©Devin Starlanyl, MD 1995-1998
You have seen patients with fibromyalgia and myofascial pain syndrome, and will see more. They are both very real medical conditions, and both very different, although often confused. They may be the answer to some of your "challenging" patients.
Fibromyalgia is a systemic neurotransmitter condition with, among other things, a disrupted adrenal-hypothalamus-pituitary axis. It is nonprogressive (although it may seem so), nondegenerative, and noninflammatory. It is responsible for diffuse body-wide pain, tender points that hurt but don't refer pain, and sleep disturbances. It is NOT a "wastebasket" diagnosis. The central nervous system can be profoundly affected.
Chronic myofascial pain syndrome (MPS) is a musculoskeletal chronic pain syndrome. It is nonprogressive (although it may seem so), nondegenerative and noninflammatory. It is composed of many Trigger Points (TrPs), which refer pain and other symptoms in very precise, specific patterns. It seems progressive because each TrP can develop satellite and secondary TrPs, which can form secondaries and satellites of their own. With treatment of the TrPs and underlying perpetuating factors, however, these TrPs can be " reversed" and minimized or eliminated. It is NOT a "wastebasket" diagnosis.
FMS and MPS are separate and unique conditions which can form a synergistic, mutually perpetuating FMS&MPS Complex. Each of us has our unique combination of neurotransmitter disruption and connective tissue disturbance. We need professionals who are willing to stick with us until an acceptable symptom relief level is reached.
Any patient with diffuse body-wide aches of long duration, coupled with a sleeping disorder -- inability to fall asleep, inability to stay asleep, light sleep, inability to get restorative sleep, and/or waking early should be evaluated for FMS . Patients with specific patterns of referred pain (trigger points), indication of blood vessel, lymph or nerve entrapment or proprioceptive disturbances should be evaluated for myofascial pain syndrome.
Your patient may be confused or stressed during an office visit. S/he may have gone through misdiagnosis and may have taken a lot of blame. On the Internet, we call it the "It's All In Your Head" syndrome, or IAIYH. You may need to ask a family member to come with them. Ask before scheduling these patients early in the morning, as morning stiffness can be considerable.
If you were no longer to practice your skill...if you lost the ability to control your muscles, and sometimes even to think clearly...if you couldn't function in your family role...if you were in severe pain, and your ankles were buckling, and you couldn't even pick up a glass of water without spilling it all over yourself, and yet your family and your friends thought you were crazy because you LOOKED JUST FINE...how would you feel? There is a relinquishment execise in the "Family and Friends" chapter in my book. I recommend that you do this and take it seriously.
Somatization is current psychiatric catchword. We "psychotize." When we get depressed, we tend to think it is because of our chronic physical illness. It is, in a way, but often because of the biochemicals created in our body. Neurotransmitters are balanced and regulated during delta-level sleep, which is frequently interrupted in FMS.
The most-studied medications that modulate neurotransmitters are psychoactive drugs. THIS DOES NOT MEAN THAT THE PATIENT'S CONDTION IS PSYCHOLOGICAL. Studies have shown that people with FMS have no more an incidence of psychological problems than any other chronic pain patients. Medications which affect the central nervous system are appropriate for FMS. They target symptoms of sleep lack, muscle rigidity, pain and fatigue. 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".
Please read the definitions section and become as knowledgable as possible about these conditions. You have seen many FMS&MPS Complex patients, although many are undiagnosed or misdiagnosed. They all need your help to cope.
Chronic pain of a non-malignant cause is often treated less vigorously than cancer pain, although the level of pain may be equal or worse. I give you the following quotes. They are from "PAIN A Clinical Manual for Nursing Practice", by McCaffrey and Beebe.
"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."
"Having an emotional reaction to pain does not mean that pain is caused by an emotional problem."
It's normal to be depressed with chronic pain, but that doesn't mean depression is causing the pain. Visits with your patient should be about empowerment, not invalidation. Your patient may have gone through a traumatizing period of not being believed, meanwhile being racked by chronic pain of unknown origin. The patient must be encouraged to be an active manager and coordinator of the treatment team, and take responsibility for his/her own actions and consequences. Methods for accomplishing this are given in my book. Most patients had a high level of activity before FMS&MPS Complex became full-blown. Now they must be careful not to push it, and understand their limits. There specific symptoms of FMS&MPS Complex that may cause confusion:
Listen to your patient, and don't be afraid to believe.