CISRA’s Synergy Health Newsletter

Issue 4. How to “Map” Fibromyalgia: Video Review and Comments (1999)

by J. C. Waterhouse, Ph.D.
“Mapping Fibromyalgia”, 15-minute video, produced by Nancy Medeiros, copyright 1999, Fibromeet (see below for ordering information).

Summary

In this video, Dr. St. Amand demonstrates his method of mapping fibromyalgia lesions. He views mapping as an alternative method of diagnosing fibromyalgia, which he believes is more useful and sensitive than the currently used detection of 11 of 18 tender points. Although this video is designed for doctors and physiotherapists, it should be of great value to anyone with an interest in fibromyalgia. Besides its use in diagnosis, it can serve the purpose of monitoring response to guaifenesin treatment, which Dr. St. Amand has found can reverse the fibromyalgia lesions and symptoms. Because of the gradual guaifenesin reversal process and the initial exacerbation that occurs (analogously to gout treatment with uricosuric drugs), this mapping is valuable for patient morale, as well as dosage fine-tuning and salicylate blockage detection. This video should help create a wider availability of doctors trained in mapping, which should greatly benefit those using guaifenesin. It also could potentially lead to increased research in the role of these lesions in other diseases, like osteoarthritis, chronic fatigue syndrome, Gulf War syndrome and a number of other disorders that may be related. In the following review, I discuss the mapping process as demonstrated in the video, as well as some references to lesions of this type in the scientific literature. I then provide some tips from my own experience on how a patient might try to detect and monitor some of their own lesions.

Review

In this fascinating and useful video, fibromyalgia specialist, internist/endocrinologist, R. Paul St. Amand, M.D., demonstrates the mapping method he has developed for diagnosing and assessing response to treatment in fibromyalgia. In 39 years of successfully treating this condition with uricosuric drugs, he has found that the detection of lesions (hard, swollen areas or “bumps”) by palpation by the physician and recording on a diagram of the body (mapping), is the most reliable method for a comprehensive view of fibromyalgia, its early detection and monitoring (St. Amand & Marek, 1997). He believes the current, most widely used method of diagnosing fibromyalgia is too dependent on the pain sensitivity of the patient and a few chosen locations (11 of 18 predetermined “tender points” must evince pain when pressed upon). Another advantage of Dr. St. Amand’s mapping method, is that it allows detection of fibromyalgia lesions in patients who experience primarily fatigue and minimal pain. These patients who have higher pain thresholds are usually diagnosed with chronic fatigue syndrome. He also finds lesions in patients who are diagnosed with various other conditions in which only local areas of the body are involved, for example, in sports injuries, carpal tunnel syndrome, migraines, vulvodynia and irritable bowel syndrome (Waterhouse, 1999). Given the right dose and salicylate avoidance, these patients also respond to uricosuric drugs, such as guaifenesin, and thus these other conditions are hypothesized to result from the same processes as fibromyalgia, in at least a portion of the cases. A detailed discussion of the theory behind this approach is beyond the scope of this review, but involves a view of fibromyalgia as due to phosphate retention and accumulation in mitochondria, which blocks ATP formation and extrusion of calcium from the cytosol of lesion tissue (St. Amand, Fibromyalgia: For Physicians). The largest obstacle to success using Dr. St. Amand’s approach has been the continually increasing number of products containing “hidden” salicylates (which block guaifenesin’s effects on the kidney), including toothpastes, cosmetics, sunscreens and many plant-based supplements (for more information, see St. Amand, most recent update of Fibromyalgia: For Patients; also, Waterhouse, 1998).

The hard/swollen areas or lesions mapped by Dr. St. Amand have also been detected by others. In the original 19th century description of “rheumatism” (an early term for fibromyalgia), they were part of the basic description (Froriep, as cited in Smythe (1989). Harrison’s Principles of Internal Medicine (1997) refers to subcutaneous nodules at the tender area locations in fibromyalgia, however they conclude they are not relevant because they are not always painful and can occur in those who do not meet the standard criteria for fibromyalgia. Although it is true that these lesions can also be found near the site of a sports injury, or in a person who has not developed full-blown fibromyalgia, Dr. St. Amand contends that these lesions are nevertheless crucial to the real nature of fibromyalgia (Waterhouse, 1999). Laboratory studies have also examined these hardened areas of muscle found by palpation. This type of area in a muscle is called a “myogelosis”, and is notable in that it remains contracted even during general anesthesia. Several of these myogeloses were studied in some fibromyalgia patients and were found to have a reduced oxygen tension, which could lead to increased lactic acid and pain (Strobel et al 1997). This contrasted with the surrounding muscles with only moderately elevated tension and relatively high oxygen values. Although myogeloses are usually associated with the trigger points of chronic myofascial pain syndrome, in Dr. St. Amand’s experience, this syndrome has basically the same cause and treatment as fibromyalgia.

This video is designed to instruct physicians, chiropractors and physiotherapists how to detect the lesions. Medical terms are used to describe the various muscles and tendons involved, as Dr. St. Amand examines a patient and marks the lesions on a diagram of the body he displays. There are particular areas that he finds are most useful to examine and they include the 18 areas that are part of the standard definition of fibromyalgia, but also include many others. He notes that with practice, the entire process can be completed in 7 or 8 minutes, although all the areas do not necessarily need to be covered, if a doctor chooses not to do so. As Dr. St. Amand maps the patient in the video, he makes a number of interesting points. For instance, he shows how lesions often occur in areas in which the muscle has its insertion into a tendon or joint. He also mentions how feet pain thought to be from a neuroma may actually come from a lesion at the point of tendon insertion in the metaphalangeal joint. We find out that irritation leading to increased blood flow in an area may influence lesion location, as in the lesions he frequently finds in women in the area where their bra strap rubs their side. A similar lesion development in response to inflammation/irritation may account for prolonged, recurring, or even permanent pain after a sports injury or accident in those susceptible to fibromyalgia. He also demonstrates the locations of the inguinal lesions, which along with other lesions deep in the pelvis, appear to cause vulvar pain.

Comments

Although designed for doctors, this video may also be of interest to patients who want to learn about the mapping process. It may help them learn some of the medical names for affected muscles and tendons. It may even aid patients who want to see if they can detect and monitor the changes in some of the lesions themselves, in case they do not have access to a doctor who can do so. In my own experience, I have been able to feel and even see some of the lesions. Although I had the help of the map of my lesions done by Dr. St. Amand, it may be that others will be able to do so even without a map. It can be difficult, because the inexperienced person does not know what an area should feel like normally. Several things may help overcome this problem and I will illustrate this with my own case (Note: others may differ in their lesion location). First, since the lesions are often asymmetrical, one can compare the two sides. For instance, if I compare the two areas just below and toward the inside of my knees under adequate light, I can see a bulge on the right side that is not there on the left. This turns out to be a lesion. Second, I can take advantage of the fact that the lesions will often be painful. Lesion detection can be even easier if I choose a time when I am experiencing an increase in pain due to the guaifenesin reversal process or from other causes. One of the best areas to detect the lesions in my own case was the back of my neck, in the area within one inch on either side of the spinal column. Most fibromyalgics who experience headaches have lesions in the neck, often including some in this area. First, I lean my head forward and place my index fingers at the hairline on the back of my neck, with one finger on either side of the spinal column. Then I slowly sweep my fingers down, pressing firmly as I let them move down my neck. You should cover about an inch on either side of the spine. If you don’t feel anything the first time, try a few more times. If you have lesions there, you will probably feel lumps that are not the same on each side. In my case, there was a large one in the middle along the right side, and then a smaller one on the left side, near where the neck meets the shoulder. If I had a headache at the time, the area would tend to be very sore, especially if I pressed on it. Since I do not generally have a high pain sensitivity, sometimes the soreness only appeared after massaging and pressing on it for a minute or two. I have even traced the development of a migraine and found that the neck lesion on the right was the first part to become sore, before the headache spread to my temples and the top of my head (Waterhouse, 1998). On other occasions, I have experimented with finding lesions in my hips, my inguinal tendons and near my elbows. In my case, the pain from pressing an area was a good verification that I had found the lesion. I usually could also feel a bump, although I’m not sure I could have always found the bump without the help of the heightened pain at the location.

Doctors or other therapists who are particularly good with their hands will probably find it relatively easy to learn how to map from this video, provided they obtain some practice. I have wondered, however, whether some doctors will wish to have an opportunity to learn and practice this mapping in a training session, where they can compare what they find with actual maps of the known lesions done by an experienced person, such as Dr. St. Amand. If there are doctors or therapists who would be interested in such a training session, they might contact me at CISRA, and if there is sufficient interest, perhaps this type of training opportunity could be organized.

Video Ordering Information

Update 2008. Nancy Medeiros is no longer selling this video, however a very similar video is available from: The Fibromyalgia Treatment Center. Other books, DVDs, CDs and videotapes are also available there.

References

1. Fauci, Anthony S., M.D., and others, editors. 1997. Harrison’s Principles of Internal Medicine. McGraw Hill.
2. Smythe, Hugh. 1989. Fibrositis syndrome: a historical perspective. J. of Rheum. Sup. 19, Vol. 16:2-6.
3. St. Amand, R. Paul, M.D., and Claudia Potter, MA, 1997. The use of uricosuric agents in fibromyalgia: theory, practice, and a rebuttal to the Oregon study of guaifenesin treatment, Clin. Bull. of Myofascial Therapy, Vol. 2(4):5-12, The Haworth Press.
4. St. Amand, R. Paul, M.D., 1999. Papers on “Fibromyalgia: For Patients,” “Fibromyalgia: For Physicians,”, and “Hypoglycemia” and Salicylate-Free product list, available at http://guaidoc.com, with further information at http://www.csusm.edu/public/guests/nancym/fibromt.htm
5. Strobel, et al. 1997. Tissue oxygen measurement and P-31 magnetic resonance spectroscopy in patients with muscle tension and fibromyalgia. Rheumatol. Int. 16: 175-180.
6. Waterhouse, J.C. 1998. A case history of FMS/CFIDS/MCS and the roles of guaifenesin, a low carbohydrate diet and environmental medicine in recovery, CISRA’s Synergy Health Newsletter, Issue 2. Vol. 1(2), CISRA.
7. Waterhouse, J.C. 1998. Natural therapies with and without salicylates”, CISRA’s Synergy Health Newsletter, Issue 3. Vol. 1(3), CISRA.
8. Waterhouse, J.C. 1999. Pre fibromyalgia: a possible explanation for many common idiopathic, functional, and pain disorders, CISRA’s Synergy Health Newsletter, Issue 4. Vol. 2(1), CISRA.

Written by synergyhn

October 30, 1999 at 3:45 am

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