Myositic Pain Syndrome and Fibromyalgia
Myositic Pain and Fibromyalgia generally lie under the remit of a Rheumatologist but they frequently manifest as back pain which can be mistaken for spinal disease, particularly if there are degenerative changes seen on the x-rays or radiological scans of the spine.
MYOSITIC PAIN SYNDROME
Myofascial pain is extremely common. Surprisingly it received little attention in the past from the medical profession but is now receiving increasing recognition among many health professional groups, particularly the complementary and alternative medical practitioners. It is a complex condition, generally causing severe pain from which is usually the affected individual’s main concern. It mostly occurs within a muscle. When it occurs it mainly affects the ‘postural’ muscles of the trunk, i.e. those muscles responsible for maintaining the upright posture of the body. The characteristic lesion of Myofascial Pain itself is the ‘trigger point’ which develops in the affected tissues and which leads to severe pain and dysfunction in the region. This is usually found within the fibres of the muscle but can also be found in the fibrous tissues as well. In essence the ‘trigger spots’ are small areas in the muscles which have gone into spasm for a number of possible reasons. Once it has begun the pain from a ‘trigger spot’ may be of variable intensity but, without treatment, is often long lasting.
Causes of Myofascial Pain
Trigger Spots
Myofascial pain is often associated with localised injury or a strain to the affected muscle, particularly if there is an imbalance or deformity of the trunk. They are also sometimes associated with degenerative conditions in the nearby skeleton but, more often, seem to arise seemingly with no obvious cause. In these cases it is assumed that there has been a local injury or possibly occur in the muscle as a result of physical or emotional overuse.
The relevant ‘trigger point’ can usually be determined by careful examination Within the muscle it is felt as markedly tender, circumscribed spot or ‘knot’ in a tight band lying within the softer muscle in line with its fibres. Electron microscope studies have shown small areas of contraction of the internal elements (sarcomeres) of the muscle fibre at these sites.
There are two types of ‘trigger points’; ‘active’ trigger points and ‘latent’ trigger points.
‘Active’ trigger points’ are spontaneously’ painful and usually give rise to the severe pain. The intensity of the pain is usually related to movement or the position of the body or limb but it can, at times, be continuous. When present, the pain can be both localised within the muscle and/or radiate into the surrounding areas of the trunk or into the adjacent limb. Because of this radiation the affected individual may experience the greatest pain at a distance. For example, ‘trigger points’ within the muscles of the upper back may present with headache and those in the lower back or buttock may present with pain in the thigh or leg. These ‘active trigger points’ are very tender to palpation, and pressure on it, after it has been found, may cause the muscle to ‘twitch’. Pressure on the ‘active’ trigger point may also reproduce the pain in the area in which it is normally experienced. The presence of an ‘active’ trigger point can give rise to a pain-induced weakness as well as ‘autonomic’ symptoms such as abdominal pain. Frequently the movement of the affected portion of the trunk or limb is restricted because the ‘trigger point’ causes shortening of the involved muscle. It is important that this ‘active’ trigger point be found as the pain and dysfunction arising from it is likely to continue if it is not treated.
‘Latent’ trigger points’ are often more numerous than the ‘active’ trigger points. They too may be found in the muscles by palpation. They are tender to pressure but they are not usually ‘spontaneously painful. Similarly, pressure on them does not cause the muscle to ‘twitch’. The ‘latent’ trigger point, however, can be activated by a number of factors and change to an ‘active trigger point’ giving rise to the characteristic symptoms of this condition.
The ‘trigger spots’, in themselves, are not too serious but the constant, boring pain which they generate frequently limits any activity can be very distressing for the affected individual. Many or those affected find it difficult to accept that the severe pain which they are experiencing is not due to a really serious condition but is only the result of a localised area of muscle spasm.
Typically myositic ‘trigger spots’ give rise to ‘referred’ pain down the limb and this may suggest a problem in the spine or even be associated with spinal pathology. As a result the pain from a ‘trigger point’ has often been misdiagnosed as arising as a result of a number of other conditions, e.g. as a symptom of a tension headache, a frozen shoulder, epicondylitis, a carpal tunnel syndrome, and prolapsed intervertebral disc, to mention a few.
Nevertheless, it must be remembered that a trigger spot may develop in association with an underlying lesion of the underlying nerves, muscles or joints and can, in fact, co-exist with these conditions. Spinal deformities are commonly associated with trigger spots, particularly those due to shortening of one leg. Hyperlaxity and activities which generate repetitive strains are also causative factors.This being so it is important to seek an opinion from a qualified medical practitioner if the pain is overly severe, prolonged, and/or is accompanied by frank neurological deficits or other constitutional symptoms.
Treatment of Trigger Spots
Reduction of psychological stress is important as this causes the muscles to tighten up which tends to perpetuate the pain.
Despite this there are a number of modalities which can be used to treat ‘trigger spots’, often effectively, which include:
- Manual therapy including intermittent stretching the affected muscle, deep pressure soft tissue massage.
- Trigger Point release, Ischaemic compression including acupressure and shiatsu.
(Self treatment can be used for these first two methods, using the hand and fingers, or one of the several ‘massagers’ on the market.)
- Physiotherapeutic manipulation can be of assistance.
- Physical Medicine including heat therapy such as a hot pack or ultrasound, electrotherapy such as Interferential or TENS
- Laser treatment.
- Needling, either dry needling or traditional acupuncture.
- Trigger point injection, local anaesthetic with or without steroid solution.
- Meditation, biofeedback, hypnosis.
If the trigger spot is associated with a spinal deformity, such as a curvature, or underlying spinal disease this may need to be corrected before the pain is fully eliminated. Shortening of one leg is a common cause.
FIBROMYALGIA
Fibromyalgia is, unfortunately, a relatively common chronic condition which gives rise to intractable, widespread bodily pain. The specific diagnostic criteria of Fibromyalgia is the finding of at least 11 of 18 possible ‘tender points’ at specific defined locations on both sides of the body. In addition, in common with the myofascial pain syndrome, Fibromyalgia also develops multiple painful ‘trigger spots’ which sometimes makes it difficult to distinguish between the two conditions. However, in addition to the pain the two commonest symptoms of fibromyalgia are early-morning stiffness of the muscles and non-restorative sleep.
Fibromyalgia may be ‘pure’, i.e. having no association with any other medical condition, or ‘secondary’ as its onset is associated by any one of a number of medical conditions such as rheumatoid arthritis, lupus erythromatosis or hypothyroidism.
Again, unlike the Myositic Pain Syndrome, Fibromyalgia is commonly accompanied by a number of other conditions which include: psychological depression, anxiety, irritable bowel syndrome, difficulty sleeping, chronic fatigue and autonomic system dysfunction as part of the condition.
Despite the degree of discomfort and disability which these symptoms engender pathological tests are generally negative. As a result this has lead to much confusion in the past as it did not appear, until recently, to have any identifiable cause.
Nature of Fibromyalgia
Unlike the Myositic Pain Syndrome, which is thought to be a disease of the muscle, Fibromyalgia is thought to be a dysfunction of the neurological system, particularly those elements responsible for the conduction and moderation of pain sensation.
Causes
Although a number of possible causes have been proposed, it is still not clear as to what exactly gives rise to the condition. It is felt that, being a chronic condition, it may be triggered by any one of a number of causes; which include emotional or physical stress, central nervous system dysfunction of some form, exposure to toxins, infections, surgery, whiplash injury, injury to the brain. Most cases occur in women and there are suggestions that there may also be a genetic predisposition. A thyroid imbalance has also been incriminated and there is also argument that psychosocial factors may be involved.
Treatment of Fibromyalgia
As with the Myositic Pain Syndrome, the treatment of Fibromyalgia centres around the treatment of the ‘trigger spots’, as is outlined in the section on Myofascial Pain above. Any co-morbidities are also treated and usually include ‘pain killers’, anti-depressants and medications to improve sleep. Although the condition and its co-morbidities can be improved there is no guarantee that it will be totally alleviated.