Fibromyalgia is a soft tissue syndrome (1), which is classified by the following experience:
The underlying concept of FMS is that the autonomic nervous system, which is responsible for the ‘rest, read and relax’ response, is dysfunctional. This means ineffective pain modulation/inhibition occurs resulting in continuous overactivation of the systemic nervous system (the flight, fright or fight response). The ultimate result of this distortion is the widespread sensation of pain with a decreased tolerance to sensory input. If this isn’t enough to deal with, the immune system in turn is heightened resulting in an increase in systemic cytokines causing excess glial cells and widespread inflammation.
In a nutshell, FMS is a deregulation of neurologic, immunologic, endocrinological and enteric systems. Here is a summary of the most common reports of symptoms in FMS patients.
|Muscle pain/tender points||99|
|Mental and physical fatigue||85|
|Morning Stiffness persisting >30mins||75|
|Cognitive and Memory Problems||71|
|Irritable Bowel Syndrome||70|
|Dry eyes and mouth||63|
(Table taken from www.physiopedia.com.au)
Fibromyalgia or FMS (fibromyalgia syndrome) is a complex syndrome, which requires many facets to be addressed in pain management. Classically FMS tends to be seen more in women.
We are unsure of what is the underlying cause of FMS. Some believe it is an autoimmune disease triggered by the environment such as stress, illness or trauma. We also know that these can also exacerbate pain and cause ‘flare ups’.
Unfortunately there is no solid diagnosis for FMS and apart from testing pressure points around the body, and so diagnosis is generally made of symptoms and history ruling out other causes of pain such as rheumatoid arthritis. This generates some assumptions that the syndrome does not really exist, which can pose problems for the patient.
WHAT IS THE BEST EVIDENCE FOR MANAGEMENT (1)
Sadly, our biggest problem is many Practitioners do not believe that FMS exists. This means patients can be mismanaged, especially if scans or MRI’s show signs such as disc bulges or osteoarthritis. They will often treat the signs and not the underlying cause of pain, which may just be related to flare ups of FMS. In physical therapy, including Chiropractic, any passive care can bring short term relief however patients can become dependent on care resulting in poor coping abilities and exacerbation of symptoms.
Here is a table to summarise the best evidence for care:
|MEDICAL||· NSAIDS and analgesia – to reduce inflammation and pain
· Cyclobenzaprine – to improve sleep patterns
· Anti-depressants such as Cymbalta – to reduce pain and improve sleep
· Blood tests to rule out other causes of pain
|PSYCHOLOGICAL||· Self regulation (see below)
· Cognitive Behavioural Therapy
|PHYSICAL||· Therapeutic Massage, Joint Mobilisation (short term pain relief only)
· Exercise: light aerobic exercise with resistance training; hydrotherapy;
SELF-REGULATION? What is this?
In essence, this is where patients learn self-regulating techniques to help them cope with flare-ups. These could be (2):
An interesting study by Hamilton et al (2004) found self-regulation and emotion had a large impact on pain perception. Setting goals that are not dependent on social factors, deemed persons more ‘self sufficient’. For example, if a person’s pain goal was ‘all I want is for someone to believe I have a genuine problem’ or ‘I am looking for a practitioner who will relieve my pain’ then ‘..the stage is set to increase dependency and personal distress’(2). In contrast, those whose goals were set to ‘get on with life despite FMS’ had an improved pain experience with less personal distress.
If you would like more info on self regulation techniques not only for fibromyalgia patients but for any chronic pain patients, Perth has a free service which gives access to a psychiatrist, psychologist and chronic pain based physiotherapist call Black Swan Health based in Joondalup and Osborne Park. If you would like more info, you can see their website: https://www.blackswanhealth.com.au/services/chronic-disease-programs/chronic-pain/
So where does Chiropractic sit in this? By Niki McGuinness
I have many FMS patients at the clinic who come for pain management in the short term. Generally I try and encourage self-care tactics such as home pain management and gentle exercise advice. If we have any concerns with our patients, we refer to their GP for further assessment /management. We are also able to refer patients directly to the free service at Black Swan Health if we believe self-regulation and CBT will be beneficial.
In regards to treating patients with FMS, the ultimate philosophy is ‘ Less is More’. Often spinal manipulation can cause flare-ups and worsen pain for FMS patients and there is limited evidence in its appropriate use in FMS. This is why we only use Activator Method and Dry Needling techniques and this is only to be used in the short term. Once pain is under control we move our ethos to “Active is Best’.
The strongest evidence supporting management is massage and muscle strength training. This is why all our patients with FMS are encouraged to engage in some sort of active care. As we are rehabilitation based Chiropractors, we are able to write a suitable home care program or if patients prefer we can refer you to an appropriate exercise physiologist in your area (3).
If you would like more advice on how to manage your pain when diagnosed with FMS, feel free to contact one of our Chiropractors on 9203 8313 or you can email me directly on firstname.lastname@example.org. We would love to help advise you on the best course of action.