Steve Selig 1

1
Pain and Fatigue syndromes

• Fibromyalgia Syndrome
• Chronic Myofascial Pain
• Chronic Fatigue Syndrome
• share a common problem of difficult diagnosis

2
Definitions

• Tender point painful with pressure, but does not
  radiate or refer pain to other regions
• Trigger point highly irritable area of skeletal
  muscle pressure on these may trigger an attack.
  There are no trigger points in fibromyalgia
  syndrome, but there are in chronic myofascial
  pain. Rock hard nodules of soft tissue
  (skeletal muscle) occur near trigger points.
  These may be central (CTrP) or near the
  attachments (ATrP).
• Pain threshold least stimulus to stimulate pain
• Pain tolerance most stimulus that can be
  tolerated
• ?? pain threshold with ? activity /- fitness ?
  benefits for participation in submaximal (but not
  maximal) activity

3
Fibromyalgia Syndrome

• Tender points painful with pressure, but do
  not radiate or refer pain to other regions

4
Chronic Myofascial Pain
5
What is fibromyalgia syndrome?

• Fibromyalgia syndrome (FMS) chronic
  musculoskeletal pain
• FMS is defined as widespread allodynia
  (ordinary sensations such as pressure,
  vibrations, sounds, light, and odors are
  experienced as pain) and hyperalgesia (pain
  sensations are intensified and amplified).
• Over 90 of people with chronic musculoskeletal
  pain have FMS
• Normal muscle morphology ? so the problem is
  oversensitisation of pain at the level of the
  central nervous system.

6
What is fibromyalgia syndrome?

• There are tender points, but not trigger points,
  peripherally. This reinforces the central nervous
  system locus of FMS
• FMS is not progressive. It is a non-degenerative,
  non-inflammatory syndrome.
• For many years, FMS was termed fibrositis
• Because the causes are unknown, the disease was
  thought to be psychological, which is now known
  to be false. Many doctors do not acknowledge FMS
  as real and therefore deny the diagnosis to their
  patients.

7
What is fibromyalgia syndrome?

• FMS is not curable, but is treatable
• FMS can be initiated by life-changing events such
  as bereavement, depression, open-heart surgery
• FMS may involve the hypothalamus-pituitary-adrenal
  axis (HPA) this is one of the main
  neurohormonal pathways for chronic stress. It is
  also possible that insulin resistance (eg NIDDM)
  may perpetuate the HPA disorder. Therefore
  treating obesity may be useful too.

8
Fibromyalgia epidemiology

• 2-5 of population
• common in 25-45 yearolds
• female male 6 1
• 40 of patients with lupus erythematosus also
  have fibromyalgia
• systemic lupus erythematosus chronic,
  progressive, inflammatory auto-immune disease
  with unknown cause and cutaneous manifestations

9
Fibromyalgia signs and symptoms

• Widespread pain low pain threshold ? pressure
  and movement may induce pain such as aching,
  burning, throbbing or stabbing pain
• Muscle stiffness
• Pins, needles, and tingling
• Blueness in the fingers
• Headaches
• Irritable bowel symptoms
• Poor quality sleep and wake up stiff and sore
• ? symptoms with exertion, cold, infection,
  humidity, poor sleep, emotional disturbances

10
Fibromyalgia signs and symptoms

• Chronic fatigue ? close relationship with chronic
  fatigue syndrome (CFS)
• Chronic pain ? stress, emotional distress,
  anxiety depression is not uncommon
• Accompanying allergic conditions erythema (skin
  blotchiness), eczema, asthma (but note that FMS
  is not an inflammatory disorder)
• Other accompanying conditions (see slide below)
• No simple diagnosis or cure ? ? emotional state

11
Fibromyalgia signs and symptoms

• Absence of these symptoms
• Inflammation ? anti-inflammatories do not work
• Musculoskeletal degeneration
• Abnormal musculature ? steroids do not work
• Abnormal neurology
• Differential diagnosis chronic myofascial pain
  this can be focal or widespread, but the pain
  emanates from the myofascia (trigger points)

12
Fibromyalgia causes

• Gross disorder of the pain system
• Often chronic pain coupled with emotional
  distress
• Widespread pain for gt 3 months
• Positive tender points

Fibromyalgia diagnosis
13
Fibromyalgia management

• Education need to understand the illness
• Medications for pain relief
• Gentle exercise Tai Chi, warm water exercise,
  Feldenkrais exercise (somatic education that uses
  gentle movement and ? ease and range of motion, ?
  co-ordination
• Stress management and relaxation
• Massage

14
Accompanying or differential diagnoses

• Chronic Fatigue (Immune Deficiency) Syndrome
  (CFS)
• Triggered by a viral infection
• Fatigue gt 6 months exacerbated by mild exertion
• Generalised aches (hence connection with FMS, but
  they are not the same)
• Fever, sore throat, inability to concentrate
• Co-morbidities must be treated and are also used
  to exclude CFS note CFS is a diagnosis of
  exclusion i.e. if the condition does not fit
  with diagnostic criteria for other conditions,
  such as FMS, then the patient may have CFS

15
Accompanying or differential diagnoses

• Irritable Bowel Syndrome (IBS)
• Gut muscles contract and relax at the wrong
  times.
• Can have feelings of fullness without eating and
  hypersensitivity.
• IBS does not cause inflammatory changes
• IBS does not cause bleeding, fever, weight loss
  or severe, enduring pain

16
Accompanying or differential diagnoses

• Lupus Erythematosus
• systemic lupus erythematosus chronic,
  progressive, inflammatory auto-immune disease
  with unknown cause and cutaneous manifestations
• genetic links
• more common in women
• joint pain
• fever and malaise
• diffuse facial erythema
• glomerulonephritis with hypertension
• pericarditis /- endocarditis
• splenomegaly
• oral ulcers
• anemia /- thrombocytopenia

17
Accompanying or differential diagnoses

• Lupus Myositis
• lupus myositis is a chronic, progressive,
  inflammatory auto-immune disease where the
  inflammation is confined to the skin scaly, red,
  pink or brown rash, often in the shape of a
  butterfly over the face, as well as other areas.
  The rash is very photosensitive.
• Other
• Migraines, Post-Traumatic Stress Disorder,
  reactive hypoglycemia (related to over-activity
  of counter-regulatory stress hormones, together
  with insulin), carpal tunnel syndrome, and many
  arthritic conditions.

18
Chronic Myofascial Pain
Sternocleidomastoid (X) trigger points ?
widespread head pain and dizziness
19
Chronic Myofascial Pain
Splenius cervicis upper and lower trigger points
? migraines
20
Chronic Myofascial Pain

• Upper trapezius trigger points ? migraines
• ? neck stiffness
• jaw clicking

21
Chronic Myofascial Pain
Levator Scapulae trigger points ? neck stiffness
and pain
22
Chronic Myofascial Pain
Subscapularis trigger points ? frozen shoulder
23
Chronic Myofascial Pain
Adductor pollicis (A) Opponens pollicis
(B) trigger points ? thumb pain and ?
tingling / numbness
24
Chronic Myofascial Pain
Deep paraspinal (multifidis) trigger points ?
buttock, upper leg and abdominal discomfort
25
Chronic Myofascial Pain
Vastus medialis trigger points ? lower thigh
cramps and medial knee pain
26
Chronic Myofascial Pain

• Hamstrings trigger points
• ? pain and numbness from buttocks to lower leg
• ? need to exclude sciatica

27
Chronic Fatigue (Immune Deficiency) Syndrome

• Also known as myalgic encephelomyelitis (ME).
• Both are not quite accurate. Myalgic
  encephelomyelitis implies an inflammation, which
  is rare, seroius and even fatal in CFS.
• But there is an involvement of the brain
  (encephelo), the nervous system (myelo) and
  the muscles (myalgia).
• A better term is myalgic encephelopathy (disease
  of the brain, accompanied by muscle pain).

28
Chronic Fatigue Syndrome possible causes

• Probably triggered by a viral infection, coupled
  with impaired (even over-reacting) immune
  response that then attacks nerve and muscle
  tissue.
• The energy in over-reacting to the infective
  pathogen (even when the original infection is
  finished) can deplete the body of energy and
  cause or exacerbate CFS.
• It is possible (but unproven in prospective
  randomized studies) that anti-oxidants may
  counter the effects of the over-reaction of the
  immune system.

29
Chronic Fatigue Syndrome possible causes

• Types of viruses
• Enteroviruses can lead to mild infections such
  as URTs through to hepatitis A, meningitis and
  encephalitis. Can enter the body via handling
  contaminated food or water, soiled nappies
• Herpes can be spread via saliva and thus is most
  common in teenagers and young adults. A cause of
  glandular fever and CFS
• Retroviruses HIV is the most important, but
  unlikely linked closely with CFS

30
Chronic Fatigue Syndrome possible causes

• Stress physical /- mental athletes are
  susceptible. ?? cortisol with very intense
  training ? infections. As a side-issue,
  complications of an enteroviral infection (e.g.
  Coxsackie endocarditis) can be life-threatening
  in athletes.
• Stress physical /- mental non-athletes with
  life-changing events (e.g. bereavements, family
  crises, major surgery) ? CFS
• ?? fast food, pesticides, smog, and smoking can ?
  immune responses and ? CFS
• Interestingly, brain stem compression such as
  caused by cervical stenosis may cause many of the
  symptoms of CFS headaches, muscle weakness,
  visual impairments, balance problems, etc.

31
Chronic Fatigue Syndrome diagnostic criteria

• Persistent, relapsing fatigue gt 6 months
  exacerbated by mild exertion
• Four or more of these for gt 6 months and which do
  not pre-date the fatigue
• inability to concentrate
• sore throat /- fever
• generalized aches including both myalgia and
  arthralgia (hence connection with FMS, but they
  are not the same)
• headaches
• sleep disturbance
• post-exertional malaise gt 24 hours

32
Chronic Fatigue Syndrome diagnosis

• Co-morbidities must be treated and are also used
  to exclude CFS note CFS is a diagnosis of
  exclusion i.e. if the condition does not fit
  with diagnostic criteria for other conditions,
  such as FMS, then the patient may have CFS
• There is no definitive diagnostic test and no
  effective cure / treatment. A sympathetic /
  empathetic treating doctor can help enormously

33
Chronic Fatigue Syndrome interesting
occurrences / outbreaks

• Florence Nightingale and Charles Darwin both
  probably suffered from CFS
• In 1985, an outbreak of a flu in Lake Tahoe
  (Nevada) that led to prolonged fatigue. All
  affected people were high achievers, leading to
  the thought that yuppie flu is similar to CFS.
• An outbreak of CFS occurred in Iceland in 1948
  (1,000 cases in a population of lt 200,000). Seven
  years later in Iceland there was a polio
  epidemic. Interestingly, none of the patients who
  had CFS seven years previously were afflicted
  with polio, suggesting that they retained
  immunity as a result of whatever pathogen they
  were originally infected with (CFS). Now thought
  that the polio and CFS viruses are similar.
• Note unusual to have epidemics. Rather CFS is
  endemic.

34
Chronic Fatigue Syndrome epidemiology

• 20-40 years
• 0.1 of population (1 in 1,000 people)
• female male 2 1
• all socio-economic groups (yuppie flu is a
  misnomer)

35
Chronic Fatigue Syndrome signs and symptoms

• Extreme, debilitating generalized fatigue
• Muscle fatigue, occasionally accompanied by pain
  (myalgia) but there is no muscle pathology such
  as chronic inflammation more likely emanating
  from the central nervous system
• ? memory
• ? concentration
• ? sleep
• muscle incoordination
• ? proprioception and ? balance

36
Chronic Fatigue Syndrome signs and symptoms

• paraesthesia (neural involvement) tingling /-
  numbness
• ? vision and headaches
• Irritable Bowel Syndrome (IBS)
• Bladder dysfunction
• Micturition syncope
• depression is common
• Note signs and symptoms of patients with CFS
  vary widely

37
Chronic Fatigue Syndrome management

• Rest
• Medications
• Modified exercise
• Diet
• Alternative therapies
• Spinal Decompression therapy (for cervical
  compression)

38
Chronic Fatigue Syndrome management

• Rest
• Medications
• NSAIDS
• Analgesics
• Antidepressants
• Antibiotics
• Modified exercise
• During the rest phase of the disease, then use
  mobilising exercise in bed, then progress to
  intermittent isometric exercise in bed and at
  home
• Use a bath at home for some hydrotherapy
• Progress to walking ? swimming and warm water
  exercise, rebounding exerciser, or even gentle
  jogging
• Be careful to monitor fatigue and myalgia (may
  flare up if patient also has fibromyalgia)

39
Chronic Fatigue Syndrome management

• Diet follow the healthy nutrition pyramid
• Alternative therapies for CFS,
• consider vitamin supplementation (especially
  anti-oxidants which may counter the effects of
  over-reaction of the immune system)
• Herbal medicines careful with these as most are
  unproven (by prospective randomized studies), and
  can even be toxic in high doses be careful of
  being sold magic bullets. On the other hand,
  some herbal medicines may eventually survive the
  tests of scientific rigor and become part of
  mainstream therapies. At the moment, most rely on
  anecdotes, or placebo effects.
• Homeopathy natural therapies that are often
  safer and more conservative than herbal medicines
• Meditation for treating depression or visualising
  recovery
• Spinal Decompression therapy (for cervical
  compression)

40
Foraminal and Canal Stenosis
canal stenosis compression on spinal cord
caused by fractures or arthritis
foraminal stenosis compression on spinal
nerves caused by disc pathology or arthritis
41
Foraminal Stenosis laminectomy
42
References

• 1. Jackson A. Understanding Chronic Fatigue
  Syndrome. St Leonards, NSW Allen Unwin 2000.
• 2. Levine PH, Goldstein JA, Hyde BM. The Clinical
  and Scientific Basis of Myalgic
  Encephalomyelitis Chronic Fatigue Syndrome
  Nightingale Research Foundation, Ottawa, Ont.,
  Canada 1992.
• 3. Teitelbaum J. From Fatigued to Fantastic! 1st
  ed. New York Avery Publishing Group 1996.
• 4. Starlanyl D, Copeland ME. Fibromyalgia and
  Myofascial Pain. 2nd ed. Oakland, CA, USA New
  Harbinger Publications, Inc. 2001.