off loading your symptoms

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(From the January '95 issue of Fibromyalgia Network newsletter*)

Are problems such as facial pain, jaw pain, headaches, ear pain,

neck/shoulder pain, and the feeling of muscle weakness ganging up on you?

Patients with fibromyalgia and chronic fatigue syndrome who have a TMJ

disorder would answer YES to this question. What follows is an explanation

of why these symptoms might be wearing you thin and a list of suggestions on

how you might " off-load " these burdens to ease your overall discomfort.

Temporomandibular joint disorder (TMJD) expert and pathologist Herbert

Gordon, D.D.S., Ph.D., who practices in Seattle, WA, offers this story his

grandfather told him years ago to demonstrate how pain impacts your sense of

well-being:

" A man went to a doctor, saying, `I need your help.' The doctor responded,

`What's wrong?' The man said, `My ankles are not doing well, my knees hurt,

my back hurts, my stomach hurts, my ears hurt, my chest hurts, my head

hurts, my tongue hurts...and I myself don't feel so good either!' "

Naturally, the more areas of pain a person has, the more rotten they are

likely to feel. FMS/CFS patients suffer from constant pain arising from

multiple body sites, much like the man in Dr. Gordon's story. Learning how

to focus in on troublesome symptoms so as to minimize their impact can be

done with the assistance of your health care team and a little understanding

about various types of regional pain syndromes, body posture mechanics, and

the way pain signals are processed in the brain.

Regional Pain Syndromes

Myofascial pain syndrome (MPS) is a term used for the kind of muscle pain

found in multiple body sites in FMS/CFS patients. In MPS, trigger points --

rather than tender points -- occur, causing pain to be referred to distant

sites. There are a number of MP syndromes and a multitude of myofascial

trigger points throughout the body. The head, neck, upper back, and

shoulders are particularly active. A common form of MPS involves the jaw

movement muscles and is called temporomandibular joint disorder (TMJD).

When a referred pain phenomenon is present, the source of the pain can be

confusing. A tooth ache may not be caused by a cavity: " If the pain

originates in one of the jaw movement muscles like the temporalis, " says Dr.

Gordon, " extracting the sore tooth won't alleviate the problem. " Another

common pain referral scenario can occur in a person who is experiencing a

heart attack. This individual may also have pain shooting down into their

left arm or hand, but a person doesn't have to have a heart problem to know

what this feels like. Patients with FMS have been reported to have trigger

points in the chest region which lead to a referral of pain down an arm as

well -- somewhat mimicking a heart attack.

To explain what might be happening at trigger points, Dr. Gordon referenced

a 1993 report by Hubbard, M.D., a researcher in San Diego, CA. Dr.

Hubbard inserted needle electrodes into the trigger points of the trapezius

muscle (back shoulder area) and another one simultaneously into a nearby

non-tender spot in the same muscle in three different study groups: patients

with muscle tension headaches (a form of MPS), patients with FMS, and

healthy individuals. He had the two electromyographs (EMGs) going at the

same time and measured the neurological activity at both muscle locations.

In the muscle tissue away from the trigger point, there was only a low level

of activity. At the trigger point, however, the EMG signals were

significantly stronger in the two patient groups as compared to the healthy

controls. Hubbard hypothesized that trigger points are caused by sustained

sympathetic nervous system activity that causes the muscle to tense up and

produce pain.

But what if the patients just relaxed their trapezius muscle? Wouldn't this

release the tension at the trigger point? When Hubbard asked the patients to

relax, the EMG amplitude at the non-pain site decreased, demonstrating that

patients could relax their muscles upon command. Yet, the EMG signals at the

trigger points didn't decrease.

" So it appears that when patients purposely relax, they aren't fully relaxed

at the trigger points, " says Dr. Gordon. " The muscle will stay tense as a

result " ...and it will require more than relaxation therapy to ease the pain.

Patients who have TMJD or other regional pain syndromes should seek prompt

treatment. Unlike the deep, diffuse aching caused by FMS, the pain of MPS is

often treatable in a variety of ways (see TMJ Disorders Update below).

Underscoring the importance of treatment, Gordon says, " A large area of your

brain is set aside for controlling mouth and jaw movements, speech and

chewing. If you have pain in jaw movement muscles or an abnormal

temporomandibular joint with clicking or popping and pain, you are going to

tie up a significant amount of your brain in a painful process. Current

research in chronic pain has shown that the longer the pain exists in a

particular site, the more involved the brain becomes, and the area of the

brain that deals with pain grows larger. This is why existing areas of

diagnosable pain need to be treated as promptly as possible in order to

reduce the overall burden on the brain and the rest of the body. This is

especially important in FMS/CFS. "

Body Mechanics

Maintaining good posture is important. " If you carry your body incorrectly,

you are going to induce strain, " says Gordon. " If you induce strain, you are

hurting the muscles, ligaments and tendons. " Just holding up your head in a

proper position may not be easy to do when you are tired, your neck and

shoulders hurt, and your postural muscles have begun to weaken due to a

decreased activity level--a situation often imposed by FMS/CFS.

What happens if you don't hold your head upright? According to Dr. Gordon,

for each inch that you bend your head forward and keep it in a forward

position, the weight of your head doubles! The additional weight of your

head will strain your jaw joints, neck, back and shoulder muscles, and of

course, cause more pain (including headaches).

Regardless of whether you are sitting, standing or lying down, pay close

attention to your posture and body mechanics. If you are having problems in

this area, ask your doctor for a referral to a physical therapist or

occupational therapist.

Your Body's Pain-Control System

By the time a pain signal from a sore toe travels up the nerves in your leg,

enters your spinal cord, and reaches your brain, the pain signal is usually

minimized, if not completely abolished. " There are specific neurons, cells

in the spinal cord and central nervous system whose job it is to block out

pain, " says Gordon. " Chemical agents in the brain have a dampening effect on

pain. "

Using marathon runners as an example, Dr. Gordon says they run until they

pass through " the wall " and reach the runner's high. How does this happen?

Their bodies produce opium-like chemicals in the brain which block out the

pain signals coming from the many muscle sites that are injured while they

are performing their run. Yes, they are in good condition, but they are

pushing their bodies and their muscles are actually hurting...it's just that

the opium-like material blocks the pain. " If you give these runners an

opium-blocking agent, they crash, " says Dr. Gordon. " They go from a high to

a feeling of painful withdrawal. "

Under normal conditions, the body is able to filter out or block pain

signals that are generated from the muscles while running a marathon. But in

people with chronic pain conditions like FMS/CFS, Dr. Gordon -- as well as

others in the field -- suspect that patients have lost some of their ability

to filter out pain at the spinal cord level and to block it out at the

higher regions in the brain. This is one of the effects of the limbic system

deregulation that many believe is the cause of FMS/CFS.

" Ongoing discomfort from previous surgeries, falls, motor vehicle accidents,

postural problems, untreated pain or incompletely treated pain for distinct

conditions should be dealt with, " says Gordon, " in order to help off-load

the body's total burden of pain. " When these measures are taken to minimize

regional pain problems, Dr. Gordon finds that FMS/CFS patients feel better

overall, although they are by no means cured.

TMJ DISORDERS UPDATE

TMJ disorders involve the muscles that move the jaw or can involve the jaw

joints as well. TMJD is the most common form of MPS and for good reason.

" The TMJ has been estimated by one person to be the most active joint in the

body, " says Dr. Gordon. " It moves approximately 2000 times in a 24-hour

day! " According to Gordon, there are two major causes of TMJD: Extensive

clenching or grinding of teeth and whiplash injuries. " We all clench and

grind our teeth. Those in severe stress, and those in chronic pain, grind

and clench more than usual. This overuses the jaw muscles and places

pressure on TMJ tissues. This can lead to dislocation of the moveable disc

in the jaw joint and produce clicking, pain, and limited movement. Whiplash

forces that can injure the neck may also injure jaw movement muscles and the

temporomandibular joints. A major reason for the high prevalence of TMJD in

FMS/CFS could be the association of the jaw musculature with the 5th

cranial, or trigeminal, nerve that feeds directly into the limbic system of

the brain.

Dr. Gordon explains: " The 5th cranial nerve supplies all of the jaw movement

muscles, the temporomandibular joints, a portion of the throat, the ears,

the back of the eye and sinus cavities and the muscles on the side of the

head. Recent studies show that the 5th nerve also supplies sensory input to

the blood vessels of the brain. "

" The 5th nerve, " notes Dr. Gordon, " is the communicating center for all pain

arising in the neck, head, jaw, eyes, ears, sinuses, and the cervical spine.

It may well be the center of integration of head and neck pain, as well as

jaw movement.

These facts help explain why TMJD can have so wide an effect and be involved

in headaches. It also explains how dysfunction of jaw muscles and joints

could amplify problems in the limbic system. "

Your Treatment Options

If you have the above symptoms of TMJD and have FMS/CFS, seek consultation

with a TMJD specialist. Your problems may be too complex for a general

practitioner of dentistry.

A diagnostic examination is necessary to determine whether a jaw muscle

problem is present or if the jaw joints are also involved. Dr. Gordon

advises that all of the FMS/CFS patients he has seen have the more severe

form of TMJD.

Treatment includes the use of special TMJ appliances--splints (not the usual

nightguards), exercises for the jaw muscles, diet, a variety of physical

therapy treatments, jaw mobilization (manipulation of the jaw to put

out-of-place discs into normal position), trigger point/jaw joint

injections, ultrasound, laser therapy to the TM joints, pain medications

(analgesics like ibuprofen, narcotic agents if needed), medications to aid

in sleep, as well as medications to help with muscle stiffness and soreness.

Biofeedback therapy is also utilized. All of the medications and therapy

must be coordinated with the overall treatment for FMS/CFS.

Medications commonly used to treat TMJD include: Non-opiod analgesics

(aspirin, Aleve, ibuprofen, etc.) and muscle relaxants such as Soma

(carisoprodol) and Flexeril (cyclobenzaprine). According to Dr. Gordon,

" These are best used on a regular schedule around the clock. " One pilot

study in 1991 showed that 0.25 - 1.0 mg per night of Klonopin (clonazepam)

may be helpful as well.

Dr. Gordon believes these methods can be beneficial in 99% of cases.

Surgical intervention is needed in only 1% of cases.

Recommendations for Self-Help:

Rest your jaw whenever possible. The best way is to keep your teeth apart

and let your jaw " hang " so as to relax all facial muscles. You might find

that it is not easy to relax muscles that hurt, so consult a

biofeedback/relaxation specialist for help.

Maintain good posture.

Stretch sore jaw muscles 2-3 times daily. At first you may not be able to

fully open your mouth. If this is due to sore muscles, heat can help. If

this is due to a joint disorder, it may cause more pain. Some patients find

that a moist hot towel or a cup of ice applied to the side of the face can

ease the pain and stiffness enough to stretch the muscles.

Massage of jaw, head, neck and shoulder muscles can be helpful on a regular

basis to ease muscle tension and improve range of motion. Seek the

assistance of a licensed massage or physical therapist, or TMJD specialist.

Chew all foods on your molar teeth. Do not bite off food with the front of

your mouth. Dice all food to 1/4-inch sized pieces. Microwave or steam all

vegetables to soften them.

Myofascial Pain Dysfunction: Treatments used by ADA members, E. Glass, et

al, J Craniomandib Prac 11(1):25- 29, 1993.

Administration of Clonazepam in the Treatment of TMD and Associated

Myofascial Pain, S. Harkins, et al, J Craniomandib Disord Facial Oral Pain

5:179-186, 1991.

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