Fibromyalgia MYOFACIAL PAIN!


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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. Myofascial pain
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 disorders are
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 diagnosis.

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.

Associated symptoms
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 commonly.

Pathophysiology
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
exercise.
ByDr  I.Khan

Treatment of Fibromyalgia & Myofacial pain

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 Fibromyalgia.
Dr I .Khan Have any questions or need help then please see services section

 


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