Editorial, Journal of the American Academy of Pain Management
By Hal Blatman, M.D.
In 1983 Drs. Janet Travell and David Simons published the first volume of their work “Myofascial Pain and Dysfunction, The Trigger Point Manual.”
Their textbooks have become the foundation of education for treating myofascial pain syndrome (MPS). Although much of the text focused on anatomical and structural aspects of MPS, chapter 4 was dedicated to a discussion of the numerous metabolic perpetuating factors that contribute to the disorder.
These factors are thought to contribute to causation as well as preventing recovery. Chapter 4 offers 294 references that support the importance of metabolic perpetuating factors. (1)
During the last several years, public awareness of Fibromyalgia has greatly increased. Practitioners have noted that much of the pain of FMS is related to myofascial trigger points, and that MPS plays a critical role in the disorder. Many physicians have postulated that FMS represents a generalized MPS that is perpetuated by the metabolic factors. Clinical experience and the scientific literature suggest that many of these perpetuating factors need to be treated despite laboratory blood testing falling within the normal range.
With this in mind, it was very exciting to read the recent randomized, double-blind, placebo-controlled study by Teitelbaum et al.(2) which, years later, finally validates the work of Drs. Travell and Simons. Titled “Effective Treatment of Chronic Fatigue Syndrome and Fibromyalgia – a Randomized Double-blind Placebo-controlled Study,” the study found that treating Fibromyalgia patients for the perpetuating factors below resulted in a dramatic improvement vs. placebo (P<0.0001): 1 – Hormonal deficiencies. Dr. Teitelbaum postulated that hypothalamic dysfunction is a key process in the etiology of Fibromyalgia. Patients with lab tests for thyroid, adrenal and ovarian/testicular function that fell in the normal range were still treated if their clinical picture suggested a hormonal deficiency. 2 – Opportunistic infections. As a number of infections can perpetuate MPS, and since FMS is associated with immune dysfunction and opportunistic infections, possible parasitic and fungal infections were treated. 3 – Sleep disorders. Lack of adequate deep sleep has been shown to be a factor in chronic pain disorders and FMS. Dr. Teitelbaum treated this very aggressively. 4 – Nutritional inadequacies. Nutritional deficiencies were suspected to contribute to chronic, pathologic muscle shortening despite lab testing sometimes being in the normal range. In this study, nutritional needs were aggressively considered and treated. In the history of medicine, people with undiagnosed and unrecognized diseases such as rheumatoid arthritis, polio and Lyme’s disease were often considered to be hypochondriacs until diagnostic tests were developed. Tests are now in development that will likely be specific for the diagnosis of FMS. In the interim, this study by Dr. Teitelbaum et al., confirms what years of clinical success have shown -that the treatment approach described in chapter 4 of The Trigger Point Manual is effective, that subclinical abnormalities are important and that the comprehensive and aggressive metabolic approach to treatment in Teitelbaum’s study is highly successful and makes FMS a very treatable disorder. The study by Dr. Teitelbaum et al., and years of clinical experience makes this approach an excellent and powerfully effective part of the standard of practice for treatment of people who suffer from FMS and MPS— both of which are common and devastating syndromes. It is very exciting that this research helps to usher in a new, more effective era in medical care by treating the patient and not only the laboratory tests! 1 – Travell J, Simons DG, Simons L: Perpetuating Factors. Chapter 4. In: Myofascial Pain and Dysfunction: The Trigger Point Manual. Ed.2. Williams and Wilkins, Baltimore MD, 1999. 2 -Teitelbaum JE, Bird B, Greenfield RM ,Weiss A., Muenz L, Gould L. Effective Treatment of CFS and Fibromyalgia —. A Randomized, Double-blind, Placebo-controlled, Intent to Treat Study. The Journal of Chronic Fatigue Syndrome. Volume 8(2), 2001,pg3-28.