When Mary Shomon’s doctor touched her, she cringed in pain. “I asked my doctor to check my fibromyalgia trigger points, and sure enough, I had pain levels that went through the roof at nearly every single spot she tested,” says the suburban Washington, D.C. resident. After suffering through bouts of chronic fatigue syndrome, chronic Epstein-Barr virus, two rear-end car crashes, and whiplash, this mother of two was feeling pretty bad. And then the muscle pain started.
“I met the criteria for a diagnosis of fibromyalgia, but my doctor and physical therapist didn’t really think the official diagnosis was all that critical,” says this previously energetic professional journalist. No matter what anyone called it, conventional medicine offered almost nothing for Shomon.
Instead, she sought out alternative treatments for her fibromyalgia pain. “My doctor’s recommended treatment was to continue the combination of myofascial release bodywork, acupuncture, thyroid hormone replacement, natural sleeping aids, and key dietary and lifestyle changes that I already had in progress,” says this patient turned alternative medicine advocate.
Pain as a Way of Life
What does fibromyalgia really feel like? “Imagine that last night you drank two glasses of wine more than you would have liked, but no water, and eaten no food. You went to bed late, and got up early. You are stiff, achy, and tired—all the time,” says Chanchal Cabrera, member of the National Institute of Medical Herbalists, a prestigious British herbalist, fibromyalgia patient, and author of Fibromyalgia: A Journey Toward Healing (McGraw-Hill, 2002).
Fibromyalgia syndrome (FMS) is an enigma, and just attempting to digest the swamp of contradictory research and opinions might become a headache of migraine proportions, but this much we know: it involves serious, widespread muscular pain and fatigue. And, if that’s not enough, there’s the loose assemblage of chronic symptoms, including foggy thinking, PMS, and allergies, that’s fairly consistent between patients, but has no obvious laboratory tests. Strangely, it overlaps with many other diseases—70 percent of patients also have irritable bowel syndrome, for example. When people get sick, with a cold, or after heavy exercise, symptoms often worsen.
Many people feel the worst ache at certain “tender points,” and 18 very common ones actually define the disease. Yet, Cabrera sees no significant correlation with the location or pattern of tender points and takes issue with the whole concept of tender points as a way to diagnose FMS. “It’s ridiculous to base diagnosis on 18 specific points,” she says. “It’s not a fair way to diagnose. It’s just a good clue. A person might have 50 or 100 points and they move around.”
The misery of FMS affects about 2 percent of Americans, making it the second most common musculoskeletal disorder after osteoarthritis. Accounting for 10–30 percent of all rheumatology consultations, FMS appears mainly between the ages of 35 and 55 and occurs 7–10 times more frequently in women.
The Body Blows a Fuse
The cause of FMS remains elusive. But that’s probably because the huge spectrum of symptoms actually starts from many causes. Jacob Teitelbaum, MD, medical director of the Annapolis Center for Effective CFS/Fibromyalgia Therapies, in Annapolis, Maryland, equates FMS to the body “blowing a fuse” if the energy account becomes overdrawn. “The blown fuse is hypothalamus suppression,” Teitelbaum maintains. “The hypothalamus controls sleep, hormonal function, temperature, and autonomic functions, such as blood pressure and blood flow. The hypothalamus uses more energy for its size than any other organ. When there is an energy shortfall, it goes offline first. FMS has no one cause,” says Teitelbaum, himself a former FMS patient. The hypothalamus decreases its function as a protection in the face of what it perceives as overwhelming stress, which can stem from infection, injury, or emotions. FMS patients have genetic differences in the stress-handling ability of their hypothalamus, pituitary, and adrenal regulation (the HPA axis). The muscles end up short of energy and in pain.
Can We Turn to Conventional Medical Treatment?
The stigma surrounding fibromyalgia still surprises Shomon. “Those of us who have suffered through it know, from firsthand experience, that it is a very real condition. We didn’t dream it up, wish it upon ourselves, or develop some psychosomatic syndrome, and we can’t just think it away, buck up, and feel better, or ‘get over it’ by sheer determination. Some doctors—and some of our families and friends—even think that fibromyalgia is psychosomatic, evidence of laziness, malingering, or is due to some inherent emotional or character weakness. The fact that fibromyalgia is not visible contributes to the lack of respect you may experience from others,” she says.
Still, many people do better when they find the proper pharmacological regimen. Conventional treatment employs medications to diminish pain and improve sleep, exercise programs that improve muscle and cardiovascular fitness, relaxation techniques to ease muscle tension and anxiety, and lifestyle educational programs to help comprehend the syndrome and manage the symptoms and limitations for life. Medical practitioners may use nonsteroidal anti-inflammatory drugs, such as ibuprofen, analgesics for pain, and tricyclic antidepressants, to improve sleep and blunt pain. Amitriptyline emerges as a good choice for FMS. Teitelbaum’s two current favorites are Lyrica (Pregabalin) for pain and Xyrem (GHB) for sleep and pain.11
Noninvasive Treatments that Work
Shomon has fibromyalgia with hypothyroidism. But she feels well now. Starting with bodywork, she surmounted the pain slowly. Turning to herbs to bring restorative sleep, she also took natural hormones to support her endocrine functions. Now, too, she follows a low-glycemic diet with lots of vegetables, fruits, and good protein. “Since that time, I’ve incorporated a Pilates-based exercise program, added more stress-reduction and mind-body efforts, and I no longer have pain,” Shomon declares. These days, she writes popular health books, advocates for patients, and keeps up with an agenda of interviews and appearances.
Massage therapy is excellent for stress management and relaxation. “Fibromites” find bodywork to be the top therapy for providing short-term relief and long-term improvement. This theme gets repeated over and over in patient interviews.
Massage increases flexibility and oxygenation of the muscles and brings fresh blood and lymph to the sore areas. Many FMS patients gain tremendous relief from massage therapy with the addition of herbal ointments. Clinical investigation found that, surprisingly, menthol-based ointment, applied directly to the tender points, was the most effective out of several types tried.13Capsaicin (derived from cayenne) ointment, applied to tender points, is also popular.
Muscular pain is the key feature of fibromyalgia, but FMS is probably not primarily a musculoskeletal problem. It is becoming increasingly clear that FMS develops as a result of nervous system imbalances caused by any of the accumulation of genetic and acquired factors. Biomechanical techniques, including massage, ease musculoskeletal discomfort, pain, and restriction, and this area is a critical component of a balanced FMS program that aims to restore balance and health in the short term and long term.
Often combined with ultrasound and/or the application of hot/cold packs, massage may be performed in a number of ways and is useful in soothing and increasing blood circulation to tense, sore muscles. It can also help reeducate muscles and joints that have become mechanically misaligned. Breathing dysfunction is essentially universal in fibromites. Massage, along with breathing training, can help restore proper breathing patterns.
A study of people with fibromyalgia published in The Journal of Clinical Rheumatology found that those who received 30 minutes of massage two times a week for five weeks had less anxiety and depression and lower levels of stress hormones. Over time, they reported less pain and stiffness, less fatigue, and less trouble sleeping. The study concluded what has become a repeated theme: massage therapy is the most effective therapy in these patients.
Another study compared massage with relaxation therapy for FMS. Twenty-four adult fibromyalgia patients received 30-minute treatments twice a week for five weeks. Both groups showed a reduction in anxiety and depressed mood immediately after the first and last therapy sessions. Only the massage therapy group reported an increase in the number of sleep hours and a decrease in their sleep movements over the duration of the study. Substance P levels decreased, and there were lower disease and pain ratings and fewer tender points in the massage therapy group.
The European Journal of Pain published a paper on connective tissue massage in FMS. This was a random study of 48 individuals diagnosed with fibromyalgia (23 in the treatment group and 25 in the reference group). The series of 15 connective tissue massage treatments created a pain-relieving effect of 37 percent, reduced depression and the use of analgesics, and positively effected quality of life. The treatment effects emerged gradually over the 10 weeks. Three months after treatment about 30 percent of the pain-relieving effect was gone, and six months after treatment, the pain was back to about 90 percent of the basic value. Again, this illustrates the need for consistency.
A German study found that massage therapy was one of the four factors found to create the highest degree of satisfaction in patients. A nurse practitioner study used a questionnaire to collect information regarding complementary treatments and their effectiveness. Massage was rated among the most effective, along with literature, aromatherapy, support groups, and heat.
There is evidence that whiplash injury causes damage in the neck that may trigger FMS. This alone speaks to the need to investigate bodywork treatments to treat whiplash before it evolves. Chronic pain resulting from cervical injury in general may be a part of the trigger mechanism of any given case. Many cases of FMS have a history of hypermobility, which has also been implicated as a cause.
Myofascial trigger points are seriously implicated in FMS, at least as far as perceived pain goes. There is evidence that the majority of cases have overlap with trigger point pain, so it seems clear that a good share of the total pain burden for a fibromite is trigger point pain. Manual trigger point therapies probably won’t treat or cure the core myalgia, but they can go a long way toward improving quality of life.
Fibromites virtually always have profound emotional distress. In some people, this may be the original trigger for the syndrome. In others, it might be the result of living with a disabling disease. In any case, massage therapy will promote stress release.
Rub Me the Right Way
Massage for FMS should be done in a warm room, with warming oils. The focus should be on gentle increase of joint range of motion. Since FMS patients have a lack of oily, lubricating “slime” in the tissues, lubricating oil should be used liberally. The patient should not feel any pain during the session.
Cabrera is a big fan of massage for FMS. She says it is an excellent treatment, and may be the best treatment. She says that one of the big benefits is taking an hour to relax from her day. For her personal healing as an FMS patient, the most effective technique was digital pressure applied directly to the tender point. It feels better afterward, and the benefits are cumulative.
Tender points do not have referred pain. Sustained pressure relieves pain. If direct pressure is applied to tender points, it should only “hurt good.”
One of the most critical aspects of massage therapy is the need to continue for what seems like a very long time. According to Cabrera, therapy should continue for years, and hundreds of sessions might be indicated. Patient compliance is critical and difficult to sustain. Though people know they will eventually feel better from their massage appointment, it is difficult for someone in pain to get up and make the effort consistently to go.
Positional release techniques offer a low force or non-force way to adjust muscle and soft-tissue structure and function. Over the years, countless versions have been developed and refined. Many of these approaches have merged, split, and combined numerous times, as is the way of clinical practices. Muscle Energy Technique (MET), a technique frequently practiced by osteopathic physicians, is one of many.
The goal of MET is to relax a muscle spasm and increase range of motion. It is used in cases where there is a need to normalize abnormal neuromuscular relationships, improve local circulation, improve local respiratory function, lengthen or normalize restricted (hypertonic, spastic) muscles and fascia, or mobilize restricted joints. It is a safe and effective way to stretch muscles without inducing further damage. This is a technique that, when applied directly, is based on the principle of reciprocal inhibition, and when applied indirectly, is based on post-contraction relaxation.
MET techniques can be employed in the therapy session when relaxing muscular spasm or contraction, or preparing for stretching, mobilizing restricted joints, and preparing joint for manipulation.
The treatment starts at the barrier for acute problem or for individuals with acute FMS. It will start short of the restriction barrier (mid-range) for a chronic problem.
Rayna Dorsey, LMT, NCTMB, is a licensed massage therapist and experienced bodywork practitioner and educator in Portland, Oregon. In practice since 1984, her private practice focuses on clients with fibromyalgia and chronic pain and trauma survivors. Dorsey describes the MET technique like this:
- Extend the muscle to the first “pathological barrier” (a feeling of being crunchy, pain, discomfort). There may be a “ratchet” or “cog” movement at the barrier.
- Contract, or extend, against resistance, in an isometric contraction.
- Do not push through the barrier.
- The patient holds the breath during contraction.
- MET is not limited to FMS and has virtually no research attached to it, but it might be appropriate in a given case to relieve pain and joint dysfunction.
Several other techniques have their proponents. Strain, counterstrain, neuromuscular therapy, and passive stretching all have good reputations in the field.
A study on the follow-up to therapy of posttraumatic fibromyalgia patients showed that the vast majority of people with disease of 4–14 years duration had a dramatic reduction in the use of all forms of physical treatments. Even though 85 percent of the patients continued to have significant symptoms and clinical evidence of fibromyalgia, 54 percent continued to use over-the-counter pain medications, and 39 percent were on antidepressants.