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Chronic Widespread Pain Overview

 

CHRONIC WIDESPREAD PAIN- Not Everything is Fibromyalgia

Chronic pain is pain that exists continuously for more than 3 months.  It may be focal such as in one elbow or knee, regional such as with reflex sympathetic dystrophy of the hand and arm, or widespread which involves most of the body.  There are many potential causes of widespread chronic pain and it is not an easy task to determine which of the many causes are responsible.   Widespread pain frequently involves joints such as in polyarthritis, muscles and ligaments as in fibromyalgia, or bone such as in metastatic cancer or effects of osteoclast inhibitor drugs such as Fosamax.  It may be rheumatologic, from an infection, due to drugs, due to muscle diseases, or problems with the cortisol response to stress.   The treatment available for widespread pain is largely empirical…that is it requires a series of different trial medications, physical therapies, exercises, or other more aggressive therapies, in order to optimize the results.  However, there is no single best treatment for chronic widespread pain.

When trying to determine the cause of widespread pain, it is important to avoid labeling it as fibromyalgia unless other causes have been ruled out.  Fibromyalgia is not a disease, but is a set of commonly occurring symptoms that have no known specific causative factor,  no known pathophysiology (mechanism of producing disease), and no effective treatment (Cymbalta, Lyrica, and Savella have been approved to treat “fibromyalgia” but generally provide less than 25% pain reduction).  There is some evidence fibromyalgia is associated with psychiatric disorders and all three of the above medications used to treat fibromyalgia also treat psychiatric disorders (Cymbalta and Savella are antidepressant drugs, Lyrica is used off label in the US and on label in Europe for the treatment of anxiety disorders).  Furthermore, labeling a person’s pain as fibromyalgia frequently causes physicians to stop looking for other causes, some of which may be fatal if left untreated.  A complete history and physical exam is the first step in determining the source of the pain.  All medications, including those stopped in the last year should be included.

Widespread pain can be thought of as coming from the muscles, bones, joints, or generalized.  By focusing on the various sources of pain, it may help your doctor make a diagnosis.  It is important not to become focused on each new area of pain that may have been present for 1day or 1 week since everyone has some transient pain at one time or another due to muscle/tendon tears, overexertion, etc.

SOME WIDESPREAD PAIN CAUSES: 

DRUGS (some may require months of taking the drug before widespread bone and or muscle pain/cramps begin)-

  • ACE inhibitors for blood pressure  (Lotensin, Capoten/captopril, Vasotec/enalapril, Monopril, Zestril, Prinivil, Lisinopril, Univasc, Accupril, Altace, Mavik ).  These substances may cause arthralgias (joint pain) and myalgias (muscle pain) that may be due to increases in inflammation in the body’s tissues
  • Diuretics that deplete potassium (Lasix/furosemide, bumex, hydrochlorothiazide)
  • Long Acting Beta Blockers-
  • Statin drugs for lowering cholesterol (Lipitor, Zocor, Crestor, Mevacor, Crestor).  The incidence of muscle pain is up to 18%.
  • Antibiotics  Aminoglycosides e.g. gentamycin (muscle pain and spasms, neuropathy)
  • Osteoporosis drugs  Fosamax, Boniva, Actonel, Forteo, Evista,  Prolia  (uncommonly causes muscle pain or bone pain usually in 1% but may be very severe)
  • Anticonvulsant drugs  Cause osteoporosis
  • Proton Pump Inhibitors  Nexium, Prilosec (these drugs may lower magnesium levels)- rare
  • Immune suppression drugs   Interferon, aldesleukin
  • Hormones-  Conjugated estrogens (back pain in 5%, leg crams in 3%, muscle aches in 1%, excess insulin
  • Illicit Drugs  Cocaine
  • Opioids  Long term use of opioid prescription painkillers especially at high doses may lead to increases in pain due to activation of the NMDA receptor and permanent changes in the brain
  • Drug Withdrawal  Sudden cessation or reduction in dosage methadone (muscle aches and bone pain may persist for months) - common

OBESITY- There is a significant increase in chronic widespread musculoskeletal pain in those with a high  fat:muscle mass ratio with a significant elevation. (http://www.ncbi.nlm.nih.gov/pubmed/25185757)  Another study found chronic widespread pain is associated with obesity (BMI>30) and an odds ratio of 1.68 of widespread musculoskeletal pain persisting over time (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4089927/).  Another study found the odds ratio of a person having chronic widespread pain was 2.71 (or 270% increase) in those that are obese. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2892725/

ELECTROLYTE IMBALANCES-low potassium, low calcium, low magnesium (these three give muscle cramps;  low sodium (severe leg cramps), low phosphate (due to inadequate vitamin D intake, low iron (exercise induced muscle pain), Fanconi’s syndrome, heavy metal poisoning, leukemia, lymphoma), diabetic ketoacidosis

VITAMIN DEFICIENCY- B12 (pins and needles in hands and feet), Folic acid, inadequate vitamin D may cause widespread muscle pain (Pain Physician. 2015 Sep-Oct;18(5):E877-87) however treatment with vitamin D is not effective (http://www.ncbi.nlm.nih.gov/pubmed/26861032)

INFECTIONS (Chronic)- Lyme disease, malaria, trichinosis, polio, Rocky Mountain Spotted Fever, hepatitis B or C

MALIGNANCY- metastatic cancer (commonly causes bone pain and muscle pain), leukemia, lymphoma

RHEUMATIC DISEASES- lupus, polymyalgia rheumatica, polymyositis, dermatomyositis, sjogrens disease, rheumatoid arthritis, osteoarthritis, mixed connective tissue disease

ENDOCRINE DISEASES- 1. diabetes mellitus (47% have polyarthritis CDC data, calcific tendonitis is 3 times that of the non-diabetic population, Charcot joints in 1%, carpal tunnel in 1/3, adhesive capsulitis in 20%, DISH in up to 26%, painful peripheral neuropathy in 26%)

  1. Addison’s disease (muscle weakness generalized sometimes painful but uncommon in Addisons),
  2. hypothyroidism (intermittent zinging shooting pain, chronic muscle pain in small percentage, 6% develop lupus and 78% have positive ANA http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401758/)

4.hypoparathyroidism (tingling in the hands, feet, around the mouth and muscle cramps throughout the body)

GI DISEASES- 1. Celiac disease (tender to touch everywhere, 15% have chronic widespread pain http://www.ncbi.nlm.nih.gov/pubmed/24021167, and there is a higher incidence of osteoporosis and bone fractures),

  1. Inflammatory Bowel Disease (Crohns disease and Ulcerative Colitis) Generalized joint pain in 44% http://www.ncbi.nlm.nih.gov/pubmed/26244648) and of those with joint pain, 55% have peripheral joint pain while 40% have back and peripheral joint pain (http://www.ncbi.nlm.nih.gov/pubmed/26512134),

3.dehydration due to vomiting or diarrhea producing electrolyte disturbances

PULMONARY- COPD with chronic hypoxia (http://www.ncbi.nlm.nih.gov/pubmed/22531146), cystic fibrosis (http://www.ncbi.nlm.nih.gov/pubmed/26873725)

CARDIAC DISEASE- congestive heart failure (leg cramps)

LIVER AND KIDNEY-  1. Cirrhosis (leg cramps, widespread pain in 27% http://www.ncbi.nlm.nih.gov/pubmed/25433921),

  1. Widespread pain is found in 22% of Hepatitis B patients (http://www.ncbi.nlm.nih.gov/pubmed/24179575) and 19% of Hepatitis C patients (http://www.ncbi.nlm.nih.gov/pubmed/14504918)
  2. Chronic kidney disease patients have chronic pain in 70% (http://ckj.oxfordjournals.org/content/2/2/111.full) and 2/3 of these are diffuse muscle pain,  
  3. Fanconi’s syndrome (generalized bone pain due to low serum phosphate levels

PSYCHIATRIC- somatization disorder (3 times higher incidence of widespread pain http://rheumatology.oxfordjournals.org/content/40/1/95.long), chronic depression, chronic severe anxiety, hypochondriasis, malingering, personality disorders, post traumatic stress disorder

NEUROLOGICAL-  1. Thalamic stroke,

  1. Parkinson’s disease- 2/3 of these patients have chronic pain.  Of these, 89.0% are musculoskeletal, 31.5% radicular/peripheral neuropathic, 15.1% dystonic, and 4.1% central parkinsonian pain.  The most severe pain was in the central pain group. (http://www.ncbi.nlm.nih.gov/pubmed/27284853)
  2. multiple sclerosis- The majority of patients with MS experience pain with 88% in one study with pain in the knees (56%), wrist (44%), neck 42% with an average VAS pain score of 5.  The majority have more than one limb involved. (http://www.ncbi.nlm.nih.gov/pubmed/26110178).  Another study found 90% of MS patients had significant pain within the one month period prior to assessment time with 52% having low back, 39% musculoskeletal, 31% neck pain, 26% painful spasms, 23% neuropathic extremity pain, and spasticity pain 21% (http://www.ncbi.nlm.nih.gov/pubmed/25868307)
  3. Charcot-Marie-Tooth disease,
  4. chronic inflammatory demyelinating polyneuropathy
  5. Stiff Person Syndrome- chronic global painful spasms rare 1:1million https://rarediseases.org/rare-diseases/stiff-person-syndrome/
  6. Small fiber neuropathy- a disease of the C or A-delta small sensory nerve fibers that may lead to widespread (sometimes patchy) pain with a normal EMG/NCV.  40% of the causes are idiopathic whereas 60% are due to one or more of the following:diabetes, hypothyroidism, Sjogren's syndrome, lupus, sarcoidosis, celiac diseases, lyme disease, HIV, alcoholism, amyloidosis, nutritional deficiency, or vascular inflammation.   Recent studies have shown a link between small fiber polyneuropathy and fibromyalgia, erythromelalgia, and Ehlers-Danlos syndrome.

HEAVY METAL POISONINGS

  1. Arsenic Poisoning:  acute arsenic poisoning gives abdominal cramps but chronic poisoning (longer than 2 weeks) leads to breakdown of the myelin on nerves and causes polyneuropathy with burning pain in both upper and lower extremities, and muscle cramps all over
  2. Cobalt Poisoning: Cobalt is used to make jet engines.  Excessive exposure leads to neurological damage and widespread pain
  3. Lead Poisoning: Chronic low dose lead exposure leads to a neuropathy resembling diabetic neuropathy (http://www.ncbi.nlm.nih.gov/pubmed/11459892)and polyarthritis
  4. Thallium Poisoning: Acute intoxication leads to pain and paresthesias in the distal extremities followed by weakness and eventual atrophy
  5. Mercury Poisoning: polyneuropathy

OTHER MEDICAL CAUSES- pregnancy, hemodialysis (leg cramps), Caisson’s disease (decompression sickness), overuse syndrome, protracted  immobilization, rhabdomyolysis), obstructive sleep apnea, insomnia

IDIOPATHIC (unknown cause)- fibromyalgia syndrome