Fibromyalgia/Myofascial Pain Syndrome

Devin Starlanyl, M.D.

Pain is often the most prominent symptom of FMS, but there are many others, especially when MPS gets in the picture. Trigger points (TPs) cause muscle spasticity (tightness), which disrupts the flow of liquids in the body.

Your eyes may often be dry, yet at times they water.

Your thermal regulatory system is out of whack. This is noticeable when you get out of bed (often, due to bladder irritability) during the night. You then wait for your temperature to regulate after getting back in bed, before you cover up again.

Spasticity can constrict your peripheral blood vessels--those close to the skin. Then, in the winter, certain areas of your body-- most often the buttocks and thighs--feel like cold slabs of meat.

Perhaps you have "vasomotor rhinitis"--a chronic runny nose, which starts a "domino effect". It's "mechanical"--not caused by a virus or bacterium.

As you sleep, stuffiness in your nose moves from side to side as you roll.

Post-nasal drip hits the back of you throat.

Throat and neck TPs--especially in the sternocleidomastoid (SCM)-- develop satellite TPs.

You get TPs down your arm, and loss of motion in your neck and shoulders.

The constant drip into ever-more restricted vessels can result in a sinus infection, because viruses and bacteria take advantage of the situation.

Dr. Janet Travell, in her autobiography, "Office Hours Day and Night" noted that dizziness, ringing of the ears, loss of balance, and other symptoms can all be caused by SCM TPs. Dr. Travell was White House physician to John F. Kennedy. She and her partner, David Simons, wrote the definitive texts on MPS.

The tight SCM complex transmits nerve impulses that inform the brain of the position of the head and body in the surrounding space. It doesn't match the input from your eyes. When head movement changes the SCM message--when you turn, or look up from changing the kitty litter, you get dizzy.

This, coupled with poor equilibrium, can make it seem that the walls are tilting.

When we take corners while driving, we get the impression that we're "banking" the turn at a steep angle, as if we're on a motorcycle.

Cold drafts can bring on neck TPs.

Be careful how you move in bed. When you turn, roll with your head flat, and use your arms to help. Don't lift your head and "lead with it" as you roll. That puts a great strain on the neck area and "loads" TPs, just as climbing steps or walking uphill "loads" the muscles of the thighs.

A common symptom of SCM TPs is a "drunken" walk, as we bump into doorways and walls.

Muscle weakness causes much FMS grief.

This is often due to "latent" TPs.

They aren't "active"--they don't cause pain unless we press them. But if we stress them, they "give out". You try to take a drink from a glass, and end up wearing your drink. As you twist your wrist to bring the drink to your mouth, a latent TP-stressed muscle is asked to support the drink. Your body couldn't tell where the drink was in relation to your mouth, nor how heavy it was.

Learn to use two hands to carry things, not to carry heavy things, and be prepared for lots of spills.

When our muscles frustrate us, don't dwell on it. Move on. Don't berate yourself for something you can't help.

Cultivate a sense of humor. Wear printed fabrics. Use straws.

Another distressing facet of TP-inspired muscle weakness is the so- called "weak-ankle, weak-knee".

You're walking across level ground and bam! You're down. Or you "catch yourself" and avoid the fall, meanwhile stressing muscles even more.

Be cautious on steps.

Be especially careful on uneven surfaces.

Vary your tasks--use different muscle groups.

Slow your working pace.

Listen to your body.

Rest often.

Cultivate a rhythm of movement. Play music while you work, if you can.

Don't fight your body, work with it. If at all possible, lie down for a few minutes at times during the day. Muscles are constantly working to hold your head up.

Don't sit too long in any one position. When you drive, pull of the road every hour and walk around the car. Stretch.

At home, use a rocker to prevent the muscles from building up electrical activity.

When you must lift, keep the load close to your body, and look up just before you lift. That tightens the long spinal muscles and prepares your back to lift.

Added stress to the body will cause FM to flare up.

Any infection, or yeast overload, is also stress.

Disrupted carbohydrate metabolism of FM patients causes intense craving for sweets, which feed yeast. In a "Scientific American" article in the January '89 issue, the Wurtmans discuss the relationship of sleep-deprivation, melatonin, serotonin, (neurotransmitters), and carbohydrate craving.

Carbohydrate-cravers snack not because they're hungry, but because eating is used to combat tension, anxiety, or mental fatigue-- especially in the late afternoon and early evening.

The alpha-delta sleep anomaly of FM makes it just about impossible to get rest.

When morning comes, you're stiff, achy, and your muscles are unresponsive.

Your body/mind hasn't received the proper quality nor quantity of sleep it needs.

You feel as though you've had a run-in with a truck the day before, and the truck won.

Level 1 sleep (alpha stage), is the lightest sleep we get. Delta is the deepest. In delta, immune chemicals and rebuilding chemicals are created, and the body/mind is repaired.

When an FM patient enters delta stage, sleep is interrupted by alpha wave intrusion.

We never get the deep, refreshing sleep others enjoy. This is a major handicap.

Medications, such as amitriptyline, may increase the quantity of our sleep, but they do nothing for the quality.

FM patients can also get bruxism (teeth clenching and grinding), muscle spasms in the arms and legs, (myoclonus), sleep apnea and shallow breathing (check out those chest TPs).

We also feel sleepy at "inappropriate" times.

If we push ourselves "over the hump", we slide into a wakefulness/ insomnia pattern.

It's important for us to eat regularly (and not too close to bedtime), avoid stimulants, avoid alcohol, and develop regular sleep patterns.

Some of us need waterbeds, and almost all of us need cervical pillows.

Devin Starlanyl, MD

This information may be freely copied and distributed only if unaltered, with complete original content.

Often, you may have to try many medications before you find the optimum ones for you. We react differently to each medication, and there is no "cookbook recipe" for FMS or MPS. What works well for one of us can be ineffective for another. A medication which puts one person to sleep may keep another awake. Each of us has our unique combination of neurotransmitter disruption and connective tissue disturbance. We need doctors who are willing to stick with us until an acceptable symptom relief level is reached. Medications which affect the central nervous system are appropriate for FMS/MPS. They target symptoms of sleep lack, muscle rigidity, pain and fatigue. Pain sensations are amplified by FMS, and so the pain of MPS pain is multiplied. FMS/MPS patients often react oddly to medications. It is the rule rather than the exception that a FMS/MPS patient will save strong pain meds from surgery or injury for when they REALLY need it -- for an FMS/MPS "flare". This is a sign that your needs aren't being met. I give you the following quotes. I hope you will pass them on to your doctor. They are from "PAIN A Clinical Manual for Nursing Practice", by McCaffrey and Beebe. Health professionals "often are unaware of their lack of knowledge about pain control." "The health team's reaction to a patient with chronic nonmalignant pain may present an impossible dilemma for the patient. If the patient expresses his depression, the health team may believe the pain is psychogenic or is largely an emotional problem. If the patient tries to hide the depression by being cheerful, the health team may not believe that pain is a significant problem." "Research shows that, unfortunately, as pain continues through the years, the patient's own internal narcotics, endorphins, decrease and the patient perceives even greater pain from the same stimuli." "The person with pain is the only authority about the existence and nature of that pain, since the sensation of pain can be felt only by the person who has it." "Having an emotional reaction to pain does not mean that pain is caused by an emotional problem. "Pain tolerance is the individual's unique response, varying between patients and varying in the same patient from one situation to another." "Respect for the patient's pain tolerance is crucial for adequate pain control." "THERE IS NOT A SHRED OF EVIDENCE ANYWHERE TO JUSTIFY USING A PLACEBO TO DIAGNOSE MALINGERING OR PSYCHOGENIC PAIN." "No evidence supports fear of addiction as a reason for withholding narcotics when they are indicated for pain relief. All studies show that regardless of doses or length of time on narcotics, the incidence of addiction is less than 1%." ] This book is so clear and so well documented that I suggested my local library buy it. I wanted everyone in the area to have access to this information. Once you read this book, you get a greater understanding of pain and pain medications, as well as coping mechanisms. Many non-pharmaceutical methods of pain control are also described thoroughly in this reference. It's normal to be depressed with chronic pain, but that doesn't mean depression is causing the pain. Maintenance with mild narcotics (Darvocet, Tylenol #3, Vicodin-Lorcet-Lortab) for nonmalignant (non-cancerous) chronic pain conditions may be a humane alternative if other reasonable attempts at pain control have failed. The main problem with raised dosages of these medications is not with the narcotic components, per se, but with the aspirin or acetaminophen that is often compounded with them. Narcotic analgesics are sometimes more easily tolerated than NSAIDs, the Non-Steroidal Anti-Inflammatory Drugs. Neither FMS nor MPS is inflammatory. NSAIDS may disrupt stage 4 sleep. Prolonged use of narcotics may result in physiological changes of tolerance or physical dependence (with- drawal), but these are not the same as psychological dependence (addiction). Under-treatment of chronic pain of MPS/FMS results in a worsening contraction which results in even more pain. "Anti- anxiety" medications are not an indication that your symptoms are "all in the head". These medications don't stop the alpha-wave intrusion into delta-level sleep, but they extend quantity of sleep, and may ease daytime symptom "flares". This is only a partial list. Stay tuned to the Fibromyalgia Network for news of more medications of possible use in FMS/MPS. Guaifenesin: Guaifenesin appears to reverse the process of FMS. It is a fairly new and experimental use. I have a whole chapter in the book on it. A flawed study was done that seemed to show it was no better than placebo. Please see the frame On Guaifenesin. Relafen (nambumetone): this is a NSAID that is often well tolerated because it is absorbed in the intestine, sparing the stomach. Benedryl:(dyphenhydramine): a helpful sleep aid/antihistamine which is safe in pregnancy. The starting dose is 50 mg 1 hr. before bed. Increase as tolerated until symptoms are controlled or 300 mgs. About 20% of patients react with excitation rather than sedation when taking Benadryl. (non-prescription) Desyrel (Trazadone): an antidepressant that helps with sleep problems. It must be taken with food. Atarax (hydroxyzine HCl): suppresses activity in some areas of Central Nervous System to produce an anti-anxiety effect. This antihistamine and anxiety-reliever may be useful when itching is a problem. Elavil(amitriptyline): a tricyclic antidepressant (TCA) is cheap and useful. It generates a deep stage four sleep. Most patients will adapt to this med after a few weeks. It can cause photosensitivity and morning grogginess. It often causes weight gain, dry mouth, as well as stopping the normal movements of the intestine. It may cause Restless Leg Syndrome. Wellbutrin (bupropion HCl): is a weak Specific Serotonin Reuptake Inhibitor (SSRI) and antidepressant that is sometimes used in FMS/MPS in place of Elavil. It can promote seizures. Ambien (zolpidem tartate): hypnotic -- sleeping pill, for short-term use for insomnia. There have been reports of serious depression. Soma (carisoprodol): acts on Central Nervous System to relax muscles, not on the muscles themselves. It works rapidly and lasts from 4 to 6 hrs. It helps detach from pain, and modulates erratic neurotransmitter traffic, damping the sensory overload of FMS. Flexeril (cyclobensaprine): this medication can sometimes stop spasms, twitches and some tightness of the muscle. It is related chemically to Elavil. It generates stage four sleep, but it may cause gastric upset and a feeling of detachment from life. Sinequan (doxepin): tricyclic antidepressant and antihistamine. It can produce marked sedation. This medication may enhance Klonopin, but can reduce muscle twitching by itself. Prozac (fluoxetine hydrochloride): anti-depressant that increases the availability of serotonin, useful for those patients who sleep excessively, have severe depression and overwhelming fatigue. Ultram (tramadol): non-narcotic, Central Nervous System medication for moderate to severe pain, in a new class of analgesics called CABAs -- Centrally Acting Binary Agents. It has a "low-abuse potential". Doctors may prescribe it more liberally than other strong pain-killers. One Internet doctor reported that 70 % FMS patients had pain control well enough that they could resume a more active life. Reports say you have to take it regularly for best benefits. Many people said it brought more alertness for longer times, and less "fibrofumble" of the fingers. It can lower the seizure threshold. Side-effects reported are grogginess, insomnia (may not be able to take at night), headache or loss of sex drive. Xanax (alprazolam): an anti-anxiety medication, that may be enhanced by ibuprofen. It must not be used in pregnancy. It enhances the formation of blood platelets, which store serotonin, and also raises the seizure threshold. When stopping this medication, you must taper it very gradually. EMLA: a prescription only topical cream, that may help cutaneous TrPs. It is a mixture of topical anesthetics. Pamelor (nortriptyline): this is used to help sleep. Some people find it stimulating, and must take it in the morning. Others use it before bed to help sleep. Some reports of depression with use. Klonopin (clonazepam): anti-anxiety medication and anticonvulsive/ antispasmodic. It is useful in dealing with muscle twitching, Restless Leg Syndrome and nighttime grinding of teeth. BuSpar (buspirone HCl): may improve memory, reduce anxiety, helps regulate body temperature, and is not as sedating as many other anti-anxiety drugs. Zoloft (sertraline): this is an SSRI and antidepressant, and is commonly used to help sleep. Tagamet, Zantac, Prilosec, Axid: often used to counter esophageal reflux. Tagamet may increase stage 4 sleep, and enhance Elavil. Paxil (paroxetine HCl): serotonin and norepinephrine reuptake inhibitor, and may reduce pain. It should not be used with other meds that also increase brain serotonin. Suggested dosage is 10 mgs (half a scored tablet) may cause insomnia or drowsiness. Effexor (venlafaxine HCl): antidepressant and serotonin and norepinephrine reuptake inhibitor. Suggested trial dosage is 25 mg, taken in the morning. Food has no affect on its absorption. When discontinuing this medication, taper off slowly. Inderal (propranolol HCl): sometimes helps in the prevention of migraine headaches, although blood pressure may drop with its use. Antacids will block its effect, and should not be used. Hismanol (astemizole): this is a potent antihistamine often given for allergies. Do not take at the same time as ketaconazole. Librax: for Irritable Bowel Syndrome. It is a combination of antispasmotic plus tranquilizer, that helps modulate bowel action. Diflucan (fluconazole): this antifungal penetrates all of the body's tissues, even the central nervous system. Very short term use can be considered if cognitive problems and/or depression is present, and yeast is suspected. Yeast may also be at the root of irritable bowel, sleep dysfunction (muramyl dipeptides from bowel bacteria induce sleep), and other common FMS problems. Potaba (aminobenzoate potassium): used to diminish fibrotic tissue. Travell and Simons recommend it for stubborn cases of myofascial pain syndrome. Do not use with sulfa. The suggested dosage 500 mg tid for 5 months. It will counteract guaifenesin. Quotane: this topical prescription ointment is helpful for TrP relief in close-to-the-surface areas not reachable by stretching. TrPs that refer burning, prickling or lightning-like jabs of pain are likely to be found in cutaneous scars. Imitrex (sumatriptan): this is available as an injectable solution or pill that will not prevent migraines, but it is effective for migraine pain in many cases. Works on serotonin release instead of blood vessel spasm, and may provide relief in less than 20 minutes. It should not be used within 24 hours of ergot (a common migraine drug) medications. It can increase blood pressure. It may cause spasm of muscles in jaw, neck, shoulders and arms. Also reported were tingling sensations, rapid heartbeat and the "shakes".

Devin Starlanyl, MD 

This information may be freely copied and distributed only if unaltered, with complete original content.

The first guidelines Dr. Starlanyl has are to avoid the following:

refined sugar

alcohol

caffeine

foods high in saturated fats

high-calorie, high-fat, low-food-value junk food

In addition, Dr. Starlanyl and Dr. Lynne August have both found that a balanced diet of moderate carbohydrate, protein, and fat has been beneficial to people with FMS/MPS.

40%carbohydrate/30%protein/30%fat for each meal and snack has enabled many people with FMS/MPS to reach their optimum weight with maximum health benefit.

It is also very important to drink lots of water! The water will help to flush toxins out of your body. Drink at LEAST 8 glasses (8oz ea.) of water every day!

Dr. Starlanyl and Dr. August recommend a book called The Zone (Sears and Lawren, 1995). There is also a sequel to this book: Mastering the Zone (Sears) that may be easier to find in bookstores. The first book, The Zone, goes into the healing aspects of this eating plan in great detail, while also giving you the basic eating plan. The second book, Mastering the Zone, includes the eating plan in great detail and has sample menus.

Dr. Sears states in his book The Zone, that this diet is of great benefit and is highly recommended to people with various diseases, including (but not limited to) MS, high blood pressure, chronic fatigue,lupus,and is also used by some olympic athletes to maximize their performance.

Dr. Starlanyl says that on this diet, people usually feel some improvement in seven to ten days. They are, however, seven to ten very uncomfortable days. She says that the headaches and fatigue can be extreme, but in one month you will see considerable improvement. In her book she states:

"This can be a tough diet, because if you really need it, you really crave carbohydrates. You try it for a few days and your body informs you "Yes, this is what you must do," because you are attacked by whopping headaches and extreme fatigue as soon as your body begins to struggle for a new balance. Your excess fat will start to break down and release large amounts of toxic substances and waste material. It is not fun. But it does work."