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.
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.
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)
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)
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.
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)
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)
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)
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.
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About the Author
Dr. Tim Bertelsman
DC, CCSP, DACO
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