• Definition
• Symptoms
• Causes
• Complications
• Preparing for your appointment
• Tests and diagnosis
• Treatments and drugs
• Coping and support

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Definition

Vasculitis is an inflammation of your blood vessels. Vasculitis causes changes in the walls of your blood vessels, including thickening, weakening, narrowing and scarring. Vasculitis is also called angiitis and arteritis. Many types of vasculitis exist.

Vasculitis can be short term (acute) or long term (chronic) and can be so severe that the tissues and organs supplied by the affected vessels don’t get enough blood. The shortage of blood can result in organ and tissue damage, even death.

Vasculitis can affect anyone, though some types of vasculitis are more common among certain groups. Some forms of vasculitis improve on their own, but others require treatment — often including taking medications for an extended period of time.

Symptoms

CLICK TO ENLARGE

	Giant cell arteritis
	Henoch-Schonlein purpura

General signs and symptoms common to most vasculitis types
The signs and symptoms of vasculitis vary depending on which blood vessels and, as a result, which organ systems are affected. However, general signs and symptoms that most people with vasculitis experience include:

• Fever
• Fatigue
• Weight loss
• Muscle and joint pain
• Loss of appetite
• Nerve problems, such as numbness or weakness

Signs and symptoms by type of vasculitis

• Behcet’s syndrome. This condition causes inflammation of your arteries and veins, and often appears in your 20s and 30s. Signs and symptoms include mouth and genital ulcers, eye inflammation and acne-like lesions on your skin.
• Buerger’s disease. Also called thromboangiitis obliterans, this condition causes inflammation and clots in the blood vessels in your extremities. Signs and symptoms can include pain in your hands, arms, feet and legs, and ulcers on your fingers and toes. This disorder is strongly associated with cigarette smoking.
• Churg-Strauss syndrome. This condition, also known as allergic granulomatosis and allergic angiitis, most commonly affects the blood vessels in your lungs. It’s often associated with asthma.
• Cryoglobulinemia. This condition is often associated with hepatitis C infections. Signs and symptoms include a rash called purpura on your lower extremities, arthritis, weakness and nerve damage (neuropathy).
• Giant cell arteritis. This condition, which occurs in people older than 50, is an inflammation of the arteries in your head, especially your temples. Giant cell arteritis can cause headaches, scalp tenderness, jaw pain while chewing, blurred or double vision, and even blindness. Giant cell arteritis is often associated with polymyalgia rheumatica.
• Henoch-Schonlein purpura. This condition is caused by inflammation of the blood vessels of your skin, joints, bowel and kidneys. Signs and symptoms can include abdominal pain, blood in the urine, joint pain, and a rash called purpura on your buttocks, legs and feet. Henoch-Schonlein most often occurs in children, but it can occur at any age.
• Hypersensitivity vasculitis. The primary sign of hypersensitivity vasculitis is red spots on your skin. It can be triggered by an allergy, most often to a medication or an infection.
• Kawasaki disease. Also known as mucocutaneous lymph node syndrome, this condition most often affects children younger than 5 years of age. Signs and symptoms include fever, skin rash and eye inflammation.
• Microscopic polyangiitis. This form of vasculitis affects small-sized blood vessels in your kidneys, lungs and skin. Signs and symptoms include skin lesions, fever, unintentional weight loss, glomerulonephritis — inflammation of the small blood vessels in the kidneys — and nerve damage.
• Polyarteritis nodosa. This form of vasculitis affects medium-sized blood vessels in many different parts of the body, including your skin, heart, kidneys, peripheral nerves, muscles and intestines. Signs and symptoms include a rash called purpura, skin ulcers, muscle and joint pain, abdominal pain, and kidney problems.
• Polymyalgia rheumatica. This condition primarily affects older adults and results in pain and inflammation of the large joints, such as your shoulders, hips and knees. Signs and symptoms include pain and stiffness in the muscles of your hips, thighs, shoulders, upper arms and neck. Polymyalgia rheumatica often occurs in association with giant cell arteritis.
• Rheumatoid vasculitis. This type of vasculitis can complicate the course of rheumatoid arthritis and usually occurs in people with a history of severe rheumatoid arthritis. Many different parts of the body, including the eyes, skin, hands and feet may be involved.
• Takayasu’s arteritis. This form of vasculitis includes the largest arteries in the body, including the aorta, and typically occurs in young women. Signs and symptoms include arm weakness or pain with use (claudication), decreased or absent pulses, lightheadedness, headaches, and visual disturbances.
• Wegener’s granulomatosis. This condition causes inflammation of the blood vessels in your nose, sinuses, throat, lungs and kidneys. Signs and symptoms can include shortness of breath, nasal stuffiness, chronic sinusitis, nosebleeds and frequent ear infections.

When to see a doctor
Make an appointment with your doctor if you have any signs or symptoms that worry you.

Causes

Vasculitis occurs when your body attacks your blood vessels. It’s not always clear why this happens, but an infection, some cancers, certain immune system disorders or an allergic reaction may serve as the trigger.

Blood vessels affected by vasculitis become inflamed, which can cause the layers of the blood vessel wall to thicken. This narrows the blood vessels, reducing the amount of blood — and therefore oxygen and vital nutrients — that reaches your body’s tissues. In some cases, a blood clot may form in an affected blood vessel, obstructing blood flow. Sometimes instead of becoming narrower, a blood vessel may weaken and form a bulge (aneurysm), a potentially life-threatening condition.

Vasculitis with no known cause (primary vasculitis)
For many of its forms, the cause of vasculitis is unknown. These forms of vasculitis are called primary vasculitis.

Vasculitis that occurs due to another disease (secondary vasculitis)
Forms of vasculitis for which an underlying disease is the cause are called secondary vasculitis. Examples of causes of secondary vasculitis include:

• Infections. Some vasculitis occurs in response to an infection. For instance, most cases of cryoglobulinemia are the result of the hepatitis C virus infection, and the hepatitis B virus infection causes some cases of polyarteritis nodosa.
• Immune system diseases. Vasculitis can also occur as the result of some diseases of the immune system, such as rheumatoid arthritis, lupus and Sjogren’s syndrome.
• Allergic reactions. Sometimes an allergic reaction to a medication may cause vasculitis.
• Blood cell cancers. Cancer that affects the blood cells, including leukemia and lymphoma, can cause vasculitis.

Complications

Complications of vasculitis depend on the type of vasculitis you have. In general, complications that can occur include:

• Organ damage. Some types of vasculitis can be severe, causing damage to major organs.
• Recurring episodes of vasculitis. Even when treatment for vasculitis is initially successful, the condition may recur and require further treatment. In other cases, vasculitis may never completely go away and requires ongoing treatment.

Preparing for your appointment

Whom to see
Make an appointment with your family doctor or a general practitioner if you have signs or symptoms that worry you. If your doctor suspects that you have vasculitis, you may be referred to a specialist. What specialist you’ll see depends on what type of vasculitis you have.

Specialists who treat vasculitis include:

• Brain and nervous system doctors (neurologists)
• Ear, nose and throat doctors (otolaryngologists)
• Eye doctors (ophthalmologists)
• Heart doctors (cardiologists)
• Infectious diseases doctors
• Joint and muscle doctors (rheumatologists)
• Kidney doctors (nephrologists)
• Lung doctors (pulmonologists)
• Skin doctors (dermatologists)

How to prepare
Because appointments can be brief, and because there’s often a lot of ground to cover, it’s a good idea to be well prepared for your appointment. Try to:

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there’s anything you need to do in advance, such as restrict your diet.
• Write down any symptoms you’re experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, as well as any vitamins or supplements, that you’re taking.
• Take a family member or friend along, if possible. Sometimes it can be difficult to absorb all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Questions to ask
Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For vasculitis, some basic questions to ask your doctor include:

• What type of vasculitis do I have?
• What’s causing my vasculitis?
• Will I need more tests?
• Is my vasculitis acute or chronic?
• Will my vasculitis go away on its own?
• Is my vasculitis serious?
• Has any part of my body been seriously damaged by vasculitis?
• Can my vasculitis be cured?
• What are my treatment options?
• What are the benefits and risks of each treatment?
• Is there one treatment you feel is best for me?
• How long will treatment last?
• Should I see a specialist? What will that cost, and will my insurance cover it?
• Are there any brochures or other printed material that I can take with me? What Web sites do you recommend?

In addition to the questions that you’ve prepared to ask your doctor, don’t hesitate to ask questions during your appointment at any time that you don’t understand something.

Tests and diagnosis

To diagnose vasculitis, your doctor will ask about your symptoms and past medical history and conduct a thorough physical exam. Tests and procedures used to diagnose vasculitis include:

• Blood tests. Blood tests used to help diagnose vasculitis include erythrocyte sedimentation rate, C-reactive protein test, complete blood cell count and anti-neutrophil cytoplasmic antibodies test.
• Urine tests. Testing samples of your urine may reveal abnormalities, such as red blood cells and increased amounts of protein, that often indicate a medical problem. If vasculitis has caused kidney problems, your prognosis tends to be poorer.
• Imaging tests. Your doctor may be able to determine whether larger arteries, such as the aorta and its branches, are affected through the use of noninvasive imaging techniques. These include X-ray, ultrasound, computerized tomography (CT) and magnetic resonance imaging (MRI).
• X-rays of your blood vessels (angiogram). During an angiogram, a flexible catheter, resembling a thin straw, is inserted into a large artery or vein. A special dye (contrast medium) is then injected into the catheter, and X-rays are taken as the dye fills these arteries or veins. The outlines of your blood vessels are visible on the resulting X-rays.
• Removing a piece of the affected blood vessel for testing (biopsy). A surgical procedure to remove a small sample (biopsy) of the affected blood vessel allows your doctor to examine the vessel for signs of vasculitis.

Treatments and drugs

Specific treatment for vasculitis depends on your type of vasculitis, the severity of your case and your general health. Though some types of vasculitis are self-limiting and improve on their own, such as Henoch-Schonlein purpura, others require medications.

Medications used to treat vasculitis include:

• Steroids to control inflammation. Treatment for many types of vasculitis consists of doses of a corticosteroid drug, such as prednisone or methylprednisolone (Medrol), to control inflammation. Side effects of steroids can be severe, especially when taken over a long period of time. Side effects can include weight gain, diabetes and bone thinning (osteoporosis). You’re likely to receive the lowest dose of steroids possible to control your disease.
• Medications to control the immune system. Severe cases of vasculitis or those that don’t respond well to corticosteroids may need treatment with cytotoxic drugs that kill immune system cells responsible for causing inflammation. Cytotoxic drugs include azathioprine (Imuran) and cyclophosphamide (Cytoxan). Researchers have had some success using the immunosuppressant drug mycophenolate mofetil (Cellcept) to treat certain types of vasculitis, but are still testing the drug in clinical trials.

Coping and support

When vasculitis is identified and treated early, the prognosis is usually good. One of your greatest challenges may be coping with side effects of your medication. The following suggestions may help:

• Understand your condition. Learn everything you can about vasculitis and its treatment. Know the possible side effects of any medications you take, and report any changes in your health to your doctor.
• Choose a healthy diet. Eating well can help prevent potential problems that can result from your medications, such as thinning bones, high blood pressure and diabetes. Choose a diet that emphasizes fresh fruits and vegetables, whole grains, and lean meats and fish, while limiting salt, sugar and alcohol.
• Try to exercise most days of the week. Regular aerobic exercise, such as walking, can help prevent bone loss, high blood pressure and diabetes. It also benefits your heart and lungs. In addition, many people find that exercise improves their mood and overall sense of well-being. If you’re not used to exercising, start out slowly and build up gradually. Your doctor can help you plan an exercise program that’s right for you.

Sjogren’s syndrome is an autoimmune disease. Autoimmune diseases are characterized by the abnormal production of extra antibodies in the blood that are directed against various tissues of the body. This particular autoimmune illness features inflammation in certain glands of the body. Inflammation of the glands that produce tears (lacrimal glands) leads to decreased water production for tears and eye dryness. Inflammation of the glands that produce the saliva in the mouth (salivary glands, including the parotid glands) leads to dry mouth and dry lips.

Sjogren’s syndrome with gland inflammation (resulting dry eyes and mouth, etc.) that is not associated with another connective tissue disease is referred to as primary Sjogren’s syndrome. Sjogren’s syndrome that is also associated with a connective tissue disease, such as rheumatoid arthritis, systemic lupus erythematosus, or scleroderma, is referred to as secondary Sjogren’s syndrome.

What causes Sjogren’s syndrome?

While the exact cause of Sjogren’s syndrome is not known, there is growing scientific support for genetic (inherited) factors. The illness is sometimes found in other family members. It is also found more commonly in families that have members with other autoimmune illnesses, such as systemic lupus erythematosus, autoimmune thyroid disease, juvenile diabetes, etc. About 90% of patients with Sjogren’s syndrome are female.

What are symptoms of Sjogren’s syndrome?

Symptoms of Sjogren’s syndrome can involve the glands, as above, but there are also possible affects of the illness involving other organs of the body (extraglandular manifestations).

When the tear gland (lacrimal gland) is inflamed from Sjogren’s, the resulting eye dryness can progressively lead to eye irritation, decreased tear production, “gritty” sensation, infection, and serious abrasion of the dome of the eye (cornea). Dry eyes can lead to infections of the eyes.

Inflammation of the salivary glands can lead to mouth dryness, swallowing difficulties, dental decay, gum disease, mouth sores and swelling, stones and/or infection of parotid gland inside of the cheeks. Dry lips often accompany the mouth dryness.

Other glands that can become inflamed, though less commonly, in Sjogren’s syndrome include those of the lining of the breathing passages (leading to lung infections) and vagina (sometimes noted as pain during intercourse recurrent vaginal infections).

Extraglandular (outside of the glands) problems in Sjogren’s syndrome include joint pain or inflammation (arthritis), Raynaud’s phenomenon, lung inflammation, lymph-node enlargement, kidney, nerve, and muscle disease. A rare serious complication of Sjogren’s syndrome is inflammation of the blood vessels (vasculitis), which can damage the tissues of the body that are supplied by these vessels.

A common disease that is occasionally associated with Sjogren’s syndrome is autoimmune thyroiditis (Hashimoto’s thyroiditis), which can lead to abnormal thyroid hormone levels detected by thyroid blood tests. Heartburn and difficulty swallowing can result from gastroesophageal reflux disease (GERD), another common condition associated with Sjogren’s syndrome. A rare disease that is uncommonly associated with Sjogren’s syndrome is primary biliary cirrhosis, an immune disease of the liver that leads to scarring of the liver tissue. A small percentage of patients with Sjogren’s syndrome develop cancer of the lymph glands (lymphoma). This usually develops only after many years with the illness. Unusual gland swelling should be reported to the physician.

How is Sjogren’s syndrome diagnosed?

The diagnosis of Sjogren’s syndrome involves detecting the features of dryness of the eyes and mouth. The dryness of the eyes can be determined in the doctor’s office by testing the eye’s ability to wet a small testing paper strip placed under the eyelid (Schirmer’s test using Schirmer tear test strips). More sophisticated eye testing can be done by an eye specialist (ophthalmologist). Salivary glands can become larger and harden or become tender. Salivary-gland inflammation can be detected by radiologic nuclear medicine salivary scans. Also, the diminished ability of the salivary glands to produce saliva can be measured with salivary flow testing. The diagnosis is strongly supported by the abnormal findings of a biopsy of salivary-gland tissue.

The glands of the lower lip are often used to obtain a biopsy sample the salivary-gland tissue in the diagnosis of Sjogren’s syndrome. The lower lip salivary-gland biopsy procedure is easily performed under local anesthesia with the surgeon making a tiny incision on the inner part of the lower lip to expose and remove a sample of the tiny salivary glands within.

Patients with Sjogren’s syndrome typically produce a myriad of extra antibodies against a variety of body tissues (autoantibodies). These can be detected through blood testing and include antinuclear antibodies (ANAs), which are present in nearly all patients. Typical antibodies that are found in most, but not all patients, are SS-A and SS-B antibodies, rheumatoid factor, thyroid antibodies, and others. Low red blood count (anemia) and abnormal blood testing for inflammation (sedimentation rate) are seen.

1. By Dawn Sanders | On April 4, 2007 | In Health-and-Fitness | Rated image NEWS FLASH: 6 out of 10 Americans are overweight and over acidic! Dr. Robert Young author of “The pH Miracle” has shown that fat is actually an over-acidification problem. What does that mean? The body creates fat cells to carry acids away from your vital organs, so these acids literally don’t choke your organs to death. Fat is saving your life! Fat is actually a response from the body to an alarming over-acidic condition. Here are some aspects regarding pH you may find useful. The body’s pH is measured on a scale of 0 – 14. Midrange at 7 is where the pH is balanced. Anything below 7 is acidic and a state where your body does not function as designed. Above 7 is called Alkaline. Alkaline is the state in which your body thrives. Disease cannot live in an alkaline environment. With that said: when you remove acid toxins from your body, you will: FLUSH Fat Fast resulting in easy weight loss GAIN Muscle Mass WATCH your skin glow ENJOY maximum energy all day, everyday. Here’s how to rid your body of that over-acidic state: Alkalizing Secret #1 — Drink Pure Alkaline Water – lots of it! Pure water meaning water that is filtered. At a minimum, you should be drinking 7 ounces of water for every 10 lbs of your body weight. So, if you weigh 130lbs, you need to drink a minimum of 91 ounces of pure water (that’s about 3 liters). Pure water meaning water that is filtered – the finest choice is an alkaline ionization unit (Jupiter is one of the finest on the market). If you don’t have this resource available, distilled water is a great choice with reverse osmosis coming next. Alkaline water means water with a pH over 7.5. Alkaline water adds oxygen to your water and helps to neutralize acids. A simple way to alkalize your water is with a dash of baking soda. There are also wonderful alkalizing agents you can purchase to buffer and alkalize the water. (P.S. Avoid: coffee, black tea and sodas. – These drinks are highly acidic and do not count towards your daily water intake) Alkalizing Secret #2 — Eat Celery…. This is one of the most alkaline foods you can eat. It quickly neutralizes acids. Eat it before, after or during a meal. Celery is so high in water content that is also works as an excellent thirst quencher. Celery is excellent for digestion. Alkalizing Secret #3 — Eat Green Salads – forget the cheese and croutons! Always have a green salad on hand. Make a huge salad every 3 days and keep it in your fridge to make it very easy to alkalize your body. Some greens that have the highest water content are: cucumbers, lettuce, tomatoes, celery, broccoli, cabbage, spinach, cauliflower, carrots, and onions. A great dressing would be cold pressed extra virgin olive oil with some lemon juice and Braggs Amino Acids. Keep this in a bowl in your fridge (tip: add cucumbers and tomatoes right before eating). Eat a HUGE salad with every meal! Alkalizing Secret #4 – Switch from cow’s milk, to almond, soy, or rice milk. Cows milk has shown to produce an abundance of mucous in the human body. There are also few adults who can metabolize the protein in cow’s milk properly. This protein, casein, is what a cow’s metabolism needs for proper health, not for a human beings health. Also note that most dairy cows are injected with hormones such as the Bovine Growth Hormone to increase their milk production. Many of these hormones have potentially horrific side effects that can be passed on when consumed. Almond, soy and or rice milk are excellent alternatives to dairy. They are well worth trying out. Alkalizing Secret #5 – Avoid artificial sweeteners! This includes: NutraSweet, Sucralose, Aspartame, Saccharin…. Not only are these acidic they also have other highly detrimental effects on the nervous system and neurological disease. Saccharin even tells you right on the package that it may cause cancer. There is one natural sugar substitute that has had no reported side effects: Stevia. Alkalizing Secret #6 – Eat a grapefruit in the morning wait 15 minutes before ingesting a carb or protein. Grapefruit, similar to lemons, is also alkalizing when ingested. Some people believe grapefruit to be a miracle fruit and I tend to support that group. Grapefruits have a very high water content and are highly alkalizing. Eat one first thing in the morning, and wait 15 minutes before eating a carbohydrate or protein (one or the other – do not mix). (The 15-minute suggestion is in accordance with proper food combining and allows your system to more easily digest. This recommendation applies to eating any fruit – fruit shouldn’t be combined with any other food type. Once eaten, wait 15 before consuming any other food type…ie: protein or carbohydrate). Alkalizing Secret #7 – Eliminate consumption of red meat, pork, lamb…substitute chicken, turkey or fresh fish in small quantities. Red meats, pork and lamb are highly acidic a very low water content, not to mention being hard on the digestive system. If you must have meat, opt for chicken or turkey. Fresh wild fish is another excellent route to take. Alkalizing Secret #8 – Reduce stress daily by adding yoga, tai chi, meditation, and proper breathing. An additional factor that adds to acidosis (acidic bodies) is stress. When the body moves into stress mode the digestive system shuts down and toxins cease to be eliminated. Thus the more toxins you keep in your system, the more the body will store them away (acids) in fat cells! Anything we can do to calm the mind/body will have a huge impact on alkalizing the body. Alkalizing Secret #9 – Drink a top quality super green supplement. : Organic super greens are known to be some of the most nutrient dense foods on the planet. They infuse the body with easily absorbed vitamins, minerals, amino acids chlorophyll, enzymes, phytonutients and alkaline salts that help neutralize acids in the blood and tissues. Alkalizing Secret #10 – Minimize/Avoid…. processed and refined foods. That means anything made with white flour and white sugar or food coloring. Our bodies were not designed to digest these chemicals and so it must do one of three things: 1. Eliminate them (if you are not hydrating properly this is very hard to do) or 2. Neutralize them by pulling alkaline buffers where it can – like from your bones leaching calcium, or from your blood, leaching iron. Or: 3. Park them away (in fat cells). Bottom line here – stay away from processed food as much as possible. In Summary: If you will start out by going down the list of tips and add one secret each day, there’s a tremendous possibility that you will be amazed with what you experience. Simply increasing the amount and type of water you drink can and often will be a HUGE shift in how you feel. Let me tell you – it only gets better! And remember…the name of the game is progress not perfection. Be gentle with yourself – for many people, these secrets represent a huge life change. I urge you to educate yourself on pH balance with the acid/alkaline dance. Note: The information in this article is for educational purposes only and is not designed to diagnose or treat an illness. About The Author: Dawn Sanders, pH Weight Loss Coach, is results oriented having learned on a personal level the magic of balancing the body’s pH for weight loss and for an extraordinary life. She follows Dr. Robert Young’s “pH Miracle” and “The New Biology”. Visit her website at: http://www.transformitnow.com

1. What is polymyositis? Polymyositis is an inflammatory muscle disease that causes muscle weakness. Myositis means inflammation of muscle. Usually, polymyositis affects the muscles that are closest to the trunk of the body. Eventually, people with polymyositis have trouble when rising from a sitting position, climbing stairs, lifting objects, or reaching overhead. In some cases, muscles that are not close to the trunk of the body become affected as the disease progresses. Polymyositis develops gradually over time, and it rarely affects people younger than 18. It is more common in women (by about two to one). If the condition is accompanied by an inflammatory process that strikes the skin as well, it is called dermatomyositis. Polymyositis can be present in combination with other illnesses. Both polymyositis and dermatomyositis can sometimes be associated with cancers, including lymphoma, breast, lung, ovarian, and colon cancer. What causes polymyositis? The cause of polymyositis is not known, but there are indications that heredity plays a role in the disease. Current research suggests that the condition might occur when immune system cells infiltrate and attack muscle tissue (an autoimmune process). Research into the workings of the immune system and what causes it to malfunction might result in more knowledge about the causes of polymyositis. What are the symptoms of polymyositis? The following are some symptoms of polymyositis. These symptoms might come and go: * Muscle weakness—This is the most common symptom. The muscles involved usually are those closest to the trunk of the body. The onset of weakness is usually gradual, occurring over three to six months or, rarely, the symptoms come on rapidly. * Difficulty getting up from chairs, climbing stairs, or lifting objects — Some people also have trouble with getting up after lying down. * Difficulty swallowing * Muscle ache — In some cases, muscles ache and are tender to the touch. * Fatigue * Shortness of breath due to heart and lung involvement * Patchy red or violet rash around the eyes — Some people also get patchy, red skin over the knuckles, elbows, and knees, or a red rash on the neck and upper chest. * Fever * Weight loss How is polymyositis diagnosed? The diagnosis of the disease usually begins with a doctor’s exam, as well as blood testing. People who have polymyositis often have unusually high levels of muscle enzymes, which are released into the blood by muscle that is being damaged by inflammation. Routine blood and urine tests can check for internal organ abnormalities. Chest X-rays, mammograms, PAP smears, and other screening tests might be considered to look for signs of cancers that might arise with polymyositis. Additional testing can rule out other conditions resembling polymyositis. Electromyography (EMG) and nerve conduction velocity studies are electrical tests of muscle and nerves that can show abnormal findings typical of polymyositis. These tests also can rule out other nerve-muscle diseases. Imaging of the muscles can show areas of muscle inflammation and can be used to find muscle biopsy sites. Muscle biopsy is a surgical procedure in which muscle tissue is removed and examined. A muscle biopsy is used to confirm the presence of muscle inflammation typical only of polymyositis. How is polymyositis treated? Polymyositis is treated with high doses of corticosteroids as a first course of treatment. Corticosteroids are given because they can effectively decrease the inflammation in the muscles. Corticosteroids do not always adequately improve polymyositis. In these patients immunosuppressive medicines are considered. These medicines include: * Methotrexate (brand names Rheumatrex and Trexall) * Azathioprine (brand name Imuran) * Cyclophosphamide (brand name Cytoxan) * Chlorambucil (brand name Leukeran) * Cyclosporine (brand name Sandimmune) In severe cases of polymyositis, the intravenous infusion of immunoglobulin (IVIG) has been an effective treatment. Physical therapy also is important in the treatment of polymyositis. With early medical treatment of the disease and disease flares, patients with polymyositis can do well. The disease frequently becomes inactive, enabling the patient to focus on muscle rehabilitation. What is dermatomyositis? When the inflammatory muscle disease polymyositis affects the skin, it is called dermatomyositis. In this condition, the eyes can be surrounded by a violet discoloration with swelling. There might be scaly, red skin over the knuckles, elbows, and knees. In addition, a red rash can occur on the face, neck, and upper chest. Hard lumps of calcium deposits can develop in the fatty layer of the skin. What causes dermatomyositis? In people with polymyositis and dermatomyositis, the body’s immune system stops working properly and begins attacking healthy tissues. Factors triggering this process are not known. What are the symptoms of dermatomyositis? Symptoms of dermatomyositis can vary a great deal from patient to patient. Some individuals might have the disease for months or years before noticing it. Muscle weakness might arise at the same time as the rash, or it might occur weeks, months, or years later. Some other common symptoms include: * Reddish or bluish-purple patches, mostly on areas exposed to the sun * Purple spots on bony prominences, especially the knuckles * Discoloration with swelling around the eyes * Ragged cuticles and prominent blood vessels on nail folds * A red rash on the face, neck, shoulders, upper chest, and elbows How is dermatomyositis diagnosed? The diagnosis of dermatomyositis is usually confirmed by the following tests: * Blood tests to detect increased amounts of muscle enzymes such as creatine kinase (CK) and sometimes lactic dehydrogenase (LDH) * Blood tests to detect auto-antibodies (antibodies that react with cells, tissues, or native proteins of the individual in which the antibodies are produced) * Skin biopsy of the rash * Biopsy of an affected muscle * Electromyography (EMG) testing * Magnetic resonance imaging (MRI) scan of muscles How is dermatomyositis treated? Doctors usually begin treatment of dermatomyositis with steroid drugs such as Prednisone. Immunosuppressants (Imuran, methotrexate) might be helpful for patients who are not helped by Prednisone. Further treatment with intravenous immunoglobulin (IVIG), used to slow down the autoimmune process, has been shown to be effective and safe. Physical therapy can preserve muscle function and prevent muscle wasting. What is inclusion body myositis (IBM)? Inclusion body myositis (IBM) is an inflammatory and degenerative muscle disease that causes painless weakening of muscles. IBM progresses slowly and is sometimes misdiagnosed as treatment-resistant polymyositis, another inflammatory muscle disease that causes muscle weakness. IBM also might be misdiagnosed as amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease). Symptoms of the disease usually begin after the age of 50, although the disease can occur earlier. IBM occurs more frequently in men than in women, and is the most common muscle disease in people aged 50 and older. What causes IBM? The cause of IBM is unknown. Because of the inflammation associated with IBM, some doctors think the disease is a form of autoimmune disorder. In this kind of disorder, the body’s immune system goes awry and attacks its own tissues — in this case, the muscles. Some experts have linked IBM to infection by a virus that has yet to be identified. Other researchers believe that the primary problem in IBM is an age-related inability of the muscle to deal with destructive chemicals. What are the symptoms of IBM? In IBM, the onset of muscle weakness usually is gradual, occurring over months or years. Falling and tripping usually are the first noticeable symptoms. For some people, IBM begins with weakness in the hands. People with IBM might have: * Difficulty with gripping, pinching, and buttoning * Weakness of the wrist and finger muscles * Atrophy (shrinking or wasting) of the muscles of the forearms * Weakness and visible wasting of the quadriceps muscles (the large muscles on the front part of the thighs) * Weakness of the lower leg muscles, below the knees * Weakness of the esophageal muscles, which can cause dysphagia (difficulty swallowing)—This occurs in about 20 percent t 40 percent of patients * Weakness of other muscle groups as the disease progresses How is IBM diagnosed? Doctors use a muscle biopsy to diagnose IBM. After administering an anesthetic, a doctor takes a sample of tissue from one of the affected muscles to be looked at in a laboratory. When viewed under the microscope, the muscle cells of a person with IBM contain vacuoles (rounded empty spaces). Within the vacuoles, there are usually abnormal clumps of several proteins including one called amyloid. The protein clumps, or inclusion bodies, give IBM its name. This is the hallmark of IBM. How is IBM treated? There is no effective course of treatment for IBM. The disease is unresponsive to corticosteroids and immunosuppressive drugs — two drugs that often treat inflammatory or autoimmune conditions. Some evidence suggests that intravenous immunoglobulin might help slightly in a small number of cases, but the benefit does not last long. Physical therapy might be helpful in maintaining mobility and helping to keep joints mobile. Other therapy, including treatments for the swallowing problems, is symptomatic and supportive.

More Evidence: Low-carb Diet Can Improve Diabetes Control and Reduce Meds
A low-carbohydrate, ketogenic diet improves glycemic control in obese type 2 diabetics, which allows some patients to reduce or eliminate their medication, according to results of a new study.

In fact, the diet allows some patients to reduce or eliminate their medication, according to the report in the medical journal Nutrition and Metabolism.

Carbohydrate restriction is at the heart of a diabetic diet. A very low carb diet causes the body to use protein to provide energy, which produces ketones, and it is therefore called a ketogenic diet. Another dietary approach is to use foods with a low glycemic index, ie, that don’t cause a rapid rise in blood sugar, and to cut back on calories.

Dr. Eric C. Westman, of Duke University Medical Center, Durham, North Carolina, and colleagues compared the effectiveness of the two diets in 84 obese patients with type 2 diabetes. They were assigned to a low carbohydrate (less than 20 grams per day) ketogenic diet or to low-glycemic reduced-calorie diet for 24-weeks. Those on the low-carb ketogenic diet had no restrictions on their daily calorie intake.

Patients in the low-carbohydrate, ketogenic diet had greater improvements in hemoglobin A1c than those in the low-glycemic, reduced-calorie diet group (-1.5% versus 0.5%, p = 0.03).

Those in the low-carb ketogenic diet group also lost more weight and had an increase in “good” HDL cholesterol compared with those in the other diet group.

Those in the low-carb, ketogenic diet group also had greater reductions in body weight (-11.1 kg versus -6.9 kg, p = 0.008), and high density lipoprotein cholesterol (+5.6 mg/dL versus 0 mg/dL, p < 0.001) compared with those in the low-glycemic, reduced-calorie diet group.

"In terms of renal function, serum creatinine and calculated glomerular filtration rate did not change significantly over the 24 weeks for either group," Dr. Westman and colleagues report. "There was a greater reduction in 24-hour urine protein for the low-carbohydrate, ketogenic diet group compared with the low-glycemic, reduced-calorie diet group."

An elimination or reduction in diabetes medication was possible for 95.2% of low-carbohydrate, ketogenic diet patients and 62.1% of low-glycemic, reduced-calorie diet patients (p < 0.01).

"Lifestyle modification using low carbohydrate interventions is effective for improving and reversing type 2 diabetes," the researchers conclude.

Nutrition and Metabolism, December 2008.

MayoClinic.com reprints 3/DSECTION=symptoms Raynaud’s disease Definition Raynaud’s disease is a condition that causes some areas of your body — such as your fingers, toes, tip of your nose and your ears — to feel numb and cool in response to cold temperatures or stress. In Raynaud’s disease, arteries that supply blood to your skin narrow, limiting blood circulation to affected areas. Women are more likely to have Raynaud’s disease. It’s also more common in people who live in colder climates. Treatment of Raynaud’s disease depends on its severity and the presence of associated conditions. For most people, Raynaud’s disease is more a nuisance than a disability. Symptoms CLICK TO ENLARGE Photograph showing hands affected by Raynaud’s disease Raynaud’s disease Raynaud’s disease is more than simply having cold hands and cold feet, and it’s not the same as frostbite. Signs and symptoms of Raynaud’s depend on the frequency, duration and severity of the blood vessel spasms that underlie the disorder. Signs and symptoms include: * Sequence of color changes in your skin in response to cold or stress * Numb, prickly feeling or stinging pain upon warming or relief of stress During an attack of Raynaud’s, affected areas of your skin usually turn white at first. Then, the areas often turn blue and feel cold and numb, and your sensory perception is dulled. As circulation improves, the affected areas may turn red, throb, tingle or swell. The order of the changes of color isn’t the same for all people, and not everyone experiences all three colors. Occasionally, an attack affects just one or two fingers or toes. Attacks don’t necessarily always affect the same digits. Although Raynaud’s most commonly affects your fingers and toes, the condition can also affect other areas of your body, such as your nose, lips, ears and even nipples. An attack may last less than a minute to several hours. People who have Raynaud’s accompanied by another disease will likely also have signs and symptoms related to their underlying condition. Causes Doctors don’t completely understand the cause of Raynaud’s attacks, but blood vessels in the hands and feet appear to overreact to cold temperatures or stress: * Cold temperatures. When your body is exposed to cold temperatures, your extremities lose heat. Your body slows down blood supply to your fingers and toes to preserve your body’s core temperature. Your body specifically reduces blood flow by narrowing the small arteries under the skin of your extremities. In people with Raynaud’s, this normal response is exaggerated. * Stress. Stress causes a similar reaction to cold in the body, and likewise the body’s response may be exaggerated in people with Raynaud’s. Blood vessels in spasm With Raynaud’s, arteries to your fingers and toes go into what’s called vasospasm. This constricts the vessels dramatically and temporarily limits blood supply. Over time, these same small arteries may also thicken slightly, further limiting blood flow. The result is that affected skin turns a pale and dusky color due to the lack of blood flow to the area. Once the spasms subside and blood returns to the area, the tissue may turn red before returning to a normal color. Cold temperatures are most likely to provoke an attack. Exposure to cold can be as simple as putting your hands under a faucet of running cold water, taking something out of the freezer or exposure to cold air. For some people, exposure to cold temperatures isn’t necessary. Emotional stress alone can cause an episode of Raynaud’s. Some researchers are studying whether Raynaud’s may be partly an inherited disorder. Primary vs. secondary Raynaud’s Raynaud’s occurs in two main types: * Primary Raynaud’s. This is Raynaud’s without an underlying disease or associated medical problem that could provoke vasospasm. Also called Raynaud’s disease, it’s the most common form of the disorder. * Secondary Raynaud’s. Also called Raynaud’s phenomenon, this form is caused by an underlying problem. Although secondary Raynaud’s is less common than the primary form, it tends to be a more serious disorder. Signs and symptoms of secondary Raynaud’s usually first appear at later ages — around 40 — than they do for people with the primary form of Raynaud’s. Causes of secondary Raynaud’s include: * Scleroderma. Raynaud’s phenomenon occurs in the majority of people who have scleroderma — a rare disease that leads to hardening and scarring of the skin. Scleroderma, a type of connective tissue disease, results in Raynaud’s because the disease reduces blood flow to the extremities. * Lupus. Raynaud’s is also a common problem for people with lupus — an autoimmune disease that can affect many parts of your body, including your skin, joints, organs and blood vessels. An autoimmune disease is one in which your immune system attacks healthy tissue. * Rheumatoid arthritis. Raynaud’s may be an initial sign of rheumatoid arthritis — an inflammatory condition causing pain and stiffness in the joints, often including the hands and feet. * Sjogren’s syndrome. Raynaud’s phenomenon can also occur in people who have Sjogren’s syndrome — an autoimmune disorder that may accompany scleroderma, lupus or rheumatoid arthritis. * Diseases of the arteries. Raynaud’s phenomenon can be associated with various diseases that affect arteries, such as atherosclerosis, which is the gradual buildup of plaques in blood vessels that feed the heart (coronary arteries), or Buerger’s disease, a disorder in which the blood vessels of the hands and feet become inflamed. Primary pulmonary hypertension, a type of high blood pressure that affects the arteries of the lungs, is frequently associated with Raynaud’s. * Carpal tunnel syndrome. The carpal tunnel is a narrow passageway in your wrist that protects a major nerve to your hand. Carpal tunnel syndrome is a condition in which pressure is put on this nerve, producing numbness and pain in the affected hand. The affected hand may become more susceptible to cold temperatures and episodes of Raynaud’s. * Repetitive trauma. Raynaud’s can also be caused by repetitive trauma that damages nerves serving blood vessels in the hands and feet. Some people who type or play the piano vigorously or for long periods of time may be susceptible to Raynaud’s. Workers who operate vibrating tools can develop a type of Raynaud’s phenomenon called vibration-induced white finger. * Smoking. Smoking constricts blood vessels and is a potential cause of Raynaud’s. * Injuries. Prior injuries to the hands or feet, such as wrist fracture, surgery or frostbite, can lead to Raynaud’s phenomenon. * Certain medications. Some drugs — including beta blockers, which are used to treat high blood pressure; migraine medications that contain ergotamine; medications containing estrogen; certain chemotherapy agents; and drugs that cause blood vessels to narrow, such as some over-the-counter cold medications — have been linked to Raynaud’s. * Chemical exposure. People exposed to vinyl chloride, such as those who work in the plastics industry, may develop an illness similar to scleroderma. Raynaud’s can be a part of that illness. * Other causes. Raynaud’s has also been linked to thyroid gland disorders. Risk factors Risk factors for primary Raynaud’s include: * Your sex. Primary Raynaud’s affects women more than men. * Your age. Although anyone can develop the condition, primary Raynaud’s often begins between the ages of 15 and 25. * Where you live. The disorder is also more common in people who live in colder climates. * Your family history. Additionally, a family history appears to increase your risk of primary Raynaud’s. About one-third of people with primary Raynaud’s have a first-degree relative with the disorder. Risk factors for secondary Raynaud’s include: * Associated diseases. These include conditions such as scleroderma and lupus, and smoking. * Certain occupations. People in certain occupations, such as workers who operate tools that vibrate, also may be more vulnerable to secondary Raynaud’s. Tests and diagnosis If your doctor suspects Raynaud’s, he or she will ask for a detailed description of your signs and symptoms. Most doctors can diagnose Raynaud’s directly from a description of your signs and symptoms. But it may be more difficult for them to identify whether you have Raynaud’s alone or whether another disease, or some aspect of your lifestyle, is causing your symptoms. Your doctor will also examine you to rule out other medical problems that may cause similar signs and symptoms, such as a pinched nerve. Your doctor may perform an in-office cold-simulation test. This test may involve placing your hands in cool water or exposing you to cold air, to invoke an episode of Raynaud’s. Sorting out primary vs. secondary Raynaud’s To distinguish between primary and secondary Raynaud’s, your doctor may perform an in-office test called nail fold capillaroscopy. During the test, the doctor examines your nail fold — the skin at the base of your fingernail — under a microscope. Tiny blood vessels (capillaries) near the nail fold that are enlarged or deformed may indicate an underlying disease. However, some secondary diseases can’t be detected by this test. If your doctor suspects that another condition, such as an autoimmune or connective tissue disease, underlies Raynaud’s, he or she may order blood tests, such as: * Antinuclear antibodies (ANA) test. A positive test for the presence of these antibodies — produced by your immune system — indicates a stimulated immune system and is common in people who have connective tissue diseases or other autoimmune disorders. * Erythrocyte sedimentation rate (ESR). This blood test determines the rate at which red blood cells settle to the bottom of a tube in the space of an hour. A faster than normal rate may signal an underlying inflammatory or autoimmune disease. Autoimmune diseases are commonly associated with secondary Raynaud’s. There’s no single blood test to diagnose Raynaud’s. Your doctor may order other tests, such as those that rule out diseases of the arteries, to help pinpoint a disease or condition that may be associated with Raynaud’s. Complications If Raynaud’s is severe — which is rare — blood circulation to your fingers or toes could permanently diminish, causing deformities of your fingers or toes. If an artery to an affected area becomes blocked completely, sores (skin ulcers) or dead tissue (gangrene) may develop. Ulcers and gangrene can be difficult to treat. See your doctor right away if you have a history of severe Raynaud’s and develop an ulcer or infection in one of your affected fingers or toes. Treatments and drugs Self-care and prevention steps usually are effective in dealing with mild symptoms of Raynaud’s. If these aren’t adequate, however, medications are available to treat more severe forms of the condition. The goals of treatment are to: * Reduce the number and severity of attacks * Prevent tissue damage * Treat any underlying disease or condition Medications Depending on the cause of your symptoms, medications may prove effective at treating Raynaud’s. To widen (dilate) blood vessels and promote circulation, your doctor may prescribe: * Calcium channel blockers. These drugs relax and open up small blood vessels in your hands and feet. They decrease the frequency and severity of attacks in about two-thirds of people with Raynaud’s. These drugs can also help heal skin ulcers on your fingers or toes. Examples include nifedipine (Adalat, Procardia), amlodipine (Norvasc), diltiazem (Cardizem, Dilacor), felodipine (Plendil), nisoldipine (Sular) and isradipine (DynaCirc Cr). * Alpha blockers. Some people find relief with drugs called alpha blockers, which counteract the actions of norepinephrine, a hormone that constricts blood vessels. Examples include prazosin (Minipress) and doxazosin (Cardura). * Vasodilators. Some doctors prescribe a vasodilator — a drug that relaxes blood vessels — such as nitroglycerin cream to your fingers to help heal skin ulcers. You and your doctor may find that one drug works better for you than another. Some drugs used to treat Raynaud’s have side effects that may require you to stop taking the medication. A drug may also lose effectiveness over time. Work with your doctor to find what works best for you. Some medications actually can aggravate Raynaud’s by leading to increased blood vessel spasm. Your doctor may recommend that you avoid taking: * Certain over-the-counter (OTC) cold drugs. Examples include drugs that contain pseudoephedrine (Actifed, Chlor-Trimeton, Sudafed). * Beta blockers. This class of drugs, used to treat high blood pressure and heart disease, includes metoprolol (Lopressor, Toprol), nadolol (Corgard) and propranolol (Inderal). * Birth control pills. If you use birth control pills, you may wish to switch to another method of contraception because these drugs affect your circulation and may make you more prone to attacks. If you have questions about how best to manage Raynaud’s, contact your doctor. Your primary care doctor may refer you to a physician who specializes in treating Raynaud’s. Other treatments Sometimes in cases of severe Raynaud’s, approaches other than medications may be a treatment option: * Nerve surgery. Nerves called sympathetic nerves in your hands and feet control the opening and narrowing of blood vessels in your skin. Sometimes it’s necessary in cases of severe Raynaud’s to cut these nerves to interrupt their exaggerated response. Through small incisions in the affected hands or feet, a doctor strips away these tiny nerves around the blood vessels. The surgery, called sympathectomy, may reduce the frequency and duration of attacks, but it’s not always successful. * Chemical injection. Doctors can inject chemicals to block sympathetic nerves in affected hands or feet. You may need to have the procedure repeated if symptoms return or persist. * Amputation. Sometimes, doctors need to remove tissue damaged from a lack of blood supply. This may include amputating a finger or toe affected by Raynaud’s in which the blood supply has been completely blocked and the tissue has developed gangrene. But this is rare. Research Scientists are evaluating the use of new drugs to treat Raynaud’s. Some examples of drugs under study include the high blood pressure drug losartan (Cozaar), the erectile dysfunction medication sildenafil (Viagra), the antidepressant medication fluoxetine (Prozac), and a class of medication called prostaglandins. Prevention Raynaud’s is a condition that you may need to manage for life once it develops. But there are ways to help prevent attacks: * Dress warmly outdoors. In winter, wear a hat, scarf, socks and boots, and mittens or gloves under mittens when you go outside. Put them on before you go outside. A hat is important because you lose a great deal of body heat through your head. Wear a coat with fairly snug cuffs to go around your mittens or gloves, to prevent cold air from reaching your hands. Wear earmuffs and a face mask if the tip of your nose and your earlobes are sensitive to cold. Run your car heater for a few minutes before driving in cold weather. * Take precautions indoors. Wear socks. When taking food out of the refrigerator or freezer, wear gloves, mittens or oven mitts. Some people find it helpful to wear mittens and socks to bed during winter. Because air conditioning can trigger attacks, setting your air conditioner to a warmer temperature may help prevent attacks. You also may find it helpful to use insulated drinking glasses. * Consider moving to a location with a milder climate. Moving to a warmer climate may help people with severe Raynaud’s. However, Raynaud’s can occur even in warmer climates when the temperature decreases. Lifestyle and home remedies A variety of steps can decrease Raynaud’s attacks and help you feel better overall: * Don’t smoke. Nicotine in cigarettes causes skin temperature to drop by constricting blood vessels, which may lead to an attack. Inhaling secondhand smoke also may aggravate Raynaud’s. * Exercise. Your doctor may encourage you to exercise regularly, particularly if you have primary Raynaud’s. Exercise can increase circulation, among other health benefits. * Control stress. Because stress may trigger an attack, learning to recognize and avoid stressful situations may help control the number of attacks. * Avoid caffeine. Caffeine causes your blood vessels to narrow and may increase the signs and symptoms of Raynaud’s. * Take care of your hands and feet. If you have Raynaud’s, guard your hands and feet from injury. Don’t walk barefoot. Take care of your nails to avoid injuring sensitive toes and fingertips. In addition, avoid wearing anything that compresses blood vessels in your hands or feet, such as tight wristbands, rings or footwear. * Avoid workplace triggers. Avoiding tools that vibrate the hand may reduce the frequency of attacks. During an attack: What should you do? What should you do if you’re experiencing an attack of Raynaud’s? The first and most important action is to warm your hands or feet or any other affected areas of skin. The following steps can help you gently warm your fingers and toes: * Move to a warmer area. * Place your hands under your armpits. * Wiggle your fingers and toes. * Make wide circles, or windmills, with your arms. * Run warm — but not hot — water over your fingers and toes. * Massage your hands and feet. If a stressful situation triggers an attack, you can help stop the attack by getting out of the stressful situation and relaxing. If you’re trained in biofeedback, you can use this technique along with warming your hands or feet in water to help lessen the attack. Alternative medicine Lifestyle changes and supplements that encourage better circulation may be effective alternatives for managing Raynaud’s. If you’re interested, talk to your doctor about: * Biofeedback. Biofeedback — using your mind to control body temperature — may help decrease the severity and frequency of attacks. Biofeedback includes guided imagery to increase the temperature of hands and feet, deep breathing and other relaxation exercises. Your doctor may be able to suggest a therapist who can help you learn biofeedback techniques. Books and tapes also are available on the subject. * Niacin. Niacin, also known as vitamin B-3, causes blood vessels to dilate, increasing blood flow to skin. This has led scientists to believe that niacin supplements may be useful in treating Raynaud’s, although niacin supplements may have side effects. Coping with the stress and nuisance of Raynaud’s takes patience and effort. Work with your doctor to manage your condition and maintain a positive attitude. The majority of people with Raynaud’s respond to treatment. By Mayo Clinic Staff Nov. 16, 2007 © 1998-2008 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. “Mayo,” “Mayo Clinic,” “MayoClinic.com,” “EmbodyHealth,” “Reliable tools for healthier lives,” “Enhance your life,” and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. DS00433 Mayo Clinic

- Myofascial Release

- Myofascial Release is a manual massage technique (using no oil, usually clothed) for releasing bonds between fascia and integument, muscles, tendons, ligaments and bones, in order to reduce pain and increase mobility, fluidity and range of motion. For some techniques, client is best clothed, and for others unclothed without or with oil. Light to strong force may be used with various techniques, frequently beginning distally of where symptoms are prevalent- the problems may be elsewhere from the pain and stiffness. Methods may include sustained or effleuraging shear, tension (pulling), compression, skin rolling, and barefoot deep tissue, sometimes coupled with active or passive joint motion, with or without stretching.

Myofascial release is one of the modalities used by sports massage therapists and physical therapists, and exists in many different forms. Most clinical therapists use direct pressure methods, such as Rolfing^®. Lighter or slower techniques, such as Bowen Technique, use more time to release the layers. Paul, with a background in sports massage and Trigger Point Therapy, trained under John Harris, David Dallmeyer, P.T. and Lamar Bush.

The goal of myofascial release is to release fascial restrictions and allow the layers to move freely, thus allowing the muscles to shorten as well as to lengthen, as they should in a healthy human body. Surprisingly, a muscle may appear tight due to the opposing muscle being restricted from shortening. This modality is sometimes confused with Myofascial Pain Syndrome and Trigger Point Therapy, which is a completely different modality. However most myofascial pain and dysfunction can be attributed to fascial restrictions and/ or trigger points, thus the two modalities of Myofascial Release and Trigger Point Therapy are usually effective, non-invasive options for relief of various types of myofascial pain, including fibromyositis, fibrositis and other conditions which are sometimes labeled idiopathic fibromyalgia syndrome due to inadequate or erroneous diagnoses. Other modalities by Trisoma, such as Deep Tissue and Proprioceptive Neuromuscular Facilitation (PNF) also help release fascia.

Restricted fascia is a common contributing cause of seemingly tight and painful muscles, and restricted joint mobility. Although massage that affects muscles also affects fascia, the effects of myofascial massage specifically may be more potent.^[4]The nervous system’s response to physical manipulation of the surface or underlying tissues of the body causes reflexive effects including:

• increased blood and lymph flow
• slowed heart rate
• slowed respiration
• increased immune response
• muscle tonus reduced
• pain reduction
• stress reduction
• general relaxation

Fascia are sheaths or bands of fibrous tissue that bind muscles and other organs. The main factors that induce fascial abnormalities are trauma, chronic strain, and immobility of fascial tissues.^[1]Injuries, stress, overuse, dehydration and poor posture contribute to restrictions in the layers due to bonding of fascia. In response to physical stress, fascia may reorganize itself and thicken and shorten along lines of tension.^[2] This affects motion of the neck, back, arms, legs, feet and elsewhere. Fascia can become more fibrotic when traumatized or overused, and it tends to web after periods of immobility, causing collagen molecules to tether together, leading to fibrosis. When muscle tissue, fascia and other tissues are damaged, the body tends to quickly patch the area with scar tissue which does not necessarily match the original composition; it becomes less elastic, less vascularized, less innervated, less oriented and thus poorer in performance, and possibly numb or painful. When a muscle is stretched, its fascia is also lengthened. If the muscle’s fascia is stuck to other layers of fascia, soft tissue, bone or other organs, tightness may be felt locally and in other areas, limiting muscle elongation, when muscle tightness may not be the actual problem. Myofascial stretching or release in one area of the body may be felt in, and may affect, other body areas. When one considers the many layers of broad tissue that the back has, it becomes clearer why myofascial issues can contribute to back trouble even when people do not feel overworked.

Fascia covers all organs, including muscles, of the body, and has two types. Superficial fasciais fibroareolar tissue and is found immediately beneath the integument over almost the entire surface of the body. It contains fat, and connects the skin with the deep fascia. Deep fasciais a dense, inelastic, parallel fibrous membrane, forming sheaths for individual muscles (epimysium) and internal organs and structures, and in some cases, such as intermuscular septa and tendons, affording them broad surfaces for attachment to aponeuroses or periosteum (bone). Examples are Tensor fasciæ latæ and Glutæus maximus in the thigh, Palmaris longus in the hand and Biceps bracchii and Biceps femoris. Targets of myofascial release include adhesions of superficial and deep fascia, integument, tendons, ligaments, retinacula, aponeuroses, bursae, bone, muscle and other organs.

Myofascial Release separates the layers of fascia from one another and from muscle and periosteum,

and it also increases the distance between the collagen fibers, allowing for increased hydration, nutrition and a decrease in capillary compression. Many people believe that lack of mobility is prima facie evidence of tight muscle strands. Trisoma believes that the muscle stretch reflex has an effect on the release of fascia. After myofascial release, many people, even highly mobile and flexible athletes, find that mobility may be improved by release of the fascia layers that can limit the extension and contraction of various muscles.

As with muscle contraction theories and muscles stretch theories, the exact mechanism for myofascial release is still disputed. Some theorize that there is a water bond or collagen bond between fascia layers. Some state that vibrational resonance or emotional unwinding affects consciousness and allows healing.^[3] Paul analogizes Myofascial Release with pulling apart a chicken carcass, or pulling the body out of a shrimp tail. If one pulls with the proper force and technique for the situation, fascia and muscles (meat) will be separated; if one pulls hard, unknown results can occur; if one pulls slowly, it might happen… or you might go hungry.

Self-help is possible with one’s own hands, or tools such as Body Stick or foam rollers.
References
1. Lowe, Dr. John C. The Purpose and Practice of Myofascial Therapy, Houston, McDowell Publishing Co., 1989 (Return to Reference 1 in text)
2. Singer, D. W., Manual Therapy Techniques, Rehab Management, June/July 1994, 153-56 (Return to Reference 2 in text)
3. John F. Barnes, et al. (Return to Reference 3 in text)
4. Marian Wolfe Dixon, Myofascial Massage, Lippincott Williams & Wilkins, 2006, ISBN 0781748321, 9780781748322, 217 pages (Return to Reference 4 in text)

Chart Above Shows Myofascial Trigger Points

Myofascia is a thin, almost translucent film that wraps around muscle tissue. It is the tissue that
holds all the other parts together. It gives shape to and supports all of the body’s musculatures.

You can see myofascia if you cut up a fresh chicken. It is the thin, sticky, somewhat filmy material that wraps around the muscle tissue. It wraps around muscle fibers, bundles of fibers, and the muscles themselves, and then goes on to form tendons and ligaments.

For people with Fibromyalgia syndrome (FMS) and/or myofascial pain syndrome (MPS), the myofascia takes on a new importance. Tightening and thickening of the myofascia occurs in many cases of FMS and/or MPS. If both of these conditions are present, this tightening causes more than double the trouble.

When the myofascial tissues become thickened and lose their elasticity, neurotransmitter ability to send and receive messages between the mind and body is damaged, and the communication between the mind and body is damaged. Myofascia, then, may well be the key to what goes wrong in FMS&MPS Complex.

In the myofascia there is a material called ground substance. This material can exist in a solid, semisolid, or fluid state.

When ground substance changes from a liquid to a gel, the myofascia tightens, and it is difficult to get it to reverse to a liquid state again without intervention.

FMS & MPS Complex

Fibromyalgia (FMS) and Myofascial Pain Syndrome (MPS) are very different syndromes. The majority of physicians lump the two conditions together, probably because they see many patients who have both FMS and MPS, which I call FMS&MPS Complex. Unless doctors have a thorough knowledge of and familiarity with individual TrPs, they don’t stand a chance of sorting out the different symptoms of the two different syndromes.

One interesting difference between the two conditions is that more women have FMS than men. Myofascial Pain Syndrome, however, affects men and women in equal numbers. One important difference is that in MPS, muscles located some distance from the trigger points have normal sensitivity, whereas in FMS, there is an overall flu-like achiness, and generalized sensitivity, but no trigger points.

There are many medical journal articles that explain why FMS and MPS are different, and why the difference is important. (See, for example, Borg-Stein and Stein (1996), Schneider (1995), Simons, Travell and Simons (1998.)

People with FMS & MPS Complex
face more than just the two sets of
symptoms of both conditions.

Fibromyalgia and MPS not only occur together, they reinforce and amplify the symptoms of both. Because of this, physical therapy and all other forms of treatment must proceed very carefully. Any treatment tried will be both more complicated and less successful than if the patient had only one of the two syndromes.

One study has already been done. Hong and Hsueh (1996) found that those with FMS and MPS experience more pain when they receive trigger point injections, that the trigger point injections have less effect, and that the effect often takes longer to develop and may not last as long than if the patients had MPS only. In FMS&MPS, chronic pain exists, which is characterized by the trigger points of MPS and many other symptoms.

All of these symptoms and trigger points are intensified by the pain amplification aspect of FMS. Furthermore, some of the treatments normally prescribed for FMS patients can damage MPS patients and the reverse is also true. In FMS, many different informational substances may be affected in different combinations interacting in different ways in different patients.

Other biochemicals in the body are affected to different degrees. For example, histamine (a neurotransmitter) is often an important factor when there are many allergic manifestations, but the possible combinations of biochemical dysfunction are endless. When the possible combinations of TrPs are calculated, it is easy to see why no two FMS&MPS Complex patients are alike. Fibromyalgia perpetuates MPS and the reverse is also true. The spiral of pain/contraction/pain/contraction continues until it is interrupted by relief in some form.

A lot can be done to relieve MPS and lighten the pain load. There are many things that help FMS, as well. It’s important for people with this combination of syndromes to take on the responsibility of managing their own treatment, seeing that the perpetuating factors are identified and dealt with as thoroughly as possible. It isn’t easy, and it takes concentrated focus to change the habits of a lifetime.

Getting as well as possible
~ optimizing your quality of life ~ takes commitment.
What is done to or for you can help a lot, but getting better is
primarily a function of what you do for yourself.

News in the World of Myofascial Pain

The World

Life has been tough for those of us with myofascial pain syndrome. We have too often been met with doctors who “don’t believe in” MPS. We have been hampered by the lack of a scientifically credible and understandable cause for this condition and an officially recognized set of diagnostic criteria. This resulted in a lack of training of physicians and therapists. The insurance companies and the Social Security Administration made our lives even more difficult. This is about to change.

We now have facts that cannot be disputed. At last we have proof that myofascial pain caused by trigger points is a true disease. We know what creates a trigger point, what it is, and many of the ways it can cause us pain and other symptoms. We know what causes those taut bands that constrict our muscles, and we know why our muscles become so tight that they hurt.

A myofascial trigger point is a localized area starving for oxygen. It creates an increased local energy demand. This local energy crisis releases neuroreactive biochemicals which sensitize nearby nerves. The sensitized nerves initiate the motor, sensory, and autonomic effects of myofascial trigger points by acting on the central nervous system. Muscles with trigger points are muscles in a constant state of energy crisis.

Myofascial trigger points can be identified and documented electrophysiologically by characteristic spontaneous electrical activity (SEA). They may also be identified histologically (which means that the structure of the cells have changed) by contraction knots– the lumps and bumps we know only too well. Both of these phenomenon seem to result from excessive release of the neurotransmitter acetylcholine (ACh) from the nerve terminal of the motor endplate (the complex end formation of the nerve).

Many of those already suffering from the pain of fibromyalgia also suffer from myofascial pain syndrome. Myofascial pain syndrome is another form of chronic pain that can affect the entire body, particularly the face and jaw. Myofascial pain can add to the already annoying symptoms of fibromyalgia, and can contribute to disability and a poor quality of life if not diagnosed properly. If you think that you may be suffering from myofascial dysfunction, visit with your health care provider to discuss your treatment options.

What is Myofascial Pain Syndrome?
Myofascial syndrome is a pain disorder that affects the muscles and fascia throughout your body. Fascia is like a web that surrounds the bones, tissues, organs, and blood vessels throughout the body. Myofascial pain syndrome can attack and cause degeneration of certain areas of the fascia, resulting in chronic pain and a variety of other symptoms.

Pain usually originates in specific areas of the body, called myofascial trigger points (TrPs), which feel like tiny nodules under the skin. These trigger points commonly develop throughout the body, typically where the fascia comes into contact with a muscle.

Myofascial pain syndrome is a very common illness, and most people will develop at least one trigger point in their body at some point in their lives. The majority of these people will not develop severe symptoms and will be able to continue on with their normal routines. However, about 14% of the population will develop a chronic form of the syndrome, resulting in persistent pain and discomfort.

Myofascial pain disorder is very common in fibromyalgia sufferers. It was once thought that myofascial pain syndrome was actually a kind of fibromyalgia. However, this is now known not to be the case. It is possible to have both fibromyalgia and chronic myofascial syndrome, and therefore it is important to be diligent when analyzing your symptoms. If you notice myofascial syndrome symptoms, record them and report them to your doctor.

Signs and Symptoms of Myofascial Pain Syndrome
The most common sign of myofascial pain is the presence of palpable trigger points in your muscles. Trigger points are areas of extreme tenderness and sensitivity, and usually form in bands of muscle underneath your skin. They are similar to the tender points caused by fibromyalgia, only trigger points can be felt beneath the skin. When touched, trigger points will produce pain and twitching in the muscles. Often, pain is felt in an area distinct from the trigger point that is actually affected � this is called referred pain.

The pain of myofascial syndrome is typically a dull ache, but can also produce a throbbing, stabbing, or burning sensation. Pain is often located in the jaw area, though any part of the body can be affected. One-third of myofascial pain sufferers report localized pain, while two-thirds report having pain all over their bodies.

Myofascial pain can also produce a variety of other symptoms, many of which may appear unrelated. These include:

• numbness in the extremities
• popping or clicking of the joints
• limited movement of joints, particularly the jaw
• muscle weakness (manifested in dropping things)
• migraine or headache
• disturbed sleep
• balance problems
• tinnitus and ear pain
• double vision or blurred vision
• problems with memory
• unexplained nausea, dizziness, and sweating

Aggravating Factors
Symptoms are often aggravated by specific factors. Stress and anxiety contribute to muscle tension and can irritate trigger points. Changes in the weather, including sudden coldness, high humidity, or extreme dryness can also exacerbate symptoms. Physical activity can also trigger symptoms.

Causes of Myofascial Pain Syndrome
There are numerous proposed causes of myofascial pain:

• Muscle and Skeletal Problems: The causes of myofascial pain dysfunction syndrome can be numerous and depend upon the individual. Generally, myofascial pain is caused by some sort of trauma to the muscles and skeleton in the body. Overworking of the muscles can cause damage to certain areas resulting in the development of a trigger point. Poor posture can also trigger myofascial pain in certain individuals. Skeletal abnormalities, such as having different sized feet, toes, or legs, can also contribute to the development of myofascial pains. Frequent exposure to cold weather may also increase the risk of developing chronic myofascial pain syndrome.
• Chronic Fibromyalgia Pain: People with fibromyalgia may get myofascial pain syndrome as a result of their fibromyalgia pain. Compensating for pain can often cause reduced movement or an unhealthy posture, leading to the formation of trigger points. The severe pain caused by fibromyalgia also causes muscle contractions around tender points, referred to as guarding. Eventually these muscle contractions cause trigger points to form in addition to the tender points of fibromyalgia.
• Depression Associated with Fibromyalgia: The depression associated with fibromyalgia may also cause myofascial pain to develop. At least 30% of fibromyalgia patients suffer from depression, which causes low levels of serotonin in the brain. Serotonin is a neurotransmitter responsible for regulating mood and pain in the body. Depression may interfere with the process of regulating pain, causing MPS.

Effects of MPS on Fibromyalgia
Having both myofascial pain syndrome and fibromyalgia can be quite trying at times. Symptoms of MPS and fibromyalgia are very similar, making it difficult for medical professionals to properly diagnose many people. Without proper diagnosis, a patient may not receive appropriate treatment, causing his or her symptoms to become even worse. In addition, myofascial pain can often contribute to the pain caused by fibromyalgia, making life much more difficult to enjoy.

It is important for healthcare providers to be aware that chronic myofascial pain (CMP) and fibromyalgia (FM or FMS) are real diseases, and should not be classified as “wastebaskets” into which patients who complain of pain but do not have other clear-cut diagnoses, should be “dumped.” The best ethical consultation that can be shared with patients is that if they encounter any healthcare provider who does not believe in the validity of CMP and FM, then the patient should change to a better-educated healthcare professional.

Patients with CMP and/or FM have “invisible” chronic pain. Since patients usually appear to be healthy, others may not understand or even believe them when they say they hurt; if practitioners do believe these patients, they frequently don’t realize how much patients with CMP or FM may suffer. Pain waxes and wanes, but is always present, and at times can be severe. Chronic pain can be exhausting and demoralizing.⁸

Patients with CMP and/or FM usually have a long history of seeking a doctor’s care yet not obtaining a diagnosis for their condition. Typically, these patients have undergone numerous provider visits and testing, have frequently been misunderstood and doubted. They may even, at times, doubt themselves and feel guilty for not being able to “do their share.”

It is not uncommon for this patient population to go from one doctor to another for several years before a diagnosis of CMP or FM is finally made. Throughout this time, these patients are likely to accumulate what amounts to their own “personal pharmacy” of prescriptions that have been tried with unsuccessful results or have intolerable side effects.

These patients often feel a profound sense of relief when they finally learn they have a recognized illness. Many patients who read the literature feel as though the common signs and symptoms were lifted directly from their lives. They are often relieved to know they are not alone and that there are others who share the same symptoms and who understand the difficulty involved in obtaining appropriate medical care.

Myofascia and Chronic Pain
Starlanyl and Copeland describe myofascia as the thin, almost translucent film that wraps around muscle tissue (“myo” means muscle).¹ Myofascia is an extensive gauze-like network that gives shape to the body and supports its musculature. There are at least three different layers of fascia: superficial, deep and subserous; all are continuous and three-dimensional. Fascia is also the material from which adhesions and scar tissue are formed.¹

Chronic myofascial pain (CMP) is sometimes referred to as “myofascial pain syndrome” (MPS), especially in older literature.^{1,2,6,7,10-16}

A syndrome includes a specific set of signs and symptoms that occur together. A disease, on the other hand, has a known and defined cause and mechanism(s) for producing symptoms. Myofascial pain due to trigger points is now considered a true disease, rather than a syndrome (i.e., CMP, rather than MPS). Fibromyalgia is a syndrome, as are rheumatoid arthritis and lupus.¹ CMP is a musculoskeletal chronic pain syndrome which is nonprogressive (although it may seem to be), nondegenerative, and noninflammatory. It is caused by the activation of one or more trigger points.¹⁸

Trigger Points: Trigger points (TrPs) are not the same as the “tender points” that occur in fibromyalgia or acupressure points; they are extremely sore or hyperirritable areas that can develop anywhere in the body and are more common than generally thought. They may feel like knots, nodules, hard lumps, or taut, ropy bands of fibers in the muscles.^1,6,18,27 In very severe cases, muscle may feel like hardened concrete.¹⁴ Trigger points may be active or latent. Active trigger points cause pain, and latent ones can be “recruited” into causing pain. While CMP is not progressive, it can appear to be since each trigger point can develop satellite and secondary trigger points, which can themselves form satellites and secondaries, and so on.^6,18 This cascade is especially likely if perpetuating or aggravating factors are not identified and corrected.^6,16

Aggravating Factors: Perpetuating or aggravating factors are numerous, and often unique.^6,16 Common ones include poor posture and body mechanics, repetitious exercises or work, and anything that restricts movement or decreases oxygen supply to the muscles.^6,16 Impaired sleep, chewing gum, smoking cigarettes, dental work, exposure to organic chemicals or heavy metals, inhalant and food allergies, nutritional deficiencies, metabolic and endocrine dysfunction, malabsorptive conditions in the gut, chronic infections, fibromyalgia, alcohol ingestion, and stress (physical and/or mental), among others, are perpetuating factors in some patients.^6,16

When a trigger point is stimulated, it refers pain to other areas of the body in specific, predictable, characteristic patterns. Stimulation of some trigger points may also cause seemingly unrelated signs and symptoms; these include migraines, other headaches, jaw pain, neck pain, lower back pain, earaches, heartburn, pseudo-heart pain, extreme dizziness, nausea, loss of balance, staggering, clumsiness, tinnitus, distorted perception of weight when lifting with hands, carpal tunnel syndrome-like symptoms, irritable bowel syndrome, bruxism, dysmenorrhea, impotence, painful intercourse, paresthesias, sciatica, leg cramps, buckling knees and ankles, blurring of vision, double vision, trouble swallowing, hypoglycemic-like symptoms, sweating, blanching, lacrimation, salivation, coryza, sinus pain, congestion, pilomotor activity, and decreased immunity.^1,6,7,16,27 Joint pain that can be mistaken for arthritis, tendonitis, bursitis, or ligament injury may also occur.²⁷ Trigger point activation may cause muscle contraction, which can pull bones out of alignment and lead to osteoarthritis.¹⁶ Trigger point activation may also be a contributing factor to the development of scoliosis.²⁷

The specific trigger points, which produce a predictable, characteristic pattern of referred pain or other symptoms, are fully mapped and documented in the Trigger Point Manuals, written by Janet Travell, who was President Kennedy’s White House Physician, and her partner, David Simons.²⁵ Together they wrote the definitive texts on myofascial trigger points and founded the field of myofascial medicine. Unfortunately, these texts were largely ignored for over 30 years. Now, however, the demand is so great that a new version will soon be released.²⁵

CMP Versus FM: Some people believe that CMP and FM are not entirely distinct entities.^3,26 Both CMP and FM may fall under the umbrella of “Central Sensitivity Syndromes” (CSS) or “Dysregulation Spectrum Syndrome” (DSS). Other conditions included under this umbrella are migraine head-aches, tension headaches, temporomandibular pain syndrome, primary dysmenorrhea, chronic fatigue syndrome, irritable bowel syndrome, periodic limb movement disorder, restless leg syndrome and Gulf War syndrome.

CMP and FM can be difficult to diagnose, especially since signs and symptoms may seem unrelated. Some clinicians diagnose fibromyalgia only if the patient has at least 11 out of 18 tender points. This test, however, was intended to be used to identify FM patients who meet the criteria for inclusion into research studies; it was never intended for use in clinical settings. A patient can have FM, even if 11 of 18 tender points are not present.^{1,11,15,18,20} A comparison of some of the characteristics of CMP and FM can be found in TABLE 4.

It is also possible for both CMP and FM to occur in the same individual. In that case, each condition reinforces and amplifies the symptoms of the other,²¹ creating a vicious cycle. When a patient has both CMP and FM, the two conditions’ deleterious effects are more than additive.^1,21 In this patient population in particular, it is essential to identify and eliminate or correct perpetuating factors.¹⁶

Treatment
For the treatment of both CMP and FM, a multi-disciplinary approach that includes the patient’s participation is most likely to be successful.^19,20,29 It is essential to identify and eliminate or correct perpetuating factors.¹⁶ When treating CMP, it is also important to remember that trigger points usually refer pain elsewhere. Therefore, the site that requires treatment may not reside in the area that is actually hurting.²⁷ This point reinforces that the healthcare professional who is treating patients with CMP must have a good working knowledge of trigger point manuals.²⁵

Nonpharmacologic: According to Travell and Simons, almost any physical intervention will affect (but not necessarily deactivate) a trigger point. On the other hand, positive thinking, biofeedback, progressive relaxation, meditation and any other nonphysical intervention will not help.²⁷ If physical methods are applied too broadly, they, too, may fail.²⁷ For example, conventional stretching exercises or yoga are not likely to be specific enough to improve trigger points, and, especially if overdone, may even make matters worse. Acupressure, shiatsu, craniosacral therapy, Swedish massage, deep tissue bodywork, myofascial release, and other forms of therapeutic touch may not be specific enough to successfully treat trigger points. Applications of heat and cold and electrical stimulation are likely to provide only temporary benefit.

Treatment needs to be applied directly to the trigger points to successfully deactivate them.^27-29 The two methods to treat trigger points that Travell and Simons discuss in most detail in their texts are “trigger point injections” and “spray and stretch.” Both treatments are usually carried out by doctors or physical therapists.

Trigger Point Injections: Trigger point injections are usually given using a local anesthetic, although the use of a dry needle, as in acupuncture, may be useful in some patients.^1,27 These injections, however, are less likely to be beneficial in patients who have both CMP and FM.^1,21 There are many doctors who perform trigger point injections, but “there are not many who can do them properly,” says one expert.¹ Administering the injections requires a great deal of skill; lack of expertise can cause more harm than good.²⁷ Even when properly done, trigger point injections can be very painful; premedication or a pre-injection block may be useful.¹ Even brief exposure to considerable pain can cause long-lasting neuroplastic changes in the spinal cord that tend to enhance pain.¹ Spray and stretch is safer and easier to use than trigger point injections, and is the method generally favored by Travell and Simons.²⁷

Spray and Stretch: Spray and stretch differs from conventional stretching in that the trigger point is directly addressed before the affected muscle is stretched. The skin is sprayed with a refrigerant, then the affected muscle is stretched. A thorough knowledge of trigger point locations and referral patterns is essential, especially since the trigger point involved may not be within the area that is actually hurting. Several other steps, including correct chilling of the skin, rewarming and possible gentle movement through the complete range of motion, are essential.

Improper technique can do more harm than good. Travell and Simons believe that the safest and most effective therapy, however, is “deep stroking massage” directly to the trigger point.²⁷ This has a more specific effect on the trigger point than spray and stretch, and poses less risk to muscle attachments. Deep stroking massage can be nearly as effective as, and in some cases superior to, trigger point injections. Perhaps most importantly, deep stroking massage can sometimes be adapted for self-treatment, which, in addition to providing pain relief, can return some degree of control to the patient.^8,27

Pharmacologic: While NSAIDs do not appear to be beneficial in treating the symptoms of CMP, the use of low-dose antidepressants or narcotics may offer relief.

Antidepressants: Low-dose antidepressants (e.g., tricyclic antidepressants) may be prescribed for patients to take at bedtime, to help relieve symptoms.³⁰

Narcotics: Narcotics (opioids) are not usually considered first-line treatment for CMP, but for most patients they may be an option–especially since NSAIDs are not n likely to be beneficial.^1,18 As always, healthcare professionals and patients must be clear about the differences between addiction, tolerance, physical dependence and pseudo-addiction; there is ample data that the development of true narcotic addiction is extremely rare in patients who use narcotics for pain relief.⁹

Thankfully, the use of narcotics to treat terminal pain in patients who have cancer is finally gaining acceptance in the medical community. More education, however, is needed on the appropriate use of narcotics in patients with chronic, nonmalignant pain. It is hoped that the abuse of Oxycontin (oxycodone tablets, controlled-release) by a relatively small number of people will not have a deleterious effect on the treatment of patients who suffer from moderate to severe chronic pain. Likewise, a small group of unethical prescribers should not be allowed to compromise the ability of the vast majority of ethical, responsible, compassionate physicians who want to adequately treat their patients’ pain.⁹

The only thing more frustrating than having patients who are in pain worry about becoming addicted to narcotics, is having fellow health professionals share this unwarranted concern.⁹ Patients who take narcotics for chronic pain do not get “high” or “euphoric;” instead, they are usually relieved to regain a semblance of what they had once considered a normal lifestyle.

Narcotics seldom totally eliminate pain entirely, but they may reduce it to a level that allows the patient to add other modalities and adjustments to further reduce pain and facilitate a healthier lifestyle.^1,18 When a combination of medications and other therapies is found that helps the patient’s pain, it is appropriate to continue using them; otherwise, symptoms will reoccur.^1,18 There is increasing interest in adding dextromethorphan to narcotics, since this appears to increase analgesia, while decreasing constipation and possibly tolerance.^31-33

Conclusion
There are few areas of patient care in which a pharmacist can have such a profoundly positive, and often immediate, effect on quality of life as in appropriate pain management. CMP and FM are both real conditions. Either CMP or FM can cause severe pain, but if both conditions are present, their deleterious effects are compounded. Chronic pain can be exhausting and demoralizing. As drug experts, pharmacists can be the patient’s advocate in exploring the best option for relief of symptoms.

Do you toss and turn at night because of fibromyalgia pain or discomfort?

“People with fibromyalgia tend to have very disturbed sleep,” says Doris Cope, MD, director of Pain Management at the University of Pittsburgh School of Medicine. “Even if they sleep 10 hours a night, they still feel fatigued, don’t feel rested.”

Research shows that with fibromyalgia, there is an automatic arousal in the brain during sleep. Frequent disruptions prevent the important restorative processes from occurring. Growth hormone is mostly produced during sleep. Without restorative sleep and the surge of growth hormone, muscles don’t heal and neurotransmitters (like the mood chemical serotonin) are not replenished. The lack of a good night’s sleep makes people with fibromyalgia wake up feeling tired and fatigued.

The result: The body can’t recuperate from the day’s stresses — all of which overwhelms the system, creating a great sensitivity to pain. Widespread pain, sleep problems, anxiety, depression, fatigue, and memory difficulties are all symptoms of fibromyalgia.

Insomnia takes many forms — trouble falling asleep, waking up often during the night, having trouble going back to sleep, and waking up too early in the morning. Smoothing out those sleep problems — and helping people get the deep sleep their bodies need — helps fibromyalgia pain improve significantly, research shows.

Medications can help enhance sleep and relieve pain. But doctors also advocate lifestyle changes to help sleep come naturally.

Tips to Get Better Sleep With Fibromyalgia

Creating a comfort zone at home is key to better sleep, whether you have fibromyalgia or not. It’s all about easing into bedtime feeling relaxed — and staying relaxed so you sleep through the night.

These 10 tips can help people sleep better:

• Enjoy a soothing (warm) bath in the evening.
• Brush your body with a loofah or long-handled brush in the bath.
• Ease painful tender points with a self-massage device (like a tennis ball).
• Do yoga and stretching exercises to relax.
• Listen to calming music.
• Meditate to tame intrusive thoughts and tension.
• Sleep in a darkened room. Try an eye mask if necessary.
• Keep the room as quiet as possible (or use a white-noise machine).
• Make sure the room temperature is comfortable.
• Avoid foods that contain caffeine, including teas, colas, and chocolate.

Therapies to Treat Insomnia When You Have Fibromyalgia

If you’re still having sleep problems, several therapies can help, including biofeedback, relaxation training, stress reduction, and cognitive therapy. A psychologist who specializes in sleep disorders can discuss these therapies with you.

The therapies help people handle stress better, which helps control fibromyalgia episodes, Cope says. “Fibromyalgia comes and goes,” she tells WebMD. “When you’re stressed out, that’s when it’s worse.” That’s when you’re most likely to have insomnia, too.

Medications can also help ease fibromyalgia pain at night, or directly treat insomnia. Medications to ease fibromyalgia at night include antidepressants, anticonvulsants, prescription pain relievers, and sleep aids.

No one therapy will control fibromyalgia pain 100%, Cope adds.

“Medications help some. Exercise helps some. Stress reduction helps some. Cognitive behavior therapy helps some… If you can get restful sleep, you’re going to function better when you’re awake.”

From acupuncture to chiropractic, from massage to meditation, alternative treatments are in great demand. That’s especially true for people with pain-related illnesses such as fibromyalgia. Alternative medicine, including herbal therapy and homeopathy, is a form of “drug-free” doctoring that views the mind and body as a fully integrated system.

For people with fibromyalgia, some alternative treatments work well. That’s because holistic therapies influence your total being. In that way, they may allow you to reduce your medications and increase your normal activities.

Study findings show that standard acupuncture may be effective in treating some people with fibromyalgia. Both biofeedback and electroacupuncture have also been used for relief of fibromyalgia symptoms. However, before you try alternative treatments, talk with your doctor. Check to see what limitations might apply to you. Working with your doctor, you can find an acceptable way to blend conventional medicine with alternative treatments or natural remedies. When you do, you may be able to increase restful sleep and reduce your fibromyalgia pain.

Can acupuncture treat fibromyalgia?

With acupuncture, a practitioner inserts one or more dry needles into the skin and underlying tissues at specific points. Gently twisting or otherwise manipulating the needles causes a measurable release of endorphins into the bloodstream. Endorphins are the body’s natural opioids. In addition, according to acupuncture practitioners, energy blocks are removed. Removing them is said to restore the flow of energy along the meridians, which are specific energy channels.

Studies show that acupuncture may alter brain chemistry. It appears to do this by changing the release of neurotransmitters. These neurotransmitters stimulate or inhibit nerve impulses in the brain that relay information about external stimuli and sensations such as pain. In this way, the patient’s pain tolerance is increased. One acupuncture treatment in some patients may last weeks to help alleviate chronic pain.

What is electroacupuncture?

Electroacupuncture is another way of stimulating the acupuncture points. It uses a needle hooked up to small wires connected to very slight electrical currents. Heat – moxibustion — and massage – acupressure — can also be used during this electroacupuncture process.

Laser acupuncture is yet another offshoot of this alternative therapy. It may occasionally be effective for the treatment of carpal tunnel syndrome. While it uses the same points, there are no needles involved.

There are precautions to take if you want to try acupuncture. First, make sure you find a licensed acupuncturist who has a lot of experience. Also, make sure the acupuncturist uses only disposable needles.

There are multiple styles of acupuncture. The style used depends on where the practitioner studied. For instance, Chinese acupuncture depends on larger bore needles and the practitioner may be more aggressive with moving them. Japanese acupuncture uses thinner bore needles with a relatively gentle approach. You’ll need to find the style that suits your fibromyalgia needs.

Of all the above, my favorite is electroacupuncture. It feels so fantastic and seems to release tight muscles. Doylene