Hi, everybody. I sincerely hope I'm not going to unduly worry, upset or offend anybody with this posting! It seems many of us are concerned about the possibility of MS, (myself included) with an alarming overlap of symptoms. I've done an awful lot of research on the subject and wrote up a little guide for my own reference, and I thought I might share it with you for your feedback and responses. I should stress at this point that I am NOT a doctor and have NO medical training -- I just read a lot (postings on MS forums sound so much like ours!)! Nobody should read this and try to self-diagnose, because medical professionals are trained to recognize theses disorders (though some of them don't seem to recognize fibro as a valid ilness yet!). I just thought that it would be handy to have an instant reference guide to compare the two illnesses. If I have made any mistakes, please reply with a correction and I'll make an amendment. All feedback welcome. Thanks, Marcus -------------------------------------------------------- MULTIPLE SCLEROSIS & FIBROMYALGIA – A DIFFERENTIAL DIAGNOSIS Multiple Sclerosis is a progressive inflammatory disorder which destroys the myelin sheath around nerves, thus ‘short-circuiting’ the CNS, and relaying/receiving aberrant messages to and from the brain. Fibromyalgia on the other hand, is a dysfunctional neurotransmitter syndrome – ‘syndrome’ because it is supposedly non-progressive and non-inflammatory. Indeed, the yield of positive results from routine diagnostic testing with FMS patients is usually minimal, with occasionally some mechanical problems with the spine revealed on MRI, or occasionally concomitant disorders such as Candidiasis or Hypothyroidism revealed with blood work. Generally, the diagnosis – as with MS – is essentially clinical, which is to say that it is based upon presenting symptoms and medical history. And yet the symptoms of both MS and FMS are markedly similar, (especially in the early stages of MS), usually prompting MS screening tests for FMS sufferers. While only thorough diagnostic testing (Cervical and brain MRI, Sensory Evoked Potentials and Lumpar puncture) can aid towards a reliable diagnosis of MS, there appear to be some small but significant differences in clinical presentation of both entities which may aid in differentiating them. These differences are by no means definitive, but are merely suggestive of one disorder or the other. (It is of course entirely possible to suffer from both.) Paresthesiae/Numbness & Tingling While both MS and FMS patients will experience transient and migratory tingling and numbness in various parts of their bodies, the paresthesiae experienced in FMS sufferers tend to be found mostly in the extremities rather than in the torso, spine or trunk. A phenomenon known as ‘L’hermittes’ – a strong electrical shock sensation down the spine, elicited upon flexion of the neck – is suggestive of a disease process in the spinal cord. MS patients will experience periods of numbness consistent with the demyelination and remyelination of nerve tissue, which leaves the patient with a fixed numbness, lasting more than 24 hours. The numbness in FMS is likely more due to constricted blood supply and nerve impingement by fibrotic muscle tissue, and generally responds to therapeutic treatment (heat, massage etc). The numbness in MS does not typically respond to palliative treatment. Both MS and FMS patients may find that their limbs ‘go to sleep’ easily if subjected to pressure or long periods of inactivity. A ‘burning’ sensation upon the skin (typically on the skin of the legs and feet) is also common in both FMS and MS, and may respond to analgesic medications like Neurontin or low-dose antidepressants like Elavil (Amitriptyline). A phenomenon known as RLS (restless leg syndrome) is commonly found in FMS, whereby the patient experiences a buzzing, ‘humming’ sensation in the legs, and finds it imperative to periodically move them. It may worsen after exercise or over-activity. This is quite distinct from the shooting electric-shock like pains experienced due to insult to the CNS from a demyelinating process. Both MS and FMS sufferers can experience all of these paresthesiae on a daily basis. Medications FMS patients are notoriously intolerant of medications, and will suffer excessive side-effects from some NSAID’s (Non-steroidal anti-inflammatories like Ibuprofen), especially gastric disturbances. MS patients are generally more tolerant of painkillers and antidepressants. FMS, on the other hand, tends not to respond to corticosteroids, which are the drugs of choice to reduce or eliminate symptoms in flares or ‘exacerbations’ of MS (because FMS is believed to be a sensitization of the CNS rather than an inflammatory process). Many over-the-counter analgesics are of little effect in both disorders. Heat While both FMS and MS patients can be uncomfortable in hot and humid conditions, the effect of heat on many MS patients is quite disturbing, as it causes a reduction in the speed of nerve conduction, making pre-existing symptoms temporarily worse. A hot bath or shower can result in weakness, blurred vision, dizziness and nausea for an MS sufferer. FMS patients on the other hand, find that heat is a useful palliative tool for dealing with muscle pain, and many FMS patients feel at their most comfortable in a hot tub. This is a significant clinical difference between the two entities. Exercise While both MS and FMS patients might tolerate exercise well, rapid fatiguing of muscle with repetitive use of a certain muscle group might cause cramping, stiffness and pain in both. With MS, this is due to a nerve conduction fatiguability, and will commonly result in the affected limb/s failing to respond at all if the patient tries to continue. In FMS, the etiology is likely to be more metabolic in origin, and although the patient may keep on exercising, the muscles may become increasingly sore and fatigued. The FMS patient is more likely to notice that his muscles are particularly sore and tender after the exercise, a phenomenon due possibly to oxygen starvation or a glycogen storage abnormality. An FMS patient will not typically report that his legs ‘stopped working’, but rather that the exercise produces pain, fatigue and malaise. Exercise is often prescribed as a therapeutic tool in both illnesses, but can be particularly detrimental to FMS sufferers if a metabolic disorder is concomitant to the CNS sensitization. An FMS sufferer may experience pain and fatigue in the used muscles for several days after the actual event. MS patients, on the other hand, must be alert to the possibilities of exacerbation of existing symptoms due to exercise-induced heat. Weakness Weakness is one of the major clinical diagnostic criteria for MS, and a clinical diagnosis of the illness is unlikely in its absence. It might typically present unilaterally or bilaterally (with the former being slightly more common), and can be either subjective or objective and variable at different times of the day (though often worse in the late afternoon). Patients might report that one or both legs want to give way from beneath them, that they are stiff and ‘wooden-feeling’ and uncoordinated. Sudden leg weakness might result in an MS patient falling, or a ‘foot-drop’ effect cause them to drag an ankle or leg. With FMS, weakness of the extremities is less common, and is due more due to a combination of trigger points within muscle groups and abnormal muscle fatigue. The combination of antagonistic muscle action and fatigue can produce sensations of weakness and incoordination in the legs that are usually accompanied by a degree of pain. While some muscle spasticity might be experienced (and consequently a painful ‘tightening’ of joints), reflexes are usually found to be normal on clinical examination. The FMS sufferer will report ‘buckling knees’ rather than a sudden onset of weakness that might precipitate a fall. The muscles in FMS sufferers seem also to undergo a ‘jelling’ phenomena, leading them to stiffen over periods of disuse (eg. sitting for long periods or after a night’s sleep), and can be unresponsive for a period upon ‘re-activation’; this sensation can be reported by the patient as weakness and incoordination; it usually resolves upon re-use of the muscle group in question. This particular manifestation is not a common finding in MS. Bladder & Bowel Bladder problems can arise in both illnesses, but there are significant differences. In MS, the problem is usually one of a neurogenic bladder, which arises from the interruption of nerve signals to and from the bladder. This can result in urge incontinence, urinary retention, or hesitancy. The patient commonly does not realize how full the bladder is, and may be caught short by an urgent need to void. With FMS, interstitial cystitis – a feeling of an uncomfortable or tender bladder – tends to be the cause of frequent urination. Urge incontinence is generally experienced less with these patients, who might also experience bladder sensitivity/over activity due to the irritation of smooth muscle. There also seems to be a greater incidence of UTI’s (urinary tract infections) in FMS patients than with MS. In MS patients, constipation is the most frequently reported complaint. In FMS, sufferers will find that diarrhea and constipation may alternate, with diarrhea being more common. This aberrant bowel behavior is known as IBS (Irritable Bowel Syndrome), and is again thought to be caused by irritation and spasm of smooth muscle rather than having neurological origins. Balance While both MS and FMS patients will complain of feeling dizzy or ‘light-headed’, the FMS patient does not usually present with true ataxia, but rather from a disequilibrium, arising from altered visual perception and compounded by trigger points within the musculature of the neck. The MS patient on the other hand will typically lose their balance on the Romberg test and when asked to perform tandem gait ambulation, the balance problems here arising from neurologic insult to the brainstem. Vision Optic/retrobulbar neuritis is a common presenting symptom of MS, and is indicative of an inflammatory process. The symptoms are sharp pain behind the eyes, blurring, hazed or double vision, and/or a shift in the perception of colors. Visual field defects might also be experienced. In FMS, eye pain, frontal headaches and ocular migraines are more prevalent, and visual effects relating to these – such as flashing lights – are common. FMS sufferers will also report blurred vision, though this is of a transitory nature and will typically fluctuate during the day according to the state of fatigue. This phenomenon is due to fatiguing of the muscles that control focusing, and may be impacted by the presence of ocular ‘trigger points’ which make eye movement more uncomfortable. Unlike optic neuritis, this symptom is not exacerbated by heat. Floaters, photophobia and problems with glare and flare are reported by both MS and FMS patients, though this complaint is more common with FMS sufferers. The etiology is unknown. Muscle Symptoms Both FMS and MS patients widely complain of muscle pains, cramps, spasms, fasciculations, and tremors. It can be hard to differentiate between neurological and metabolic causality with these phenomena, but again, there are subtle differences: In MS, the primary cause of muscle pain is spasticity, which is the involuntary contraction of extensor or flexor muscle groups, causing the limb in question to become rigid. This can be accompanied by painful cramping as the stressed muscle exhausts its oxygen supply. This phenomenon is not as widely found in FMS; rather a milder spasticity arising from trigger points and over-fatigued muscle is likely to be found, where the spasms are less violent and traumatic. These can appear anywhere in the body, appearing sometimes as abdominal pains or sometimes even as throat discomfort. Cramps are common to both, and are typically found more in MS patients at rest, (being neurological in origin), whereas FMS patients may experience them more frequently during exercise. Fasciculations (muscle twitching) are extremely common in FMS (despite established diagnostic criteria making little mention of them), but are not, on the other hand, part of the clinical picture of MS. Tremors can be experienced by patients of both illnesses, and may come and go; sometimes these might be experienced as internal or invisible tremors. In MS, the more common tremor is of the intentional variety, and is provoked by the patient reaching out to touch or hold an object. With FMS, the tremor is induced by muscle fatigue and is usually observed as a very fine ‘essential’ tremor (at rest), which presents bilaterally. Again it is possible to have both. Fatigue With MS, fatigue can be experienced as a body-wide ‘heaviness’ or as an overwhelming, almost narcoleptic ‘shutdown’, where the patient simply cannot continue to function without a period of rest or sleep. While fatigue is very common in FMS, it is not usually as incapacitating as the ‘central fatigue’ of MS, and is more commonly attributable to sleep disturbances and the strain of having to deal with so much pain on a day-to-day basis. It might be seen therefore, that based on the above symptoms, enough subtle differences exist that an experienced clinician should be able to differentiate between what are two very similar disorders, though of course, diagnostic testing will always provide the cornerstone of a reliable diagnosis.