Article on Treatment by Dr Bennett

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          * Local Pain

Although you are experiencing widespread body pain -- a manifestation of central sensitisation - you will also have multiple areas of tenderness in muscles - so called "myofascial trigger points". The severity of pain and the location of these "hot spots" typically varies from month to month, and the judicious use of myofascial trigger point injections and spray and stretch is worthwhile in selected patients. It is often worthwhile for your physician to identify the most symptomatic points for myofascial therapy. The steps involved in the injection of trigger points are:
1. Accurate identification of the trigger point.
2. Identification and elimination of aggravating factors.
3. The precise injection of the myofascial trigger points with 1% procaine (a local anaesthetic).
4. Passive stretching of the involved muscle after the local anaesthetic has taken effect; this is often aided by spraying the overlying skin with an ethyl chloride spray.

In most FM patients, this myofascial therapy needs to be repeated over a period of several weeks and occasionally over several months.
Unresponsiveness is usually due to failure to eliminate an aggravating factor, imprecise injection of the trigger point, or failure to inject satellite trigger points. Trigger points are usually injected with 3 to 5 ml of 1-% procaine. Please note that these are not “steroid shots.”  Performing “myofascial spray and stretch” often enhances the efficacy of trigger point injections immediately after the injections. Spray and stretch consists of an application of a vapocoolant spray, such as ethyl chloride over the muscle with simultaneous passive stretching. A fine stream of the spray is aimed toward the skin directly overlying the muscle with the active trigger point. A few sweeps of the spray are passed over the trigger point and the zone of reference. This is followed by a progressively increasing passive stretch of the muscle. Evaluation by an occupational and physical therapist often provides worthwhile advice on improved ergonomics, biomechanical imbalance and the formulation of a regular stretching program. Hands-on physical therapy treatment with heat modalities is reserved for major flares of pain, as there is no evidence that long-term therapy alters the course of the disorder. The same comments can be made for acupuncture, TENS units and various massage techniques.

Treatment of Sleep Disorders

Non-restorative sleep is a problem for most of you and contributes to your feelings of fatigue and seems to intensify experience of pain. Effective management involves:

1. Ensuring an adherence to the basic rules of sleep hygiene

2. Regular low grade exercise

3. Adequate treatment of associated psychological problems (depression, anxiety etc.)

4. The prescription of low dose tricyclic antidepressants (amitriptyline, Trazodone, doxepin (Sinequan), Imipramine etc. 


Some Fibromyalgia patients cannot tolerate TCAs due to unacceptable levels of daytime drowsiness or weight gain. In these patients, benzodiazepine-like medications such as Zolpidem are usually very useful. Some Fibromyalgia patients suffer from a primary sleep disorder, which requires specialised management. About 25% of male and 15% of female Fibromyalgia patients have sleep apnoea. Unless specific questions about this possibility are asked, sleep apnoea will often be missed. Patients with sleep apnoea usually require treatment with positive airway pressure (CPAP) or surgery. By far the commonest sleep disorder in Fibromyalgia patients is restless leg syndrome. This can be effectively treated with L-Dopa/carbidopa (Sinemet 10/100 mg at suppertime) or clonazepam (Rivotril).

Exercise for Fibromyalgia Patients

Fibromyalgia patients cannot afford not to exercise as deconditioned muscles are more prone to microtrauma and inactivity begets dysfunctional behavioural problems. However, musculoskeletal pain and severe fatigue are powerful conditioners for inactivity. All Fibromyalgia patients need to have a home program with muscle stretching and gentle strengthening, and aerobic conditioning.  There are several points that need to be stressed about exercise in FM patients:

1. Exercise is health training, not sport’s training

2. Exercise should be non-impact loading

3. Aerobic exercise should be done for 30 minutes each day. This may be broken down into three 10 minute periods or other combinations, such as two 15 minute periods, to give a cumulative total of 30 minutes. This should be the aim - it may take 6-12 months to achieve this level

4. Strength training should emphasise on concentric work and avoid eccentric muscle contractions. 5. Regular exercise needs to become part of the usual lifestyle; it is not merely a 3-6 month program to restore them to health. Suitable aerobic exercise includes: regular walking, the use of a stationery exercycle or Nordic track (initially not using the arm component). Patients who are very deconditioned or incapacitated should be started with water therapy using a buoyancy belt (Aqua-jogger). 

Recognition and treatment of psychological distress

As you suffer from chronic pain there is a distinct possibility that you may develop secondary psychological disturbances, such as depression, anger, fear, withdrawal and anxiety. When “an event” is associated with the onset of the Fibromyalgia you may adopt the role of a "victim". Sometimes these secondary reactions become the "major problem" for some patients. The prompt diagnosis and treatment of these secondary features is essential to effective overall management of Fibromyalgia patients. Some Fibromyalgia patients develop a reduced functional ability and have difficulty being competitively employed. In such cases your doctor will hopefully act as an advocate in sanctioning a reduced or modified load at work and at home.  Unless you have a severe psychiatric illness (e.g. major depressive illness or a psychosis), referral to psychiatrists is usually non-productive. Psychological counselling, particularly the use of techniques such as cognitive restructuring and biofeedback, may benefit some patients who are having difficulties coping with the realities of living with their pain and associated problems.

Fibromyalgia associated syndromes

It is not unusual for Fibromyalgia patients to have an array of bodily complaints other than musculoskeletal pain. It is now thought that these symptoms are a result of the abnormal sensory processing – as described in the previous section. Recognition and treatment of these associated problems are important in the overall management of your Fibromyalgia. These include:
 - Non-restorative sleep
 - Cognitive dysfunction
 - Chronic fatigue
 - Cold intolerance
 - Restless Leg Syndrome
 - Multiple Sensitivities
 - Irritable Bowel Syndrome
 - Dizziness
 - Irritable bladder syndrome
 - Neurally Mediated Hypotension

Source: © Robert Bennett M.D., FRCP.
Edited for UK audience by R. Wright, BSc (Hons)

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