Fibromyalgia and Myofascial Pain: Twins, Cousins, or Unrelated?

Fibomyalgia and Myofascial Pain: Twins, Cousins, or unrelated?

Robert D. Gerwin, M.D. Associate Professor of Neurology Johns Hopkins University, Baltimore, MD, USA And

Pain and Rehabilitation Medicine, Bethesda, MD, USA

Disclosure ď Ž

Nothing to Disclose

Learning Objectives 

 

Explain the relationship between Myofascial pain and Fibromyalgia List signs and symptoms of Myofascial Pain Define the criteria for how Myofascial Pain can become Fibromyalgia

Myofascial Pain and Fibromyalgia: unique and distinct?

Cutty Sark

FMS/MPS: POSSIBLE RELATIONSHIPS •Two: unrelated •Two: Continuum •One: but FMS (MPS) is misdiagnosed •Two: one initiates the other

Thessalonika, Greece

Myofascial pain : Fibromyalgia Overlap syndromes?

Regional vs generalized?

Sensitization: peripheral vs central?

Fibromyalgia thermogram

•1. Myofascial Pain: •Peripheral muscle disorder • secondary central sensitization •2. Fibromyalgia •disorder of descending pain inhibitory system • widespread pain (migraine, dyspareunia, interstitial cystitis, irritable bowel)

Modulation of Descending Inhibition ď Ž

ď Ž

Descending noxious inhibition control (DNIC) is impaired in FMS and contributes to pain Expectation of relief enhances DNIC, resulting in pain relief

Goffaux et al, Pain 145 (2009) 18-

Most associated conditons are more common in females: Migraine

TMJ

Hypothyroid

IC

Dyspareunia

IBS

Is MPS different than FMS? Seventy-two percent of persons diagnosed with fibromyalgia (18/25) had trigger points consistent with MPS. Current ongoing studies in Europe confirm this observation.

Overlap syndromes?

Misdiagnosis?

Implications for tender points and trigger points?

Gerwin R. A study of 96 subjects examined both for fibromyalgia and myofascial pain. J Musculoskel Pain 1995;3(Supple1);121

70-100% of FMS pain is referred from trigger points Clin J Pain. 2011 Jun;27(5):405-13.

Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity.

Alonso-Blanco C, Fernández-de-las-Peñas C, Morales-Cabezas M, Zarco-Moreno P, Ge HY, Florez-García M. Arthritis Res Ther. 2011 Mar 22;13(2):R48.

Reproduction of overall spontaneous pain pattern by manual stimulation of active myofascial trigger points in fibromyalgia patients.

Ge HY, Wang Y, Fernández-de-Las-Peñas C, Graven-Nielsen T, Danneskiold-Samsøe B, Arendt-Nielsen L.

Fibromyalgia TePs and Trigger Points 

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

The 18 sites selected for tender point examination in the ACR criteria for FMS were examined for myofascial trigger points Results: Trigger Points were found in 100 % of the sites Conclusion: the FMS tender points at the ACR sites are myofascial trigger points. print

Hong Ge et al, 2009, in

trigger point features

The Taut band: The trigger point taut band can now be objectively imaged by 1. MR Elastography Local Pain

Taut band

2. Ultrasound sonography with vibration There are no muscle imaging techniques for fibromyalgia

MR elastography

1. Chen, Q., J. Basford, and K.N. An, Ability of magnetic resonance elastography to assess taut bands. Clin Biomech (Bristol, Avon), 2008.

23(5): p. 623-9.

2. Chen, Q., et al., Identification and quantification of myofascial taut bands with magnetic resonance elastography. Arch Phys Med Rehabil, 2007. 88(12): p. 1658-61.

1. Local Twitch Response 

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  

High amplitude, Polyphasic discharge Elicited by mechanincal stimulation Spinal cord mediated No supraspinal inflluence Confined to the taut band (not a tendon reflex)

There is no taut band in fibromyalgia

Hong and Torigoe, 1994

2. SEA/EPN ď Ž

Hubbard and Berkoff (1993) identified a continuous background electrical activity at the trigger point site not found in normal muscle (now called endplate noise

by Simons), and without motor action potentials There are no EMG changes in fibromyalgia, except at trigger points

3. Endplate noise in taut band ď Ž

Simons, Hong, Simons found that there was a 5-fold increase in endplate noise regions in the trigger point taut band compared to normal muscle.

Conclusion: Increased endplate potential activity is associated with the myofascial trigger point

4. Sympathetic modulation of EPN

ď Ž

Sympathetic Nervous System modulation of endplate potentials: Phentolamine (alpha 2 adrenergic antagonist) reduces endplate noise (Chen et al, Arch Phys Med Rehab 1998; 79:78094)

(This is a modulation of trigger point taut band activity unique to the

trigger point)

ACh leak and sustained contraction: true or false?

The expanded integrated hypothesis remains hypothetical

5. Attenuation of Endplate Noise by Botulinum Toxin

motor nerve terminal

2

ACh-containing vesicle

Botulinum toxin 3

1

a 4

b 5

c

Botulinum toxin light chain

Blocked docking by cleavage of fusion protein complex

normal docking with fusion protein complex

Normal release of ACh through fusion pore

Kuan et al, 2002

5: Attenuation of Endplate Noise by Botulinum Toxin  

Botulinum toxin attenuates endplate noise.

Implication:  

1) specific inhibition of nerve-stimulated release of acetylcholine as critical for endplate noise and/or 2) Inhibition of non-specific, non-quantal release of acetylcholine release.

There is no equivalent response in fibromyalgia to botulinum toxin Kuan et al. Am J Phys Med Rehabil 2002;81:512-520

6. Sampling the Trigger Point Milieu

Real-time microdialysis Shah JP, Phillips TM, Danoff JV, Gerber LH, J Applied Physiology 2005;99:1977-84

6. Trigger Point Biochemistry ď Ž

ď Ž

At the trigger point region, there is lowered pH, increased 5-HT, Substance P, CGRP, norepinephrine, and a variety of cytokines There are no comparable muscle biochemical changes in fibromyalgia

Shah et al, 2005

CGRP

BKN

IL-6

IL-8

TNF-α

IL-1β

5-HT

norepinephrine

pH

sub P

6. Implications of Trigger Point microdialysis ď Ž

ď Ž

Low pH and elevated CGRP: important for actions at the neuromuscular junction, EPN and muscle contraction Elevated protons, bradykinin, substance P, CGRP, and cytokines: important for pain mechanisms

6. Implications of Trigger Point microdialysis ď Ž

ď Ž

Low pH and elevated CGRP: important for actions at the neuromuscular junction Elevated protons, bradykinin, substance P, CGRP, and cytokines: important for local nociceptor activation, edema and capillary compression

7. Central and Peripheral Sensitization 

Microdialysis also shows elevated bradykinin, IL-1β,IL6,IL-8, bradykinin, TNF-α, norepinephrine, SP, and CGRP, in the gastrocnemius muscle at a distance from a trapezius muscle containing trigger points  Trigger Points only in trapezius muscle; biochemical abnormalities in trapezius and gastrocnemius muscles  Suggests both central and peripheral sensitization limited peripheral sensitization fibromyalgia Shah J, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, Gerber LH. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil 2008;89:16-23.

TNF-Îą

Trapezius

gasttrocnemius

IL-6

pH

BKN

8. Single Fiber Electromyography ď Ž

ď Ž

Stimulated single fiber electromyography: increased mean consecutive differences (increased jitter) in muscles of MPS subjects, increasing with duration of pain Implication: axonal degeneration and regeneration of motor nerve terminals OR motor neuron degeneration with collateral reinnervation, increasing with time of involvement Not reported in fibromyalgia

Chang et al, 2008; Eur J Pain, 12:1026-1030

9. fMRI evidence of Central Hypersensitizaion in MPS 

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Event-related fMRI: Stimulation of hypersensitive MTrP causing subjective hyperalgesia results in significantly enhanced somatosensory (SI, SII, inferior parietal, mid-insula) activity compared to normal controls.

MPS has both peripheral and central manifestations (Not unique to the trigger point) Niddam et al, Neuroimage 2008;39:1299-1306

(A) Patients with low stimulus intensity and high pain intensity (B)

controls with low stimulus intensity and low pain intensity

(C)

controls with high stimulus intensity and high pain intensity

Niddam DM, Chan RC, Lee SH, Yeh TC, and Hsieh JC, Central modulation of pain evoked from myofascial trigger point. Clin J Pain. 23(5): 440-8, 2007 Niddam DM, Chan RC, Lee SH, Yeh TC, and Hsieh JC, Central representation of hyperalgesia from myofascial trigger point. Neuroimage. 39(3): 1299-306, 2008

Radiculopathy? MTrP referred pain? Both?

Conclusion The Taut Band is Unique to the TRP; Sensitization is Common to Both TrP and TeP 

 

The peripheral abnormalities that induce localized muscle contractions called taut bands, and that cause local pain, are unique to the TrP Peripheral sensitization: unique to the Trigger Point ?

Central activation sensitization causes referred pain: not unique to the TrP

Do tender points in FMS refer pain like trigger points do?

Summary ď Ž

ď Ž

The structural and physiologic changes in the myofascial trigger point are unique to the trigger point The sensory changes, both peripheral sensitization and central sensitization, are general phenomena, not unique to the myofascial trigger point, but are not necessarily shared by FM

Can Myofascial Pain Syndrome become Fibromyalgia?

Fibromyalgia or Myofascial Pain?

ACR criteria for diagnosis of FMS: 3-4 quadrant pain of >3 months duration 35% of chronic MPS have widespread pain (3-4 quadrants)

Myofascial Pain can spread through secondary trigger points in functional muscle units, and through altered kinetic chains. Regional myofascial pain can thus become generalized.

Is this fibromyalgia?

Unique Genetics of Fibromyalgia 

Familial aggregation:  



26% blood relatives 19% husbands

Genetic polymorphisms  

Serotonin 5HTT polymorphism Catecholamine-Omethyltransferase (COMT) polymorphism through adrenergic mechanisms and genetic predisposition

Conclusion:

Genetic influences: unique to fibromyalgia

Autonomic Dysregulation or Myelopathy?

•fibromyalgia and Ehlers Danlos with MPS •Orthostatic hypotension •Neurogenic tachycardia •Bladder and bowel irritability •Anisocoria •FM patients have increased sympathetic and decreased parasympathetic tone Cohen, Neumann, Shore, Amir, Cassuto, Buskila, Semin Arth Rheum, 2000;29:217-227

Cervical Spinal Cord Compression 

Quantitative sensory analysis:  



Thermal perception thresholds 



sensory dysfunction associated with Chiari I cervical cord compression elevated in the face in FMS, and in the neck and upper and lower extremities in spinal cord stenosis.

painful sites/extent of pain 

greatest in Chiari I, more in cervical spine compression than in normals

Thimimeur M, Kitaj M, Kravitz E, Kalizewski T, Sood P. Clin J Pain 2002;18:171-179

Chiari and EDS 

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More Chiari I patients met the criteria for FMS and complex regional pain syndrome than cervical cord compression or normal controls Medullary compression is likely in the Chiari I subjects, with particular dysfunction of the rostral ventral medulla.

Suggests a defect in descending inhibition of ascending nociceptive impulses

Thimimeur M, Kitaj M, Kravitz E, Kalizewski T, Sood P. Clin J Pain 2002;18:171-179

Cervical Spinal Cord Compression 

cervical spinal cord compression 



descending anti-nociceptive projections from the RVM are impaired, whereas the trigeminal sensory fibers are spared, in contrast to Chiari I.

abnormalities of the cervical spinal canal and of the posterior fossa brainstem structures 

influence the extent and character of chronic pain,

Thimimeur M, Kitaj M, Kravitz E, Kalizewski T, Sood P. Clin J Pain 2002;18:171-179

Normal Cervical Spine

medulla

Key area of compression

Cervical Spinal Cord Compression •Compression is significant when the canal diameter is <10 mm.

•Compression is worse in cervical spine extension.

•Here, Cervical spinal cord compression at C34, with loss of free space around cord Holman A. Clin J Pain 2008;9:613-22

Positional Cervical Cord Compression •53/107 subjects had FMS •22/107 had CWP without FMS •A dynamic cervical spine MRI in flexion and extension is necessary to make the diagnosis.

•68% had symptoms after prolonged neck extension (dentist chair, hair wash in sink): dizziness, weakness Holman, J Pain, 2008;9:613

MRI of C-Spine

Holman, J Pain 2008;9:613

Cervical Cord Compression • alters autonomic tone • alters descending inhibition of ascending nociceptive impulses •Mense, Scand J Rheumatol 2000;29 S113:24-9 for importance in fibromyalgia

• Adversely affects sleep efficiency • promotes restless legs syndrome The patients at risk : hypermobility patients

Interstitial Cystitis: an FMS comorbidity

Brainstem Compression â&#x20AC;˘Forward head posture can cause excessive angulation of the brainstem, compressing the medulla. Forward head posture is a problem in persons with kyphoscoliosis, and in hypermobile persons of all ages (Ehlers-Danlos Syndrome).

Hypermobility 

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Fibromyalgia patients: 64% were hypermobile Control patients: 22% were hypermobile Symptoms in Hypermobile patients:     

Widespread pain Multiple soft tissue lesions Fatigue Forward head posture Autonomic dysfunction  Palpitations, presyncope, IBS

Hakim and Grahame. Rheumatol 2004;43:1194-5; Gazit et al, Am J Med 2003;115:33-40

Hypermobility ď Ž

13% of fibromyalgia patients were hypermobile, and 30% of hypermobile patients were diagnosed with fibromyalgia (8% in controls) Hudson et al, 1995

hypermobility is also a risk factor for MPS

Treatment of TrPs in FMS

ď Ž

Treatment of Myofascial trigger points in FMS reduced pain significantly to day 8

.Eur J Pain 2011 Jan;15(1):61-9.

Effects of treatment of peripheral pain generators in fibromyalgia patients.

Affaitati G, Consantini R, Fabrizio A, Lapenna D, Tafuti E, Gaimberadinio MA Curr Pain Headache Rep. 2011 Oct;15(5):393-9.

Effects of treatment of myofascial trigger points on the pain of fibromyalgia.

Giamberardino MA, Affaitati G, Fabrizio A, Costantini R.

Summary •Fibromyalgia and Myofascial Pain Syndrome overlap •Some underlying conditions like hypermobility may predispose to both (multi) regional myofascial pain and to generalized fibromyalgia pain •Evidence suggests that pain in FMS is from MTrPs

Treatment of Myofascial trigger points in FMS reduced pain significantly to day 8 .

Eur J Pain 2011 Jan;15(1):61-9.

Effects of treatment of peripheral pain generators in fibromyalgia patients.

Affaitati G, Consantini R, Fabrizio A, Lapenna D, Tafuti E, Gaimberadinio MA Thatâ&#x20AC;&#x2122;s all, folks!