Fibromyalgia is also known as Fibromyalgia Syndrome (FMS) and is difficult to categorize specifically. The World Health Organization loosely categorizes FMS as “other soft tissue disorders,” “not elsewhere classified,” or “unspecified” and classifies FMS with other “unspecified disorders” such as Rheumatism.

FMS presents as chronic pain with tender points (TePs) in soft tissue – especially muscles (although the pain may actually originate in central nervous system neurotransmitters substance P and nerve growth factor) ⁽¹⁾. “It is one among a collection of chronic disorders that often go hand-in-hand. FMS is frequently seen with chronic fatigue syndrome, irritable bowel syndrome, sleep disorders and other chronic disorders” ⁽¹⁾. It also involves allodynia, which is a painful response to a stimulus that would not normally be painful. FMS is non-progressive and not life threatening.

What causes FMS is not yet known. FMS is non-contagious and has recently been considered to have genetic factors contributing to its onset ⁽⁶⁾. It is associated with sleep disorders, fatigue, pain, and tender points ⁽¹⁾ and can start from a trauma, surgery, or some diseases (for example, Lyme disease may cause FMS). Stress and Post Traumatic Stress Disorder also correlate with FMS ⁽⁷⁾.

FMS has a high comorbidity with other disorders that likely trigger it (for instance gluten sensitivity and irritable bowl syndrome ⁽⁸⁾). It also has correlations with abnormalities in dopamine, serotonin and/or human growth hormone and/or accumulations in phosphate and calcium.

“Experts estimate that 3 million to 6 million Americans have Fibromyalgia. Of these, 80% are women” ⁽⁴⁾. A higher diagnosis of women to men may be due to the willingness of women to seek medical assistance as well as the variation in severity of symptoms between genders. Recent studies show women experience more severe symptoms than men ⁽⁹⁾. Also the World Health Organization has released information regarding the health outcome of FMS related to violence against women⁽¹²⁾. FMS usually impacts people between the ages of 20 and 50, though it may occur in childhood.

There is much confusion surrounding FMS due to its wide range of signs and symptoms and overlap with many other conditions. Signs and symptoms are usually gradual and widespread, with a general fatigue that presents in flares and remissions.

“Symptoms of fibromyalgia include:

• Chronic muscle pain, muscle spasms or tightness, and leg cramps
• Moderate or severe fatigue and decreased energy
• Insomnia or waking up feeling just as tired as before sleep
• Stiffness upon waking or after remaining in one position for too long
• Difficulty remembering, concentrating, and performing simple mental tasks
• Abdominal pain, bloating, nausea, and constipation alternating with diarrhea (irritable bowel syndrome)
• Tension or migraine headaches
• Jaw and facial tenderness
• Sensitivity to one or more of the following: odors, noise, bright lights, medications, certain foods, and cold
• Feeling anxious or depressed
• Numbness or tingling in the face, arms, hands, legs, or feet
• Increase in urinary urgency or frequency (irritable bladder)
• Reduced tolerance for exercise and muscle pain after exercise
• A feeling of swelling (without actual swelling) in the hands and feet
• Painful menstrual periods
• Dizziness

Symptoms may intensify depending on the time of day -- morning, late afternoon, and evening tend to be the worst times, while 11 a.m. to 3 p.m. tends to be the best time. They may also get worse with fatigue, tension, inactivity, changes in the weather, cold or drafty conditions, overexertion, hormonal fluctuations (such as just before a menstrual period or during menopause), stress, depression, or other emotional factors” ⁽⁴⁾.

FMS is often misdiagnosed because it loosely resembles other diseases, especially chronic fatigue syndrome. There is no specific test for FMS. Researchers are still working on the best diagnostic methods for FMS pain. These range from general mapping (refer to Appendix A: Fibromyalgia tender point maps) to coding schedules defining widespread pain at a minimum of eleven points (refer to Appendix B: Coding schedules for chronic widespread pain). The American College of Rheumatology considers FMS diagnosed if the above tender points are widely distributed and the pain has been chronic for a minimum of three months ⁽²⁾.

Medications are available to reduce pain, stiffness and promote better mood and sleep. Much responsibility for treatment lies with the patient who has FMS. Improved fitness with exercise along with occupational and physical therapy can reverse atrophy from inactivity. Proper sleep hygiene, techniques in stress reduction, and general relaxation can all help avoid overexertion that can exacerbate symptoms. Massage treatment is discussed below.

A person with FMS can expect to have the same life expectancy as a non-FMS peer. However, FMS requires vigilant lifestyle management in order to minimize relapses. FMS is not curable, but the treatments above can help minimize progression of the syndrome. The old adage “movement equals life” is even more important for a person with FMS who needs to be active, in just the right amount, to maintain wellness. A person with FMS needs a team of arthritis and other professionals on his or her side to help maintain good health. He or she will also need to consider a career that provides a balanced amount of movement utilizing all muscle groups.

FMS indicates massage to client tolerance. Massage has been shown to have beneficial effects in sleep, mood, pain and tender points ⁽¹⁰⁾. “Care must be taken not to over-treat, however, because clients are extremely sensitive to pain and may have accumulations of waste products in the tissues that are difficult to flush out adequately. These people are extremely hypersensitive and easy to over -treat” ⁽¹⁾.

Massage can improve the length of time in Stage IV sleep. “Studies consistently report that subjects who are massaged (with a variety of modalities) experience deeper, more restorative, less disturbed sleep and a reduction in pain-sensitizing neurotransmitters” ⁽⁵⁾.

Special massage techniques are helpful for treating Fibromyalgia. Following is a summary of an eight-step recommendation for “Medical Massage Protocol for Fibromyalgia” ⁽¹¹⁾:

1. Start in the para-vertebral muscles as well as skin and connective tissue with effleurage. An effleurage introduction restores pain receptor thresholds.
2. Remain aware that FMS client’s pain threshold is low; perform connective tissue massage without lubrication in constant communication about sharpness of pain and protective muscular contraction reflex.
3. All strokes directed toward the heart to improve venous blood flow.
4. Breakdown pathological accumulations of calcium gradually increasing pressure during cross-fiber massage.
5. Use kneading techniques to bring about muscle relaxation.
6. In tender point therapy apply enough pressure to detect the clients threshold and then slightly reduce the amount of applied pressure (opposite of trigger point therapy where slightly more pressure is applied). Ischemic pressure should be withdrawn very quickly to reinforce reflex vasodilatation (refer below for reconsideration of this approach).
7. Pos-isometric muscular relaxation as long as the client does not contract a muscle.
8. Periosteal massage is introduced in later sessions to client tolerance.

All eight steps above align with other research regarding massage for Fibromyalgia except for one aspect of step six – removing pressure “very quickly.” Other research emphasizes proceeding carefully and slowly ⁽³⁾. Some fast deep muscle massage will usually worsen symptoms by triggering a rebound contraction. This causes muscles to tighten up worse than they were before the massage, with continued deterioration ⁽³⁾. Taking a slow approach, while involving feedback from the client, is important to remember for a healthy outcome of massage for FMS pain.

FMS sufferers can develop physiological obsession or depression, and it almost always appears as a comorbid disorder. A new approach in scientific medicine is appearing called psychoneuroimmunology (PNI). This approach is researching the numerous hypotheses surrounding FMS and how they fit together.

Appendix A: Fibromyalgia tender point maps. Ruth Werner (2005). “A Massage Therapists Guide to Pathology” (Third Edition). Baltimore, MD. Philadelphia, PA. Lippincott Williams & Wilkins. Page 65 Figure 2.3.
      

Appendix B: Coding schedules for chronic widespread pain. Daniel J. Wallace, Daniel J. Clauw (2005). “Fibromyalgia & Other Central Pain Syndromes.” Philadelphia, PA. Lippincott Williams & Wilkins. p. 19 Figure 3-1. American College of Rheumatology (ACR) and Manchester definitions.
      

        Books:

1. Ruth Werner (2005). “A Massage Therapists Guide to Pathology” (Third Edition). Baltimore, MD. Philadelphia, PA. Lippincott Williams & Wilkins.
2. Daniel J. Wallace, Daniel J. Clauw (2005). “Fibromyalgia & Other Central Pain Syndromes.” Philadelphia, PA. Lippincott Williams & Wilkins.
3. Devin Starlanyl, M.D., Mary Ellen Copeland, M.S., M.A. (1996). “Fibromyalgia & Chronic Myofascial Pain Syndrome; A Survival Manual.” Oakland, CA. New Harbinger Publications, Inc.

Web Sites:
4. WebMD (2008). “Fibromyalgia guide.” http://www.webmd.com/fibromyalgia/guide/understanding-fibromyalgia-basics
5. MassageTherapy.com (2008). “Sleep: Have You Had Your Eight Hours?” http://www.massagetherapy.com/articles/index.php/article_id/1236

Journal articles:
6. Buskila D, Sarzi-Puttini P (2006). "Biology and therapy of fibromyalgia. Genetic aspects of fibromyalgia syndrome." Arthritis Research & Theapy. 8 (5): 218.
7. Amital D, Fostick L, Polliack ML, Segev S, Zohar J, Rubinow A, Amital H (2006). "Posttraumatic stress disorder, tenderness, and fibromyalgia syndrome: are they different entities?" Journal of Psychosomatic Research 61 (5): 663-9.
8. Frissora CL, Koch KL (2005). "Symptom overlap and comorbidity of irritable bowel syndrome with other conditions." Current gastroenterology reports 7 (4): 264-71.
9. Muhammad B. Yunus (2001). “The role of gender in fibromyalgia syndrome.” Current Rheumatology Reports 3 (2): 128-134.
10. Field, Tiffany; Diego, Miguel; Cullen, Christy; Hernandez-Reif, Maria; Sunshine, William; Douglas, Steven (2002). “Fibromyalgia Pain and Substance P Decrease and Sleep Improves After Massage Therapy.” Journal of Clinical Rheumatology 8(2):72-76.
11. Ross Turchaninov, M.D., Boris Prilutsky, M.A. (Feb-Mar 2004). “Massage Therapy, a beneficial tool in treating Fibromyalgia.” Feb.-Mar. 86.

Other resource:
12. United Nations Secretary General, Kofi Annan (1999). “Fibromyalgia As a health outcome of violence against women. Fact Sheet: Women, Health and Development Program.”

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