Fibromyalgia Information & Local Support
©Devin Starlanyl, MD 1995-1998
Fibromyalgia is NOT a wastebasket diagnosis. It is also not the same as Trigger Points, or as chronic myofascial pain syndrome, or as FMS&MPS Complex.
Every patient is different. TrPs in the Travell and Simons books are approximate areas only, as they state. That's what makes diagnoses of these conditions such a challenge. This is true with FMS, MPS and FMS&MPS Complex. Single or multiple trigger point problems are much less complicated, and if there are no perpetuating factors, can be eradicated easily.
FMS is a truly systemic illness -- not just a form of muscular rheumatism. FMS is a systemic, non-degenerative, non-inflammatory, non-progressive neurotransmitter dysfunction. Once you understand the concept, the signs and symptoms are logical. MPS is body-wide and neuromuscular only (all four quadrants and spinal involvement), altho there can be nerve and vascular entrapments. These TrPs must be of 6 months or longer duration to be chronic MPS.
FMS&MPS Complex is a double whammy. You have a severe pain condition in MPS, and a pain amplification condition in FMS. It is synergic -- more grief than the sum of its parts.
Vigorous massage of hyperirritable TrPs can cause a rebound reaction with marked increase in pain. When the patient is experiencing rest pain for a considerable part of the time, Travell and Simons say the TrPs are very active and rarely respond favorably to anything more than gentle passive stretch and hot packs.
Mechanical stresses, such as body asymmetry, paradoxical breathing, immobility, poor body mechanics, short upper arms and/or short lower legs and poor posture perpetuate TrPs in most patients with persistent myofascial pain syndromes. When the patient has pain without moving the affected area, gentle stretching in a hot tub may help.
People need to learn good coping behaviors. The struggle you go through with these conditions is incredible, and yet you look "just fine". Psychological stress is part of this, and makes things worse. It is not causal, but a result. We have to learn to "work ourselves down", just as we can "work ourselves up" to panic.
There is NO DANGER of "creating another dependency" by physical treatment of FMS or MPS. Patients must learn to take control and responsibility for their health care, however, just like in all medical conditions.
Studies have shown that the incidence of depression in FMS patients is the same as that of rheumatoid arthritis patients, and that psychological status does not correlate with FMS symptoms. With FMS and FMS&MPS Complex, there can come an inability to concentrate, think clearly, or remember things that goes far beyond frustrating and can be frightening. This "fibrofog" can be aggravated by weather changes, excess carbohydrate intake, cold, humidity, excessive physical activity, physical inactivity, hormonal fluctuations, sleeplessness, anxiety, stress, depression, mental or physical fatigue. It adds stress to everything your patient does You may need to write out instructions for patients.
Many of us cannot sit for longer than 20 minutes without becoming stiff. Severe "morning stiffness" can take an hour or more to wear off.
To fully inactivate the TrPs by passive stretch, the muscle must be extended to its full normal length. Ice massage or "spray and stretch techniques" is needed. These techniques are covered in full in the Trigger Point Manuals. Patient relaxation, spray and stretch with subsequent rewarming is vitally important. This method must be used with extreme care in patients with "hypermobility". Passive stretching by itself can cause pain and reflex spasm, obstructing further movement.
Gels for ultrasound with electrostim, GMS, etc. may contain salicylate! This is inappropriate if the patient is on guaifenesin for FMS reversal. Salicylate will block the excretion of excess phosphates and liberated toxins. TENS is often not of use in MPS, since a contraction is necessary to break up myofascial TrPs. NMES and galvanic stim often work well.
The patient may have extreme fatigue after a physical therapy session. If the therapy is effective, toxins trapped in the myofascial will be released. Ensure that the patient has recovered from one session, ie the liver has detoxed the blood of liberated material, before you begin work again. This may mean that beginning work is slow. The patient may only be able to tolerate a half hour of PT a week. This may be increased as the first flush of toxins are dealt with. Monitor the patient's fatigue. This is often a function of the released toxins.
If there are active Trigger Points, according to Travell and Simons, "...at that stage, active exercise that loads a contracting muscle is not indicated." Exercise should be regarded like a prescription. You must ensure that the patient gets the proper kind, dose and timing. Specify rate, number of repetitions, how often in one day and conditions (not when patient is over-stressed, ill, cold, etc.). Specify relaxation and breathing between each cycle of exercise. The number of counts to the pause must equal the number of counts needed to perform the exercise. If mild muscle soreness results, but is gone by the next day, that's a sign that the exercise may continue. If soreness remains, postpone the exercise. If the soreness is still there after the 3rd day, change the exercise plan to a lighter one. Use rest and moist heat to help post-exercise soreness. Any exercise that increases referred pain during or after its performance should be stopped.
Active TrPs can vary from hour to hour and day to day, as can the aches and pains of FMS. It's very important that you ask your patient often what is happening with his/her body and mind.
Ask your patient to keep an on-going list of symptoms that occur between treatments. Symptoms that your patient might not recognize as being related to TrPs include:
Your patient will come in with complaints due to the most recently activated TrP. Don't get discouraged if, once that is deactivated, pain shifts to an earlier TrP. Be cautious in starting exercise, as FMS patients have reduced growth hormone secretion, which plays an important role in muscle tissue repair. Inappropriate exercise can often make the symptoms much worse. In MPS, repetitive exercise can be destructive.
Any pool with a temperature outside the 88 to 94 degree range can cause long-range worsening of symptoms in MPS, and even immediate cramping. According to Travell and Simons, the crawl and breaststroke are contraindicated at first, as they will electrically load muscles.
As a rule, treat the muscle group first that is causing or adding to sleep disruption. Then deal with the one causing greatest pain, or restriction of movement. First restore flexion, then side bending, rotation, and then, finally, extension.
In FMS patients, exercise causes a reduction in temperature and cerebral blood flow. They often can't think clearly enough during exercise to set limits. Tell them to set a timer or exercise with a friend.
TrPs that refer burning, prickling or lightning-like jabs of pain are likely to be found in cutaneous scars. Scar TrP deactivation by intracutaneous injection with 0.5% procaine or by repeated topical application of topical anesthetic, dimethisoquin HCl ointment (Quotane). TrPs may also be found in joint capsules and ligaments. Periosteal TrPs often cause autonomic reactions, such as sweating, blanching, and nausea.
Pain on contraction shifts to weakness as the affected muscle learns to avoid contractions that are forceful enough to cause pain.
Palpating TrPs can severely exacerbate their referred pain activity for a day or two.
A lump at a TrP site could be due to damming of blood and other fluids by obstructed blood flow.
You can use galvanic muscle stimulation or ultrasound with electrostim as a "search and destroy" method, as both modalities cause pain in the immediate area of the Trigger Point, until the TrP is broken up.
Cold will relieve the nerve entrapment pain. Warm, moist heat will relieve the myofascial/muscle pain. This can give you clues as to what is happening.
Galvanic muscle stimulation, NMES (neuromuscular "microstim"), and sinewave ultrasound with electrostim seems to be effective for myofascial trigger points (TrPs), and spray and stretch of TrP muscles can also have dramatic effects if it is done correctly. The passive stretch is very important at the end. The muscle must be put through several range of motion series, followed by rewarming. It is important that you be familiar with "Myofascial Pain and Dysfunction: The Trigger Point Manual" Vol I and II by Travell and Simons.
As a physical therapist, you are also an educator. As your patient learns more self-PT techniques, such as tennis ball acupressure, stretching, good body mechanics and posture, and exercise, your patient will be responsibility for assuming more and more of the physical therapy required. Healing can only begin when the cycle of pain/contracture is broken. Much of this task belongs to you and your patient. With perseverance, guiding FMS&MPS Complex patients on the healing path can be an exceedingly fulfilling occupation.