Fibromyalgia is defined as having 11 of 18 tender points produce a pain response when up to or less than 4 kgms per cm2 was applied.¹These points exist in all four quadrants of the body including the torso. Despite an extensive amount of research over the years, today there remains no objective medical markers to diagnose this dysfunction. Interest has focused on numerous markers such as blood measures,^2-4sleep⁵and the brain,^6,7but nothing today exists as the "gold standard."

Since 1995 Myosymmetries-Calgary has developed a multi-disciplinary team to assess and treat fibromyalgia. The staff consist of psychologists, a massage therapist, EEG technicians, myofascial release therapist and (although not presently) a physical therapist. To date, more than 500 patients have been treated with mixed results. In addition, Myosymmetries has been involved in two major research studies and the authors have published papers and presented at conferences throughout Europe and North America.

A Different View

As psychologists with an interest in psychophysiology and biofeedback, we view fibromyalgia from a learning model and in particular a neuroplasticity model. Neuroplasticity (also referred to as brain plasticity, cortical plasticity or cortical re-mapping) is the changing of neurons, the organization of their networks and their function via new experiences.

The brain consists of nerve cells, or neurons, and glial cells which are interconnected. Learning can happen by changing the strength of the connections between neurons, adding or removing connections, or adding new cells. According to the theory of neuroplasticity, thinking, learning and acting change both the brain's physical structure (anatomy) and functional organization (physiology) from top to bottom.

By applying the concept of neuroplasticity to the nervous system, some of the features of fibromyalgia can be explained. In The Brain That Changes Itself, Dr. Norman Doidge discusses how the brain can be "fooled" into rewiring itself.⁸

If the brain is constantly bombarded with the pain signal, the pain pathways and associated areas of the homunculus alter their structure(s) in order to accommodate the bombardment. It's believed that eventually, this bombardment alters areas of the sensory motor strip, the thalamus and the prefrontal cortex (indirectly via the thalamus). The impact of the bombardment on the sensory motor strip appears to be related to the phenomena known as allodyna and hyperalgesia. The impact on the prefrontal cortex produces the symptoms that are commonly referred to as "fibro fog."

The same principles that affect the brain may be also applied to the peripheral and autonomic nervous systems.

Evaluation

When someone is referred with the diagnosis of fibromyalgia, an extensive workup is conducted. Included in the evaluation are interviews to determine the cause or time of onset of the pain, how it evolved, and its present status. Pain and pain patterns are monitored through completion of diagrams and a physical examination.

Using a dolorimeter, a massage therapist examines the 18 tender points as outlined by the ACR criteria. Examination of brain wave activity is conducted using a quantitative electroencephalograph (qEEG). The muscle activity is evaluated using standard surface electromyographic (SEMG) protocols. Information about these procedures can be found at www.myosymmetries.ca under "publications."^9-11As previously stated, our goal is to understand how the nervous system is working and how to calm the nervous system down.

Research using a qEEG indicates that the brains of all fibromyalgia sufferers are deficient in Delta (.5-3.5 Hz) activity.⁹This appears to be related to the sleep problems and possibly autonomic functions.

The research data further suggests that the fibromyalgia population appears to be sub-dividable into three groups.⁹

One group has excessive Beta (12-30 Hz) activity throughout the entire cortex. This subtype comprises about 60 percent of the fibromyalgia sample seen. This subtype will present as tired with complaints of mind racing and never shutting off. For example, when they go to bed they either think about any and everything in rapid fire, or they obsess on one thing (usually their health). To calm this activity down, EEG neurotherapy is used in conjunction with cognitive behavioral modification.

A second group has excessive Alpha (8-12 Hz) activity in the front of the brain. This subtype represents about 24 percent of the patients seen. They present as tired and wired as well but are more physically restless than the Beta group. They will often report feeling like they can't get centered, always restless and ready to go but too tired to do so. To modify this activity, EEG neurotherapy is used along with a gentle exercise program such as walking, and relaxation training such as deep breathing.

A third subtype has excessive Theta (3.5-7.5 Hz) activity in the front of the brain. This subtype represents about 16 percent of patients seen. They usually have more emotional problems such as depression, irritability and occasionally severe psychopathology.

This is the one group to which we recommend medications. Usually these patients do well on SSRIs, which help relieve depression but usually don't touch the pain. Routine EEG neurotherapy counseling, relaxation and pain management training are all employed with this group.

Treatment Options

Brain Waves. In all cases, the results of the qEEG are used to direct neurotherapy. Our goal is to normalize the brain wave activity through increasing or decreasing the relative power and improving any coherence and phase problems, which are indicators of neurological problems.

We start all treatments by working on brain wave activity. Until brain wave activity changes, no physical therapy is performed. In our experience, physical improvements won't be maintained until the brain changes. This appears to have something to do with the thalamus and its projections to the­ ­forebrain.

Physical Therapy. Any type of physical therapy employed is initially geared toward improving the level of activity slowly and carefully. Massage therapy initially focuses on improving blood flow and lymphatic drainage. Only after a change in brain wave activity occurs does physical therapy become more aggressive by introducing myofascial release techniques to muscles identified as presenting with trigger points (not tender points). Trigger points that aren't addressed may cause relapses after treatment stops, because they will continue overstimulating the nervous system, which depletes this system of neurotransmitters and increases system irritability.

Therapy that is too aggressive causes tissue to flare up and increase the stimulation to the brain, thus increasing pain and setting back progress. As brain wave patterns are constantly being monitored in our program, flare ups can be seen in the brain immediately. Setbacks are dealt with through EEG neurotherapy, while aggressive physical therapy is halted until changes in brain waves reoccur.

Bumps in the Road

As with any treatment program several things can and do go wrong. Most of our patients are on some form of medication. Medication tends to slow down the rate of recovery as most pain medications somewhat mask the activity level of the brain.

Viral infection will delay treatment since the brain reacts by increasing Theta production.¹²sup> onsequently, treatment is not conducted while someone is sick (i.e., with flu, cold). If the patient's environment is noted as stressful then therapy will need to be conducted to alter the stimulus leading to the stress. Usually the stress is marital or family in nature, or work-related. There's no point in treating someone just to send them back to the same environment; they will likely be back within six months.

People are discharged with specific advice about their conditions. First, they need to understand their nervous system and why controlling their level of stimulation is important. They are advised on the effect of viral infections, fatigue and aging on their nervous system. Finally, they are taught that they have to be responsible for their health. This treatment program is labor- and time-intensive, and usually requires clinic attendance two times per week for four to six months. Patients who complete the program show a high rate (over 70 percent) of eradication of symptoms and return to functionality. Mueller demonstrated the success of this type of program.¹³The changes which occur are usually permanent in nature, with only 10 percent of patients returning for future treatments. The question that we continue to ask is, Is fibromyalgia an adaptation dysfunction of the body's neurological systems?

References are available at www.advanceweb.com/pt or on request.

C.C. Stuart Donaldson and Mary W. Donaldson are managers of Myosymmetries in Calgary, Alberta, Canada. Special thanks to Doneen Moran. Author's Note: In Scientific American MIND September/October 2009, an article by Frank Porreca and Theodore Price, "When Pain Lingers," fully supports the conceptual model put forward. It talks about how the nerves become sensitized due to the repeated pain stimulation leading to the development of chronic pain. 

Hand-Held Tools Can Enhance Soft-Tissue Mobilization

By Hannah Baylor

Therapists and massage practitioners agree that their hands are often the best tools to relieve trigger-point pain, soft-tissue restrictions and other chronic pain syndromes. However, hands are increasingly subject to arthritis, pain and wear and tear. Because therapists can only do so much to protect their hands, massage tools can become a vital part of therapy.

Sue Fleshman, PT, senior physical therapist at Sports Specialty and Rehab Center in Cape Coral, FL, believes that assistive tools provide a better position within the tissue, an ability to vary pressure, and a way to protect the hands from pain. Tools come in different shapes, sizes and materials, and each one performs a little differently.

Hot and cold stones. Hot and cold therapy helps increase flexibility in connective tissues to reduce pain, stiffness and muscle spasms. Hot rocks made of volcanic basalt, which retain heat, are often used during therapy. The movement of the rocks, combined with direct heat, relaxes the tissues, increases circulation and allows for a more intense manipulation. Cool rocks can stimulate the tissues and decrease inflammation.

Gua Sha. Gua Sha are a series of rounded tools that scrape across the skin to fascial depth. They help increase circulation, stimulate movement and release connective tissue. Each tool has four distinctly shaped treatment edges that contour to the body and allow practitioners to easily treat each area with the required pressure.

Wedge baton. A large wedge-tipped baton uses its own weight to distribute pressure and friction deep into the tissue. It's often used for trigger point therapy, muscle stripping and cross-fiber friction.

T-bars. A t-bar is a wooden tool tipped with a flat or pointed rubber end. The tips act like fingers so you can pinpoint different areas with the proper amount of pressure. The size of the tip depends on the treatment surface area. A small, flat round tip allows you to manipulate smaller and deeper tissues, such as those surrounding the spine, neck and joints. A larger round tip allows broader pressure for tougher tissues, such as thigh and paraspinal muscles.

Trigger tools. A trigger tool is a small handheld device with nodules that pinpoint pressure to a specific area. These tools are used when the manipulation area is small and deep within the tissue.

Electric vibration. Some therapists use various electric vibration tools, usually before or at the end of a session. Applying a large vibrating wand before a massage shakes the tissue to separate the layers and fibers. A similar tool can be used after manual therapy to increase circulation and enhance neurostimulation and fascial mobility.

You can also offer several therapeutic devices for clients to use at home to foster their treatment.

Fascial release balls. Release balls equalize muscle tension throughout the body. Different size balls allow the client to treat trigger points based on size and sensitivity, customizing pressure and intensity to release the soft tissue. By placing the ball on the affected area, a client uses his own shifting weight to massage the area.

Foam roller. Foam rollers release tension and improve mobility by using the client's own body weight to apply pressure to sore spots. A client rolls back and forth across the roller for a self massage. Foam rollers work well for tissue release, especially in the legs for iliotibial band tightness.

Posture curve. A posture curve provides traction along the spine and uses trigger points to alleviate constricted tissue. The tool has two knobs on either side that position along the spine and can be moved from segments to deliver deep muscle therapy. A client can be sitting or lying down.

S-tool. An S-shaped tool allows a client to perform trigger point therapy at home. The tool has nodules to help place pressure on most points of the body.

Trying new tools can be helpful for clinicians and clients, and the plethora of in-clinic and at-home devices can greatly promote healing.

Hannah Baylor is a former staff writer at ADVANCE.