Case study

Her business survives but she has had to employ one full-time and one part-time person to handle the 95% of the work she can no longer do, and in order to achieve this she has had to sacrifice almost all the profit from the venture and undertake debts with the bank which she is having difficulty servicing. She is fearful that she will lose everything. Her GP is sympathetic but feels unable to assist beyond offering low dosage antidepressants (which did not help at all but dulled her faculties even more and which she has now stopped) and pain-killing prescriptions (which do not help more than marginally).

Jenny was referred to a Consultant Rheumatologist at the local hospital who diagnosed fibromyalgia syndrome (FMS) some 18 months ago. She was then referred to a pain clinic at the hospital where she was given 10 sessions of electro-acupuncture,

which provided short-term relief of the neck symptoms but not to any of her other symptoms or general pain. She reports that she became very tearful during acupuncture treatment. She was subsequently offered a neck support which she uses at times when she feels she cannot sustain the weight of her head. She was also advised to 'learn to live with the problem'.

Jenny has no allergy history; her periods are, and always have been, normal, and her diet is balanced. She developed thrush after the accident which lasted for some 6 months, having been treated with antifungal medication by her GP.

Her attitude is determined but despairing, as her marginal degree of progress to date is so slow. She presents as a tense, intense individual, making a heroic effort to concentrate on what she is saying and what is

being said. She talks slowly and deliberately, weighing each word before speaking. Her shoulders are held high and tense, in a posture of anxiety, or defence. Her breathing is very much in the upper chest.

The clinical perspective exercise this month will pose the following questions, of different health care providers (an osteopath/naturopath; a chiropractor; a psychologist expert in cognitive behaviour therapy and a massage therapist). What would your approach be to this case if Jenny consulted you? What tests or evaluations would you want, and for what reason, and depending upon the results and evidence obtained, what treatment might be offered, with what expectations? What manual approaches (if any) would you consider appropriate, with what objective and what anticipated outcome?

Fibromyalgia: osteopathic- naturopathic approach L. Chaitow

In the case of Jenny there seems to have been a specific traumatic incident that triggered the start of her symptoms, having enjoyed 'perfect' health prior to the whiplash incident. However, over the years during which

Leon Chaitow ND DO

c/o Centre for Community Care and Primary Health,

University of Westminster, 115 New Cavendish Street,

London WIM 8JS, UK

Correspondence to: L. Chaitow

Tel: +44 171 224 4220; Fax: +44 171 486 1241

Received May 1998

Accepted June 1998

Journal of Bodywork end Movement Therapies (1998) 2(4), 195-199 © Harcourt Brace & Co. Ltd 1998

her health has declined a variety of associated symptoms have emerged, and a strategy is needed to evaluate which of these can be modified or eliminated, while trying to understand what mechanisms might be maintaining her symptom picture (Goldstein 1996).

Where a condition (such as fibromyalgia syndrome (FMS) or chronic fatigue syndrome (CFS)) involves multiple interacting features it makes clinical sense to try to reduce the burden of whatever factors are imposing themselves on the defence, immune and repair mechanisms of the body. At the same time, it is important to do all that is possible to enhance immune and repair functions without creating excessive demands on a

patient's adaptive capacity and current vitality (Figs 1 and 2). It is therefore vital to:

• Get the diagnosis right. Many rheumatic-type problems produce widespread muscular pain, e.g. polymyalgia rheumatica. Laboratory and other tests can identify most non-FMS conditions and these should be eliminated from the picture (Yunus 1989) (Fig. 3).

• Carefully evaluate Jenny's neck and cranial status to see whether the whiplash has left any residual and treatable dysfunctional patterns (Buskilla 1997).

• Identify associated myofascial trigger-point activity and treat these

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Chaitow

Allergic and autoimmune conditions

Neural and/or limbic !ii system malfunction l i ~ .

Infections - bacterial - fungal - viral - parasitic etc

Possible nutrient deficiencies - vitamins - minerals - EFA's I

Acquired toxicity - pesticides etc - heavy metals - petrochemicals - self-generated - via infection - i a t e r o g e n i c

influences etc

Lifestyle factors - poor sleep patterns - inadequate or excessive exercise - alcohol, tobacco usage - social and medical drugs - poor food choices

Emotional distress - personality traits - powerlessness - anxiety - depression - i n t e r p e r s o n a l issues

Genetically inherited tendencies - hypermobility - genetic inscription influences

on hormonal function

Bowel dysbiosis Organ dysfunction (liver, kidneys) etc Endocrine imbalance

Multiple current symptoms: pain, fatigue, insomnia, IBS, digestive, allergic, recurrent infections, genito-urinary etc

Functional problems - hyperventilation - digestive enzyme

deficit etc

Trauma - physical +/or psychological

Fig. 1 Fibromyalgia in context - the multiple stressors.

appropriately, possibly incorporating aspects of bodywork, analgesic injection (xylocaine etc.), acupuncture, nutrition, hydrotherapy, postural and/or breathing re-education, relaxation methods etc. (Sandford Kiser 1983; Travell & Simon 1983, Deluze et al 1992, Baldry 1993). Provide appropriate soft-tissue manipulative treatment plus teaching gentle self-help methods (Box 1)(Rubin etal 1990, Jimenez et al 1993, Stoltz 1993). Assess and treat (or refer elsewhere) associated conditions such as

allergy, anxiety, hyperventilation, yeast or viral activity, bowel dysfunction, underactive thyroid, sleep disturbance, depression etc. (Holti 1966, Joly 1991, Paganelli 1991, Moldofsky 1993, Timmons 1994, Clauw 1995, Lowe 1995, Tuncer 1997).

* Gradually, and in consultation with * Jenny, introduce constitutional ('whole body') health enhancement methods such as: breathing retraining, deep relaxation methods (e.g. autogenic training), graduated exercise programmes, regular (weekly or fortnightly)

detoxification (fasting) days, hydrotherapy for anxiety/pain and, perhaps, progressive cold bathing for circulation, plus regular non- specific massage and acupuncture for 'energy balancing' and pain control (Ferraccioli 1989, Barelli & 1994, Bland 1995). Offer appropriate nutritional advice (herbs and supplements), relying on those for that have a research-based validity (magnesium, malic acid, manganese glycinate, methionine, N-acetyl cysteine (NAC), vitamin B 1 (thiamine), DLPA etc) as well as amino acids for growth hormone

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The interacting influences of a biochemical, biomechanical and psychosocial nature do not produce single changes. For example:

- - a negative emotional state (e.g. depression) produces specific biochemical changes, impairs immune function and leads to altered muscle tone

- - hyperventilation modifies blood acidity, alters neural reporting (initially hyper and then hypo), creates feelings of anxiety/apprehension and directly impacts on the structural components of the thoracic and cervical region - muscles and joints

- - altered chemistry affects mood; altered mood changes blood chemistry; altered structure (posture for example) modifies function and therefore impacts on chemistry (e.g. liver function) and potentially on mood

- - w i t h i n these categories - biochemical, biomechanical and psychosociat- are to be found most major influences on health.

Fig. 2 Three major categories of health influence interacting with the individual's unique inherited and acquired characteristics defence, repair, immune function (homeostasis).

production enhancement (arginine, ornithine). Specific herbal help to enhance circulation to the brain (e.g. Ginkgo biloba) may be useful since studies show circulatory deficit in the brain stem which may be aetiological. Other herbal products can be used for their pain reducing properties (e.g. Boswellia) or for relaxation properties (kava kava, valerian etc). One homeopathic remedy (Rhus tox 6C) has been shown to be useful in

FMS (Fisher et al 1989, Jacobsen 1991, Yunus et al 1992, Kacera 1993, Sahley 1996). Advise on regular exercise within tolerance - if possible including cardiovascular training and stretching movements (yoga and/or T'ai chi) (M'Cain et al 1988). Possibly, if herbal and nutritional methods fail to achieve the desired result, suggest medication - under medical supervision - to enhance sleep. In this respect, antidepressant

drugs (very low dosage) may offer short-term benefit (Goldenberg 1986, Hudson 1996).

- Encourage Jenny to join support groups, to read about the condition and health enhancement; and to take control of the condition even if progress is apparently slow.

• Suggest stress, or general, counselling or behaviour modification approaches which may help in the learning of coping skills and lead to stress reduction (Goldenberg 1991, Fry 1993, Waylonis 1994, Yunus 1994).

Recovery from FMS is slow at best and it is easy to make matters worse by over-enthusiastic and inappropriate interventions, or by introducing too many quite appropriate changes too rapidly. Patience is required by both the health care provider and the patient, avoiding raising false hopes while realistic therapeutic and educational methods are used that do not make matters worse and that offer ease and the best chance of improvement.

I would anticipate that a broad, and slowly unfolding, approach such as that outlined above would lead to progress, albeit slowly. Jenny could come to understand her condition better and, as her associated symptoms modified (allergy, irritable bowel, fatigue) and as her pain became something she could do something about herself (self-help positional release methods for example) (Fig. 4), her functioning would improve; something approaching normal life could resume. This progression, however, would almost certainly be erratic, with set-backs when inevitable life stresses or infections once more overloaded her adaptive capacity.

Within the framework of such a programme the bodywork component should be seen to be supportive, and not primary, since FMS is not primarily a musculoskeletal problem, but one in which, while the major pain symptoms manifest in the muscles, the

JOURNAL OF BODYWORK AND MOVEMENT THERAPIES OCTOBER 1998

Chaitow

/

!j ~i / /

/ ) _.;_.,.,

\

~I'. ;J I °" ....................... !

................... .4 / ~ I

.......... } :: ~ " i /:' iI ! /

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Fig. 3 The 18 bilateral tender point sites used in establishing a fibromyalgia diagnosis. Eleven of the 18 need to be reported as painful on application of 4 kg pressure (see Box 1).

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Fig. 4 Strain/counterstrain self-treatment of a tender point in the 2nd costal interspace. Patient applies sufficient pressure to cause discomfort and then positions head, neck, trunk until pain in tender point reduces by at least 70%. This is held for up to 90 seconds to enhance circulation and reduce pain.

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cause lies deeper in the body chemistry and psyche.

This is an ideal condition for collaborative inter-professional dialogue and cooperation.

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