Fibromyalgia and Chiropractic

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

If there are terms in these articles you don't understand, you can get a definition from the Merriam Webster Medical Dictionary.   If you want information about a specific disease, you can access the Merck Manual.   You can also search Pub Med for more abstracts on this, or any other health topic.

Chiropractic Management of Fibromyalgia

	The Vast Majority of Patients With Fibromyalgia Have a Straight Neck Observed on a Lateral View Radiograph of the Cervical Spine: An Aid in the Diagnosis of Fibromyalgia and a Possible Clue to the Etiology J Clinical Rheumatology 2022 (Nov 3) [EPUB] Most patients with fibromyalgia share an abnormality in common that is verifiable by a simple radiograph. In 83.2% of the patients, the cervical spine was essentially straight (Cobb angle ≤10 degrees). In fibromyalgia patients, the loss of cervical curvature was approximately 6.5 times greater than in control subjects (50.3% vs. 7.8%). A straight neck without other radiographic abnormalities may be a major anatomical abnormality in fibromyalgia that has gone unnoticed. It may assist in the diagnosis, as well as suggest increased muscle tension/pressure as a possible etiology.
	Chiropractic Management of a Patient With Chronic Fatigue: A Case Report J Chiropractic Medicine 2016 (Dec); 15( 4): 314—320 ~ FULL TEXT The patient was placed on an anti-inflammatory ancestral diet and given recommendations to decrease the aerobic intensity of her exercise routine. On the basis of the result of conventional and functional laboratory tests, she was prescribed a treatment plan of targeted supplementation. After 12 weeks of application of dietary, lifestyle, and supplementation recommendations, the patient reported experiencing increased energy and weight loss of 15 pounds. Her thyroglobulin antibodies returned within reference range, salivary cortisol increased and closely followed the proper circadian rhythm, and ehydroepiandrosterone-sulfate increased.   This report describes improvement in a patient with chronic fatigue with the use of nonpharmaceutical polytherapy involving dietary changes, lifestyle modification, and supplementation.
	Chiropractic Management of Fibromyalgia Syndrome: Summary of Clinical Practice   (PDF) Recommendations from the Commission of the Council on Chiropractic Guidelines and Practice Parameters Our search yielded the following results: 8 systematic reviews, 3 meta-analyses, 5 published guidelines, 1 consensus document. Our direct search of the databases for additional randomized trials did not find any chiropractic RCTs that were not already included in one or more of the systematic reviews/guidelines. The review of the MANTIS and ICL databases yielded an additional 38 articles regarding various non-pharmacological therapies such as chiropractic, acupuncture, nutritional/herbal supplements, massage, etc. Review of these articles resulted in the following clinical practice recommendations regarding non-pharmaceutical treatments of FMS. Strong evidence supports aerobic exercise and cognitive behavioral therapy. Moderate evidence supports massage, muscle strength training, acupuncture, and spa therapy (balneotherapy). Limited evidence supports spinal manipulation, movement/body awareness, and vitamins, herbs, and dietary modification.
	Chiropractic Management of Fibromyalgia Syndrome: A Systematic Review of the Literature J Manipulative Physiol Ther. 2009 (Jan); 32 (1): 25–40 ~ FULL TEXT Fibromyalgia syndrome (FMS) is an elusive condition of unknown etiology, in which patients report chronic widespread pain as their predominant symptom, along with a variety of other complaints including fatigue, sleep disorders, cognitive deficit, irritable bowel and bladder syndrome, headache, Raynaud syndrome, bruxism, atypical patterns of sensory dysesthesia, and other symptoms. [1] In conclusion, we found that there is an emerging literature regarding a number of CAM therapies for the conservative treatment of FMS syndrome, including spinal manipulation. There is a dearth of experimental chiropractic literature on the management of soft tissue conditions and FMS. It is recommended that the chiropractic research community take notice of this information gap and take steps to design high-quality experimental research studies to help close this information gap.
	Effects of Resistance Training and Chiropractic Treatment in Women with Fibromyalgia J Altern Complement Med. 2009 (Mar); 15 (3): 321–328 In women with FM, resistance training improves strength, FM impact, and strength domains of functionality. The addition of chiropractic treatment improved adherence and dropout rates to the resistance training and facilitated greater improvements in the domains of functionality.
	Short and Long-Term Results of Connective Tissue Manipulation and Combined Ultrasound Therapy in Patients with Fibromyalgia J Manipulative Physiol Ther 2006 (Sep); 29 (7): 524–528 ~ FULL TEXT This is an observational prospective cohort study of 20 female patients with Fibromyalgia (FM). Intensity of pain, complaint of nonrestorative sleep, and impact of FM on functional activities were evaluated by visual analogue scales. All evaluations were performed before and after 20 sessions of treatment, which included connective tissue manipulation of the back daily, for a total of 20 sessions, and combined US therapy of the upper back region every other session. One-year follow-up evaluations were performed on 14 subjects. Statistical analyses revealed that pain intensity, impact of FM on functional activities, and complaints of nonrestorative sleep improved after the treatment program. CONCLUSION: The methods used in this study seemed to be helpful in improving the pain intensity, complaints of nonrestorative sleep, and impact on functional activities in patients with FM.
	A Combined Ischemic Compression and Spinal Manipulation in the Treatment of Fibromyalgia: A Preliminary Estimate of Dose and Efficacy J Manipulative Physiol Ther 2000 (May); 23 (4): 225–230 ~ FULL TEXT Fifteen women (mean age 51.1 years) completed the trial. A total of 9 (60) patients were classified as respondents. A statistically significant lessening of pain intensity and corresponding improvement in quality of sleep and fatigue level were observed after 15 and 30 treatments. After 30 treatments, the respondents showed an average lessening of 77.2 (standard deviation = 12.3) in pain intensity and an improvement of 63.5 (standard deviation = 31.6) in sleep quality and 74.8 (standard deviation = 23. 1) in fatigue level. The improvement in the 3 outcome measures was maintained after 1 month without treatment.
	The Effectiveness of Chiropractic Management of Fibromyalgia Patients: A Pilot Study J Manipulative Physiol Ther 1997 (Jul); 20 (6): 389–399 Chiropractic management improved patients' cervical and lumbar ranges of motion, straight leg raise and reported pain levels. These changes were judged to be clinically important within the confines of our sample only. Further study with a sample size of 81 (for 80% power at alpha < or = .05) is recommended to determine if these findings are generalizable to the target population of fibromyalgia suffers.

What is Fibromyalgia?

Thanks to Medscape for access to these materials!

Fibromyalgia is a chronic syndrome that occurs predominantly in women and is marked by generalized pain, multiple defined tender points, fatigue, disturbed and nonrestorative sleep, and numerous other somatic complaints. Fibromyalgia is not a discrete disease; rather, it lies at the far end of a continuum of psychological distress and chronic pain in the general population. Fibromyalgia largely overlaps with other syndromes, such as chronic fatigue syndrome, irritable bowel syndrome, temporomandibular joint pain, and multiple other regional pain syndromes, all of which feature symptoms that remain unexplained after usual clinical and laboratory assessment and all of which are related to, but not fully dependent on, depression and anxiety. Fibromyalgia frequently coexists with diseases of structurally defined pathology, such as systemic lupus erythematosus (SLE) or rheumatoid arthritis.

Otherwise unexplained widespread pain occurs in about 10% of the general adult population in Western countries, with approximately half of those affected—mostly women—meeting American College of Rheumatology (ACR) classification criteria for fibromyalgia. It becomes more common after 60 years of age but occurs not infrequently in children. On a typical day, primary care physicians should expect to interact with several patients with fibromyalgia, many of whom will be seeking care for illness other than fibromyalgia. For example, more than 25% of patients with SLE exhibit painful tender points and other clinical and psychological features of fibromyalgia.

The cause of fibromyalgia is unknown. Despite extensive research, no structural pathology has been identified in muscles or other tissues. Although psychological factors associated with chronic distress appear to be important for the development of fibromyalgia in many patients, abundant evidence now indicates that pain in fibromyalgia reflects abnormal pain processing in the central nervous system (i.e., central sensitivity). Clinically, fibromyalgia syndrome is best viewed from a biopsychosocial perspective encompassing multiple variables that contribute to chronic pain and fatigue.

Fibromyalgia has been classified as one of a group of disorders that are variously termed symptom-based conditions, functional somatic syndromes, and affective spectrum disorders. Common somatic symptoms in these illnesses are chronic musculoskeletal or abdominal pain, persistent fatigue, disturbed sleep, and cognitive difficulty. Advances in the understanding of the psychophysiologic and neurophysiologic dysregulation in such illnesses is impelling researchers to develop a unifying reclassification of these illnesses as central sensitivity syndromes.


Clinical Symptoms of Fibromyalgia

Pain is the hallmark of fibromyalgia. The pain radiates diffusely from the axial skeleton and is localized to muscles and muscle-tendon junctions of the neck, shoulders, hips, and extremities. Fibromyalgia patients describe the pain with such terms as exhausting, miserable, or unbearable. Generalized hyperalgesia is a cardinal feature. Patients frequently complain that even gentle touch is unpleasant, a manifestation of allodynia.

Fibromyalgia patients also experience severe fatigue, insomnia, and low mood or depression. In fibromyalgia, fatigue occurring most times of the day on most days, together with subjective weakness and nonrestorative sleep, is almost universal. Cognitive complaints, such as difficulties with concentration and memory, may be prominent. Depression, anxiety disorders, and personality disorders contribute to ongoing psychological distress. Other complaints result from somatization, which can be defined as translating psychological distress into somatic symptoms (which are considered more socially acceptable) and seeking care for those symptoms.

Functional impairment is usually present, at least in patients with fibromyalgia who seek care. Patients report difficulty doing usual activities of daily living and lack of exercise—indeed, they actually fear and avoid exercise.

Regional pain syndromes, such as headache, temporomandibular joint disorder, or irritable bowel syndrome, are often present in fibromyalgia patients. It is essential that the physician not automatically attribute all such symptoms to fibromyalgia, however, because fibromyalgia frequently coexists with other disorders of defined structural pathology, such as SLE and rheumatoid arthritis. Optimum therapy requires recognition of both fibromyalgia and comorbid disease.


Tender Points may occur at nine bilateral locations:

Thanks to (the departed) About.Com for access to these pictures.

Front of the Body: Low Cervical Region: (front neck area) at anterior aspect of the interspaces between the transverse processes of C5–C7. Second Rib: (front chest area) at second costochondral junctions. Lateral Epicondyle: (elbow area) 2 cm distal to the lateral epicondyle. Knee: (knee area) at the medial fat pad proximal to the joint line.

Back of the Body: Occiput: (back of the neck) at suboccipital muscle insertions. Trapezius Muscle: (back shoulder area) at midpoint of the upper border. Supraspinatus Muscle: (shoulder blade area) above the medial border of the scapular spine. Gluteal: (rear end) at upper outer quadrant of the buttocks. Greater Trochanter: (rear hip) posterior to the greater trochanteric prominence. Thanks to (the departed) About.Com for access to these pictures.

The Diagnosis of Fibromyalgia

Thanks to Fibromyalgia Network for access to this information.

To meet the fibromyalgia criteria for medical diagnosis, patients must experience:

1. Widespread pain in all four quadrants of their body, for a minimum of three months, and
   

2. At least 11 of the 18 specified tender points (see the sketches)

The 18 sites used for the fibromyalgia diagnosis cluster around the neck, shoulder, chest, hip, knee, and elbow regions. The finger pressure that must be applied to these areas during a "palpation" exam is roughly equivalent to the amount that causes the finger nail bed to blanch or start to become white. Over 75 other tender points have been found to exist, but are not used for diagnostic purposes.

While many chronic pain syndromes display symptoms that overlap with fibromyalgia, the 1990 American College of Rheumatology (ACR) multi-center criteria study (published in the February 1990 issue of Arthritis and Rheumatism) evaluated a total of 558 patients, of which 265 were classified as controls. These control individuals weren't your typical healthy "normals." They were age and sex matched patients with neck pain syndrome, low back pain, local tendonitis, trauma-related pain syndromes, rheumatoid arthritis, lupus, osteoarthritis of the knee or hand, and other painful disorders. These patients all had some symptoms that mimic fibromyalgia, but the trained examiners were not foiled—they hand-picked the fibromyalgia patients out of the "chronically ill" melting pot with an accuracy of 88%. Fibromyalgia is not a wastebasket diagnosis!

Although the above diagnosis focuses on tender point count, a consensus of 35 fibromyalgia experts published a report in 1996 saying that a person does not need to have the required 11 tender points to be diagnosed and treated for fibromyalgia
(Wolfe F, et al. J Rheumatol 1996 (Mar);   23 (3):   534–539).

This criteria was created for research purposes and many people may still have fibromyalgia with less than 11 of the required tender points as long as they have widespread pain and many of the commonly associated symptoms listed below.

• fatigue
  
• irritable bowel (e.g., diarrhea, constipation, etc.)
  
• sleep disorder (or sleep that is unrefreshing)
  
• chronic headaches (tension-type or migraines)
  
• jaw pain (including TMJ dysfunction)
  
• cognitive or memory impairment
  
• post-exertional malaise and muscle pain
  
• morning stiffness (waking up stiff and achy)
  
• menstrual cramping
  
• numbness and tingling sensations
  
• dizziness or lightheadedness
  
• skin and chemical sensitivities

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Updated 11-07-2022