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Fibromyalgia Syndrome

1a – Definition of Condition

Fibromyalgia Syndrome (also called ‘FMS’ or ‘FM’) is a complex, chronic condition, which
causes wide spread pain and fatigue.

Its effects are felt primarily in muscles, tendons and ligaments throughout the body. FM is
also sometimes called Fibrositis.

The pain of Fibromyalgia Syndrome is usually described as aching, throbbing or burning and
is unpredictable in nature. Its severity varies from mild, tired, to feeling all-consuming
exhaustion and weakness.

Although Fibromyalgia seems mainly to affect women between 30 and 50, increasing
experience is showing that males and all age groups can be affected.

It can be set off or triggered by having another medical condition, especially Arthritis.

It is not uncommon to find that people with Rheumatoid Arthritis or Osteoarthritis have
Fibromyalgia at the same time. This can sometimes complicate the diagnosis and the
management for some people. Survey has shown that most patients develop the syndrome
in their 30s and 40s. Fibromyalgia infrequently evolves during adolescence. Whereas 60
percent of cases are diagnosed in people between the age of 30 and 49, another 35 percent
of patients are diagnosed in their 20s or between the age of 50 and 65 (1).

It often surprises people to learn that Fibromyalgia is not a true Arthritis as such.

The world Arthritis means inflammation of the joints and is a term that is used to describe
those large groups of different conditions that affect the joints of the body.

Fibromyalgia refers more to pain that is felt in the non-bony or ’soft-tissue’ structures around
the joints, such as muscles and tendons.
Fibromyalgia muscles are weak and painful, tire easily, demonstrate poor repair qualities,
have multiply biochemical abnormalities are associated with abnormal neural function, and
yet, as stated previously, FMS is not principally a musculoskeletal problem. The causes lie
elsewhere in the system (2).

1b - Aetiology

The cause of fibromyalgia remains unknown. Researchers have suggested that fibromyalgia
patients experience pain amplification caused by abnormal sensory processing in the central
nervous system. Other research has determined that some fibomyalgia patients have:

 Increased level of substance P (a chemical which increases nerve sensitivity to pain) in


the spinal cord
 Decreased blood flow to the thalamus region of the brain
 Imbalance of hormones in hypothalamic-pituitary-adrenal axis (affecting how the patient
copes with stress)
 Low levels of serotonin and tryptophan
 Abnormal cytokine function

1c – Clinical Feature

Other than the primary symptom associated with fibromyalgia -- widespread muscular pain --
there are other symptoms which are linked to the syndrome. The symptoms can come and
go and vary in intensity:

 Severe fatigue
 Headaches
 Irritable bowel syndrome
 Irritable bladder
 Cognitive and memory problems
 TMJ or temporomandibular joint disorder
 Restless leg syndrome
 Pelvic pain
 Noise and temperature sensitivity
 Anxiety or depression
 Skin color changes

Overlapping symptoms with other rheumatic conditions makes diagnosing fibromyalgia


difficult. People who already have a rheumatic disease such as lupus, rheumatoid arthritis,
or ankylosing spondylitis are at greater risk for developing fibromyalgia.

Activity level, time of day, weather patterns, sleep patterns, and stress can all affect
fibromyalgia pain and other symptoms. Being aware of certain patterns may help you
manage fibromyalgia. Fatigue or sleep disturbance occurs in 90 percent of fibromyalgia
patients. More research is ongoing to study the role of genetics, environmental stress, and
physical trauma.

References:

2 – By Daniel J. Wallace, Janice Brock Wallace, Fibromyalgia: an essential guide for


patients and their families, Oxford University Press, 2003
2 - Leon Chaitow, Peter Baldry, Fibromyalgia syndroms: A Practitioners guide to treatment,
volume 1, Hartcourt Limited Publisher, 2000

2. Client Assessment

2a

Observation

Commonly there are some physical signs for people, including:

1. Fatigue, night sweats and sleep disturbances.

2. Memory difficulties and cognitive difficulties.

3. Tension or migraine headaches, temporomandibular joint syndrome, rib cage pain


(noncardiac chest pain), chronic pelvic pain, plantar or heel pain.
4. Fluctuations in weight, heat or cold intolerance, subjective feeling of weakness.

5. Ear-nose-throat complaints, multiple chemical sensitivities and a wide array of allergic


symptoms.

6. Hearing, vision, and vestibular (balance) abnormalities.

7. Heartburn, palpitations and irritable bowel syndrome.

8. Evidence on echocardiogram of mitral valve prolapse, esophageal dysmotility (muscles


of esophagus not working properly), neurologic conditions causing hypotension (low
blood pressure) and syncope (fainting).

Palpation

 occiput: bilateral, at the suboccipital muscle insertions

 low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-7

 trapezius: bilateral, at the midpoint of the upper border

 supraspinatus: bilateral, at the origins, above the scapulae spine near the medial
border

 second rib: bilateral, at the second costochondral junctions, just lateral to the
junctions of the upper surfaces

 lateral epicondyle: bilateral, 2cm distal to the epicondyles

 gluteal: bilateral, in 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

ROM:

2b. Contra indication:

 Anxiety

 Changes in weather -- for example, cold or humidity

 Depression

 Fatigue

 Hormonal fluctuations such as PMS or menopause

 Infections

 Lack of sleep or restless sleep

 Periods of emotional stress

 Physical exhaustion
 Sedentary lifestyle

3. Treatment strategy

3a. Rationale:

Encourage circulation in the muscles, which increases the flow of nutrients and eliminates
waste products. This is particularly beneficial for those with fibromyalgia as it can reduce
heart rate, relax muscles, improve range of motion in joints and increase production of the
body's natural painkillers. Also decreased stress and depression.

To feel more relaxed and get a better night's rest. Deep sleep is truly beneficial to managing
fibromyalgia as it is during this time that the restorative process occurs. Will also leads to
reducing pain and stiffness.

3b. Client Symptoms

As 33 years old teacher, Jenny Powers is in painful and stressful fibromyalgia patient. The
pain is felt from all over her body makes her difficult to teach. Especially in back, neck and
arms. This pain brings her to sleep disorder that will distract her ability in work. She has
visited the doctor and being advised to get a massage to reduce the pain.

3b. In assessment client stated regularly suffered from pain and tightness in her neck, back
and arms also with several other places. To analyse more, patient will get a diagnosis of
fibromyalgia, 11 of 18 tender point sites must be painful when pressed.

3c.Specific massages techniques:

Specific techniques can be used include:

 Myofascial release: helps to release adhesions and reshape restricted fascia


surrounding muscle fibres.
 Deep muscle stripping (longitudinal) using knuckles or thumbs – help release muscle
tension (i.e. scalenes and deep cervical muscles)
 Trigger point therapy at relevant regions (i.e. upper trapezius, Levator scapulae,
rotator cuff, SCM)
 Hydrotherapy – use of heat to help relieve muscle spasms, relax muscle fibres or ice
to reduce inflammation. Alternate to create pump action for chronically contracted
muscles
 Massage of the lower rib cage: standing on the opposite side to the rib cage being
worked effleurage the intercostal between the ribs. Try to access the lateral sides as
far as you can. ‘Trace’ the rib cage in this way several times gradually increasing
finger pressure. Repeat on the other side.
3c. The massage therapy lower anxiety and depression, and their cortisol levels were lower
immediately after the therapy sessions on the first and last. The massage also improved on
the dolorimeter measure of pain. They bring less pain the last week, less stiffness and
fatigue, and fewer nights of difficult sleeping.
4. Treatment Plan

Client lies on her side. Place a folded towel between the neck and pillow. Place fingers
around the occipital bone at the insertion of neck muscles to the skull. Gradually massage
the region, while increasing pre massage is a kneading technique where the thumbs act as
barriers for soft tissue movement, and the four fingers mobilize soft tissue in the direction of
the thumbs.

Both hands perform the same action simultaneously. Do not massage the carotid artery.

If possible, place the arm of the client behind her back. Place a hand on the anterior part of
the shoulder joint for support. With the top of the fingers of the other hand, massage under
the scapula area. If it is difficult or impossible for the client to place her arm behind the back,
perform the sub-scapular mobilization in a normal position.

Perform massage No. 2 on the lateral part of the neck and upper trapezius. Massage No. 2
is a kneading technique where the thumbs act as barriers for soft tissue movement and four
fingers mobilize soft tissue in the direction of the thumbs. This technique is not simultaneous
— each hand follows the other.

Place both thumbs on the lateral part of the neck as close as possible to the occipital bone.
Thumb after thumb; massage the entire lateral side of the neck.

The client lies on her stomach. Place your right palm on the lower back region. Place your
left hand on top of the right hand. With application of initial pressure, perform ironing
techniques from the bottom up on all areas of the back. Upon reaching the upper part of the
back, disconnect the hands and return to the lower part without contact.

Place the back of the fingers on the lower part of the back and, with initial pressure from the
bottom up, massage the entire area of the back. Upon reaching the upper part of the back,
disconnect the hands and return to the lower part without contact.

Place the hands on the lateral parts of the back. Under initial pressure, massage the entire
back, hand against hand in a manner of crossfiber friction.

Perform massage No. 1 and No. 2 on the entire area of the back.

Connective tissue massage can release tension in myofascial tissue.

5. COMMUNICATION

5a. Pre Treatment

According to your symptoms and your assessment, I assume you have fibromyalgia
syndrome. I will check 18 points in your body by physical exam of pressure points that takes
about five minutes. When light pressure is applied to the surface of the muscles throughout
the body, you might find this painful, especially at the specific tender point areas used for
diagnosis.

I will start slowly and lightly pressure. Please do tell me if you found it too painful. Do you
have any question? I am glad to answer it.
5b. Post Treatment

I recommend the first 10 massages be frequent - 2x week, with initial focus on high pain
levels , leading to full body treatments starting 4th or 5th session. After the first 10
treatments, the client should do exercise 2 or 3 x week and get 5 additional massage
treatments. Take a 2 week break from massage (but not from exercise) and come back for
another 15 massages (2x week) while exercising 4 x week. Take a 3 week break from
massage, continue to exercise 4x week, and them continue 1 massage per week to prevent
re accumulation of tension.

Strategy 1

29/11/2011 Healing Palm Massage

533-535 Elizabeth st

Surry Hills, NSW

To: Counsellor Martha

Dear Martha,

I’m referring my client, Jenny Powers under your supervising to check her fibromyalgia
problem and get more details about it. Jenny Powers just diagnosed and it reduces her
confidence due to she cannot handle the pain while she was working or out with friends.
Although all of her friends and working mates know about her condition, it doesn’t make her
confidence enough.

In my supervise, I give her a light myofascial massage due to she was in pain if I gave her
massage. Please advise.

Regards,

Bella Wang

Strategy 2

02/11/2011 Healing Palm Massage

533-535 Elizabeth st

Surry Hills, NSW

To: Dr. Seaman


Joann Bach is my client who just has diagnosed for fibromyalgia syndrome. I give her
myofascial and mild massage release her muscles from tightness. As she is also under your
medical care, I would like to have more detail about her condition so I can give her more
massage therapy needed to help her ease her asthma. For now I give her 1 hour
session/week for massage which can be re-evaluate as needed.

I thank you for referring this client.

Best regards,

Bella Wang

Strategy 3

01/11/2011 Healing Palm Massage

533-535 Elizabeth st

Surry Hills, NSW

Pacific Health Insurance Company

To: Whom It May Concern,

Case Number: 099

Jenny Powers has presented with fibromyalgia syndrome. I have asserted Joann Bach and
gave found that there is stiffness and painful in trapezius, splenius, rhomboideus, pectoralis
major.

Treatment plan for Jenny Powers is as follow: 1hour session/week for about 25 seasons.
Re-evaluation for treatment will be given after 10th session based on feedback from Jenny
Powers. Massage focus on releasing the stiffness of muscle to ease her during and If there
any question or looking for more information, do not hesitate to contact me.

Best regards,

Bella Wang.

Strategy 4

3/11/2011 Healing Palm Massage

533-535 Elizabeth st

Surry Hills, NSW

To: Dr. Allan Harper (Chiropractor)

Dear Dr. Allan,


I am referring Jenny Powers for deeper and detail assessment of her trigger point and 18
point. Although it isn’t a bone related disease, she still need to make sure no problem that
fibromyalgia syndrome.

I thank you for your reviewing to this client.

Regards,

Bella Wang

6. Specialized Treatment

Children and adolescent

Published in the Journal of Rheumatology in 1993, a team of doctors in Israel reported that
6.2 percent of 338 healthy schoolchildren between the ages of nine and 15 met the criteria
for the fibromyalgia syndrome. At nearly the same time, a rheumatologist in the US asserted
that 45% of the children referred to him had FM. Of these 15 children, nine had been
diagnosed incorrectly with juvenile chronic arthritis, three had been told they had growing
pains, and two had been given a psychiatric diagnosis. Since then, doctors have been
paying more attention to children's Fibromyalgia was considered an adult disorder; children
were thought not to get it. Then, in a study complaints of pain and are diagnosing FM with
increasing frequency.

Children's complaints of pain must be taken seriously, lest they grow up with untreated FM.
Growing pains are a particularly pernicious myth. It should not hurt to grow, and the child
whose pain is brushed off that way is a very unfortunate little person. FM is often a family
affair. Children need us to take their complaints of pain seriously. Fibromyalgia can make a
child's life miserable at school and on the playground. The child with FM needs a great deal
of special help and understanding.

Many adults think of childhood as a carefree time, full of fun and excitement. Some find it
hard to comprehend the depth to which children can feel pain, both emotional and physical.
Small children want nothing so much as to please the adults around them, and to gain their
respect and affection. If parents place a high value on stoicism, then their child will believe
that the way to gain approval is to grin and bear it, and is likely to miss badly needed medical
attention.

Women

Fibromyalgia affects predominantly women (over 80% of those affected are women)
between the ages of 35 and 55. Several studies indicate that women who have a family
member with fibromyalgia are more likely to have fibromyalgia themselves, but the exact
reason for this—whether it is hereditary or caused by environmental factors or both—is
unknown.

Sleep problems are associated with an increased risk of fibromyalgia in women, especially
those who are middle-aged and older, a new study says.
Fibromyalgia is a chronic musculoskeletal pain condition that affects more than 5 million
adults in the United States. Women account for up to 90 percent of people with fibromyalgia,
which typically begins in middle age.

Men

Recent research suggests that 1 in 8 fibromyalgia patients is male. However, it is difficult to


know if this number is truly an accurate reflection of the real number of male sufferers of the
disorder. Because it is so often thought of as a woman's illness, many men suffering from
fibromyalgia actually don't get diagnosed with the syndrome. As a result, a large number of
male sufferers may go unreported. It is thought that the number of men suffering from
fibromyalgia could in fact, be closer to 30%.

Symptoms in men are very tend to be quite different when compare to the symptoms
suffered by women. Most research illustrates that men actually experience milder symptoms
than women, and also experience less:

•tender points

•fatigue

•morning stiffnes

•IBS

Male symptoms also tend to last for shorter periods of time and occur less often than those
appearing in female patients. However, a recent study shows that male symptoms may
actually be more severe than those experienced by women. Under-reporting or misreporting
of symptoms may affect the general understanding of fibromyalgia symptoms in men.

Diagnosis of fibromyalgia syndrome also tends to be different in male sufferers. Male


sufferers are often reluctant to admit to severe pain or discomfort, and as a result, may
report milder symptoms then they acutally have. This can make it difficult for your health
care provider to accurately diagnoseyour fibromyalgia. Some health care providers are also
convinced that fibromyalgia affects only women, refusing to diagnose men who display
symptoms of the disorder, with fibromyalgia.

Because of societal expectations and gender roles, many men don't receive helpful
fibromyalgia treatments. Men are often forced by society to deal with their pain quietly, and
as a result many men don't ask their health care providers for fibromyalgia medications. Men
who experience pain are often seen as less "manly" and therefore many men don't seek
active treatments for their fibromyalgia.

Geriatric care

While it may seem there is a link, no evidence shows that caregivers are at higher risk for
developing fibromyalgia, according to the National Fibromyalgia Association (NFA).
Fibromyalgia affects about 10 million Americans, occurs most often in women and can be
extremely debilitating. About 80 percent of those diagnosed with fibromyalgia are women,
and most people are diagnosed during middle age, according to the National Institute of
Arthritis and Musculoskeletal and Skin Diseases.
Mental Health Care

Fibromyalgia is also often associated with psychiatric disorders. Adults with fibromyalgia are
3.4 times more likely to be diagnosed with depression than people without the disease,
according to the CDC. A 2008 study that looked at 76 adolescents with fibromyalgia found
that 67.1 percent of patients had at least one current psychiatric diagnosis, and 71.5 percent
had at least one lifetime psychiatric diagnosis, with more than half of the psychiatric
diagnoses being anxiety disorder.