Fibromyalgia is a chronic invisible condition that has finally come "out of the closet".

In 1987, the American Medical Association (AMA), recognized FMS as a true illness and a major cause of disability. Nearly ten years later, it is still, unfortunately, too often dismissed as the "newest fad disease". Most physicians still lack the training to diagnose and treat it. What we now call FMS is not homogeneous, and too often what is diagnosed as FMS is actually myofascial pain, a totally different, although often co-existing, condition. It is incorrect and a disservice to the patient to lump all soft tissue widespread pain conditions as "fibromyalgia".

Fibromyalgia is not a catchall, "wastebasket" diagnosis. FMS is a specific, chronic non-degenerative, non-progressive, noninflammatory, truly systemic pain condition. Diseases have known causes and well-understood mechanisms for producing symptoms. FMS is a syndrome, which means it is a specific set of signs and symptoms that occur together. This in no way means that fibromyalgia is any less serious or potentially disabling than a disease. Rheumatoid arthritis, lupus, and other serious afflictions are also classified as syndromes. The term "syndrome" is a measure of our ignorance, not a reflectance of the impact FMS has on our lives.

The official research definition further requires that tender points must be present in all four quadrants of the body--that is, the upper right and left and lower right and left parts of your body. Furthermore, you must have had wide-spread, more-or-less continuous pain for at least three months. Many doctors who don't stick close to the "research definition", will consider patients with body-wide flu-like symptoms, multiple tender points (NOT trigger points!), characteristic sleep disruption and resultant fatigue as FMS. The tender points are important, although the number may not be, because the other symptoms can be caused by many things, they can even be the side-effects of medications.

Tender points occur in pairs on various parts of the body. Because they occur in pairs, the pain is usually distributed equally on both sides of the body. Tender points can vary from person to person, which can cause further problems with diagnosis. FMS can occur at any age. Many doctors who are expert diagnosticians of FMS have picked out developing FMS in children at the toddler stage. There are also people who develop FMS in their geriatric years. (Trigger points of myofascial pain may occur during birth.)

FMS is a sensitivity-amplification syndrome. This means that you can be hypersensitive to smells, sounds, lights, and vibrations and changes in weather conditions. The noise emitted by fluorescent lights can drive you crazy. You may be unable to tolerate crowds or cities. FMS sensitizes nerve endings, which means that the ends of the nerve receptors have changed shape. Because of this, for example, your body might interpret touch, light, or sound as pain. Your brain knows pain is a danger signal--an indication that something is wrong and needs attention--so it mobilizes its defenses. Then, when those defenses aren't used, it become anxious.

Sleep, or the lack of it, plays a crucial role in FMS. Perhaps you aren't getting enough sleep, or the right kind of sleep. You may have insomnia of several types, or a host of other sleep-related problems. We wake up feeling like we've been hit by a truck. That's the sign of unrestorative sleep. We often have sleep deprivation.

Only about 20% of FMS cases have a known triggering event that initiates the first obvious "flare." During a flare, current symptoms become more intense, and new symptoms frequently develop. Life is out of control. Even the best organized support systems become strained at this time, and your whole focus has to be on survival. The best way to deal with flares is to prevent them, and your best preventative weapon is knowledge.

Myofascia

Myofascial is a force which permeates the entire body. It is the reason we hurt in so many places, and in so many ways. Myofascia is the thin, almost translucent film that wraps around and through body tissue and infliltrates it in three-dimensions down to the DNA. It gives shape to and supports all of the body's musculature. You can see myofascia if you cut up a fresh chicken. It is the thin, sticky, somewhat filmy material that wraps around the muscle tissue. It also wraps around each muscle fiber, bundles of fibers, and the muscles themselves. When the muscle cells end, layers of it stick together to form tendons and ligaments.

It appears that tightening in the myofascia occurs in many cases of FMS and CMP. If both of these conditions are present, this tightening causes more than double the trouble. Your muscles feel like they are swollen, as if they were encased in a skin several sizes too small. Edema is common in FMS and CMP­interstitial edema that holds excess water in the ground substance, and does not respond well to diuretics.

In the myofascia there is a material called ground substance. This material can exist in a solid, semisolid, or fluid state. When ground substance changes from a liquid to a gel, and then changes back into its more solid form, the myofascia tightens, and it is difficult to get it to reverse to a liquid state again without intervention. When an area of the body is in pain, the myofascia in that area becomes rigid to prevent movement, to "splint" the affected part. If pain continues, layers, CMP and bands of tightened, hardened myofascia develop. Your myofascia has given birth to a trigger point.

Myofascial Trigger Points

Trigger Points (TrPs) are found as extremely sore points occurring individually or in ropy bands throughout the body. The bands are often easier to feel along the arms and legs when you stretch your muscle about 2/3 of the way out, you often are able to feel them. Sometimes your muscles get so tight that you can't feel the CMP, or even the tight bands. TrPs can occur in myofascia, skin, and ligaments as well as other tissues. TrPs have referred pain or other symptom patterns that are carefully documented. Myofascial TrPs cause weakness and dysfunction, not just pain.

Most specific localized pains commonly attributed to FMS are actually from TrPs. You can't have "FMS in your hands", or in your back, etc. It is biochemical, and systemic. Local TrPs seem to form throughout life as a response to many things that happen to your body, and just about everyone may have one or two now and then in response to life situations. Janet Travell felt that many of the aches and pains attributed "old age" could actually due to TrPs, and reversible! We need to get at the perpetuating factors to relieve ours. TrPs form due to excess acetylcholine produced in a region of the muscle called the motor end plate. Now that we know the mechanism, myofascial pain from TrPs has been documented and confirmed as a true neuromuscular disease. Overuse, repetitive motion trauma, bruises, strains, joint problems, etc can all cause TrPs.

An active TrP not only hurts when it is pressed, like an FMS tender point, but it may "trigger" a referred pain pattern somewhere else in the body. This pain pattern is similar from patient to patient. These TrPs often produces other symptoms, also usually in its referred pain zone. Such a TrP hurts whenever you use the involved muscle. When the point becomes very active, pain and other symptoms occur even when the muscle is at rest. The fact that these pain patterns are very much similar from patient to patient really helps make a diagnosis if the person doing the diagnosing is familiar with the patterns so well described by Travell and Simons. That's why familiarity with TrPs and an ability to take a good medical history is so important. An educated doctor will know where to look for TrPs before the physical exam begins.

A "latent" type of TrP also occurs. A latent TrP doesn't hurt at all, unless you press it. You might not even know it's there, but your body does. It restricts movement, weakens and prevents full lengthening of the affected muscle. If you press on the TrP, it refers pain in its characteristic pattern. A latent TrP may be activated by overstretching, overuse, or chilling the muscle.

When you have TrPs, muscle strength becomes unreliable. You may have also have noticed that if one part of your body turns over another while you sleep, the part being compressed goes numb. Some other symptoms of TrPs include stiffness, muscle tightness and weakness, localized sweating, tearing, salivation, poor balance, dizziness, nausea, tinnitus, goosebumps, runny nose, buckling knees, weak ankles, illegible handwriting, staggering gait, headaches, and muscle cramps.

TrPs often form as a result of other medical conditions. A case of arthritis may be otherwise well managed, for example, but the accompanying TrPs are overlooked. The pain load of that patient could be substantially lessened if the secondary TrPs were treated successfully. Diagnosis gets really challenging when body-wide TrPs develop with overlapping referral zones. This "spread" of TrPs gives the impression that the condition is progressive, but it isn't. It may be getting steadily worse, but with proper attention to perpetuating factors and appropriate treatment, the "progression" can be reversed.

Chronic Myofascial Pain

If TrPs are treated immediately and vigorously, and perpetuating factors (conditions that aggravate and perpetuate the TrPs), are avoided or remedied, the TrPs can be eliminated. Unfortunately, if TrPs are left untreated, are inappropriately treated, or muscle action is restricted to avoid pain, the TrP usually becomes latent. It doesn't hurt any more unless you press on it, but the muscle can "give out" when stressed. If the muscle is pushed to work in spite of the pain, especially if perpetuating factors exist, active TrPs may develop secondary and satellite TrPs. Chronic myofascial pain can involve all four quadrants of the body, and so can be widespread pain. Not all patients who have widespread pain from CMP have FMS.

FMS and CMP are different. Too, physicians lump them together, and they need to be treated differently. Unless doctors have a thorough knowledge of and familiarity with individual TrPs, they don't stand a chance of sorting out the symptoms. One interesting difference between the two conditions is that more women than men have FMS, but CMP affects men and women in equal numbers. Another difference is that muscles in locations that are some distance from the TrPs of CMP have normal sensitivity. In fibromyalgia, there is a generalized sensitivity.

FMS is, among other things, a systemic neurotransmitter dysregulation, with many biochemical causes. There are other problems as well, but they are systemic in nature, such as the alpha-delta sleep anomaly. CMP however, is a neuromuscular condition. CMP happens because of mechanical failures--the mechanics of physics, not biochemistry. Due to the nature of trigger points, some of the symptoms may seem to be systemic, but they are not. Initiating events, such as repetitive motion injury, trauma, and illness, can start a cascade of TrPs. There are many medical journal articles which explain why FMS and CMP are different, and why the difference is important.

FMS/CMP Complex

This is a name I picked out to describe a condition which I feel is relatively common, yet which has not been noticed by the medical community. I have the perverse blessing of having this in a rather severe form, so I have an inside edge for the understanding thereof. People with FMS and CMP face more than just the two sets of symptoms of both conditions. FMS and CMP not only occur together, they reinforce each other, and amplify the symptoms. Therefore, physical therapy and all other forms of treatment must proceed carefully. Any treatment tried will be both more complicated and less successful than if the patient had only one of the two conditions. One study has already been done which has found that people with both FMS and CMP have more pain on TrP injections, and they have less of an effect, and that effect often takes a longer time to develop and may not last as long as if the patient only had CMP. As more researchers and clinicians realize that this synergistic condition exists, there will be more studies, and I hope more light will be shed on just what we are coping with, and how to deal with it.

In FMS, many different neurotransmitters may be affected in different combinations interacting in different ways in different patients. Other biochemicals in the body are affected to different degrees. Various hormones may be involved. Histamine (a neurotransmitter) is often a important factor when there are many allergic manifestations, but the possible combinations are endless. When you figure in the possible combinations of TrPs, no two patients are alike. FMS perpetuates CMP and the reverse is also true. A lot can be done to relieve CMP and lighten the pain load. And there are many things that help FMS as well.

For more information, see http://www.sover.net/~devstar

Modified for "The Fibromyalgia Advocate"
ASAMS extends our sincere thanks to Dr. Starlanyl for her contribution of
this article.