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Home , Chronic pain, Myalgia, Myofascial pain syndrome

Annals ofthe Rheumatic 1996; 55: 497-501 497

REVIEW: Series editor: Bruce L Kidd Ann Rheum Dis: first published as 10.1136/ard.55.8.497 on 1 August 1996. Downloaded from syndromes

Simon Carette

Chronic pain has traditionally been defined as with widespread pain and tender points.3 This pain lasting more than three to six months. growing interest in studying in Many conditions in can produce recent years is reflected by the number ofindex chronic pain. These include diseases such as entries extracted from Index Medicus, which rheumatoid and osteoarthritis. Pain in have increased from 37 in 1974 to more than these conditions can usually be attributed to 500 since 1990. specific pathological mechanisms such as By contrast with the other chronic pain syn- inflammatory synovitis or joint destruction. dromes related to the musculoskeletal system, Effective treatment modalities are available to fibromyalgia is the only one for which validated relieve some, if not most, of the pain in these classification criteria have been proposed.4 situations. Thus, a patient with widespread pain as defined Over the past two decades or so, more by pain affecting the axis and the right and left attention has been given to previously existing sides of the body, above and below the waist, conditions, now redefined as syndromes, that and in whom can be shown on produce chronic musculoskeletal pain but in digital palpation of at least 1 1 of 18 pre- which the underlying pathophysiological determined sites can be classified as having mechanisms responsible for the pain have not fibromyalgia. Based on these criteria, 3 4% of been elucidated. These conditions have been women and 0 5% of men in the general arbitrarily divided into those causing diffuse population ofWichita, KS, USA were found to versus regional pain. Fibromyalgia is by far the be affected.5 The prevalence increased with most common chronic diffuse musculoskeletal age, with highest values attained between 60 pain syndrome seen by rheumatologists. Myo- and 79 years. Seventy six per cent of affected fascial pain syndromes (MPS) and repetitive patients had seen a in the preceding syndromes (RSS) represent examples of six months; two thirds took some form of pain chronic regional pain syndromes. These diffuse medication and 19-7% had applied for, and and regional pain syndromes have many 7-3% had received, disability benefits. Fibro- features in common including the absence of accounts for as many as 20% to 25% http://ard.bmj.com/ an identifiable organic cause, behavioural of new referrals to rheumatologists, ranking maladaptations to pain, and much overlap in second after osteoarthritis.6 symptoms and signs (table). The purpose of The aetiology of fibromyalgia is basically this article is to review some of the recent unknown. The finding that it occurs at least 10 concepts and controversies related to these times more often in women than men is still three syndromes. unexplained.7 No genetic predisposition has been documented.8 Whereas it has been on September 27, 2021 by guest. Protected copyright. suggested that fibromyalgia may in some cases Fibromyalgia arise after trauma, surgery, or a medical illness, The syndrome that we now call fibromyalgia such associations do not prove causality.9 has been known for a long time. The asso- Despite intensive research, the pathogenesis ciation of diffuse musculoskeletal pain, sleep is not understood.'0 No specific abnormalities disturbances, and exhaustion can be traced to have been found in the tender muscles of biblical times.' Various names have been used patients with fibromyalgia by light microscopy, over the centuries to describe this association histochemistry, or electron microscopy." The of symptoms as new explanations for their possibility that fibromyalgia could result from cause were proposed.2 A renewed interest in defects in muscle energy metabolism was this condition followed the description by suggested by studies in which local hypoxia'2 Moldofsky and Smythe of distinct electro- and reduced high energy phosphate concen- encephalographic sleep anomalies in patients trations were demonstrated at sites of muscle tenderness.'3 A recent study with phosphorus Department of magnetic resonance spectroscopy reinforced Medicine, Laval Comparison offibromyalgia (FM), myofascialpain University, Ste-Foy, syndrome (MPS), and repetitive strain syndrome (RSS) this hypothesis by documenting a higher rate Quebec, of phosphodiester resonance among the S Carette Vaiable FM MPS RSS patients with fibromyalgia than among healthy Correspondence to: Pain Diffuse Regional Regional subjects.'4 However, another study using the Dr S Carette, Physical Tender points Trigger points Tender points Centre Hospitalier de examination same technique showed no difference in any of l'Universite Laval, 2705 +++ ++ ++ the measures of muscle energy metabolism in Boulevard Laurier, Ste-Foy, Sleep disturbance +++ ++ ++ PQ, Canada G1V 4G2. Psychological +++ ++ ++ patients with fibromyalgia compared with distress controls carefully matched for their level of Accepted for publication Unknown Unknown 28 December 1995 Pathophysiology Unknown aerobic fitness.'5 498 Carette

The role of disturbed sleep in the aetiology unconditional believers in the specificity of the or perpetuation of symptoms of fibromyalgia condition.3" Using modifications of previously has been studied extensively in the past 20 published criteria, fibromyalgia was found in Ann Rheum Dis: first published as 10.1136/ard.55.8.497 on 1 August 1996. Downloaded from years.'6 The documentation of ao wave in- only 0.75% of the Finish population.36 In this trusion into stages 3 and 4 of the non-rapid eye study, fibromyalgia was associated with a high movement sleep (NREM) was initially thought risk ofmental disorder and all subjects fulfilling to be specific for the syndrome especially after the criteria for fibromyalgia also fulfilled the symptoms of fibromyalgia were reproduced criteria for at least one other musculoskeletal experimentally in healthy sedentary volunteers disorder. This led the authors to conclude that with artificial sleep manipulation.'7 However, there was little epidemiological support for the recent studies have shown that these electro- concept of fibromyalgia as being a distinct encephalographic sleep anomalies lack both disorder. The specificity of tender points has sensitivity'8 and specificity.'9-20 also been questioned.37 In a cross sectional Several investigators have suggested the study conducted in two general practices in possibility that neuroendocrine abnormalities north west England, 40% of patients with such as a deficiency in serotonin23-25 and chronic widespread pain had tender point hyothalamic-pituitary axis perturbations26 27 counts of 11 or more. However, 19% of could be implicated in the syndrome. These patients with regional pain and 5% with no findings need to be confirmed in studies using pain also had as many tender points. Whereas controls matched for pain and sleep the presence of tender points was related to disturbances rather than normal subjects. So complaints of pain, they were also indepen- far, two studies have shown higher concen- dently associated with , fatigue, and trations of in the cerebrospinal poor sleep, suggesting that tender points are a fluid of patients with fibromyalgia than in measure ofgeneral distress rather than markers normal controls.28 29 However, the significance of a distinct entity. of this potentially interesting finding was At this time, I think that recognising the dampened when an inverse relation was found physical and psychological of patients between the substance P concentrations and with these symptoms is really what matters, the severity of pain which was the opposite of whether we call their condition "fibromyalgia" that expected if substance P was a key factor or "chronic diffuse pain syndrome". So far, all in the pathophysiology of the syndrome.29 reports from tertiary referral centres that have It is well accepted that pain perception can looked at the prognosis of these patients be influenced by multiple factors including indicate that symptoms and signs tend to past experiences, culture, personality, and a persist with time in the vast majority.38-4' The host of psychosocial factors. Patients with outcome in patients from community based fibromyalgia and their family members have practices may be better.42 Tricyclic agents43-47 been shown to have had a greater history of and aerobic exercises48 49 are the therapeutic depression.30 One recent study showed that modalities that have been most extensively http://ard.bmj.com/ previous sexual abuse, physical abuse, and studied. Both produce short term benefit in a drug abuse were higher in patients with fibro- small percentage of patients. By contrast, non- myalgia compared with control patients with steroidal anti-inflammatory drugs44 50 and rheumatic disease.3' These findings are in corticosteroids5' are ineffective. Behaviour contrast with another study in which the preva- modification approaches have a lot of appeal as lence and type of sexual abuse were not differ- their primary objective is to de-emphasise the ent between women with fibromyalgia and pain focus in favour of active patient partici- community controls.33 However, the abused pation towards increased function and return on September 27, 2021 by guest. Protected copyright. patients with fibromyalgia reported signifi- to full, unrestricted work and play.52 53 How- cantly more symptoms than did the non- ever, their efficacy has yet to be evaluated in sexually abused women. Although these randomised controlled trials. studies have been criticised because of the biases inherent in retrospective studies,33 they represent a step in the right direction because Myofascial pain syndromes they consider the crucial issues of better Even less is known about myofascial pain defining the psychological background of those syndromes than about fibromyalgia. This de- who develop these puzzling symptoms. nomination was introduced by Travell in the Because of the non-specific nature of the 1950s to describe regional pain syndromes, symptoms reported by the patients and the often of sudden onset, characterised by the failure of research efforts to define specific presence of trigger points. These points are disease markers, it is not surprising that signifi- defined as tender areas deep within the muscle cant controversy still surrounds the existence belly which, when palpated, result in referred of fibromyalgia as a distinct syndrome. The pain that reproduce the patient's pain absence of diagnostic tests, serological and complaint.54 The does not follow radiological signs, and truly objective physical simple segmental patterns and is not signs led Dudley Hart to suggest that fibro- necessarily situated in the same dermatome, myalgia is a "common non-entity".34 Cohen myotome, or sclerotome as that of the trigger and Quintner criticised the American College point. Specific patterns of pain referral have of Rheumatology criteria described previously been described for all muscles of the body.55 on the basis that they were derived via a It is thought that many regional pain circular argument in which the gold standard conditions, including subsets of low back and was the opinion of experts known to be cervical disorders, tension , and Chronic pain syndromes 499

temporomandibular joint syndrome represent Various hypotheses have been postulated but myofascial pain syndomes. none has been adequately tested. No controlled

Trigger points are said to be located within studies of histological findings using clear case Ann Rheum Dis: first published as 10.1136/ard.55.8.497 on 1 August 1996. Downloaded from taut bands of muscle fibres. These represent definitions has been reported. Studies evalu- tense muscle fibres, ranging from a few milli- ating the electromyographic activity of trigger metres to a centimetre in width, that are found points have yielded conflicting results58 59 and by palpation along the longitudinal axis of the so have studies looking at the clinical usefulness muscle among the normally slackened fibres.55 of thermography for the documentation of A transient muscle contraction, the local twitch trigger points.60 61 response, can be induced by rolling the trigger The psychosocial factors associated with the point under the fingers.55 Trigger points have development and perpetuation of myofascial been described as being either active or latent. pain have received little attention. High levels An active trigger point, when palpated, results of psychological distress have been docu- in pain in the trigger point's reference zone mented in patients with myofascial pain syn- which reproduces the pain that is a problem to drome.62 In a recent study, patients with low the patient whereas a latent point is tender considered to be of myofascial origin locally and may reproduce referred pain that is had higher levels of somatisation and phobia different from the patient's complaint. The than patients with herniated disc syndrome.63 distinction between trigger and tender points is The best way to manage patients with a currently the source of much debate. remains contro- One ofthe main problems to plague research versial. The removal of factors susceptible to over the years in this field has been the absence "activate" trigger points such as sudden over- of agreement on a uniform definition of myo- loading and repetitive motion has been rec- fascial pain and trigger points. In an important ommended as an essential component of man- study, experts on myofascial pain and fibro- agement. The "stretch and spray" technique myalgia examined 23 subjects, including seven popularised by Travell and her colleagues, patients with fibromyalgia, eight patients with which consists of passively stretching the myofascial pain, and eight healthy subjects, affected muscle fibres after applying a vapo- while blinded to diagnosis.56 For the purpose coolant spray, has been claimed to be the most of this study, an active trigger point included effective treatment modality.55 Unfortunately, the following characteristics: local muscle this approach has not been evaluated in con- tenderness, taut band, twitch response, and trolled trials. Local injection of trigger points referred pain that reproduced the patient's with either local anaesthetics or complaint. A latent trigger point had similar have also been claimed to be effective. One characteristics except that the zone of refer- controlled trial suggested that local anaesthetics ence, when present, did not correspond to the were better than dry needling.64 A double blind pain that was a problem to the patient. crossover trial showed no beneficial effect oflow Important questions concerning the validity of level laser treatment in the management of the trigger point definition were raised by this myofascial pain.65 http://ard.bmj.com/ study. Thus latent trigger points occurred in Until more controlled studies are conducted less than 3% of patients with myofascial pain. to better define myofascial pain and establish Taut bands and twitch responses, which are the validity and reliability of the trigger point usual requirements for the diagnosis of trigger examination, the interpretation of the medical points, were found in equal proportions among literature will be extremely difficult and contro- patients with myofascial pain, patients with versy surrounding this diagnosis and its treat- fibromyalgia, and healthy controls. Whereas ment will remain. on September 27, 2021 by guest. Protected copyright. active trigger points were found in only 1P3% of the muscle sites examined from healthy subjects, they occurred in an equal proportion Repetitive strain syndromes of muscles from patients with myofascial pain Much has been written about "repetitive strain (17*3%) and fibromyalgia (17*2%). When the syndromes" and the controversy that this entity requirement for the presence oftaut bands and generated, particularly in Australia where it twitch response was eliminated from the reached an epidemic proportion during the definition of an active trigger point, the preva- 1 980s.6"9 This syndrome, also known as lence of trigger points increased to 38% in the "repetitive strain " (RSI), "occupational patients with fibromyalgia and to only 23% in overuse syndrome", and in the , the patients with myofascial pain. The as "cumulative trauma disorder", defines a reliability of some aspects of the trigger point non-specific regional pain syndrome that examination was also questioned because the develops in the context of work, in the absence experts differed significantly in their ability to of identifiable disease of the muscle-tendon- identify taut bands and muscle twitches. In bone unit.70 Typically, the pain starts in the another study, different physical therapists wrist and forearm area and spreads within days were also unable to reliably determine the to weeks to the arm, shoulder girdle, and neck presence of trigger points in patients with low regions.7" Those with the syndrome complain back pain.57 The findings from these studies of poor sleep, score higher than controls on cast significant doubts about the concept of questionnaires evaluating and de- myofascial pain syndromes as currently pression, and show pronounced disease con- defined. viction.72 Physical examination typically dis- As is the case for fibromyalgia, the patho- closes areas of muscle tenderness, often in the genesis of myofascial pain is not known. same sites as described in fibromyalgia. Pain 500 Carette

can be elicited by stressing the wrist, hand, and syndromes and hopefully provide better ways elbow joint capsules but there is no evidence to prevent them.

of underlying synovitis. Grip strength is Ann Rheum Dis: first published as 10.1136/ard.55.8.497 on 1 August 1996. Downloaded from Many thansk to Dr E Anne Langlois for her critical review of typically decreased despite a normal neuro- the manuscript. logical examination. Skin rolling tenderness is often present over the upper tarpezius region. Some patients eventually develop a chronic 1 Smythe H A. Fibrositis syndrome: a historical perspective. widespread pain syndrome that satisfies the J Rheumatol 1989; 19 (suppl): 1-6. 2 Reynolds M D. The development of the concept of classification criteria for fibromyalgia. fibrositis. J Hist MedAllied Sci 1983; 38: 5-35. Whether or not this syndrome can be 3 Moldofsky H, Scarisbrick P, England R, Smythe H. Musculoskeletal symptoms and non-REM sleep causally related to particular work practices has disturbance in patients with "fibrositis syndrome" and been at the centre of controversy.65-69 Although healthy subjects. Psychosom Med 1975; 37: 341-51. 4 Wolfe F, Smythe H A, Yunus M B, et al. The American no one will deny that symptoms of arm pain College of Rheumatology 1990 criteria for the classifi- and fatigue can develop in the context of work, cation offibromyalgia. Arthritis Rheum 1990; 33: 19-31. 5 Wolfe F, Ross K, Anderson J, Russell I J, Hebert L. The there is no scientific evidence that repetitive prevalence and characteristics of fibromyalgia in the movements can cause the symptoms of repeti- general population. Arthritis Rheum 1995; 38: 19-28. 6 White K P, Speechley M, Harth M, Ostbye T. Fibromyalgia tive strain injury. The significant difference in in rheumatology practice: a survey of Canadian the prevalence of reported cases of repetitive rheumatologists. J Rheumatol 1995; 22: 722-6. strain in 7 Carette S, Dessureault M, Belanger A. Fibromyalgia and injury employees doing the same type sex hormones [letter]. J Rheumatol 1992; 19: 831. ofwork and with the same equipment, suggests 8 Horven S, Stiles T C, Holst A, Moen T. HLA antigens in primary fibromyalgia syndrome. Jf Rheumatol 1992; 19: that psychosocial variables are far more 1269-70. important than specific work activities in the 9 Greenfield S, Fitzcharles M A, Esdaile J M. Reactive fibromyalgia syndrome. Arthritis Rheum 1992; 35: expression of the syndrome.73 The Australian 678-81. epidemic has taught the world how miscon- 10 Carette S. Fibromyalgia 20 years later. what have we really accomplished? Rheumatol 1995; 22: 590-4. ceptions reinforced by the medical profession, 11 Yanus M B, Kalyan-Raman U P, Masi A T, Aldag J C. unions, public, and the worker's compensation Electron microscopic studies of muscle biopsy in primary fibromyalgia syndrome: a controlled and blinded study. system have succeeded in transforming an J'Rheumatol 1989; 16: 97-101. essentially benign condition into a major public 12 Lund N, Bengtsson A, Thorborg P. Muscle tissue oxygen pressure in primary fibromyalgia. Scand J Rheumatol health problem.74 While the court decisions 1986; 15: 165-73. made in Australia and the United Kingdom75 13 Bengtsson A, Henriksson K G, Larsson J. Reduced high- have an to energy phosphate levels in the painful muscles ofpatients put end the epidemics of repetitive with primary fibromyalgia. Arthritis Rheum 1986; 29: strain injury, this obviously does not mean that 817-21. 14 Jubrias S A, Bennett R M, Klug G A. Increased incidence chronic pain syndromes developing in the of a resonance in the phosphodiester region of P nuclear workplace have disappeared. However, by de- magnetic resonance spectra in the of fibromyalgia patients. Arthritis Rheum 1994; 37: 801-7. emphasising the role of work or specific move- 15 Simms R W, Roy S H, Hrovat M, et al. Lack of association ments in causing these symptoms, the real between fibromyalgia syndrome and abnormalities in muscle energy metabolism. Arthritis Rheum 1994; 37: issues of causation and prevention can now be 794-800. considered. 16 Moldofsky H. Sleep and fibrositis syndrome. Rheum Dis Clin North Am 1989; 15: 91-103. http://ard.bmj.com/ 17 Moldofsky H, Scarisbrick P. Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. Psychosom Med 1976; 38: 35-44. Conclusion 18 Carette S, Oakson G, Guimont C, Steriade M. Sleep Whether we are dealing with a patient with and the clinical response to or amitriptyline in patients with fibromyalgia. Arthritis fibromyalgia with an individual with a Rheum 1995; 38: 1211-7. chronic regional pain syndrome that has de- 19 Moldofsky H, Lue F A, Saskin P. Sleep and morning pain veloped isidiously or in the context of work or in primary osteoarthritis. J Rheumatol 1987; 14: 124-8.

20 Hirsch M, Carlander B, Verge M, et al. Objective and on September 27, 2021 by guest. Protected copyright. trauma, an important and currently un- subjective sleep disturbances in patients with . A reappraisal. Arthritis Rheum 1994; 37: 41-9. resolved issue is to determine which personal 21 Leventhal L, Freundlich B, Lewis J, Gillen K, Henry J, and environmental factors may have led the Dinges D. Controlled study of alpha-NREM sleep in patients with fibromyalgia [abstract]. Arthritis Rheum patient to develop a chronic pain syndrome. 1992; 35 (suppl 5): R9. This aspect of the clinical approach, 22 Scheuler W, Kubicki S, Marquardt J, et al. The alpha-sleep pattern: quantitative analysis and functional aspects. In: unfortunately, is often neglected. Perhaps this Koella W P, Obal F, Schultz H, Visser P, eds. Sleep '86 is due to the fact that too little attention has Stutgart: Fischer, 1988. 23 Yanus M B, Dailey J W, Aldag J C, Masi A T, Jobe P C. been devoted by researchers to elucidate the Plasma tryptophan and other amino acids in primary risk factors associated with the development of fibromyalgia - a controlled study. J Rheumatol 1992; 18: 90-4. these syndromes. The emphasis in the past 20 24 Russell I J, Vaeroy H, Javors M, Nyberg F. Cerebrospinal years, particularly concerning fibromyalgia, fluid biogenic amine metabolites in fibromyalgia/fibrositis syndrome and rheumatoid arthritis. Arthritis Rheum 1992; has been to search for biological markers ofthe 35: 550-6. condition.10 This approach may have done 25 Russell I J, Michalek J E, Vipraio G A, Fletcher E M, Javors M A, Bowden C A. Platelet H- uptake more harm than good by implying to the receptor density and serum serotonin levels in patients patient that they must wait and hope for a cure with fibromyalgia/fibrositis syndrome. J Rheumatol 1992; 19: 104-9. through medical science. The future of 26 Bennett R M, Clark S R, Campbell S M, Burckhardt C S. research in chronic pain syndromes must con- Low levels of somatomedin C in patients with the fibromyalgia syndrome - a possible link between sleep and sider more thoroughly the psychological muscle pain. Arthritis Rheum 1992; 35: 1113-6. factors involved in the development of these 27 Crofford L J, Pilemer S R, Kalogeras K T, et al. Hypothalamic-pituitary-adrenal axis perturbations in conditions. Case-control studies, or preferably patients with fibromyalgia. Arthritis Rheum 1994; 37: longitudinal studies, looking specifically at 1583-92. 28 Vaeroy H, Helle R, Forre 0, Kass E, Terenius L. Elevated previous traumatic experiences, psychiatric CSF levels of substance P and high incidence of history, job satisfaction, family stress, and Raynaud's phenomenon in patients with fibromyalgia: new features for diagnosis. Pain 1988; 32: 21-6. financial constraints, to name a few, will help 29 Russell I J, Orr M D, Littman B, et al. Elevated cerebro- advance our understanding of these spinal fluid levels of substance P in patients with the Chronic pain syndromes 501

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