Information for Neurologists

©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. Patients with FMS and/or MPS may react differently to surgery and its associated care.

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 a pain amplification syndrome. Some of our receptor endings have changed, so we feel pain more intensely. We have allodynia, so be prepared for more intense post-surgical pain, as well as longer healing time due low growth hormone and associated healing factors.

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.

When occurring together, what I call the "FMS&MPS Complex" forms. This is a condition of interconnected symptom spirals that get increasingly worse until the spiral is interrupted. For example, the pain causes muscle contraction which causes more pain which causes more contraction, etc. The patient can sometimes have muscles that are like cement, due to myofascial splinting. Immobility will usually cause symptoms to worsen, and muscles to contract. Sometimes patients will not be able to endure the hard hospital beds. Some of us even find water beds too hard, and need additional padding.

Two excellent medical texts are available on MPS, "Myofascial Pain and Dysfunction: The Trigger Point Manual Vol. I and II" by Janet G. Travell M.D. and David G Simons M.D. The second volume is important to you, as it deals with lower body TrPs. This chapter is but an introduction to them. The Manuals show the referred patterns, tell what causes them, and how to relieve them.

Many of your patients may suffer from allodynia or hyperesthesia, and there are specific symptoms of FMS&MPS Complex that should put up a red flag.

Morning stiffness:

This is primarily due to the immobility of the night. Any time we stay in one position for any length of time, our body stiffens in that position due to inflexible myofascia. This stiffness may take hours to work out.

Muscle twitching:

Eye twitching is often the first noticeable twitch in FMS&MPS Complex, and it's very common. Check the periorbital TrPs, especially around the upper eye ridge. You will probably find some real screamers. Also check the sternocleidomastoid, the temporalis and the trapezius TrPs for possible causes of the eye twitch. You may also find other head TrPs. Other muscles twitching can become bothersome. Sometimes it can be a continuous twitch. Sometimes one or two muscles will fire off now and then. Fasiculations and waves of twitches can be due to low-level TrPs. This has been described as having your nerves plugged in to twinkling Christmas lights. Other people have severe twitches that disrupt their functioning. These can become painful cramping.

Trouble falling asleep, trouble staying asleep,light sleeping, interrupted sleep, wake up feeling tired and unrefreshed :

These are symptoms of the alpha-delta sleep disorder, which often occurs with FMS&MPS Complex.

Difficulty getting out words you know, especially nouns and pronouns:

This is part of the "cognitive deficits" package we get with FMS. Names and nouns get awfully hard to find. It's frustrating.

Difficulty distinguishing right from left and/or difficulty finding places or following directions:

They say that there will never be a rally for fibromyalgia because none of us could find where it was held.

Short-term memory problems, confusional states:

We often can't do a number of steps in sequence. I found that I was unable to deal with appointments on the half-hour while working on my book. My mind wouldn't register them as half-hour. I'd come a half-hour early or a half-hour later. The concept was too much for me to grasp, because of the extra work load.

Severe problems estimating distance and depth perception:

This can cause driving to be extra exciting, especially if sternocleidomastoid TrPs are involved. They can cause severe dizziness when the field of vision is changed rapidly, and many other proprioceptor disturbances. Any pattern on light and dark, such as window blinds, escalator steps, trees along a road or patterns in fabrics can cause dizziness or even a seizure-like feeling.

Free-floating anxiety, panic attacks, rapid mood swings, irritability with unknown cause, trouble concentrating, inability to recognize familiar surroundings:

This is all part of what we term "fibrofog", and can be part of the neurotransmitter imbalancing. This can be worsened by reactive hypoglycemia, which must be modified by diet (see patient handouts).

Sensory overload:

This is what I call the feeling that information and stimulation is coming at you so fast you can't deal with it. We either go into a "fugue" state -- we stare into space for a while until our brain catches up (this can happen mid-sentence) -- or we close down some sensory input. In the latter case, we shut off car radios, leave noisy rooms and avoid cities. We need our "space".

Depression:

Too little serotonin may trigger depression. Acute pain that diminishes in the course of a natural healing process is something that most of us can live with. Recurrent or persistent pain, especially due to an unrecognized or untreatable cause can threaten our future function and well-being, which can lead to frustration, depression and progressive disability.

Sensitivity to cold, sensitivity to heat, sensitivity to humidity, sensitivity to barometric pressure and approaching storms:

these are part of body "thermostat" regulation problems. One minute we're hot, and the next minute we have the chills. I've not had as many chilly periods since I started taking timed-release niacin. That opens up the peripheral circulation. Bodywork helps as well, although it won't do much about the thermostat problems. The hypothalamus at base of brain is our thermostat, so this is part of the disrupted HPA axis. The hypothalamus sends a message to the body to contract or dilate blood vessels, via neurotransmitters. Some of us run a low-normal temperature, and some of us have chronic low-grade fevers.

Take a good history. We often have abnormal electromyographic results due to nerve entrapment by TrPs, and even abnormal EEGs, although these vary, like the symptoms, from hour to hour and day to day. There are often white blotches in the MRIs. Once you see this pattern of signs and symptoms and understand the concepts of FMS and MPS, they will become easier to recognize.

Fibromyalgia Support - Ottawa West
S.C. Alder
Mar/99