It all started Thursday morning. I got up about 8 AM and followed my usual morning routine - take medications and read the papers online. I was pretty achy, but figured that was just a result of walking all over Mystic, CT the previous day. By 8:30 I was struggling to keep my eyes open. I don’t mean tired as in physically tired for doing some kind of work. This is a fatigue that seems to swallow my whole body. I have no energy in my muscles at all and it takes a major, conscious effort to do anything - it takes an act of will! My eyes just want to droop closed and it takes everything I’ve to to keep them open. I finally gave up and went back to bed. That seems to help the overwhelming fatigue, but then the muscle aches increase. I can’t win.

Somehow, I muddled through Thursday, though I didn’t get much accomplished. It seems unfair that, after 2 really good days, I should get tagged with such a flare-up. I know, whoever said life would be fair?

Friday morning dawned dank and murky. It’s so humid, it feels like being in a cold steam room. I slept really well last night, or so I thought until I woke up. It felt like I’d been hit by a truck - a box truck instead of a big rig perhaps. My arms, legs and back ached - it’s a gnawing, dull ache, like having a toothache throughout your body. There was also a bit of pain in the left side of my neck that was beginning to cause a headache. Not a good way to begin the day.

I “celebrated” Independence Day by taking some Tylenol along with my usual morning meds, cooking up a plate of scrambled eggs with mushrooms and cheese (which I’ve been craving) and going back to bed after I ate. Neither the food nor the medication worked any magic. When I got up around 10 AM, not having slept any more sadly, I still hurt. So I took some Aleve and ate some crackers (low fat Wheatables). I’ve lost over 25 lbs in the past 6 months and I hate to ruin it, but food seems to help with the pain somehow. I really hate to lose any weapons in my pain fighting arsenal

My husband had spent all morning putting in a new dry well to help rainwater drain away from our basement. I knew he’d want a good meal and I sure wasn’t up to cooking. So we went out - I let him choose, since I knew I wouldn’t choose wisely. Besides, I really didn’t care. That’s where fibromyalgia becomes dangerous. It sucks out nearly all of my self discipline. I begin to care only about relief. My husband decided on the Clam Box. Was I good? Did I stick with broiled fish? Of course not! I had deep fried whole-belly clams. Boy, were they good! Fries, too. The food tasted great, though I’m sure it didn’t help the weight loss cause. I took muscle relaxant and 800 mg Ibuprofen with my meal.

I tried to vary my activity a bit more in the afternoon and evening - back and forth between the chair at the computer and the sofa to watch TV. Not that I could keep my attention on either one for very long. I took more Tylenol. Not much help there either. At bedtime, I took a second dose of the Ibuprofen and muscle relaxant.

Here it is Saturday morning and I haven’t made any progress. Neither has the weather, which is still damp and grey. I awoke feeling like that truck came back last night. I tried spending 20 minutes doing stretches before I even got out of bed - it didn’t help. Now I sitting here at the computer. It’s quarter to 10 AM. I’ve managed to read my e-mail and check the obits in the local paper (online). Now I’m trying to write - emphasis on trying. After each sentence or clause, I pause because my eyes drift shut. I’m not sure how long they are closed before I force them open again and plod on.

The crazy thing is that I take Ritalin as one of my morning medications, to keep me more awake and alert. It’s a small dose, but it usually helps. Not with this flare-up, though. I think I’ll take my second dose soon, before I fall asleep sitting here. I’ll take pain meds of some kind, too.

I really hope I can shake this flare-up before tomorrow. I’m serving at the altar in the morning. Not a good place to fall asleep. Then we’re going to my sister-in-law’s for a cookout. We got a last minute phone call Friday to see if we wanted to go and I hated to say no. My husband doesn’t have much contact with his siblings, so I usually try to support any that comes along. I won’t be a very pleasant and chatty guest if I haven’t beaten this flare-up by then. Someone will have to wake me when my burger arrives!

Oops, it happened again - the eyes closed and I have no idea how long they stayed that way. I may have to add a bit of caffeine to my diet today. Usually I avoid it like the plague - it makes me feel queasy. But desperate times call for desperate measures!

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The symptoms are very characteristic.

* Abrupt, sudden onset
* May occur anytime, but often noticable when eating and talking simultaneously and something feels like it went down the wrong way
* May be awakened in the middle of the night unable to breath.
* I personally have had it happen while camping, when a tiny bug flew down my throat.
* Feels like you are going to die or never breathe again
* Yet typically, it lasts less than 30 or 60 seconds.
* Very noisy and difficult “breathing in”
* Rather easy breathing out, still able to cough.
* Faster “breathing in” makes it worse.

This syndrome results from a spasm in the adductor muscles - the muscles closing or bringing the vocal folds together. From a technical standpoint, my observation is that the lateral cricoarytenoid is the main muscle activated, but possibly the thyroarytenoid as well. As soon as your voice box or the area of the windpipe below the voicebox detect the entry of water or other substance, the vocal folds spasm shut. Evolutionarily speaking, this works very well to keep water out of the lungs - if you start to drown or a bug flies down your throat while you were starting to inhale, or you inhale that glass of water, then the vocal cords very immediately and very effectively close.

That closure is a benefit to protect the airway, but it makes “breathing in”, very difficult. It can happen even when only the sensation is present of something other than air entering the windpipe.

A management program

An exam of the neck and throat is extemely important to eliminate serious problems. Your physician may consider asthma or a narrowing of the windpipe or even heart conditions as possible causes of shortness of breath. The symptoms of laryngospasm are extremely characteristic, but, one should never assume anything without a history and physical exam.

1. Knowing what the condition is and its short duration helps patients deal with the episodes more confidently
2. The Bernoulli principle - the one you may have learned about in high school physics that keeps airplanes in the air - is the reason laryngospasm worsens with stronger attempts at breathing in. The faster the air flow through a narrow area, the lower the pressure. The voice box is the narrowest part of the windpipe so it has the lowest pressure during rapid breathing. And, in fact, laryngospasm might not be a spasm at all. It may be an inhibition or lack of ability for the opening muscles of the voice box to operate momentarily. Then, the rapid airflow through the voice box, in effect, more easily sucks the vocal folds tighter together.
3. With the Bernoulli principle in mind, one can see that slower breathing in will effectively get more air into the lungs than rapid breathing in. In fact, we spend most of our life breathing out, as in talking, then we take a quick breath in and spend more time talking. When one has an episode of laryngospasm, one can reverse this usual trend and take most of your time to breath in slowly and then a quick breath out can be followed by another slow breath in. This can be repeated until the spasm stops.
4. An observation was made by a person with the condition that if they tilted their head backwards during an episode, it made the slow breathing in easier. I certainly think that is plausible as I find it more difficult to oppose my own vocal cords with my neck extended backwards. By stretching the neck, it effectively lowers the voicebox in the neck and that may prevent some of the clamping down by the vocal cord muscles.

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Diazepam is used to treat anxiety disorders, alcohol withdrawal symptoms, or muscle spasms. Diazepam may also be used for other purposes not listed in this medication guide.

Diazepam can cause birth defects in an unborn baby. Do not use diazepam without your doctor’s consent if you are pregnant. Tell your doctor if you become pregnant during treatment. Use an effective form of birth control while you are using this medication. Diazepam may pass into breast milk and could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. The sedative effects of diazepam may last longer in older adults. Accidental falls are common in elderly patients who take benzodiazepines. Use caution to avoid falling or accidental injury while you are taking diazepam. Do not give this medication to a child younger than 6 months old.

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Graded doses of active compounds were further evaluated for ED50 estimation by probit analysis. ED50 values (mg/kg) were estimated for the following compounds: baclofen (6.4), chlorpromazine HCl (3.8), cyclobenzaprine HCl (24.6), dantrolene Na (14.4), diazepam (8.3), haloperidol (6.2), naloxone HCl (8.7), phenoxybenzamine HCl (47.6), phentolamine HCl (265), and trifluoperazine HCl (25.4). These ED50 values appeared to correlate with initial adult human daily oral doses for muscle relaxation.

The following compounds inhibited the Straub tail response in 40% of the mice tested at the doses indicated (mg/kg): carisoprodol (300), lidocaine (100), mephenesin (300), phenytoin (100), procainamide HCl (100), procaine HCl (100), propranolol HCl (100), quinidine sulfate (100); and all selected calcium-channel blockers (30), antidepressants (30), and neuromuscular blocking agents (> 10 times the literature i.p. ED50 values with the exception of gallamine triethiodide at 30 mg/kg) that were tested. Pentobarbital Na was active only at doses that impaired the righting reflex. This animal model was thus determined to be useful for evaluating SMR efficacy and in predicting.

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Casale studied the effectiveness of dantrolene sodium, 25-mg daily, in the treatment of low back pain and found patients to demonstrate significant improvements in visual analogue scores, pain behavior, and electromyographic (EMG) evaluations of “antalgic reflex motor unit firing,” when compared with the placebo group. The findings of this study are interesting in that they demonstrate improvement secondary to a pure muscle relaxant, which does not possess other outside anti-nociceptive properties.

Baclofen is a derivative of gamma-aminobutryic acid (GABA) and is believed to inhibit mono and polysynaptic reflexes at the spinal level. Treatment with baclofen was compared to placebo in a double blind, randomized study of 200 patients with acute low back pain. Patients with initially severe discomfort were found to benefit from baclofen, 30- to 80-mg daily, on days four and ten of follow up. Forty-nine percent of treatment patients complained of sleepiness, 38% of nausea, and 17% discontinued treatment.

Sedation Side Effect

Sedation is the most commonly reported adverse effect of muscle relaxant medications. These drugs should be used with caution in patients driving motor vehicles or operating heavy machinery. More absolute contraindications do exist to the use of carisoprodol, cyclobenzaprine, and diazepam. Rare idiosyncratic reactions have also been reported to carisoprodol and its metabolites such as meprobamate. Benzodiazepines have potential for abuse and their use should be avoided. By initially prescribing muscle relaxants at bedtime, the physician might take advantage of their sedative effects and minimize daytime drowsiness.

These agents have been found to be effective when used either alone or in combination with an analgesic/anti-inflammatory agent within seven days of symptom onset. The prescribing physician should monitor patients receiving these medications and tailor dosages in an attempt to minimize the drowsiness and sedation often associated with their use. The use of benzodiazepines does not appear to offer any significant benefit to patients experiencing acute low back pain. Further research is needed before the role of baclofen and dantrolene sodium in the treatment of muscle spasm of local origin can be more clearly defined.

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Range of Motion

Muscle relaxants are often prescribed in the treatment of acute low back pain in an attempt to improve the initial limitations in range of motion from muscle spasm and to interrupt the pain-spasm-pain cycle. Limiting muscle spasm and improving range of motion will prepare the patient for therapeutic exercise.

Types of Muscle Relaxants

In an attempt to determine the mechanism of action of carisoprodol (Soma) in the treatment of low back pain, a double blind study was carried out comparing its effectiveness to that of a sedative control, butabarbital (a sedative), and a placebo in the treatment of 48 laborers with acute lumbar pain. Carisoprodol was found to be significantly more effective in providing both subjective pain relief and objective improvements in range of motion when evaluated by finger to floor testing. The results of this study suggest that the effects of carisoprodol are not secondary to its sedative effects alone.

In 1989, Basmajian compared the effectiveness of cyclobenzaprine (Flexeril) alone with diflunisal (Dolobid), placebo, and a combination of cyclobenzaprine and diflunisal in the treatment of acute low back pain and spasm. During the ten-day study period, the combined treatment group demonstrated significantly superior improvements in global ratings on day four, but not on day two or seven. This study suggested some effectiveness of combined analgesic and muscle relaxant therapy when utilized early in the initial week of pain onset.

Borenstein compared the effects of combined cyclobenzaprine and naproxen (Naprosyn) with naproxen alone and also found combination therapy to be superior in reducing tenderness, spasm, and range of motion in patients presenting with ten days or less of low back pain and spasm. Adverse effects, predominantly drowsiness, were noted in 12 of 20 in the combined group and only four of 20 treated with naproxen alone.

Cyclobenzaprine and carisoprodol were compared in the treatment of patients with acute thoracolumbar pain and spasm rated moderate to severe and of no longer than seven days duration. Both drugs were found to be effective, without significant differences between the treatment groups. Significant improvements were noted in physician rated mobility and in patients’ visual analogue scores on follow up days four and eight. While 60% of patients experienced adverse effects in the form of drowsiness or fatigue, these differences were not significantly different between groups, and only eight percent of patients from each group discontinued treatment.

Baratta found cyclobenzaprine, 10-mg t.i.d. (three times per day), superior to placebo in a randomized, double blind study of 120 patients with acute low back pain presenting within five days of symptom onset. Significant improvement was noted in range of motion, tenderness to palpation, and pain scores on follow up days two through nine. Sixty percent of treatment group patients reported drowsiness or dizziness compared with 25% of those in the placebo group.

In an earlier study, diazepam (Valium) was found to offer no significant subjective or objective benefit, when compared to placebo, in patients treated for low back pain. Carisoprodol was found to be superior to diazepam in the treatment of patients with “at least moderately severe” low back pain and spasm of no longer than seven days duration. In this study, the overall incidence of adverse reactions was higher in the diazepam treated group but was not of statistical significance.

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To keep your back healthy and strong:

* Exercise. Regular low-impact aerobic activities — those that don’t strain or jolt your back — can increase strength and endurance in your back and allow your muscles to function better. Walking and swimming are good choices. Talk with your doctor about which activities are best for you.
* Build muscle strength and flexibility. Abdominal and back muscle exercises (core-strengthening exercises) help condition these muscles so that they work together like a natural corset for your back. Flexibility in your hips and upper legs aligns your pelvic bones to improve how your back feels.
* Quit smoking. Smokers have diminished oxygen levels in their spinal tissues, which can hinder the healing process.
* Maintain a healthy weight. Being overweight puts strain on your back muscles. If you’re overweight, trimming down can prevent back pain.

Use proper body mechanics:

* Stand smart. Maintain a neutral pelvic position. If you must stand for long periods of time, alternate placing your feet on a low footstool to take some of the load off your lower back.
* Sit smart. Choose a seat with good lower back support, arm rests and a swivel base. Consider placing a pillow or rolled towel in the small of your back to maintain its normal curve. Keep your knees and hips level.
* Lift smart. Let your legs do the work. Move straight up and down. Keep your back straight and bend only at the knees. Hold the load close to your body. Avoid lifting and twisting simultaneously. Find a lifting partner if the object is heavy or awkward.

Alternative medicine

Many people choose hands-on therapies to ease their back pain:

* Chiropractic care. Back pain is one of the most common reasons that people see a chiropractor. If you’re considering chiropractic care, talk to your doctor about the most appropriate specialist for your type of problem. In addition to chiropractors, many osteopathic doctors and some physical therapists have training in spinal manipulation.
* Acupuncture. Some people with low back pain report that acupuncture helps relieve their symptoms. The National Institutes of Health has found that acupuncture can be an effective treatment for some types of chronic pain. In acupuncture, the practitioner inserts sterilized stainless steel needles into the skin at specific points on the body.
* Massage. If your back pain is caused by tense or overworked muscles, massage therapy may help loosen knotted muscles and promote relaxation.

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Your doctor may prescribe nonsteroidal anti-inflammatory drugs or in some cases, a muscle relaxant, to relieve mild to moderate back pain that doesn’t get better with over-the-counter pain relievers. Narcotics, such as codeine or hydrocodone, may be used for a short period of time with close supervision by your doctor.

Low doses of certain types of antidepressants — particularly tricyclic antidepressants, such as amitriptyline — have been shown to relieve chronic back pain, independent of their effect on depression.

Physical therapy and exercise

A physical therapist can apply a variety of treatments, such as heat, ice, ultrasound, electrical stimulation and muscle-release techniques, to your back muscles and soft tissues to reduce pain. As pain improves, the therapist can teach you specific exercises to increase your flexibility, strengthen your back and abdominal muscles, and improve your posture. Regular use of these techniques will help prevent pain from coming back.

Injections

If other measures don’t relieve your pain and if your pain radiates down your leg, your doctor may inject cortisone — an anti-inflammatory medication — into the space around your spinal cord (epidural space). A cortisone injection helps decrease inflammation around the nerve roots, but the pain relief usually lasts less than six weeks.

In some cases, your doctor may inject numbing medication into or near the structures believed to be causing your back pain. Early studies indicate that botulism toxin (Botox) also may help relieve back pain, perhaps by paralyzing strained muscles in spasm. Botox injections typically wear off within three to four months.

Surgery

Few people ever need surgery for back pain. There are no effective surgical techniques for muscle- and soft-tissue-related back pain. Surgery is usually reserved for pain caused by a herniated disk. If you have unrelenting pain or progressive muscle weakness caused by nerve compression, you may benefit from surgery. Types of back surgery include:

* Fusion. This surgery involves joining two vertebrae to eliminate painful movement. A bone graft is inserted between the two vertebrae, which may then be splinted together with metal plates, screws or cages. A drawback to the procedure is that it increases the chances of arthritis developing in adjoining vertebrae.
* Disk replacement. An alternative to fusion, this surgery inserts an artificial disk as a replacement cushion between two vertebrae.
* Partial removal of disk. If disk material is pressing or squeezing a nerve, your doctor may be able to remove just the portion of the disk that’s causing the problem.
* Partial removal of a vertebra. If your spine has developed bony growths that are pinching your spinal cord or nerves, surgeons can remove a small section of the offending vertebra, to open up the passage.

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If there is reason to suspect that you have a tumor, fracture, infection or other specific condition that may be causing your back pain, your doctor may order one or more tests:

* X-ray. These images show the alignment of your bones and whether you have arthritis or broken bones. X-ray images won’t directly show problems with your spinal cord, muscles, nerves or disks.
* Magnetic resonance imaging (MRI) or computerized tomography (CT) scans. These scans can generate images that may reveal herniated disks or problems with bones, muscles, tissue, tendons, nerves, ligaments and blood vessels.
* Bone scan. In rare cases, your doctor may use a bone scan to look for bone tumors or compression fractures caused by osteoporosis. In this procedure, you’ll receive an injection of a small amount of a radioactive substance (tracer) into one of your veins. The substance collects in your bones and allows your doctor to detect bone problems using a special camera.
* Nerve studies (electromyography, or EMG). This test measures the electrical impulses produced by the nerves and the responses of your muscles. Studies of your nerve-conduction pathways can confirm nerve compression caused by herniated disks or narrowing of your spinal canal (spinal stenosis).

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In rare cases, back pain can signal a serious medical problem. See a doctor immediately if your back pain:

* Is constant or intense, especially at night or when you lie down
* Spreads down one or both legs, especially if the pain extends below the knee
* Causes weakness, numbness or tingling in one or both legs
* Causes new bowel or bladder problems
* Is associated with pain or pulsation (throbbing) in the abdomen, or fever
* Follows a fall, blow to your back or other injury
* Is accompanied by unexplained weight loss

Also, see your doctor if you start having back pain for the first time after age 50, or if you have a history of cancer, osteoporosis, steroid use, or drug or alcohol abuse.

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