(844) GO-CHIRO info@chiroup.com

On December 26th, 2018, the Journal of Psychiatry and Clinical Neurosciences published a study showing that transcranial magnetic stimulation may provide benefit for fibromyalgia patients. (96) Whew…we can all breath a sigh of relief knowing that our treatment options are no longer limited to the 410 preexisting interventions. (43)

Most evidence-based chiropractors recognize that an abundant number of “solutions” for a singular problem generally indicates that there are no outstanding interventions. So what works and what doesn’t?

The ChiroUp advisory board, with the help of NIH senior staff physiatrist Dr. Jay Shah, has answered that question. We are pleased to publish our 95th protocol, detailing the evidence-based assessment and treatment of fibromyalgia. We invite you to review the protocol and provide your comments and suggestions for improvement.

Introduction

The American College of Rheumatology defines fibromyalgia as “chronic widespread pain and reduced pain thresholds to palpation.” (1) The diffuse symptoms are commonly attributed to central sensitization with enhanced responsiveness to stimuli. (2,78) Fibromyalgia patients perceive pain from noxious stimuli at lower thresholds than healthy patients. (71,72, 78) Offhandedly, the disorder has been termed “irritable everything” due to widespread heightened pain perception.

Etiology

The specific pathophysiology for this hyperexcitability is not well defined. (3) Various speculations implicate the CNS, ANS, PNS, neurotransmitters, endocrine system, immune system, as well as mitochondrial dysfunction, adrenal fatigue, and psychological origins. (3-10,76) Some focus has been placed upon PNS involvement via small fiber pathology. (3-10) Limited, recent electrodiagnostic studies have implicated large nerve involvement after identifying muscle denervation and chronic inflammatory demyelinating polyneuropathy (CIDP). (11)

Fibromyalgia’s origins are generally believed to be psychological and neurologic rather than muscular, as the disease shows no pathologic or biochemical abnormality involving the muscles. (71-75) Cumulative mental or physical trauma is believed to be an etiological trigger and exacerbating factor for the disturbed pain modulation seen in fibromyalgia patients. (71-73) Some experts teach that fibromyalgia is a variant of PTSD wherein the hallucination is nociceptive rather than visual or aural. (68)

Fibromyalgia is the most common diagnosis in patients complaining of widespread chronic pain with fatigue. (19,64) Estimates for the prevalence of the condition vary between 0.2 and 8.0% (12,19,61-63) with fibromyalgia patients accounting for almost 1 in 5 rheumatologic visits. (13,14) Fibromyalgia may strike at any age; though most people are diagnosed midlife, with increasing prevalence thru age. (15) The condition is at least twice as common in women. (15) There appears to be a strong genetic correlation. (77) Obesity is a known risk factor that is proportionately related to the disease’s symptom severity and diminished quality of life. (16) Additional risk factors include repetitive injury, trauma, PTSD, and systemic illness. (15) In more than half of cases, fibromyalgia overlaps with other rheumatologic diseases, particularly lupus, rheumatoid arthritis, and ankylosing spondylitis. (15,17,18,64)

Symptoms

The classic fibromyalgia presentation is a middle age or older adult with chronic neuropathic pain (>3 months), spread fairly diffusely and symmetrically throughout the appendicular and axial skeleton. (3,20,21) The disease can disrupt quality of life, primarily due to its musculoskeletal and psychological impacts.  Musculoskeletal symptoms include muscle, tendon, and joint stiffness with exquisite tenderness to touch. (22,23) Headaches and dizziness commonly accompany the disorder. (23) Gait and balance problems are well-recognized features of fibromyalgia and are likely secondary to pain and muscle weakness; nonetheless increasing the risk of falling. (26,27)

The average VAS pain score for fibromyalgia patients is 5.1+/- 3, and 50% of patients rate their pain as “severe.” (24) Psychological overlay, such as emotional or affective components and catastrophizing, may serve to modulate fibromyalgia pain. (69) Self-perceived pain scores show an inverse relationship to a patient’s education and economic status. (24)

Psychological aspects of the disease are commonly described as “fibro-fog,” consisting of cognitive deficits, lack of concentration, slower processing, memory lapses, fatigue, mood swings, and insomnia. (22,25,28) Sleep disturbances are particularly prevalent in fibromyalgia patients (79,80) Almost three out of four fibromyalgia patients report no consistent sleep pattern. (24) A similar percentage of fibromyalgia patients experience depression (74%) or anxiety (60%) at some point in their lifetime. (23)

Multiple outcome measures exist for tracking fibromyalgia symptoms.  The Health-Related Quality of Life (HRQoL) attempts to measure a disease’s physical and emotional impact. (29) The Widespread Pain Index (WPI) and Fibromyalgia Symptom Severity (FSS) are now combined into a single assessment and are used as the current American College of Rheumatology Diagnostic Criteria for fibromyalgia. (30,31) The new WPI/FSS criteria correctly classify 88% of fibromyalgia patients. (30) Alternately, the Fibromyalgia Rapid Screening Tool (FiRST) self-questionnaire, developed and validated by the French Rheumatic Pain Study Group, shows a reported sensitivity of 90.5% and a specificity of 85.7%. (65)

Download Fibromyalgia Diagnostic Criteria

Clinical Findings

The classic clinic finding for fibromyalgia is diffuse widespread tenderness upon palpation in multiple axial and appendicular sites.  The original 1990 American College of Rheumatology (ACR) classification criteria implicated a diagnosis of fibromyalgia when palpation elicited tenderness over at least 11 of 18 predefined locations. (32) The 1990 ACR criteria had numerous shortcomings and are no longer considered a valid means of diagnosis. (69) The American College of Rheumatology now recommends using the new WPI/FSS assessment, however, unfortunately, many clinicians still rely upon the antiquated criteria. (31,33) 

Clinicians must be mindful to differentiate between fibromyalgia “tender points” vs. “myofascial trigger points” that are associated with myofascial pain syndrome. The name “tender points” is somewhat misleading, as there are no specific “points” associated with fibromyalgia, rather only diffuse tenderness. Any fibromyalgia tender point is palpably indistinguishable from the normal surrounding tissue. (35) In contrast, myofascial trigger points are firm, hard, hyperirritable nodules in a taut band of muscle that are palpable during examination. (21,35,70) True active myofascial trigger points would also show elevated levels of inflammatory biomarkers and would be detectable under ultrasound. (69) Another distinguishing feature is that myofascial pain syndrome patients will experience local or regional pain, sometimes referred, while fibromyalgia patients will be intolerant to pressure most anywhere on their body. (36) Although fibromyalgia and myofascial pain syndrome are distinctly unique diagnoses requiring distinctly unique management, the conditions commonly coincide. (21)    

Other than palpation, there are no additional orthopedic or objective diagnostic tests to rule in fibromyalgia. (38) The patient’s neurologic exam is typically normal. (39) Compensatory musculoskeletal problems frequently develop secondary to pain and balance impairments. (37) One diagnostic key in differentiating fibromyalgia from true mechanical disorders is that physical touch is generally more provocative than movement in fibromyalgia cases.

Differential Diagnosis

Fibromyalgia is a diagnosis of exclusion; however, in a rush to diagnose, clinicians may fail to fulfill the necessary exclusion component. Dr. Jay Shah, senior staff physiatrist and clinical investigator at NIH, commented: “For many years, clinicians mistakenly applied the tender point count and if positive, diagnosed fibromyalgia and therefore stopped investigating other potential causes via a differential diagnosis. Essentially, this was a diagnosis by inclusion rather than exclusion. There are many potential causes of widespread tenderness.” (69)

The mottled clinical presentations of fibromyalgia overlap with a variety of concurrent or alternate disorders including hypothyroidism, anemia, inflammatory arthropathy, Lyme disease, multiple sclerosis, occult malignancy, irritable bowel syndrome, celiac disease, chronic fatigue syndrome, migraine, myofascial pain syndrome, reaction to statins, hypermobility syndrome, parasitic diseases, and adult growth hormone deficiency syndrome. (33,36,38,41,69) Clinicians should screen for psychiatric disorders, particularly depression, which has a significantly higher prevalence in patients with fibromyalgia. (33)

Metabolic and rheumatologic diseases may require lab workup, including CBC, T3, T4, TSH, ESR, CRP, RA factor, and ANA. (42) However, there are no reliable lab or imaging tests specifically for fibromyalgia. (33)

Treatment

The ambiguity of fibromyalgia’s etiology and assessment is mirrored by a lack of a reliable management approach.  A systematic review of fibromyalgia research published from 1997-2017 revealed more than 410 unique interventions for the treatment of fibromyalgia. (43) These abundant solutions to a singular problem indicate that there are no outstanding interventions.  Thus, management of fibromyalgia is palliative with no known cure.  (44)

Initial management should include non-pharmacologic therapies. (81) Patients must take self-responsibility for all aspects of their recovery. (45) Fibromyalgia is perhaps the best example of how patient-centered active interventions are superior to passive strategies. Unfortunately, poor patient compliance is both a precursor to the disorder and a sequelae of inadequate treatment options. The current treatment focus is on proactive patient-directed activity and mind-body interventions. Research provides strong support for aerobic exercise and cognitive behavioral therapy. (46-48)

Fibromyalgia patients should avoid sedentary lifestyles and regularly engage in moderate physical activity at home, work, and leisure. (49,50) Low-impact aerobic training, (i.e., walk, cycle, swim, water aerobics, etc.) is generally the most successful. (87-91) Optimally, patients would work up to three 30-minute aerobic sessions per week at 55-85% of their maximum heart rate. Resistance training of three 60-minute sessions per week has been shown to positively impact quality of life, anxiety, and depression. (44) Due to overactive response to stimuli, fibromyalgia patients should expect some exercise-related soreness and begin with light intensity exercise then progress on a slow, graduated basis. (51,52)

Some chiropractic rehab experts recommend employing graded motor imagery for fibromyalgia patients. (93) The process involves having the patient perform a single biomechanically correct repetition of a pain-free movement (i.e., lunge) and then asking the patient to sit down, close their eyes, and imagine performing ten additional perfect, pain-free repetitions. Graded motor imagery progresses by increasing the variety of movements and repetitions.

Mind-body interventions hold promise and may include cognitive behavioral therapy, tai chi, yoga, meditation, mindfulness, guided imagery, hypnosis, biofeedback, and balneotherapy. (46,47,53,95) Tai chi has demonstrated outcomes superior to aerobic exercise for relieving pain and improving some psychological components of fibromyalgia. (95)

Download Mind Body Best Practices

Formal cognitive behavioral therapy (CBT) entails “talk therapy” with a mental health counselor to encourage hands-on problem solving for catastrophizing or other dysfunctional emotions, behaviors, and thoughts. CBT helps patients become aware of negative thoughts in order to change the way they view challenging situations and respond in a more effective way. For fibromyalgia patients, self-directed, web-based CBT programs (https://www.ecentreclinic.org/?q=PainCourse) may be an effective potential alternative to formal face-to-face therapy sessions. (82)

Patient education is a proven tool for managing fibromyalgia. (23,83,84) Clear explanation of a fibromyalgia diagnosis results in lower utilization for follow-up visits, referrals, diagnostic testing, and medications. (83,85,86) Patients must be reassured that fibromyalgia is a bona fide disease. After more threatening diseases have been ruled out, clinicians should emphasize the benign nature of the disease. Counseling should emphasize self-management and coping strategies while providing techniques to help with the understanding by family, friends, and society. (54) Patients must comprehend that they may continue to lead full and active lives in spite of ongoing waxing and waning symptoms. Clinicians should provide counseling on healthy sleep habits.      

There is sparse and questionable support for hot, cold, whole body cryotherapy, massage, stretching, and shockwave therapy (ESWT). (57-59) There is minimal evidence for the utility of chiropractic spinal manipulation, acupuncture, or dietary supplements in the treatment of fibromyalgia. (46,53,55,56)

A 2015 systematic review found “moderate evidence that myofascial release is beneficial for fibromyalgia symptoms and massage therapy improved the quality of life of fibromyalgia patients.” (94) However, when manual therapy is employed on fibromyalgia patients, clinicians should use a light touch and avoid deep massage or forceful manipulation. (67) Dr. Stephen Perle, Professor of Clinical Sciences and author of multiple published fibromyalgia papers, provides the following advice: Chiropractors should be cautious about using any hands-on treatments with patients who actually have fibromyalgia.  They will likely find it painful and unhelpful.” (68)              

While there are no strongly endorsed nutritional or dietary recommendations, it would seem reasonable to eliminate pro-inflammatory foods and initiate weight control measures in overweight patients. (16) In spite of no conclusive evidence that nutritional supplementation provides benefit for fibromyalgia patients, many clinicians still prescribe from a cornucopia of scantly supported options including 5-HTP, Melatonin, St. John’s Wort, SAM-e, L-carnitine, magnesium, turmeric, B vitamins, Vitamin D, coenzyme Q10, Boswellia, and probiotics.  Clinicians and patients should recognize the possibility of supplement and medication interactions.

The FDA has approved three drugs to treat fibromyalgia: the antidepressants Cymbalta and Savella, plus the anti-seizure medicine Lyrica. (60) Common off-label pharmacologic strategies include alternate anti-depressants, anti-seizures, gabapentin, muscle relaxants, and analgesics, including opioids. (47,60,66) However, “the majority of fibromyalgia patients do not achieve great benefit from any single medication”. (96)

Summary

Fibromyalgia must be viewed as a centrally mediated sensory disorder rather than a physical muscular disease. Patients may be better served by therapies that provide less touch and more talk, i.e., education with exercise and lifestyle counseling. Overambitious manual techniques can delay recovery. Outcomes improve when patients clearly understand the disease, as well as the importance of taking an active role in their own recovery.

For ChiroUp subscribers, this information has already been incorporated into your platform. Once you make the diagnosis, you can rest-assured that you patients are automatically receiving the most appropriate education, exercise, and lifestyle advice – consistent with the current evidence-based standard of care.

Suggestions?

ChiroUp is our profession’s premier knowledge-transfer resource – but only because you and more than 1000 like-minded chiropractors share your real-world best practices.  We welcome your feedback and suggestions for improvement on this or any other protocol. Scroll to the bottom of the page to leave us a comment. 

ChiroUp Empowers

References

1. M. Imamura, D.A. Cassius, F. Fregni, Fibromyalgia: from treatment to rehabilitation, Eur. J. Pain 3 (2009) 117e122.
2. Kindler LL, Bennett RM, Jones KD. Central sensitivity syndromes: mounting pathophysiologic evidence to link fibromyalgia with other common chronic pain disorders. Pain Manag Nurs: Off J Am Soc Pain Manag Nurses 2011;12(1):15–24.
3. Levine TD, Saperstein DS. Routine use of punch biopsy to diagnose small fiber neuropathy in fibromyalgia patients. Clin Rheumatol 2015;34(3):413–7.
4. Koroschetz J, Rehm SE, Gockel U, Brosz M, Freynhagen R, To€lle TR, et al. Fibromyalgia and neuropathic pain differences and similarities. A comparison of 3057 patients with diabetic painful neuropathy and fibromyalgia. BMC Neurol 2011; 11(1):55.
5. Oaklander AL, Herzog ZD, Downs HM, Klein MM. Objective evidence that small- fiber polyneuropathy underlies some illnesses currently labeled as fibromyalgia. Pain 2013;154(11):2310–6.
6. Uceyler N, Zeller D, Kahn AK, Kewenig S, Kittel-Schneider S, Schmid A, et al. Small fibre pathology in patients with fibromyalgia syndrome. Brain 2013;136(Pt 6):1857–67.
7. Doppler K, Rittner HL, Deckart M, Sommer C. Reduced dermal nerve fiber diameter in skin biopsies of patients with fibromyalgia. Pain 2015;156(11):2319–25.
8. Giannoccaro MP, Donadio V, Incensi A, Avoni P, Liguori R. Small nerve fiber involvement in patients referred for fibromyalgia. Muscle Nerve 2014;49(5): 757–9.
9. Kosmidis ML, Koutsogeorgopoulou L, Alexopoulos H, Mamali I, Vlachoyiannopou- los PG, Voulgarelis M, et al. Reduction of Intraepidermal Nerve Fiber Density (IENFD) in the skin biopsies of patients with fibromyalgia: a controlled study. J Neurol Sci 2014;347(12):143–7.
10. Oudejans L, He X, Niesters M, Dahan A, Brines M, van Velzen M. Cornea nerve fiber quantification and construction of phenotypes in patients with fibromyalgia. Sci Rep 2016;6:23573.
11. Caro XJ, Galbraith RG, Winter EF. Evidence of peripheral large nerve involvement in fibromyalgia: a retrospective review of EMG and nerve conduction findings in 55 FM subjects. Eur J Rheumatol 2018; 5: 104-10.
12. Amelia Pasqual Marques, Adriana de Sousa do Espírito Santo, Ana Assumpc ̧ão Berssaneti, Luciana Akemi Matsutani, Susan Lee King Yuan. Prevalence of fibromyalgia: literature review update. Rev Bras Reumatol. 2017;57(4):356–363
13. Marder W et al. The present and future adequacy of rheumatology manpower: A study of health care needs and physician supply. Arthritis Rheum 1991;34:1209-17
14. White KP et al. Fibromyalgia in rheumatology practice. A survey of Canadian rheumatologists. J Rheumatology 1995; 22:722-6
15. CDC Fibromyalgia. https://www.cdc.gov/arthritis/basics/fibromyalgia.htm
16. Rossi A, Di Lollo AC, Guzzo MP, Giacomelli C, Atzeni F, Bazzichi L, Di Franco M. Fibromyalgia and nutrition: what news? Clin Exp Rheumatol. 2015 Jan-Feb;33 (1 Suppl 88):S117-25. Epub 2015 Mar 18.
17. Katz P et al. Performance of the PROMIS 29-item profile in rheumatoid arthritis, osteoarthritis, fibromyalgia, and systemic lupus erythematosus. Arthritis Care Res (Hoboken) 2016 Dec 28 [Epub ahead of print].
18. www.cdc.gov/arthritis/basics/fibromyalgia.htm
19. Alunno A, Carubbi F, Stones S, Gerli R, Giacomelli R, Baraliakos X. The Impact of Fibromyalgia in Spondyloarthritis: From Classification Criteria to Outcome Measures. Front Med (Lausanne). 2018;5:290. Published 2018 Oct 24. doi:10.3389/fmed.2018.00290
20. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33: 160–72
21. E.C. Yap, Myofascial pain: an over view, Ann. Acad. Med. Singap. 36 (2007) 43e48.
22. Bellato E, Marini E, Castoldi F, Barbasetti N, Mattei L, Bonasia DE, et al. Fibromyal- gia syndrome: etiology, pathogenesis, diagnosis, and treatment. Pain Res Treat 2012;2012:426130.
23. Clauw DJ. Fibromyalgia: A clinical review. JAMA 2014; 311:1547.
24. Demirbag BC, Bulut A. Demographic characteristics, clinical findings and functional status in patients with fibromyalgia syndrome. J Pak Med Assoc. 2018 Jul;68(7):1043-1047.
26. Nelson, N.L., 2015. Muscle strengthening activities and fibromyalgia: a review of pain and strength outcomes. J. Bodyw. Mov. Ther. 19:370–376. http://dx.doi.org/10.1016/j. jbmt.2014.08.007.
27. Costa, I. da S., Gamundí, A., Miranda, J.G.V., França, L.G.S., de Santana, C.N., Montoya, P., 2017. Altered functional performance in patients with fibromyalgia. Front. Hum. Neurosci. 11. http://dx.doi.org/10.3389/fnhum.2017.00014.
28. Williams DA, Schilling S. Advances in the assessment of fibromyalgia. Rheum Dis Clin North Am. 2009;35(2):339-57.
29. Blanca Gavilán-Carrera B et al. Association of objectively measured physical activity and sedentary time with health-related quality of life in women with fibromyalgia: The al-Ándalus project. Journal of Sport and Health Science, In press, uncorrected proof, Available online 27 July 2018
30. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. https://deepblue.lib.umich.edu/bitstream/handle/2027.42/75772/20140_ftp.pdf
31. Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity Arthritis Care Res (Hoboken), 62 (2010), pp. 600-610
32. Wolfe F et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee.
Arthritis Rheum. 1990 Feb;33(2):160-72.
33. Goldenberg DL. Diagnosis and differential diagnosis of fibromyalgia. Am J Med. 2009 Dec;122(12 Suppl):S14-21. doi: 10.1016/j.amjmed.2009.09.007.
34. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990. Criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis and Rheumatism. 1990;33(2):160–172
35. Bourgaize S, Newton G, Kumbhare D, Srbely J. A comparison of the clinical manifestation and pathophysiology of myofascial pain syndrome and fibromyalgia: implications for differential diagnosis and management. The Journal of the Canadian Chiropractic Association. 2018;62(1):26-41.
36. Schneider MJ, Brady DM, Perle SM. Commentary: differential diagnosis of fibromyalgia syndrome: proposal of a model and algorithm for patients presenting with the primary symptom of chronic widespread pain. J Manipulative Physiol Ther. 2006 Jul;29(6):493–501.
38. Kia S, Choy E. Update on Treatment Guideline in Fibromyalgia Syndrome with Focus on Pharmacology. Biomedicines. 2017;5(2):20. Published 2017 May 8. doi:10.3390/biomedicines5020020
39. Gilliland BC. Fibromyalgia, arthritis associated with systemic disease, and other arthritides. In: Kasper DL, Harrison TR, editors. Harrison’s Principles of Internal Medicine. 16th edition. Vol. 2. New York, NY, USA: McGraw-Hill, Medical Publication Division; 2005. pp. 2055–2064.
41. Rossi A, Di Lollo AC, Guzzo MP, Giacomelli C, Atzeni F, Bazzichi L, Di Franco M. Fibromyalgia and nutrition: what news? Clin Exp Rheumatol. 2015 Jan-Feb;33(1 Suppl 88):S117-25. Epub 2015 Mar 18.
42. Clauw DJ. Fibromyalgia: an overview. American Journal of Medicine. 2009;122(12, supplement):S3–S13.
43. Bourgaize S et al. Fibromyalgia and myofascial pain syndrome: Two sides of the same coin? A scoping review to determine the lexicon of the current diagnostic criteria. Musculoskeletal Care. 2018 Oct 23. doi: 10.1002/msc.1366. [Epub ahead of print]
44. Andrade A, Sieczkowska SM, Vilarino GT. Resistance training improves quality of life and associated factors in patients with fibromyalgia syndrome. PM&R. Accepted: 13 September 2018 DOI: 10.1016/j.pmrj.2018.09.032
45. Arnold LM, Clauw DJ, Dunegan LJ, Turk DC. A framework for fibromyalgia management for primary care providers. Mayo Clin Proc 2012;87:488–96.
46. Schneider M, Vernon H, Ko G, et al. Chiropractic management of fibromyalgia syndrome: a systematic review of the literature. J Manipulative Physiol Ther. 2009;32(1):25-40.
47. Talotta R, Bazzichi L, Di Franco, Casale R, Batticciotto A, Gerardi MC, Sarzi-Puttini P. One year in review 2017: fibromyalgia. Clin Exp Rheumatol 2017; 35 (Suppl. 105): S6-S12.
48. Kia S, Choy E. Update on Treatment Guideline in Fibromyalgia Syndrome with Focus on Pharmacology. Biomedicines. 2017;5(2):20. Published 2017 May 8. doi:10.3390/biomedicines5020020
49. Withall J, Stathi A, Davis M, Coulson J, Thompson JL, Fox KR. Objective indicators of physical activity and sedentary time and associations with subjective well-being in adults aged 70 and over. Int J Environ Res Public Health. 2014;11(1):643-56. Published 2014 Jan 2. doi:10.3390/ijerph110100643
50. Cerón-Lorente L et al. The influence of balance, physical disability, strength, mechanosensitivity and spinal mobility on physical activity at home, work and leisure time in women with fibromyalgia. Clinical Biomechanics. Accepted: 9 October 2018. doi:10.1016/j.clinbiomech.2018.10.009
51. Schneider MJ, Brady DM, Perle SM. Commentary: differential diagnosis of fibromyalgia syndrome: proposal of a model and algorithm for patients presenting with the primary symptom of chronic widespread pain. J Manipulative Physiol Ther.. 2006 Jul;29(6):493–501.
52. Macfarlane GJ et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017 Feb;76(2):318-328. doi: 10.1136/annrheumdis-2016-209724. Epub 2016 Jul 4.
53. Sarac AJ, Gur A. Complementary and alternative medical therapies in fibromyalgia. Current Pharmaceutical Design. 2006;12(1):47-57.
54. Lempp HK, Hatch SL, Carville SF, Choy EH. Patients’ experiences of living with and receiving treatment for fibromyalgia syndrome: a qualitative study. BMC Musculoskelet Disord 2009;10:124.
55. Langhorst J, Klose P, Musial F, et al. Efficacy of acupuncture in fibromyalgia syndrome—a systematic review with a meta-analysis of controlled clinical trials. Rheumatology. 2010;49(4):778-788.
56. Vas J et al.: Acupuncture for fibromyalgia in primary care: a randomised controlled trial. Acupunct Med 2016; 34: 257-66.
57. Ramon S., Gleitz M., Hernandez L., Romero LD. Update on the efficacy of extracorporeal shockwave treatment for myofascial pain syndrome and fibromyalgia. International Journal of Surgery 24 (2015) 201e206
58. Harden RN et al. A Critical Analysis of the Tender Points in Fibromyalgia. Pain Medicine, Volume 8, Issue 2, 1 March 2007, Pages 147–156,
59. Viteneta M et al. Effect of whole body cryotherapy interventions on health-related quality of life in fibromyalgia patients: A randomized controlled trial. Complementary Therapies in Medicine Volume 36, February 2018, Pages 6-8
60. What Medicines Treat Fibromyalgia? WebMD. Accessed https://www.webmd.com/fibromyalgia/guide/medicines-to-treat-fibromyalgia#1
61. Vincent A, Lahr BD, Wolfe F, Clauw DJ, Whipple MO, Oh TH, et al. . Prevalence of fibromyalgia: a population-based study in Olmsted County, Minnesota, utilizing the Rochester epidemiology project. Arthritis Care Res. (2013) 65:786–92. 10.1002/acr.21896
62. Haliloglu S, Carlioglu A, Akdeniz D, Karaaslan Y, Kosar A. Fibromyalgia in patients with other rheumatic diseases: prevalence and relationship with disease activity. Rheumatol Int. (2014) 34:1275–80. 10.1007/s00296-014-2972-8
63. Duffield SJ, Miller N, Zhao S, Goodson NJ. Concomitant fibromyalgia complicating chronic inflammatory arthritis: a systematic review and meta-analysis. Rheumatology (Oxford) (2018) 57:1453–60. 10.1093/rheumatology/key112.ory
64. Clauw DJ. Fibromyalgia: a clinical review. JAMA (2014) 311:1547–55. 10.1001/jama.2014.3266
65. Perrot S, Bouhassira D, Fermanian J. Development and validation of the Fibromyalgia Rapid Screening Tool (FiRST). Pain (2010) 150:250–6. 10.1016/j.pain.2010.03.034
66. Littlejohn GO et al. Is there a role for opioids in the treatment of fibromyalgia? Pain Manag 2016; 6: 347-55.
67. Donohue A. DCs and Fibromyalgia Syndrome. ACA News. Jan 7, 2016. Accessed 11/27/18 from: https://www.acatoday.org/News-Publications/ACA-News-Archive/ArtMID/5721/ArticleID/37/-DCs-and-Fibromyalgia-Syndrome
68. Perle SM. RE: “Fibromyalgia Protocol.” Message to Tim Bertelsman regarding advice on chiropractic management of fibromyalgia patients via direct email on 11/27/2018
69. Shah J. RE: “Fibromyalgia Protocol.” Message to Tim Bertelsman regarding advice on chiropractic management of fibromyalgia patients via direct email on 11/27/2018
70. Simons, D. G., Travell, J. G., Simons, L. S., & Travell, J. G. (1999). Travell & Simons’ myofascial pain and dysfunction: The trigger point manual. Baltimore: Williams & Wilkins.
71. Sarzi-Puttini P, Atzeni F, Mease PJ. Chronic widespread pain: from peripheral to central evolution. Best Pract Res Clin Rheumatol 2011; 25:133.
72. Schmidt-Wilcke T, Clauw DJ. Fibromyalgia: from pathophysiology to therapy. Nat Rev Rheumatol 2011;7:518.
73. Goldenberg DL. Do infections trigger fibromyalgia? Arthritis Rheum 1993; 36:1489.
74. Meeus M, Nijs J. Central sensitization: a biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clin Rheumatol 2007; 26:465.
75. Simms RW, Roy SH, Hrovat M, et al. Lack of association between fibromyalgia syndrome and abnormalities in muscle energy metabolism. Arthritis Rheum 1994; 37:794.
76. Cordero MD, de Miguel M, Carmona-López I, et al. Oxidative stress and mitochondrial dysfunction in fibromyalgia. Neuro Endocrinol Lett 2010; 31:169.
77. Buskila D, Sarzi-Puttini P. Biology and therapy of fibromyalgia. Genetic aspects of fibromyalgia syndrome. Arthritis Res Ther 2006; 8:218.
78. Dadabhoy D, Crofford LJ, Spaeth M, et al. Biology and therapy of fibromyalgia. Evidence-based biomarkers for fibromyalgia syndrome. Arthritis Res Ther 2008; 10:211.
79. Roizenblatt S, Neto NS, Tufik S. Sleep disorders and fibromyalgia. Curr Pain Headache Rep 2011; 15:347.
80. Rizzi M, Sarzi-Puttini P, Atzeni F, et al. Cyclic alternating pattern: a new marker of sleep alteration in patients with fibromyalgia? J Rheumatol 2004; 31:1193.
81. Bazzichi L, Rossi A, Massimetti G, et al. Cytokine patterns in fibromyalgia and their correlation with clinical manifestations. Clin Exp Rheumatol 2007; 25:225.
82. Friesen LN, Hadjistavropoulos HD, Schneider LH, et al. Examination of an Internet-Delivered Cognitive Behavioural Pain Management Course for Adults with Fibromyalgia: A Randomized Controlled Trial. Pain 2017; 158:593.
83. Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA 2004; 292:2388.
84. Fitzcharles MA, Ste-Marie PA, Goldenberg DL, et al. Canadian Pain Society and Canadian Rheumatology Association recommendations for rational care of persons with fibromyalgia: a summary report. J Rheumatol 2013; 40:1388.
85. Hughes G, Martinez C, Myon E, et al. The impact of a diagnosis of fibromyalgia on health care resource use by primary care patients in the UK: an observational study based on clinical practice. Arthritis Rheum 2006; 54:177.
86. Annemans L, Wessely S, Spaepen E, et al. Health economic consequences related to the diagnosis of fibromyalgia syndrome. Arthritis Rheum 2008; 58:895.
87. Busch AJ, Webber SC, Richards RS, et al. Resistance exercise training for fibromyalgia. Cochrane Database Syst Rev 2013; :CD010884.
88. Bidonde J, Busch AJ, Webber SC, et al. Aquatic exercise training for fibromyalgia. Cochrane Database Syst Rev 2014; :CD011336.
89. Häuser W, Klose P, Langhorst J, et al. Efficacy of different types of aerobic exercise in fibromyalgia syndrome: a systematic review and meta-analysis of randomised controlled trials. Arthritis Res Ther 2010; 12:R79.
90. Perrot S, Russell IJ. More ubiquitous effects from non-pharmacologic than from pharmacologic treatments for fibromyalgia syndrome: a meta-analysis examining six core symptoms. Eur J Pain 2014; 18:1067.
91. Busch AJ, Schachter CL, Overend TJ, et al. Exercise for fibromyalgia: a systematic review. J Rheumatol 2008; 35:1130.
92. Goldenberg DL. Is there evidence for any truly effective therapy in fibromyalgia? Pain Manag 2016; 6:325.
93. Tucker J, RE: “Fibromyalgia Protocol.” Message to Tim Bertelsman regarding advice on chiropractic management of fibromyalgia patients via direct email on 11/28/2018
94. Susan Lee King Yuan et al. Effectiveness of different styles of massage therapy in fibromyalgia: A systematic review and meta-analysis. Manual Therapy. Volume 20, Issue 2, April 2015, Pages 257-264
95. Wang C, Schmid CH, Fielding RA et al. Effect of tai chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial BMJ 2018; 360 :k851
96. Cheng CM et al. Analgesic effects of repetitive transcranial magnetic stimulation on modified 2010 criteria-diagnosed fibromyalgia: A pilot study. Psychiatry Clin Neurosci. 2018 Dec 26. doi: 10.1111/pcn.12812. [Epub ahead of print]

About the Author

Dr. Tim Bertelsman

Dr. Tim Bertelsman

DC, CCSP, DACO

Dr. Tim Bertelsman graduated with honors from Logan College of Chiropractic and has been practicing in Belleville, IL since 1992. He has lectured nationally on various clinical and business topics and has been published extensively. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as President of the executive board.

Share this article!


Facebooktwittergoogle_plusredditpinterestmail