Fibromyalgia is a common cause of multi-regional pain and disability. This condition shows a female preponderance and is a condition whose etiology is poorly understood, despite the various intensive and invasive investigations of modern medicine. Two hypotheses have been proposed to be the underlying etiological factors in relation to this condition. The first being an abnormality in the non-rapid eye movement sleep stage, which may be due to biochemical disturbances in the body. Abnormal pain processing is the second theory that may be responsible for the exaggerated pain in response to a stimulus. (Sarac & Gur, 2006)
Worldwide literature on the subject has established that stress is an important and established risk factor to this condition. Such life stressors can cause significant psychosocial distress. In some cases of fibromyalgia, the pain remains refractory to medications. In such cases, non-pharmacologic modalities are used, such as, psycho-social modification and relaxation therapies.
Non-pharmacological modalities can be classified into physiological and psychological methods. Chiropractic and massage therapies are examples of physiological modes of therapy. Behavior modification through cognitive behavioral therapy is an example of a psychological approach to treatment. The aim of this article is to analyze the usefulness of two non-pharmacological treatments, mentioned above, for the management of fibromyalgia.
The rationale for using manipulative or massage techniques in fibromyalgia is based on their modes of action. Activation of trigger points in the human body has been postulated to be the underlying mechanism of chronic pain experienced by patients suffering from fibromyalgia. Trigger points are tiny bands of contracted muscle fibers. These points develop when over stimulated sarcomere become unable to release their contracted state. Prolonged contractions of these muscle fibers can cause significant injury and soft-tissue changes. These tissues eventually become chronically congested, thus hampering blood flow. During therapy, these spastic points are located and techniques are employed to increase blood flow and allow the injured tissue to heal in a way that allows mobility. (Bennett & Goldenberg, 2011)
Chiropractic techniques can be considered when designing an integrated approach for the management of chronic pain in fibromyalgia. The efficacy of this care has been established for musculoskeletal pain, such as lower back pain, neck pain and headaches. The effectiveness of this approach has been a matter of debate. However, chiropractic techniques can decrease the use of pharmacological drugs, thus reducing its various adverse effects. Moreover, no pharmacologic therapy has proven to be successful in the long-term treatment of fibromyalgia. This method causes a positive cascade of biochemical effects that help to reduce pain and inflammation. (Sarac & Gur, 2006)
Results of one study, conducted on chiropractic management of fibromyalgia patients, revealed an improved range of motions in the lumbar and cervical region. There was also an improvement on straight leg raising ability and on pain levels. Although the improvement was clinically significant, this study only included a sample of twenty one patients, and so the results can not be generalized. (Blunt, Ranjwani & Guerriero, 1997)
Remedial massage therapy is one of the many types of massage techniques. This technique uses controlled pressure on deep muscles to reduce muscle tension, facilitate recovery of injured myocytes, and increases blood flow and lymphatic drainage. Blood flows from high pressure areas to low pressure areas. This technique creates the pressure difference required, thus enhancing blood flow. The increased blood flow allows rapid healing and also removes toxins and prevents their accumulation. Currently, there is no literature that supports the use of remedial massage therapy in particular; however, other massage techniques have been discussed as a cure for fibromyalgia. (Sarac & Gur, 2006)
According to a meta-analysis of 740 research articles by the Australian Association of Massage Therapy, therapeutic massage improved pulmonary function, decreased exercise related muscle tension, improved the outcome of chronic pain and anxiety disorders. In this review, 5 out of 740 studies were found related to fibromyalgia, which displayed limited evidence (Level C) for its incorporation into current guidelines. (Kenny & Marc, 2008)
The usefulness of massage therapy in fibromyalgia was analyzed in three studies, other than those used in the meta-analysis conducted by AAMT. Out of these, in only two studies were the effects isolated. Both these studies used different types of massage techniques. In the study conducted by Brattberg (1999), the connective tissue massage technique was employed, which displayed a thirty seven percent decrease in pain. It also reduced depression and the use of analgesics, thus improving the quality of life. On the other hand, Hanen et al. (1991) used a form of massage that promoted relaxation. Key factors analyzed in this study were response to pain, fatigue and sleep pattern. He compared his results to hypnotherapy, which showed no major difference in outcome. (Kenny & Marc, 2008)
Another study determined the usefulness of massage-myofascical release therapy in the management of pain, anxiety, quality of sleep, depression and the overall quality of life in fibromyalgia patients. This therapy was compared with placebo on seventy-four subjects over a period of 20 weeks. Results revealed immediate improvement at 1 month on all key factors measured. However, these results were not as significant 6 months post intervention. (Sanchez et al., 2010)
Cognitive behavioral therapy is another non-pharmacological approach for the treatment of fibromyalgia. The rationale behind the use of this method is based on the relationship of the mind on perception. This therapy is a form of psychotherapy that combines two main approaches, that is: cognitive therapy and behavioral therapy. This approach focuses on the relationship between perception and the experienced symptom. Cognitive therapy eliminates the effect of thought patterns on a particular symptom whereas behavioral therapy helps modify behaviors that may cause it. (Richardson, Adams & Poole, 2006)
Researches have revealed many biochemical changes in fibromyalgia patients. These chemicals substances are substance P, serotonin, endorphins and enkephalins. Substance P. And serotonin are the involved chemical mediators responsible for pain and sleep. Since chronic stress is the most possible etiological factor responsible for fibromyalgia, it has been hypothesized to be the cause for the above mentioned biochemical changes in the body. Such biochemical changes can cause sleep disruption which in turn leads to a variety of other symptoms. (Baker, 2005)
Cognitive behavioral therapy helps patients modify the way they perceive stressful situations. The psychological perspective of the situation emphasizes on the effects that the mind may have on our emotions and behaviors. This therapy facilitates patients to identify thoughts that are destructive and helps them replace such thoughts that lead to more desirable actions. This may prevent flare-ups of symptoms and may reduce the intensity of pain in patients suffering from fibromyalgia. (Richardson, Adams & Poole, 2006)
Cognitions and behaviors can be influenced by certain interventions and coping strategies. A coping strategy can be defined as a mechanism used by oneself for self-regulation when faced with a life stressor. Such an intervention or strategy starts with patient education and reassurance. According to the recommendations published by the American Pain Society, patient counseling is described with level A evidence of symptom modulation in fibromyalgia. (Buckhardt et al., 2005) Other aspects of cognitive behavioral therapy include training patients with coping strategies and stress management. Cognitive reconstruction, distraction problem solving, changing pain behavior, increasing physical activity, goal setting and pacing are other interventions which are specifically useful to patients suffering from this condition. These interventions not only provide pain relief but also help with other symptoms of the disease, such as, easy fatigability, decreased mobility, depression and poor quality of sleep. (Richardson, Adams & Poole, 2006)
In a Randomized Control Trial conducted by Alda et al., (2011) the efficacy of CBT was compared with pharmacotherapy and with the usual management of fibromyalgia. This study not only added to the growing literary evidence of CBT in fibromyalgia but also commended the extent of its usefulness. According to this study, effects of CBT were mainly seen on anxiety and depression, but also in pain management. When compared with the recommended pharmacological treatment and the usual treatment, patients undergoing CBT displayed better outcomes in quality of life, function, pain and acceptance.
Data compiled from two meta-analyses identifies significant evidence for recommending CBT in the management of fibromyalgia. The reviews identified 1396 and 910 patients, respectively. Both studies were at consensus that CBT reduced depressed mood and health seeking behavior. Evidence for pain reduction according to both analyses was relatively small but robust and comparable to other pain and drug treatments used for this disorder. (Glombiewski et al., 2010)
Clinical-based evidence for the management of fibromyalgia varies across three guidelines. Currently, three evidence-based guidelines for the management of fibromyalgia exist, namely: The American Pain Society, published in 2005, the European League against Rheumatism, published in 2007, and the AWMF, published by Germany in 2008. The APS and AWMF are more similar regarding there recommendations, and differ from the EULAR on certain grounds. The task forces of the EULAR consisted of physicians that were mainly rheumatologists, where as, the task forces of AWMF and the APS were mainly patient centered. Also the level of…