Fibromyalgia: The Muscle Pain Epidemic :Is it ME by Another Name? (Part 1)

Note

The majority of the research discussed in this article derives
from the USA where the distinction between CFS and Myalgic
Encephalomyelitis (ME) is largely unknown And since there is
still disagreement amongst experts as to whether CFS is the same
as ME or not – and it seems likely that this argument will run
for some time – this text will therefore bracket the
condition(s) as CFS(ME).

In marked contrast to the time it has taken for research into ME
and CFS to emerge there has over the past few years been an
explosion in the medical literature featuring Fibromyalgia
Syndrome (FMS).

The more the condition has been researched (FMS that is) the more
obvious it has become that there is a vast overlap between it and
ME/CFS.

The Commonest Symptoms Found in Fibromyalgia Are: ^1,2,3,4

100% of people with FMS have muscular pain, aching and/or
stiffness (especially in the morning)
Almost all suffer fatigue and badly disturbed sleep.
Symptoms are almost always worse in cold or humid weather.
The majority of people with FMS have a history of injury –
sometimes serious but often only minor within the year before
the symptoms started.
70% to 100% (different studies show variable numbers) are
found to have
depression (though many consider that this is more likely to be a
result of the muscular pain rather than part of the cause).
73% to 34% have Irritable Bowel Syndrome
56% to 44% have severe headaches
50% to 30% have Raynaud’s phenomenon (hands go dead white and
cold)
24% suffer from anxiety
18% have dry eyes and/or mouth (Sicca syndrome)
12% have osteoarthritis
7% have rheumatoid arthritis
An as yet unidentified number of people with FMS have had
silicone breast implants and a newly identified Silicon Breast
Implant Syndrome (SBIS) is now being defined.
Between 3 and 6% are found to have substance (drugs/alcohol)
abuse problems.

Other Conditions Which Are Extremely Common with Fibromyalgia
Include:

Allergies, chronic rhinitis (almost constant runny nose), easy
bruising, night cramps, restless leg syndrome, dizziness
(sometimes caused by the widely prescribed anti-depressant
medication given to help the sleep problems in FMS), sleep
apnoea (breathing seems to stop while asleep), dry eyes and
mouth, bruxism (teeth grinding), extreme sensitivity to light
(photophobia), premenstrual syndrome, digestive disturbances,
viral infections, Lyme disease (resulting from tick-bite), itchy
skin – with or without a rash, loss of hair, sensitive bladder,
mouth ulcers, generalised muscular stiffness, ‘foggy’ brain
(difficulty in concentrating and poor short term memory),
dyslexia (wrong words come out or what is read is not
understood), panic attacks, phobias, mood swings, irritability, a
feeling of hands and feet being swollen without evidence of fluid
retention.

The Official Definition of/criteria for FMS ⁵

Many people suffer from generalised, muscular aching and pain,
however this only officially becomes the medical condition
labelled ‘Fibromyalgia Syndrome’ (FMS) when this aching muscle
pain is accompanied by pain produced when pressure is applied to
certain specific body areas.
The most commonly accepted definition is that the person affected
needs to show:

1. History of Widespread Pain

Pain is considered widespread when all of the following are
present : pain in the left side of the body, pain in the right
side of the body, pain above the waist and pain below the waist.
In addition there should be pain in the spine or the neck or
front of the chest, or thoracic spine or low back.

2. Pain in 11 of 18 Tender Point Sites on Finger Pressure

There should be pain on pressure (around 4kg of pressure
maximum) on not less than 11 of the following sites:

Either side of the base of the skull where the subocciptal
muscles insert.
Either side of the side of the neck between the 5th and 7th
cervical vertebra, technically described as between the
‘anterior aspects of inter-transverse spaces’.
Either side of the body on the midpoint of the muscle which
runs from the neck to the shoulder (upper trapezius)
Either side of the body on the origin of the supraspinatus
muscle which runs along the upper border of the shoulder blade.
Either side, on the upper surface of the rib, where the second
rib meets the breast bone, in the pectoral muscle.
On the outer aspect of either elbow just below the prominence
(epicondyle)
In the large buttock muscles, either side, on the upper outer
aspect in the fold in front of the muscle (gluteus medius)
Just behind the large prominence of either hip joint in the
On either knee in the fatty pad just above the inner aspect of
the joint.

The similarities between Fibromyalgia syndrome, Chronic Fatigue
Syndrome and Irritable Bowel Syndrome are listed below ^6,7,8

	Fibromyalgia	Irritable Bowel	CFS
Age	Young Adult	Young Adult	Young Adult
Primary Sex	Female	Female	Female
Prevalence	Common	Common	Common
Cause	Not Known	Not Known	Not Known
Chronic	Yes	Yes	Yes
Lab. Studies	Normal	Normal	Normal
Pathological	None	None	None
Disabling>	Yes	Yes	Yes

Goldenberg lists other similarities between fibromyalgia and
chronic fatigue syndrome. ⁸

There is no known cause

There are no highly effective treatments

There are chronic symptoms which include fatigue, myalgias,
neurocognitive dysfunction, mood disturbances and sleep
disturbances.

The population most affected is women aged between 20 and 50.

How Disabling is Fibromyalgia (FMS):

100 out of 394 patients (that is 25.3%) with FMS (all female)
and 12 out of 44 males (27%) were shown in a recent survey to be
sufficiently badly affected by the condition as to be unable to
work – they were effectively disabled. ^8a

Almost all the others surveyed claimed that their FMS affected
their job performance very badly.
In Canada a single insurance company, London Life, reported in
1989 that it was issuing monthly long-term disability payments to
over 630 people with a diagnosis of fibromyalgia – involving a
total of around a million dollars a month.

Change the Name, Change the Attitude

An example of why the naming of a condition matters can be seen
from the word ‘fibrositis’ the previously used name for
fibromyalgia. When a word ends in ‘itis’ in medicine it
signifies that there is an inflammatory process involved. No
evidence has ever been produced that the muscular aches and pains
of fibrositis and/or fibromyalgia have much to do with
inflammation.

Anti-inflammatory drugs therefore do not influence the condition
and because of this many doctors assumed that the condition was
a fiction – and that the symptoms complained of were unimportant
or were imaginary.

By changing its name to ‘fibromyalgia syndrome’ the
‘inflammation’ element was removed and with this came the
possibility for research and a wider understanding of the
processes involved.
The change in name has been accompanied by a rash of research
and review articles in the medical journals – with a few in 1985
but around 100 in 1990.

CFS(ME) and FMS: Are They the Same? ⁹

There is disagreement amongst experts as to whether or not
‘fibromyalgia syndrome’ and ‘chronic fatigue syndrome’ are the
same condition.

Both CFS(ME) and FMS often seem to begin after an infection or a
severe trauma (physical or emotional) , and as indicated above
the symptoms are very similar. The only obvious difference seems
to be that for some people the fatigue element is the most
dominant while for others the muscular pain symptoms are
greatest (and for an unfortunate few both are markedly present).
In other words for many people the diagnosis CFS(ME) and FMS
seem to be interchangeable terms, although there are certain
symptoms (fever, swollen glands for example) which are found in a
higher percentage of CFS(ME) patients than those with FMS, which
makes the comparison less precise.

Some doctors insist that the psychological aspects of these
conditions [FMS as well as CFS(ME)] is the most important cause
and they use the terms ‘masked depression’ and ‘somatoform
disorder’ to describe such conditions. This is resented by those
afflicted by CFS(ME) or FMS who see the psychological and
emotional symptoms as being the result of their fatigue, pain
and general illhealth, and not as causes.

‘Foggy Brain’ Symptoms ¹⁰

Memory lapses, inability to concentrate, dyslexic episodes
[inability to recall simple words], are all part of many people’s
fibromyalgia (and of most people’s chronic fatigue) and modern
technology has now identified what may be happening in the brain
with these conditions.

Among the abnormalities so-far found in the brains of many
patients with FMS and CFS(ME) are reduced blood flow and energy
production in key sites of the brain. While any such changes
might themselves merely be symptoms of the syndrome it is
thought by many researchers that the most important imbalance
in these conditions probably lies in the brain and central
nervous system itself.

New technologies for visualising the brain in a non-invasive
manner (SPECT, BEAM, PET) show that there are few if any
differences in the scans of patients with CFS(ME) and FMS.

What’s Going on in the FMS Patient’s Muscles? ^11,12,13

A host of stress related adaptations and changes are likely to
have taken place in the muscles of someone with fibromyalgia
resulting from overuse, misuse, abuse or disuse (postural,
occupational, leisure activity, repetitive use, trauma etc) plus
a number of additional factors.

A biochemical imbalance which may be the direct result of
disturbed sleep leads to inadequate growth hormone production
and poor repair of minor muscle damage.
Low levels of a serotonin in the blood and tissues lead to
lowered pain thresholds because of the reduced effectiveness of
the body’s natural endorphin painkillers, and the increased
presence of ‘substance P’ which increases pain perception.
The sympathetic nervous system, which controls muscle tone can become disturbed leading to muscle ischemia (oxygen lack)
resulting in greater ‘substance P’ release and increased
sensitivity.
Duna proposes that these two elements are combined in
fibromyalgia. Disordered sleep leading to reduced serotonin
leading to reduced natural pain killing effects of endorphins,
combined with a disturbed sympathetic nervous system which has
resulted in muscle ischemia and increased pain sensitivity. Both
disturbances involve reduced pain thresholds and activation of
latent trigger points, with muscle pain as the end result.
‘Micro-trauma’ (tiny amounts of damage) of muscles occurs in
FMS patients ( genetic predisposition is a possible cause)
leading to calcium leakage which increases muscle contraction,
further reducing oxygen supply. This seems to be associated with
a reduction in the muscle’s ability to produce energy , causing
it to fatigueand to be unable to pump the excess calcium out of
the cells. A similar mechanism is said by Travell and Simons to
be involved in myofascial trigger point activity. ¹¹
James Daley MD has tested just what happens in the muscles of
people with CFS(ME) when they exercise. Tests involving people
with FMS (by Robert Bennett MD) gave similar results showing that
muscles produced a great amount of lactic acid, adding to the
discomfort. Some of the patients showed low carbon dioxide
levels when resting, which is an indication of a
hyperventilation tendency.

There is some evidence that progressive cardiovascular training
(graduated training through exercise) improves muscle function
and reduces pain in FMS but this is not thought desirable (and is
often quite impossible anyway because of the degree of fatigue)
in CFS(ME). ^12,13

The special features of fibromyalgia seem to involve a
combination of circulatory and nerve imbalances which make the
muscle changes even more pronounced and the symptoms more
unpleasant.

Treatment ^14,15,16

Manual therapy, nutrition, stress reduction, breathing and
postural reeducation, exercise (in some cases), acupuncture,
non-specific immune system modulation such as hydrotherapy ,
medication (herbal, homeopathic and standard), among other
things, have all been useful in encouraging recovery.

Goldenberg has shown that the following methods all produce
benefits in treatment of FMS.: ¹⁷

Cardiovascular Fitness Training ¹⁸

EMG-Biofeedback ¹⁹

Hypnotherapy ²⁰

Regional Sympathetic Blockade ²¹

Cognitive Behavioural Therapy ²²

My Own Protocol

Where a condition has multiple interacting causes it makes
clinical sense to try to reduce the burden of whatever factors
are imposing themselves on the defence, immune and repair
mechanisms of the body, while at the same time doing all that is
possible to enhance those mechanisms.

In my own practice the following are the methods suggested and
used in treatment of FMS not necessarly in the order listed:

It is vital to get the diagnosis right. Many other rheumatic-
type problems can produce widespread muscular pain such as
polymyalgia rheumatica. Laboratory and other medical tests can
identify most conditions which are not FMS.
Where muscle pain exists it is necessary to discover how much
of the problem might be related to myofascial trigger point
activity since the pain from trigger points is relatively easy
to eliminate using methods chosen from injections, acupuncture,
bodywork and postural and/or breathing reeducation.
It is important to assess and treat any associated conditions
such as allergy, anxiety, hyperventilation, yeast or viral
activity, bowel dysfunction, underactive thyroid, sleep
disturbance.
It is useful to introduce constitutional health enhancement
methods such as breathing retraining, deep relaxation methods
(e.g. autogenic training ) regular (weekly or fortnightly)
detoxification (fasting) days (which boost growth hormone
production), hydrotherapy (neutral bath for anxiety and possibly
progressive cold bathing), regular non-specific massage and
acupuncture for ‘energy balancing’ and pain control.
Provision of suitable nutritional advice in important as well
as use of supplements if necessary, such as specific amino acid
supplementation for stimulating growth hormone production
Specific herbal help for circulation to the brain [e.g. Ginko
biloba] and the taking of homoeopathic remedies such as Rhus tox
6C may be useful.
Appropriate osteopathic soft tissue treatment of the muscular
condition, as well as regular (daily if possible) gentle self-
treatment methods are usually helpful.
Regular exercise within tolerance, if possible including
cardiovascular training and stretching movements (yoga and/or
T’ai chi)
Medication under medical advice only, to enhance sleep
patterns may be worth considering, antidepressant drugs in very
low dosage commonly give some benefit.
Patients should be encouraged to join support groups, and
to read about their condition and health enhancement, and to
take control of their condition, even if progress is apparently
slow. Stress or general counselling may help them learn coping
skills and stress reduction tactics.

References

1. Sydney Block Fibromyalgia and the Rheumatisms Controversies in Rheumatology
Vol19(1)1993pp61-78

2. Don Goldenberg Fibromyalgia, chronic fatigue syndrome and myofascial pain
syndrome. Current Opinion in Rheumatology 5:199-208 1993

3. George Duna and William Wilke Diagnosis, etiology and therapy of fibromyalgia
Comprehensive Therapy 19(2)60-63;1993

4. Bruce Rothschild Fibromyalgia : An explanation for the aches and pains of the
nineties Comprehensive Therapy 17(6):9-14 1991

5. Wolfe F et al The American College of Rheumatology 1990 Criteria for the
classification of Fibromyalgia Report on Multicentre Criteria Committee Arthritis
Rheum 33:2;160-172, 1990

6. Block S. op cit

7. Yunus M . ‘Fibromyalgia and other functional syndromes’ Journal of Rheumatology
16(sup 19)69 1989

8. Goldenberg D. ‘Fibromyalgia and its relationship to chronic fatigue syndrome,
viral illness and immune abnormalities’. Journal of Rheumatology 16(sup 19)92 1989

8a. Goldenberg D Presentation to the 1994 American College of Rheumatology meeting

9. Harvey Moldofsky Fibromyalgia, sleep disorder and chronic fatigue syndrome

Ciba Foundation Symposium 173 Chronic Fatigue Syndrome p 262-270 1993

10. As reported in Fibromyalgia Network (May 1993 Compendium, July 1993, January
1994)

11. David Simons Fibrositis/fibromyalgia A form of myofascial trigger points ?
American Journal of Medicine 81(suppl 3A)pp93-98

12. Report in Fibromyalgia Network May 1993 Compendium on First national Seminar
for patients, Columbus Ohio., April 1990 (Robert Bennett MD presentation on muscle
microtrauma – pages 23 – 25)

13. Report in Fibromyalgia Network (Compendium 2 pp48-49) on 2nd Los Angeles CFIDS
Conference may 18/19 1991.

14. Frederick Wolfe, David Simons et al The Fibromyalgia and myofascial pain

syndromes Journal of Rheumatology 1992;19:6pp944-951

15. Vladimir Janda Muscles and Cervicogenic pain and syndromes. from Physical

Therapy of the cervical and thoracic spine Ed.R.Grant Churchill Livingstone
London 1988 pp153-166

16. Gwendolen Jull and Vladimir Janda Muscles and Motor Control in Low Back Pain
Physical Therapy of the low back. from Physical Therapy of the low back Ed.Lance
Twomey Churchill Livingstone London 1987 pp253-278

17. Goldenberg D Fibromyalgia : Treatment programs J of Musculoskeletal Pain Vol.1
3/4 1993 pp71-81

18. McCain G et al Controlled study of supervised cardiovascular fitness training
program Arthritis Rheum 31:1135-1141 1988

19. Ferraccioli G et al EMG-Biofeedback in fibromyalgia syndrome J. Rheumatology
16;1013-1014 1989

20. Haanen H et al Controlled trial of hypnotherapy in treatment of refractory
fibromyalgia J Rheum 18:72-75 1991

21. Bengtsson A et al Regional sympathetic blockade in primary fibromyalgia Pain
33; 161-167 1988

22. Goldenberg D et al Impact of Cognitive-behavioural therapy on fibromyalgia
Arthritis Rheum 34(suppl9):S 190, 1991

23. Stoltz A Effects of OMT on the tender points of FMS Report in Journal of
American Osteopathic Association 93(8)p866 August 1993

24. Lo K et al Osteopathic Manipulative Treatment in Fybromyalgia syndrome J
American Osteopathic Association (abstract) 92(9)1177 1992