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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.