Identifying, Managing cases of Fibromyalgia
By: Dale J. Buchberger, PT, DC, CSCS, DACBSP
In chiropractic and physical therapy practice patients usually visit the office with a complaint of pain that has started to affect their ability to function on a daily basis. Therefore it is common for any given patient to add the phrase, “I also have fibromyalgia” during the course of their history. Fibromyalgia as defined by the US Department of Health and Human services is a common and chronic disorder characterized by widespread pain, diffuse tenderness and a constellation of symptoms ranging from sleep disorders to irritable bowel syndrome. It is this constellation of symptoms that makes accurate diagnosis difficult and over diagnosis common.
Roughly 5 million Americans over the age of 18 are affected with fibromyalgia and 80-90% of those are women. Women who have a family member previously diagnosed have an increased risk of being diagnosed themselves. This maybe because of heredity, shared environmental factors or a combination of both. While the actual cause of fibromyalgia is unknown several factors have been associated with it. These include but are not limited to physically or emotionally stressful or traumatic events, motor vehicle accidents, repetitive strain injuries, illness or even spontaneous onset. The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) has identified several genes that appear more commonly in patients diagnosed with fibromyalgia. The current theory is that a particular gene may result in the patient reacting painfully to submaximal stimuli that most individuals would not find to be painful. Essentially patients diagnosed with fibromyalgia process pain differently and subsequently normal sensations can be perceived as painful.
Patients with fibromyalgia have characteristically seen several doctors of different disciplines before receiving a diagnosis of fibromyalgia. One study found 46% had consulted 3 to 6 healthcare providers prior to diagnosis. As mentioned previously, patients with fibromyalgia present with many coexisting disorders with overlapping symptom patterns. Since there is no available “test” for fibromyalgia it is often a diagnosis by exclusion of other “testable” causes of the presenting symptom patterns. This generally creates a lengthy fact finding journey for the patient with stops in many different doctors offices. Since the mortality rate of fibromyalgia is extremely low, it is not at the top of most diagnostic flow charts. Typically, sensory disturbances are rarely diagnosed by the initial practitioner or early in onset. Fibromyalgia falls into this category. It should also be pointed out that depression is a frequent comorbidity of fibromyalgia. Some researchers feel that chronic stress maybe related to post traumatic stress from possible emotional trauma earlier in life regardless of perceived significance.
The American College of Rheumatology (ACR) has established the following diagnostic criteria: a history of “widespread pain” or pain in all four quadrants of the body (left and right sides of the body and above and below the waist) for more than 3-years with the presence of diffuse tenderness. The patient must have pain at 11 of 18 specifically established tender points in the body. This is not a perfect diagnostic criterion and leaves a lot of room for subjective alteration.
Currently there is no “cure” for fibromyalgia and therefore there really is no treatment only management. It is key for patients having been diagnosed with fibromyalgia to understand the difference between treatment and management. Treatment implies that the disorder will be resolved once the treatment is applied. Management recognizes that the disorder will not resolve and will require recurrent intervention to keep the symptoms related to the disorder at a level that allows the patient to function personally and occupationally. Fibromyalgia is a condition that is managed not cured.
Management of fibromyalgia involves combining pharmaceutical and non-pharmaceutical methods. Physical aerobic exercise is the first line intervention that improves functional capacity and sense of well-being in patients with fibromyalgia. Secondly, individualized programs of cognitive behavioral therapy (CBT) with an emphasis on achieving competence in relaxation methods and improving emotional self-awareness. Thirdly, there are several pharmaceutical interventions that have been shown to reduce pain including Lyrica, Ultram, Cymbalta and Zoloft. There is no single most effective modality for managing fibromyalgia. These interventions must be used in combination on some level to achieve the best possible level of pain control and functional restoration.
There are alternative interventions that have been looked at without any conclusive evidence of success. These include but are not limited to massage, movement therapies, chiropractic interventions, acupuncture and dietary supplements. Diets that focus on reducing chronic low-level inflammation and reduce bioengineered and processed foods such as the “paleo” diet may have promise for further study.
Good management of fibromyalgia requires a healthcare team and a patient that recognizes the need for serious lifestyle changes including aerobic exercise, CBT, pain management, dietary changes and communication with family members and healthcare providers. Patients with fibromyalgia cannot be managed in medical or pharmaceutical isolation and expect to improve.
