Chronic myofascial pain (CMP) is a musculoskeletal chronic pain syndrome that is nonprogressive, nondegenerative, and noninflammatory. It is characterized by pain and stiffness that is restricted to certain locations on the body. Like fibromyalgia, chronic myofascial pain is not a psychological disturbance, and neither condition is a mental illness, although chronic pain can cause anxiety and lead to depression.1-7 The American Medical Association, the World Health Organization, and the National Institutes of Health are among those who have accepted these as legitimate physical illnesses and major causes of disability.1 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. Where to Go for More Information There is a great deal of information and misinformation available about CMP and FM on the Internet, as well as in tabloids, magazines, journals, health-food stores and bookstores. Since the severity of CMP and FM varies widely among patients, and waxes and wanes in each individual, both conditions are excellent candidates for questionable treatments, possible quackery and scams. Some of the most reliable sources for information are from healthcare professionals who write about and themselves suffer from CMP and/or FM. Such people include Devin J. Starlanyl, MD,1,2 Mark J. Pellegrino, MD,3 R. Paul St. Amand, MD,4 Jacob Teitelbaum, MD,5 and the author of this article. Dr. Starlanyl, in particular, offers a wide variety of information and handouts geared towards patients and specific healthcare professionals, as well as a listing of support groups, newsletters and other related links.10-23 She has also made a video, "Chronic Myofascial Pain Syndrome: Guide to the Trigger Points."24 Many patients who establish their own web sites draw largely from Dr. Starlanyl's publications. Some resources provided by Dr. Starlanyl are listed in TABLE 1. Resources from some other healthcare professionals who write about and also suffer from CMP and/or FM are found in TABLE 2. Other recommended resources are listed in TABLE 3. It should be noted that information on "chronic myofascial pain" may be revealed if one searches under "fibromyalgia." 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. 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. 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 Table 4: A Comparison of Selected Characteristics of CMP and FM Chronic myofascial pain Fibromyalgia Disease Syndrome Trigger points (TrPs) Tender points Pain is referred Pain is localized Localized, predictable pain Generalized or body-wide pain, achiness or "flu-like" feeling Can worsen FM Can worsen CMP 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.