The Fibromyalgia Syndrome/Thyroid Disease Connection

The following are excerpts from the article by Mary Shomon:

A significant percentage of the estimated 20 million people with hypothyroidism end up also being diagnosed with fibromyalgia.  Both conditions share symptoms, including fatigue, exhaustion, depression, brain fog, and varying degrees of muscle and joint pain. Some experts believe that like most cases of hypothyroidism, fibromyalgia is also autoimmune in nature. Others believe that fibromyalgia may be one manifestation of an underactive metabolism – hypometabolism – and is therefore one variation on thyroid dysfunction.

The Hypothalamic Connection

Dr. Teitelbaum believes that at the core of thyroid dysfunction and fibromyalgia is a problem with the dysfunction or suppression of a master gland in the brain called the hypothalamus.  Says Dr. Teitelbaum…

This gland controls sleep, your hormonal system, temperature regulation, and the autonomic nervous system (e.g. — blood pressure, blood flow, and movement of food through your bowel). This is why you can’t sleep, you have low temperature, you gain weight, and (because poor sleep causes immune dysfunction) you are prone to multiple and recurrent infections. The hypothalamic dysfunction by itself can therefore, cause most of the symptoms! I suspect that problems with the “energy furnaces” in your cells (called the mitochondria) often cause the hypothalamic suppression.

The Thyroid Connection and T3

If you are a thyroid patient who has signs and symptoms of fibromyalgia, you should consider being evaluated by a practitioner with expertise in the condition, whether it’s a holistic or complementary MD, an internist or rheumatologist.

And, if you are a fibromyalgia patient, it’s also worth digging somewhat deeper to determine if you have an underlying thyroid problem that may be contributing to – or even causing – your fibromyalgia symptoms.

People typically have a thyroid TSH test to determine if they have a thyroid imbalance, but fibromyalgia expert Dr. John Lowe, who heads the Fibromyalgia Research Foundation, and is author of The Metabolic Treatment of Fibromyalgia, questions what he calls the four “conventional endocrinology mandates” –

(1) The only cause of thyroid hormone deficiency symptoms is hypothyroidism

(2) only patients with hypothyroidism “according to lab results” should be permitted to use thyroid hormone

(3) the hypothyroid patient should only be allowed to use T4 (levothyroxine) and

(4) the patient’s dosage should not suppress the thyroid stimulating hormone (TSH) level.

Dr. Lowe has had to challenge these preconceptions as part of his long-standing effort to learn more about treatment-resistant fibromyalgia. The result is a treatment protocol based on his findings that the unresolved symptoms associated with treated hypothyroidism and fibromyalgia are actually evidence of untreated or undertreated hypothyroidism, or partial cellular resistance to thyroid hormone.

A unique aspect of Dr. Lowe’s theories is his recognition that a patient with cellular resistance may have perfectly normal circulating thyroid hormone levels yet have the symptoms and signs of hypothyroidism. This is an important aspect of Dr. Lowe’s treatments that may point to the reason for his success. He has found, however, from his discussions with other fibromyalgia/CFS researchers, that most are unaware of such potential mechanisms. He says:

To them, if a patient has a normal TSH level, and especially if the patient’s symptoms don’t improve with replacement dosages of T4 (levothyroxine), her condition cannot possibly be related in any way to thyroid hormone. Recent scientific research, however, has shown this belief to be false.

If you have autoimmune hypothyroidism, it’s fairly common to develop some classic fibromyalgia symptoms — such as muscle/joint pain, aches, and sleep disturbances. According to Dr. Lowe, the conventional physician is likely to consider any new or worsened symptoms as evidence that the there’s yet another condition — such as fibromyalgia — in addition to the autoimmune thyroid problem. To Dr. Lowe, however, that means that the newly developing symptoms are likely evidence of undertreated hypothyroidism:

As thyroid hormone deficiency worsens, the number of tissues involved and the severity of the resulting symptoms increase. The patient typically experiences the worsening deficiency as an increased number of symptoms of greater severity. In most cases, such patients simply need a more appropriate dosage or form of thyroid hormone to recover from all their symptoms.

Dr. Lowe believes that rigid adherence to the so-called “normal range” does not show whether a patient has enough circulating T3 (the active thyroid hormone at the cellular level, which is produced in part by the thyroid, and in part by conversion of T4 hormone to T3) to maintain normal metabolism in cells. His research shows that safe but suppressive doses are often more effective at eliminating the associated health problems that are of greatest concern. T4 to T3 conversion can be impaired, so the fact that a patient has a normal TSH level does not mean that her tissue metabolism is normal.

According to Dr. Lowe, one study showed that replacement dosages of thyroid hormone– dosages that keep the TSH within the normal range — mildly lowered patients’ high cholesterol levels, but TSH-suppressive dosages lowered the levels significantly further.

Many published reports and our studies show that the TSH level does not correlate with various tests of tissue metabolism. Dr. Lowe feels this is important because making tissue metabolism normal should be the goal of all treatment with hypothyroid patients. When the hypothyroid patient is restricted to a dosage of T4 that keeps the TSH within the normal range, testing will produce evidence of abnormal metabolism in multiple tissues.

Dr. Lowe has found that TSH-suppressive dosages of thyroid hormone can also reduce a patients’ risk for disease. Dr. Lowe finds that lower dosages of thyroid hormone have been found to be associated with progression of coronary atherosclerosis and higher dosages (including TSH-suppressive dosages) associated with a halting of the progression. In his studies, Dr. Lowe has extensively tested patients and determined that there is nothing harmful to patients in having their TSH suppressed by these dosages of thyroid hormone. Dr. Lowe sees the far greater danger being the clear adverse consequences of undertreated resistance, resulting in conditions such as fibromyalgia, CFS, and liver and cardiovascular diseases.

Dr. Lowe believes the hypothyroid patient has two options: She can submit to using a replacement dosage of thyroid hormone and remain symptomatic, thus risking premature death from cardiovascular disease. Or she can find a physician who will completely ignore her TSH level and find a dosage that produces normal tissue metabolism.

Some researchers dismiss thyroid hormone replacement as a possible treatment for fibromyalgia symptoms or CFS. According to Dr. Lowe, however, “replacement” as defined by these researchers typically doesn’t work because replacement means the use of only T4 to keep the TSH within normal range, and that is simply not enough to free most hypothyroid patients from their symptoms. The assumption that replacement dosages of T4 are the only acceptable treatment prevents other researchers from seeing the mechanism of most patients’ fibromyalgia/CFS — inadequate thyroid hormone regulation of tissues. Dr. Lowe believes that the combination of T4 and T3 generally works better than T4 alone with hypothyroid patients, and in some cases T3 alone works best. Dr. Lowe found that when hypothyroid patients were treated with T4 first, gradually increasing the dosage, if it didn’t provide much benefit or any at all, patients were switched to T3.

Many patients do not benefit from the use of T4, regardless of how high the dosage.

T4 alone is a poor option for many hypothyroid fibromyalgia patients, and it is useless for fibromyalgia patients with cellular resistance to thyroid hormone. Most of these patients, who make up about 44 percent of the fibromyalgia patient population according to our studies, benefit only from very large dosages of T3. Only a minority of hypothyroid fibromyalgia patients satisfactorily improved with the use of T4 alone.

Entire article can be found at about.com

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Fibromyalgia Syndrome (FMS) Alternative Treatment: Thermotherapy

Reviewed By:
Vikas Garg, M.D., MSA

Summary

Thermotherapy is the use of heat to treat symptoms of acute or chronic pain, especially those related to muscle tension or spasm. It is also a common treatment for arthritis, bursitis, tendinitis, back pain, shoulder pain and other kinds of joint pain.

Thermotherapy widens blood vessels and increases blood flow to the skin. It relaxes superficial muscles, decreases muscle spasms and reduces stiffness of joints. Research has shown that it can also block pain receptors.

People often apply heat therapy at home for minor conditions. It is also used in healthcare settings, such as physical therapy, manipulation therapy and occupational therapy.

There are several methods of delivering thermotherapy to the body. They include:

• Warm compresses and hot packs
• Heating pads
• Heat creams and ointments
• Paraffin dips and whirlpool baths
• Ultrasound therapy
• Diathermy, a treatment using microwaves or shortwaves

Moist heat appears to be more effective in treating pain than dry heat, as the moisture allows the heat to penetrate more deeply into the muscle. Thermotherapy is frequently used combination with other therapies to relieve pain, such as hydrotherapy (water therapy). In many cases, cryotherapy (cold therapy) is used to reduce inflammation before thermotherapy is used to increase blood flow to muscles.

Thermotherapy is generally safe but does carry risks if improperly used and is not appropriate for some individuals and conditions. Patients should consult their physician before using thermotherapy.

About thermotherapy

Thermotherapy is the application of heat to the body to relieve symptoms of acute or chronic pain. It is especially effective in treating pain related to muscle tension or spasm, but can also relieve other types of pain. Moist heat appears to be more effective in treating pain than dry heat because the moisture allows the heat to penetrate more deeply.

Many people use forms of thermotherapy at home to treat minor conditions, such as a hot pack applied to a stiff neck. Thermotherapy is also used in healthcare settings, such as physical therapy, manipulation therapy and occupational therapy. For example, a physical therapist may apply therapeutic ultrasound to a limb before exercise, a massage therapist may apply heated rocks to an aching back, and an occupational therapist may dip an arthritic hand in a warm paraffin bath before addressing fine-motor activities.

Thermotherapy produces several benefits that help relieve pain. Heat can increase blood flow to the skin. Application of heat produces vasodilation (widening of blood vessels), which increases oxygen and nutrient delivery to tissues. Heat relaxes muscles near the surface and makes them more elastic, decreasing stiffness of joints. Research has shown that superficial heat can also block internal pain receptors.

Heat also helps prepare the skin for the application of physical agents. Patients often find the application of moist heat to be soothing and relaxing.

Thermotherapy is often used combination with other therapies to relieve pain. In many cases, cryotherapy (cold therapy) is used to reduce inflammation before thermotherapy is applied to increase blood flow to muscles. Thermotherapy frequently incorporates moisture or water (hydrotherapy). Some forms of electrical therapy supply heat to injured tissues.

Thermotherapy generally should not be used during the first several days after an injury, because heat increases blood flow and may worsen swelling. Heat treatments are inappropriate for some individuals and conditions. For example, people who have impaired sensation (e.g., from neuropathy due to diabetes) are at risk of burns from overuse of thermotherapy. Individuals with poor sensation or other conditions of concern are advised to consult their healthcare provider before trying thermotherapy. Caution should be used not to overdo the therapy, which may burn the skin.

Conditions treated

Thermotherapy can be used to treat a number of pain conditions. These include:

• Muscle spasm. Persistent and often painful tension and shortness in a muscle or group of muscles that cannot be released voluntarily.
• Arthritis. Inflammation of a joint. Types of arthritis that may benefit from thermotherapy include:
• • Osteoarthritis
  • Rheumatoid arthritis
  • Juvenile arthritis
  • Juvenile rheumatoid arthritis
  • Ankylosing spondylitis
  • Gout
  • Psoriatic arthritis
  • Reiter’s syndrome
• Sources of back pain, such as a herniated disc. A frequently painful condition in which the cartilage (the tough, elastic, fibrous connective tissue) of an intervertebral disc (discs that serve as cushions between the vertebrae) bulges through its protective covering and presses on a nerve. Most of the time a herniated disc is associated with overlying muscle spasm, which heat therapy decreases.

Other conditions that may be treated with heat include back strain or sprain, degenerative disc disease, sciatica and scoliosis, as these conditions are usually associated with muscle spasm.

• Whiplash and other musculoskeletal types of neck pain.

Shoulder pain, such as rotator cuff injuries. The rotator cuff is made up of the muscles and tendons that connect the humerus to the shoulder blade. Tendons in the rotator cuff are normally strong, but they can become inflamed and tear as a result of overuse, wear and tear associated with aging or an accident such as a collision. Another condition that may be eased by application of heat is a frozen shoulder.

Other types of joint pain, including many forms of:

• Arm pain (e.g., tennis elbow)
• Leg pain (e.g., restless leg syndrome)
• Knee pain (e.g., injured anterior cruciate ligament)
• Foot pain (e.g., plantar fasciitis)

• Tendinitis. Inflammation of a tendon, a fibrous tissue connecting a muscle with its bony attachment.

• Bursitis. Inflammation of a bursa, a sac located between a tendon and a bone.
• Sprain. A painful wrenching or laceration of the ligaments of a joint.
• Eye pain. An ophthalmologist or other clinician may suggest applying warm compresses to relieve minor conditions such as blepharitis (inflammation of the eyelids).
• TMJ disorder. Applications of heat may help tender areas.
• Chest pain. Heat can supply relief from disorders such as costochondritis.
• Abdominal pain and pelvic pain. Researchers have found that externally applied heat such as hot-water bottles can relieve even deep internal pain for up to an hour by blocking pain receptors.
• Fibromyalgia. Therapeutic use of heat may help treat this chronic pain condition, characterized by musculoskeletal aches, pain and stiffness, tenderness in soft tissues, general fatigue and sleep disturbances.
• Other chronic pain disorders, including lupus and myofascial pain syndrome
• Asthma (see Types and differences)

Heat can also be used as a minimally invasive alternative to surgery. For example, several treatments for benign prostatic hyperplasia use microwaves, lasers or other sources of heat to destroy excess prostate tissue. High-intensity heat is also used to destroy some types of benign and cancerous tumors.

In addition, thermotherapy is used to reduce spasticity in neurological conditions. Recent studies indicate that a combination of thermotherapy and cryotherapy may help stroke patients recover arm function and may ease symptoms in people with heart failure. And other recent research suggests that a microwave form of thermotherapy might benefit women with advanced cervical cancer.

Types and differences of thermotherapy

Patients should notify their physician if they suffer pain that is persistent or that fails to respond to treatment. There are several types of thermotherapy. Therapies that may be tried by patients at home include:

• Heat creams and ointments. These popular over-the-counter remedies can provide relief from minor muscle pain. However, these topical treatments do not penetrate very deeply into muscle tissue, making them less effective in treating more significant pain.
• Hot packs. Heated, cloth-covered pouches with a core of silica gel. They provide relief of pain located in a patient’s trunk, spine or limbs. Hot packs also are used to treat muscle spasms, and the inflammations of tendinitis and bursitis. Variations of this type of therapy include hot water bottles, warm and moist compresses and electric heating pads.

Treatments that are more likely to be administered by a professional include:

• Whirlpool baths. This and other forms of thermal hydrotherapy can also be used to elevate tissue temperature, promote vasodilation (dilation of blood vessels) and help stretch collagen tissue. Patients who have whirlpool baths at home may be able to use these treatments at home.
• Paraffin treatments. Paraffin (waxy white or colorless solid hydrocarbon mixture used to make lubricants) is mixed with mineral oil in a special basin into which the affected limb is immersed. This treatment can provide relief of arthritic symptoms. These units can also be bought for use at home.

• Ultrasound therapy. A method of applying deep heat to tissues using high-frequency sound waves. Transmission gel, oil or water is applied to the skin covering certain areas of the body. Energy derived from a quartz crystal is then the passed from an applicator through the gel, creating deep heating to soft tissue and bone that increases blood flow and tissue metabolism and raises a patient’s pain threshold. At frequencies from 1 megahertz to 3 megahertz, ultrasound penetrates to deeper structures such as joint capsules, tendons and ligaments and can increase their range of motion. Ultrasound also has powerful anti-inflammatory effects and is effective in treating muscle spasms associated with back pain and various types of neuritis (inflammation of nerves or a group of nerves).
• Diathermy. In this treatment, microwaves or shortwaves are selectively absorbed by tissues with high water content. Microwave therapy is especially helpful for patients who have sprains, strains, herniated discs, rotator cuff tears or arthritis. Shortwave therapy is often used to treat low back pain, tenosynovitis (inflammation of a tendon sheath) and osteoarthritis of the knee.

Some forms of electrical therapy also provide a thermal effect.

In addition, a new technique called bronchial thermoplasty is being developed to treat asthma, a major cause of chest pain. This method applies heat to the airway through a bronchoscope to relax smooth muscle of the bronchi. Another thermal treatment for asthma is a heat-exchange mask, which may relieve attacks triggered by breathing cold, dry air.

Potential risks with thermotherapy

Thermotherapy should generally not be used during the first several days after an injury, because heat increases blood flow and may worsen swelling. For example, soaking a sprained ankle in warm water will increase pain and swelling and prolong the injury, according to the American College of Foot and Ankle Surgeons. Patients are advised to use cold therapy (cryotherapy) first to reduce inflammation before switching to thermotherapy. A physician can help a patient decide when to switch from cryotherapy to thermotherapy.

Heat therapy should not be used on tissue that has received radiation treatment or on tissue that is directly over a cancer site. People with poor sensation, such as some individuals with diabetes, are at increased risk of burns. In addition, pregnant women should not use any form of heat therapy that exposes their fetus to prolonged heat. This includes hot tubs.

Other potential risks associated with thermotherapy include:

• Hot packs. May increase core body temperature and blood flow. In some cases they may aggravate the inflammatory response. In addition, hot packs can cause burns. 
• Paraffin baths. Paraffin can burn the skin. This therapy should not be used by patients who have active bleeding or infection, neoplasm (abnormal growth of tissue such as a tumor), skin desensitization or vascular insufficiency (insufficient blood flow to a particular part of the body).
• Ultrasound therapy. May cause cavitation (gas bubble formation in tissue) or superheating of the periosteum (fibrous membrane covering the surface of bones) over bony surfaces. This therapy should not be used near the spine in patients who have had some types of spinal surgery, such as those that expose the spinal cord. It also should not be used over the eye, fluid-filled sacs or neoplasms. Pregnant women should not receive this treatment near their abdomen. Patients who cannot perceive pain or heat should not be treated with ultrasound thermotherapy.
• Diathermy. There is a risk of tissue burns associated with this therapy. Microwave or shortwave therapy should not be used by patients who are pregnant or who have a pacemaker or any other implants with electrical leads.

• Heat creams and ointments. Patients should avoid getting these ointments into their eyes or in contact with sensitive skin.  Patients should not combine other forms of thermotherapy with topical analgesics such as pain-relief ointments. Chemicals in these medications increase blood flow to the skin surface and may hinder the thermoregulatory response of heat redistribution. This can cause burns.

Questions for your doctor on thermotherapy

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about thermotherapy:

1. How can thermotherapy help relieve my pain?
2. Do you recommend thermotherapy for me?
3. Which form of thermotherapy will be most useful to me?
4. For how long should I apply heat, and how often?
5. Which conditions require me to wait before using thermotherapy? How long should I wait?
6. When and how should I use cold therapy with heat therapy?
7. Will combining hydrotherapy with thermotherapy offer me greater relief?
8. Should I perform thermotherapy at home? If so, how?
9. At what point should I try other treatments or notify you if thermotherapy does not seem to be helping me?
10. Does thermotherapy pose any risks for me?
11. Do I have any conditions that rule out use of thermotherapy?

Article found at ivillage

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Finding a Doctor for Your Fibromyalgia

Your Best Bet? A Rheumatologist!

Fibromyalgia (FMS) is a complicated syndrome that is different in every patient. It doesn’t show up in conventional medical tests (although now one blood test can conclusively identify one sub-set of sufferers), the pain comes and goes and can move around the body in a seemingly random way, and a vast number of symptoms may appear to be so unrelated that you don’t realize they have the same cause. Who would think their skin problems were related to severe abdominal pain?

On top of all that, not all health-care providers are up to speed with the latest developments on FMS. Doctors specialize for a reason, and that’s because the human body is too complex for any human being to be educated on everything that can go wrong with it.

Also, it’s important to note that some doctors still have the opinion that fibromyalgia is “all in your head” and not a real illness at all. That’s why it’s important for you to find a specialist if you’ve been diagnosed with fibromyalgia or if you suspect it’s behind the pain and other various problems you’ve been having.

In the last few years, research has shown that fibromyalgia is caused by a sensitization of the central nervous system. However, people were reporting symptoms to doctors long before anyone knew what caused them. Because FMS symptoms are similar to symptoms of several rheumatic illnesses, such as lupus and rheumatoid arthritis, rheumatologists became most familiar with the condition. Then, in 1990, the American College of Rheumatology established the first diagnostic criteria for fibromyalgia. A rheumatologist can test you for other rheumatic diseases with similar signs and symptoms, give you a credible diagnosis and help manage your treatment.

Not only does it make good medical sense to see a rheumatologist for fibromyalgia, it makes good legal sense, too. If someday you have to quit working because of FMS, you’ll have a better chance of getting Social Security disability if you’ve been diagnosed by a rheumatologist.

Finding a Rheumatologist

You have a lot of resources at your disposal for finding a rheumatologist. If you have a family doctor or primary care provider, you can ask who he or she would recommend. (Depending on your insurance plan, you may need a referral.) In addition, you can check with area clinics and hospitals to see if they have referral services, check your insurance company’s list of providers who are covered and talk to friends and family. If you see a physical therapist, massage therapist or chiropractor for your pain, ask who he or she would recommend.

You can search online for a doctor in your area at the following sites:

• “Find a Doctor” from About.com:health
• The American College of Rheumatology website
• American Medical Association’s Physician Select website (to verify credentials).
• Co-Cure ME/CFS and Fibromyalgia “Good Doctor” List

Once you have the names of rheumatologists practicing in your area, you may want to do a little more investigating. Here’s a list of questions you may want to ask:

• How much experience does the doctor have with FMS?
• How long will you have to wait to get an appointment?
• If you call with a problem or question, will you get to talk to the doctor?
• Does the doctor use a multidisciplinary approach to treatment?

You’ll also want to find out whether the doctor is accepting new patients, if the office will accept your insurance (and vice versa) and whether payment or co-pays are due at the time of your appointment.

Meet with the Doctor

Once you’ve come up with a short list of rheumatologists, you might want to consider a “get acquainted” appointment where you can meet the doctor face to face, ask more questions and get a feel for whether this is someone you’d like to work with. Managing fibromyalgia requires teamwork between the doctor and patient, so it’s important for you to have a positive relationship. If it’s not possible to meet this way, treat your first appointment in the same way so you can decide whether this rheumatologist is a good fit for you.

_Sources:

2002 - 2007 Hearthstone Communications Ltd. All rights reserved. “Your Rheumatologist”

2007 Spondylitis Association of America. All rights reserved. “Locating a Rheumatologist”

From Adrienne Dellwo.  About.com Health’s Disease and Condition content is reviewed by Kate Grossman, MD

Article found at about.com

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Gabapentin Shown Effective for Fibromyalgia Pain

New research supported by the National Institutes of Health’s National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) shows that the anticonvulsant medication gabapentin, which is used for certain types of seizures, can be an effective treatment for the pain and other symptoms associated with the common, often hard-to-treat chronic pain disorder, fibromyalgia.

In the NIAMS-sponsored, randomized, double-blind clinical trial of 150 women (90 percent) and men with the condition, Lesley M. Arnold, M.D., director of the Women’s Health Research Program at the University of Cincinnati College of Medicine, and her colleagues found that those taking gabapentin at dosages of 1,200 to 2,400 mg daily for 12 weeks displayed significantly less pain than those taking placebo. Patients taking gabapentin also reported significantly better sleep and less fatigue. For the majority of participants, the drug was well tolerated. The most common side effects included dizziness and sedation, which were mild to moderate in severity in most cases.

NIAMS Director Stephen I. Katz. M.D., Ph.D., remarked that “While gabapentin does not have Food and Drug Administration approval for fibromyalgia¹, I believe this study offers additional insight to physicians considering the drug for their fibromyalgia patients. Fibromyalgia is a debilitating condition for which current treatments are only modestly effective, so a study such as this is potentially good news for people with this common, painful condition.”

Fibromyalgia is a chronic disorder characterized by chronic, widespread muscle pain and tenderness, and is frequently accompanied by fatigue, insomnia, depression, and anxiety. It affects three million to six million Americans, mostly women, and can be disabling.

The precise cause of fibromyalgia in not known, but research suggests it is related to a problem with the central nervous system’s processing of pain. As with some other chronic pain conditions, people with fibromyalgia often develop a heightened response to stimuli, experiencing pain that would not cause problems in other people. Yet, unlike many other pain syndromes, there is no physical evidence of inflammation or central nervous system damage.

Although gabapentin has little, if any, effect on acute pain, it has shown a robust effect on pain caused by a heightened response to stimuli related to inflammation or nerve injury in animal models of chronic pain syndromes. Researchers have suspected that it might have the same effect in people with fibromyalgia. The new research, published in the April 2007 edition of Arthritis & Rheumatism, indicates the suspicions were correct.

Although the researchers cannot say with certainty how gabapentin helps reduce pain, Dr. Arnold says one possible explanation involves the binding of gabapentin to a specific subunit of voltage-gated calcium channels on neurons. “This binding reduces calcium flow into the nerve cell, which reduces the release of some signaling molecules involved in pain processing,” she says.

How gabapentin improves sleep and other symptoms is less clear, and there are probably different mechanisms involved in fibromyalgia symptoms. “Gabapentin improved sleep, which is an added benefit to patients with fibromyalgia who often report unrefreshing or disrupted sleep,” Dr. Arnold says.

What is important is that people with fibromyalgia now have a potential new treatment option for a condition with few effective treatments. “Studies like this give clinicians evidence-based information to guide their treatment of patients,” says Dr. Arnold.

The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the Department of Health and Human Services’ National Institutes of Health, is to support research into the causes, treatment and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases. For more information about NIAMS, call the information clearinghouse at (301) 495-4484 or (877) 22-NIAMS (free call) or visit the NIAMS website at http://www.niams.nih.gov.

The National Institutes of Health (NIH) — The Nation’s Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. 

Arnold, LM et al. Gabapentin in the treatment of fibromyalgia; a randomized, double-blind, placebo-controlled multicenter trial. Arthritis Rheum. 2007; 56: 1336-1344.

1. The FDA approved Lyrica (pregabalin) for treating fibromyalgia on June 21, 2007 (http://www.fda.gov/bbs/topics/NEWS/2007/NEW01656.html; http://www.fda.gov/consumer/updates/fibromyalgia062107.html). [Please note that this footnote was added to the online version of this release on Friday, June 22, 2007.]

Article found at nih.gov

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Fibromyalgia Syndrome: Trigger Points and Their Treatment

What are trigger points [TPs]?
A trigger point is simply a small contraction knot in muscle. This knot feels like a pea buried deep in the muscle, and can feel as big as a thumb. It maintains a hard contraction on the muscle fibres connected to it, thus causing a tight band that can also be felt in the muscle. These trigger points in muscles and in the thin wrapping around each muscle [called fascia] are called myofascial trigger points, to distinguish them from trigger points which can occur in other soft tissues such as skin, ligaments and tendons, and also in scar tissue.

Are TPs the same as a muscle spasm or strain or tear?
No, a TP is not the same thing as a muscle spasm. A spasm involves a violent contraction of the whole muscle, whereas a TP is contraction in only a small part of a muscle. A strain or tear involves physical damage to the muscle or tendon fibres, Such damage has not been demonstrated in studies of TPs. [However, such injuries may predispose one to developing TPs there later on.]

Why are they called trigger points?
Pulling the trigger of a gun makes a noise in the gun but it also sends out a bullet that causes pain at a distant target site. Pressing firmly on muscle TPs hurts right where you are pressing, making you jump, wince and pull away. But, more importantly, TPs also send ['refer'] pain or tenderness to some other site, often quite far away. So, for example, a headache may not be caused by a problem in the head itself, but have been sent to the head from a TP on the side of the neck. Never assume the problem is at the place that hurts.

What does this referred pain feel like?
The referred pain caused by TPs is usually steady, dull and aching, often deep. It may occur at rest, or only on movement. It varies from being a low-grade discomfort to being severe and incapacitating.

Are TPs common?
Myofascial trigger points are among the most common, yet poorly recognised and inadequately managed, causes of musculoskeletal pain seen in medical practice. Unfortunately, many general practitioners and orthopaedic surgeons do not know about TPs, and as TPs do not show on XRays or scans, the patient may be told there is nothing wrong with them or that there is nothing that can be done to help fix their pain.

What common conditions are thought to be due to referred pain from TPs?
TPs are known to cause or contribute to headaches, neck and jaw pain, low back pain, the symptoms of carpal tunnel syndrome and tennis elbow, and many kinds of joint pain mistakenly ascribed to arthritis, tendonitis, bursitis, or ligament injury.

What other symptoms may TPs cause?
Apart from pain, TPs may cause numbness, tingling, weakness, or lack of normal range of movement. TPs can also cause earaches, dizziness, sinus congestion, nausea, heartburn, and false heart pain. And they may result in depression if pain has been chronic.

How can one know where the TPs are?
It is important to realize that the TPs themselves do not hurt, [other than when you are actually pressing firmly on them.] In other words, the gun has a silencer on it, so you don’t know there is a gun or that it is being fired. You only know that you’re wounded. Most patients are surprised when I locate a very painful tight spot in a muscle well away from where they tell me their pain is. They were usually completely unaware that this painful tight spot even existed, let alone that such a small spot could be the cause of all their pain.

So how did I know where to find that spot?
Fortunately, referred pain occurs in predictable patterns, which have been clearly mapped out in The Trigger Point Manual by Simons and Travell. Using their maps I know which areas to search for the TPs that characteristically send pain to the place where you are hurting. I then feel for a tight muscle in that area, feel for tight bands within that muscle, and localize an area within the band which is exquisitely tender and that is the TP. As I press or twang it, the muscle may twitch. As I keep pressure on it, it will cause your usual referred pain, thus confirming that we’ve got the spot.

Could there be more than one TP causing my problem?
Yes, TPs tend to gang together, so in practice it is common to find more than one TP in the tight muscle, and more than one muscle whose TPs refer pain to the area where you are hurting. All your TPs need to be hunted out and treated before you’ll gain full relief of your symptoms. I will show you the relevant TPs for your problem, and after a while you’ll become expert at finding them for yourself. .

What causes TPs to develop?
All of us develop tight bands in our muscles as we age, but some people have more than others, for various reasons that are listed in the red box labelled: ‘Predisposing factors’. Then, some of these tight bands go on to develop TPs in them, when one or more ‘Precipitating factors’ arise. For example, a TP may develop following an acute muscular strain such as during a car accident, a fall, a sprain or fracture, or excessive or unusual exercise. Or following chronic overload of the muscles used to maintain posture because of poor sitting, working or sleeping habits, or by repetitive work tasks.

Could poor general health be making my TPs even worse?
Yes, particularly if your pain has been happening awhile, it is very likely that one or more of the following ‘Perpetuating factors’ is present:
 - Mechanical stresses such as a short leg, flat foot, poor posture, or immobility.
 - Nerve root pressure, eg sciatica.
 - Chronic internal diseases, and some prescription medications.
 - Nutritional deficiencies, especially vitamins C, B-complex and iron.
 - Hormone imbalances [low thyroid hormone levels, premenstrual or menopausal]
 - Infections [bacterial, viral or yeast]
 - Allergies [wheat and dairy in particular]
 - Poor oxygenation of tissues [aggravated by tension, stress, inactivity, poor sleep, smoking ]

These factors MUST be detected and corrected if specific treatment of the TPs is to be successful or lasting, so your doctor will spend some time sorting these out with you. Chronic fatigue syndrome and fibromyalgia also predispose one to develop TPs, [in addition to all the other tender spots characteristic of those conditions].

So how long will the pain take to get better?
With TPs of recent onset, significant relief of symptoms often comes in just minutes, and most acute problems can be eliminated within 3 to 10 days. But longer-standing chronic conditions are more complex and less responsive to treatment. None the less, even some of these problems can be cleared [in as little as 6 weeks] IF you persist with treatment AND if you fix the Perpetuating factors referred to above.

How are TPs treated?
TPs can be treated in a number of different ways, depending on the speciality or training of the practitioner. Doctors may use local anaesthetic, saline, or cortisone injections, but acupuncture needling, use of a cold spray whilst stretching the muscle, or specific trigger point massage also works. Some physiotherapists or masseurs have a real knack in treating TPs, and I can guide you as to who they are. However there are good reasons to learn how to apply trigger point massage to yourself. With self-treatment you don’t have to wait for an appointment, you can get help whenever you need it, and you don’t pay a cent. You can be the expert in knowing how to get rid of your own pain.

How does massage work?
In 3 ways:
- Massage breaks into the self-sustaining vicious circle that has kept the muscle contracted. 
- It increases the circulation, which has been restricted in the immediate area by the contracted fibres, thus enabling oxygen and nutrients to flow to the spot.
- It directly stretches the trigger point’s knotted muscle fibres.

What’s the best way to massage them?
The Trigger Point Therapy Workbook by Clair Davies gives the following guidelines: 1. Use a tool if possible [such as a firm rubber ball] and save your hands. 2. Use deep stroking massage, [a repeated milking action] not static pressure. 3. Massage with short repeated strokes, moving the skin with your fingers, and releasing at the end of each stroke to go back to the starting point. 4. Do the massage stroke in one direction only, whether with the grain of the fibres or across them. 5. Do the massage stroke slowly, no more than one stroke per second. 6. Aim at a pain level of 7 on a scale of 1 to 10. 7. Limit massage to one minute per trigger point. 8. Work a trigger point 6 to 12 times per day, until pressure on it elicits a pain level of only 2 or 3. 9. If you get no relief, you may be working the wrong spot. Is there anything more I need to do after massage has relieved the symptoms? Yes. After massage it is very important to: 7 Apply a hot pack covered with a dampened flannel or towel to the treated area for a few minutes. 7 Then gradually and gently stretch the treated muscle through its full range of movement 3 times, with a pause to deep breathe and consciously relax between each cycle.

What else can I do or avoid to achieve lasting recovery? 
- Learn respect for your muscles. They were not designed to be held for long periods in a sustained contraction or in a fixed position. Vary your tasks each day. Lift very carefully. 
- Slow your working pace, and take short rests frequently, especially if feeling muscle fatigue. 
- Do a daily program of passive stretches that puts the affected muscles through a full range of movement, and repeat the stretches throughout the day. Be like the cat– it rarely tries to walk after a sleep without first stretching smoothly and slowly. 
- Massage any TPs up to a dozen times a day, for a minute at a time, as described above. 
- Learn relaxation techniques, [eg yoga, meditation]. 
- Always watch your posture when sitting, reading, using the computer car or phone. Don’t stay too long in any one position. 
- Work out what particular postures, movements and activities stir up your TPs. If you don’t have to do that activity, then don’t. If you do, then modify how its done.[eg use the other hand]. 
- Avoid getting the muscles cold, by wearing an extra warm layer of clothing, and adjusting heating etc. 
- Correct any imbalances in your diet, and take vitamin and mineral supplements as recommended by your doctor.

What about exercise?
Exercise should be regarded as a prescription, and the kind of exercise prescribed depends largely on how active your TPs are at that time. Your physio will give you the details. 
- When the TPs are very active and you have pain at rest, then gentle stretches and hot packs are your limit 
- Once the TPs are inactivated and constant rest pain fades, then a carefully graded exercise program is needed to increase muscle endurance and strength. This involves muscle lengthening exercises [adding a new exercise on alternate days], before working up to shortening exercises. Post-exercise soreness and stiffness should not last longer than 3 days or the program needs altering. 
- Then a regular conditioning program is recommended, at least twice a week, for example swimming or cycling.

Would the TPs get better if I just rested up?
Yes and no. Studies have shown that with a short period of rest and the avoidance of whatever activated the trigger point, the pain symptoms may disappear over a few weeks. This makes people believe their problems have gone away. But, if you examine the muscle properly you will find it is still tight stiff and weak, and still tender when pressed on. In other words, the TPs are still there; they are just lying dormant [latent], and not causing referred pain at that time. The bad news is that they can be very easily reactivated  to cause pain again, by acutely overloading the muscle in a new or repetitive task, working or sleeping in an awkward position, chilling the muscle, or during emotional stress, fatigue, or viral infections. How much it takes to reactivate a latent TP will depend on the degree of muscle conditioning, so keeping fit can help reduce the likelihood of this. But the only way to get rid of the TPs for lasting relief is through actively hunting out and treating all the active and latent TPs. Although this involves more effort, its truly worth it in order to escape “the endless replay” of TP pain.

REFERENCES:
Travell J., Simons D.: Myofascial Pain and Dysfunction, the trigger point manual, Vol 1 & 2.Williams and Wilkins 1982 Davies C.

Article found at pain-education.com

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Overconfident Doctors Need Dose Of Reality

Misdiagnoses Occur up to 15% of the Time, and Physician Overconfidence May Be Partly to Blame, Study Shows

April 29, 2008 — Most of the time a medical diagnosis is on point. But misdiagnoses do occur, and an overly confident doctor may be partly to blame, a new review suggests.

The rate of diagnostic error is as high as 15%, Eta S. Berner, EdD, and Mark L.. Graber, MD, write in a special edition of The American Journal of Medicine dedicated to understanding and addressing diagnostic errors.

Physician overconfidence and a lack of feedback following a diagnosis are two important contributors to the problem, they note.

“When directly questioned, many clinicians find it inconceivable that their own error rate could be as high as the literature demonstrates,” Berner and Graber write. “They acknowledge that diagnostic error exists, but believe the rate is very low, and that any errors are made by others who are less skillful or less careful.”

Berner says it is often the cases physicians perceive as routine and unchallenging that end up being misdiagnosed.

“With the hard cases, doctors generally seek out different opinions or turn to (computer-based) decision support tools,” she tells WebMD.

A Missed Diagnosis

Retired engineer Paul Mongerson is all too aware of the problem of medical misdiagnosis, and he has spent the last 28 years addressing the issue.

In 1980, Mongerson was incorrectly told by four different doctors that he had pancreatic cancer, a highly deadly cancer that kills most people who have it within five years.

Mongerson made up a matrix charting his symptoms and test results to help him assess the probability that his doctors were right.

“I determined from that matrix that I didn’t have cancer,” he tells WebMD.

Just two days before he was scheduled for cancer surgery, a fifth doctor agreed and Mongerson canceled the operation.

“I said at the time that if I survived I was going to see what I could do to help other people,” he says.

What Mongerson did was form a foundation to fund the development of computer-based programs designed to assist physicians in diagnosing disease.

While such programs are being used in many hospital and educational settings, they are not yet widely used by private practice physicians.

Mongerson says performing more autopsies and having systems in place to crosscheck medical diagnoses would help address the issue of lack of feedback.

Barriers to Patient Follow-up

In one of the newly published essays, Gordon D. Schiff, MD, associate director of the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital, addressed the barriers to the follow-up of patients in the real-world, clinical practice setting.

Not surprisingly, lack of time was at the top of his list, followed by fragmentation of care, the large number of symptoms for which there is no clear diagnosis, cost and managed care barriers, and physician defensiveness about critical feedback from peers.

“Learning and feedback are inseparable,” Schiff writes. “The old tools (used by physicians) — individual idiosyncratic systems to track patients, reliance on human memory, and patient adherence to or initiating of follow-up appointments — are too unreliable to be depended upon to ensure high quality in modern diagnosis.”

He calls for a systematic approach to link diagnoses with patient outcomes.

In a different essay, Mark Graber, MD, of the department of medicine at State University of New York at Stony Brook and VA Medical Center in Northport, N.Y., proposes new roles for patients that can help. One is to have the patient become a “watchdog for cognitive errors” by having doctors communicate to patients more about what diagnoses they are considering rather than just telling patients what tests to get or what medications to take. Sharing more information with patients can help patients be more active in checking for errors.

A second role is as a “watchdog for system-related errors” to help keep track of their own medical information such as test results and medication lists. By doing so, “the patient can play a valuable role in combating errors related to latent flaws in our healthcare systems and practices,” Graber writes.

Berner adds that patients can help by questioning their doctors carefully during the diagnostic process, and, especially, letting them know when they might have made the wrong call.

“If your doctor says you should be better in a week, and you aren’t, call the office and let them know,” she says, adding that a surprising number of patients do not do this.

Patients who aren’t sure about their diagnosis should also ask their doctors what else their condition might be, she says.

The simple suggestion was a major focus of the best-selling 2007 book How Doctors Think by Harvard Medical School physician Jerome Groopman.

In it Groopman writes that instead of being intimidated by their doctors, patients should ask questions like, “Is there anything that doesn’t fit your diagnosis?” and “Is it possible that I may have more than one problem?”

Mongerson tells WebMD that the point is not to put physicians on the defensive, but to explore all medical possibilities.

“After everything I went through I am still very high on doctors,” he tells WebMD. “They are very dedicated people who work very hard and go through hell when they find out they have made a mistake. The problem is, they don’t normally find out.”

By Salynn Boyles
WebMD Medical News

Reviewed by Louise Chang, MD

Article found at WebMD

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MYOSITIS Part III: Treatment and Prevention

There is no known means of preventing myositis and treatment results are highly variable. In some cases, the symptoms are highly responsive to corticosteroid therapy, the first treatment method typically used. At other times, symptoms do not respond to any treatments. In many cases, general physicians refer patients to specialists, particularly rheumatologists (physicians who specialize in inflammatory diseases), for treatment. If left untreated and the disease becomes severe and progressive (worsening), it can be fatal.

Treatment of myositis is highly individualized. Physicians typically attempt to predict treatment outcomes according to a variety of points. These include:

• Age (in children). Children usually respond better to treatment than adults. Younger children tend to respond better than teenagers.
• Duration of disease before diagnosis and treatment. Responsiveness is best with early therapy, particularly within three to six months of the onset of symptoms.
• Severity of muscle weakness. Typically, the more severe the muscle weakness, the more resistant the myositis is to treatment.
• Dysphagia (difficulty swallowing). When dysphagia is present, the myositis is usually more resistant to treatment.
• Involvement of cardiac or respiratory muscles. When myositis affects the heart or the muscles involved in breathing, treatment is typically less effective.
• Form of myositis present. Different forms of myositis respond differently to treatment. Myositis associated with cancer is typically responsive only to the effective treatment of the cancer. Myositis associated with medications or infections typically goes away when the drug is removed or the infection is treated. Inclusion body myositis (IBM) is particularly unresponsive to treatment.

Pregnancy may worsen the signs and symptoms of myositis, and active myositis may increase the risk of premature birth or stillbirth. This risk is greatly reduced when the disease is in remission. Physicians usually recommend that the patient ensure that the disease is controlled before attempting to conceive. Many pharmacological agents are best avoided during pregnancy. However, if absolutely necessary, corticosteroids may be used throughout the pregnancy with close supervision by a specialist.

Restricting strenuous activities when inflammation is most intense often helps with pain and healing. When symptoms are less severe, physical therapy and rehabilitation may prove helpful. Physical therapists can teach a patient how to be aware of positioning to reduce the risk of pressure sores in bed or wheelchairs and can recommend exercises, including low-impact activities (e.g., walking, swimming) and active or passive range of motion exercises to prevent or improve joint contractures (when the joint remains in a bent position). Occupational therapy may be prescribed if myositis hinders the patient’s performance of daily activities.

Certain nutritional concerns exist for myositis patients. Protein in the diet is important for muscle growth and healing. Calcium is important for strong bones. During corticosteroid therapy, the diet needs to be low in salt and sugar.

Several medications may be used to treat myositis. Typically, the first medications attempted are corticosteroids. These may help to relieve muscle and joint pain and swelling, improve muscle strength, and control fever and rash. Corticosteroids are generally given in pill forms and in high doses. Muscle enzyme levels in the blood are monitored during treatment to determine if the corticosteroid treatment is working and to catch any signs of relapse. In general, if corticosteroids are started earlier in the course of the disease, they work faster and more effectively. Usually 90 percent of patients attain some response with corticosteroids, and 50 to 70 percent of these attain complete remission.

After about four to 12 weeks on the initial high dose of corticosteroids, the muscle enzyme levels have usually returned to normal and muscle strength has returned. At this time, the dose is gradually reduced. Most adults continue taking a low dose for many years or even indefinitely to prevent a relapse. Most children, however, are able to stop corticosteroid therapy entirely without fear of further relapses after about two years. Prolonged use of corticosteroids has been associated with complications including diabetes and osteoporosis, and may affect children’s bone development. Usually corticosteroids are tapered slowly after prolonged use; stopping corticosteroids abruptly can make a person very sick.

In some cases, intravenous corticosteroids are used as an alternative to pill form. When using this method, the corticosteroids are typically administered for three consecutive days weekly or monthly as needed.

Not all forms of myositis respond well to corticosteroids. In cases of inclusion body myositis (IBM), corticosteroids may have no effect or only stabilization or slight improvement of muscle strength.

Sometimes, corticosteroids may not be effective or may even worsen myositis conditions. In these cases, other drugs may be prescribed, including:

• Immunosuppressive drugs. May be employed as initial treatment in patients with indicators of poor prognosis (e.g., those with a delayed diagnosis or with difficulty swallowing) and those at significant risk of corticosteroid side effects. Immunosuppressive drugs may also be used with corticosteroid therapy.
• Intravenous immune globulin (IVIG). Contains large quantities of many antibodies and may be given when other drugs are not effective. IVIG has shown some cases of great improvement or even full remission. It may provide even greater benefit when patients also have difficulty swallowing. IVIG is usually given for two to five consecutive days a month for as long as nine months. However, the costs of this treatment are very high and relapse is common once treatment has stopped.
• Antimalarial drugs, including DMARDs (disease-modifying antirheumatic drugs). May be used to treat rash in dermatomyositis. Typically, the medications for myositis treat pain, inflammation and muscle weakness, not rash. There are some cases where adverse reactions to antimalarial drugs may be confused with the rash and weakness of dermatomyositis itself.

When these drugs prove ineffective, a number of other medications and therapies may be used, such as alkylating agents (cancer drugs), blood plasma exchange or radiation therapy. These drugs and therapies have shown mixed results in studies and may not be effective.

In addition to medical treatment, some physicians may recommend certain complimentary or alternative pain therapies, including acupuncture or thermotherapy (heat therapy). However, these treatments remain controversial and unproven.

In cases of dermatomyositis, the use of sunscreen helps with the prevention and management of photosensitive rashes.

When dysphagia (difficulty swallowing) is involved with myositis, it increases the risk of inhaling food or liquids into the lungs (aspiration), which can cause pneumonia. In some cases, feeding tubes may be necessary. Speech therapists may offer advice about aspiration risk and precautions (e.g., elevation of the head of the bed, semisolid diets).

Dermatomyositis may be accompanied by calcinosis (deposits of calcium and phosphate in the fat layer beneath the skin), particularly in children who do not receive prompt treatment. This can be medically treated in its early stages, but once calcinosis becomes established, it is highly resistant to treatment. In some cases, deposits may need to be surgically removed, particularly if they interfere with joint function, persistently drain, or are painful or infected.

Questions for your doctor regarding myositis

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about myositis:

1. What form of myositis do I have?
2. How may myositis affect my other medical conditions?
3. How severe is my myositis likely to become?
4. What treatment options are available to me?
5. Which do you recommend?
6. How well is my myositis likely to respond to treatment?
7. How long will I have to remain on treatment?
8. How can my medications affect pregnancy? What other side effects might I experience?
9. How should I consider restructuring my life to work with my myositis?
10. What signs of relapse should I be on the lookout for?

Reviewed By:
Vikas Garg, M.D., MSA

Article found at ivillage

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MYOSITIS Part II: Causes, Symptoms, and Diagnosis Methods

Risk factors and potential causes of myositis

The cause of myositis is not known. Most researchers agree that the muscle degeneration characteristic of myositis results from an autoimmune response, in which white blood cells and autoantibodies attack the muscles. However, it is not known what initiates this response. Many researchers speculate that a genetic predisposition to viral or drug complications may cause myositis. Possible causes and risk factors include:

• Family history. A genetic predisposition to myositis seems to exist, at least in some families and particularly in the juvenile manifestations. Certain genes involved in the immune response may play a role. For example, studies have shown that a defect in the tumor necrosis factor alpha gene may increase risk of myositis in children. Another possibility of increased risk for children involves the presence of a mother’s cells in the blood of a child in many cases of juvenile myositis. The genetic makeup of the mother may cause a transfer and/or persistence of maternal cells in the blood of the fetus that somehow makes the child more susceptible to myositis.
• Cancer or connective tissue disorder. Autoimmune reactions against cancer and various connective tissue disorders (e.g., rheumatoid arthritis, scleroderma, systemic lupus erythematosus) may be directed against the muscles as well. 
• Viruses. Myositis may occur during or just after a viral infection. Certain viruses may trigger an autoimmune reaction that does not stop with recovery from the virus. With no virus left to attack, the white blood cells and autoantibodies may, in some instances, turn their attack on healthy body tissues. The connection between viral infection and myositis has not been proven. Some of the viruses that may have links to myositis include the Coxsackie B virus, the echovirus and the human immunodeficiency virus (HIV).
• Drug complications. The use of antibiotics is common in the three months preceding onset and diagnosis of myositis in children. It has been suggested that an abnormal reaction in the immune system may cause these antibiotics to attack healthy muscles.

Recent research indicates that, in children with dermatomyositis, a protein called heat shock protein 60 (HSP60) triggers an immune reaction. Further research would be needed to show if this finding may be useful in diagnosis or treatment.

Signs and symptoms of myositis

Symptoms of myositis typically develop slowly, over a period of weeks to months. Progression may be so gradual that people do not notice the disease for years. However, children usually develop symptoms more quickly than adults. Symptoms often vary in intensity and occur in periods of flare-up and remission. Symptoms are usually symmetrical (occur equally on both sides of the body).

Symptoms are highly individualized and variable. Some people may experience mild weakness that causes little or no detriment. For others, myositis may be a relentless downhill course resulting in confinement to a wheelchair or bed. Spontaneous, long-lasting remission is rare but may occur.

Symptoms of myositis include:

• Muscle weakness. Muscles close to the center of the body, particularly the neck, shoulders, upper arms, hips and thighs, are more often affected. The throat and esophagus may also be affected, but other internal organs and muscles of the hands, feet, eye and face are not usually affected. Weakness may be accompanied by warmth, pain or inflammation in the muscle. In advanced stages of the disease, the muscle may atrophy (deteriorate). Many activities may become very difficult, including:
• • Lifting arms above shoulders
  • Climbing stairs
  • Getting out of a chair
  • Getting into and out of automobiles
  • Raising the head from a pillow
  • Getting up off of the floor
• Difficulty swallowing (dysphagia). Muscle damage to the upper part of the esophagus may lead to dysphagia and food regurgitation. In some cases, food may be misdirected into the lungs, possibly leading to pneumonia. Any instances of dysphagia may indicate the need for immediate assistance.
• Shortness of breath and cough. Rarely, the lungs may be affected by weakness, causing shortness of breath and cough. This may indicate the need for immediate medical assistance.
• Raynaud syndrome. This peripheral vascular disorder, marked by discoloration of the fingers and toes accompanied by tingling sensations, may occur in any form of myositis.
• Myocarditis (inflammation of the heart muscle). Rarely, the heart may be affected by inflammation and weakness. This may lead to heart failure or arrhythmia (irregular heartbeat).
• Gastrointestinal abnormalities. Bleeding ulcers in the intestine or stomach may cause abdominal pain and black or bloody bowel movements. This is more common in children than in adults.
• Contractures. Muscles may shorten and cause a joint to remain in a flexed (bent) position. This may occur due to scarring during healing or to lack of exercise. It is seen more often in children than adults.
• Vasculitis. The blood vessels that lie under the skin and in the muscles may become inflamed. In some cases, these inflamed vessels may lead to open sores in the skin that may be as small as a pencil point or as large as a silver dollar. These sores may be deep or just on the surface and may last from a few days to several months. They typically go away with treatment. Vasculitis with or without open sores occurs in children more often than in adults.
• Lipodystrophy. Abnormal redistribution of fat may occur with myositis. It occurs in children more often than adults.
• Other symptoms include:
• • Low-grade fever
  • Fatigue
  • Unexplained weight loss
  • Myalgia (muscular pain and stiffness)
  • Malaise (general unwell feeling)
  • Irritability
  • Nasal voice or loss of voice
  • Stunted growth in children

Dermatomyositis may have any of the general symptoms of myositis, but is characterized by the addition of skin abnormalities. A brown coloration or pale discoloration and scarring or shriveling may develop after any rashes fade. Skin abnormalities that may be seen in dermatomyositis include:

• Heliotrope rash. Shadowy reddish-purple rash on the face, particularly the nose, cheeks and eyelids. Rash on the eyelids is usually accompanied by edema (swelling).
• Gottron sign. Pink or purple rash that may be scaly, smooth or raised. This may appear anywhere on the body, but typically occurs on the knuckles, elbows, knees and ankles.
• Smooth erythema (discolored inflammation). Smooth, violet-colored inflammation. May appear on the backs of the shoulders and neck (shawl sign) or on the front of the neck and upper chest (V sign).
• Rash affecting the fingertips. The bed of the fingernail may become red and the area around the nail may swell.
• Calcinosis. Deposits of calcium and phosphate in the fat layer beneath the skin. These may be as small as a period or as large as a pebble and small deposits may join together to form larger lumps.

Several symptoms of inclusion body myositis (IBM) occur and develop differently from other forms of myositis. The characteristic muscle weakness in the trunk may be accompanied by muscle weakness in the limbs and some facial muscles for IBM patients. Asymmetric weakness occurs more commonly in IBM than in other forms of myositis, but still does not occur more often than symmetric weakness. For IBM patients who experience difficulty in swallowing, this may be the first complaint, preceding muscle weakness by as many as seven years.

Diagnosis methods for myositis

Early diagnosis leads to early treatment and better chances of recovery. Physicians will perform a physical examination, evaluate the patient’s medical history and request laboratory and imaging tests. Other possible conditions that could be causing the symptoms will be evaluated and ruled out. When diagnosing children, many physicians avoid using painful or invasive tests.

If a child demonstrates typical muscle weakness, elevated muscle enzymes in the blood and (in the case of dermatomyositis) characteristic rash, these tests may not be needed. In adults, proximal (closer to the body’s midline) muscle weakness on physical examination, elevated levels of enzymes derived from muscles, myopathic changes on electromyography and muscle biopsy evidence of inflammation are diagnostic criteria for polymyositis.

Physicians typically look for certain criteria before diagnosing a patient with myositis. These criteria include:

• Muscle weakness at shoulder or hips
• Increased levels of muscle enzymes in the blood
• Characteristic muscle tissue changes observed under a microscope
• Abnormal electrical activity in the muscles measured by electromyography
• In the case of dermatomyositis, characteristic rash

Physical examination pays particular attention to strength testing. Physicians typically hold a patient’s arm or leg and have the patient move it while mild resistance is applied. This can help the physician determine the degree of muscle weakness that is present.

Several tests are particularly helpful in the diagnosis of myositis. These include:

• Muscle biopsies. A small piece of muscle tissue is removed and examined for abnormal proteins and enzyme deficiencies. Muscle biopsy is the definitive test for myositis and may reveal abnormalities such as damage, inflammation, disease or infections. The particular form of myositis present can typically be identified by small differences in inflammation patterns. Muscle biopsy is particularly useful in diagnosing inclusion body myositis (IBM). Muscle biopsy is essential for establishing the diagnosis of polymyositis.
• Blood tests. Certain enzymes tests may indicate elevated levels of creatine kinase for some forms of myositis. This indicates muscle damage and may be used to help rule out other conditions. An ANA test can identify the presence of antinuclear antibodies, which may be present in some forms of myositis. Complete blood count and sedimentation rate tests are typically normal in myositis patients and may be performed to rule out other conditions. There are a few other autoantibodies that can be measured in blood (e.g., Anti-Jo1, Ati SRP).  
• Electromyography (EMG). A thin electrode is inserted into a muscle and electrical activity is measured as the patient relaxes or tightens the muscle. Although EMG can be painful, it reveals abnormal muscle function and may be used to assist in ruling out other conditions.

• MRI (magnetic resonance imaging). Images of the muscle are generated using magnetic and radio waves. MRI can demonstrate areas of muscle inflammation and, because large areas can be accessed, sampling errors may be avoided. This is a nonpainful and noninvasive or minimally invasive procedure.

Certain other conditions may have symptoms similar to those seen in myositis. It is important to rule these out as the cause of the symptoms so that the proper condition may be treated. These conditions include:

• Viral infections
• Scleroderma
• Systemic lupus erythematosus (SLE)
• Muscular dystrophy
• Various other myopathies (muscle diseases)
• Exposure to toxins
• Drug reaction
• Hypothyroidism

Reviewed By:
Vikas Garg, M.D., MSA

Article found at ivillage

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MYOSITIS Part I: Distant Relative to Fibromyalgia Syndrome (FMS)?

Summary

Myositis may refer to a number of muscle diseases, including polymyositis, dermatomyositis and inclusion body myositis (IBM). These are all rare conditions characterized by pain, inflammation, weakness and degeneration of the muscles, particularly those close to the torso. Most researchers suggest that myositis may be similar to autoimmune disorders, in which white blood cells and antibodies attack healthy tissues.

Myositis may affect children or adults. It typically affects women more often than men and African Americans more often than whites. In some instances, myositis can be fatal.

Polymyositis is the most common form of myositis. It affects many muscle systems, usually near the trunk. Dermatomyositis includes all of the muscle weakness characteristics of polymyositis as well as a rash. Inclusion body myositis (IBM) is similar to polymyositis but involves more muscle in the limbs. IBM is resistant to treatment. Myositis may also be associated with other conditions, such as cancer, viral infections and rheumatoid arthritis.

The cause of myositis is not known. Many researchers believe that genetic factors may trigger the white blood cells and antibodies in the blood to attack muscles after a viral infection or use of certain medication.

Symptoms of myositis usually develop slowly and may range from mild to severe in intensity. Weak muscles are the primary symptom and often lead to other symptoms, such as difficulty swallowing or shortness of breath. Other less serious symptoms include fever, fatigue and weight loss.

Diagnosis of myositis relies on physical examination and tests. Physicians look for signs of weak muscles. Typically, blood tests, muscle biopsies and electromyography (EMG) are used to rule out other conditions as the cause of the patient’s symptoms.

No methods of preventing myositis are known. The effectiveness of treatment varies among individuals. Corticosteroids are typically given in high initial doses. When symptoms go away, the dose is gradually reduced. Although adults usually continue taking corticosteroids for a long time or indefinitely, children typically stop therapy after two years. If corticosteroids do not work, other drugs may be used.

About Myositis

In general terms, myositis is simply muscle inflammation that tends to be painful and tender and that does not issue pus (is nonsuppurative). However, myositis is often used to refer to any of a number of related inflammatory myopathies (muscle diseases), such as polymyositis, dermatomyositis and inclusion body myositis (IBM). These are rare, chronic connective tissue diseases involving the immune system. They are characterized by symmetrical (occurring on both sides of the body equally) pain, inflammation, weakness and degeneration of the strong muscles close to the torso, particularly those of the shoulders and hips.

Most researchers believe that the weakness and muscular degeneration of myositis is the result of the white blood cells and autoantibodies attacking healthy tissues. This attack is particularly concentrated on the small blood vessels in the muscles and leads to degeneration of the muscle.

Myositis may occur at any age, but onset typically occurs either between the ages of 5 and 15 years or between 30 and 60 years. There are numerous differences between myositis affecting children and adults. Polymyositis and dermatomyositis are more common in women. Inclusion body myositis (IBM) is more serious and occurs more often in men. The diseases occur more frequently among people with medical conditions that affect the immune system, such as autoimmune disorders or human immunodeficiency virus (HIV).

On rare occasions, myositis can be life-threatening. Complications leading to infection, respiratory failure or inability to eat due to difficulties with swallowing are the usual causes of deaths related to myositis.

Types and differences of myositis 

Myositis occurs in a variety of forms:

• Polymyositis. This is the most common form of myositis, affecting many symmetrical muscular systems, usually near the trunk (e.g., shoulder or pelvic girdle). Generally, when the term “myositis” is used to refer to a chronic condition rather than short-term muscle inflammation, it is referring specifically to polymyositis.
• Dermatomyositis. When a rash accompanies polymyositis, the condition is called dermatomyositis. Photosensitive (sensitive to light) rashes usually appear, along with muscle weakness and other symptoms. In children, dermatomyositis is much more common than polymyositis. Sometimes its characteristic rash may lead to a diagnosis of dermatomyositis without the accompanying myopathy (muscle disease).
• Inclusion body myositis (IBM). Only recently distinguished from polymyositis, IBM is characterized by a particularly gradual onset and progression of symptoms. Most patients have symptoms for about five to six years before diagnosis. This disease predominantly affects men over 50 years of age and tends to be more dangerous than polymyositis. It is resistant to treatment and often leads to severe disability, leaving patients wheelchair-bound or bedridden. IBM may lead to death, usually due to respiratory complications.

Myositis may also occur in association with other conditions or diseases. In many cases, if the associated condition can be treated or stopped, the symptoms of myositis subside. Myositis may occur in association with:

• Connective tissue disorders (e.g., lupus, scleroderma)
• Cancer
• Viruses, including HIV
• Certain medications

Because the term myositis broadly refers to muscular inflammation, the term may be applied to a range of conditions unrelated to the three myopathies described above. For example, myositis trichinosa is a parasitic disease caused by eating undercooked meat, myositis ossificans is a condition that causes bone-like hardening in soft tissues, and the destruction of muscle by necrotizing fasciitis (“flesh-eating bacteria”) may be referred to as necrotizing myositis.

Reviewed By:
Vikas Garg, M.D., MSA

Article found at ivillage

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Johnson & Johnson Recalls Some Transdermal Pain Patches

The Ortho-McNeil-Janssen unit of drug and consumer giant Johnson & Johnson is voluntarily recalling all of its 25 microgram-per-hour-strength Duragesic pain patches, which the company said have the potential to expose patients to a dangerous gel inside. Duragesic is used to manage persistent moderate to severe chronic pain that needs to be treated around the clock. The patches are sold in the United States by PriCara, an Ortho-McNeil division, and Sandoz Inc.

The company says the recall, conducted in cooperation with the U.S. FDA, affects all lots of its 25 mcg/hr Duragesic CII patches sold in the United States with expiration dates on or before December 2009, because theses patches may have an opening that could result in release of the gel made of the drug fentanyl inside, leading to potentially serious harm.

“Exposure to fentanyl gel may lead to serious adverse events, including respiratory depression and possible overdose, which may be fatal,” notes a press release from the company on the recall. “Anyone who comes in contact with fentanyl gel should thoroughly rinse exposed skin with large amounts of water only; do not use soap. Immediately dispose of affected patches with cut edges by flushing them down the toilet, using caution not to handle them directly. Patches with a cut edge that have leaked gel will not provide effective pain relief.”

The company says that anyone who has 25 mcg/hr Duragesic or Sandoz Inc. fentanyl patches (fentanyl transdermal system) should check the box or foil pouch for the expiration date to see if they have patches that are being recalled. The cut edge in affected patches can be seen upon opening the sealed foil pouch that holds the patch. Affected patches should not be handled directly.

Anyone with 25 mcg/hr Duragesic patches being recalled should call 800-547-6446. Anyone with 25 mcg/hr Sandoz Inc. patches being recalled should call 800-901-7236. Other strength patches (12.5, 50, 75 and 100 mcg/hr) are not affected by this recall, nor are Duragesic patches sold in Europe, Latin America, and Asia, according to the company. For more information, visit www.DURAGESIC.com or http://www.jnj.com/news/.

Article found at OHSOnline

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