A chiropractic team approach providing spinal-muscular stabilization proves to be successful in managing fibromyalgia symptoms.
Patients diagnosed with fibromyalgia are the ones no one wants to treat. Too often, fibromyalgia or myofascial pain syndrome patients go from one disappointing treatment experience to the next. When they come to you with doubt and pain, a simple evaluation may seem impossible. However, they will be the first to recognize your contribution in providing relief, which will lead to positive word-of-mouth.
Chiropractic has a unique perspective to offer in treating fibromyalgia. I wish that chiropractic had been given the opportunity early in the development of the condition to restore normal relationships of the spine, extremities, and muscles. Despite the months or years of compensation and adaptation, chiropractic works tiny miracles with adjustments and gentle rehabilitation. Restoring harmony and health takes some time.
Figure 1: Trigger areas on a fibromyalgia patient.2
Among these patients, it is common to uncover unresolved physical or emotional traumas dating several years before the onset of the fibromyalgia symptoms. For example, in whiplash symptoms, the common pattern of neck and upper-back trigger points and associated headaches (Figure 1) is easy to explain. However, the other complaints of nonspecific muscle tenderness/weakness and dysfunction are difficult to objectify, and patients are often accused of malingering or are told (or begin to believe) that it is all in their head. In the review of 266 medicolegal cases, it was found that 45% continued to have symptoms 2 years after legal settlements were reached.1 Even more common among fibromyalgia patients are subtle traumas for which they may have never received any treatment.
Team Player
A team approach has been shown to be the most successful way to manage fibromyalgia symptoms. According to Harris H. McIlwain, MD, even in the most difficult cases, patients are twice as likely to improve and return to work when treated by a comprehensive team compared to individual treatments alone.2 Your team should include a panel of experts on whom you can rely to provide pain management, psychiatric counseling, massage, acupuncture, and personal/job training, as deemed necessary.
Fibromyalgia patients have chronic pain, difficulty sleeping, and a lack of energy and self-esteem. More than anything, these patients need someone who believes in them, provides relief, and restores balance to the physical body to allow proper healing. As the chiropractic team leader, it will be your focus to reverse the downward-spiraling inactivity cycle by providing the necessary structural balance that favors a return to increased activity, balanced hormone levels, and better sleep (Figure 2).
Figure 2: Demonstrates activity and inactivity with
fibromyalgia patients.2
Where to Begin?
When beginning their chiropractic care, only a few patients make the connection between the traumatic event and their current condition. The symptoms of fibromyalgia creep up in a way that the two are rarely associated. However, in seven of 10 patients with back pain, postural fatigue and spinal strain cause their discomfort.3 Chiropractors find that the ultimate cause of pain may originate in any tissue or joint involved in the kinetic structure. The stress can be traced to altered foot biomechanics, which can lead to pelvic and spinal distortions.4
Case Study A 40-year-old female was involved in two motor vehicle accidents in the 15 years prior to treatment in my office. Her primary complaints included multiple and diffuse trapezius, sternocleidomastoid (SCM), and lower extremity trigger points, in addition to restricted spinal joint motion. Medical treatment, including physical therapy, muscle relaxants, and antidepressants, had not been successful at reversing her fibromyalgia diagnosis, although it did allow her to maintain a successful part-time small business. However, the patient had no extra energy for simple activities including walking her dog. In addition, sleep was sporadic, and normal physical relationships were painful. She was immediately diagnosed with an asymmetrical, bilateral pronation problem and hypersensitive feet. Lumbo-pelvic radiographs revealed leg-length inequality, pelvic unleveling, and lateral lumbar curvatures. Cervical spine films revealed a loss of cervical lordosis common to whiplash injuries. Due to excessive lower extremity trigger points, she mainly wore sandals, so we prescribed a custom-made orthotic sandal designed from weight-bearing casting. She was also provided with a cervical support pillow. During a 3-month period, the patient received weekly massages and chiropractic adjustments. As a result, her medical doctor was able to reduce her medications by 40% to 50%. The patient’s overall condition improved 80% with extended periods void of fibromyalgia symptoms. |
I expect chiropractors to be familiar with the need to provide segmental and global postural stability, but I was astonished by what D.M. Fraser, MD, heard at a meeting of the American Association of Orthopedic Medicine. He was instructed by an orthopedic physician "that it was mandatory to check the feet in all cases of car accidents as the force comes up through the floor board of the vehicle and travels through the body to the neck."5 Furthermore, he was instructed to evaluate the tarsals, which could be "subluxed" after accidents, and to perform a "simple manipulation," to restore the foot to its normal integrity.5 This medical evaluation and treatment attempted to restore musculoskeletal integrity not only in the feet, but also throughout the entire biomechanical chain, including the knees, pelvis, lumbar spine, shoulders, and cervical spine. Unfortunately, most medical treatment received by our fibromyalgia patients is nothing like this logical and global approach—which is chiropractic.
Ideal spinal posture and muscle tone require coordination of bone, soft tissue, and proprioception to respond to and control forces of gravitational loading. Faulty foot mechanics, usually pronation, can affect all supporting joints above the foot. When the body is erect and its weight evenly distributed between the feet, there is minimal demand for muscle tension. While ideal posture would not involve muscle action of any kind, the fact that none of the supporting joints below the pelvis are locked means the slightest pathological shift in weight initiates excess recruitment of postural muscles and inefficiency, even pain—all symptoms of fibromyalgia.
Body symmetry is essential for pain-free function. When symmetry is absent, patients are prone to develop and retain muscular trigger points, where its presence limits activity, creates pain and depression, and creates a secondary cause for spinal-muscular irritations. According to Starlanyl and Copeland, "It is vitally important that doctors identify their patients’ perpetuating factors. For example, symptoms such as unequal leg length or another kind of musculoskeletal imbalance may not even be noticed until something else activates a trigger point in that area. Then, the unequal legs become a perpetuating factor of that trigger point."6 Excessive foot pronation is the most common cause of a functional leg length inequality.7
Evaluation Criteria
Chiropractic examinations should include evaluating for leg-length inequalities and other postural distortions. For a patient with fibromyalgia, this evaluation is essential because it is unlikely that other health care providers will perform a functional postural analysis. Begin the evaluation with the feet. Pronation is easy to spot or measure objectively with a navicular drop test. Lower extremity trigger points and foot conditions are so common among fibromyalgia patients that it is described as the "fibromyalgia foot."6 This presentation includes many of the characteristics of Morton’s toes, including a long second metatarsal, irritations of the peroneus, gluteal, and quadriceps muscle groups, and excessive callus formation over the metatarsal heads.
The reason a team approach is so critical is that painful trigger points and depleted energy reserves must be addressed. Until relief is provided, the patient can never return to a normal, active lifestyle that promotes healthy muscles. However, it is important to remember that removing the trigger points permanently is a byproduct of balancing the musculoskeletal structure.
Chiropractic care, with its emphasis on spinal health and global muscular balance, is well suited to lead a team approach in cases of traumatic fibromyalgia. Research indicates that half of all whiplash patients can expect to achieve full recovery.8-10 Without appropriate and thorough care, many develop chronic painful syndromes including fibromyalgia. A chiropractic systematic approach to treatment, including structural analysis, rehabilitation, and custom supports for affected extremity and spinal structures, can achieve better than average results.
About the Author
Jeffrey D. Olsen, DC, is in private practice with his two brothers since 1997 in Roanoke, Va. He has also taught as an adjunct faculty member at the College of Health Sciences in Roanoake, teaching anatomy and physiology in the physician assistant department. He can be reached via email: olsen_jeffrey@hotmail.com.
References
1. Macnab I. Acceleration extension injuries of the cervical spine. In Rothman RH, Simeone FA, eds. The Spine. 2nd edition. Philadelphia: WB Saunders; 1982:654.
2. McIlwain HH, Bruce DF. The Fibromyalgia Handbook. Ontario, Canada: Fitzhenry & Whiteside; 1996:148.
3. Brunarski DJ. Chiropractic biomechanical evaluations: validity in myofascial low back pain. JMPT. 1982;5(4):155–161.
4. Schafer RC. Clinical Biomechanics: Musculoskeletal Actions and Reactions. Baltimore: Williams & Wilkins; 1983.
5. Fraser DM. Whiplash: a total body approach. J Neurol Orthop Med Surg. 1994;15:10–12.
6. Starlanyl D, Copeland ME. Fibromyalgia & Chronic Myofascial Pain Syndrome. Oakland, Calif: New Harbinger; 1996.
7. Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. JMPT. 1988;11:373–379.
8. Beutler C, England D, Masse J. Basic examination and documentation for whiplash injury. Today’s Chiropractic. 1992;21(6):50–52.
9. Lewkovich GN, Wallenius R. Legal duty of doctors treating whiplash trauma. Digest of Chiropractic Economics. 1990;33(1):20–22.
10. Croft AC. Treatment paradigm for cervical acceleration/deceleration injuries (whiplash). ACA J of Chiro. 1993;30:41–45.
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