 100 mg/24 hrs or sympathetic blocks of the lumbar, thoracic, cervical areas for the more persistent and serious problems. A newer therapy, Botulinium toxin, 10-15 units per TP, or in the fascial spaces (Brachial/Lumbar) Blocks 100 u may be helpful. Prior to the botulinium therapy, one may try pentolium 5-15 mg per trigger point. All trigger points can be electronically elucidated with EMG-guided injections, however most clinicians will not need that level of control.
Many chronic muscular pain patients need significant vitamin additions. We recommend at least B-Complex, <= 100 mg/24 hrs, E, <= 1000 mg/24 hrs, C, <= 4000 mg/24 hrs, as well as additional supplementations of potassium and magnesium. Females, of course, need additional calcium intake.
In some contrasts to firbromyalgia, myofascial pain syndrome (MPS) is demonstrated by specific trigger points in one or several muscles, usually caused by a spinal reflex or perhaps neuropathic and/or supra sympathetic activity. MPS is usually secondary to trauma, arthritis, nerve injuries, visceral disease involving a nearby body segment.
Trigger Points may be either latent (not symptomatic) or active (producing pain, at rest or with motion or loading the muscle). One need only produce modest pressure to cause local pain and possibly radiation to distant predestined sites. MPS triggers are quite common: 54% females 45% males in shoulder girdle according to Sola. The syndrome demonstrates a greater incidence in females at 2-3 to 1 in males. Locations of the TP in head and neck, shoulder and pelvic girdle, thoracic and lumbar spine are most common. Sedentary life style, with no or minimal exercise, repetitive motions at work or play is most common. According to the Nuprin Survey, 53% Americans had muscle pain, with 33% for >11 days, and 10% for >100 days.
The etiology of this syndrome seems to be acute overload or repeated trauma of muscles. Latent TPs are activated by intense heat or cold, changing or damp weather, repetitive injury, weekend athletic syndrome. They cause local/distant pain, loss of ROM, and loss of strength. According to Travell and Simmons, vulnerable factors are short leg syndrome, small hemipelvis, poor posture, prolonged immobility, vitamin and mineral deficiencies, endocrine dysfunctions, intense emotional stresses, and poor work habits.
Active TPs commonly radiate to unsuspected distant locations, such as neck to lateral or anterior face, lower central back to lateral buttocks, and arm muscles to hand areas. TPs are 2-6 mm diameter areas, demonstrate Travell's "Jump" sign, exhibit decreased high energy phosphates (ATP/PC) in biopsies where their glycogen values < normal. Some theories of etiology are that the extracellular materials not resorbed, trauma and overload of muscles, neuropathy, or a spinal reflex. "Injury Pools" of latent triggers can produce accrued response from minimal event to end with major muscle pain halting normal activity until TP release. Sympathetic nervous system activity can be primary and secondary, i.e., either a cause or effect of this syndrome.
Chronic Pain patients must find a Doc than can help! Because it will probably not end but the future can be Better and Brighter with appropriate exercise and treatment.
Funding for pain medicine is sometimes quite difficult to obtain over a prolonged time as these patients require. Private insurance, the Blues. Federal programs of Medicare and Medicaid vary by region in their support of the problems of these patients. One must have Chronic Hope with chronic pain because the difference between ordinary and extraordinary, is usually just a little extra. If one is the acknowledge that the difference between feeling bad and feeling better is just a step further, a bite less, and a little more knowledge one with chronic musculoskeletal pain will not be harmed by the medical profession in ignorance and improve in the long run as these patients endure.
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