Fibromyalgia pain syndrome

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FibroFunctional Restoration Program

Using our advanced technology, including C.A.R.E.N (computer assisted rehabilitation environment) and sonoelatography, we have created a FibroFunctional Restoration Program, not based on pharmacological intervention, but on neuromodulation and desensitization. The program employs a graded movement habituation approach, using a combination of immersive reality physical therapy, ultrasound guided dry needling, extracorporeal shockwave therapy, neuromuscular manual therapy and nutritional counseling

Fibromyalgia trigger points

Fibromyalgia syndrome is a condition of chronic pain that affects the musculoskeletal system. In addition to widespread body pain, the condition is marked by fatigue, sleep disorders and moodiness. FMS is sometimes accompanied by affective and anxiety disorders. Sufferers of FMS seek frequent medical care and have a high rate of absenteeism from work or school.

FMS has physiological, psychological, and social aspects, posing a challenge to health care providers seeking effective treatments. In many cases, treatment is limited to pain medication without additional supporting interventions. Emerging research shows promise for psychological interventions that harness technology to provide virtual reality distractions from pain, and to reduce fear of pain during exercise.


Diagnosis of FMS

The primary symptoms of FMS are widespread flu-like aches and pains, chronic fatigue, mental fog, skin flushing and itching, tingling and numbness, and feeling too hot or too cold. The condition’s symptoms are similar to Lyme disease, chronic fatigue syndrome, under-active thyroid, arthritis, and other chronic multiple-region pain syndromes.

FMS is marked by the presence of classic tender points where muscles attach to bones. While most people are tender at those points, we are not normally aware of them unless strong pressure is applied. In FMS sufferers, those points are always tender, and patients have a heightened and constant awareness of them.

Diagnosis of fibromyalgia is based primarily on symptoms reported by the patient. The American College of Rheumatology’s guidelines stipulate that FMS should be diagnosed if the patient experiences widespread pain in all four quadrants of the body for at least three months.


Fibromyalgia pain treatment

In conventional medical treatment, a patient labeled with fibromyalgia is often prescribed pain medications without any other interventions. Over the long run, patients may become dependent on pharmaceuticals without ever getting to the source of FMS.

Exercise has been shown to be a key aspect in the management of FMS. However, patients with FMS are often reluctant to participate in exercise therapy, because they fear that exercise will exacerbate their pain.

At NYDNRehab, we take a broader approach to the treatment of FMS, acknowledging its multi-faceted nature. We believe in getting to the source of pain and correcting it, not just treating the symptoms.

Treatments we commonly use for FMS include:

Virtual Reality physical therapy, to reduce the fear of pain and enhance exercise compliance. In this treatment approach, the patient is engaged in a game-like virtual reality environment as they exercise, creating a distraction from pain symptoms.

Ultrasound-guided dry needling of muscle trigger points to eliminate neuromuscular dysfunction. Under the guidance of ultrasound imaging, a dry needle is inserted into active trigger points to deactivate them, decreasing the sensation of pain.

Soft-focused shockwave therapy, to increase metabolic activity around the area of pain and stimulate healing. In this nonsurgical treatment, shock waves are delivered to painful muscle areas, with the goal of reducing pain and promoting healing.

Acupuncture, to redirect energy flow and relieve tension, stress, and pain. Acupuncture is becoming increasing recognized as an effective treatment for FMS. In this procedure, thin needles are inserted through the skin to ease pain, reduce symptoms and improve function.

Physical therapy exercises, to improve muscle strength and range of motion. Exercise has been shown to help FMS patients by increasing energy, relieving pain and stiffness, elevating mood, and improving sleep quality. Warm water pool exercise is particularly effective, as the water’s buoyancy supports joints during movement.

Early treatment is geared to eliminating pain and improving pain-free range of motion, so that patients are eventually able to transfer from passive care to active self-care.



This field of ultrasound guided dry needling is not based on the concepts of acupuncture . Acupuncture is performed by inserting needles superficially into body’s channels in order to harmonize energies in the body by stimulating body’s meridians Functional guided dry needling is predicated upon evidence-based Western medical knowledge and the rules of anatomy and physiology.The needles are inserted deeper based on anatomy visualization under ultrasound.


Fibromyalgia specialist NYC

In 1997 Dr.Kalika personally learned dry needling from Karel Lewit ( the founder of dry needling method) himself when he moved to Prague.In 2006 Dr.Kalika became a member of ISMST (international society of medical shockwaves) further progressing his knowledge in treatment of myofascial pain by using extracorporeal shockwave technology.In 2014 Dr.Kalika became interested in ultrasound diagnosis of trigger points and conducted multiple studies in Europe delivering this method for the first time in NYC. At NYDNRehab we use very comprehensive approach by combining functional guided dry needling, extracorporeal shockwave therapy, neuromuscular manual therapy and ontogenetically based physical therapy approach for treatment of myofascial pain.


About the Author

Dr. Lev Kalika is clinical director of NYDNRehab, located in Manhattan. Lev Kalika is the author of multiple medical publications and research, and an international expert in the field of rehabilitative sonography, ultrasound guided dry needling and sports medicine Dr. Kalika works with athletes, runners, dancers and mainstream clients to relieve pain, rehabilitate injuries, enhance performance and minimize the risk of injuries. His clinic features some of the most technologically advanced equipment in the world, rarely found in a private clinic.

LDN Treatment for Fibromyalgia
For millions of people suffering from fibromyalgia, only a handful of available treatments is able to offer long-term relief. Recently, a medication used to treat opioid addiction, Naltrexone, is showing some promise for relieving muscle and joint pain in fibromyalgia patients.

Naltrexone is classified as an opioid antagonist — that is to say that it binds to opioid receptors throughout the human body, occupying them so that opioids are unable to bind. Unlike opioids, Naltrexone does not induce an endorphin release at the receptor sites, and therefore does not produce a psychoactive effect. When ingested prior to taking opioid drugs or drinking alcohol, Naltrexone prevents the brain from producing endorphins, depriving the user of the desired euphoric high.

Low Dose Naltrexone and Pain Relief

Opioids are among the many treatments prescribed for fibromyalgia pain. Yet fear of addiction makes opioid drugs a last-resort option for many fibromyalgia sufferers. As an opioid blocker, one might think that Naltrexone would have an opposite effect to opioid medications. Yet when administered in low doses (1-5 mg as opposed to 50 mg commonly used for addiction), Naltrexone appears to reduce muscle and joint pain in fibromyalgia patients.

How Low Dose Naltrexone Reduces Pain

The mechanisms by which low dose Naltrexone (LDN) works to reduce fibromyalgia pain are somewhat of a mystery, although two theories prevail.

One theory proposes that since fibromyalgia produces chronic pain, endorphin production must be unusually low in fibromyalgia patients. When LDN is introduced, endorphin receptors become blocked, and the brain responds by producing more endorphins, thereby easing fibromyalgia symptoms.

The second theory is that LDN interacts with glial cells in the spinal cord and brain. When the brain sends chronic pain signals, the glial cells respond by releasing inflammatory chemicals that surround nerve endings, heightening their sensitivity to pain. LDN binds to receptors on the glial cells, interfering with the release of inflammatory chemicals, thereby reducing pain.

LDN as a Promising Treatment for Fibromyalgia

When taken in larger doses as an opioid blocker, Naltrexone has pronounced side effects that include jaundice, unusual bleeding, reduced appetite and fatigue. But when taken in low doses, side effects are almost undetectable, with the worst reported being vivid dreams and difficulty falling asleep. The low cost of LDN and its effectiveness in reducing pain make it an attractive treatment option for fibromyalgia symptoms.

Fibromyalgia Treatment at NYDNR

When it comes to treating fibromyalgia symptoms, the pain management experts at NYDNR pull out all the stops. In addition to pharmacological intervention, we use innovative therapies to target fibromyalgia pain.

Treatment methods may include:

  • Acupuncture
  • Ultrasound guided dry needling
  • Virtual reality physical therapy
  • Soft-focused shock waves
  • Exercise and stretching

At NYDNR, our goal is to reduce your fibromyalgia symptoms so you can move and live, pain-free.

Fibromyalgia is one of the most misunderstood and misdiagnosed illnesses of our time. For years the prevailing opinion of medical community was that the pain originates in the muscles, hence the name fibro-fiber and myalgia- muscle pain. This, however was later disproved. There are many scientific theories of why people have fibromyalgia , however there is still no real scientific study explaining the cause. Fibromyalgia is not a disease. It is possibly a metabolic, hormonal and neurotransmitter imbalance affecting internal and external stimuli perception, which ultimately decreases pain threshold. There is no real damage which occurs with fibromyalgia.Fibromyalgia results in lowered pain threshold which results in higher perception of pain. This higher perception of pain is either caused by increased level of adrenaline or this increase level of adrenaline is simply an outcome of fibromyalgia. Every patient with fibromyalgia is affected with chronic stress. This chronic stress is affecting our limbic system which is our emotional brain. It is believed that this dysfunction within the limbic system causes depletion of dopamine which in turn makes our body more sensitive to normal sensations which normally we are not aware of. The level of dopamine in our brain establishes our pain threshold.

How Is Fibromyalgia Diagnosed?

Majority of patient suffering from fibromyalgia are not diagnosed immediately. The medical diagnostic criteria for fibromyalgia diagnosis is the presence of classic tender points. The tender point are the places where muscle attaches to the bone. In reality these are the most sensitive spots which we normaly have in our body, however we don’t usually feel them unless strong pressure is applied to them. This criteria is very misleading and can not be the sole of fibromyalgia diagnosis. Any one with poor posture will have tenderness in all these points. In person with fibromyalgya the sensation from these tender points is heightened. This leads to constant increased awareness of these spots.

What Are the Symptoms Associated with Fibromyalgia?

Constant pains and aches , flu like condition, feeling chronically tired, confusion, skin flushing, itching, unexplained tingling and numbness, feeling to cold or to hot.

What Are the Causes of Fibromyalgia?

Poor interrupted sleep, sleep apnea, dysfunctional beathing patterns, stress, anxiety and panic disorders, depression, posttraumatic stress disorder, restless leg syndrome, history of trauma, hypermobility, multiple regional pain syndromes in the locomotor system.

What Other Conditions Commonly Coexist with Fibromyalgia?

Patient with fibromyalgia frequently have other syndromes (headaches, TMJ pain, irritable bowel syndrome, chronic sinus infection,PMS and others) together with it . Although they may not be directly related, removing those generally improves fibromyalgia.

What Other Conditions Can Mimic Fibromyalgia?

Lyme disease, chronic fatigue syndrome, underactive thyroid and arthritis. Chronic multiple regional pain syndromes.

Why Is Fibromyalgia so Difficult to Treat?

Primarily most of the patients with fibromyalgia are not diagnosed timely and not being properly treated ones the condition is established. This create a chronic state which is more difficult to treat.

Each patien’s clinical presentation with fibromyalgia is slightly different from another. There is however not even one patient with fibromyalgia who is totally emotionally balanced. Patients with fibromyalgia may or may not be clinically depressed. Stress management and identification of patients emotional problems is one of the most important factors in dealing with fibromyalgia.

Another important factor in management of fibromyalgia is the coexistance of myofascial dysfunction and regional pain syndromes.

Since most of the patient presenting with fibromyalgia are 40-60 age group it is obvious that there are some either functional or structural spinal pathology or frequently both which are present. Often times these patient have a history of trauma or multiple regional pain syndromes within their body. In my clinical experience 40% of all fibromyalgia patients have locomotor system dysfunction.

Much improvement can be achieved if these physical insults are removed. This removes some of already existing nonciception (pain) and allows patients to deal with their other symptoms. Most of my patients report improvement in range of movement, improvement in sleep and reduction of their hypersensitivity after the treatment. This approach is however missed by medical community because once the patient is labeled with fibromyalgia he/she is prescribed medications (lyrica, mirapex, requip) whithout any other intervention. These medication unfortunately are very poorly tolerated by patient. In more sever cases these medications and necessary measure, however since fibromyalgia is a multy-factorial disease not combining these medication with other treatments leads to dependency and chronicity.

Fibromyalgia Specialist in NYC – Advanced Approach

Treatment of fibromyalgia requires cooperation of different specialties. Most important is a cooperation between neuromuscular specialist, rheumatologist and psychologist.

We also use natural supplements to alleviate the symptoms of fibromyalgia:

  • Calcium and magnesium – to relax the muscles
  • 5-HTP and SAMe increase serotonin, leading to reduction of pain signals
  • Sugar D -ribose to improve energy production within cells
  • Neprinol- a specifically developed enzyme for patient with fibromyalgia and other arthritic conditions. It works by removing excess fibrin.
  • Various meditation technigues work to reduce stress and hyperactivity of autonomic nervous system. We found paradoxical relaxation method by Edmund Jacobson to be most effective.

Fibromyalgia patients usually have neck and back and other pains within the locomotor system. The problems within the locomotor system could be either one of the causes or outcomes of the chronic fibromyalgia. Therefore removing dysfunction in the locomotor system, thus allowing for pain free motion is one of the beginning steps in treatment of fibromyalgia. Although this is not always works with all fibromyalgia patients in my clinical experience it does work for majority of patients with fibromyalgia.

There is however one most important aspect of treating fibromyalgia patients. It is trusting doctor patient relationship. Patients with fibromyalgia are frequently feel turned off and unempathized by other doctors as well as being helpless due to numerous unsuccessful treatments undertaken over the years. Establishing the patient doctor trust is the key component for successful treatment of fibromyalgia. The transference of patient from passive care to active self care is crucial. When physical treatment is successful in removing pain and increasing rage of motion patients feel relieve and gain trust. The new gained movement and pain relieve allows patients to reactivate their life style.This allows the practitioner to implement other treatment which are necessary for successful treatment of fibromyalgia.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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