Fibromyalgia

What is Fibromyalgia?

Fibromyalgia (FM) is a condition defined by generalised, chronic musculoskeletal pain for more than three months duration. It is present in four or more different areas of the body (widespread pain) with hyperalgesia (heightened sensation) and psychosomatic symptoms such as fatigue, non-restorative sleep, anxiety/depression, cognitive deficits, headaches, and digestive disturbances. Fibromyalgia primarily affects women between the ages of 20 to 50 years old. It is estimated that 3-6% of Australians suffer with fibromyalgia, as many as one million people.

What are the symptoms of Fibromyalgia?

• Widespread pain (4 or more areas of the body are affected)
• Hyperalgesia (abnormally heightened sensitivity to pain)
• Allodynia (painful response to a non-painful stimulus)
• Fatigue
• Non-restorative sleep
• Cognitive dysfunction
• Anxiety
• Depression
• Headaches/migraines
• Gastrointestinal issues/abdominal pain

How is Fibromyalgia diagnosed?

In the past, doctors would assess tenderness on palpation in 18 distinct areas on the body. A tender point assessment is now not necessary following recent recommendations from the American College of Rheumatology.

A diagnosis is made when 4 or more of the following conditions are met:

• Widespread pain index (WPI) ≥7 and symptom severity (SS) scale score ≥5 or WPI 3 – 6 and SS scale score ≥9.
• Symptoms have been present at a similar level for at least 3 months.
• The patient does not have a disorder that would otherwise explain the pain.
• Generalised pain, defined as pain in at least 4 regions. To meet the criteria, you must have pain in at least four of these five areas:
  • Left upper region, including shoulder, arm, or jaw.
  • Right upper region, including shoulder, arm, or jaw.
  • Left lower region, including hip, buttock, or leg.
  • Right lower region, including hip, buttock, or leg.
  • Axial region, which includes neck, back, chest or abdomen.

Diagnosis of FM can also be confirmed by performing a blood test in people who are showing 4 symptoms of FM. Whilst blood tests won’t confirm any markers or signs of FM it will exclude similar conditions.

What are the risk factors of Fibromyalgia?

• Females
• Obesity/improper diet
• History of stressful/traumatic events with or without associated post-traumatic stress disorder (PTSD)
• If you have osteoarthritis, lupus, or rheumatoid arthritis you are more likely to develop it
• If there’s a family history of the condition
• Repetitive injuries
• Illness such as viral infections
• Hormonal imbalances

How is Fibromyalgia treated with physiotherapy?

Exercise

Aerobic and resistance exercise are the most indicated and widely used for their therapeutic effect on reducing pain and fatigue and have been shown to have no adverse effects. Exercise as we know, improves psychological well-being, stress, and anxiety. Individuals with FM who partake in regular exercise are more likely to maintain these physical habits and therefore, improve their quality of life by becoming more active and decreasing their symptoms. With sufferers varying in their presentation, exercise therapy must be tailored to the patient’s physical function, level of pain, and other FM symptoms.

Patient Education

Education is a vital part of rehabilitation. Validating that FM is a condition has been shown to assist with improved quality of life and treatment outcomes. Encouraging individuals to adopt behaviours that will help improve physical, mental, and bio-psychosocial wellbeing will subsequently affect quality of life and outcomes of treatment. Your physiotherapist is a great resource to assist you with goal setting and planning. Quite often FM can be misdiagnosed and mistreated by practitioners. The following links are to websites and support groups that show patient focused material to enhance understanding of the condition.

Fibromyalgia Australia – Information/education resource

Understanding Your Condition

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Manual Therapy

The benefit of manual therapy and soft tissue release for FM in the literature remains unclear. Myofascial release has been investigated due to its connection with the nociceptive pathways and involved in central sensitisation – altering someone’s pain perceptions. Massage/myofascial release therapy has been shown to reduce the sensitivity to pain at tender points in patients with fibromyalgia, improving their pain perception. Release of fascia and trigger-point restrictions has the capacity to reduce anxiety levels, enhance sleep quality, and physical function.

One study compared aerobic/resistance exercise and connective tissue massage to exercise alone. Results were in favour of massage being more effective with reducing pain, fatigue and improving sleep. Whilst there are non-specific effects of manual therapy that create a level of uncertainty regarding its efficacy when compared to other therapies, this is not cause for disregarding it from intervention options.

Electrotherapy Modalities

Electrotherapy options for treatment of FM include ultrasound and low-level laser therapy. Electrotherapy works by inhibiting the excitability of nociceptive neurons in the spinal cord and subsequently reducing pain by acting on descending inhibitory pathways coming from the brain. Studies evaluating their efficacy found significant reductions in pain when combined with alternative therapies. This did not translate to large changes to quality of life or fatigue reports.

Clinically, electrotherapy should be used conjunction with exercise and other alternative management strategies to create more meaningful results. Additional meaningful treatments will include exercise prescription. Aerobic and resistance exercise is one of the most important interventions for increasing overall quality of life, decreasing pain and fatigue.

Dry Needling

Dry needling works to inactivate myofascial trigger point’s (MTrP’s) to reduce pain and regain a balance of soft tissue. Dry needling appears to be beneficial in the short term for reducing pain, disability, and quality of life, according to moderate quality data (up to 6 weeks).

Hydrotherapy

Water exercises have also been suggested for the management of FM in addition to land activities. The buoyancy, density, viscosity, and hydrostatic pressure of water create resistance to movement, causing muscle relaxation and strengthening, reduced joint impact, and improved venous return. Aquatic therapy provided moderate to strong evidence of a modest improvement in quality of life and a small reduction in pain.

Conclusion

Among the different exercise interventions, aerobic and resistance exercise are the most indicated and widely used. More research with acceptable methodological quality and established treatment protocols are required to better evaluate the effectiveness of these physical therapy modalities in people with FM. For people with a recent diagnosis of FM it is important to see a physiotherapist regularly to create a management plan involving evidence-based treatments that are going to improve quality of life, fatigue, pain and function.

References:

1. Antunes MD, Marques AP. The role of physiotherapy in fibromyalgia: Current and future perspectives. Frontiers in Physiology. 2022;13.
2. Araújo FM, DeSantana JM. Physical therapy modalities for treating fibromyalgia. F1000Research. 2019;8:2030.
3. Valera-Calero JA, et al. Efficacy of dry needling and acupuncture in patients with fibromyalgia: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health. 2022;19(16):9904.
4. Wolfe F, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care & Research. 2010;62(5):600-610.
5. Toprak Celenay S, et al. A comparison of the effects of exercises plus connective tissue massage to exercises alone in women with fibromyalgia syndrome: A randomized controlled trial. Rheumatology International. 2017;37(11):1799-1806.