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Myalgia is muscle pain or pain of muscular origin, There are two major types of
myalgia or pain that are commonly diagnosed. One is fibromyalgia (FMS), It is a
syndrome in which there is chronic, widespread muscle tenderness as a result of
inflammation. FMS is denoted as primary when there is no co-existent disease
that causes widespread muscle pain.
FMS is considered secondary when myalgia is secondary to other disorders.
syndrome (MPS), the other common muscle pain syndrome, is associated with
discrete taut bands of hardened muscle that contain regions of exquisite
muscle tenderness.. A striking property
of MPS painful regions is that they generate referred pain that is felt in a
different, usually distal, site. The site of referred pain perception can be in
the same limb, in the same region, in the body wall, or in a visceral organ.
Referred pain tends to be segmental, so that referred pain patterns are usually
located in sites innervated by adjacent or nearby spinal cord segments. Hence,
trigger points in the posterior shoulder muscles like the supraspinatus and
infraspinatus both shoulder muscles. A region of the taut band is
exquisitely tender and can refer pain to another, usually distal, region. Sleep
disturbance in addition to pain will more likely result in the diagnosis of FMS.
Exercise intolerance can be seen with either FMS or MPS. Many cases of FMS are
in fact cases of MPS that have been misdiagnosed as a result of poor muscle
palpation techniques that miss the presence of taut bands and referred pain.
Nevertheless, the comments regarding underlying, etiological or co-morbid
applicable to both syndromes.
Thus, the diagnosis of FMS or MPS based on the presence of muscle pain, fatigue,
and exercise intolerance, and the physical findings of tenderness or of
myofascial trigger points, is not sufficient to give primary consideration
solely to FMS or MPS.
Fibromyalgia Characteristics FMS is a chronic, widespread myalgia that by
definition involves the body above and below the waist, and to the right and
left sides of the midline, such that three or four quarters of the body are
involved. Chronic and widespread pain of muscle origin are reflected in the
criteria for diagnosis published by the American College of Rheumatology (ACR).
Using the ACR criteria, 3.5% of women and 0.5% of men in the United States have
been estimated to have FMS. The ACR criteria, intended to provide a uniform
definition of fibromyalgia for research studies, require that: 1) symptoms have
been present for at least three months; and 2) 11 sites of a specified 18 sites
be tender (Table 1). Diagnosis of FMS in clinical practice was never intended to
be as strict as that required for research purposes. Chronic and widespread
muscular pain are still required to make a diagnosis, but the extent of muscle
tenderness may vary over time, and there may be far fewer then 11 tender sites
found on examination at any time. Chronic symptoms including widespread
tenderness distinguish FMS from other musculoskeletal pain syndromes with a
specificity of 81% and a sensitivity of 88%.
However, they do not distinguish FMS from chronic, widespread MPS or any other
chronic condition where there is widespread muscle tenderness, since tenderness
is the sole significant physical finding specified in the ACR criteria. In fact,
MPS is the most common condition that must be considered in the differential
Education and practice
Any condition associated with myofascial trigger points will produce
tenderness to palpation. Such
conditions include nutritional deficiency states such as iron
insufficiency, vitamin B12 deficiency,
hormonal disorders eg hypothyroidism, and trauma or cervical strain
injury (‘whiplash’). Consequently,
the physical examination performed for the evaluation of myalgia
must include palpation for the taut bands of myofascial trigger
points (see below), including an attempt to elicit referred pain, as
well as for the tender
points of FMS. A comprehensive medical evaluation also indicated in
order to identify conditions in which diffuse myalgia occurs
secondarily. A localized regional muscular pain syndrome such as
that associated with whiplash is not FMS when there is no muscle
pain that occurs above and below the waist. Even when there is
widespread pain, it may be due to MPS, and not to FMS. The
acceptance of the ACR criteria fostered a virtual explosion in the
publication of research studies on the nature of fibromyalgia, even
though the diagnostic criteria were criticized as invalid and based
on circular reasoning. Nevertheless, despite the criticism, the
criteria serve a useful purpose as similarly established criteria do
in other chronic or recurring pain states that lack objective
markers, such as non-specific low back pain and migraine headache
without aura. The clinical diagnosis of FMS continues to be based on
the history andl examination. Laboratory tests and imaging
procedures are not useful for making a positive diagnosis, but are
required to evaluate the patient for co-morbid conditions or to
identify other reasons of the chronic pain.
FMS is above all else a chronic muscular pain syndrome, but it is
associated with a number of other symptoms that include sleep
disturbance and fatigue, headache, morning stiffness, irritable
bowel syndrome (IBS), interstitial cystitis (IC), dyspareunia, mood
disturbance. Some of these symptoms are of referred muscle pain from
trigger points (headache, dyspareunia, morning stiffness), and
others, like IBS and IC are other pain syndromes, that occur more
Fibromyalgia has been extensively studied to try to
identify an underlying physiological or biochemical
basis to explain the fatigue and the muscle tenderness.
Evidence has accumulated that tenderness in FMS is
related to central sensitisation with amplification of
nociception, resulting in a broad array of stimuli
perceived as being more painful among FMS patients
than they are in control populations.
A modest benefit is achieved with growth
hormone (GH) replacement in the subset of about
one in three FMS patients who have a demonstrated
deficiency of GH or insulin-growth-factor-1. The
treatment is expensive, and is of benefit only as long
as the replacement is given. Thyroid hormone
replacement is likewise beneficial in those patients
who have demonstrated hypothyroidism, but there
are no data that suggest that hypothyroidism is more
common in FMS than in the general population.
Graded, progressive exercise programmes provide
both short and long-term improvement in FMS.
Cognitive therapy is effective when combined with
By Dr Gerwin
Treatment of Fibromyalgia &
With recent research it is clear that FMS is secondary to a infection of Mycoplasma and is autoimmune. Thus treating this with Doxycycline or Vibramycine results in complete resolution of symptoms. You just have to take one tablet a day. For any reason you cannot take these then just use a Tens unit please see the electronic section link below for a guide.
Myofacial pain is easily treated
by a neurobione or cynacobalamine injection in the tender spot
or even sublingual tablet is effective taken daily. We
have found great success in injecting ceftraxione in the
myofacial trigger pain, vitamin-D intake patients.
Magnetic stimulation of the pain point is very effective.
Use of a Tens unit is effective for both Myofacial pain and
By Dr I. Khan