Fibromyalgia:New Perspectives for the Manual Therapist

February 16, 2010 by stevegold
Filed under Articles, Research and Industry News

Introduction

By Steven Goldstein BHSc MST, BA Education

Fibromyalgia classically presents as wide spread musculoskeletal pain and we know that the origin of this pain is multifaceted and systemic. Because of this, a more comprehensive understanding is required of you to be successful in your treatment options. In this article I’m going to introduce the concept of ‘Central Sensitization’, a fibromyalgia research blog, and the FIQ Fibromyalgia Impact Questionaire. All three of these components will give you a greater understanding of how to work with and treat your Fibromyalgia client.

There has been much written regarding Fibromyalgia and Massage Therapy, but a short review may be in order to the salient features of the syndrome.

Fibromyalgia FMS is a syndrome that is considered by many to be a chronic, culmative overload of the body’s coping and cushioning mechanisms (1. Gillick) in which on going residuals of macro-traumas (whiplash, system disorders, post traumatic stress syndrome, are perpetuated with numerous and cumulative micro-traumas (chronic sinusitis, repeated impact trauma, musculoskeletal dysfunction in the upper or lower extremities, positional sleep traumas) which sensitizes the central nervous system in such a manner as to amplify pain 24/7 and create pain from usually non-painful stimuli.

This is known as Hyperalgesia: the amplification of pain sensations and Allodynia: non-painful sensations such as touch, noise, vibration, lights or smells are painful.

Prevalence indicates usually affecting women over men by a 4/1 ratio, but Fibromyalgia can occur at any age. Although it usually manifests between the ages of 30 to 50. (Rattray p983)

There is an enormity of presenting symptoms with a wide range of variance as to fool the manual therapist, and probably the best source for the presenting symptoms would be to check out Dr. Devin Starlanyl’s website: http://homepages.sover.net/~devstar/. I’ll cover presenting symptoms in a subsequent article.

Central Sensitization

“Fibromyalgia (FM) pain is frequent in the general population but its pathogenesis is only poorly understood. Many recent studies have emphasized the role of central nervous system pain processing abnormalities in FM, including central sensitization and inadequate pain inhibition. However, increasing evidence points towards peripheral tissues as relevant contributors of painful impulse input that might either initiate or maintain central sensitization, or both.

It is well known that persistent or intense nociception can lead to neuroplastic changes in the spinal cord and brain, resulting in central sensitization and pain. This mechanism represents a hallmark of FM and many other chronic pain syndromes, including irritable bowel syndrome, temporomandibular disorder, migraine, and low back pain. Importantly, after central sensitization has been established only minimal nociceptive input is required for the maintenance of the chronic pain state. Additional factors, including pain related negative affect and poor sleep have been shown to significantly contribute to clinical FM pain. Better understanding of these mechanisms and their relationship to central sensitization and clinical pain will provide new approaches for the prevention and treatment of FM and other chronic pain syndromes.”

Central sensitisation is defined as ‘‘an augmentation of responsiveness of central pain-signalling neurons to input from low-threshold mechanoreceptors’’ (Meyer et al.,1995). “While peripheral sensitisation is a local phenomenon, central sensitisation means that central pain processing pathways localised in the spinal cord and the brain are sensitised.”

The science is fascinating, but the clinical implications through the application of this understanding is essential. An important and ongoing source of pain is required before the process of peripheral sensitisation can establish central sensitisation. Progression towards chronic widespread pain is associated with injuries to deep tissues which do not heal within several months (Vierck, 2006).

Consequently, appropriate and effective manual therapy in those with (sub)acute musculoskeletal disorders is important to prevent evolvement from an acute, localized musculoskeletal pain problem to complex clinical cases, characterised by chronic widespread pain and even symptoms outside the musculoskeletal system such as increased sensitivity to bright lights, auditory loudness, odours, and other sensory stimuli. Pain due to damage or inflammation of peripheral tissues is clearly capable of causing chronic widespread pain/FM (Clauw, 2007). 15-20% people with whiplash injuries develop chronic pain and disability (Spitzer et al., 1995; Radanov and Sturzenegger, 1996; Coˆ te´ et al., 2001). Regardless of whether FM is present in chronic whiplash, altered central pain processing and central sensitisation is evident (Curatolo et al., 2001; Sterling et al., 2002, 2003, 2006; Banic et al., 2004). Moreover, altered central pain processing rather than impaired motor control has been identified as one of the prime prognostic factors for developing chronic whiplash (Sterling et al., 2003, 2006).

Excerpted below from ‘From acute musculoskeletal pain to chronic widespread pain and fibromyalgia: Application of pain neurophysiology in manual therapy practice .’

Science Direct Manual Therapy 14 (2009) 3e12

Myofascial Treatment

“Anecdotally, muscles and fascia often become hypertonic and develop trigger points in people with chronic widespread pain/FM. Soft-tissue mobilisation is required to free up restrictions and restores local blood flow. However, it is important not to increase pain during treatment. The vicinity of myofascial trigger points differs from normal muscle tissue by its lower pH levels (i.e. more acid), increased levels of substance P, calcitonin gene-related peptide, tumour necrosis factor-a and interleukine-1b, each of which has its role in increasing pain sensitivity (Shah et al., 2005). Sensitised muscle nociceptors are more easily activated and may respond to normally innocuous and weak stimuli such as light pressure and muscle movement (Shah et al., 2005). Therefore, starting the soft-tissue mobilisation superficially with well-tolerated strokes along the length of the muscle fibres (referred to as ‘stripping’ in Benjamin and Tappan, 2005) and progressing towards deeper strokes that go perpendicular to the soft-tissue fibres is recommended Aggressive ways of treating trigger points (e.g. by using ischaemic pressure) are usually not well tolerated and therefore not recommended.”

The research is clearly demonstrating a lighter approach is needed when applying soft-tissue therapies with the sufferer of fibromyalgia. We know from the studies of ‘facilitation’ with regard to active and latent trigger points, that once the dorsal horn of the spinal cord is switched on, it maintains its’ ‘facilitation’, with a low thresh hold barrage of stimulus.

An awareness is needed of the mechanisms that activate the autonomic nervous system, such as ‘flight and fight’; and the de-activation of ‘high sympathetic tone’ (Shea 1995), so that the therapist modulates the ANS from a lower sympathetic state into a parasympathetic state which is demonstrated by ‘rest and repose’. With this type of client, modification of duration of treatment, amount of force or pressure and specific tissues totarget, i.e., myofascial tissue, are all essential to a greater degree of success through the cessation of the barrage of nocioceptive stimulus.

The clinical approach I utilize, uses a skill set that employs lighter touch, autonomic nervous system modulation, the use of mind-body techniques such as neuro-linguistic programming (NLP), awareness and imagery technique, along with low load resistive for targeting intrinsic ligament and axial spinal muscle groups, forms of applied kinesiology, reflexology; all have efficacy in the treatment application of the sufferer of fibromyalgia.

Finally remember you have to have a strong referral network due to the systemic nature of the presentation, that means you need to refer to qualified therapists who practice CAM therapies, including naturopaths, CAM therapy friendly allopath physicians, mind body therapists, rheumatologists, and cognitive therapists that deal with emotional and psychological issues that are part of the overall clinical picture.

Fibromyalgia Impact Questionnaire

A very important tool for the manual therapist in their treatment of Fibromyalgia is the FIQ or Fibromyalgia Questionaire. This is the tool recognized for use in clinical trials around the world, and therefore is the major current tool to measure changeable outcomes for your client.

It was developed by Dr. Robert Bennett in the 1980’s in Portland Oregon in an attempt to capture the total spectrum of problems related to fibromyalgia and the responses to therapy. It was first published in 1991 and since that time has been extensively used as an index of therapeutic efficacy. Overall, it has been shown to have a credible construct validity, reliable test-retest characteristics and a good sensitivity in demonstrating therapeutic change. The original questionnaire was modified in 1997 and 2002, to reflect ongoing experience with the instrument and to clarify the scoring system. The latest version of the FIQ can be found at the web site of the Oregon Fibromyalgia Foundation (www.myalgia.com / F I Q / F I Q). The FIQ has now been translated into eight languages, and the translated versions have shown operating characteristics similar to the English version.

Based on an intake questionnaire used in the OHSU Rheumatology Clinic and informal discussions with fibromyalgia patients, the initial version of the FIQ was developed in 1986. In particular, the functional component of the questionnaire was purposely biased to the use of large muscle groups rather than fine hand movements.

Make sure you download the questionnaire and thoroughly read the research behind the study, as it will allow you the insight about how the questions were formed and why they were asked. In particular the scoring is designed to target physical functioning versus physical impairment. The categories are such as to ascertain how ADL activities of Daily Living are affected.

Every client should be filling out this questionnaire and then you actually have the ‘research tool’ in your hand to validate and contribute to studies and findings from a research perspective.

FIBROMYALGIA IMPACT QUESTIONNAIRE (FIQ)

Name: _________________________________ Date: / /

Directions: For questions 1 through 11, please circle the number that best describes how you did overall for the past week. If you don””””””””””””””””””””””””””””””””t normally do something that is asked, cross the question out.

Always Most Occasionally Never

Were you able to :

1. Do shopping? …………………………………………… 0 1 2 3

2. Do laundry with a washer and dryer? …….. 0 1 2 3

3. Prepare meals? ………………………………….. 0 1 2 3

4. Wash dishes/cooking utensils by hand?….. 0 1 2 3

5. Vacuum a rug?……………………………………. 0 1 2 3

6. Make beds? ……………………………………….. 0 1 2 3

7. Walk several blocks? ………………………….. 0 1 2 3

8. Visit friends or relatives? ……………………… 0 1 2 3

9. Do yard work?…………………………………….. 0 1 2 3

10. Drive a car? ……………………………………….. 0 1 2 3

11. Climb stairs? ……………………………………… 0 1 2 3

12. Of the 7 days in the past week, how many days did you feel good?
0 1 2 3 4 5 6 7
13. How many days last week did you miss work, including housework, because of fibromyalgia?
0 1 2 3 4 5 6 7

FIBROMYALGIA IMPACT QUESTIONNAIRE (FIQ) – page 2

Directions: For the remaining items, mark the point on the line that best indicates how you felt overall for the past week.

14. When you worked, how much did pain or other symptoms of your fibromyalgia interfere with your ability to do your work, including housework?