Poly? Fibro?

What is the distinction between polymyalgia and fibromyalgia?

muscle34322The word myalgia means pain within the muscles. Both fibromyalgia and polymyalgia are characterized by muscle pain, but many other aspects of the two conditions differ.

Polymyalgia, or polymyalgia rheumatica, is an inflammatory disease of muscle. The cause is uncertain but it is believed to be an autoimmune disease in which the body’s own immune system attacks the connective tissues. The primary symptoms are severe stiffness and pain in the muscles of the neck, shoulder and hip areas. People with this condition also may have flulike symptoms, including fever, weakness and weight loss, and approximately 15 per cent develop a potentially dangerous condition called giant cell arteritis – an inflammation of the arteries that supply the head.

silhouette-roseFibromyalgia is not an inflammatory condition. It is caused by abnormal sensory processing in the central nervous system. People with fibromyalgia may be extremely sensitive to pain and other unpleasant sensations. To be diagnosed with fibromyalgia, one must experience pain on both sides of the body and in both the upper and lower half of the body. They are also typically tender points throughout their body. Other common symptoms of fibromyalgia include fatigue, difficulty sleeping and concentrating, irritable bowel syndrome and headaches.

Both fibromyalgia and polymyalgia are more common in women than men. Fibromyalgia can occur at any age, but polymyalgia rarely occurs before age 50. The average age of onset is 70. And whereas fibromyalgia is chronic, often lasting a lifetime, polymyalgia usually resolves itself within two years.

womanneckTreatment differs, too. Fibromyalgia is treated with exercise, relaxation techniques, analgesic medications and antidepressants to relieve pain and promote sleep. Treatment for polymyalgia is targeted at relieving inflammation. For some people, daily doses of NSAIDs, such as ibuprofen (Advil, Motrin), are sufficient, but more often corticosteroids, such as prednisone, are required to control inflammation.

Although polymyalgia will eventually go away completely, it’s important that to be mindful – both now and after your disease resolves – of symptoms such as headaches and blurred vision, which could mean giant cell arteritis. If you develop arteritis, high doses of corticosteroids may be necessary to control the condition and prevent vision loss.

 

Pull the Trigger

Trigger point injections (TPI) is an option many of us choose to treat pain.

trigger-point-injections-300x201TPI is a procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. Many times, such knots can be felt under the skin. Trigger points may irritate the nerves around them and cause referred pain, or pain that is felt in another part of the body.

TPI is used to treat many muscle groups, especially those in the arms, legs, lower back, and neck. In addition, TPI can be used to treat FM and tension headaches. The technique is also used to alleviate myofascial pain syndrome that does not respond to other treatments.

What Happens During a Trigger Point Injection?

trigger-point-injectionsIn the TPI procedure, a health care professional inserts a small needle into the patient’s trigger point. The injection contains a local anesthetic that sometimes includes a corticosteroid. With the injection, the trigger point is made inactive and the pain is alleviated. Usually, a brief course of treatment will result in sustained relief.

05001_05XInjections are given in a doctor’s office and usually take just a few minutes. Several sites may be injected in one visit. If a patient has an allergy to a certain drug, a dry-needle technique (involving no medications) can be used.

The effectiveness of TPI for treating myofascial pain is still under study.

 

Further Reading:

What is the Difference between Trigger Points and Tender Points?

The terms tender point and trigger point are often used interchangeably; however, they are different from each other.

At first glance, the medical community appears divided over whether they in fact are the same thing. You can even find a lot of websites and books, written by healthcare professionals (but we know how much help they can be!), who talk about diagnosing FM with trigger points and treating it with trigger-point injections.

Nonetheless, the scientific literature makes it clear that, while tender points and trigger points both appear to play roles in FM, they are not the same thing. Some of the confusion may be because it’s extremely common for people with FM to also have myofascial pain syndrome (MPS), which is a diagnosis of chronic pain from multiple trigger points. (Some doctors also question whether FM and MPS are different illnesses.)

  • Tender Point: One of 18 specific places on the body that are used to diagnose widespread pain and tenderness in FM. The presence of widespread tender points helps your doctor diagnose FM.
  • Trigger Point: Also called myofascial trigger point (TrPs or MTrPs), a trigger point is a small, hard knot in the muscle (myo) or connective tissue (fascia) that won’t relax. TrPs are painful when pressure is applied. In the absence of pressure, they may cause pain in the immediate area and/or cause pain in a different area. This is called a referred pain pattern. Chronic pain from multiple TrPs is called myofascial pain syndrome.

A 2011 study describes several key differences between them:

Tender Points in FM

See Umm…What Exactly are Tender Points?

Trigger Points in FM

Multiple studies show that TrPs can in fact play significant roles in FM, as a cause of significant pain, and possibly even in a causal role.

In one study, researchers were able to fully reproduce FM pain by manipulating the TrPs. They also found that the participants with more active TrPs had more intense spontaneous pain. What they concluded was that pain from TrPs may help lead to something called central sensitization, which is believed to be an underlying mechanism of FM. Essentially, central sensitization means that the central nervous system (the brain and spinal cord) are hypersensitive to pain and other stimuli, such as light, noise and temperature (hypervigilence). Central sensitization is also believed to play a role in migraines, osteoarthritis and chronic fatigue syndrome.

A review of literature on tender points and trigger points states that confusion between the two and the interchangeable use of the terms can lead to misdiagnosis, which in turn leads to ineffective treatment.

BUT 90 per cent of the 18 predetermined tender points are actually TrPs. Pressing on a trigger point hurts in the area and also shoots pain to other regions, while pressing on a tender point is believed to only cause discomfort to the local area.

The finding that most of your tender points are actually trigger points is good news because it opens up your treatment options. There are specific therapies for relieving the painful knots in the muscles where the trigger points are located, and research shows that relieving the pain of just one trigger point can have a significant on reducing your body-wide pain. One of the more popular approaches is therapeutic massage, which involves working out the trigger points to try to get the muscles to relax. During my time at the rehabilitation pain clinic, my physio spent her time teaching me ways to de-sensitize my trigger points – which in time, would help to reduce pain. This mostly involved self-massage regularly. In fact, anything that eases muscle tension, such as a hot shower or soaking in a hot tub, will reduce the impact of the trigger points. Unlike tender points, trigger points cause a restricted range of motion (muscle tightness) and they radiate pain to other areas of the body.

Despite all of this, FM requires different treatment than MPS. For the many people who have both, it’s essential to treat both in order to alleviate symptoms and regain function.

Please, Help Yourself


I’ve been in pain all day – does that actually surprise anyone?

Back to the point, the pain in my cheek and the spots above my eyes have been intolerable despite numerous pain killers and soothing eye masks. Then, idiot that I can be when fibro fog enters my brain, I realised that the rehab physio told me about some self-treatment for the area. It’s still not my first thought when it comes to pain treatment but I’m working on it and I find that it can help – it doesn’t take it all away but it soothes it, like tucking it into bed with a blanket and letting it relax.

The muscle that affects this area is called the sternocleidomastoid (SCM). It is a muscle of the neck so-named because it originates on the sternum (sterno) and the clavicle (cleido) and inserts on the mastoid process (mastoid) which is an easily located bony prominence behind the ear. The muscles pass diagonally across the front and side of the neck beginning at the top of the sternum and ending behind the ear. This two-sided muscle is large and ropy, making it the most prominent muscle visible at the front of the neck.

There is rarely pain present in the SCMs themselves but they have the potential to refer a large amount of pain to areas of the head, face, throat, and sternum (see all those red dots and marks in the picture to the left).

Trigger points in the sternal branch of the SCM can cause deep pain around the eyes, headaches behind the ear, at the top of the head, and over the eye (sound familiar?). They may cause pain in the pharynx (throat) and the tongue when swallowing, giving you a “sore throat.” They may also contribute to temporomandibular joint (jaw) pain along with the muscles of mastication.

Dizziness or balance problems, nausea, fainting, lacrimation (excess tear production,) blurred vision, eyelid jerking or droopy eyelid and visual disturbances have all been claimed to be a possible result of trigger points along the SCM.  A host of other systemic symptoms such as cold sweat on the forehead, distorted weight perception, excess mucus in sinuses, nasal cavities and throat, and chronic cough have also been attributed to them.

So what is it that I’ve been told to do?

Self-massage

  • Lay back flat on a cushion.
  • Put some cream on your fingers (not too much as it’s just to make the massage movement easier). It doesn’t really matter what type of cream you use.
  • Find the spot (with the opposite hand) behind your ear where the muscle begins. For example: use your right hand to find the top of the muscle behind your left ear (this means that you’re not putting excess pressure on your left shoulder by scrunching it up).
  • Then follow the muscle down (it runs diagonally) until you get to the bottom of it, at those clavicle bones.
  • Basically, rub your fingers up and down (slowly, and DO NOT use a circular motion) that muscle (at the most 10 times).
  • Use only as much pressure as you can tolerate. If you feel any pain or dizziness, reduce the pressure.
  • Then do the other side.

Initially, it may be extremely painful and may even bring on the referred pain symptoms, such as a headache. But the pain should get better quickly upon subsequent sessions and referred pain symptoms should begin to subside almost immediately. I have been told to do this daily.

Stretching

To stretch and strengthen this muscle, move your head sideways (your ear towards your shoulder) then look at your underarm. Hold that position for 5 seconds (working up to 10 seconds). Do 10 of these on each side (you can alternate or do one side at a time – it doesn’t matter).

I hope some of you find this helpful (and that you can understand my directions).

The Painful Face of Fibromyalgia

Every day I wake up with a major headache (what a coincidence…you, too?) but recently they seem to be getting worse; and my cheeks hurt – oh, and of course, my neck. I’m not talking the general stiffness type of pain – I’m talking the severe pain when your head spins as you get out of bed and being unable to face any light without my face exploding, and I can forget about turning my head in any direction.

Supposedly, this could all be Temporomandibular Joint Disorder (TMJD). It is rather common for patients to complain of suffering chronic fatigue along with all the pain of FM, but it seems to me that too often perhaps doctor and patient neglect to discuss the pain of TMJD, which is also seen commonly in FM patients. Perhaps this is because the patient and doctor think it is a dental problem, better left to a dentist. Unfortunately, many dentists think TMJD is at least in part a muscular problem, better left to the patient’s medical doctor.

The reality is that the many patients suffering from fibromyalgia unfairly end up facing the facial pain of TMJD alone.

What is the TEMPOROMANDIBULAR JOINT?

The TMJ is the area directly in front of the ear on either side of the head where the upper jaw (maxilla) and lower jaw (mandible) meet. Within the TMJ, there are moving parts that allow the upper jaw to close on the lower jaw. This joint is a typical sliding “ball and socket” that has a disc sandwiched between it. The TMJ is used throughout the day to move the jaw, especially in biting and chewing, talking, and yawning. It is one of the most frequently used joints of the body.

The TMJs are complex and are composed of muscles, tendons, and bones. Each component contributes to the smooth operation of the TMJ. When the muscles are relaxed and balanced and both jaw joints open and close comfortably, we are able to talk, chew, or yawn without pain.

You can locate the TMJ by putting a finger on the triangular structure in front of the ear. The finger is moved just slightly forward and pressed firmly while opening the jaw. The motion felt is from the TMJ. You can also feel the joint motion if you put a little finger against the inside front part of the ear canal. These maneuvers can cause considerable discomfort to a person who is experiencing TMJ difficulty, and doctors use them for making the diagnosis.

TMJD can cause a patient to experience nausea, headache, dizziness, and difficulty chewing due to jaw pain. By some estimates, 90% of FM patients experience facial and jaw pain; many of these same patients are thought to suffer from TMJD. You can see how it might be difficult to make a diagnosis.

TMJD affects the functioning of the jaw, but it can also result in muscle pain throughout the head and neck. A person suffering from TMJD can suffer a range of problems, from headaches to a “locked” jaw. When coupled with the problems seen in FM, TMJD can be almost disabling. This is all the more concerning, when data shows that over 75% of people with FM also suffer from TMJD.

 

There is a school of thought that divides TMJD into two types:

  1. Joint TMJD, caused by damage to the cartilage or ligaments of the temporomandibular joint. This can in turn be the result of prior injury, dental problems, or grinding of the teeth (also known as ‘bruxism’). This can present as popping or clicking of the jaw joint, the inability to open the mouth very wide, TMJ pain, and headaches.
  2. Muscular TMJD, which more commonly affects the FM patient. This affects the muscles used to chew and move the face, neck and shoulders. Muscular TMJD can be caused by a lack of sleep, muscular trauma, and stress. It can present as headaches, and difficulty with opening and closing the mouth.

Stress has a major impact on both FM and TMJD. Stress can cause some to clench or grind their teeth, causing continued stress on the muscles and the TMJ, making both joint and muscular TMJD worse. Stress must be brought under control: life styles may need to be changed, and medications may be necessary to relax the facial muscles, lessen the pain, and relieve the sleeplessness. Massage can certainly be of great value in such cases. Dental intervention is needed for those with missing teeth; and an orthotic occlusal plate may help to stabilize the bite and bring balance to the muscles of the jaw and head and neck areas.  I had an NTI-tss (nociceptive trigeminal inhibitor) dental guard fitted by my dentist. Nociceptor nerves sense and respond to pressure. The trigeminal nerve supplies the face and mouth. The NTI appliance snaps onto the front teeth. Normally when the mouth is closed, the upper and lower front teeth overlap: The NTI prevents this overlap and translates the bite force from attempts to close the jaw normally into a forward twisting of the lower front teeth. The intent is for the brain to interpret the nerve sensations as undesirable, automatically and subconsciously reducing clenching force. Unfortunately, for patients who do not stop subconsciously clenching, the NTI can lead to more severe damage from clenching. I find that I just clench harder, but now it’s onto a piece of plastic

The efficacy of such devices has been debated. Randomly controlled trials with these type devices generally show no benefit over other therapies.

Unfortunately, as with so many things in medicine, the economics of properly caring for the TMJD patient becomes a barrier for so many patients. This is not surprising, in light of the two types of TMJD discussed above.

Insurance companies often do not cover the cost of treating TMJD claims for the following reasons:

  1. They see the two types of TMJD as representing a controversy about both the causes and treatments of TMJD.
  2. There is not a large amount of scientific validation of TMJD therapies.
  3. The perceived conflict regarding whether TMJD is a medical or a dental problem results in a tug-of-war between medical and dental insurance companies, resulting in a situation where neither insurance group feels it is their responsibility to pay.

Now, the whole reason this post came about was because I had heard about using botox to stop the teeth grinding. Botulinum (Botox) can lessen bruxism’s effects. An extremely dilute form of Botox is injected to partially weaken muscles and has been used extensively in cosmetic procedures to relax the muscles of the face.

In the treatment of bruxism, Botox weakens the muscle enough to reduce the effects of grinding and clenching, but not so much as to prevent proper use of the jaw muscle for eating.

Botox treatment typically involves a number of small injections into the masseter muscles. It takes a few minutes per side, and you can start to expect feeling the effects as quickly as the next day, although 3-4 days is more common. The optimal dose of Botox must be determined for each person as some people have stronger muscles that need more Botox. This is why you should always see someone specifically trained in the application of Botox for treatment of clenching.

The effects last for about three months. Over time it is usually possible either to decrease the dose or increase the interval between treatments.

So, later today, I am phoning a dentist I found that specialises in this kind of treatment to see how much it costs and if my medical/dental insurance covers it – Please, oh please!

Good Pain to You All!

Yippee! I have a day off! Yes, I realise that I’m not working but I’ve been filling my days with Pilates, acupuncture, doctors’ visits, warm water classes, babysitting, etc. So, today is all mine!

I just woke up and spent two hours trying to work out how to get of bed. I couldn’t sit myself up. Damn Joseph Pilates! The muscles deep, deep (under all and any fat) inside my tummy have said ‘No More!’ The pains are right where my appendix scar is (on the right side – and before they did it laproscopically) and the mirror image on my left side.  I need one of those metal thingys that they have above hospital beds for patients to lift themselves up.

When you exercise, your abdominal muscles contract and expand over and over again. Repeating an activity several times causes the tissue fibres in your muscles to tear at the microscopic level. This is how you build muscle and bulk up. But it can also be (slightly?) painful – I can’t cough without feeling excruciating pain tearing at my insides; and I can’t sit upright (I can sit hunched over or I can lean back against the couch).

Pain is your body’s way of telling you that there is something wrong, but not all pain is bad. Many people seek out exercise that gives them the ‘good pain factor’ (WHAT-THE-?) as they like to feel that they have worked themselves hard.  So how are we supposed to distinguish good pain from bad pain?

Good pain feels like a moderate to strong discomfort (sometimes burning as in lactic acid build up sensation) in the muscles you are working and should go away after discontinuing the movement.  Any delayed onset muscle soreness, as a result of the exercises session, should disappear within a day or two after exercise. Ummm, oops, I may have overdone it (again?)

So between attempts at getting out of bed and dozing, I finally worked out that I can bend my legs (no lifting them) and roll onto my side, then I have to unfold my legs and angle them over the side of the bed, and push myself up using my elbows – long process but I’m up!

And now it’s my day off – so I have time (and maybe the energy) to hang out my washing, do another load, pick up the clean clothes that I had thrown on my bed so I would put them away before bed (two nights ago) but, instead just shoved them onto the floor. I want to attempt to put my FM Awareness nail decals on. Oh, yeah, Passover starts tonight so early dinner at my Dad’s; and I have to remember to pick up the flowers for Dad’s partner, Yvonne.

Umm, did anyone say day off?

Happy Easter and Passover to you all!