Fibromyalgia is an incredibly complex, widespread, and disabling neuromusculoskeletal disorder. Fibromyalgia affects between 2-8% of the American population, somewhere between 6 million to 25 million individuals (1). A literature search of the National Library of Medicine of the United States using the key work “fibromyalgia” will locate 8,489 citations (May 8, 2015).
Daniel Clauw, MD, is a Professor of Anesthesiology, Medicine (Rheumatology) and Psychiatry at the University of Michigan. In May, 2015, Dr. Clauw published a study in the journal Mayo Clinical Proceedings, titled (2):
Fibromyalgia and Related Conditions
The abstract from this publication includes these points:
“Fibromyalgia is the currently preferred term for widespread musculoskeletal pain, typically accompanied by other symptoms such as fatigue, memory problems, and sleep and mood disturbances, for which no alternative cause can be identified.”
“Earlier there was some doubt about whether there was an ‘organic basis’ for these related conditions, but today there is irrefutable evidence from brain imaging and other techniques that this condition has strong biological underpinnings, even though psychological, social, and behavioral factors clearly play prominent roles in some patients.”
“The pathophysiological hallmark is a sensitized or hyperactive central nervous system that leads to an increased volume control or gain on pain and sensory processing. This condition can occur in isolation, but more often it co-occurs with other conditions now being shown to have a similar underlying pathophysiology (eg, irritable bowel syndrome, interstitial cystitis, and tension headache) or as a comorbidity in individuals with diseases characterized by ongoing peripheral damage or inflammation (eg, autoimmune disorders and osteoarthritis).”
“The term centralized pain connotes the fact that in addition to the pain that might be caused by peripheral factors, there is superimposed pain augmentation occurring in the central nervous system.”
“It is important to recognize this phenomenon (regardless of what term is used to describe it) because individuals with centralized pain do not respond nearly as well to treatments that work well for peripheral pain and preferentially respond to centrally acting analgesics and nonpharmacological therapies.”
It is the “nonpharmacological therapies” that are emphasized in this review.
The world’s leading authority on fibromyalgia is Fredrick Wolfe, MD. Dr. Wolfe is a Clinical Professor of Medicine at the University of Kansas School of Medicine. A search of the National Library of Medicine of the United States using the key words “wolfe f AND fibromyalgia” finds 119 articles.
In 1990, Dr. Wolfe and colleagues published the Criteria for the Classification of Fibromyalgia for the American College of Rheumatology (3). To complete this task, Dr. Wolfe and colleagues studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Trained, blinded assessors performed interviews and examinations. The authors concluded that the clinical diagnosis of fibromyalgia required both of the following:
These fibromyalgia diagnostic criteria became the standard for the next 20 years, from 1990 to 2010. The location of the 18 specific tender point sites is included below:
In 2010, Dr. Wolfe and colleagues updated the Criteria for the Classification of Fibromyalgia for the American College of Rheumatology (4). There had been a growing concern in the original diagnostic criteria for fibromyalgia that relied significantly on the presence of tender points. This is because of the fact that women in general are more sensitive to pressure point tenderness than are men. Relying on pressure point tenderness could cause a sex bias, which might account for the finding that about 90% of diagnosed fibromyalgia sufferers are women. It had become apparent that the “focus on tender points was not justified.” (5) Consequently, Dr. Wolfe and colleagues developed simple, practical criteria for clinical diagnosis of fibromyalgia that did not require a tender point examination, and to provide a severity scale for characteristic fibromyalgia symptoms (4). Specifically, they used an amalgamation of two prior developed assessment protocols:
1) The Widespread Pain Index (WPI)
This is a measure of the number of painful body regions (a total of 19 locations).
2) The Symptom Severity (SS) Scale.
This scale is designed to grade adjunct fibromyalgia symptoms, specifically cognitive symptoms (trouble remembering or thinking), un-refreshed sleep, fatigue, and number of somatic symptoms.
A sample of the questionnaire is included below.
The authors concluded that this simple form correctly classified 88.1% of fibromyalgia cases, and that classifying fibromyalgia “does not require a physical or tender point examination.” This approach to the diagnosis of Fibromyalgia Syndrome continues to be supported (6). To diagnose fibromyalgia, patients should:
New Fibromyalgia Diagnostics 2010
All Three Are Needed For the Diagnosis of Fibromyalgia Syndrome
1) Either WPI ≥ 7 and SS ≥ 5 OR WPI 3 – 6 and SS ≥ 9
2) Symptoms are present and essentially unchanged for ≥ 3 months
3) There is no alternative explanation for the pain
Widespread Pain Index
Score: 1 For Each Spot
0
1
2
3
No Problem
Mild
Moderate
Severe
No Problem
Mild
Moderate
Severe
No Problem
Mild
Moderate
Severe
None
Few
Moderate
Many
Total Symptom Severity (SS): (0-12)
Recent studies have assessed the influence of spinal mobilization and/or manipulation on the clinical status of patients with fibromyalgia.
In 2014, Michel Reis and colleagues from the School of Medicine, Federal University of Rio de Janeiro, Brazil, published a study in the journal
Rehabilitation Research and Practice titled (7):
Effects of Posteroanterior Thoracic Mobilization on Heart Rate Variability and Pain in Women with Fibromyalgia
These authors note that fibromyalgia is classically characterized by chronic pain, fatigue, depression, insomnia, and reduced cognitive performance. In addition, fibromyalgia is also associated with cardiac autonomic abnormalities.
Heart rate variability is used to investigate cardiovascular autonomic abnormalities. It is a simple, sensitive, and noninvasive tool. Heart rate variability is reduced in fibromyalgia with increased sympathetic tone and activity. It is thought that there is a relationship between increased sustained sympathetic activity and tone and the symptoms of fibromyalgia. Studies suggest autonomic imbalance mechanistically contributes to the symptoms of fibromyalgia. The autonomic imbalance for fibromyalgia is characterized by sympathetic hyperactivity at rest.
Sympathetic hyperactivity may also be responsible for frequent complaints of cold extremities in fibromyalgia patients. Studies have shown that fibromyalgia may be related to changes in autonomic tone, shifting toward an increase in sympathetic activity.
The purpose of this study was to evaluate the effects of one session of a posteroanterior (P-A) glide technique on both autonomic modulation and pain in woman with fibromyalgia. The study used 20 women, half with diagnosed fibromyalgia. This is the first study to demonstrate the effect of a posteroanterior glide mobilization to the thoracic spine on autonomic modulation in patients with fibromyalgia. The mobilization technique used in this study was passive P-A push, sustained for 60 seconds at the T1-T2 spinal level, “corresponding to the thoracic sympathetic preganglionic neurons.”
The upper thoracic mobilization was able to improve heart rate variability and improve autonomic profile through increased vagal activity. In women with fibromyalgia and impaired cardiac autonomic modulation, one session of spinal mobilization was able to acutely improve heart rate variability. In addition, the authors note that, in agreement with other studies, manual therapy protocols are effective in improving pain intensity in fibromyalgia patients. Their conclusions include:
This study shows that “patients with fibromyalgia have increased sympathetic activity and decreased activity in the vagal control of heart rate.” “This sympathetic excitation could contribute to the diffuse pain and tenderness at specific points experienced by patients with fibromyalgia.”
“The potentially significant impact of our findings is the demonstration that only one session of this manual intervention to the thoracic spine was able to modify heart rate variability in women with fibromyalgia.”