Are problems such as facial pain, jaw pain, headaches, ear pain, neck/shoulder pain, and the feeling of muscle weakness ganging up on you? Patients with fibromyalgia and chronic fatigue syndrome who have a TMJ disorder would answer YES to this question. What follows is an explanation of why these symptoms might be wearing you thin and a list of suggestions on how you might "off-load" these burdens to ease your overall discomfort.

Temporomandibular joint disorder (TMJD) expert and pathologist Herbert Gordon, D.D.S., Ph.D., who practices in Seattle, WA, offers this story his grandfather told him years ago to demonstrate how pain impacts your sense of well-being:

"A man went to a doctor, saying, 'I need your help.' The doctor responded, 'What's wrong?' The man said, 'My ankles are not doing well, my knees hurt, my back hurts, my stomach hurts, my ears hurt, my chest hurts, my head hurts, my tongue hurts ... and I myself don't feel so good either!'"

FMS/CFS patients suffer from constant pain arising from multiple body sites, much like the man in Dr. Gordon's story. Naturally, the more areas of pain a person has, the more rotten they are likely to feel. Learning how to focus in on troublesome symptoms so as to minimize their impact can be done with the assistance of your health care team and a little understanding about various types of regional pain syndromes, body posture mechanics, and the way pain signals are processed in the brain.

Regional Pain Syndromes

Myofascial pain syndrome (MPS) is a term used for the kind of muscle pain found in multiple body sites in FMS/CFS patients. In MPS, trigger points (rather than tender points) occur, causing pain at distant sites. There are a number of MP syndromes and a multitude of myofascial trigger points throughout the body. The head, neck, upper back, and shoulders are particularly active. A common form of MPS involves the jaw movement muscles and is called temporomandibular joint disorder (TMJD).

When a referred pain phenomenon is present, the source of the pain can be confusing. A tooth ache may not be caused by a cavity: "If the pain originates in one of the jaw movement muscles like the temporalis," says Dr. Gordon, "extracting the sore tooth won't alleviate the problem." Another common pain referral scenario can occur in a person who is experiencing a heart attack. This individual may also have pain shooting down into their left arm or hand, but a person doesn't have to have a heart problem to know what this feels like. Patients with FMS have been reported to have trigger points in the chest region which lead to a referral of pain down an arm as well -- somewhat mimicking a heart attack.

To explain what might be happening at trigger points, Dr. Gordon referenced a 1993 report by David Hubbard, M.D., a researcher in San Diego, CA. Dr. Hubbard inserted needle electrodes into the trigger points of the trapezius muscle (back shoulder area) and another one simultaneously into a nearby non-tender spot in the same muscle in three different study groups: patients with muscle tension headaches (a form of MPS), patients with FMS, and healthy individuals. He had the two electromyographs (EMGs) going at the same time and measured the neurological activity at both muscle locations. In the muscle tissue away from the trigger point, there was only a low level of activity. At the trigger point, however, the EMG signals were significantly stronger in the two patient groups as compared to the healthy controls. Hubbard hypothesized that trigger points are caused by sustained sympathetic nervous system activity that causes the muscle to tense up and produce pain.

But what if the patients just relaxed their trapezius muscle? Wouldn't this release the tension at the trigger point? When Hubbard asked the patients to relax, the EMG amplitude at the non-pain site decreased, demonstrating that patients could relax their muscles upon command. Yet, the EMG signals at the trigger points didn't decrease.

"So it appears that when patients purposely relax, they aren't fully relaxed at the trigger points," says Dr. Gordon. "The muscle will stay tense as a result" ... and it will require more than relaxation therapy to ease the pain.

Patients who have TMJD or other regional pain syndromes should seek prompt treatment. Unlike the deep, diffuse aching caused by FMS, the pain of MPS is often treatable in a variety of ways (see TMJ Disorders Update below). Underscoring the importance of treatment, Gordon says, "A large area of your brain is set aside for controlling mouth and jaw movements, speech and chewing. If you have pain in jaw movement muscles or an abnormal temporomandibular joint with clicking or popping and pain, you are going to tie up a significant amount of your brain in a painful process. Current research in chronic pain has shown that the longer the pain exists in a particular site, the more involved the brain becomes, and the area of the brain that deals with pain grows larger. This is why existing areas of diagnosable pain need to be treated as promptly as possible in order to reduce the overall burden on the brain and the rest of the body. This is especially important in FMS/CFS."

Body Mechanics

Maintaining good posture is important. "If you carry your body incorrectly, you are going to induce strain," says Gordon. "If you induce strain, you are hurting the muscles, ligaments and tendons." Just holding up your head in a proper position may not be easy to do when you are tired, your neck and shoulders hurt, and your postural muscles have begun to weaken due to a decreased activity level--a situation often imposed by FMS/CFS.

What happens if you don't hold your head upright? According to Dr. Gordon, for each inch that you bend your head forward and keep it in a forward position, the weight of your head doubles! The additional weight of your head will strain your jaw joints, neck, back and shoulder muscles, and of course, cause more pain (including headaches).

Regardless of whether you are sitting, standing or lying down, pay close attention to your posture and body mechanics. If you are having problems in this area, ask your doctor for a referral to a physical therapist or occupational therapist.

Your Body's Pain-Control System

By the time a pain signal from a sore toe travels up the nerves in your leg, enters your spinal cord, and reaches your brain, the pain signal is usually minimized, if not completely abolished. "There are specific neurons, cells in the spinal cord and central nervous system whose job it is to block out pain," says Gordon. "Chemical agents in the brain have a dampening effect on pain."

Using marathon runners as an example, Dr. Gordon says they run until they pass through "the wall" and reach the runner's high. How does this happen? Their bodies produce opium-like chemicals in the brain which block out the pain signals coming from the many muscle sites that are injured while they are performing their run. Yes, they are in good condition, but they are pushing their bodies and their muscles are actually hurting...it's just that the opium-like material blocks the pain. "If you give these runners an opium-blocking agent, they crash," says Dr. Gordon. "They go from a high to a feeling of painful withdrawal."

Under normal conditions, the body is able to filter out or block pain signals that are generated from the muscles while running a marathon. But in people with chronic pain conditions like FMS/CFS, Dr. Gordon, as well as others in the field, suspect that patients have lost some of their ability to filter out pain at the spinal cord level and to block it out at the higher regions in the brain. This is one of the effects of the limbic system deregulation that many believe is the cause of FMS/CFS.

"Ongoing discomfort from previous surgeries, falls, motor vehicle accidents, postural problems, untreated pain, or incompletely treated pain for distinct conditions should be dealt with," says Gordon, "in order to help off-load the body's total burden of pain." When these measures are taken to minimize regional pain problems, Dr. Gordon finds that FMS/CFS patients feel better overall, although they are by no means cured.

Dr. Gordon explains: "The 5th cranial nerve supplies all of the jaw movement muscles, the temporomandibular joints, a portion of the throat, the ears, the back of the eye and sinus cavities and the muscles on the side of the head. Recent studies show that the 5th nerve also supplies sensory input to the blood vessels of the brain."

"The 5th nerve," notes Dr. Gordon, "is the communicating center for all pain arising in the neck, head, jaw, eyes, ears, sinuses, and the cervical spine. It may well be the center of integration of head and neck pain, as well as jaw movement.

These facts help explain why TMJD can have so wide an effect and be involved in headaches. It also explains how dysfunction of jaw muscles and joints could amplify problems in the limbic system."

Your Treatment Options

If you have the above symptoms of TMJD and have FMS/CFS, seek consultation with a TMJD specialist. Your problems may be too complex for a general practitioner of dentistry.

A diagnostic examination is necessary to determine whether a jaw muscle problem is present or if the jaw joints are also involved. Dr. Gordon advises that all of the FMS/CFS patients he has seen have the more severe form of TMJD.

Treatment includes the use of special TMJ appliances--splints (not the usual nightguards), exercises for the jaw muscles, diet, a variety of physical therapy treatments, jaw mobilization (manipulation of the jaw to put out-of-place discs into normal position), trigger point/jaw joint injections, ultrasound, laser therapy to the TM joints, pain medications (analgesics like ibuprofen, narcotic agents if needed), medications to aid in sleep, as well as medications to help with muscle stiffness and soreness. Biofeedback therapy is also utilized. All of the medications and therapy must be coordinated with the overall treatment for FMS/CFS.

Medications commonly used to treat TMJD include: Non-opiod analgesics (aspirin, Aleve, ibuprofen, etc.) and muscle relaxants such as Soma (carisoprodol) and Flexeril (cyclobenzaprine). According to Dr. Gordon, "These are best used on a regular schedule around the clock." One pilot study in 1991 showed that 0.25 - 1.0 mg per night of Klonopin (clonazepam) may be helpful as well.

Dr. Gordon believes these methods can be beneficial in 99% of cases. Surgical intervention is needed in only 1% of cases.

Recommendations for Self-Help:

• Rest your jaw whenever possible. The best way is to keep your teeth apart and let your jaw "hang" so as to relax all facial muscles. You might find that it is not easy to relax muscles that hurt, so consult a biofeedback/relaxation specialist for help.
• Maintain good posture.
• Stretch sore jaw muscles 2-3 times daily. At first you may not be able to fully open your mouth. If this is due to sore muscles, heat can help. If this is due to a joint disorder, it may cause more pain. Some patients find that a moist hot towel or a cup of ice applied to the side of the face can ease the pain and stiffness enough to stretch the muscles.
• Massage of jaw, head, neck and shoulder muscles on a regular basis can be helpful to ease muscle tension and improve range of motion. Seek the assistance of a licensed massage or physical therapist, or TMJD specialist.
• Chew all foods on your molar teeth. Do not bite off food with the front of your mouth. Dice all food to 1/4-inch sized pieces. Microwave or steam all vegetables to soften them.

Want to lighten your load? Become a Member of the Fibromyalgia Network (click here).

Myofascial Pain Dysfunction: Treatments used by ADA members, E. Glass, et al, J Craniomandib Prac 11(1):25- 29, 1993.

Administration of Clonazepam in the Treatment of TMD and Associated Myofascial Pain, S. Harkins, et al, J Craniomandib Disord Facial Oral Pain 5:179-186, 1991.

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