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INVISIBLE DISABILITIES ASSOCIATION OF CANADA

Fibromyalgia/Myofascial Pain Syndrome/TMJ

Definition
Diagnosis
Symptoms
Treatment


Definition:

Fibro - refers to fibrous tissues such as tendons and ligaments.

my - muscle

algia - pain

Fibromyalgia or Fibromyalgia Pain Syndrome (FMS) is a chronic pain condition, that can lead to exhaustion. There are many symptoms and also a connection with other health problems such as arthritis, CFS, thyroid, etc.

Fibromyalgia affects men, women, and children. However, women between the age of 25 and 50 seem most affected (the ratio of women to men is 10 to 1). Children are often misdiagnosed as having growing pains or behavioral problems.

Diagnosis:

Fibromyalgia is diagnosed in two steps.

  1. Other illnesses and conditions are ruled out using
    1. a medical history and
    2. laboratory tests.
  2. Apply the criteria explain below. (In 1986, a committee of 24 doctors from medical centres across North America began a study to determine criteria for the classification of Fibromyalgia.)
    • History of widespread pain (present for at least three months). Pain is considered widespread when it is felt in ALL of the following regions:
    1. left side of the body
    2. right side of the body
    3. above the waist
    4. below the waist
    5. axil skeleton (cervical spine or anterior chest or thoracic spine or lower back). Shoulder and buttock pain is considered pain on the side or sides reported; 'lower back' is considered pain below the waist.
    • Pain on digital palpitation in 11 of the 18 tender point sites (9 on each side) (see Figure).

For a tender point to be considered positive, the person MUST state that the palpitation was 'painful'. Digital palpitation should be performed with an approximate force of four kg.

Musculoskeletal pain and fatigue experienced by Fibromyalgia patients is a chronic problem which tends to have a waxing and waning intensity. There is often a concern on the part of patients and sometimes physicians, that FMS is the early phase of some more severe disease, such as multiple sclerosis, systemic lupus esthematosus, etc. Long term follow up of Fibromyalgia patients has shown that it is very unusual for them to develop another rheumatic disease or neurological condition. However, it is quite common for patients with "well established" rheumatic diseases, such as rheumatoid arthritis, systemic lupus and Sjogren's Syndrome to also have Fibromyalgia. Patients with Fibromyalgia do not become crippled with the condition, nor is there any evidence it effects the duration of their expected life span. Nevertheless, due to varying levels of pain and fatigue, there is inevitable contraction of social, vocational and avocational activities which leads to a reduced quality of life.

Symptoms:

Fibromyalgia patients have widespread body pain which arises from their muscles. Some FMS patients feel their pain originates in their joints. Pain that emanates from the joints is called arthritis, extensive studies have shown FMS patients do not have arthritis. Although many Fibromyalgia patients are aware of the pain when they are resting, it is most noticeable when they use their muscles, particularly with repetitive activities. Their discomfort can be so severe it may significantly limit their ability to lead a full life. As a consequence of muscle pain, many FMS patients severely limit their activities including exercise routines. This results in their becoming physically unfit, which eventually makes their Fibromyalgia symptoms worse.

Generally people with Fibromyalgia state that they hurt all over, especially in the parts that are used the most. Stiffness, especially on waking, sleep disorders, irritable bowel syndrome (see separate sheet), irritable bladder syndrome, premenstrual syndrome, restless leg syndrome, headaches (especially migraines and tension headaches) (see separate sheet), muscle spasms, cold intolerance, TMJ, cognitive difficulties, numbness and tingling in the extremities are some of the symptoms. Other common symptoms include a decreased sense of energy, disturbances of sleep, and varying degrees of anxiety and depression related to patients' changed physical status.

There are significant similarities between Fibromyalgia and Myofascial Pain Syndrome. MPS is discussed in this booklet as well.

We do not know what causes Fibromyalgia. Many people pinpoint a time when the symptoms started, for example, after a trauma, such as a car accident. Others say that their symptoms came on gradually.

Treatment:

Treatment centers on the symptoms, not the illness.

In general, drugs used to treat musculoskeletal pain, such as aspirin, non-steroidals and cortisone are not particularly helpful in this situation. Also, routine use of sleeping pills such as Halcion, Restoril, Valium, etc. should be avoided as they impair the quality of deep sleep.

Low dosages of antidepressants are often used to treat pain and sleep disorders. Zostrix (capaiscin cream) is a prescription/over-the-counter cream which can be helpful to alleviate pain. It is made from natural ingredients from hot peppers and penetrates through the skin and into muscles.

If you have Fibromyalgia, decrease the amount of stress placed on the liver. If your liver isn't able to function properly, the body becomes more prone to pain, fatigue and allergic reactions. The juice of one half lemon, unsweetened in water, 20 minutes before breakfast daily, can help improve its function (if you have any pain that appears to originate from the gall bladder you may be reacting to the lemon).

Many people with Fibromyalgia may have problems with decreased oxygen flow to the muscles, resulting in lactic acid build-up which leads to pain. To help alleviate this the following can be used daily: B vitamin complex (50 mg once/twice daily), elemental calcium (citrate or aspartate, 1000-1200 mg/daily), magnesium (citrate or aspartate, 400-500 mg/daily), vitamin D (400-600 i.u.) and manganese (150 mg/daily). Apple cider vinegar (must say "pure" on label) can be helpful for reducing muscle pain, as it contains malic acid. Chronic muscle pain has been linked to heavy muscle toxicity with some people and malic acid has the ability to bind with these and carry them out of the body. Two teaspoons of vinegar daily is enough.

Feverfew is a natural pain reliever. It is especially helpful for migraine headaches. The pill form is usually taken (1-2, 125-150 mg up to four times daily) when needed. Although you may need to take it regularly if it does not help your pain. Caffeine may intensify pain. Decaffeinated tea or coffee also have other chemicals (other than caffeine) that can be harmful as well, so do not drink decaffeinated tea or coffee either.

Eat as close to a vegetarian diet as possible. There is arachidonic acid in meat that stimulates the production of inflammation and pain. Those with Fibromyalgia tend to be deficient in the essential fatty acids. Essential fatty acids act as natural anti-inflammatories. You can have your essential fatty acids tested at the Efamol Research Centre in the Coldbrook Industrial Park. If you have a requisition form from your physician the test is paid for through MSI. You may have to ask for the test to be read by a professional on site because many doctors are not able to interpret the results.

Flaxseed oil, borage oil, evening primrose oil are a few of the oils containing essential fatty acids. If you take evening primrose oil take either the marine blend or take cod liver oil with it because fish oil is required to help evening primrose oil work effectively.

If you suffer from digestive problems with Fibromyalgia you can take digestive enzymes containing amylase, protease and lipase (1-2 at each meal) or as needed.

Panax ginseng is good for increasing energy (25-50 mg/daily), but you should not take Panax ginseng if you are diabetic or suffer from hypertension.

Exercise according to the body's needs and ability. Overall, FMS patients must avoid impact loading exertion such as jogging, basketball, high-impact aerobics, etc. Low-impact aerobics such as regular walking, the use of a stationary exercycle and pool therapy utilizing an Aqua jogger (a floatation device which allows the user to walk or run in the swimming pool while remaining upright) seem to be the most suitable activities for FMS patients to pursue. Supervision by a physical therapist or exercise physiologist is of benefit wherever possible. In general, 20 minutes of physical activity, three times a week at 70% of maximum heart rate (220 minus your age) is sufficient to maintain a reasonable level of aerobic fitness.

Massage, hydrotherapy, physiotherapy, heat, and rest are of benefit. None cure Fibromyalgia but give much needed relief from pain.

Massage assists the removal of waste from muscles, while increasing blood and nutrient flow. This results in a greater availability of oxygen to cells.

Massage is useful for those with Fibromyalgia. Fibromyalgia affects all of the major systems (circulatory, respiratory, lymphatic, digestive, immune and endocrine) of the body and all of these systems respond favorably to massage. That means massage helps move a person towards wellness.

Hydrotherapy, a part of some physiotherapy clinics, has been used since the 1930's to address a wide variety of conditions. You may be able to join an aquatic (aerobic in the water) program at your community center. Hydrotherapy gives people benefits such as gravity-free exercise, local heat and massage, relaxation and pain management.

Particularly painful areas often may be helped for a short time (2-3 months) by tender point injections. This involves injecting a tender point with a local anesthetic (usually 1% Procaine) and then stretching the involved muscle with a technique called spray and stretch. It should be noted the injection of a tender point is quite painful (indeed, if it is not painful the injection is seldom successful). After the injection, there is typically a 2-4 day lag before any beneficial effects are noted.

Myofascial Pain Syndrome

Definition
Diagnosis
Treatment


Definition:

MPS is a neuromuscular condition. It happens because of mechanical failure. Repetitive motion injury, trauma, and illness cause trigger points and these points are all over the body. It affects as many men as women. The pain is in specific spots rather than generalized as with Fibromyalgia.

Diagnosis:

Fibromyalgia seems to trigger MPS. Others say that MPS (specific, local) triggers FMS (general, overall). We often say that people suffering from Fibromyalgia have 18 trigger points. They are actually called tender points because they hurt when pressure is applied. However, MPS has trigger points. It hurts someplace else when pressure is applied to a trigger point. This is called referred pain.

Treatment:

Very similar to Fibromyalgia.

  1. Identify active and latent (latent means not painful unless pushed) trigger points and perpetuating factors.
  2. Estimate the degree of limitation on a person's life as a result of having particular trigger points (causing the most debilitating effects).
  3. Develop a specific treatment program dealing with the specific trigger points.

Compiled from:
Fibromyalgia Syndrome. An Informational Guide for FMS Patients, Their Families, Friends and Employers. Robert Bennett, MD. Distributed by: National Fibromyalgia Research Association, Inc.
Fibromyalgia and Chronic Myofascial Pain Syndrome. A Survival Manual. Devin Starlanyl, MD, Mary Ellen Copeland, MS, MA.
The Fibromyalgia Help Book: A Practical Guide to Living Better with Fibromyalgia. Jenny Fransen, RN, I. Jan Russell, MD, PhD.
Taking charge of your Fibromyalgia: A Self Management Program for your Fibromyalgia. Julie Kelly, MS RN & Rosalie Devonshire, BA.
Shirley Soleil's lecture notes. Notes from Dr. Cheryl Lycette's Workshop presentation April 1997.

Please note that you should always check with your doctor before undertaking any type of treatment.

TMJ

TMJ (temporomandibular) disorders are a family of problems related to your complex jaw joint. If you've had symptoms like pain or a clicking sound, you'll be glad to know that these problems are more easily diagnosed and treated than they were in the past.

TMJ disorders develop for many reasons. You might clench or grind your teeth, tightening your jaw muscles and stressing your TM joint. Or, you may have a damaged jaw joint due to an injury or disease. Whatever the cause, the results may include a misaligned bite, pain, clicking or grating noises when you open your mouth, or trouble opening your mouth wide.

Environmental Sensitivities

  • Are you aware of grinding or clenching your teeth?
  • Do you wake up with sore, stiff muscles around your jaws?
  • Do you have frequent headaches or neck aches? Does the pain get worse when you clench your teeth?
  • Does stress make your clenching and pain worse?
  • Does your jaw click, pop, grate, catch or lock when you open your mouth?
  • Is it difficult or painful to open your mouth, eat or yawn?
  • Have you ever injured your neck, head or jaw?
  • Have you had problems (such as arthritis) with other joints?
  • Do you have teeth that no longer touch when you bite?
  • Do your teeth meet differently from time to time?
  • Is it hard to use your front teeth to bite or tear food?
  • Are your teeth sensitive, loose, broken or worn?

The more times you answered "yes", the more likely it is that you have a TM disorder. Understanding TM disorder will also help you understand how they're treated.

Understanding TM Disorders

When you understand the anatomy involved in your TM disorder, you can better understand your role in relieving your symptoms.

Muscles Provide Power

Around your jaw joint are groups of muscles that contract and relax so you can open and close your mouth, talk and chew. When they are flexible and not under stress, they work in harmony with other parts of your jaw.

Jaws Form Joints

Your TM joints are where your upper jaw and lower jaw (mandible) meet. Like gears of a car, the joints have moving parts that allow the lower jaw to move. This lets you open and close your mouth for talking, biting and chewing.

Your Dental and Medical Evaluation

An evaluation confirms a diagnosis of TM disorder. It also clarifies the causes of your disorder, helping to set the stage for treatment.

Your dental and medical history helps your doctor gather information on your symptoms, your overall health, and your family history of any related problems. With the answers you give, your doctor begins to determine the causes of your disorder. Your might be asked: Are you under stress at work or home? Do you clench or grind your teeth? Have you had bite problems or joint disorders?

Your doctor examines you to detect your symptoms. One technique is to firmly touch (palpate) your muscles and jaw joint, checking for pain, muscle tension and tenderness. Your doctor may also insert a little finger into your ear to feel how smoothly your jaw works. A stethoscope picks up clicking sounds in your joint and a ruler measures how wide you can open your jaw.

Diagnostic tests pinpoint even further the possible cause of your TM disorder, indicating what the best treatment might be for you.

Imaging Tests: Tomographic or transcranial x-rays are head x-rays that record images of bones and reveal joint damage, fracture, or tumors. MRI (magnetic resonance imaging) produces detailed images of soft tissue, revealing damage in disks or ligaments.

Dental Casts: Dental casts are models of your teeth that help determine how muscle or jaw problems such as bruxism have affected your teeth and your bite. Casts help your doctor study if your teeth have worn down or how your teeth line up. Your doctor takes an impression of your mouth and forms plaster models, which may be mounted on a jaw movement simulator. This mechanical device helps reproduce the movement of your lower jaw.

Your Treatment Program

Treatment works best with a team approach of self-care and professional care. Treatment may take time and include many options.

Resting your Jaw: The most important kind of self-care, resting your jaw relaxes muscles and takes the pressure off your joint, which can then heal more easily. The key to resting your jaw is keeping your teeth apart. Practicing good posture, eating soft foods, and reducing stress will also relax tense muscles and help give your jaw a break.

Keep your teeth apart: Bring your teeth together only when swallowing or eating. Learn to recognize when you clench your teeth, such as when you're under stress; then relax your jaw and separate your teeth.

Practice good posture: Good head, neck and back posture help maintain good jaw posture, too. Try to hold your head up straight, avoid leaning on your hand when reading or watching TV, and use a lumbar roll for support behind your lower back.

Eat soft foods: Eat soft foods like eggs, yogurt, casseroles, and soup. Don't chew gum, and avoid hard foods like carrots (or put them in a blender before eating them). Eating soft foods is a temporary measure that helps you rest your jaw.

Applying Ice and Heat

Ice: Massage with ice directly on the painful area the first 24-48 hours after injury. Apply for 3-5 minutes or until the area becomes numb. Repeat several times.

Heat and Ice: Apply moist heat on tense muscles for 10 minutes, then lightly brush the painful area with an ice cube. Rewarm the area for 1-2 minutes. Repeat ice and heat combination 4-5 times.

Exercising Your Jaw

Open and close: Looking in a mirror, gently open and close your mouth straight up and down, keeping your two upper teeth and two bottom teeth aligned. Do this exercise for a few minutes in the morning and in the evening.

Taking Medications

Aspirin is a very effective pain reliever. Your doctor may also prescribe an anti-inflammatory to help reduce the pain and swelling or a muscle relaxant.

Biofeedback

This technique helps you know what's going on inside your body, so you can learn to consciously control your body's stress responses, such as tightening muscles around your jaw.

Relaxation Techniques

Deep breathing may lessen tension. Or try yoga or visualizing something peaceful, like basking in the warmth of a sunny meadow filled with flowers.

Getting Support

Support from a group or individual may help you manage stress, ease the isolation caused by chronic pain, or help you contact other TM disorder patients.

Electrical Stimulation

An electrical impulse sent through your skin relaxes muscles, aids circulation and relieves pain.

Ultrasound

Painless sound waves reduce pain and swelling in your joint and muscles, and improve circulation.

Occlusal Splint

How a Splint Works: Your doctor makes a splint to help diagnose and improve your joint problems. There are different types of splints for different purposes. A bruxism splint or night guard - worn mostly at night - helps you stop clenching or grinding your teeth and reduces muscle tension. An anterior positioning appliance moves your jaw slightly forward, relieving pressure on parts of your jaw. It may be worn 24 hours a day to help your jaw heal. An orthopedic stabilization appliance - worn 24 hours or just at night - relaxes muscles and lets your joint move into its proper position.

"I sound funny when I talk..." At first, your voice may sound different because you've got a bulky piece of material in your mouth. Try reading out loud for a few nights to adjust to talking with a splint.

"I can't eat anything..." Yes, you can still eat with your splint, although you'll probably need to change your diet by eating softer foods. Later, you may only have to wear your splint at night.

Orthodontics

Orthodontics is a kind of dental work that moves and repositions groups of teeth to create a stable bite. Braces are the most common type of orthodontics.

Restorative Work

Restorative dental work changes the shape or size of individual teeth to create a stable bite. If a tooth is missing, a bridge may be built to replace it. If a tooth is too big, it can be "shaved down" to make your teeth hit more evenly (occlusal adjustment). If a tooth is too small, a crown can be added so teeth come together better.

Surgery

Surgery can help restore your jaw joint and eliminate the pain and other symptoms of TM disorders. With other treatment available, surgery is rarely needed, especially if a problem is diagnosed and treated early. In some cases, however, the joint becomes so severely damaged that surgery is needed to correct it.

Compiled from:
TM Disorders: A Guide to Managing your Temporomandibular Joint Problem. Consultant - Charles McNeil, DDS, Contributions - Patricia Rodd, PT. Kramer Communications.

Please note that you should always check with your doctor before undertaking any type of treatment.

INVISIBLE DISABILITIES ASSOCIATION OF CANADA
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