Fibromyalgia Syndrome (FMS)



Fibromyalgia Syndrome (FMS)

By Dale Alsager, D.O., Ph.D. FACOFP

What is FMS?

Fibromyalgia is a mysterious, potentially debilitating syndrome, affects an estimated three to six million people in the U.S. The term, Fibromyalgia, means pain in the muscles, ligaments and tendons or, in other words, the myofascial tissues in the body. The Second World Congress of Myofascial Pain and Fibromyalgia held in Copenhagen August 20, 1992 officially defined the condition as wide spread pain affecting both sides of the body above and below the waist, axial-skeletal pain involving the cervical spine, anterior chest, thoracic spine and low back. The hallmark of this disease is focal tender points at specific locations in the body with exquisite pain on pressure. These myofascial tender points are localized in the neck, shoulder, mid back, elbow, wrist, hip and knee regions of the body.

The Country Doctor Clinic provides cost effective, comprehensive management for FMS.

In house we provide:

- Osteopathic medical diagnosis and treatment of FMS

- Osteopathic manipulation

- Medication management for chronic pain, chronic fatigue & insomnia

- Cranial manipulation to Cranial Academy standards

- Radiological leg length studies and treatment

- Sacral leveling and lift therapy

- Lymphatic system treatments

- Research design, management and clinical trials.

Adjunctive Therapies:

Our physician directed, hand picked referral network includes:

Physical and pool therapy

Massage therapy

Acupuncture

Naturopathy/Homeopathy

Biofeedback

Counseling and life management skills

Related Symptoms

Fibromyalgia typically presents with a constellation of signs and symptoms, which contributes to its difficulty in diagnosis. The most common presenting symptoms are:

- Generalized myalgia or pain

- Chronic fatigue

- Sleep disorder

The pain of FMS is widespread. Patients describe FMS pain as deep muscular aching, burning, throbbing, sometimes shooting and stabbing, and flu-like aches on a continuing basis. Quite often the pain and stiffness are worse in the morning and chronically wax and wane with periodic flare-ups that can be debilitating.

Fatigue can range from mild in some patients to incapacitating in others. FMS patients have difficulty getting mobile in the morning and describe a feeling of having to drag their arms and legs in order to make them work. Patients often describe brain fatigue in which they feel so totally drained of energy that their mental capabilities are impaired. Symptoms include an inability to concentrate, decreased short-term memory, visual changes, frequent headache, and depression.

Most FMS patients have sleep disorders, which result in a lack of deep restful sleep, which is referred to as stage IV REM sleep. Consequently, FMS patients arise in the morning with great difficulty accompanied by the feeling that they have been run over by a Mack truck. The most frequent sleep disorder is known as Alpha-EEG disturbance, but also present are sleep apnea, sleep myoclonus (night time jerking of the arms and legs), restless leg syndrome and teeth grinding.

This triad of principal symptoms (pain, chronic fatigue and sleep disorders) is cyclical and self-perpetuating. Chronic pain begets lack of sleep. Lack of sleep begets chronic fatigue. Chronic fatigue begets exacerbation and hypersensitivity to pain, and around it goes. Patients are caught in a spiral of steadily worsening symptoms that make it increasingly difficult to function in activities of daily living and work.

Other Symptoms Associated with FMS

Chronic headaches, irritable bowel syndrome, temporal mandibular joint malfunction, joint stiffness, numbness or tingling sensations, particularly in the upper extremities, depression, sensitivity to temperature changes, multiple allergies, excessive thick mucous production, (especially in the sinuses, upper respiratory or vaginal tract) painful premenstrual syndromes, irritable bladder syndrome, migraines, alterations in sensory perception of hot or cold, or the position or size of limbs are all part of the constellation of presenting signs and symptoms of FMS.

Who Gets FMS?

FMS used to be thought of as a psychosomatic illness that affected only middle-aged women. We now know this not to be true and, although the majority of FMS patients are women falling between the ages of 25 and 50 years, it does affect both sexes. Our practice manages patients, male and female, from ages 11 through 80 years, all with FMS. It is a very real entity that cuts across many age groups, and occupations, both sexes, and is particularly debilitating if not treated.

What Causes FMS?

At present, the precise cause of FMS is unknown. However there are several theories emerging.

1. A genetic tendency: Because this disease often tends to run in families, it is suspected that a breakdown or change in the DNA in a person’s body may result in this condition. It is not sex linked, nor does it follow any other standard genetic pattern, however there may be a familial tendency. If you have FMS in your family, particularly a sibling, parent or grandparent, it is important to bring this to the attention of your doctor.

2. Is it a virus? Some researchers and clinicians suspect this to be a cause. Although none has been formally identified, it is possible that a virus may be affecting the function of a centrally located endocrine gland, organ or structure in the central nervous system. This could explain the large variety of associated signs and symptoms, which affect a large number of body systems and functions in FMS patients.

3. A structural dysfunction involving the brain, spinal cord and/or sacrum: There is considerable evidence for some structural abnormality as the cause, or at least as a triggering mechanism. Almost without exception, FMS patients present with a history of significant impact trauma, either through motor vehicle accident, fall or other calamity at sometime in their past. It may be recent, or it may be as much as one or two decades ago. Also supporting this theory is the fact that patients respond favorably to treatments involving physical modalities, in particular osteopathic manipulation and spinal re-alignment. Cranial manipulation, which concentrates on re-positioning and normalizing the movement of bones of the skull, is also an effective treatment modality in some patients. A surprisingly high percentage of FMS patients have a history of short leg syndrome - a condition where, through congenital defect or surgery or injury, one leg is anatomically shorter than the other. It appears that the strain and imbalance that the body endures in compensating for such a difference, either exacerbates or may even cause, FMS. It is for this reason that FMS patients benefit from leg length studies and a thorough osteopathic diagnosis for somatic dysfunction early in their treatment program.

4. Endocrine dysfunction: Another theory is that there may be dysfunction of the endocrine system involving one or more of the central controlling glands, such as the pituitary, pineal and/or adrenal complex. Supporting this theory is the fact that some FMS patients seem to respond favorably to very low doses of corticosteroid therapy, or adrenal gland stimulants.

5. Central nervous system dysfunction: One theory ascribes to a possible dysfunction in a part of the brain known as the limbic system. This is a central information-processing center located deep in the brain. It is a part of the brain from which information is read or heard from a number of sensory systems in the body in a manner that recalls past events and compares and contrasts these to what is going on within and around us. The limbic system decides what action must be taken in order to ensure survival and sends messages to the brain and the rest of the body to take action. The limbic system incorporates a number of neuronal pathways in the central nervous system which all function to integrate neural sensory perception and facilitate social behavior. Malfunctions of the limbic system produce disturbances of emotion, motivation and memory. Other functions such as arousal, sleep, memory, primary behavior such as maternal instinctive behavior, grooming, and sexually stereotyped behavior are also influenced by this system. Because some of these primary behaviors and functions are unaffected in FMS patients, this theory may now be falling out of favor as a cause of FMS. Another theory involves dysfunction to an area of the brain called the reticular formation or reticular system. This is the region of the brain that collectively includes key parts of the brain stem, the diencephalon (including the thalamus, hypothalamus) and the Raphe‚ nucleus. The reticular system coordinates extensive nervous sensory and motor relays to the cerebellum, midbrain and higher brain centers as well as the spinal cord. This extensive system of neuronal tracts influences such functions as sleep/wake cycles, day-to-day functions of the viscera, mood and effect, the production of neurotransmitters including noradrenalin, serotonin, and dopamine. This system influences our level of arousal and consciousness, level of sensory attentiveness, motor reflexes, muscle tone, as well as learning ability and alertness, pain and sensitivity all functions vitally affected by FMS.

6. A hyperactive sympathetic nervous system: The sympathetic nervous system is a system of nerve centers (called ganglia) and nerve network located outside the central (main) nervous system that controls autonomic functions throughout the body. Sympathetic hyperactivity and dysfunction go hand in hand. When there is disease there is almost always hyperactivity of the sympathetic nervous system corresponding with that particular level of the spinal cord and sympathetic ganglia. It is responsible for both general and referred pain. FMS always has hyperactive sympathetic activity. Could FMS be the product of a malfunction in the sympathetic nervous system? It is noteworthy that osteopathic treatment techniques (such as rib raising, thoracic vertebral mobilization and paraspinal inhibition) are a drugless means of segmentally affecting the sympathetic nervous system. The sympathetic chain ganglia are located along the rib heads throughout the thoracic region and can be influenced through manipulation and mobilization of the rib heads.

The Diagnosis of FMS

Typically, FMS patients present with multiple diagnoses and doctor visits in their history, without an accurate diagnosis, or relief of symptoms. In spite of severe muscle pain and myalgia, all electromyographic studies, muscle enzyme levels, biopsies and blood tests in FMS patients are typically normal. The diagnosis of FMS is based upon clinical examination and a methodical exclusion of other diseases known to have similar presenting signs and symptoms. If musculoskeletal pain and myalgia have been present for more than three months, in the setting of insomnia and chronic fatigue then screening blood tests are taken to rule out other rheumatological conditions known to present with similar signs and symptoms. These include rheumatoid arthritis, systemic lupus erythematosus (SLE), Sjogren’s syndrome, polymyalgia rheumatica, polymyositis, hypothyroidism, hyperparathyroidism, metabolic myopathies, widespread osteoarthritis, and regional myofascial pain syndromes. Laboratory findings designed to screen for these diseases are typically found to be normal in FMS patients. The next critical part of the diagnosis is a thorough physical examination. The hallmark of FMS patients is the presence of specific tender points in the myofascial tissues. These precisely located tender points are often confused with muscle trigger points, Chapman’s sympathetic reflex points, and micro-tears or strains to muscles or tendons. Myofascial tender points are palpable and exquisitely tender with the application of direct pressure. Patients are sometimes unaware of these tender points and are amazed when a knowledgeable physician zeros in on them with precision. If the physician is not aware of their precise location, then the results of the physical examination may appear to be normal and the patient appears to be malingering. There are eight paired tender points and four control points. In order to meet the criteria for a diagnosis of FMS, 11 of these tender points must be present in the setting of normal laboratory findings to exclude other diseases. Chronic fatigue, insomnia, and generalized myalgia must be present for at least three months duration. Once these criteria are met, the diagnosis of FMS is made.

How is FMS Treated?

Because the etiology of FMS is unknown at the present time, treatment focuses on symptoms. Of the constellation of symptoms, pain, chronic fatigue, and insomnia are the most significant and warrant aggressive early therapy.

Pain from FMS

Pain is most effectively treated with spinal manipulation (osteopathic or chiropractic) to ensure optimal body mechanics and alignment, often supplemented with carefully selected pain medications. It is as if the pain sensitivity thermostat is cranked way up and stuck in FMS. Ordinary muscle tweaks, aches and pains, easily ignored in unaffected persons, are magnified in FMS patients. Misalignments of bones or an unleveled sacral bone result in uneven strain on muscles holding the body and head erect. These imbalances result in magnified myofascial pain that can be debilitating if not treated. Regular osteopathic manipulation treatments utilizing spine mobilization techniques such as counter strain, soft tissue, and myofascial release, indirect and muscle energy techniques and cranial manipulation seem to be the best-tolerated and most effective methods. It is important that short leg syndrome be screened early and treated with appropriate heel lift therapy and orthotic prescription if necessary. Proper leveling of the sacral base as well as spinal alignment is critical in the efforts to reduce myofascial and axial skeletal pain and prevent re-occurrence. Non-steroidal anti­-inflammatory drugs such as ibuprofin, naproxen, sulindac and others are of limited benefit. As a general rule, narcotic medications should be avoided in FMS patients for pain. A newer, central acting pain analgesic known as Ultram is generally reasonably well tolerated, has a low side effect profile and is developing a favorable record for myofascial pain control in this clinic.

Chronic Fatigue & Insomnia

These two conditions cannot be considered separately in the FMS patient. Some patients respond well to amitriptyline initially and are often on this drug when presenting to this clinic for management and/or treatment. We are now finding that a combination of Desyrel (trazodone) at bedtime to counteract insomnia, as well as a 5HT receptor blocking drug (such as Prozac, Paxil or Zoloft) taken early morning, is the best combination to counteract the long term effects of loss of sleep and chronic fatigue. This combination will replace amitriptyline in most patients with far fewer side effects. It is important for patients to remember that it takes approximately 30 days for the levels of serotonin to build up in the body in response to these medications, so they must be patient and not expect an overnight improvement. The effects of continued full night restful sleep as well as the energy boost provided by the extra serotonin in their system often results in significant decreased pain or decreased perception of pain in these patients thereby reducing the need for analgesic drugs.

Lymphatic System

The lymphatic system in the body is a system of thin walled vessels, lymph nodes and organs that are responsible for carrying fluid from the intercellular space back to the blood system and maintaining immune function. Occasionally, blockages can occur and this may cause exacerbation of symptoms in FMS patients. Osteopathic lymphatic treatments are useful (pedal pump, liver pump, splenic pump, and thoracic negative pressure techniques) to improve the flow of lymph through the body.

Trigger Point Injections

Trigger point injections have a known therapeutic effect for myofascial tender point pain in FMS patients. The technique involves placing a small amount of marcaine, or other long acting local anesthetic, in combination with liquid B12, directly into the myofascial tender point. A very thin needle is used which provides surprisingly little discomfort and no bleeding to the patient. Trigger point injections in FMS patients do significantly reduce pain level however, recurrences are frequent. Repeated trigger point injections eventually decrease the frequency of injections to the point where the trigger point injections are no longer needed.

Exercise

Exercise is an important component of the treatment; however it should be low impact, low load training (warm pool therapy is very helpful), which focuses on ample warm up in the form of stretching. Stretching, particularly first thing in the morning, appears to benefit daytime symptoms significantly. There is a fine line between too much exercise and not enough. FMS patients experiencing frequent pain flare-ups need to consider over-exercise or over­ exertion as the triggering event. Each exercise and treatment program must be tailored to the individual to avoid over exertion but maintain optimum muscle tone and conditioning.

Physical Therapy & Massage Therapy

Some patients benefit from myofascial release type of therapy and massage therapy. However, it is important that these be of the gentle variety focusing on effleurage and light petrissage techniques. Deep fiber cross friction muscle massage techniques often result in worsening of FMS pain. Physical and massage therapists experienced in FMS can be of good benefit to patients in integrated treatment programs.

Depression

Depression is a frequent accompanying symptom, which must be treated on an individual basis. Tricyclic antidepressants are sometimes helpful. Trazodone, in addition to treating insomnia, is a favorable choice as an anti-depressant in combination with a serotonin uptake inhibitor drug, and is giving good results at this clinic.

Counseling

Counseling is often recommended depending upon the individual and family situation. FMS should be considered a family disease in that it impacts significantly on the children, spouses, parents and siblings of the affected person. It is NOT contagious. However, the functional disability and constraints must be understood and accommodated by all those sharing the patient’s work and home environment.

Diet and Nutrition

Diet and nutrition are of importance in the evaluation and treatment of FMS patients. Frequently, patients are affected by allergies and/or food intolerance and it is important that these are diagnosed early and corrective measures be taken. Antioxidant therapy is often indicated. Vitamins and minerals may be necessary if deficiencies are identified or suspected.

Cranial Manipulation

Cranial manipulation is a system of diagnosing and moving bones of the skull in a manner that is therapeutic and restores the intrinsic cranial rhythm to normal. Cranial manipulation dates back to the 1940’s when an osteopathic physician, Dr. William S. Sutherland, made the discovery that the cranium moves in a rhythmical fashion in response to internal forces. This discovery has only recently been verified by sophisticated radiological and MRI studies, however, osteopathic physicians, for decades, have claimed the ability to palpate this motion with their hands. Cranial manipulation is a highly specialized modality that requires a considerable degree of expertise and training to perform. The accrediting agency for the training in the cranial field is The Cranial Academy of the American Academy of Osteopathy. Cranial Academy accredited training is only made available to D.O.’s, physicians, M.D.’s and dentists. Alternative courses of much shorter duration are taught by D.O.’s to physical therapists, M.D.’s, dentists, chiropractors and other professionals, however these are not accredited by The Cranial Academy.

There are now reports of FMS cases responding encouragingly to cranial treatments. It is theorized that the physical movement of the cranial bones effected by cranial manipulation results in a change of the blood flow to an affected part of the brain and/or a central endocrine gland, allowing the body to repair itself.

Naturopathy & Homeopathy

Tincture of Poison Oak diluted in ethanol has been used as a homeopathic remedy for FMS patients in the past. There are some studies that indicate that this treatment results in significant improvement in the pain and sleep disturbances. There are indications that Rhus Toxicodendron (Rhus Tox) and Suma Complex are helpful for FMS patients as well, and individual therapies are often designed to include these homeopathics. Vitamins and trace minerals to boost the immune function include beta-carotene, vitamins E and C, magnesium and zinc. Naturopathic remedies such as wild yam/chaste tree combo, melatonin, echinacea, goldenseal, licorice root, lomatium dissectum, shiitake mushroom, and panax ginseng may be of benefit and are sometimes integrated into a nutritional regime. Other useful products may be pantothenic acid, adrenal gland extracts and thymus gland extracts. Although there remains a dearth of confirming scientific evidence supporting the real benefits of these therapies, many patients believe they benefit.

Other Modalities

There are numerous other modalities that may or may not be helpful depending on the individual. Some of these treatments are controversial in terms of their therapeutic value but, nevertheless, include guided imagery, biofeedback, acupuncture, therapeutic touch, reflexology, TENS, Tai Chi and yoga.

Specialized intravenous therapies using powerful vitamin/mineral mixtures for fatigue and analgesics for pain control are available at this clinic for severe FMS flares.

Avoidance of Known Exacerbating Factors

Certain things are known to exacerbate FMS. These include exposure to cold, high stress situations, over-activity, sudden exertion, lack of sleep, alcohol, tobacco, loud noises, obesity and de-conditioning.

What is the Prognosis?

Long-term follow up studies on FMS have shown that it is a chronic condition for which the symptoms will wax and wane over time. While the impact of FMS can have serious consequences on daily activities and the ability to work at a full time job, there is significant individual variation between patients. Patients who do not seek treatment may find themselves extremely debilitated and depressed. It is important that the patient seeks treatment at the earliest opportunity and embarks on a treatment program that is managed by a physician who understands this syndrome thoroughly. With a treatment program designed to preserve and maintain optimum function, most patients do very well and are able to stay in control of their bodies and their lives. With treatment, the overall impact of the disease on their daily activities and work can be minimal. It is vital that each patient participates in his/her own care and becomes knowledgeable on all aspects of this mysterious disease syndrome. Eight-five percent of Dr. Alsager’s patients achieve remission of FMS within one year of starting treatment.

Ongoing Research

Dr. Alsager is an experienced medical researcher with many publications in the scientific literature. We monitor the literature and research regularly on a worldwide basis for new developments in FMS. We have clinical trials ongoing from time to time, with new medications and treatments. A number of alternate medical therapeutic regimes are available for patients not responding to conventional therapy.

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