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The prognosis for myofascial pain syndrome (MPS) is good if treatment is started before symptoms become acute and aggravating factors, such as poor posture or excessive muscle overload, are eliminated. Other conditions, including many that are symptoms of or occur simultaneously with MPS (e.g., migraines, depression, anxiety, diabetes, fibromyalgia, insomnia) should be treated, as they may aggravate other MPS symptoms when uncontrolled.

Finding the right physician is crucial in treating MPS because not all physicians have experience treating this type of pain disorder. It is recommended that patients seek care with a physician specializing in pain management, a growing medical specialty incorporating anesthesia and physical medicine and rehabilitation.

Treatment of MPS centers on reducing the musculoskeletal pain and improving muscular function. All treatment options, including those the individual can do on their own, should be discussed with a physician. These may include:

* Physical therapy. Therapists focus on correction of muscle shortening by targeted stretching and strengthening of the affected muscles, and correction of aggravating factors (e.g., improper posture and ergonomics). Modalities such as diathermy and ultrasound therapy can be used to reduce pain.

Therapists may also perform a spray and stretch technique. This involves spraying a muscle with a topical anesthetic to numb the area and then stretch out the painful, contracted muscle to reduce pain and stiffness. Many therapists use ice instead of the spray, because the spray is costly and ice usually is just as effective.

* Manipulation therapy. Myofascial release therapy involves working on tight, contracted muscles and TrPs to release or stretch out the problem areas. Massage therapists generally work lightly and progress slowly in doing deep muscle work. The results of massage can last a considerable time.

* Occupational therapy. This type of therapy can be helpful in assessing and setting up ergonomically correct workstations to prevent exacerbation and/or recurrence of symptoms. Properly set-up work sites can help to decrease aggravating factors, such as poor posture. Occupational therapists can also offer expertise on home modifications, task simplification and energy conservation to reduce fatigue and pain.

* Cryotherapy (cold therapy). Therapy using a cold substance can reduce pain and inflammation; however, prolonged use can injure skin.

* Thermotherapy (heat therapy). Heat therapy is usually used in rehabilitation to relieve joint stiffness. Moist heat, done by combining hydrotherapy with thermotherapy, penetrates deeper into the muscle and offers more relaxation than dry heat. Too much heat can cause burns. Heat should not be used on sensitive skin and may need to be avoided when using analgesics.

* Cognitive behavioral therapy. This form of psychological treatment can help people replace negative thoughts with positive ones and provide coping strategies.

* Injection therapy. Physicians may inject medication directly into the TrPs to relieve pain.  A physician may recommend trigger point injections only when other, less invasive methods fail to eliminate the pain. These treatments can be very effective in individuals who have long standing pain.

Other complementary and alternative medicine techniques can be tried in some patients:

* Dental appliances. A mouth guard worn at night can help in cases caused or exacerbated by clenching or grinding of the teeth.

* Biofeedback. Information about typically unconscious bodily functions (e.g., muscle tension and blood pressure) is used to help gain conscious control over those functions. Electrodes are placed on the muscles to identify which are in use. People can then try to consciously lower muscle tension in that area.

* Acupressure. Pressure is used on target points of the body to control symptoms.

* Acupuncture. Thin needles are inserted into target points of the body to ease pain and improve sleep patterns. Controversy remains as to its effectiveness, but some studies show significant beneficial results.

When used in conjunction with active treatment therapies, the use of certain medications may help alleviate symptoms. These include:

* Nonsteroidal anti-inflammatory drugs (NSAIDs). Usually used to treat inflammation, NSAIDs also help ease muscle aches and may help make patients more comfortable in exercising and returning to daily activities.

* Muscle relaxants. By reducing the ability of the muscles to contract, these drugs help alleviate muscle pain.

* Antidepressants. Used in lower doses when treating MPS than when treating depression unless the patient is also suffering with depression. Even at low doses, side effects are common, including dry mouth, weight gain, constipation and lack of concentration. Tricyclic antidepressants relax muscles and heighten the effects of endorphins and may be taken at bedtime to help promote restorative sleep. The U.S. Food and Drug Administration (FDA) has approved a  selective serotonin and norepinephrine reuptake inhibitor (SSNRI) to relieve some types of nerve pain.

Patients should be aware that a physician may need to adjust the dosage or change medications to achieve the best results with minimal side effects. In addition, the U.S. Food and Drug Administration has advised that antidepressants may increase the risk of suicidal thinking in younger patients and all people being treated with them should be monitored closely for unusual changes in behavior.

For improvement to be significant, patients must adhere to an active medical treatment plan as outlined by their physician. In addition, patients should continue seeing their physician until symptoms have resolved or stabilized at maximum medical improvement.

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There is no known cure or preventive method for fibromyalgia, but symptoms can be treated. Treatment usually concentrates on reducing symptoms and improving function. No one treatment method can control all symptoms. In fact, most options control only one or two. This makes finding the right combination important.

Other conditions, including many that are symptoms of or occur simultaneously with fibromyalgia (e.g., migraines, depression, anxiety, irritable bowel syndrome) should be treated, as they may aggravate fibromyalgia symptoms when uncontrolled.

Finding the right physician is crucial in treating fibromyalgia. An empathetic physician who understands the diagnosis and treatment of fibromyalgia and is willing to listen to and work with the patient is important.  A family physician may send a fibromyalgia patient to a rheumatologist. Patients’ self-education is a key to better results. Individuals are encouraged to keep communication with their physicians open. It may help to make a list of everything that needs to be discussed and bring it along to appointments. All treatment options, including those individuals can do on their own, should be discussed with a physician.

In 2007 the U.S. Food and Drug Administration gave its first approval of a medication specifically to treat fibromyalgia: an anticonvulsant called pregabalin (Lyrica). This drug is also used to relieve diabetic nerve pain, post-shingles pain and some types of seizures.

Other medications may also reduce symptoms of fibromyalgia. These include:

* Antidepressants. Used in lower doses when treating fibromyalgia than when treating depression, unless the patient is also suffering with depression. Even at low doses, side effects are common, including dry mouth, weight gain, constipation and lack of concentration. Tricyclic antidepressants (TCAs) relax muscles and heighten the effects of endorphins and may be taken at bedtime to help promote restorative sleep. Selective serotonin reuptake inhibitors (SSRIs) promote the release of serotonin and may reduce fatigue.

* Analgesics (painkillers). Over-the-counter and prescription drugs can be used to help with the pain associated with fibromyalgia. Stronger narcotic (opioid) preparations are sometimes prescribed in severe cases. These drugs have the potential for tolerance and dependence.

* Nonsteroidal anti-inflammatory drugs (NSAIDs). Usually used to treat inflammation, NSAIDs also help to relieve pain caused by inflammation and may help ease muscle aches in fibromyalgia patients.

* Benzodiazepines. A kind of tranquilizer, which acts on the central nervous system to reduce anxiety, relax tense, painful muscles and stabilize erratic brain waves. They may be administered at bedtime to help with sleep, but there is a potential for dependence in some patients, and they should not be used for long periods of time.

Muscle relaxants may be prescribed, but they are usually not very effective even though sometimes they work by acting as depressants on the central nervous system.

Most medications useful in the treatment of adults with fibromyalgia have demonstrated little or no effect in children, though TCAs have had good results in pediatric patients.

Nutrition may also play an important role in the treatment of fibromyalgia. Proper nutrition ensures that the body has what it needs to function and heal. Fibromyalgia patients have been encouraged to reduce certain foods (e.g., corn, wheat, dairy products, citrus fruits, sugar). Doing so is believed to help improve symptoms of pain, depression, fatigue, headache and digestive tract difficulties.

Remaining active as much as possible is a must for fibromyalgia patients. Regular exercise has been shown to decrease pain and increase endurance and may be essential to managing fibromyalgia, but it must be done correctly. Most fibromyalgia patients will need to modify their old exercise habits. Eccentric contraction (contracting and lengthening at the same time, such as with reaching motions) should be avoided. It is recommended for fibromyalgia patients to start at a low level of exercise and increase gradually, working with low-impact forms of exercise such as walking. The type of exercise activity should be alternated at least every 20 minutes.

Fibromyalgia patients are more likely to experience more intense and longer-lasting pain than healthy individuals. Muscle soreness may be minimized with relaxation, heat, steady breathing and drinking plenty of water. Stretching is important to lengthen muscles and maintain their length, help muscles relax, improve ability to move muscles and decrease pain. Proper exercise has been shown to decrease symptoms of fibromyalgia and reduce severity of symptoms.

Striving for restful sleep is important in the treatment of fibromyalgia. A healthy sleep regimen is crucial to improving sleep and includes:

*Going to bed and getting up at the same time every day
*Avoiding caffeine, sugar and alcohol before bed
*Avoiding eating immediately before bed
*Practicing relaxation exercises while falling to sleep
*Avoiding exercising within three hours of bedtime
*Maintaining a sleep environment that is quiet, free from distractions such as TV and of comfortable room temperature

In some cases, sleep medications may be helpful, particularly when sleep is disturbed by aggravating conditions such as restless leg syndrome.

Many other therapies may be used in the treatment of fibromyalgia. It is important to find therapists specially trained and educated for working with fibromyalgia. A physician may be able to recommend a qualified therapist. Not all therapies are equally efficient and what works for one patient may not work for another. Treatments that have demonstrated benefits for patients with fibromyalgia include:

* Manipulation therapy. For example, massage that progresses slowly during deep muscle work produces results that seem to last a considerable time. Another variation, myofascial release, involves working on tight, contracted muscles and trigger points to release or stretch out the problem areas. Although fibromyalgia is not spinal, some patients have reported that proper chiropractic care by therapists specially trained to work with fibromyalgia helps reduce pain.

* Relaxation techniques. Relaxation may be employed to manage pain and stress. Deep breathing, visual imagery and relaxing audio may be used as effective tools for relaxation.

* Physical therapy. Physical therapists can give instruction in exercise and supply pain-relieving modalities such as heat therapy.

* Occupational therapy. Occupational therapists can offer instruction in conserving energy, simplifying tasks, modifying the home and using adaptive equipment.

* Acupressure. Pressure is used on target points of the body to control symptoms.

* Acupuncture. Needles are inserted into target points of the body to provide pain relief and improve sleep patterns. Controversy remains as to the effectiveness of the use of acupuncture in the treatment of fibromyalgia, but some studies show significant beneficial results.

* Cryotherapy (cold therapy). Cold therapy is used for chronic pain to increase the pain threshold. Too much cold can cause nerve damage.

* Thermotherapy (heat therapy). Heat therapy is usually practiced in rehabilitation to relieve joint stiffness. Moist heat penetrates deeper into the muscle and offers more relaxation than dry heat. Too much heat can cause burns. Heat should not be used on sensitive skin or when using analgesics.

* Cognitive behavioral therapy. This treatment helps individuals change the way they view and think about pain to increase their ability to positively deal with illness. The concept used is that individuals’ perceptions of themselves and their surroundings affect their emotions and behavior.

* Biofeedback. Information about typically unconscious bodily functions (e.g., muscle tension and blood pressure) is used to help gain conscious control over those functions. Electrodes are placed on the muscles to identify which are in use. People can then try to consciously lower muscle tension in that area.

* Injection therapy. Physicians may inject medication into tender points to offer pain relief. These injections are used only when one specific area remains painful and offer only temporary relief. The injection of lidocaine has been shown to reduce pain and improve mood for up to a few  days, but the injection of local anesthetics and corticosteroids have shown no proven benefit over injecting local anesthetics alone.

* Spray and stretch technique. Therapists spray a muscle with a topical anesthetic to numb the area and then stretch out the painful, contracted muscle to reduce pain and stiffness. Many therapists use ice instead of the spray, since the spray is costly and ice works just as effectively.

* Stress management. Individuals use stress management techniques to reduce stress. Stress may aggravate symptoms of fibromyalgia.

* Hypnotherapy. Hypnosis may be used to induce a trance-like state of altered awareness and perception during which there may be heightened responsiveness to suggestions to manage stress, induce deep relaxation and reduce muscle pain.

* Magnet therapy. Some individuals use magnets to try to increase blood flow and help symptoms. Although this is one of the most widely used complementary treatments, studies have shown no real benefit.

Patients are advised to consult their physician before considering any complementary or alternative therapy.

Many fibromyalgia patients have trouble coping with their disorder. There are many means to help an individual cope with fibromyalgia or any other chronic illness. Psychological counseling may also help. Fibromyalgia support groups can provide important information, encouragement and positive feelings.

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Over-the-counter NSAIDs (non-steroidal anti-inflammatory drugs): These will help reduce swelling (or inflammation) while relieving your pain; that’s how NSAIDs differ from acetaminophen. If an over-the-counter NSAID is an option for you, you have plenty to choose from. You can use ibuprofen (Advil), aspirin, or Aleve.

By taking an NSAID, you are building up an anti-inflammatory effect in your system, so it’s necessary to take it for awhile. That is, NSAIDs won’t be as effective if you take them just when you have pain. Because they build up in your body and work to limit inflammation, NSAIDs are better for chronic pain sufferers.

Pronounced “ensayds,” these drugs help reduce pain and swelling while decreasing stiffness. NSAIDs that require a prescription include Naproxen®, Relafen®, Indocid®, Voltaren®, Feldene® and Clinoril®. Other NSAIDs are available over-the-counter. These include ASA (Aspirin®, Anacin® and others), and ibuprofen (Motrin IB®, Advil® and others.) When a low dose is taken, NSAIDs control pain, but higher doses are required to reduce inflammation. The problem with NSAIDs is their side effects. Taking more than one NSAID at a time increases the possibility of heartburn and severe side effects such as ulcers and bleeding. NSAIDs inhibit the blood’s ability to clot properly and may therefore interact with blood-thinning medications such as coumadin.

Muscle relaxants that address back pain are available as prescription and over-the-counter medications. Over-the-counter muscle relaxant medications include Robaxin® (methocarbamol), Robaxacet® (methocarbamol and acetaminophen) and Robaxisal® (methocarbamol and ASA). Prescription medications include Soma® (carisoprodol), Flexeril® (cyclobenzaprine) and Valium® (diazepam). Soma is typically prescribed on a short-term basis and may be habit-forming, particularly if used with alcohol or other drugs that affect the mind. Flexeril may be used on a longer term basis. This drug may impair mental and physical function and can lead to urinary retention in men with enlarged prostates.

Valium is usually restricted to one to two weeks of use. Due to this drug’s habit-forming potential, and its propensity to alter the sleep cycle, it is not prescribed for the long-term. Since valium is a depressant, it can worsen the depression often associated with chronic back pain.

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Spasmolytics like carisoprodol, cyclobenzaprine, metaxalone, and methocarbamol are commonly prescribed for low back pain or neck pain, fibromyalgia, tension headaches and myofascial pain syndrome. However, they are not recommended as first-line agents; in acute low back pain, they are not more effective than paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs), and in fibromyalgia they are not more effective than antidepressants. Nevertheless, there is some (low quality) evidence suggesting that muscle relaxants can add benefit to treatment with NSAIDs. In general, there is no high quality evidence to support their use. No drug has been shown to be better than another, and all of them have adverse effects, particularly dizziness and drowsiness. Concerns about possible abuse and interaction with other drugs, especially if increased sedation is a risk, further limit their use.

Centrally acting agents like dantrolene and baclofen are not advised for orthopedic conditions, but rather for neurological conditions such as spasticity in cerebral palsy and multiple sclerosis.

Muscle relaxants are thought to be useful in painful disorders based on the theory that pain induces spasm and spasm causes pain. However, there is considerable evidence to contradict this theory.

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On June 21, 2007, Lyrica (pregabalin capsules CV) were approved by the U.S. Food and Drug Administration (FDA) for the treatment of fibromyalgia. The approval of Lyrica was long-awaited because it’s the first medicine that is FDA-approved to treat fibromyalgia. More fibromyalgia drugs are in development. Doctors also treat fibromyalgia with a variety of drugs developed and approved for other purposes. Below are some of the most commonly used categories of fibromyalgia medications.

Analgesics

Analgesics are painkillers. They range from over-the-counter drugs, such as acetaminophen, to prescription drugs, such as tramadol, and even stronger narcotic drugs. For a subset of people with fibromyalgia, narcotic medications are prescribed for severe muscle pain. However, there is no solid evidence showing that narcotics actually work to treat the chronic pain of fibromyalgia, and most doctors hesitate to prescribe them for long-term use because of the potential that the person taking them will become dependent on them.

NSAIDs

NSAIDs (nonsteroidal anti-inflammatory drugs) are used to treat inflammation. Although inflammation is not a symptom of fibromyalgia, NSAIDs also relieve pain.

NSAIDs work by inhibiting prostaglandins, which play a role in pain and inflammation. These drugs, some of which are available over-the-counter, may help ease the muscle aches of fibromyalgia. They may also relieve menstrual cramps and the headaches often associated with fibromyalgia.

Antidepressants

Perhaps the most useful medications for fibromyalgia are several in the antidepressant class. Antidepressants elevate the levels of certain chemicals in the brain, including serotonin and norepinephrine. Low levels of these chemicals are associated not only with depression, but also with pain and fatigue. Increasing the levels of these chemicals can reduce pain in people who have fibromyalgia. Doctors prescribe several types of antidepressants for people with fibromyalgia.

Tricyclic Antidepressants

When taken at bedtime in dosages lower than those used to treat depression, tricyclic antidepressants can help promote restorative sleep in people with fibromyalgia. They also can relax painful muscles and heighten the effects of the body’s natural pain-killing substances called endorphins.

Selective Serotonin Reuptake Inhibitors (SSRIs)

If a tricyclic antidepressant fails to bring relief, doctors sometimes prescribe a newer type of antidepressant called a SSRI. As with tricyclics, doctors usually prescribe these for people with fibromyalgia in lower dosages than are used to treat depression. By promoting the release of serotonin, these drugs may reduce fatigue and some other symptoms associated with fibromyalgia.

SSRIs may be prescribed along with a tricyclic antidepressant. Doctors rarely prescribe SSRIs alone. Because they make people feel more energetic, they also interfere with sleep, which often is already a problem for people with fibromyalgia.

Cymbalta (duloxetine) is a selective serotonin and norepinephrine reuptake inhibitor (SSNRI) that is also showing promise.

Mixed Reuptake Inhibitors

Some newer antidepressants raise levels of both serotonin and norepinephrine, and are therefore called mixed reuptake inhibitors.

Researchers are actively studying the efficacy of these drugs in treating fibromyalgia.

Benzodiazepines

Benzodiazepines help some people with fibromyalgia by relaxing tense, painful muscles and stabilizing the erratic brain waves that can interfere with deep sleep. Benzodiazepines also can relieve the symptoms of restless legs syndrome, which is common among people with fibromyalgia. Restless legs syndrome is characterized by unpleasant sensations in the legs as well as twitching, particularly at night. Because of the potential for addiction, doctors usually prescribe benzodiazepines only for people who have not responded to other therapies.

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