Fibromyalgia Syndrome

FMS is not new. It was first described by William Balfour, a surgeon at the University of Edinburgh, in 1816. The medical profession called it many different names, including chronic rheumatism, myalgia, pressure point syndrome, and fibrositis. The condition was also thought to be psychological by some physicians, but that notion must now be relegated to the Dark Ages of medicine.

General Background

In 1987, the American Medical Association (AMA), recognized FMS as a true illness and a major cause of disability. Now, nearly ten years later, it is still ,unfortunately, too often dismissed as the "newest fad disease", and most physicians still lack the training to diagnose and treat it.

FMS is not a catchall, "wastebasket" diagnosis. FMS is a specific, chronic non-degenerative, non-progressive, noninflammatory, truly systemic pain condition. Diseases have known causes and well-understood mechanisms for producing symptoms. FMS is called a syndrome, which means it is a specific set of signs and symptoms that occur together. Don't let this fool you into thinking that fibromyalgia is any less serious or potentially disabling than a disease. Rheumatoid arthritis, lupus, and other serious afflictions are also classified as syndromes. Lab tests for fibromyalgia are valid only to rule out other conditions. There is no blood test that can accurately identify fibromyalgia.

The official definition for patients to be admitted into clinical study requires that tender points must be present in all four quadrants of the body -- that is, the upper right and left and lower right and left parts of your body. You must have had widespread, more-or-less continuous pain for at least three months. Because tender points can fluctuate and vary from day to day. Tender points occur in pairs on various parts of the body. Because they occur in pairs, the pain is usually distributed equally on both sides of the body. In traumatic FMS, tender points are often clustered around an injury instead of, or in addition to, the 18 "official" points. These clusters can also occur around a repetitive strain or a degenerative and/or inflammatory problem, such as arthritis. Localized pain usually indicates a co-existing condition, such as myofascial pain syndrome (MPS).

FMS can occur at any age. Most patients, when questioned carefully, reveal that their symptoms began at an early age. About 25 percent of the FMS patients I see are men. This ratio differs from most sources in the literature. I think that this is due to FMS being underdiagnosed in males. Flu-like achiness is frequently the most prominent symptom of FMS, but there are many others. For example, your eyes may be too dry, but at other times they will water. Your thermal regulatory system is out of whack. You may notice this thermal fluctuation when you get out of bed (which may be often, due to bladder irritability) during the night. You may have to wait for your temperature to cool down after getting back in bed before you can pull the bedcover up. Another symptom of FMS is spasticity (tightness) which can constrict the peripheral blood vessels -- those close to the skin. This symptom, especially in the winter, makes certain parts of our bodies -- most often the buttocks and thighs -- feel like cold slabs of meat. You may experience skin mottling, and nail ridges Fingernails can break off, often in crescent-shaped pieces. If nails do grow, they sometimes start to curve under.

FMS is a sensitivity-amplification syndrome. This means that people with Fibromyalgia can be sensitive to smells, sounds, lights, odors, pressure and temperature fluctuations and vibrations. The noise emitted by fluorescent lights can drive you crazy. FMS sensitizes nerve endings as well as the rest of the autonomic nervous system, which means that the ends of the nerve receptors may have changed shape. Because of this, for example, your body might interpret touch, light, or sound as pain. Your brain knows pain is a danger signal -- an indication that something is wrong and needs attention -- so it mobilizes its defenses. Then, when those defenses aren't used, you become anxious.

Sleep plays a crucial role in FMS. Perhaps you aren't getting enough sleep, or the right kind of sleep. You may have insomnia, or a host of other sleep-related problems. People with FMS often have the alpha-delta sleep anomaly. As soon as we reach deep delta level sleep, alpha waves (awake) intrude and either jolt us to an awakening or to a lighter stage of sleep. Our body heals and many neurotransmitters are restored during delta sleep, so we soon suffer from the effects of sleep deprivation. Neurotransmitters are electro-biochemical agents that cross nerve synapses. They are the vehicles that carry information back and forth between your body and mind. One might say that neurotransmitters are the "information superhighway" between the body and mind.

Much of our mental and physical sense of continuity and security depends upon our ability to repeat appropriate and predictable actions. This is disrupted in FMS. Neurotransmitters normally inform muscles constantly about what they're doing, so their actions can be modified. Much of our muscle tension function is improperly controlled by these neurotransmitters. Healthy people think nothing of picking up a glass of water and bringing it to their lips. They know just how tightly their hand has to grip, how heavy the glass of water feels, and how much speed is appropriate to accomplish this act smoothly. people with Fibromyalgia, however, lack proper sensory feedback. The thumb grasps with too little pressure, and the wrist muscle lets go when flexed. The economy of effort is not there. To enable us to sit , walk, and stand, the entire musculature must be able to feel its own activity, and we often can't do that.

Only about 20% of FMS cases have a known triggering event that initiates the first obvious "flare." During a flare, current symptoms become more intense, and new symptoms frequently develop.

Myofascia

Myofascial pain is probably the most common cause of musculoskeletal pain in medical practice (Imamura, Fischer, Imamura et al.1997). It is a vital factor in the practice of internists, in physical medicine and rehabilitation, internal medicine, gynecology, rheumatology, neurology, pediatrics, gastroenterology, proctology, cardiology, and just about any other specialty you can think of. Pain from myofascial dysfunction is probably at the source of many of your symptoms. So why is there so little common knowledge about the myofascia?

Fascial and facial are similar words with two different meanings, although you do have fascia under your face In the United States, the word "fascia" is usually pronounced "fashia", similar to "fashion". In other English-speaking countries, the word is often pronounced "fassia". Many doctors prefer to avoid mentioning the word entirely. Most doctors don’t know a lot about the workings of the myofascia. One way doctors learn about anatomy is through cadaver dissection. Dead, embalmed fascia has little in common with living fascia. The magic is gone.

A small change in the myofascia can cause great stress to other parts of your body. Restriction of one major joint in a lower extremity can increase the energy expenditure of normal walking by as much as 40%, and, if two major joints are restricted in the same extremity, it can increase by as much as 300% (Greenmar, 1996). Multiple minor restrictions of movement, particularly in the maintenance of normal gait, can also have a detrimental effect upon total body function

In "Principles of Manual Medicine" (Greenman, 1996), the author finds it convenient to separate fascia into three layers, but remember as you read this that it is all continuous and three dimensional. Superficial fascia is attached to the underside of your skin. Capillary channels and lymph vessels run through this layer, and so do many nerves. The subcutaneous fat is attached to it. If your superficial fascia is healthy, your skin can move fluidly over the surface of your muscles. In FMS and CMP, it is often stuck. In the superficial fascia, there is a great potential to store excess fluid and metabolites, which are the breakdown products of informational substances and other chemicals in your body. This is the area of fascia that often is the easiest to palpate. Palpation is the art and skill of being able to touch meaningfully, interpreting what the skin and fascia are willing to tell about your state of health.

Deep fascia is much tougher and denser material. Your body uses deep fascia to separate large sections, such as the abdominal cavity. Deep fascia covers some areas like huge sheets, protecting them and giving them shape. Deep fascia also separates your muscles and organs. The bag-like covering around your heart (the pericardium), the lining of your chest cavity the pleura), and the area between your external genital and your anus (the perineum) are all made up of specialized deep fascia.

There is a third layer of fascia, called sub serous fascia. This is loose tissue that covers your internal organs and holds the rich network of blood and lymph vessels that keep them moist. Even your cells have a type of cytoskeleton connected to fascia network, which is what gives your cells shape and allows them to function. Myofascia is fascia that is related to muscle tissue. Healthy myofascia allows for compression and tension, as well as relaxation.

The dural tube is another fascial connection. This is the tube surrounding and protects your spinal cord, and it contains the cerebrospinal fluid. This tube is connected to the membranes surrounding your brain. Together, they hold and protect your craniosacral system.

Fascia is also the material that forms adhesions and scar tissue. When you are healthy, your ground substance has a gelatinous consistency so that it can absorb the forces that are created when you move, or if you are involved in trauma. When the ground substance hardens, it’s as if glue or cement has been poured into our fascial spaces (Barnes, 1990). When this happens, it isn’t enough for a therapist to break up cross-links. They need to return your ground substance to its healthy, more fluid state.

In the myofascia there is a material called ground substance. The ground substance part of the fascia can be like a loose gelatin, or like gel-foam medical packing, or like sprayed on Styrofoam insulation. It can harden and lose its elasticity. When ground substance changes from a liquid to a gel, and then into its more solid form, the myofascia tightens. It won’t reverse to its previous more liquid state without outside intervention. One of the main jobs of the ground substance is transferring nutrients from where they are broken down into usable materials to their place where they will be used, and to remove the waste products from these areas of use. This exchange and transport through diffusion takes part in the ground substance.

Another important job for your ground substance is to maintain the distance between connective tissue fibers. This prevents microadhesions from forming, and keeps your tissues supple and elastic. When the critical distance is not maintained, the fibers become cross-linked by newly synthesized collagen, which are also part of the fascia. Collagen crosslinks are arranged haphazardly, unlike healthy linkages, and are hard to break up.

Sheets of fibrous myofascial adhesion can form anywhere along nerves and block normal healthy function. Too often, fascia has been considered by the medical world as merely packing material, simply a connective tissue between areas of function. The mobility, elasticity, and slipperiness of living fascia can never be appreciated by dissecting embalmed cadavers in medical school (Leahy and Mock 1992).

Where muscles and tendons, bones and ligaments come together, there are areas of attachment. The cellular membranes in these attachment areas can become extremely convoluted, which increases the surface area and changes the angle of force. This increases the potential for things to get stuck together , and causes the tissue there to become more easily torn (Simons, Travell and Simons, 1999).

Myofascial Trigger Points

Trigger Points (TrPs) are found as extremely sore points occurring in ropy bands throughout the body. They can also be felt as painful lumps of hardened fascia. The bands are often easier to feel along the arms and legs. If you stretch your muscle about 2/3 of the way out, you might be able to feel them. Sometimes the muscles get so tight that you can't feel the lumps, or even the tight bands. Your muscle feels like "hardened concrete". TrPs can occur in the myofascia, skin, ligaments, bone lining, and other tissues. They can be caused by a surgical incision, as is often the case with abdominal surgery. You have probably never heard of TrPs, yet they are quite common. Each specific TrP on the body has a referred pain or other symptom pattern that is carefully documented in the Trigger Point Manuals.

The first time I opened the Trigger Point Manuals ("Myofascial Pain and Dysfunction: The Trigger Point Manual Vol I & II" by Janet Travell M.D. and David Simons M.D.), I was dumbfounded. After being told for so many years by medical experts that the pain patterns I described did not and could not exist, seeing them illustrated in a medical text brought a flood of emotions. I felt so relieved I cried. I felt validated. Then, as the truth started to hit home, I started to get angry. Why didn't these "experts" have knowledge of Travell and Simons' work? Why hadn't I learned about these texts in medical school! Most specific pains commonly attributed to FMS are actually from trigger points. TrPs seem to form throughout life as a response to many things that happen to our bodies. Overuse, repetitive motion trauma, bruises, strains, joint problems, etc. Pain creates a neuromuscular response, and the muscle around the pain site tightens, "guarding" the hurt area.

When muscles are in a state of sustained tension, they are working, even if you're not. A working muscle needs more nutrition and oxygen, and produces more waste, than a muscle at rest. This creates an area in the myofascia starved for food and oxygen, and loaded with toxic waste -- a trigger point.

Dr. Janet Travell, in her autobiography, "Office Hours Day and Night" explains how dizziness, ringing of the ears, loss of balance, and other symptoms can all be caused by TrPs in the side of the neck, in the muscle group called the sternocleidomastoid (SCM) complex. This muscle has many functions, one of which is to hold your head up. Receptors in the SCM complex transmit nerve impulses inform the brain of the position of the head and body in the surrounding space. With TrPs, the receptors lies. What they tell the brain is not what the eyes tell the brain. If there are TrPs in the muscles of the the eyes, they are lying too -- only probably not in the same way as the SCM. When head movement changes the SCM message -- when you turn, or look up from changing kitty litter, you get dizzy. This, coupled with poor balance, can make it seem that the walls are tilting. When we take corners while driving, we get the impression that we're "banking" the turn at a steep angle, as if we're on a motorcycle. Cold drafts alone can bring on neck TrPs. And be careful how you move in bed. When you turn, roll with your head flat, and use your arms to help. Don't lift your head and "lead with it" as you roll. That puts a great strain on the neck area and electrically "loads" the SCM TrPs, just as climbing steps or walking uphill "loads" the muscles of the thighs. This means that the electrical potential of the muscles are changed, and the change is not to our benefit. A common symptom of SCM TrPs is a "drunken" walk, as we bump into doorways and walls. An active TrP not only hurts when it is pressed, like an FMS tender point, but it "triggers" a referred pain pattern somewhere else in the body. This pain pattern is similar from patient to patient. These trigger points often produce other symptoms, also usually in the referred pain zone. Such a TrP hurts whenever you use the involved muscle. When the point becomes very active, pain and other symptoms occur even when the muscle is at rest. The fact that these pain patterns are very much similar from patient to patient really helps make a diagnosis IF the person doing the diagnosing is familiar with the patterns so well described by Travell and Simons. That's why familiarity with TrPs and an ability to take a good medical history is so important. An educated doctor will know where to look for TrPs before the physical exam begins.A "latent" type of TrP also occurs. The latent TrP doesn't hurt at all, unless you press it. You might not even know it's there, but your body does. It restricts movement, weakens, and prevents full lengthening of the affected muscle. If you press on the TrP, it refers pain in its characteristic pattern. Latent TrPs may be activated by overstretching, overuse, or chilling the muscle. People who get little exercise have a greater chance of developing latent points. This is important, because some people feel that by restricting their range of motion, they are getting rid of their TrPs. Nothing can be farther from the truth. Physical stress isn't the only thing that can cause TrPs. Tension TrPs can occur. These are not the psychological result of tension, but they are physiological biological effects of long term emotional abuse or mental trauma. If you are constantly holding your muscles tight in a "fight-or-flight" stress response, this changes your body patterns. When you have TrPs, muscle strength becomes unreliable. You may have also have noticed that if one part of your body turns over another while you sleep, the part being compressed goes numb. Some other symptoms include: stiffness, muscle tightness and weakness, localized sweating, tearing, salivation, poor balance, dizziness, nausea, tinnitus, goosebumps, runny nose, buckling knees, weak ankles, illegible handwriting, staggering gait, headaches, and muscle cramps.

TrPs often form as a result of other medical conditions. A case of arthritis may be otherwise well managed, for example, but the accompanying TrPs are overlooked. The pain load of that patient could be substantially lessened if the secondary TrPs were treated successfully.

Chronic Myofascial Pain Syndrome

If TrPs are treated immediately and vigorously, and perpetuating factors (conditions that aggravate and perpetuate the TrPs, are avoided or remedied, TrPs can be eliminated. Unfortunately, if TrPs are left untreated, are inappropriately treated, or muscle action is restricted to avoid pain, the TrP usually becomes latent. If the muscle is pushed to work in spite of the pain, especially if perpetuating factors exist, active TrPs may develop secondary and satellite TrPs.

Secondary trigger points develop when a muscle is subject to stress because another muscle with a trigger point isn't doing its job. Satellite TrPs develop when a muscle is in a referred pain zone of another TrP. Without proper intervention, and with perpetuating factors, the TrPs can lead to severe and widespread chronic myofascial pain syndrome (MPS).

Developing secondary and satellite TrPs can give the false impression that MPS is a condition that will steadily worsen with time -- that it is progressive. MPS is not progressive. With proper intervention, these trigger points can be broken up and eliminated.

FMS and MPS are different syndromes. However, the vast majority of physicians lump them together because they see many patients with the FMS & MPS Complex. Unless doctors have a thorough knowledge of and familiarity with individual TrPs, they can't sort out the symptoms. One interesting difference between the two syndromes is that more women than men have FMS, but MPS affects men and women in equal numbers. Another difference is that muscles in locations that are some distance from the trigger points of MPS have normal sensitivity. In FMS, there is a generalized sensitivity.

FMS is, among other things, a systemic neurotransmitter dysregulation, with many biochemical causes. There are other problems as well, but they are all systemic in nature, such as the alpha-delta sleep anomaly. Myofascial Pain Syndrome, however, is a neuromuscular condition. MPS happens because of mechanical failures -- the mechanics of physics, not biochemistry. Due to the nature of trigger points, some of the symptoms may seem to be systemic, but they are not. Initiating events, such as repetitive motion injury, trauma, and illness, can start a cascade of TrPs.

FMS & CMP:  More than double trouble

We are just beginning to discover why FMS and CMP together cause more trouble than just the sum of their symptoms. It may be more than the simple amplification of pain and other symptoms that come with heightened FMS sensitivity. It is important that the patients and the medical team understand the differences, so that the cause of symptoms can be evaluated and treated. Fibromyalgia and CMP both share muscle pain as a symptom. This has resulted in many persons with bilateral or widespread muscle pain being diagnosed as having FMS when in fact they have CMP or other types of myalgia.

Right now there is no cure for FMS, although there are many treatments that help. There are cures for many of the other causes of widespread pain, but your doctor must understand that all widespread pain is not FMS.

Why the differences between FMS and TrPs are important

"The fibromyalgia literature remain stuffed with references to myofascial pain as a regional syndrome in contrast to fibromyalgia as the widespread syndrome. This is a particularly dangerous concept in chronic pain, where myofascial pain is more likely to be generalized." (Gerwin, 1999). It is important to study individual TrPs to learn their referral patterns, but it is important for medical team members to understand that complex overlapping pain patterns exist in chronic pain patients. As the perpetuating factors are addressed and the TrPs are adequately treated, the single muscle pain patterns will eventually again become apparent, and then those TrPs can be treated.

People with the FMS and CMP face more than just the two sets of symptoms of both conditions. Physical therapy and other forms of treatment must proceed carefully. Any treatment tried will be both more complicated and less successful than if the patient had only one of the two conditions. Myofascial TrPs need to be treated locally, and the perpetuating factors addressed. Fibromyalgia needs to be treated systemically, and the perpetuating factors addressed. (Borg-Stein and Stein 1996).

Some doctors will tell you that they never saw a patient with just FMS, or just CMP, so they must be the same thing. Unless you understand the concepts behind each condition, it may seem so, because it takes a great deal of training and experience to palpate TrPs and the muscles may be guarded or fibrotic. You can’t get palpation experience by looking at diagrams. Too many doctors do not have this skill, which is why it is often easier for some bodyworkers to palpate TrPs. One doctor who does understand these conditions is Robert Gerwin MD, one of the first doctors to grasp the significance of Travell and Simons’ work.

In a study of 96 patients, he found that 74% of the patients had only myofascial pain. 35 % of the myofascial pain patients had generalized TrP pain in three or four quadrants. In other words, even though these patients had CMP and not FMS, they had widespread pain. These patients had the symptoms of CMP, but they did not have the generalized hypersensitivity and tender points of FMS. Among the FMS patients in this study, 28% had only FMS. Of all the patients, 72% had both FMS and CMP (Gerwin 1995).

I have seen or heard of too many cases where a patient with both FMS and CMP had one or the other condition undiagnosed. Some people have suffered needlessly for years because of this, and were often given inappropriate therapy. Some had co-existing conditions that were missed because their doctors attributed all the pain to FMS. The same TrPs were treated over and over, without any attempt to search for hidden perpetuating factors. In some cases of cancer and other life-threatening illnesses, this lack of understanding on the doctor’s part proved deadly.

FMS is a chronic illness that is to be controlled, and myofascial pain is a condition that is potentially curable, unless there is a fixed, uncorrectable underlying cause. The focus of treatment in both conditions is to restore more normal function with minimized pain (Gerwin, 1998).

Some Practical Differences

Restricted motion is not a part of FMS. Generalized fatigue is, but not the specific muscle weakness that is due to TrPs. With TrPs, there is no pain in areas of the muscle that don’t have TrPs, unless FMS or something else is causing it. Disturbed non-restful sleep can be found in either condition, from different causes (Sleep and Fatigue)

You are not going to find hard lumps and bumps and ropy bands in FMS. Those are part of TrPs. You are not going to find generalized hypersensitivity and allodynia (feeling pain from non-painful stimuli) in CMP. That is FMS. If you have both symptoms, you may have both conditions. Other conditions can cause body-wide pain, so you need a doctor who knows how to make the diagnosis. This is not the same things as having a doctor who has heard of these conditions. If your doctor doesn’t understand this, take in the medical references in the 2nd edition Survival Manual. If s/he won’t look up the references and won’t listen and won’t learn, document it in writing. Then get another doctor. Even if you are in an HMO, you can make a good case for your need to have a doctor and physical therapist that recognizes, understands and can treat your illnesses.

FMS and CMP: Why They Are More Than Double the Trouble

Treatment of patients with both FMS and CMP requires special skills . In CMP, a chronic pain condition exists, with many different symptoms and TrPs and perpetuating factors, which are magnified by the pain amplification aspect of FMS. You can’t simply prescribe a set regimen of pills, send the patient off to a physical therapist, and expect good results. Furthermore, some of the treatments normally prescribed for FMS patients can cause damage to CMP patients, and the reverse is also true (Starlanyl, 1997). For example, mild but repetitious exercises may be tolerated by someone with FMS. Repetition will perpetuate myofascial TrPs. FMS patients can tolerate slow and gentle strengthening of muscles. CMP patients can’t. You cannot strengthen a muscle that harbors a TrP. The muscles may already be contractured and under considerable strain. Exercise is like a prescription, and so is bodywork. If you have FMS and CMP, you are not as likely to experience any pain relief from TrP injections. Some people get pain relief for a few weeks. Some get no relief at all. Even if you do receive some relief, you may have more severe post-injection soreness (Hong 1995). Improper bodywork on a patient with myofascial TrPs can lead to extreme pain. Even appropriate bodywork, if done beyond patients toleration, can lead to severe distress. This may be delayed. If the patient has FMS amplifying the symptoms (including autonomic symptoms from TrPs), the patient can develop shock symptoms. There can also be delayed autonomic and proprioceptor dysfunction. This is important for the care provider to remember, especially if the patient is driving home from the office visit, and/or will be alone for the rest of the day.

Both FMS and TrPs can cause microcirculation problems. So can co-existing conditions such as Raynaud’s. It is important to remember that these conditions may feed into each other. It often gives alternatives to symptom relief. For example, if there is a problem with the microcirculation in the fingers, and additional pressure from bodywork worsens the symptoms, it is important to know that TrPs in the scalenes in the neck and pectoralis minor in the chest may cause nerve entrapment and blood vessel and lymph entrapment in the hands. Appropriate treatment to these TrPs, and TrPs in the arm muscles, may significantly help the Raynaud’s. In another instance, dizziness and unintentional veering may be adding to balance problems. This is especially dangerous in the elderly, or in pregnant women. Attention to contributing TrPs may prevent many a stumble. 

The FMS/MPS Connection: Some Theories

To understand what happens when FMS and CMP combine, we need to look at the big picture. Most of your body’s processes rely on the unobstructed movement of fluids through the system. Blood circulates, carrying food, fuel, oxygen, and other materials. It also carries away wastes. Lymph circulates, carrying fats, salts, proteins, white blood cells, and other substances. Ducts release biochemicals, and these ducts can be constricted too. On a microscopic level, every cell in the body depends on the motion of liquids from outside to inside the cell, and back. In one Star Trek episode, an alien called human beings bags of dirty water. The description, while unsavory, is quite correct. Your body depends on the motion of this dirty water in and out of its cells. When there is impaired microcirculation, which happens in both FMS and CMP, this motion is restricted. This happens because these bags of dirty water are floating in a fascial sea.

In CMP, the layers of fascia tend to stick to other microscopic fascial layers and to other tissues. The fascia loses elasticity. This compromises function and may cause pain. Autonomic function and proprioception may be disturbed. Treatment regimens must be developed that take into consideration all of these factors. Neurotransmitter activity determines the elasticity of the tissues ( Starlanyl, 1998) but in FMS, the neurotransmitter balances are out of whack. Connective tissues become stiffened, shortened, and tightened, and fluid exchange is disrupted.

FMS perpetuates CMP and the reverse is also true. You can’t get rid of the CMP until you successfully treat the FMS, and you can’t successfully treat the FMS until you get rid of the CMP. They each perpetuate the other. Then, too, chronic pain, all by itself, causes stress, which can create TrPs. That’s another reason why so many cases of FMS are accompanied by CMP. These conditions are often accompanied by insulin resistance, and this further complicates the diagnosis and treatment. If excess carbohydrates are avoided, and a balanced diet is followed, the symptoms of all of these conditions can often be lessened. Controlling perpetuating factors is always the key to symptom relief.

What you to do help FMS will indirectly help the CMP, and the reverse is true. Many traditional TrP therapies may need to be modified due to FMS sensory amplification, or sensory overload from pain secondary to therapy could induce FMS flare. Tolerance to therapy can vary considerably. For example, during times of high stress and heavier workload, a longer recovery may be needed between therapy sessions.

Even physical examination can be exceedingly painful and have lasting repercussions. Often, much exam pain can be avoided by careful history taking. Extra medication may be needed before the exam process to minimize discomfort. For the following week, extra supportive therapy may be required in the form of more medication, less work, minimizing of stimuli, and extra craniosacral therapy.

Any new therapy, or new area of bodywork, should be attempted with caution in a patient with severe FMS and CMP. At times, therapies that might prove beneficial in the long-term may cause extra symptom load in the short-term. Go into every new therapy with the knowledge that no matter how gentle, it may provoke a flare response if too many toxins and wastes are released.

In patients with coexisting FMS and CMP, we have discovered the presence of multiple geloid or hard clearly definable, measurable masses that seem to overlie TrPs (Starlanyl DJ, Jeffrey JL. Geloid masses in a patient with both fibromyalgia and chronic myofascial pain. Phys Ther Case Rep 4(1):22-31. 2001). These are very sore, and add to the pain burden. They also make bodywork very difficult. They are accompanied by a specific type of swelling, and extremely taut areas of dense tissue. We believe that we know why they occur in patients with both of these conditions, and what causes them, as well as what to do about it. This topic is covered in the New Research chapter in the 2nd edition Survival Manual. A clinical study will be published in the autumn of 2001 (The effect of transdermal T3 (triiodothyronine) on geloid masses found in patients with both fibromyalgia and myofascial pain. Blinded, crossover N-of-one clinical study ). The geloid mass may be one of the first objective indications that FMS and CMP together form a separate illness that is more than the sum of the two.

For the person with CMP and FMS, your body and mind can seem to be a war zone, but in reality peace talks are progressing! Armed with up-to-date knowledge, you can take the responsibility of managing your own treatment.