Distinguishing Fibromyalgia, Myofascial Pain Syndrome and Chronic Fatigue Syndrome
Other syndromes have some of the same symptoms as FMS and sometimes determining which syndrome a person has is difficult.  In this section, we will compare the symptoms of two other syndromes that manifest symptoms similar to FMS.

Myofascial Pain Syndrome
As stated above in the history section, Myofascial Pain Syndrome (MPS) was popularized by Janet Travell in her work with myofascial trigger points.  MFS is a condition that develops when muscles and fascia are injured or traumatized in some way, even at the microscopic level.  Instead of healing normally, the injured tissue gets stuck in a cyclical pattern of pain-muscle spasm-pain, the positive feedback loop of a muscle spasm that leads to pain which creates more muscle spasm and more pain.  The affected tissues are usually ischemic (lack of blood flow) and this propagates the cycle.  This syndrome is particularly marked by the onset of myofascial trigger points, which are hyper-irritable foci laying within taut bands of muscle and fascia.  These trigger points, which are painful on compression and refer pain to a distant site, can be palpated with the finger.  There are some primary differences between MPS and FMS:

 

Fibromyalgia Syndrome

Myofascial Pain Syndrome

Prevalence

2-4% of the U.S. population

Undetermined

Demographics

85% Female

Equally affects male and female

Prognosis

Chronic long-term problem

Short-term problem

Symptoms

Global “tender points” that do not have a referral pattern

Regional “trigger points” that have a predictable referral pattern.

Indications for massage

Patients can benefit from gentle massage, but direct pressure on tender points may aggravate them.

People respond well to massage and direct pressure on trigger points may alleviate them.

Chronic Fatigue Syndrome
Chronic Fatigue Syndrome (CFS) has some of the same associated conditions as FMS and therefore can be potential differential diagnosis.  A great deal of debate has surrounded the issue of how best to define CFS.  According to the Center for Disease Prevention (CDC), in an effort to resolve these issues, an international panel of CFS research experts convened in 1994 to draft a definition of CFS that would be useful both to researchers studying the illness and to clinicians diagnosing it.  In essence, in order to receive a diagnosis of CFS, a patient must satisfy two criteria:

  1. Have severe chronic fatigue of six months or longer duration with other known medical conditions excluded by clinical diagnosis; and
  2. Concurrently have four or more of the following symptoms:  substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern or severity; un-refreshing sleep; and post-exertional malaise lasting more than 24 hours.

The symptoms must have persisted or recurred during six or more consecutive months of illness and must not have predated the fatigue.  Similarities exist between FMS and CFS, including demographics, chronicity and many of the same conditions (headaches, memory difficulty, morning tiredness, muscle pain and sleep disturbances).  Although these similarities exist, some researchers believe a primary precursor in the evolution of CFS is recent viral infection.  This has not been completely substantiated and the etiology of CFS remains unknown, but there is enough evidence to say that CFS and FMS are two distinct syndromes.

Research-Based Etiology Hypotheses of Fibromyalgia
With all of the symptoms and conditions associated with FMS, it has become a debated issue as to which of these, if any, are causal and which are solely symptomatic.  There are a number of hypotheses which try to explain the etiology of FMS.  The main hypotheses are outlined here.

Chronobiological Hypothesis
In this hypothesis, altered biological (circadian) rhythms, including diurnal physiological functions, seasonal environmental influences and psychosocial influences, cause imbalances that lead to FMS.  Moldofsky, a psychiatric physician, describes a “non-restorative sleep syndrome” that leads to fatigue, pain, cognitive difficulty and irritable bowel problems.  This syndrome emerges from Central Nervous System (CNS) disruption caused by altered chemical function, especially serotonin, substance P, interleukin-1, growth hormone and cortisol.(10)  His research shows that sleep disturbances shift the late nocturnal cortisol release and decrease growth hormone production.  This shift in biologic rhythm creates a cascade of metabolic imbalances that lead to FMS.

Genetic Hypothesis
There are some studies that show clear indications of familial tendencies to the development of FMS.  FMS has been associated with genetic joint hypermobility, mitral valve prolapse and the presence of specific patterns of human leukocyte class II antigens.(11) 

Integrated Hypothesis
This hypothesis attempts to show a connection between the local muscle changes (reduced energy phosphates, scattered red-ragged muscle fibers, ischemia and contraction bands) and CNS changes in people with FMS.  These alterations in focal muscle may occur due to micro-muscle trauma.  The sleep disturbances associated with CNS dysfunction lead to reduced production of growth hormone, which is essential for normal muscle repair and homeostasis.  The combination of a genetic propensity to micro-muscle trauma and the CNS dysfunction lead to the chronic myofascial pain associated with FMS.

Immune Dysfunction Hypothesis
This general hypothesis links a viral infection, trauma or some other major life stressor to the overstimulation of the immune system.  The over-active immune system leads to over-production of interferons and interleukins, which create CNS dysfunction by disturbing serotonin balance and hypothalamic homeostasis.

Nociceptive Hypothesis
Wolfe proposed that chronic pain leads to a lowered pain threshold and that amplified pain (along with genetic disposition, disease, sleep disturbance and psychological stress) evolves into FMS.  Wolfe also proposed that there may be many different types of fibromyalgia that are caused by various and different events that lead to chronic pain.(13)

Hormone Imbalance Hypotheses
The imbalance of key hormones has been reported in patients with FMS.  Particularly, cortisol imbalances, which affect how the body handles infection, inflammation, physical and emotional stress.  Deficiency in cortisol has been characterized by fatigue, weakness, muscle and joint pain, irritable bowel and increased allergic reactions.(14)  Many of these symptoms mimic FMS symptoms. One way to increase the production of cortisol is by getting the right amount of sleep. Studies and research show that a person helps her body regenerate cells especially those of her vital organs in the body by sleeping.  For individuals with low cortisol, sleep in total darkness and if possible without the use of an alarm clock is recommended. Cortisol production increases rapidly during stressful situations. Learning to manage and reduce stress in your life will allow cortisol to gradually, increase in your system instead of being produced all at once in high-pressure situations. Increased intake of grapefruit is another type of diet to increase cortisol levels naturally. Grapefruit has properties that triggers the deactivation of enzyme responsible for breaking down the cortisol hormones. You can increase cortisol levels naturally by taking the herb licorice. It is a type of herb that provides various health advantages, and one of these is maintaining the balance of cortisol in our body. It has glycyrrhizin acid that also helps destroy the enzyme that breaks down cortisol and therefore increase the low level of one’s cortisol. Have your thyroid levels tested at your next doctor's appointment. Your doctor can prescribe medication to regulate thyroid hormone production if your levels are too low. Regulating these hormones in your body will also increase your body's production of cortisol. Exercise puts stress on the cardiovascular system which increases the levels of cortisol.

The symptoms of FMS also closely resemble those of hypothyroidism.  Several randomized controlled trials have been conducted involving Triiodothyronine (T3) medication for patients with FMS.  T3 is also known to regulate substance P (a neuropetide associated with pain) in the brain, therefore low T3 levels could account for the high substance P levels in patients with FMS.(16)

Neurosomatic Hypothesis
As more evidence supported multiple causes, the hypotheses naturally grew broader in scope.  The neurosomatic hypothesis shows that a dysfunction of body and CNS functions can lead to the global symptoms of FMS.  In this complex pathway, major physical or psychological trauma, developmental issues, viral infection or cumulative effects of multiple stressors combines with genetic predisposition to create CNS and hormonal dysfunction.  This causes imbalances in growth hormone, serotonin, interleukins, T3, substance P and cortisol.  The combination of CNS and hormonal disturbances also cause sleep disturbance, digestive dysfunction, impaired memory, depression, anxiety and fatigue.  Interrelated to these imbalances are the symptoms of pain, inactivity, deconditioning, hyperventilation and allergy.  The neurosomatic hypothesis appears to take all of the physical, neurological, genetic and psychological elements of FMS and bring them together into a holistic hypothesis. 

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