Fibromyalgia Syndrome

By David BenEliyahu

Fibromyalgia syndrome (FS) is a diagnosis given to patients who present with chronic pain and stiffness. It is a complex syndrome, and although controversial, it is widely recognized by rheumatologists as a distinct diagnostic entity. 
It affects about six million people, four million of which are female. It is often accompanied by fatigue, sleep disturbances, morning stiffness, anxiety and decreased pain thresholds. Widespread pain and tenderness at many tender spots on the body are the hallmark findings. In 1990, the American College of Rheumatology (ACR) developed specific criteria for classifying FS:

I. History of widespread pain: pain present on the right and left side of the body, and both below and above the waist.

Axial skeletal pain must be present in one of these area: cervical spine, dorsal spine, anterior chest and lumbar spine.

II. Pain in at least 11 of 18 tender points:

right/left suboccipital area	second rib
cervical spine C5-C7	lateral epicondyle
trapezius	gluteals
supraspinatus	knee

greater trochanter

FS has been divided into two types. Primary FS occurs in a spontaneous idiopathic form; its cause is unknown. Secondary FS is found in association with a primary associated disorder such as trauma, rheumatoid arthritis, postsurgical, spinal disorders, etc.

FS predominantly affects women. The etiology of FS is poorly understood at this time, however, some studies have implicated neurohormonal, CNS, metabolic and/or biochemical dysfunction. In a study of middle-aged women with FS, SPECT studies were obtained to evaluate cerebral blood flow in the thalamus and caudate nucleus, as well as measuring pain thresholds with psychological assessments. As expected, all three were abnormal in the FS group. Other studies have shown that FS patients have elevated levels of substance P, low levels of serotonin and tryptophan and 5-hydroxytryptamine. As a result, deficient 5-hydroxytryptamine activity can cause altered sleep, substance P metabolism and allodynia. An interesting study on the role of glycolysis and FS revealed increased pyruvate and lactate production in FS patients and hypothyroid patients and decreased ATP and LDH in FS patients, suggesting glycolytic impairment.

Some studies have suggested an association between thyroid dysfunction and FS (myofascitis, also). In a study by Carette et al., symptomatic improvement was noted in 10 of 19 FS patients. In a paper by Lowe et al., it was theorized that there is failed transcription regulation by the thyroid hormone that leads to serotonin deficiency in FS patients. They tend to be euthyroid with normal thyroid blood test findings, due to low affinity thyroid hormone receptors coded by a mutated C-eba beta-1 gene, yielding resistance to thyroid hormone. This causes alpha-adrenergic dominance and an increase in cyclic ADP and inhibitory GI proteins.

It is important for the chiropractic clinician to recognize FS, because it is not uncommonly seen after trauma. In a study of 67 patients with FS that met the ACR criteria, 60% noted onset subsequent to MVA; 12% after a work injury; 7% after surgery; and 5% after sports injury. Posttraumatic FS patients have shown higher degrees of pain disability and life interference, and are more difficult to manage. Fifty-six of the 67 patients had pain in 11 or more of the tender points (averaging 13.5). Patients received medication, biofeedback, manipulation, massage therapy, physical therapy and injections.

There was a dramatic reduction in use of all the therapies after a two year follow-up, although 86% still had symptoms and had signs of FS. This implies that a significant percentage of patients coming to our office may have FS and can benefit from a trial of chiropractic care. It should be noted that the patient would benefit most from a holistic package of chiropractic care, including not only manipulative therapy/adjustments, but with physiotherapy, massage, nutritional supplementation and exercise.

In a study comparing relaxation technique and exercise, aerobic exercise, flexibility and strength training were shown to have a beneficial effect on FS patients, without any adverse effect. In a Norwegian study, FS patients who exercised reported less symptoms than sedentary patients. Similar findings were observed in a Scandinavian study. EMG biofeedback and electroacupuncture have also been demonstrated to help lower pain and EMG activity in FS patients. In a study in the BMJ, was shown to decrease use of analgesics, pain scores, sleep disturbance and morning stiffness. In a study of 90 patients with FS, the usage of complementary therapies/alternative medicine was evaluated. Seventy-one percent of the patients utilized complementary therapies; the most popular was nutritional oral supplementation.

A similar study by Pioro et al. found 91% of the FS patients used alternative therapies. Two thirds of FS patients used multiple interventions.

All of these studies show that FS patients want and need a viable alternative therapy in addition to their standard medical care. Chiropractic doctors who offer advice on nutrition, exercise, and behavioral modification, in addition to chiropractic care, provide these patients with a valuable service. It is imperative to make the patient an active participant in their care and to establish a good home exercise program with stretching, strengthening and aerobic exercise. This will empower the patient to return to a functional lifestyle. Nutritional supplements can include vitamins, mineral and herbal medicine.

It is important to emphasize that FS is not myofascial pain syndrome (MPS), and the tender points are not trigger points. A muscle study showed that there are no histological changes at the tender points. In a review article in JMPT, Schneider pointed out that FS and MPS are two distinct entities that require different treatment approaches. FS is a systemic problem that involves neuroendocrine dysfunction and requires multidisciplinary treatment. MPS is due to muscle dysfunction caused by trigger points which responds well to manual treatment, like myofascial release, ischemic compression, spray-stretch, etc. MPS and FS can be seen in the same patient and coexist, especially subsequent to trauma (MVA or whiplash injuries), so treatment must be individualized to the two different problems.

The doctor of chiropractic should be able to recognize fibromyalgia syndrome and participate in the care of this patient in conjunction with a rheumatologist and or psychotherapist. Kelli et al. in the July/August 1997 issue of JMPT documented the efficacy of chiropractic care in a random clinical trial on fibromyalgia patients. Twenty one rheumatoid patients with FS participated in the study. Four weeks of spinal manipulation, soft tissue therapy, and stretching were compared to control patients taking medication only. Chiropractic care resulted in increased cervical and lumbar ROM, straight leg raise, visual analog pain scores, Oswestry and neck pain disability index scores. The Kelli et al. pilot study suggests that DCs can help FS patients, albeit larger clinical trials are necessary to confirm their findings.