60 M A S S A G E & B O DY WO R K • F E B R U A RY / M A R C H 2 0 0 6

Fibromyalgia…

Fact or Fic on

B y E r i k D a l t o n

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Fibromyalgia syndrome (FMS)is a widespread muscu-loskeletal pain and fatigue

disorder for which the cause isstill unknown. Ongoing investiga-tions continue as medical andmanual therapy offices are floodedwith increasing numbers ofreported fibromyalgia cases but,like the oft-quoted analogy of theblind man and the elephant, wecurrently know more about thecomponents of FMS than weknow about the “beast” as awhole. Now that rheumatologistshave granted legitimacy by label-ing and classifying this vague andcontroversial syndrome currentbeliefs regarding possible originsmust be discussed.

Fibromyalgia primarily manifestsas pain in muscles, ligaments andtendons — the fibrous tissues inthe body. FMS was originallytermed fibrositis, implying thepresence of muscle inflammation,but contemporary research provedthat inflammation did not exist.Some in the complementary med-ical community believe thatfibromyalgia should be a primaryconsideration in any client/patientpresenting with musculoskeletalpain that is unrelated to a clearlydefined anatomic lesion.Conversely, many researchers ques-tion the very existence of the syn-drome since fibromyalgia suffererstypically test normal on laboratoryand radiologic exams.

For more than a century, medicalscience has continued to move for-ward in its ability to recognize, cat-egorize, and name painful patientdisorders. Technological advanceshave made it much easier for med-ical doctors to rule out specific mal-adies from a variety of symptomspresented in the clinical setting.Additionally, modern testing meth-ods have allowed researchers tobecome more confident in theirability to determine what is andwhat is not a disorder or disease.However, this newfound confi-dence has created controversy

and debate over some disorders,which cannot be universallyproven, even though the symptomsare undeniable.

In recent years, many commondiseases have been named andtreatments discovered. This appliesto mental health as well as physio-logical disorders. Today’s societyseems to be more open now thanever before to the possibility that

there exists mental and physicaldysfunctions not yet recognizablethrough medical testing, but realjust the same.

Part of this acceptance comesfrom mankind’s history of diseasediscoveries. It was not so long agothat people with epilepsy werebelieved to be possessed by thedevil. Today, it is an accepted dis-order with known biological caus-es and medical treatment options.The historical fact that symptoms,dysfunctions, and diseases oftenappear long before researchers areable to devise reliable diagnostictesting procedures to identify andtreat the malady makes it appearunreasonable that the existence ofthe condition would be doubted ordebated … but this is the casewith fibromyalgia.

Psychosomatic orPhysiologic

Fibromyalgia has come underfire in many circles including

medical, psychological, and manu-al therapy. There are two campsfirmly divided on their beliefs as

to the cause and treatment of thedisorder while a third group ofresearchers and medical practi-tioners reject the existence offibromyalgia altogether.1

Simply put, one camp believesthat FMS is a mental health issuewithout a biological origin.Whereas, the other camp is firmlyconvinced that it is a physiologicaldisorder even though researchers

have yet to identify definitive diag-nostic criteria. While each sidesquabbles over the fibromyalgiaconundrum, thousands ofAmericans each year suffer diverseand sometimes disabling symptomswith little help coming from themedical and insurance industry.

Meantime, the debate as to thetrue reality of the disorder carrieson as scientific evidence continuesto accumulate in favor of thephysiological aspect of fibromyal-gia. Currently, traditional andcomplementary medicine successrates in treating the disorderpoints to the fact that it is prima-rily a physiological condition withbiological origins.

In the face of the debate as to theorigin of disorder, the AmericanCollege of Rheumatology compriseda list of criteria for the purpose ofclassifying fibromyalgia. The listincludes classic symptoms such ashaving a history of widespread painfor more than three previousmonths. The college went on todefine a series of 18 checkpoints(tender points) for the pain sites

Today’s society seems to be more

open now than ever before to the

possibility that there exists mental

and physical dysfunctions not yet

recognizable through medical

testing, but real just the same.

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(See Figure 1). A client is required tohave pain in 11 or more of the 18sites to be considered a true case offibromyalgia.2 Since the symptomsare relatively simple to recognize,why the continued debate? Part ofthe trouble lies in the fact that thesymptoms are sometimes vague andreminiscent of other musculoskeletalcomplaints.

Confusing Symptoms

From the massage therapist’s officeto the traditional medical facility,

clients/patients are presenting inincreasing numbers with a variety ofunexplained symptoms. However,there are definitely some sharedsymptom commonalities such as pre-dictable tender points, extremefatigue, poor sleeping patterns, andwhole-body pain upon awakening.Regrettably, musculoskeletal painresearch generally lags behind well-funded scientific projects with possi-bilities for more lucrative outcomes.It often takes years to definitivelyconfirm and classify conditionswith vague, widespreadsymptoms like fibromyal-gia. This confusing dis-order continues to bepoorly understood,and clients oftensuffer for severalyears before amedical diagno-sis is made.Figure 2 illus-trates an inter-esting biologicalexplanationdetailing thedownward degener-ative spiral seen inmany fibromyalgiaclients.

Fibromyalgic symptomshave been described as steady,radiating, burning, and spread-ing over large areas of the body.The pain often involves theneck, shoulders, back, andpelvic girdle. Clients report thatpain seems to emanate specifically from muscles, ten-dons, ligaments, bursa, and joints. Most identify pain astheir cardinal symptom. Fibromyalgia pain appears toworsen with cold temperatures, increased humidity,

weather changes,overexertion, andstress. Many clientsreport symptomaticpain reduction with

hot baths, heatingpads, and warm

weather.Fatigue and lethargy

are also on the following listof symptoms (see page 64) for

the disorder. Clients commonlycomplain of feeling extremelyfatigued and unable to muster theenergy to do the things that theyneed to get done. This can entail alack of energy for cleaning house,getting to work, performing at

work, participating in social outings, etc. Poor sleepingpatterns are another classic symptom of the disorder.Many report that they wake several times each night andoften have a difficult time returning to sleep.3

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Figure 1— American College ofRheumatology’s tender point list for

classifying fibromyalgia. Clientsare required to have pain in 11

or more of the 18 sites to beconsidered a true

fibromyalgic case. Adaptedfrom John W. Karapelou, withpermission, 2000.

Figure 2 — Biological cellular breakdowndiagram details the downward degenerativespiral seen in many fibromyalgia clients.

�

Irritable bowel syndrome (IBS) is another commonality thatfibromyalgia clients tend to share. It is interesting that IBS is anaccepted medical disease eventhough there is no concrete medicalproof of its origin or existence. YetIBS is widely accepted by the fieldof medicine while fibromyalgia isstill under scrutiny. The reducedability to concentrate as well as fre-quent bouts of depression also topsthe fibromyalgia symptom list.

Physical Examination

Careful examination revealsareas of pain on palpation but

without the classic inflammatorysigns of redness, swelling, and heatin the joints and soft tissues. Skillin palpating tender points is criticalto establishing a correct assessmentfor fibromyalgia. Physical findingsencountered during soft-tissue pal-pation include tender points,increased resting muscle tension,and tissue texture changes in theskin and subcutaneous fascia.

When assessing the possibilitiesof fibromyalgia, it is important thatother potential conditions be ruledout as well. The symptoms maymimic dysfunctions such asmyofascial pain syndrome, periph-eral neurogenic pain, medicinal tox-icity, and some types of arthritis.Therefore, when presented with thepossibility of a true fibromyalgiacase, detailed assessment and histo-ry intake are of utmost importance.Since the most significant area of

pain tends to shift over time, thefirst step in assessing truefibromyalgia is to determine if simi-lar functional/structural disordersare at play.

Myofascial Pain orFibromyalgia

Myofascial pain syndrome(MPS) emanating from

hyperirritable trigger points isoften confused with fibromyalgia.To complicate the situation, MPSmay occur in clients sufferingwith fibromyalgia. However, acarefully conducted history intakeand physical examination usuallyhelps the therapist determine ifthe client is presenting withfibromyalgic symptoms, MPS, orboth. While fibromyalgia pain iswidespread with changing areas ofemphasis, myofascial tenderpoints are typically restricted toone spot, though the point mayrefer pain to other areas.

Contrary to popular belief, manyin the medical field do not believeMPS symptoms arise from taughtmyofascial trigger point bands, butinstead from peripheral nerve painat motor end plates.4 Much of theneurological literature today doesnot include the trigger point tautband theory as a recognizedanatomical cause of entrapmentneuropathy. Since the connectivetissues of human peripheral nervesare well-innervated, someresearchers believe peripheral nervepain (aching, tingling, and numb-ing) best describes the symptomsoccurring in many myofascial painsyndrome cases. MPS is said toresult from hyperexcited chemore-ceptors activated by inflamed, dis-organized nerve ending bundles.

Regardless of the outcome of themyofascial pain syndrome debate,the disorder still should be easy toidentify during the evaluationprocess since the client’s pain willbe limited to a particular region(over time), often eliciting a referralpattern when digital pressure isapplied. Although location does lit-tle to distinguish between MPS andfibromyalgic tender points (sincethey often occur in similar bodyareas), specific hands-on assess-ments help to clearly differentiatebetween myofascial pain andfibromyalgia (See Figure 3).

The Psychologic DebateGoes On

As is the case with many disor-ders, fibromyalgia is attracted

to one gender more than another.This agonizing condition is morepervasive in women with the mostcommon onset between 25 and 50years of age. Estimates of preva-lence are 3.4 percent for womenand 0.5 percent for men.5 It is esti-mated that 20 percent of the femalepopulation will end up in arheumatologists’ office.

Women suffering fibromyalgiaoften report high levels of stress intheir daily lives, which also con-tributes to the idea that it may haveroots as a mental health disorder

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Figure 3 — Therapist palpates suboc-cipital tender points with client sittingand standing to determine if pain isreduced while sitting. Pain reductionin seated position indicates possiblepelvic imbalances initiating themyofascial/neurologic pain syndrome.Fibromyalgia tender points shouldremain unchanged in both the stand-ing and sitting positions.

Commonly AssociatedSymptoms of Fibromyalgia

� Chronic headaches� Cognitive or memory impairment� Dizziness or light headedness� Fatigue� Irritable bowel syndrome� Jaw pain� Muscle pain or morning stiffness � Painful menstruation � Skin and chemical sensitivities� Sleep disorders

�

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and not completely physiological innature. Because the brain’s emo-tional center (limbic system) is thehighest cortical level regulatingmuscle tone, any alteration in lim-bic function may precipitatemyofascial pain patterns.

Psychologic disorders have been,and continue to be, researched todetermine if a relationship existswith fibromyalgia. The disordersof depression, somatization, panic,and obsessive-compulsive behaviorhave been seen in some fibromyal-gia clients. Depression occurs inabout 20 percent of clients andmay be the result of having to livewith chronic pain. The debate is based on the beliefthat some think fibromyalgia isactually a mental health issue.There are those who believe it to bea subconscious attempt to avoid thestresses of daily life and work.Currently there is not a knownphysiological explanation for thewidespread array of symptoms com-mon to all sufferers of the disorder.

It is because of the lackof a generally acceptedphysiologically-basedexplanation that it isoften suggested to be amental rather than aphysical disorder. Fibromyalgic symp-toms could also becaused by mental mal-functioning accordingto those who do notbelieve it has a physio-logical basis. Over half ofthose diagnosed with thecondition have a pasthistory of other ail-ments, which also haveno medical proof of exis-tence including chronic fatigue syn-drome, irritable bowel syndrome,and chronic headaches.6 It is thisdilemma that causes some expertsto reject a medical origin and pointto mental health networks foranswers to the problem.

The confusion with the mentalhealth suggestion is that it does not

explain certain physical changesthat take place in patients withfibromyalgia. Certain organic aber-rations have been found in peoplewith fibromyalgia, although it is notyet known whether these camebefore or after the syndrome devel-oped. Among them are changes innervous system chemicals that mayexplain the common problem ofdisturbed sleep. Fibromyalgiapatients typically lack restorative orslow-wave (theta and delta) sleep,which can result in chronic fatigueand heightened sensitivity.

Researchers have found levels ofsubstance P, a chemical related topain, and some abnormal pain-related peptides to be excessivelyhigh in the cerebrospinal fluid offibromyalgia patients.7 Heightenedlevels usually mean the person per-ceives more pain. In a study report-ed in the Journal of Rheumatology,Muhammad Yunus, M.D., andassociates, discovered that peoplewith fibromyalgia actually haddiminished blood flow — meaningless functional activity in two areasof the brain that help regulate theamount of pain signals the brainreceives.8 This study supports theauthor’s belief that poor upper cer-vical alignment from forward headpostures may be a contributingstructural factor to fibromyalgia.Poor occipitoatlantal (O-A) andatlantoaxial (A-A) alignment cancompromise (occlude) vertebral and

Careful What You Say

Massage and other bodywork therapists should be cautious when assessing,speculating and particularly labeling perceived causes contributing to a

client’s neck and back pain — i.e., work-related accidents, specific diseases oroveruse syndromes (fibromyalgia, degenerative disc disease, sciatica, etc.).A goodhistory with helpful notes can be recorded without verbally labeling our individualthoughts about the client’s condition.

Very few states grant massage therapists the legal authority to label (i.e., diag-nosis).And for good reason — most lack the diagnostic ability or testing equip-ment to properly label a client’s acute or chronic condition beyond dispute. Inaddition, verbally attributing musculoskeletal pain conditions to specific causes cancreate inappropriate fears, anxieties, or avoidant behavior in clients.

Noted pain specialist Dennis Turk, Ph.D., believes that “since fear is a naturalconsequence of pain, pain-related anxiety and fear may actually accentuate thepain experience in many chronic pain cases.”1 If clients with pain are exposed tofearful situations, they typically respond with either unnecessary worry orescapist behavior to avoid any anticipated harm.

Avoidant behavior can sometimes be useful in the context of acute pain butloses beneficial quality in clients suffering chronic pain disorders such asfibromyalgia. Reliance on the acute model of pain in cases of chronic pain is ofteninappropriate. For example, leading the client to believe that activity might aggra-vate the disorder and cause more harm can result in fear of engaging in rehabili-tative efforts.This can lead to obsessive mental preoccupation with bodily symp-toms and physical deconditioning that only exacerbate the pain, thus causing theclient to maintain the disability.

Reference1 Turk, D. The Spine Journal 2004 16(3):185–187.

Figure 4 — The vertebral artery is vulnerableduring head on neck extension and rotationalmovements as it is compressed against the posterior arch of the atlas. Poor occipitoatlantaland atlantoaxial alignment from forward headpostures and stomach sleeping compromisesblood flow to posterior and mid-cranial regions.Adapted from Blaussen Medical, with permission, 2002.

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basilar artery output to posteriorand mid-cranial regions, robbingthe brain of vital nutrients, espe-cially oxygen (See Figure 4).

Treatment Options

Because the symptoms offibromyalgia wax and wane,

treatment (as with that of otherchronic diseases) should be con-sidered an ongoing process ratherthan management of a singleepisode. Flare-ups often exacer-bate the client’s underlying stress.Furthermore, stress can also pre-cipitate flare-ups of fibromyalgia.

The first line of defense forrelieving basic fibromyalgic symp-toms should be body therapy andexercise. Although pain from thiscondition primarily manifests inspecifically designated areas, thetrained manual therapist refrainsfrom “chasing the pain” andinstead, seeks to restore whole bodyfunction by testing for ART: asym-metry; restriction of motion; andtissue texture abnormality.

Postural evaluations usingVladimir Janda, M.D.’s Upper andLower Crossed Syndromes (seeFigure 5) have proven extremelybeneficial in identifying asymmet-rical muscle imbalance patternsthat exasperate fibromyalgic symp-toms. Specific hands-on techniquesthat lengthen tight, neurologicallyfacilitated muscles and tonifyweak, inhibited muscles helpsrestore balance and symmetrywhile fighting off the compressiveforces of gravity.

Tissue texture abnormalities mustbe closely evaluated in clients pre-senting with fibromyalgic symp-toms. Boggy, leathery, fibrotic, con-tractured, and spasmodic tissues arepotential pain generators, with eachrequiring a uniquely differenthands-on approach. Post-isometricrelaxation routines such as thosedemonstrated in Figures 6 and 7prove very beneficial in recoveringlost range of motion to fibrotic spinerelated tissues such as joint cap-sules, ligaments, and paravertebralmyofascia. Any deep tissue tech-nique that calms central nervous

system hyperactivity and lowerssympathetic tone will greatly benefitthose with fibromyalgia.

While it is tempting for the clientto relax and not move joints andmuscles that are hurting, movingthem is one of the best preventiveand curative measures found so farto alleviate the painful symptoms.Traditional massage techniques arehelpful in desensitizing hyperexcit-ed cutaneous (skin and fascial)

neuroreceptors. However, deep-tis-sue techniques that incorporateactive client movements(enhancers) during the hands-onwork add additional therapeuticpower by calming pain generatingarticular (joint) receptors. Intrinsicmuscles and joints are inseparable;what affects one always affects theother. Therefore, a more holisticapproach to treating fibromyalgiaand myofascial pain syndromes

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Figure 5 — Tender point therapy must be accompanied by postural correc-tions using Vladimir Janda’s unique muscle-balancing formula. Following pos-tural evaluation, specific deep tissue, assisted stretching, and myoskeletal rou-tines help restore symmetry, strength, and pain-free range of motion.

should include soft-tissue tech-niques that create extensibility incontractured tissues; tonify weakmuscles; and decompress impacted,motion-restricted joints and theirsupporting ligaments.

Exercise … gooood!

Incrementally, the more exerciseclients are able to do, the better

they will feel. It doesn’t matterwhat kind of aerobic exercise —swimming, biking, jogging, walk-ing, dancing — as long as they hittheir target heart rate for at least 30minutes a day. Some clients reportfeeling better as they graduallyincrease their exercise programs to30 minutes twice a day.

Why do clients sufferingfibromyalgia improve with vigorousexercise? One notion suggested isthat aerobic exercise beefs up thebody’s supply of endorphins, a nat-ural pain-dampening and sleep-deepening substance. Exerciseincreases levels of serotonin and

growth hormones, theexact pain-reducing, mus-cle-repair hormones thatpeople with fibromyalgiamay lack. Exercise alsoincreases blood flow to themuscles. It is well-docu-mented that people withfibromyalgia do have slight-ly less blood flow to theirmuscles, which might alsocontribute to pain. Exerciseand bodywork together areoften just the answer forhelping reverse this oftendebilitating condition.

***Fibromyalgia is a disor-

der with no widely accept-ed medical proof. It is achronic condition charac-terized by symptoms ofwidespread pain and tenderpoints as well as fatigue,depression, and sleep disor-ders. While scientists at thepresent time have found no

generally acceptedway to medicallydocument the exis-tence of fibromyal-gia, it has beenproven that there arephysiological changespresent in many whohave the disorder. Thedebate will continue torage as to its origin andexistence. Some insist thatit is a medical conditionwhile others are con-vinced that it is a mentalhealth issue. Meantime, asthe research rolls in andthe truth is eventuallydecided, it is in theclient’s best interest toimmediately begin rou-

tinely scheduled bodyworksessions in conjunction witha specialized exercise regimeregardless of origin. Well-structured manual therapysessions and individualizedrehabilitation programsappear to be the treatment ofchoice for this chronic and

sometimes disabling condition thataffects an estimated 2 millionAmericans each year.

Erik Dalton, Ph.D., Certified AdvancedRolfer founded the Freedom From PainInstitute and created Myoskeletal AlignmentTechniques to share his passion for massage,Rolfing, and manipulative osteopathy. Visitwww.erikdalton.com for workshop, book, andvideo information.

References1 Quinter, J., Cohen, M. Fibromyalgia falls foul of a fallacy.

Lancet 1999; 353:1092–1094.2 Sinclair, J.D.,Turk, D.C., Okifuji,A., et al. Interdisciplinary

treatment for fibromyalgia: treatment outcome and 6month follow-up. Arthritis Rheumatism 1996;39(9):S91.

3 Sprott, H., Franke, S., Kluge, H., et al. Pain treatment offibromyalgia by acupuncture. Arthritis Rheumatism1996;39(9):S91.

4 Devor, M., Rappaport, Z.H. Pain and pathophysiology ofdamaged nerve. In Fields, H.L., ed. Pain Syndromes inNeurology. Oxford: Butterworth Heinemann; 1990:47–83.

5 Goldenberg, D.L. Fibromyalgia syndrome a decade later:what have we learned? Archives of Internal Medicine 1999;159:777–85.

6 Perlmutter, Cathy.The truth about fibromyalgia.Musculoskeletal disorder. Prevention 1997 April 1;Vol. 49(86):8.

7 Wilke,W.Treatment of resistant fibromyalgia. RheumaticDisease Clinic of North America 1995 Feb 21;21(1),247–60.

8 Yunus, Muhammad B.Towards a model of pathophysiologyof fibromyalgia.Aberrant central pain mechanisms withperipheral modulation. The Journal of Rheumatology. 199231:2464–7.

M&B

Figure 6 — The “windshield wiper” tech-nique is a perfect post-isometric relaxationmaneuver for improving posture by bringingparavertebral fascia back toward the mid-line in hyperkyphotic clients.With handfirmly planted on the therapy table, thera-pist hooks the erector fascia.The clientinhales and pulls up on the therapy table toa count of five and relaxes. A broad power-ful fascial sweep brings the tissue mediallyto create thoracic extension.

Figure 7 — Therapist hooks the deep cervicalfascia, spinal ligaments, and joint capsules asthe client inhales and attempts left headrotation against the therapist’s resistance.Upon exhalation, the therapist releasesfibrotic tissues by pulling with right handwhile stabilizing with his left.Three to fiverepetitions calms the central nervous systemand lowers sympathetic tone.

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