Fibromyalgia was described as a puzzling and painful condition by the NIH. It was also described as a complex diagnosis and the cause is not fully understood. According to the Center for Disease Control (CDC) fibromyalgia is a condition that causes pain all over the body (widespread pain), sleep problems, fatigue, and emotional and mental distress. National Fibromyalgia & Chronic Pain Association defined Fibromyalgia as a common and complex chronic pain disorder that causes widespread pain and tenderness to touch that may occur body wide or migrate over the body. Fibromyalgia affects about 5-million United States adults, approximately 2% of the adult population. Fibromyalgia affects all ages including children. This condition affects women more than men and children.
The purpose of this article is to provide additional information to the understanding of fibromyalgia and the role of physical therapy or physical medicine in the treatment of this condition.
Crofford (2016) say:” “To make things more challenging, there are no blood tests or X-rays that are abnormal in people with the fibromyalgia disorder”. The diagnosis of those with fibromyalgia depends on the following diagnostic criteria.
Fibromyalgia is a disease being diagnosed by two clinical diagnostic criteria available to help healthcare providers make an accurate fibromyalgia diagnosis (1) The 1990 American College of Rheumatology Fibromyalgia Diagnostic Criteria; and (2) the 2010 American College of Rheumatology Preliminary Diagnostic Criteria.
The 1990 American College of Rheumatology Fibromyalgia Diagnostic Criteria: includes a history of chronic and widespread body pain and the presence of at least 11 of 18 tender points that are revealed through a physical examination of the patient. Pain is considered widespread when the following are present: pain in both sides of the body, and pain above and below the waist. In addition, axial skeletal pain (cervical spine, anterior chest, thoracic spine or low back pain) must be present and all lasting for at least three months.
The 2010 American College of Rheumatology Preliminary Fibromyalgia Diagnostic Criteria: includes a physician physical and interview examinations, including a widespread pain index (WPI), which is a measure of the number of painful body regions. The most important diagnostic variables were WPI and categorical scales for cognitive symptoms, un-refreshed sleep, fatigue, and number of somatic symptoms. The categorical scales were summed to create a Severity Scale (SS) which combined with WPI to recommend a new case of fibromyalgia. This criterion does not include a tenderness scale, but rather a 42 question symptom questionnaire. Based on the number of symptoms checked off along with answers to other pertinent diagnostic questions a mathematical formula is used to determine an accurate Fibromyalgia diagnosis.
Frederick Wolfe (1997) stated that it would seem appropriate to consider the entire range of tenderness and distress in clinic as well as in research studies rather than treating fibromyalgia as a discrete disorder.
POSSIBLE CAUSES OF FIBROMYALGIA
Recent studies suggested that changes in the central nervous system in the brain, spinal cord and nerves may be responsible for fibromyalgia pain. Fibromyalgia is thought to be the result of overactive nerves. These nerve issues may be responsible for the chronic widespread pain and tenderness.
The suggestion of the recent studies, lack of abnormal blood tests and X-ray film in people with fibromyalgia paint a perfect picture of fascia. Therefore, to understand this fibromyalgia disorder we need to understand the body fascia.
Fascia is much more than plastic wrap around the muscle. Varela & Frenk (1987) stated that fascia is the organ system of stability and mechano-regulation. Fascia forms the biological container and connector for every organ including the muscle. Fascia is all one net with no separation from top to toe, from skin to core or from birth to death (Shultz & Feitis 1996). Every cell in the body is hooked into and responds to the tensional environment of the fascia (Ingber 1998). The body and fascia net is a single connected unity in which the muscle and bone float. It’s no wonder that this system like the nervous and circulatory systems would develop complex signaling and homeostatic mechanisms (Langevin et al., 2006). Fascia is defined as a systemic net of connective tissue (Huijing & Langevin 2009). Connective tissue includes the blood and blood cells, and extra-cellular matrix, which includes everything in the body that is not cellular and fibroblast and mast cells, which produce fibers and glue that respond to the demands of injury.
The extra-cellular matrix consists of three main elements:
- Fibers: are the strong pliable weave –consisting primarily of collagen (which has 12 types) and its cousin’s elastin and reticulin that both separate compartments and binds them together.
- Glue which are variable and colloidal gels like heparin, fibronectin and hyaluronic acid that accommodate change and provide the substrate for other cell like nerve and epithelia. This glue contain proteins called glycosaminoglycan (GAG), which are mucopolysaccharide a colloidal substance, which by varying its chemistry slightly, can display array of properties, from thick and sticky to fluid and lubricating. The fernlike molecule of mucous open to absorb water (hydrophilic) or close and bind to themselves when water is absent. Depending on their chemistry, they either bind layer together or allow them to slide on each other (Grinnell 2008).
- Water- is the fluid that surrounds and permeates the cells as a medium of exchange, mixes with the glue to make materials of differing properties and keeps the fibers wet and pliable (Meyer 2011).
When the fascia is dehydrated, it is stuck together and prevents easy gliding/sliding of muscle fibers, neurovascular bundle, and organs. This reduces blood circulation and oxygen supply to all parts of body and in turn causes widespread pain, numbness/tingling sensation and stiffness and tenderness which are identified as fibromyalgia. Strain transfer between myofascial chains might have an impact in the radiating pain (Krause F, Wilke J, Vogt L. Banzer W. 20115) such as the widespread pain that fibromyalgia patient have.
Fibromyalgia includes other symptoms including sleep problems, fatigue and tiredness, headaches, thinking, memory, concentration problems, depression and anxiety. All these are as a result of severe pain which cause sleeping disturbance; lack of sleep leads to fatigue and tiredness which cause headaches, thinking, and memory and concentration problems. These lead to depression and anxiety.
With knowledge of this disorder, as physical therapists we can plan perfect treatments that will help alleviate our patient’s symptom and improve their functional activities level. Although, some studies stated that fibromyalgia is a chronic pain state in which the nerve stimuli causing pain originates mainly in the tissues of the body and therefore movement and strenuous exertion will increase pain and aggravate fibromyalgia. I believe this statement because the majority of physicians do not to refer their fibromyalgia patient to physical therapy because of the notion that all physical therapy treatment is focused on is strengthening exercises which could increase a patient’s symptoms. This is far from true because physical therapy is a treatment that utilize of any physical means that could help alleviate/ cure the symptoms.
In physical therapy, patient’s interview will include how the symptoms started, what relieves the symptoms if anything, patient’s daily habits, functional activities before the symptoms began, and current functional ability. Physical examination will include range of motion, muscle strength, muscle tenderness, pain level, and posture and fascia restriction, gait assessment, vital signs (blood pressure, saturate oxygen, and auscultation) and breathing pattern. These will show which parts of the patient’s body fascia is/are restricted. The results of all these put together will help plan treatments that are appropriate for the individual patient.
The following treatment procedures may be utilized:
- Myofascial release: This is a treatment technique where pressure electric is being utilized to energize fascia molecules to return its chemical component back to normal level and eliminate the widespread pain.
- Therapeutic exercise with emphasis on breathing exercises to improve lung tidal volume and reduce anxiety.
- Therapeutic exercise with stretching technique to relax restricted fascia, increase neuromuscular bundle motility, increase circulation, increase range of motion, increase neurovascular bundle motility and reduce pain.
- Patient education with important of drinking water for dehydration.
- Gait training with emphasis on body posture and energy conservation.
- Soft tissue mobilization to release restricted fascia, increase circulation, increase neurovascular bundle motility, increase neuromuscular bundle motility, increase thoracic cage volume, increase lung tidal volume and reduce pain.
- Joint mobilization may be used to restore joint disorder/dysfunction to improve posture and improve arthrokinematic in order to improve range of motion for functional activities.
If you are suffering from fibromyalgia and you have had physical therapy or pain management without relief or benefit do not give up until you speak with us. The treatment you had might not have been the right one for you.
Raifu Olorunfemi, PT., MS.
- Frederic Wolfe. The relation between tender points and fibromyalgia symptom variables: evidence that fibromyalgia is not a discrete disorder in the clinic: Annals of Rheumatic Disease 56(4) 1997, 268-271.
- Frederick Wolfe, el at. The American College of Rheumatology Criteria for the Classification of Fibromyalgia: Arthritis and Rheumatism Vol. 33, No. 2, Feb. 1990.
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- National Fibromyalgia & Chronic Pain Association (NFMCPA).
- Fascia Congress. 2007. (www.fasciacongress.org/2007).
- Fascia Congress. 2009. (www.fasciacongress.org/2009).
- Fascia Congress. 2015(www.fasciacongress.org/2015).
- NIH Medline Plus the magazine: Fibromyalgia: Puzzling and Painful Condition. Spring 2016 Issue: Vol. 11 No1 Pgs. 20-21.
- Thomas Myers. Fascia Fitness: Training in the Neuromyofascial Web. Mar 23, 2011.
- Langevin, H., et al. Fibroblast cytoskeletal remodeling contributes to connective tissue tension: Journal of Cellular Physiology. E-pub ahead of Publication. Oct. 13 2010.
- Langevin, H. Connective tissue: A Body-wide signaling network? Medical Hypotheses, Vol. 66, No 6, pgs. 1074-77 2006.
- Huijing, P.A., & Langevin, H. Communication about fascia: History, pitfalls and recommendations. In P.A.
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- Varela, F., Frenk, S. The organ of form: Journal of Social and Biological Structures, 10 (1), 1073-83, 1987