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Posted to Co-Cure Tue 10 Mar 1998 19:03:49 -0500

[Moderator's note: This article was most graciously prepared and written by
Dr. Starlanyl specifically for Co-Cure. She has an extensive website at
http://www.sover.net/~devstar/ which includes information on both FMS and CFIDS.
Our sincerest thanks to Dr. Devin for this article.]

Fibromyalgia (FMS): Most Critical Causative and Treatment Factors
by Devin J. Starlanyl, M.D.

There is a simple answer to the question, "What causes fibromyalgia?" We don't know. There are usually many factors involved, and tracing factors is like unraveling balls of knotted yarns which have been wound of different and diverse threads over many years. It takes time, and there is a different scenario for each patient.

Evidence exists for a genetic tendency towards developing fibromyalgia (*) . It runs in families. There is no evidence of greater increases of fibromyalgia incidence in non-related family members., i.e. no evidence of a contagious process. The genetic predisposition is not enough, however.

What is required seems to be a stressor or a group of stressors. This may be a cumulative process, such as prolonged stress, grief or terror, or may come as a single event, such as an auto accident, fall, illness, or other trauma. Myofascial pain syndrome may also be produced by either cumulative or single event stressors (+).

There is a great lack of training in the medical profession in regards to both fibromyalgia and myofascial pain syndrome, which are quite different and yet are often either lumped together or misdiagnosed, to the great detriment of the patients (**). Many doctors confuse the fatigue that comes with sleep deprivation from fibromyalgia-related sleep disorders or the pain of myofascial pain syndrome with CFIDS, and slap the "chronic fatigue" diagnosis on the patient, further complicating matters. Many doctors refuse to believe that any of these syndromes exist at all, invalidating the patient and denying the support structure s/he so urgently requires (++). They prefer to believe it's psychological, in spite of the overwhelming evidence to the contrary.

Fibromyalgia is predominantly a neuroendocrine disorder, not a musculoskeletal one, that profoundly affects the central nervous system, which in turn, affects the whole body(***). Early intervention will often halt the neurotransmitter cascade, and prevent many symptoms.

Myofascial pain syndrome is mechanical, and once satellite and secondary trigger points develop, with sufficient perpetuating factors, the whole body area can have trigger points, with overlapping referral patterns that are difficult for even the trained doctor to distinguish.

Unchecked, untreated or mistreated, often with inappropriate physical therapy and "work hardening", the patient often develops full-blown FMS/MPS Complex, with many of the muscles electrically loaded with active trigger points, and symptoms magnified by fibromyalgia.

Fibromyalgia, as well as myofascial pain syndrome, has perpetuating factors. In the case of fibromyalgia, these are conditions which perpetuate the neurotransmitter dysfunction and hypersensitive central nervous system and peripheral nerves for FMS. With many neurotransmitters affected in many possible ways, and many possible trigger points, the field of FMS/MPS is no place for "cookbook medicine". A doctor does not have the luxury of saying, "Ah, you have "abc". Take "xyz" and you will feel better in 2 weeks. It doesn't work that way. Each patient has to be handled individually.

It has been my observation that in spite of warnings in the medical literature (Travell, Simons. 1992), doctors and pain clinics keep using inappropriate treatment regimens for myofascial pain syndrome/active trigger points, such as repetitive exercises and weight training, which further electrically load the trigger points and aggravate the co-existing FMS. Again, most doctors are unaware of perpetuating factors. It is vital that patients with FMS and MPS and their health care team track down the factors which may be adversely affecting the patients' health, as soon as possible, and measures taken to reduce the impact of these factors.

For example, I have found that many patients with FMS and MPS have reactive hypoglycemia. This has been described as a perpetuating factor for MPS and FMS (Travell, Simons 1992; Starlanyl 1997; Starlanyl, Copeland 1996). It may also be a major component of the infamous "fibrofog" in many cases (+++). The proper diet is needed to control reactive hypoglycemia (see website for handout).

Perpetuating factors may be metabolic or mechanical, and some are explained briefly in a handout on my website. Track them down and deal with them. They can range from lack of restorative sleep to lack of adequate pain control. You attitude can be a major perpetuating factor, and you may have to make major adjustments in your life style. It can seem overwhelming at first. Take it in simple steps. No change comes overnight.

To sum it up, the most critical causative factors are a genetic predisposition and a stressor, or assortment of stressors. The most critical factor in the development of so many cases of full-blown FMS and FMS/MPS Complex is lack of training on the part of the medical team members, and the complexity of FMS and MPS. The most critical treatment factor is prompt identification of perpetuating factors, and specific attention to each of them.

It is tough to deal with all the symptomology of FMS and MPS, but even tougher to have to educate your medical team and companions at the same time. Keep in mind that you are not alone. Researchers are working on FMS. More information is coming out every day. There is a push to mandate education in FMS and MPS for all medical students. Right now, we can identify the problems, and the factors perpetuating them. For tomorrow, there are many promising research leads. Keep the faith. The path is rocky, and some of it may be uphill, but there are many hands to help you along the way.

+ Alonzo R. A., A. Delahoz Martinez, and A. C. Zea Mendoza. 1985. "Fibromyalgia as a late complication of toxic oil syndrome." J Rheumatol 12(6):1207-1208.

*** Bendtsen L., J. Norregaard, R. Jensen and J. Olesen. 1997. "Evidence of qualitatively altered nociception in patients with fibromyalgia." Arth Rheum 40(1):98-102.

*** Bennett R. M., D. M. Cook, S. R. Clark, C. S. Burckhardt, and S. M. Campbell. 1997. "Hypothalamic-pituitary-insulin-like growth factor-I axis dysfunction in patients with fibromyalgia." J Rheumatol 24(7):1384-1389.

+++ Blackman J. D., V. L. Towle, J. Sturis, G . F. Lewis, J-P Spire and K. S. Polenske. 1990. "Hypoglycemic thresholds for cognitive dysfunction in humans." Diabetes 39:828-835.

** Borg-Stein J. and J. Stein. 1996. "Trigger points and tender points: one and the same? Does injection treatment help?" Rheum Dis Clin N Am 22 (2):305-322.

++ Buchwald D. 1996. "Fibromyalgia and chronic fatigue syndrome: similarities and differences." Rheum Dis Clin North Am 22 (2): 219-243.

+ Buskila D., A. Shnaider, L. Neumann, D. Zilberman, N. Hilzenrat and E. Sikuler. 1997. "Fibromyalgia in hepatitis C virus infection. Another infectious disease relationship." Arch Intern Med 157(21):2497-2500.

++ Buskila D., L. Neumann, D. Sibirski, and P. Shvartzman. 1997. "Awareness of diagnostic and clinical features of fibromyalgia among family physicians." Fam Pract 14(3): 238-241.

* Buskila D. and L. Neumann. 1997. "Fibromyalgia syndrome (FM) and nonarticular tenderness in relatives of patients with FM." J Rheumatol 24(5):941-944.

+ Buskila D., L. Neumann, G. Vaisberg, D. Alkalay, F. Wolfe. 1997. "Increased rates of fibromyalgia following cervical spine injury. A controlled study of 161 cases of traumatic injury." Arth Rheum 40 (3): 446-452.

* Buskila D., L. Neumann, I. Hazanov and R. Carmi. 1996. "Familial aggregation in the fibromyalgia syndrome." Semin Arthritis Rheum 26(3):605-611.

+ Buskila D., D. D. Gladman, K. V. Straaton P. Langevitz, S. Urowicz and H. A. Scythe. 1990. "Fibromyalgia in human immunodeficiency syndrome virus infection." J Rheumatol 17(9):1202-12-6.

*** Carrett S., M. Dessureault and A Belanger. 1992. "Fibromyalgia and sex hormones." J Rheumatol 19(5):831.

+ Carette, S. and L. Lefrancois. 1988. "Fibrositis and primary hypothyroidism." J Rheumatol 15 (9):1418-1421.

*** Crofford L. J .1994. "Neuroendocrine aspects of fibromyalgia." J Musculoskel Pain 2(3):125-133.

+ Culclasure, T. E, R. J. Enzenauer and S. G. West. 1993. "Post-traumatic stress disorder presenting as fibromyalgia." Am J Med 94 (5):548-549.

+ Dinerman H. and A. C. Stere. 1992. "Lyme disease associated with fibromyalgia." Ann Int Med 117(4):281-285.

+++ Eisinger, J., A. Plantamura and T. Ayavou. 1994. "Glycolysis abnormalities in fibromyalgia." . J Am Col Nutri 13(2) 144-148.

+ Fernstrom J. D. 1991. "Effects of the diet and other metabolic phenomena on brain tryptophan uptake and serotonin synthesis." Adv Exp Med Biol 294:369-376.

+ Godfrey R. G. 1997. "Fibromyalgia as a manifestation of petroleum fume toxicity in a family of four." J Clin Rheum3:54-57

+ Griep E. N., J. W. Boersma, and E. R. de Kloet. 1994. "Pituitary release of growth hormone and prolactin in the primary fibromyalgia syndrome." J Rheumatol 21(11):2125-2130.

*** --- 1993. "Altered reactivity of hypothalmic-pituitary-adrenal axis in the primary fibromyalgia syndrome." J Rheumatol 20 (3):469-474.

+++ Hovidberg A., C. G. Fanelli, T. Hershey, C. Terkamp, S. Craft and P. E. Cryer. 1996. "Impact of recent antecedent hypoglycemia on hypoglycemic cognitive dysfunction in nondiabetic humans." Diabetes 45(8):1030-1036.

+ Hudson J. I. and H. G. Pope Jr. 1995. "Does childhood sexual abuse cause fibromyalgia?" Arth Rheum 38(2):161-163.

*** Johansson G., J. Risberg, U. Rosenhall, G. Orendahl, L. Svennerholm and S. Nystrom. 1995. "Cerebral dysfunction in fibromyalgia: evidence from regional cerebral blood flow measurements, otoneurological tests and cerebrospinal fluid analysis." Acta Psychiatr Scand 91(2):86-94.

++ Johannson, V. 1993 ."Does a fibromyalgia personality exist?" J Musculoskel Pain 1(3/4):245-252.

++ Jones R. C. 1996. "Fibromyalgia: misdiagnosed, mistreated and misunderstood?" Am Fam Phys 52(1):91-92.

*** Kosek E., J. Ekholm and P. Hansson. 1996. "Sensory dysfunction in fibromyalgia patients with implications for pathogenic mechanisms." Pain 68 (2-3): 375-383.

+ Lapossy E., R. Maleizke, P. Hyrcaj, W. Mennet and W. Muller. "The frequency of transition of chronic low back pain to fibromyalgia." Scand J Rheumatol 24(1):29-33.

++ Lebovits A. H., I. Florence, R. Bathina, V. Hunko, M. T. Fox and C. Y. Bramble. 1997. "Pain knowledge and attitudes of healthcare providers: practice characteristic differences." Clin J Pain 13(3):237-243.

+++ Lentjes E. G. , E. N. Griep, J. W. Boersma, F. P. Romijn and E. R. de Kloet. 1997. "Glucocorticoid receptors, fibromyalgia and low back pain." Psychoneuroendochrinology 22(8):603-614.

* Lowe J. C., M. E. Cullum, L. H. Graf Jr., J. Yellin. 1997. "Mutations in the c-erbA beta gene: do they underlie euthyroid fibromyalgia?" Med Hypo 48 (2): 125-135.

*** Martinez-Lavin M., A. G. Hermosillo, C. Mendoza, R. Ortiz, J. C. Cajigas, C. Pineda, A. Nava, and M. Vallejo. 1997. "Orthostatic sympathetic derangement in subjects with fibromyalgia." J Rheumatol 24(4): 714-718.

*** McDermid A. J., G. B. Rollman, G. A. McCain. 1996. "Generalized hypervigilance in fibromyalgia: evidence of perceptual amplification." Pain 66 (2-3): 133-144.

+ Middleton G. D., J. E. McFarlin and P. E. Lipsky. 1994. "The prevalence and clinical impact of fibromyalgia in systemic lupus erythematosus." Arth and Rheum 37(8):181-188.

*** Moldofsky H. 1995 "Sleep and the immune system". Int J Immunopharmacol 17(8):649-654.

+ Moldofsky H. 1994. "Chronological influences on fibromyalgia syndrome. Theoretical and therapeutic influences." Ballieres Clin Rheumatol 8(4):801-810.

+ Morand E. F., M. H. Miller, S. Whittingham and G. O. Littlejohn. 1994. "Fibromyalgia syndrome and disease activity in systemic lupus erythematosus." Lupus 3(3): 187-191.

*** Mountz J. M., L. A. Bradley, J. G. Modell, R. W. Alexander, M. Triana-Alexander, L. A. Aaron, K. E. Stewart, G. S. Alarcon, J. D. Mountz. 1995. "Fibromyalgia in women. Abnormalities of regional cerebral blood flow in the thalamus and the caudate nucleus are associated with low pain threshold levels." Arthritis Rheum 38: 926-938.

*** Nielson W. R., G. M. Grace, M. Hopkins and M. Berg. 1995. "Concentration and memory deficits in patients with fibromyalgia syndrome." J Musculoskel Pain 3(Suppl 1):123 (Abstract).

*** Ostensen M., A. Rugelsjoen and S. H. Wigers. 1997. "The effects of reproductive events and alterations of sex hormone levels on the symptoms of fibromyalgia." Scand J Rheumatol 26(5):355-360.

* Pellegrino M., G. W. Waylonis and A. Sommer. 1989. "Familial occurrence of primary fibromyalgia." Arch Phys Med Rehab 1989 70 (1):61-63.

*** Pillemer S. R., L. A. Bradley, L. J. Crofford, H. Moldofsky and G. P. Chrousos. 1997. "The neuroscience and endocrinolgy of fibromyalgia. Arth Rheum 40(11):1928-1939.

++ Potts M. K. and S. L. Silverman. 1990. "The importance of aspects of treatment for fibromyalgia (fibrositis). Differences between patient and physician views." Arth Care Res 3(1):11-18.

++ Powers R. 1993. "Fibromyalgia: an age-old malady begging for respect." J Gen Int Med 8(2):93-105.

+ Rivera J., A. De Diego, M. Trinchet and A. Garcia Monforte. 1997. "Fibromyalgia-associated hepatitis C virus infection." Br J Rheumatol 36(9):981-985.

*** Rosenhall U., G. Johannson and G. Omdahl. "Otoneurologic and audiologic findings in fibromyalgia." Scand J Rehabil Med 28 (4): 225-232.

*** --- 1987. "Eye motility dysfunction in chronic primary fibromyalgia with dysthesia". Scand J Rehabil Med 19 (4):139-145.

++ Schneider M. J. 1996. "Tender Points/fibromyalgia vs. trigger points/myofascial pain syndrome: a need for clarity in terminology and differential diagnosis." J Manip. Physiol Ther 18(6):398-406.

++ Scudds R. A., L. C. Traschel, B. J. Luckhurst and J. S. Percy. 1989. "A comparative study of pain, sleep quality and pain responsiveness in fibrositis and myofascial pain syndrome." J Rheumatol 16(Supp 19):120-126.

++ Scythe, H. 1992. "Links between fibromyalgia and myofascial pain syndromes." J Rheumatol 19 (6):842-843.

+ Simms R. W., C. A. Zerbini, N. Ferrante, J. Anthony, D. T. Felson and D. E. Craven. 1992. "Fibromyalgia syndrome in patients infected with human immunodeficiency virus. Boston City Hospital Clinical AIDS Team." Am J Med 92(4):368-374.

*** Simms R. W., and D. I. Goldenberg. 1988. "Symptoms mimicking neurologic disorders in fibromyalgia syndrome. J Rheumatol 15(8):1271-1273.

*** Smart P. A., G. W. Waylonis, K. V. Hackshaw. 1997. "Immunologic profile of patients with fibromyalgia." Am J Phys Med Rehabil 76(3):231-234.

++ Starlanyl D. J. 1997. " Fibromyalgia and Myofascial Pain Syndrome: A Special Challenge." Clin Bull Myofas Ther 2 (2/3): 75-89.

++ Starlanyl D. J. and M. E. Copeland. 1996. Fibromyalgia and Chronic Myofascial Pain Syndrome: A Survival Manual. Oakland: New Harbinger Publications.

*** Steinhart Stetvold H., T. C. Stiles and N. I. Landro. 1995. "Information processing in primary fibromyalgia, major depression, and healthy controls" J Rheumatol 22:137-142.

* Stormorken, H. and E. Brosstad. 1992. "Fibromyalgia: family clustering and sensory urgency with early onset indicate genetic predisposition and thus a "true" disease." Scand J Rheumatol 21 (4):207.

** Travell J. G. and D. G. Simons. 1992. Myofascial Pain and Dysfunction: The Trigger Point Manual Volume II: The Lower Body. Baltimore: Williams and Wilkins.

+ Trojan D. A and N. R. Cashman. 1995. "Fibromyalgia is common in a postpolio clinic." Arch Neuro 52(6):620-624.

(*+) Turk D. C., A. Okifuji, T. W. Starz and J. D. Sinclair. 1996. "Effects of type of symptom onset on psychological distress and disability in fibromyalgia syndrome patients." Pain 68(2-3):423-430.

++ Van Loon E. 1995. "Fibromyalgic (FMS) depression (DEPR): Surely it's all in her head?" J Musculoskel Pain 3(Suppl 1):141 (Abstract).

*** Wadsworth R., S. Kennedy, A. Bradlow, D. Barlow and J. David 1995. "Gynaecological symptoms in fibromyalgia." Brit J Rheumatol 34(9):888-889.

++ Walker E. A., W. J. Keegan, G. Gardner and M. Sullivan. 1997. "Predictors of physician frustration in the care of patients with rheumatological complaints." Gen Hosp Psychiatry 19(5):315-323.

*** Wallace D. J. 1990. "Genitourinary manifestations of fibrositis: and increased association with female urethral syndrome." J Rheumatol 17(2):238-239.

++ Westgaard R. H., C. Jensen, D. Bansevicius and O. Vasselein. 1995. "Differential surface EMG responses of the trapezius in fibromyalgia or myofascial pain." J Musculoskel Pain 3(Suppl 1):49(Abstract).

*** Wilke W. S. 1996. "Fibromyalgia. Recognizing and addressing the multiple interrelated factors." Postgrad Med 110(1):153-156, 159, 163-166.

*** ---1995. "Treatment of ‘resistant' fibromyalgia." Rheum Dis Clin N Am 21 (1):247-260.

*** Yunus, M. B. 1992. "Towards a model of pathophysiology of fibromyalgia: Aberrant central pain mechanisms with peripheral modulation." J Rheumatol 19:6:846-850.

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