What is Fibromyalgia?
Fibromyalgia, also called fibromyalgia syndrome (FMS), is a long-term condition that causes widespread pain all over the body.
Why do People with Fibromyalgia have widespread pain?
The Central Nervous System and Central Sensitization
Abnormalities in the central nervous system are associated with the intense widespread enhancement of pain in fibromyalgia. Where there is imbalance in the neuropeptides that regulate pain sensitivity in the central nervous system. In particular it has been found that there is sustained 2- to 3-fold elevation of Cerebrospinal fluid substance P and other neuropeptides that facilitate pain in patients with fibromyalgia, as well as diminished metabolites of Cerebrospinal fluid serotonin, norepinephrine, and dopamine, which act to inhibit pain perception (Hawkins, 2013).
Pain is the sine qua non of fibromyalgia, and patients with this disorder experience widespread allodynia (perception of pain caused by a stimulus that should not normally cause pain) and hyperalgesia (exaggerated sense of pain in response to a noxious stimulus) (Hawkins, 2013).
Musculoskeletal Soft Tissues
The connective tissue overlying the musculoskeletal soft tissues known as fascia can be dysfunction in Fibromyalgia. The fascial dysfunction in fibromyalgia leads to widespread pain and central sensitization (Liptan et al. 2010).
Sign and Symptoms of Fibromyalgia
Differentiating Between Fibromyalgia and Myofascial Pain Syndrome
In accordance with guidelines of the American College of Rheumatology (ACR), the Fibromyalgia Syndrome is diagnosed on the basis of two basic criteria. The first is a generalized pain stated during the anamnesis (that is: occuring on the left and right side, below and above waist, and concerning at least one part of spine and chest). The second criterion is a pressure achiness of at least 11 out of 18 tender points (TP) of precisely determined location (Chochowska et al. 2015).
Myofascial Pain Syndrome is defined as as sensory, motor and autonomic complaints, caused by the occurrence of trigger points (TrP). Presence of TrP makes up minimal criteria provided by Simons and collaborators – TrP have to occur in order to enable recognizing MFPS. The other predicates are: palpable tense muscle strand (so called “tense ribbon”) in the area of which a presence of at least one painful nodule (papule) is stated. Subsequently in the area of aforesaid nodule there is a hypersensitive point which – if being pressed, scratched by needle, or when only the tissues surrounding it are stretched – cause pain disproportionate to the intensity of stimulus and frequently radiating. Such pain is recognized by the patient as the one experienced before. This sensitive point is defined as a trigger point (Chochowska et al. 2015).
Fibromyalgia massage may improve pain, anxiety, depression, and sleep disturbance by complex interplay of both physical and mental modes of action (Li et al. 2014).
Myofascial release can be used to treat fascial restrictions that occur with fibromyalgia, where the aim of treatment focuses primarily on muscle relaxation. The involves direct mechanical stimulation of connective tissue can potentially reverse connective tissue fibrosis in fibromyalgia. Myofascial fibrotic changes can theoretically be treated by breaking up excessive collagen adhesions through soft-tissue and myofascial release techniques. If there is excess tension in the fascial system in fibromyalgia due to chronic sympathetic nervous dominance, manual therapy may also help reduce that tension (Liptan et al. 2010).
What Style of Massage Works Best for Fibromyalgia?
There is moderate evidence that myofascial release has positive effects on multiple fibromyalgia symptoms, especially pain, anxiety and depression, for which the effect sizes are clinically relevant. Effects on pain and depression were observed in the medium and short terms, respectively. When comparing connective tissue massage or shiatsu with educational approaches, limited evidence supports the application of these styles of massage. Manual lymphatic drainage might be superior to connective tissue massage in terms of stiffness and depression. Swedish massage may not be beneficial for fibromyalgia. Overall, most styles of massage therapy consistently improved the HRQoL of fibromyalgia patients (Yuan et al. 2015).
All of these styles of massage can be performed by the Osteopaths at Cam Osteopathy Ltd.
How Does Massage Effect Fibromyalgia
Effect of Massage on the Peripheral Microcirculation and Musculoskeletal Soft Tissues
When massage therapy is delivered to soft and connective tissues, local biochemical changes would be stimulated. This helps to improve muscle flexibility, and modulate local blood and lymph circulation. As a result, local nociceptive and inflammatory mediators may be reabsorbed (Li et al. 2014).
Massage treatment helps improve the microcirculation of the muscles and fascia causing better fluid exchange bringing more nutrients to the soft tissues and prevents the accumulation of inflammation. This is because the connective tissue (fascia) encasing the muscles in fibromyalgia develops entrapment patterns can appear when a body segment stops receiving appropriate stimuli, establishing a pathological process with deficient circulation and limitation in nutrient supply to the fundamental substance of connective tissue, with its consequent densification. Because dense tissue is hypomobile, this situation leads to movement limitations (Castro-Sánchez et al. 2011). Massage treatment can also help break down the dense connective tissue.
Effect of Massage on the Central Nervous System
Some studies found that massage therapy improved pain by modulating serotonin levels in patients with FM. The local effects may change neural activity at the spinal cord segmental level, which is responsible for both mood and pain perception. Some studies maintained that massage therapy resulted in the reduction in the H-reflex. A large reduction in the H-reflex would seem to be desirable, because spinal hyperexcitability is associated with a variety of chronic pain syndromes (Li et al. 2014).
How Often Might I Need Fibromyalgia Massage?
Everyone’s requirements are different and treatment is tailored to your needs. Though it has been suggested that fibromyalgia massage needs to be painless and performed once or twice a week, with intensity increasing gradually according to symptoms (Kalichman, 2010).
Evidence Base for Fibromyalgia Massage?
A systematic review found the positive evidence that massage therapy with duration 5 weeks had beneficial immediate effects on improving pain, anxiety, and depression in patients with FM. Massage therapy should be one of the viable complementary and alternative treatments for FM. However, given fewer eligible RCTs in subgroup meta-analyses and no evidence in follow-up effects, large-scale RCTs with long follow-up are warrant to confirm the current findings of massage therapy for FM (Li et al. 2014).
Where as a long term, 20-week massage-myofascial release program significantly improved the pain, anxiety, quality of sleep, and quality of life in FMS patients. The treatment reduced the sensitivity to pain at sensitive points, mainly at the lower cervicals, gluteal muscles, and right greater trochanter (Castro-Sánchez et al. 2011).
Multi-Disciplinary Management of Fibromyalgia
Ultimately managing this condition is going to involve multiple treatments and therapies, so this will involve psychologists to do cognitive behavioral therapy, exercise and medication prescribed by a GP or rheumatology specialist doctor.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (to address maladaptive thoughts) and stress-reduction techniques have been shown to be effective in some patients. Recognizing and addressing behavioral issues of catastrophizing behavior and learned helplessness can aid in focusing treatment on self-management technique (Hawkins, 2013).
Aerobic exercise and muscle strength training can reverse deconditioning and improve sleep, pain, and function in patients with fibromyalgia. Patients who choose activities they like (eg, walking, pool exercise, group activities) and who start at low levels of exercise are more likely to be successful in managing their fibromyalgia in the long term. Exercise intensity should be increased very slowly to avoid injury and flares of pain, which may cause the patient to abandon the activity. Patients with good coping skills are most likely to adhere to an exercise program (Hawkins, 2013).
Antidepressants appear to exert their effects by modulating serotonin and norepinephrine pathways. Tricyclic antidepressants (TCAs) such as amitriptyline, desipramine, and nortriptyline have been shown in short-term studies to improve pain, sleep, fatigue, and overall sense of well-being. However, they are associated with more adverse effects when used at higher doses.Tricyclic antidepressants are often prescribed initially for patients with fibromyalgia who do not have depression (Hawkins, 2013).
Pregabalin, which is approved by the US Food and Drug Administration for the management of fibromyalgia, and gabapentin appear to inhibit the release of pain pathway neurotransmitters, including substance P and glutamate.They have been demonstrated to improve pain, sleep, fatigue, and overall quality of life in patients with fibromyalgia (Hawkins, 2013).
Combined Treatment Safety
One pilot study showed that combined Osteopathic Manual Manipulative treatment and gabapentin are safe and clinically efficacious treatment of pain and other constitutional and somatic symptoms associated with fibromyalgia (Marske et al. 2018).
Massage Treatment at Cam Osteopathy
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Castro-Sánchez AM, Matarán-Peñarrocha GA, Granero-Molina J, Aguilera-Manrique G, Quesada-Rubio JM, Moreno-Lorenzo C (2011). Benefits of massage-myofascial release therapy on pain, anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia. Evid Based Complement Alternat Med. 561753.
Chochowska M, Szostak L , Marcinkowski JT , Jutrzenka-Jesion J (2015). Differential diagnosis between fibromyalgia syndrome and myofascial pain syndrome. Journal of Pre-Clinical and Clinical Research, Vol 9, No 1, 82-86.
Hawkins RA (2013). Fibromyalgia: a clinical update. J Am Osteopath Assoc. Sep;113(9):680-9.
Kalichman L (2010). Massage therapy for fibromyalgia symptoms. Rheumatol Int. Jul;30(9):1151-7
Li YH, Wang FY, Feng CQ, Yang XF, Sun YH (2014). Massage therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. PloS One. Feb 20; 9(2):e89304
Liptan GL (2010). Fascia: A missing link in our understanding of the pathology of fibromyalgia. Journal of Bodywork and Movement Therapies, Volume 14, Issue 1, January, Pages 3-12
Marske C, Bernard N, Palacios A, Wheeler C, Preiss B, Brown M, Bhattacharya S, Klapstein G (2018). Fibromyalgia with Gabapentin and Osteopathic Manipulative Medicine: A Pilot Study. J Altern Complement Med. Jan 3
Yuan SL, Matsutani LA, Marques AP (2015). Effectiveness of different styles of massage therapy in fibromyalgia: a systematic review and meta-analysis. Man Ther. Apr; 20(2):257-64.