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Research-Based Massage for Fibromyalgia Syndrome (2 CE Hours)

This course is approved for 2 hours of Continuing Education for Massage Therapists by the Texas Department of State Health Services: Approved Provider: MARK SCOTT URIDEL CE0009 and by the NCBTMB for Nationally Certified Massage Therapists.

Learning Objectives: After reading this course, you will...

  1. be able to describe the history of fibromyalgia syndrome and list the 2 main criteria for this disorder.
  2. be able to list the prevalence of associated symptoms in fibromyalgia syndrome according to the research.
  3. be able to list the fibromyalgia tender points.
  4. be able to explain the difference between fibromyalgia, chronic fatigue and myofascial pain.
  5. be able to list the various different research hypotheses that described the etiologies of fibromyalgia.
  6. be able to explain different interventions proven by research to be effective in the treatment of fibromyalgia.
  7. be able to describe different research proving massage effective in the treatment of fibromyalgia.

 

Research-Based History of Fibromyalgia
Although conditions that are similar to fibromyalgia have been reported throughout documented history, fibromyalgia syndrome (FMS) has been specifically categorized by modern clinicians.  The history of this process is interesting and sheds light on the current definition of fibromyalgia.  In the mid 1700’s in Europe, the term rheumatism was used to describe a painful inflammatory process involving the connective tissue.  In the mid 1800’s in France, Valleix noted painful points on patients that, when palpated, referred pain to other body regions.  He used the term neuralgia to describe this phenomenon.1  In the mid-19th century, Mezger of Amsterdam developed massage techniques for treating nodules and taut cord-like bands associated with neuralgia.  In 1858, Inman remarks in the British Medical Journal that radiating pain in these conditions were not associated with nerve routes and called the condition myalgia.  Helleday, a Swedish physician, described these nodules as part of “chronic myitis.”  Cornelius, a German physician, in 1903 demonstrated that external influences including climate, physical exertion or emotional stress could exacerbate these hyper-active nodes or tender points.(1)  Sir William Gowers reported in the British Medical Journal (1:117-121) that the word fibrositis be used believing that inflammation was a key component.  In the early 1900’s, the condition was given various names by various clinicians (myofascitis, myofibrositis, muscular rheumatism, and neuro-fibrositis).(1)  In 1940, Steindler, an American orthopaedic physician injected “trigger points” with Novocain to relieve sciatica.(2)  Janet Travell followed his work and popularized the term myofascial pain syndrome.(3)  The term fibromyalgia was first popularized by Yunus, et al. in 1981.(4)  In 1986, Simons found overlap in the symptoms of myofascial pain syndrome and fibromyalgia.(5)  In the mid-1980’s, clinicians were beginning to experiment with various treatments for patients with fibromyalgia.  Goldenberg, et al. demonstrated that low doses of antidepressants improved sleep, reduced morning stiffness and alleviated pain.(6)  McCain and Scudds  showed some benefit of cardiovascular training in the reduction of symptoms of fibromyalgia.(7)

In 1990, the American College of Rheumatology (ACR) creates a classification system and official definition of fibromyalgia: 

1. History of widespread pain.
Definition.  Pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist, and pain below the waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. "Low back" pain is considered lower segment pain. (8)

2. Pain in 11 of 18 tender point sites on digital palpation. (note that many of these tender points are bilateral see image below)

Definition.  Pain, on digital palpation, must be present in at least 11 of the following 18 sites:
Occiput:  bilateral, at the suboccipital muscle insertions.
Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7.
Trapezius: bilateral, at the midpoint of the upper border.
Supraspinatus:  bilateral, at origins, above the scapula spine near the medial border.
Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces.
Lateral epicondyle:  bilateral, 2 cm distal to the epicondyles.
Gluteal:  bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
Greater trochanter:  bilateral, posterior to the trochanteric prominence.
Knee:  bilateral, at the medial fat pad proximal to the joint line.
Digital palpation should be performed with an approximate force of 4 kg.
For a tender point to be considered "positive" the subject must state that the palpation was painful. "Tender is not to be considered "painful."

Fibromyalgia Tender Points

The main problem with the definition and criteria for diagnosis of FMS is that many people have widespread pain including many of these test points.  However, if they do not have 11 out of 18 painful test points, they do not have FMS.  So then what do they have?  In 1992, the Second World Congress on Myofascial Pain and Fobromyalgia came to a consensus that people with FMS may present with fewer than 11 painful points.  They agreed with the ACR definition and added to the definition symptoms including persistent fatigue, morning stiffness and sleep disturbances.  In this declaration, the consensus was reached that if a patient had all of the symptoms of FMS, but did not meet all of the required painful points, then they could be diagnosed with “possible FMS” and reassessed on follow-up.  The importance of meeting the “11 out of 18 rule” is related to confirmation of diagnosis for purposes of reimbursement, disability benefits and possible differential diagnosis.  Possible differential diagnoses are Myofascial Pain Syndrome (MPS), which involves multiple myofascial trigger points (TrP), and Chronic Fatigue Syndrome (CFS), in which patients have most of the symptoms of FMS, with a greater amount of fatigue rather than pain.  The document also reported that FMS can be a part of a larger complex of symptoms, including headaches, irritable bladder, irritable bowel, dysmenorrhea, sensitivity to cold, restless legs, odd patterns of numbness and tingling, sleep disturbance and intolerance to exercise.  In addition to these physical symptoms, the report identified psychological components of FMS as anxiety and depression.(9)    The prevalence of these associated conditions is outlined in the table below , which represents data from a 1997 Fibromyalgia Network Survey of 6000 patients with FMS:

Prevalence of Associated Conditions


Condition

% in FMS

% in general population

Chronic headache

59%

5%

Irritable bowel or bladder

64%

10%

Dysmenorrhoea

60%

15%

Multiple chemical sensitivities

40%

5%

Restless legs

30%

2%

Memory/concentration difficulty

86%

undetermined

Waking tired in the morning

89%

undetermined

Sleep disturbance

94%

undetermined

Intolerance to exercise

89%

undetermined

Depression (non-clinical)

94%

5%

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