Over the last ten years, Fibromyalgia has become an increasingly common diagnosis. 10%-20% of new patients in a rheumatology practice have Fibromyalgia Syndrome (FMS), and approximately 2% of the U.S. population (3-6 million people) are thought to have the condition. Because of the widespread musculoskeletal manifestations of this condition, patients suffering from it are very likely to seek chiropractic care. This paper will review FMS, with emphasis on chiropractic management.

Fibromyalgia History and Terminology

The condition we now know as fibromyalgia appears to have been recognized for many years, but with other names. In the mid 1800's, European literature refers to a "neurasthemia' and "spinal irritation" (exaggerated tenderness to palpation). In 1904, Sir William Gavers coined the term "fibrositis", which appeared in North America rheumatology texts in 1940. After WWII, 50%-70% of rheumatological referrals from the British armed forces were for fibrositis. In 1981, Yunas, et. al. began using the term fibromyalgia, since the condition was shown to not involve inflammation. In 1987, an editorial appeared in JAMA acknowledging the existence of fibromyalgia.

The American College of Rheumatology (ACR) devised the current definition and diagnostic criteria for fibromyalgia in 1990 (see below).

Fibromyalgia Pathophysiology

* Sleep Disturbance: Stage 3 and 4 non-REM sleep are especially affected. Serotonin and somatomedin C are produced during stage 4 of sleep. Sleep regulation is often key to treatment.

* Somatomedin C deficiency: A growth hormone instrumental in muscle repair and function.

* Serotonin deficiency: Associated with FMS and lowered pain threshold.

* Substance P: CSF levels increase in FMS.

* Autonomic Dysfunction: Current thinking implicates an abnormal hypothalamic-pituitary-adrenal axis, and changes in the sympathoadrenal system (Mense & Simons).

* ATP: Reduced levels in FMS red blood cells. Low capillary blood flow and hypoperfusion of muscles results.

* Magnesium: Reduced levels in FMS red blood cells.

* Genetics: Autosomal dominant pattern has been reported (Mense & Simons).

Diagnosis

ACR Guidelines:

1) Subjective aching for 3 months
2) Subjective stiffness for 3 months
3) Widespread pain: (bilateral, above and below the waist, includes axial skeletal pain)
4) Tenderness to palpation (4 kg pressure) at 11 or the following 18 (bilateral) points:

1. Upper trapezius
2. Supraspinatus
3. Gluteal
4. Pec Major (2nd costochondral jt.)
5. Inferior SCM ("lower cervical")
6. Greater Trochanter
7. Medial knee (pes anserine)
8. Suboccipital
9. Lateral Epicondyle

In addition to the ACR criteria, sleep disturbance, fatigue, weakness, and irritable bowel syndrome may also be present.

General Treatment Goals

1) Evaluate prior treatment history. Which provider(s) already consulted? Prior treatment, medications, etc., successes and failures.
2) Optimize sleep quality and quantity.
3) Educate patient. Emphasize patient as the active director of their treatment. Avoid passive or "victim" mindset of patient.
4) Increase exercise and activity through guided, achievable goals. Improve aerobic capacity.
5) Optimize posture, ergonomics, biomechanics, etc.
6) Assess diet and nutritional status.
7) Make patient aware of other health care resources when appropriate. FMS is typically a multi-disciplinary problem.

Specific Treatment Considerations

A. Manual Therapy
1) Evaluate posture, ergonomics, and biomechanics. Apply postural training, stretching, strengthening as needed.
2) Chiropractic spinal evaluation with chiropractic manipulative therapy (adjustments) to dysfunctional areas. Correlate this treatment with appropriate home care, de-emphasize passive treatment, and avoid frequent manipulation of hypermobile areas.
3) Massage, trigger point therapy, and related soft tissue techniques.
4) Mobilization, "Muscle Energy Technique,"¹ PIR², PNF³, etc. Especially useful if patient is unable to tolerate high velocity adjusting.

B. Potential Sleep-Aids
1) Magnesium
2) Malic Acid (available as Magnesium Malate)
3) Tryptophan or high tryptophan foods
4) 5-HTP (serotonin precursor from tryptophan)
5) Valerian
6) Passiflora
7) Hops
8) Hypericum (St. Johns Wort)
9) Kava (beware current hepatotoxicity concerns)
10) Lengthy "wind down" period before bed
11) No television before bed
12) Avoid caffeine and other stimulants
13) Meditation, relaxation and breathing techniques
14) Regular exercise (earlier in day)

C. Exercise
Aerobic fitness appears to play a key role in FMS and improvements in myalgic scores tend to parallel improvements in aerobic fitness. Previously mentioned manual and nutritional therapies are not merely an end in themselves, but should serve to facilitate the patient's return to increased activity, exercise, energy, and aerobic fitness. The Chiropractic physician may serve as guide, motivator, and "coach" throughout this process. Specific applications include:
1) Walking
2) Treadmill, Elliptical Device, Nordic Track, etc.
3) Exercise bike
4) Swimming or water aerobics
5) Tai Chi
6) Yoga
7) Guide patient in "listening to their body" to build incremental success with exercise, and not over-do. Patient may need help in differentiating normal exercise soreness from a true flare-up of their condition.

D. Pharmacological Considerations
1) Tricyclic antidepressant e.g. amitriptyline
2) Muscle relaxer e.g. cyclobenzapine (Flexeril)
3) Selective Serotonin Reuptake Inhibitors (SSRI) e.g. Prozac, Paxil, Zoloft
4) Sedative e.g. Ambien (Zolpidem)

E. Referral and Co-Treatment
Fibromyalgia patients often have complex presentations, and require management by more than one practitioner. The proper combination of therapeutic approaches may have a synergistic effect. The chiropractor may be in a unique position to facilitate or coordinate the referral and co-treatment process. Following is a list of resources to consider, using your clinical judgment and the patient's history:
1) PCP
2) Rheumatologist
3) Psychotherapist, counselor, or related professional
4) Naturopath
5) Acupuncturist
6) Physical Therapist
7) Personal trainer
8) Support group

¹ Stretch-- isometric contraction -- stretch technique
² Post-isometric-relaxation
³ Proprioceptive Neuromuscular Facilitation

F. Resources

From fatigued to Fantastic, Jacob Teitelbaum, M.D. Avery Publishing, N.Y., 2001.
www.endfatigue.com

The Fibromyalgia Survivor, Mark Pellegrino, M.D. Anadem Publishing, Columbus, OH, 1995.

Fibromyalgia Network
PO Box 31750
Tuscon, AZ 85751
800-853-2929 www.fmnetnews.com

Chronic Fatigue and Immune Deficiency Syndrome assoc. of America
800-442-3437 www.cfids.org

National Fibromyalgia Research Association
PO Box 500
Salem, OR, 97302 www.nfra.net

References

Mense S, Simons DG. Muscle Pain: Understanding Its Nature, Diagnosis and Treatment. Lippincott Williams & Wilkins, Baltimore, 2001. Chapter 9.

Schneider MJ, Brady DM. Fibromyalgia Syndrome: A New Paradigm for Differential Diagnosis and Treatment. JMPT 24(8):529-541, 2001.

Jamison JR. A Psychological Profile of Fibromyalgia Patients: A Chiropractic Case Study. JMPT 22(7):454-457, 1999.

Ang D, Wilke WS. Diagnosis, Etiology and Therapy of Fibromyalgia.
Comprehensive Therapy 25(4):221-227, 1999.

Forseth KO, Foree O, Gran JT. A 5.5 Year Prospective Study of Self-Reported Musculoskeletal Pain and of Fibromyalgia in a Female Population: Significance and Natural History. Clin Rheum 18:114-121, 1999.

Wallace DJ. The Fibromyalgia Syndrome. Annals of Med 29(1):9-21, 1997.

Blunt KL, Moez H, et al. The Effectiveness of Chiropractic Management of Fibromyalgia Patients. JMPT 20(6):389-399, 1997.

Bennett RM. Multidisciplinary Group Programs to Treat Fibromyalgia patients.
Rheum Diseases Clin N Amer 22(2):351-367, 1996.