ChiroACCESS Article



Chiropractic Management of Fibromyalgia



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ChiroACCESS Editorial Staff

  

ChiroACCESS



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September 8, 2010

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Fibromyalgia syndrome (FMS) is a challenging chronic pain disorder that imparts a great deal of disability, cost and comorbidities upon those that suffer from it.  Based upon the Job Analysis of Chiropractic, fibromyalgia is commonly seen in chiropractic practice.  Although there are accepted diagnostic criteria, the treatment focuses on symptomatic relief rather than cure.  The treatment options are varied and include medications, cognitive therapy, exercise, nutrition, chiropractic, physical therapies and other interventions.  A 2009 systematic review of chiropractic management of fibromyalgia concluded that "Several nonpharmacologic treatments and manual-type therapies have acceptable evidentiary support in the treatment of FMS."

Human BodyA recent theoretical paper from the Department of Medicine, Oregon Health & Science University noted that in fibromyalgia "inflammation of the fascia is similar to that described in conditions such as plantar fasciitis and lateral epicondylitis, and may be better described as a dysfunctional healing response. This may explain why NSAIDs and oral steroids have not been found effective in fibromyalgia. Inflammation and dysfunction of the fascia may lead to central sensitization in fibromyalgia. If this hypothesis is confirmed, it could significantly expand treatment options to include manual therapies directed at the fascia such as Rolfing and myofascial release, and direct further research on the peripheral pathology in fibromyalgia to the fascia."  Chiropractic currently plays a significant role in managing fibromyalgia.  If future research provides evidence supporting this hypothesis, the role of chiropractic could be greatly increased.

For more information on the prevention, diagnosis and therapy for fibromyalgia, please see the following clinical reviews at ChiroACCESS:
Note:  These mini-reviews are designed as updates and direct the reader to the full text of current research.  The abstracts presented here are no substitute for reading and critically reviewing the full text of the original research.  Where permitted we will direct the reader to that full text.

Fascia: A missing link in our understanding of the pathology of fibromyalgia.  [LINK]

J Bodyw Mov Ther. 2010 Jan;14(1):3-12.

Liptan GL.
Dept. of Medicine, Oregon Health & Science University, Portland, 97239, United States. gliptan@lhs.org

Significant evidence exists for central sensitization in fibromyalgia, however the cause of this process in fibromyalgia-and how it relates to other known abnormalities in fibromyalgia-remains unclear. Central sensitization occurs when persistent nociceptive input leads to increased excitability in the dorsal horn neurons of the spinal cord. In this hyperexcited state, spinal cord neurons produce an enhanced responsiveness to noxious stimulation, and even to formerly innocuous stimulation. No definite evidence of muscle pathology in fibromyalgia has been found. However, there is some evidence for dysfunction of the intramuscular connective tissue, or fascia, in fibromyalgia. This paper proposes that inflammation of the fascia is the source of peripheral nociceptive input that leads to central sensitization in fibromyalgia. The fascial dysfunction is proposed to be due to inadequate growth hormone production and HPA axis dysfunction in fibromyalgia. Fascia is richly innervated, and the major cell of the fascia, the fibroblast, has been shown to secrete pro-inflammatory cytokines, particularly IL-6, in response to strain. Recent biopsy studies using immuno-histochemical staining techniques have found increased levels of collagen and inflammatory mediators in the connective tissue surrounding the muscle cells in fibromyalgia patients. The inflammation of the fascia is similar to that described in conditions such as plantar fasciitis and lateral epicondylitis, and may be better described as a dysfunctional healing response. This may explain why NSAIDs and oral steroids have not been found effective in fibromyalgia. Inflammation and dysfunction of the fascia may lead to central sensitization in fibromyalgia. If this hypothesis is confirmed, it could significantly expand treatment options to include manual therapies directed at the fascia such as Rolfing and myofascial release, and direct further research on the peripheral pathology in fibromyalgia to the fascia.

Chiropractic management of fibromyalgia syndrome: a systematic review of the literature.  [LINK]

J Manipulative Physiol Ther. 2009 Jan;32(1):25-40.

Schneider M, Vernon H, Ko G, Lawson G, Perera J.
School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pa, USA. drmike@city-net.com

OBJECTIVE: Fibromyalgia syndrome (FMS) is one of the most commonly diagnosed nonarticular soft tissue conditions in all fields of musculoskeletal medicine, including chiropractic. The purpose of this study was to perform a comprehensive review of the literature for the most commonly used treatment procedures in chiropractic for FMS and to provide evidence ratings for these procedures. The emphasis of this literature review was on conservative and nonpharmaceutical therapies.

METHODS:
The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. Online comprehensive literature searches were performed of the following databases: Cochrane Database of Systematic Reviews; National Guidelines Clearinghouse; Cochrane Central Register of Controlled Trials; Manual, Alternative, and Natural Therapy Index System; Index to Chiropractic Literature, Cumulative Index to Nursing and Allied Health Literature; Allied and Complementary Medicine; and PubMed up to June 2006.

RESULTS:
Our search yielded the following results: 8 systematic reviews, 3 meta-analyses, 5 published guidelines, and 1 consensus document. Our direct search of the databases for additional randomized trials did not find any chiropractic randomized clinical trials that were not already included in one or more of the systematic reviews/guidelines. The review of the Manual, Alternative, and Natural Therapy Index System and Index to Chiropractic Literature databases yielded an additional 38 articles regarding various nonpharmacologic therapies such as chiropractic, acupuncture, nutritional/herbal supplements, massage, etc. Review of these articles resulted in the following recommendations regarding nonpharmaceutical 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, vitamins, herbs, and dietary modification.

CONCLUSIONS:
Several nonpharmacologic treatments and manual-type therapies have acceptable evidentiary support in the treatment of FMS.

Clinical and economic characteristics of patients with fibromyalgia syndrome.  [LINK]

Clin J Pain. 2010 May;26(4):284-90.

Lachaine J, Beauchemin C, Landry PA.
Faculty of Pharmacy, University of Montreal, Montreal, Canada. jean.Lachaine@umontreal.ca

OBJECTIVES: Fibromyalgia syndrome (FMS) is a chronic disorder defined by widespread muscle pain and multiple tender points. The objectives of this study were to estimate prevalence of comorbidities, healthcare resources utilization, and costs associated with FMS.

METHODS:
A retrospective cohort study was conducted using data from the Quebec provincial health plans (RAMQ) for a random sample of patients with diagnoses of FMS and a control cohort of patients without FMS, matched for age and gender. Prevalence of comorbidities was estimated. Healthcare resources consumed by FMS and non-FMS patients were identified in terms of visits to physicians, physician's interventions, pain-related medications, nonpain-related medications, and hospitalizations.

RESULTS:
A total of 16,010 patients with 2 diagnoses of FMS were identified, and control patients were randomly selected with a ratio of 1:1. Incidence of most comorbidities was significantly higher in the FMS group and the chronic disease score (3.8 vs. 2.8; ANOVA P <0.001). The proportion of patients with at least 1 comorbidity was 87.4% in the FMS group and 60.1% in the control group (chiP<0.001). The annual number of visits to physician and physician's interventions was 25.1 for FMS and 14.8 for non-FMS patients. The amount paid by the RAMQ was significantly higher for patients with FMS ($4065) compared with patients without FMS ($2766) (ANOVA P<0.001).

DISCUSSION:
Results of this analysis of the RAMQ database illustrate the high prevalence of comorbidities among patients with a diagnosis of FMS and strongly indicate that the economic burden of FMS is substantial

Attitudes towards fibromyalgia: a survey of Canadian chiropractic, naturopathic, physical therapy and occupational therapy students.  [LINK]

BMC Complement Altern Med. 2008 May 31;8:24.

Busse JW, Kulkarni AV, Badwall P, Guyatt GH; Medically Unexplained Syndromes Study Group.
Collaborators (12)

Badii M, Barsky A, Busse JW, Dufton J, Greidanus N, Guyatt GH, Krasnik C, Montori VM, Mills E, Qureshi R, Reid S, Wu P.
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. j.busse@utoronto.ca

BACKGROUND: The frequent use of chiropractic, naturopathic, and physical and occupational therapy by patients with fibromyalgia has been emphasized repeatedly, but little is known about the attitudes of these therapists towards this challenging condition.

METHODS:
We administered a cross-sectional survey to 385 senior Canadian chiropractic, naturopathic, physical and occupational therapy students in their final year of studies, that inquired about attitudes towards the diagnosis and management of fibromyalgia.

RESULTS:
336 students completed the survey (response rate 87%). While they disagreed about the etiology (primarily psychological 28%, physiological 23%, psychological and physiological 15%, unsure 34%), the majority (58%) reported that fibromyalgia was difficult to manage. Respondants were also conflicted in whether treatment should prioritize symptom relief (65%) or functional gains (85%), with the majority (58%) wanting to do both. The majority of respondents (57%) agreed that there was effective treatment for fibromyalgia and that they possessed the required clinical skills to manage patients (55%). Chiropractic students were most skeptical in regards to fibromyalgia as a useful diagnostic entity, and most likely to endorse a psychological etiology. In our regression model, only training in naturopathic medicine (unstandardized regression coefficient = 0.33; 95% confidence interval = 0.11 to 0.56) and the belief that effective therapies existed (unstandardized regression coefficient = 0.42; 95% confidence interval = 0.30 to 0.54) were associated with greater confidence in managing patients with fibromyalgia.

CONCLUSION:
The majority of senior Canadian chiropractic, naturopathic, physical and occupational therapy students, and in particular those with naturopathic training, believe that effective treatment for fibromyalgia exists and that they possess the clinical skillset to effectively manage this disorder. The majority place high priority on both symptom relief and functional gains when treating fibromyalgia.

Fibromyalgia syndrome: practical strategies for improving diagnosis and patient outcomes.  [LINK]

Am J Med. 2010 Jun;123(6):S2.

Arnold LM, Clauw DJ.
Women's Health Research Program, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.

Recent advances in the understanding of the etiology, epidemiology, diagnosis, and treatment of fibromyalgia must be applied in clinical practice to achieve optimal patient outcomes. Current evidence indicates that fibromyalgia is a hyperalgesic state, resulting from a generalized problem with augmented pain processing that likely results from the way the spinal cord and the brain process pain and other sensory information. The descending pain pathway involving serotonin, norepinephrine, and dopamine, as opposed to the descending opioid pain pathway, appears to be selectively attenuated. Newer treatment options targeted at the pain mechanisms include the alpha(2)-delta pregabalin, which binds to the alpha(2)-delta subunit of voltage-gated calcium channels in neurons, and the serotonin-norepinephrine dual reuptake inhibitors duloxetine and milnacipran. The US Food and Drug Administration (FDA) has approved pregabalin, duloxetine, and milnacipran for the management of fibromyalgia. In addition to pharmacologic therapy, patient education, cognitive behavioral therapy, aerobic exercise, and strength and flexibility training are important components of care. An individualized treatment plan should be developed with consideration of each patient's unique combination of fibromyalgia symptoms, functional level, and the presence of the comorbid psychiatric and medical conditions that are common in patients with fibromyalgia. This educational activity provides clinicians with the tools necessary to differentiate fibromyalgia syndrome from other chronic pain conditions through a review of recent clinical data and an application of an advanced understanding of pain pathways. Strategies to manage patients with comorbid conditions are explored, with an emphasis on the importance of a multidisciplinary approach to patient care.

Online Access: http://www.cmeaccess.com/cme/ajm_fibro_program/

Biology and therapy of fibromyalgia: pain in fibromyalgia syndrome.  [LINK]

Arthritis Res Ther. 2006;8(3):208. Epub 2006 Apr 24.

Staud R.
Division of Rheumatology and Clinical Immunology, McKnight Brain Institute, University of Florida, Gainesville, Florida 32610, USA. staudr@ufl.edu

Fibromyalgia (FM) pain is frequent in the general population but its pathogenesis is only poorly understood. Many recent studies have emphasized the role of central nervous system pain processing abnormalities in FM, including central sensitization and inadequate pain inhibition. However, increasing evidence points towards peripheral tissues as relevant contributors of painful impulse input that might either initiate or maintain central sensitization, or both. It is well known that persistent or intense nociception can lead to neuroplastic changes in the spinal cord and brain, resulting in central sensitization and pain. This mechanism represents a hallmark of FM and many other chronic pain syndromes, including irritable bowel syndrome, temporomandibular disorder, migraine, and low back pain. Importantly, after central sensitization has been established only minimal nociceptive input is required for the maintenance of the chronic pain state. Additional factors, including pain related negative affect and poor sleep have been shown to significantly contribute to clinical FM pain. Better understanding of these mechanisms and their relationship to central sensitization and clinical pain will provide new approaches for the prevention and treatment of FM and other chronic pain syndromes.
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