The CFS case definition currently in use has been defined by the CDC, Fukuda et al., 1994. This definition was presented as a means intended for research. A first set of criteria, [Holmes et al., Ann Intern Med 1988; 108:387-9] was hereby revised and replaced.
The amount of scientific literature on CFS/ME has not grown at a pace comparable to that on FM. The apparent stagnation over the past decade suggests that if this domain of research is to survive, aggressive efforts may be required to promote a more inclusive case definition, friedberg.etal07.txt,friedberg.etal.07.txt, friedberg.etal07.pdf.
In 1991 psychiatrists (of British origin mainly) lauched their own CFS-criteria, the Oxford criteria [Sharpe et al., J R Soc Med, 1991 Feb; 84(2):118-21], oxford.criteria91.txt. By this criteria CFS is defined less strict omitting the 8 minor criteria required by the CDC-definition, including patients with fatigue as their only symptom (e.g. psychiatric patients). The absurd situation imposed by this psychiatric CFS case definition is brilliantly enlightened, Jason et al., 1997.
The Nightingale Definition of Myalgic Encephalomyelitis (M.E.), nightingale.definition06.txt, Definitions and aetiology of Myalgic Encephalomyelitis (ME): how the Canadian Consensus Clinical Definition of ME Works, carruthers06.txt. Comparing the Fukuda et al. criteria and the Canadian Case Definition for CFS, jason.etal04.txt, jason.etal04.pdf, d Both definitions select individuals who are significantly different from psychiatric controls with chronic fatigue, and the Canadian criteria select cases with less psychiatric co-morbidity, more physical functional impairment, and more fatigue/weakness, neuropsychiatric, and neurological symptoms.
Identification of ambiguities in the 1994 CFS research case definition and recommendations for resolution, reeves.etal03.txt, reeves.etal03.pdf. The Swedish CFS research team’s results raise fundamental questions about the 1994 Centers for Disease Control criteria as (1) there was no empirical support for the requirement of four of eight cardinal CFS symptoms; (2) these eight symptoms were not equivalent in their capacity to predict fatigue; and (3) no combination of symptoms was markedly more heritable, sullivan.etal05.txt, sullivan.etal05.pdf.
Three methods for improving the 1994 CDC-diagnostic criteria: identification of new diagnostic symptoms, the use of severity ratings for symptomatology, and the identification of standardized measures that differentiate cases of CFS from other conditions, king.jason04.txt, king.jason04.pdf.
CFS in International Classification of Diseases (ICD)
CFS is classified (coded) in WHO’s (1992) ICD-10 (International Classification of Diseases) as G93.3, a subcategory under diseases of the brain, (i.e. a neurological disease). On the classification issue following a WHO note 23 Jan 2004, who.classification.us04.txt. The WHO website on this issue, who.guide.online.link04.txt.
In the US a modification of the previous WHO coding ICD-9, a so called ICD9-CM is still in use (CM “Clinical Modifications”). This results in difficulties in relation to CFS, as this disease is not covered by the ICD-9. However, the US has adopted the ICD-10 (including clinical modifications) supposedly to be in use by 2004. A short note on the classification of CFS and ME by the WHO, codes.who.explanation04.txt.
What is costochondritis? cost= rib, chond = cartilage, itis = inflammation Costochondritis is an inflammation of the cartilage that attaches the ribs to the breastbone
How do you get costochnodritis? Costochondritis may be caused by trauma, such as bumping the rib cage; as a result of a viral infection; or as part of an inflammatory disease process. Usually the cause is unknown
Does it go away? For most people, it goes away in six months to a year; however, for some people it remains a chronic condition. Note the costochondritis is most painful in the early stages; the pain does lessen after awhile!
What does costochondritis feel like? Costo is an inflammation of the rib cartilage, and is sometimes diagnosed by pushing on the sternum, (area at the top where your ribs join) or by pushing on any sore spot on your ribs. Either should cause intense pain. *However*, not everyone with CC will respond like that.
In the beginning, costo is usually worse,it feels like there is an elephant sitting on your chest, it hurts to breathe, ribs hurt all over with intermittent sharp, stabbing pains, and usually a few “sore spots” on your ribs, that you would faint if someone poked you there. You might also feel like you are having a heart attack. Eventually, it might go down to a dull, but constant ache, or simply the feeling of sore ribs. It hurts to wear a bra, and different motions, like picking a child up from the floor, can cause a flare up, with intense pain. When it is a chronic condition, it tends to wax and wane, come and go. It might be better for a while, then you will reach for something in the wrong position and bam!, it is right back again.
My doctor say the pain of costochondritis is benign. What does this mean? Benign means nonmalignant. But, “benign” is often wrongly translated as “harmless and easy to live with”. Costochondritis is neither!
It feels like I am having a heart attack, what causes this? When there is that much inflammation and swelling in one area there is no room for more swelling- the nerves are over reactive and the muscles turn into tight knots – this causes the feeling of having a heart attack. You have all of the muscles and nerves running between the ribs themselves, then you also have your chest muscles that are tightening and swollen. With one on top of your heart and the others on the bottom, there is going to be a heart attack feeling ( You only have so much room). However, cardiac symptoms cannot be ignored, and must be ruled out first!
I am having trouble breathing- does this affect my lungs? Costochondritis is simply the swelling of the joints and has absolutely nothing to do with your lungs and will not hurt them. When the body is hurt, it automatically keeps everything away from the injured area so that it can heal. Which is the case with costochondritis – there is the swelling – the body is in fact telling the lung not to expand completely, allowing you that deep breath, due to the fact that when the lungs expand they press up against the joints where the ribs meet thebreastbone. So our body is trying to heal itself but in doing so it doesn’t allow us to breath properly.
I feel pain radiating in my shoulders, arms, or back- what causes this? Nerves radiate throughout our rib cage and around to the back along our spine, so the pain/inflammation from the joints can and will radiate from the breastbone all the way to our spines in back. If there is anything irritating the nerves, then you might feel it all the way around. Down the arms and into the shoulders may be caused from muscle pain which can radiate all over without any rhyme or reason.
Does stress make it worse? Yes, stress can make it worse, like most health conditions. Stress causes the nerves to be more on edge and tightens the muscles, both of which trigger our CC pain. I have found that the pain increases quite a bit in stressful situation versus non stress times. With stress our bodies go into their fight or flight reaction, which is why some doctors put us on relaxing types of medication so that our bodies won’t go into that reaction, raising the pain level.
How do I treat costochondritis? Rest, heat or ice on affected areas, and anti-inflammatories like aspirin, acetaminophen (Tylenol), Ibuprofen (Advil), or naproxen (Aleve), or prescription anti-inflammatories. Most people have not found much to help the pain. Medications and supplements will be discussed more in what helps?
What about cortisone shots? Cortisone shots have been helpful to some people- however, they are a temporary measure to kill the pain and reduce inflammation, and not a cure. Most have not noticed enough help from them to be considered worth it. There has been some discussion about cortisone weakening the cartilage.
Supplements Some people have had luck with the following supplements
Glucosamine/Chondroitin Sulfate (heals cartilage)
Ginger Root (inflammation)
Evening Primrose Oil (inflammation)
Vitamin C (boosts immune system)
Vitamin E (anti-oxidant, inflammation)
Eating fatty fish, such as salmon or sardines for their Omega-3 oils (inflammation)
White Willow Bark (inflammation)
Goldenseal (inflammation, cleansing, good for viral)
Echinacea-(boosts immune system, take for two weeks, two weeks off, etc., will not work as well if taken continuously)
Kava Kava (calming)
Valerian Root (calming, helps sleep)
Grape Seed Extract (antioxidant)
Here is one regimen taken with good results
Glucosamine/Chondroitin Complex (500 mg) 3 x a day
Bromelain (Pineapple enzyme 500 mg) 3 x a day on empty stomach
Vitamin C with Bioflavanoids (1000 mg) 4 x a day
St. John’s Wort (300 mg) 3 x a day (good for nerve pain and depression)
A good multivitamin 1 x a day
B Complex 1 x a day
Traumed brand cream applied to area as needed.
Plain coated aspirin (325 mg) four a day
Hot mineral baths (Batherapy Brand) once or twice a day
Glucosamine/Chondritin Complex 1500mg/1200mg per day
Ginger – two tablets, (550 mg each) morning and evening
Evening Primrose Oil (1300 mg) morning and evening
Vitamin C -1000mg three times per day
Bromelain- 500mg three times per day, on an empty stomach
I take a warm shower twice a day, and do light stretches on my back/neck area after each shower; this keeps me flexible. I also get a swedish massage every two weeks, concentrating on my neck and shoulder area, and work out the neck/shoulder/back area with light weights on a weight machine, to strengthen.
After three days on the above regimen (except for the Bromelain), the dull ache I had constantly in my ribs went away. It was no miracle cure, I still had a *lot* of pain, but I would estimate that about 20% of my pain was gone. A few days later, I woke up with no chest pain at all, although it came back shortly after I started moving around. I then added Bromelain, but noticed no difference; in fact there has not been much of a change since the first week.
I started taking warm baths with Batherapy bath salts once or twice a day, and using myoflex creme on my ribs, both seemed to help. I had gotten to the point where 40% of my rib pain was gone, but then I stopped the glucasomine/chondroitin and a lot of the pain came back.
I also had to quit working out with the light weights, I was pulling too many muscles, seems like I need to get my neck/shoulders/upper back stretched out-more flexible before I continue with weights. The massages are helping a lot in this area. The supplements that seemed to help me the most were the glucasomine/chondroitin, ginger, EPO oil and Vitamin C.
The following is a list of prescription medications that have been prescribed for costochondritis
Indocin- useful for reducing pain and inflammation, but side effects include liver and kidney damage, and drowsiness
NASAIDS-(non-steriod, anti-inflammatory agent) such as Relafen (Nabumetone); side effects include gastrointestinal disorders
What else helps?
Acupuncture has helped some people
Physical Therapy- has helped, and has hurt some people. Check this out carefully!
Chiropractors- once again, some people have been helped, some hurt- look for a chiropractor who uses an activator, or an adjuster.
Massages help the sore muscles around the neck and shoulders a lot of us tend to get from “hunching over”, because it hurts to breathe.
There is a book called “Pain Free” by Pete Egoscue, which uses simple but time consuming exercises to get our body back in alignment. I recommend this book highly for people suffering from muscle pain in their neck, shoulders, arms or upper back, or are having a lot of trouble with their breathing .
Delphi-Costo Forum-Wednesdays @ 7:00 p.m. , central time
For Women Only
Frequently Asked Questions
I have pain in my breasts, can this be from costochondritis? Yes, pain in the breasts, can be from nerve pain radiating from the ribs. However, any pain of this type should be checked out by your doctor. My costochondritis gets worse just before or during my periods, why would this be? Prostaglandins are chemicals released at the site of an injury. The are believed to be the substances responsible for producing pain and inflammation following tissue damage and in immune reactions. All the NSAIDs block the production of prostaglandins.
The levels of prostaglandins in the body increase as menstruation approaches, with the highest levels at the onset of the menstrual period. Higher protaglandin levels increase uterine contractions causing cramps and pain. In essence, the uterus squeezes so hard that it compresses the uterine blood vessels and cuts off the blood supply. This situation is similar to when the blood supply is cut off from the heart causing pain (angina). In both instances the result is the same–pain because the muscle does not have sufficient oxygen.
In addition, some of the excess prostaglandins escape from the uterus into the bloodstreamwhere they may affect other smooth muscles. Thus, prostaglandins are responsible for the headaches, dizziness, hot and cold flashes, diarrhea and nausea that can accompany painful periods, and can also increase the pain of costochondritis.
Some women have found relief by taking NASAIDs several days before your period is expected to start, building up the anti-prostaglandins into your system BEFORE the pain-producing prostaglandins are secreted! Keep taking until the end of the second day of your period or whenever the pain usually eases up.
There is a company that makes comfortable cotten bras to size with no hardware, and will do free adjustments for the first two months. Ask for a soft, wide lycra band at the bottom instead of elastic for free. Prices start at $26. Go to http://decentexposures.com/
Bali makes a stretchy, comfortable bra called “Barely There” that also has no hardware, and a wide band at the bottom. These can be found in most department stores, or go to http://www.onehanesplace.com/
I am a 64 year old woman and have always been physically active and have a pretty stressful job. On May 22 , 1998, I had severe chest pains at work and was taken to the ER for possible heart attack. An angiogram showed no blockage or heart problems and I was put on indocin for 10 days after being diagnosed with costochondritis. My symptoms were chest pain (no redness or swelling), pain in elbows and wrists and labored breathing.
I learned more about costo from the internet and about glucosamine & condroitin as a possible treatment. I already knew from reading Dr. Andrew Weil’s books that Omega-3 and diet of fatty acids nourish soft tissue and cartilage and that ginger is good as an anti-inflammatory supplement, as well as Vitamin E. I began all this and cut way down on eating beef and began eating more salmon and sardines. I also used ice packs. I began a steady recovery and went back to work after complete rest for two weeks after being discharged from hospital. By the end of 5 or 6 weeks I had no symptoms. Remembering back to February and March that I had constructed a new patio laying 128 twelve inch square cement slabs after removing river stones by shoveling them out , led me to believe this to be the cause of the costo. Why it took so long to reach the pain stage is still a puzzle, but I don’t know what else could have caused this condition.
Costo generally strikes people from 20 to 40 years of age. I think one reason for the complete recovery could have something to do with my age and the fact that I just over did it physically. I also feel that younger people who contract costo have a weakness in that area already probably caused from poor diet growing up. Hope this will help others who have suffered much more than I have.
Articles of interest (various articles collected from a search on the internet)
Article # 1
Ask The Experts (Medicine Net)
Questions & Answers Question from Chris of Wyoming, USA–November, 1996. What is costochondritis? What are the health effects, concerns for the long term? How does someone learn to live with it, or cure it? Is this a genetic disorder?
Costochondritis is inflammation of the cartilage at the junction between the ribs and the breast bone (sternum). Symptoms of costochondritis are pain and tenderness in the front of the chest wall near the sternum.
Costochondritis is usually treated with ice and/or heat applications, local injections of anesthetic and/or cortisone, and pain relievers. It can recur.
There is no evidence that costochondritis itself is genetic. Costochondritis can be associated with other conditions, such as psoriasis, psoriatic arthritis, ankylosing spondylitis, and Reiter’s syndrome.
MedicineNet is committed to bringing you medical information to help you, your family, and friends become better informed patients. Please remember, information is never a substitute for an open doctor-patient relationship.
Thank you for your question.
What is It?
* Painful inflammation (swelling) of the cartilage of the ribs (attaching ribs to sternum).
* Commonly affects the 3rd or 4th ribs.
* Age of onset before 40.
* Both sexes are affected equally.
* May mimic cardiac pain.
Cause of the inflammation is often unknown.
Signs and Symptoms
1. Pain in the chest wall, usually sharp in nature, especially on pressure.
2. Pain may occur in more than one location and may radiate into the arm.
3. Pain worsens with movement.
4. Tightness in chest.
5. Affected area is sensitive to the touch.
* Trauma, such as a blow to the chest.
* Unusual physical activity.
* Upper respiratory infection.
Avoidance of activities that may strain or cause trauma to the rib cage.
Diagnosis and Treatment
* Ice packs applied to the affected area.
* Avoidance of sudden movements that will intensify the pain.
* Mild pain medications, such as aspirin, acetaminophen or ibuprofen may help relieve discomfort.
* Stronger pain medicines and non-steroidal anti-inflammatories may be prescribed..
* Steroid injections may be prescribed for some patients.
No special diet.
Complete healing. The disorder is benign and the course is usually of a short duration.
Costochondritis is anterior chest wall pain associated with tenderness of the costochondral and costosternal regions. It produces diffuse tenderness without swelling in more than one joint in the rib cage. It usually follows unusual excessive physical activity or trauma, and is more prevalent in females ages 20-40.
Costochondritis and PBC….(PBC stands for Primary Biliary Cirrhosis (PBC) , a rare chronic liver disease)
Costochondritis is one of many disorders associated with Auto Immune
Diseases. Normally this disorder will go away on its own. When
associated with an auto immune diseases such as PBC, it may linger for
years or a lifetime.
Costochondritis is an inflammation of the cartilage that attaches theribs to the breastbone (costo = rib, chond =cartilage, itis =inflammation).
Costochondritis causes mild to severe pain in the lower rib area orupper breastbone. Some patients fear they are having a heart attack. Themost severe pain is usually in the lower rib area between the breast andupper abdomen. The pain may be more noticeable in sitting or recliningpositions, and stress is known to aggravate this condition.
Costochondritis may also be caused by trauma, such as bumping the ribcage; as a result of a viral infection; or as part of an inflammatorydisease process. Usually the cause is unknown.
Once the diagnosis of costochondritis is made, it usually responds wellto a course of a pain-killing, anti-inflammatory medications such as aspirin,ibuprofen, or any of a number of prescription medications. If this conditiondoesn’t respond to simple treatment measures, the patient should undergomore tests. When costochondritis is associated with liver disease, it is more difficult to treat.
Costochondritis Authored by Lynn K. Flowers, M.D., LCDR MC USNR, Assistant Professor, Eastern Virginia Medical School
Background: Costochondritis is a benign cause of chest pain, in contrast to myocardial ischemia or infarction, which is an important consideration in the differential diagnosis of chest pain. Although the term costochondritis is often used interchangeably with fibrositis and Tietze’s Syndrome, these are distinct diagnoses.
Pathophysiology: Costochondritis is an inflammatory process of the costochondral or costosternal joints that causes localized pain and tenderness. Any of the seven costochondral junctions may be affected and more than one site is affected in 90% of cases. The second to fifth costochondral junctions are most commonly involved.
Frequency: In the U.S.: The exact prevalence of a musculoskeletal etiology for chest pain is not known. However, in one clinic study the overall prevalence of a musculoskeletal etiology for chest pain was found to be about 10%. In a 1994 Emergency Department (ED) study 30% of chest pain patients were judged to have costochondritis.
Mortality/Morbidity: The course is generally self limited, but often with recurrent or persistent symptoms.
CLINICAL History: The onset is often insidious. Chest wall pain with a history of repeated minor trauma or unaccustomed activity (i.e. painting, moving furniture, etc.) is common.
Pain description: Worse with trunk movement, deep inspiration, and/or exertion Better with decreased movement, breathing quietly, or changing position Sharp, nagging, aching, or pressure-like Usually well-localized, but may extend or radiate extensively Can be severe May wax and wane
Physical: Pain with palpation of affected costochondral joints is a constant finding in costochondritis. The second through the fifth costochondral junctions are the sites typically involved. More than one junction is involved in >90% of cases. Surprisingly, patients may not be aware of the chest wall tenderness until examination. The diagnosis should be reconsidered in the absence of local tenderness to palpation. Tietze’s Syndrome is characterized by nonsuppurative swelling, whereas costochondritis has no palpable swelling.
Causes: The etiology is not well defined. Repetitive minor trauma has been proposed as the most likely cause. Bacterial or fungal infections of these joints occur uncommonly. These patients are more likely to be intravenous drug abusers or postoperative thoracic surgery patients. DIFFERENTIALS
Abdominal Trauma, Blunt
Gout and Pseudogout
Sternoclavicular Joint Injury
WORKUP Lab Studies: There are no specific studies for costochondritis. Labs orders should be guided by the clinical scenario and the most likely differential diagnoses.
Imaging Studies: Chest x-ray should be obtained in the work up of the differential diagnoses. Bone (gallium) scans have been used in the U.S., though not an ED study. TREATMENT Emergency Department Care: Reassurance of the benign nature of the condition and adequate pain control are the important objectives. Narcotic analgesics are not generally required. Drug Category: Nonsteroidal Anti-inflammatory Drugs –
Provides pain management and anti-inflammatory effects
Drug Name ibuprofen (Motrin) Adult Dose 400-800 mg POq4h-q6hmaximum daily dose 3200mg Pediatric 10 mg/kg per dose qid Contraindications hypersensivity to NSAIDS or aspirin Interactions anticoagulants,aspirin,methotrexate,furosemide, , lithium Pregnancy Precautions Not recommended during pregnancy Further Outpatient Care: Nonsteroidal anti-inflammatory drugs Local heat Local infiltration of local anesthetic, steroid, or both, or intercostal nerve block. (Reserved for refractory cases.) Biofeedback
Complications: Misdiagnosing myocardial ischemia or infarction Extensive and expensive negative work-ups
Prognosis: Excellent After one year about one-half may continue with some discomfort, but only one-third report tenderness with palpation. Patient Education: Patients should be given reassurance of the benign nature of the problem and they should be instructed regarding the avoidance of provoking activities. Patients should have a good understanding of the proper use and potential adverse effects of NSAIDs.
Costochondritis is an inflammation of the ribs, usually where they attach to the breastbone or sternum.
A person with costochondritis may have pain in the front of the rib cage. Sometimes there is redness and swelling of the tissues around the sternum. The chest pain is described as dull and aching. The pain gets worse if pressure is put on the sore ribs.
It is very important to have all pain in and around the chest evaluated by your healthcare provider. Costochondritis is not life threatening but a heart attack is.
Sometimes a blow to the chest wall will cause costochondritis. Many times it is not known why inflammation sets in.
Treatment for the problem is simple. It includes:
anti-inflammatory medication like aspirin or ibuprofen,
ice packs over the sore areas,
avoidance of movements and activities that increase the pain,
rest until movement becomes comfortable, and
a gradual return to exercise, using slow stretching to avoid reinjury.Your healthcare provider may suggest cortisone injections if the problem is stubborn.
Tag : what is costochondritis , what causes costochondritis , what is costochondral calcification , what is costochondral chest , costochondritis symptoms