Kirstie Bender Segarra
Kirstie Bender Segarra, MA, LMT, RMTI, ERYT, has been practicing bodywork and yoga since 1996 and structural integration since 2007. She originally trained with traditional healers in Bali, Indonesia, continued her training in massage therapy to become an LMT, and then furthered her education with Erik Dalton and in KMI Structural Integration. She is the author of Myofascial Yoga: A Movement and Yoga Therapists Guide to Asana. She is on the faculty at the University of New Mexico-Taos and chair of Integrative Health and Medical Massage. She trains yoga teachers and medical massage therapists. She is currently completing her doctorate in Integrative Medicine. This article is inspired by Kirstie’s doctorate thesis. You may contact her at [email protected] or balinesetraditionalmassage.com.
Abstract
This article includes the history of fibromyalgia (FM), current findings in fascia research that correlate to FM, research that describes the benefit of structural integration to address symptoms of FM, and a summary of effective alternative medicine and complementary alternative medicine (CAM) therapies for FM. Lastly, I recommend a protocol for managing the health of those with FM that includes structural integration, diet and nutrition changes, and gentle exercise that stimulates the mechanoreceptors of fascia.
This article will demonstrate that managing fascial health, which includes structural integration, is necessary for mitigating the widespread symptoms of pain from fibromyalgia (FM). As a structural integrator trained in the field of integrative health who experienced FM, I found that my pain was alleviated with the application of structural integration, slow myofascial exercise, and nutritional support. I found the same to be true for my clients with FM.
This article presents the first part of a study that I will be conducting. I intend to present the results from the research when it is complete and hope to encourage other structural integrators to conduct formalized studies. I will demonstrate why structural integration is an important part of the protocol I recommend. Structural integration, as you know, is inherently different than other types of bodywork, as it includes rebalancing the structure of our clients. A client with FM will need a change in his structure in order to change the response pattern of his central nervous system. My experience living with FM has shown me that the pain is held in the fascial net. Structural integration, along with anti- inflammatory diet and gentle exercises, offered relief of FM symptoms. I have been able to live without the “flare-ups” of fibromyalgia for over a year.
History of Fibromyalgia: The Princess and the Pea
As early as 180 A.D., Galen, a Greek physician and anatomist, “attributes symptoms associated with widespread pain to the rheuma. When later interpreted, Galen’s words suggest that rheuma represents ‘a great fluxion which races to various parts of the body and goes from one to another’” (Springer, 2013, para. 2). Terry Springer, author on FM, even cites Hans Christian Andersen’s story of “The Princess and the Pea [1835], a literary fairytale describing a princess who suffered from a heightened state of physical sensitivity that interferes with her ability to sleep” (Springer, 2013, para. 6).
Setting fairy tales aside, FM has a very tenuous history within the medical field. It is difficult to diagnose and treat. It is commonly considered a term for several symptoms associated with widespread chronic pain. Dr. Ginevra Liptan in her book Figuring Out Fibromyalgia states that “for almost 100 years, doctors have been arguing about whether it was a ‘real’ illness. It has gone through five name changes, reflecting the confusion surrounding the illness. There are still doctors that insist fibromyalgia is not real, even though there are thousands of studies documenting that it is” (2013, p. vii).
In the last 200 years, fibromyalgia has gone by many titles including chronic rheumatism, muscular rheumatism, fibrositis, neurasthenia, psychogenic rheumatism, and fibromyositis. The symptoms of chronic rheumatism are described as “aching, stiffness, a readiness to feel muscular fatigue, interference with free muscular movement, and very often a want of energy and vigor” (Stockman, 1904, p. 107).
Fibromyalgia is from the Latin fibra (fiber) and the Greek words myo (muscle) and algos (pain). Dr. Hench used the term fibromyalgia for the first time in 1976 (Häuser, 2009, p. 383); rheumagologist Mohammed Yunus also coined the term (Yunus, Masi, Calabro, Miller, & Feigenbaum, 1981). The first controlled study of the characteristics of FM syndrome was published in 1981 (Winfield, 2007). In 1984, an interconnection between FM syndrome and other similar conditions was proposed. In 1986, trials of the first proposed medications for FM were published (Inanici & Yunus, 2004). A 1987 article in the Journal of American Medical Association used the term fibromyalgia syndrome (Goldenberg, 1987). The American College of Rheumatology published its first classification criteria for FM in 1990 (Wolfe, 1990).
Figure 1. Location of tender points as defined by the American College of Rheumatology.
In 1990, “The American College of Rheumatology (ACR) attempts to establish criteria to differentiate fibromyalgia patients from other individuals with widespread pain, in light of statistics that reveal 15% of the general population experiences widespread pain at any given point in time. The 1990 ACR diagnostic criteria state that in order to receive a diagnosis of fibromyalgia, patients should have widespread pain and at least 11 of 18 possible tender points. Moreover, these criteria assert that a decreased threshold for pain is the hallmark sign of fibromyalgia” (Springer, 2013, para. 23; see Figure 1).
In 1991, the Fibromyalgia Impact Questionnaire (FIQ) was created by Carol Burckhardt, PhD. “The FIQ was developed from information gathered from patient reports, functional status instruments, and clinical observations. This instrument measures physical functioning, work status (missed days of work and job difficulty), depression, anxiety, morning tiredness, pain, stiffness, fatigue, and well-being over the past week” (American College of Rheumatology, 2013, para. 2). It was revised several times and is available for academic and clinical use. In 2010 the revised criteria replaced the tender point scale with the Widespread Pain Index (WPI) as well as a measurement of symptom severity, known as the Symptom Severity scale (SS). A copy of the WPI is available at www.fmnetnews.com/fibro-basics/ diagnosis/new.
Symptoms and Proposed Causes of Fibromyalgia
The primary symptom of FM is widespread pain. Another common symptom is “fibrofog” or “brainfog,” which describes the experience of poor memory, reduced attention span, and difficulty multi-tasking. Not feeling rested after sleeping is also often reported. Other associated symptoms are irritable bowel syndrome and bladder symptoms, low blood pressure, dizziness on standing, poor balance, frequent headaches, numbness or tingling in hands or feet, and sensitivity to loud noises (Bennett, 2007).
Dr. Liptan writes that there is a strong correlation “between childhood trauma or abuse and the later development of fibromyalgia” (2013, p. 20). Studies have shown direct links to the occurrence of fibromyalgia and a history of sexual abuse, physical assault, and post-traumatic stress disorder (PTSD). The symptoms of FM may appear later in life after experiencing a second trauma since the original stress-response pattern is developed during childhood. This may happen after experiencing a car accident or major illness or surgery. Some clients do not have traumas associated with childhood. Thus, theories such as constant spinal cord compression have been developed to explain the development of FM (Al-Allaf et al., 2002).
“In people with fibromyalgia, intermittent or constant spinal cord compression in the neck may be causing or promoting sympathetic nervous system over-activity. Spinal cord impingement may activate or irritate the sympathetic nervous system. Anything that irritates the spinal cord in the neck could potentially trigger a prolonged activation of the fight-or-flight response” (Liptan, 2013, p. 21).
The consequence of the abnormal sleep patterns is a positive feedback loop with regards to a fight- or-flight response pattern; the hypothalamus is in overdrive and this inhibits deep sleep. “The symptoms of fibromyalgia can be induced in healthy people by simply depriving them of deep sleep” (Liptan, 2013, p. 23). Dr. Liptan notes that one of the most important repair signals sent out by the brain during sleep is growth hormone. Several studies support that there is low growth hormone in patients with fibromyalgia.
The Emergence of Central Sensitization In the last twenty years, studies (Gracely, Petzke, Wolf, & Clauw, 2002) that look at the correlation of central sensitization to symptoms of widespread pain in FM have found a direct link to how the FM patient experiences pain through the central nervous system. The client experiences a heightened sense of pain through touch. “Essentially, the spinal cord starts turning up the volume on all signals it gets, including pain signals” (Liptan, 2013, p. 25).
In 2003, a study entitled Neurophysiologic Evidence for a Central Sensitization in Patients with Fibromyalgia by Desmeules et al. found that: “A decrease in the NFR [nociceptive flexion R-III reflex] and the subjective pain thresholds to electrical stimulations is a key result of our study and brings forth psychophysical evidence of abnormally processed input to central nociceptive pathways in patients with FM” (p. 1425). The absence of the peripheral nerve fiber lesions leads to the conclusion that “FM may be the consequence of modified stimulus processing by the CNS [central nervous system] without recognizable peripheral sources of nociceptive input or peripheral nerve dysfunction” (p. 1425).
Then, in 2013, Robert Hawkins, MD, wrote that “fibromyalgia is increasingly understood as one of several disorders that are referred to as central sensitivity syndromes; these disorders share underlying causes and clinical features. Tender points are often detected in patients with fibromyalgia and were formerly required for diagnosis” (p. 680). The study by Gracely et al., in 2002, mentioned above, demonstrated that the peripheral nervous system in a client with FM has heightened sensitivity. She indeed experiences sensation of touch at a heightened state of awareness, which would not trigger a response of pain in a healthy client.
In the last twenty years, studies that look at the correlation of central sensitization to symptoms of widespread pain in FM have found a direct link to how the FM patient experiences pain through the central nervous system.
From a reductionist point-of-view, the explanation of central sensitization is very helpful in understanding how clients with FM process pain. One viewpoint of how organisms may develop chronic pain is a correlation with neuroplasticity, which “refers to changes in neural pathways and synapses which are due to changes in behavior, environment, and neural processes, as well as changes resulting from bodily injury. Neuroplasticity has replaced the formerly-held position that the brain is a physiologically static organ, and explores how— and in which ways—the brain changes throughout life” (Neuroplasticity, 2013, para. 1). Neuroplasticity is a viable explanation of the relationship of the CNS to how we move in and out of pain.
Individuals who suffer from chronic pain experience prolonged pain at sites that may have been previously injured, yet are otherwise currently healthy. This phenomenon is related to neuroplasticity due to a maladaptive reorganization of nervous system, both peripherally and centrally. During the period of tissue damage, noxious stimuli and inflammation cause an elevation of nociceptive input from the periphery to the central nervous system. Prolonged nociception from periphery will then elicit a neuroplastic response at the cortical level to change its somatotopic organization for the painful site, inducing central sensitization.
(Neuroplasticity, 2013, para. 30)
The plastic nature of our brain is how one is able to adapt in chronic conditions of pain. Chronic pain reduces the volume of grey matter; following treatment of the chronic condition, the abnormalities in cortical reorganization and grey matter volume are resolved (Wikipedia, 2013). When the last piece, central sensitization, is added, we have another level of understanding of the causes of widespread pain and fibromyalgia.
If we are too focused on the explanation of central sensitization, we may direct treatments to manage pain on the CNS or try to bypass the inhibitory response patterns. However, this is not how the human organism is designed. Indeed, our CNS is not separate from our structure. In order to treat fibromyalgia we have to include the structure, which is explained further in the section titled Research on Fascia and Structured Systems.
Alternate Diagnoses: Does the Client Really Have Fibromyalgia?
One of the confusing aspects working with FM is how it overlaps with other chronic pain conditions such as osteoarthritis, chronic fatigue syndrome, and myofascial pain syndrome. In fact, I once missed that a client had FM. While most structural integrators are not able to diagnose FM within our scope of practice, we see clients with musculoskeletal pain, and being aware of different diagnoses is helpful.
Leon Chaitow references additional diseases which may mimic the same symptoms of fibromyalgia in his book, Fibromyalgia Syndrome: A Practitioner’s Guide to Treatment (2003).
What about Myofascial Pain Syndrome?
There are symptoms that occur in both myofascial pain syndrome (MPS) and FM. Additionally, some clients have both MPS and FM simultaneously.
The symptoms they have in common include:
Symptoms associated with MPS but not with FM include:
Symptoms associated with FM but not with MPS include:
(Dellwo, n.d., para. 9-12)
It may be easy to confuse myofascial pain with FM. One author makes the distinction that myofascial pain has trigger points present and not the classic tender areas of FM. For a practitioner, there is a clear distinction between the pea-sized trigger point and tender points. One can be quite aggressive while working a trigger point, unlike a tender area where gentler techniques are required. Sometimes, I wonder whether or not the use of the term tender points is necessary, since the experience of widespread pain is so overwhelming for the client.
Clients with MPS have more localized pain instead of the chronic overall pain of FM. As one doctor noted:
And while the treatment for MPS sounds awfully similar to that given to our fibromyalgia friends, let us not forget the key differences between these two chronic pain syndromes:
(Borigini, 2013, para. 10)
The literature suggests listening closely to a client and identifying the difference between trigger points and tender points as well as the associated symptoms listed above.
What about Chronic Fatigue Syndrome?
Chronic Fatigue Syndrome (CFS) places more emphasis on fatigue.
Although the two illnesses have many symptoms in common, the most prevalent symptom of FM is widespread pain while the primary symptom of CFS is extreme fatigue that does not improve with rest. The differences in the diagnostic criteria reflect this emphasis on the primary symptom. Fibromyalgia’s diagnosis revolves around the pain, while chronic fatigue syndrome’s diagnosis focuses more on the fatigue.
(Richards, n.d., para. 1)
What about Osteoarthritis?
The third disease that often overlaps with FM is osteoarthritis, which is more prevalent in older populations and may occur in younger people as early as twenty who played high impact sports. There is no established link between FM and osteoarthritis. However, “it is important to note that fibromyalgia can occur in people with rheumatoid arthritis, SLE [Systemic Lupus Erythematosus], or osteoarthritis. Thus, it may be difficult to determine whether symptoms of chronic pain and fatigue are caused by fibromyalgia or another condition” (Goldenberg, n.d., para 19).
One might draw a conclusion that osteoarthritis is joint-centric whereas FM pain is more macro vis-à- vis the fascial net. My experience, having developed severe osteoarthritis at age 19 due to a congenital condition, is that the FM symptoms became more dominant. My symptoms of FM were triggered primarily by stress in winter of 2011. I was working on-call apprenticing in a birth center for deliveries (therefore had lack of sleep), and my father was in ICU on a long recovery from a life threatening illness, not to mention single parenting with a full- time practice and teaching job. Additionally, my history included trauma, abuse, and PTSD. At first, I thought my pains were the ones I experienced from osteoarthritis and fasciitis. However, I also experienced “brainfog” and more widespread pain with seven or more tender areas. The doctors I had met with at that time did not have a diagnosis for me. They saw me as “more fit” and athletic than most of their patients. My clients with fibromyalgia were my mirror. I saw through their experiences what I was experiencing and it slowly dawned on me that I was experiencing fibromyalgia. That is when I relied on myself to develop a protocol towards healing through structural integration, myofascial yoga, and diet.
How is Fascia Related to Fibromyalgia? Dr. Liptan writes that “an emerging body of evidence points to peripheral pain generated from muscle and fascia as the trigger of central sensitization in FM” (2010, p. 366). The evidence of fascia cited as the source of pain dates back to 1904 when Dr. Stockman found pathological changes in white fibrous tissue and intra-muscular septa, which led to the name fibrositis and was linked to chronic rheumatism (Stockman, 1904). My own experience concurs with Dr. Liptan’s, as I indeed perceived my pain as moving through my fascial net. In fact, due to the nature of fascia and the fascial mechanoreceptors I experience fascial pain differently than other types of pain in the body such as spinal nerve impingement, sciatica, and muscle and tendon tears.
Not only does fascia carry our form, it is a communication organ. Your kinesthetic body sense comes mostly from your fascia, not so much from your muscles, via sensory receptors that sense stretch, pressure, shear (Golgi, Pacini, and Ruffini endings respectively), and also touch. A myriad of tiny unmyelinated ‘free’ nerve endings, which are found almost everywhere in fascial tissues, but particularly in periosteal, endomysial and perimysial layers, and in the visceral connective tissues, give us a sense—mostly unconscious—of where we are in space and how we ‘feel.’
Our fascia is the largest and richest sensory organ of our body—with more nerves imbedded in it than even the eye or the tongue. In embryological development, fascia forms the morphogenetic blueprint for our specific personal form. Once we are born and progress toward standing and moving on our feet, fascia is constantly working for us, shifting, changing, and doing its best to hold us together while allowing us to move. It is a wonderful and self-adjusting design. Unfortunately, physical trauma or psychic ‘holding’ can create pain in our systems. It is possible to change the pattern of the system— through structural integration, yoga, exercises, or good manipulation—to stop the holding and move through our pain and suffering—but it does require a mind shift and a physical shift. (Segarra, 2013, p. 11)
Research on Fascia and Structured Systems In a report summarizing Robert Schleip’s work in fascial research in 2005, RolferTM Jason DeFilippis states that the “practitioner is therefore seen as communicating with an actively self-regulating, living organism” (DeFilippis, 2005, p 9). The summary of the research points out that fascia is able to contract in a smooth-muscle-like manner, and the contraction influences musculoskeletal dynamics. Furthermore, the dense innervation of mechanoreceptors in the fascia, which directly connects the fascia to the central nervous system, triggers a response in the ground substance viscosity. This is of particular interest with relation to FM as this demonstrates a direct link from the fascia to the CNS vis-à-vis the mechanoreceptors. Schleip suggests “an attitudinal shift from a mechanical body concept towards a cybernetic model, in which the practitioner’s intervention is seen as stimulation for self-regulatory processes within client’s organization”
(Schleip, 2003b, p. 104).
It is the systems approach that makes the difference in whether or not the treatments for FM are effective, since FM is a diagnosis of several symptoms that are a result of adaptation of the system to life stressors and trauma.
I was delighted to read that others were recognizing the importance of a systems approach and how ever-changing biological systems are directly affected by their relationship to their environment. It is the systems approach that makes the difference in whether or not the treatments for FM are effective, since FM is a diagnosis of several symptoms that are a result of adaptation of the system to life stressors and trauma. Structural integration is a systems approach, and it is this type of strategy that invites change so the client is able to adapt out of pain. In fact, the work that follows is a critical influence for bridging a scientific approach to systems theory versus alternative approaches. I would like to recognize Alfred Pischinger’s influence through research published in The Extracellular Matrix and Ground Regulation: Basis for a Holistic Biological Medicine (2007). However, I am inviting a meta-level of understanding that is offered vis-à-vis Chilean scientist Maturana, a forefather in the cybernetic world that Schleip mentions above. I found that the symptoms of FM have as much to do with our external environments as our internal biology.
Humberto Maturana, PhD, and Francisco Varela, PhD, discovered some very important facts from their experiment on the frog’s eye. They rotated one eye of a tadpole 180 degrees. When the frog fully developed and was fed prey with its good eye uncovered and rotated eye covered, it shot its tongue up and out and caught the prey. When the good eye was covered and the rotated eye uncovered, the frog projected its tongue with a deviation of 180 degrees and missed. The frog continued to miss no matter how many times the prey was presented.
The experiment reveals in a very dramatic way that, for the animal, there is no such thing as up and down, front and back, in reference to an outside world, as it exists for the observer doing the study. There is only an internal correlation between the place where the retina receives a given perturbation and muscular contractions that move the tongue, the mouth, the neck, and, in fact, the frog’s entire body. (Maturana & Varela, 1992, p. 126)
This study, as well as others in the 1950s, gives “direct evidence that the operation of the nervous system is an expression of its connectivity or structure of connections and that behavior arises because of the nervous system’s internal relations of activity” (Maturana & Varela, 1992, p. 126).
Furthermore, Maturana and Varela describe structural plasticity: a “history of interactions is a history of structural changes that forms a particular history of transformations of an initial structure in which the nervous system participates by expanding the realm of possible states” (p. 127). They explain that systems have circular relationships; structural plasticity happens in relationship through time.
Each interaction triggers a response in the structure in which there are various potential states in the nervous system.
The frog’s eye experiment demonstrates that the activation of the nervous system is dependent on structure. Maturana and Varela define this as structured determined systems (p. 96). A FM client is in a hypersensitivity response pattern with regards to their CNS. Each time, as structural integrators, we interact with the fascia of our clients we our inviting the necessary change in the client’s nervous system.
A Deeper Understanding of how Fascial Mechanoreceptors Influence Change in the Fascial Matrix
Schleip, in his article Fascial Plasticity—A New Neurobiological Explanation (2003a), refers to four types of mechanoreceptors in fascia: Golgi (Type 1b), Pacini and Paciniform (Type II), Ruffini (Type II) and Interstitial (Type III & IV). The Golgi tendon reflex arc and organs involved in muscle contraction are noted by Cottingham to respond to slow stretch. However, Schleip states it is “too bad—it is not a simple reflex!” (Schleip, 2003a, p. 2). As later research shows ( Jami, 1992), passive stretching of myofascial tissue does not stimulate the Golgi tendon organs. Stimulation happens when the muscle fibers are actively contracted. For example, when a practitioner works passively on the quadriceps, the Golgi tendon organs are not stimulated, but they are when the client engages the quadriceps by drawing his “toes to the nose.” Dietz (1992) states that “in order to handle the extreme antigravity balancing challenges as a biped, our central nervous system can reset the Golgi tendon receptors and related reflex arcs so they function as very delicate antigravity receptors” (Schleip, 2003a, p. 2 ). To translate, our Golgi tendons give us the neurofeedback we need for balance.
In addition to the Golgi mechanoreceptors mentioned above, there are four additional. Three are classified as Type II and the fourth, Interstitial, is a Type III and IV found almost everywhere inside bone with the highest density in the periosteum.
The Interstitial mechanoreceptors respond to rapid and sustained pressure changes. Of the Type II mechanoreceptors, the first are the Pacini (Type II), which respond to rapid changes in pressure and to vibrations. Next are the Paciniform (Type II) corpuscles, which perform a similar function as the Pacini with an increased sensitivity. Last are the Ruffini (Type II), which respond to sustained pressure. “Ruffini endings will also be activated by slow and deep ‘melting quality’ soft tissue techniques” (Schleip, 2003a, p. 17).
Mechanoreceptors are found throughout the fascia. Slower, deeper techniques, as Schleip notes: “deep manual pressure–specifically if it is slow or steady” (2003a, p. 17) lowers the tone of the sympathetic nervous system and invites the overall feeling of relaxation. As researchers are now proposing (Schleip, 2012), our largest sensory organ is our muscle with the related fascia. Fascia is an interconnected web, like a school of fish or a flock of birds. When one fish shifts, as in a change of a singular motor unit, the rest follow (Schleip, 2003a).
With the discovery of the Ruffini mechanoreceptors, we have our explanation of how we are able to shift patterns, like a school of fish changing direction, in our fascial net. In fact, I often combine slow and deep targeting of the Ruffini mechanoreceptors, muscle contractions for engagement of Golgi tendons, and sound vibrations (e.g., music, gongs, tuning forks and Tibetan bowls) for the Pacini and Paciniform mechanoreceptors.
In my practice, combining fascial scooping to create more space between the fascial layers and muscles with slow movement for lengthening has proven the most effective.
Fascial Health in Nutrition
Several studies (Lindsay, 2008; Ruberg, 1984; Tinker, 1985; Berg, 1992) have demonstrated that collagen production responds to diet, both in the short-term and long run. Factors to consider are caloric intake, protein intake, carbohydrates, and fats. Fascia likes a healthy intake of calories. Restrictive diets impair the repair of fascia. “Prolonged caloric restriction will generally result in a subsequent protein intake deficiency that in turn will be reflected by an increased rate of protein breakdown in the muscle tissue” (Lindsay, 2008, p. 190). During times of intake deficiency, the body draws protein from muscles and connective tissue. Mark Lindsay, DC, sites a study (Friedlander, 2005) that points to protein malnutrition as a significant factor in preventing the normal turnover and healing of connective tissues.
Furthermore, carbohydrates are important as they provide sufficient energy in the form of monosaccharide (glucose) to support the role of “phagocytes and other white cells that mediate the inflammatory process” (Lindsay, 2008, p. 194). The activity of these cells aids in the repair and healing of tissues. “Diets low in carbohydrates typically cause body water loss” (Lindsay, 2008, p. 194).
Fascia requires a high water content for optimal functioning under stress.
Fats are an important source of energy as well. There are saturated and polyunsaturated fatty acids (PUFAs). They are both precursors for hormones such as steroids and prostaglandins. “PUFAs are essential constituents of the cell membrane, contributing to their structural and functional integrity” (Lindsay, 2008, p. 194). According to Lindsay, saturated fats have little direct importance in the physiology of connective tissue. Thus, the focus is on PUFAs, which are divided into two main groups: omega-3 and omega-6. PUFAs are particularly low in the North American diet. They have been found to play a major role in moderating the length of the inflammatory process due to the important role of eicosanoids of which the omegas are a precursor.
Thus, the FM client is advised to maintain a diet with healthy caloric intake, protein, healthy fats (omega-3 and 6), and sufficient water.
A Summary of Effective Complementary and Alternative Medicine (CAM) Therapies
The National Center for Complementary and Alternative Medicine (NCCAM) states “much of the research on complementary health approaches for [FM] is still preliminary” (n.d., para. 9). However, tai chi, qi gong, and massage have been shown to relieve the symptoms of FM.
A summary of some of the complementary therapies and the research results follows:
Tai Chi. A 2010 NCCAM, funded study (Wang et al., 2010) found that those who participated in twice-weekly, 60-minute tai chi classes had significant improvements in “measures used to assess pain, sleep quality, depression, and quality of life, and these benefits were sustained at 24 weeks” (pp. 753-4).
Qi Gong. After a seven-week program of Qigong for participants with fibromyalgia “significant improvements were found for the intervention group, at post-treatment, regarding different aspects of pain and psychological health and distress” (Haak & Scott, 2008, p. 625).
Lymph Drainage Therapy. A randomized controlled trial (Ekici, Bakar, Akbayrak, & Yuksel, 2009) compared manual lymph drainage therapy and connective tissue massage in 50 women with fibromyalgia. Improvements were found in participants from both groups, but manual lymph drainage therapy had better outcomes in terms of morning tiredness, anxiety, and total FIQ score.
Acupuncture. “A systematic review of different studies using acupuncture for fibromyalgia concluded that acupuncture had a small pain-relieving effect that was not distinguishable from bias” (Langhorst, Klose, Musial, Irnich, & Häuser, 2010, p. 778).
Other Studies examined balneotherapy, biofeedback, homeopathy, Reiki, chiropractic care, hypnosis, or magnet therapy for FM and various natural products—such as topical creams containing capsaicin (the substance that gives chili peppers their heat) or dietary supplements like S-adenosyl-L- methionine (SAMe) or soy—for FM. All of these studies had no conclusive results for individuals with fibromyalgia.
Hatha Yoga. One final study to add is on gentle Hatha yoga. The study concluded that there is “evidence of association between participating in gentle Hatha yoga classes and reduced fibromyalgia- related symptoms” (Rudrud, 2012, p. 53).
To summarize, the CAM therapies that have been shown in studies to relieve symptoms of FM are Tai Chi, Qi Gong, massage therapy, and Hatha yoga.
Recommended Health Management Protocols for Fibromyalgia
In this section we will take a look at what types of testing and protocols may be the most effective in treating fibromyalgia and why. The primary symptom of FM is widespread pain or tender areas through the body. The protocols I developed to manage FM for myself and my clients are structural integration, myofascial exercise, and nutrition.
Structural Integration
Structural integration strategies will be used in the bodywork therapy sessions, drawing on ideas originally from Ida Rolf, PhD (1977), and later developed by several of her students including Tom Myers (KMI), Erik Dalton (Myoskeletal Alignment), and Joseph Heller (Hellerwork).
There are many tools and techniques for the application of structural integration, but they share a focus on “the connective tissue, or fascia, of the body . . . to restore postural balance, ease of movement” (IASI, n.d., para. 1, 3). The goals of treatment will be to balance the structural system and alleviate pain. Each client will be seen for a minimum of 90 minutes once a month, preferably twice a month, for a total of six sessions. My structural integration training is in the myofascial meridians. I assess the client for tilt, bend, shift, and rotations, then release the superficial myofascial meridians with a goal of neutral posture. Eventually, I focus on the deep front myofascial line. I have a tendency to be meticulous about clearing the lamina groove, especially for my clients with FM.
Exercise
Exercise has proved important for those with FM (Liptan, 2013). My experience has shown that aggressive exercise and fast approaches such as running, power yoga, and aerobics aggravated the symptoms of pain. The challenge is to develop a workout that is appropriate for the person in chronic pain. Myofascial Yoga is a slower approach to yoga asana based on the myofascial meridians outlined by Tom Myers in his book, Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists (2013). The basic differences are in the longer holds of asana, a minimum of five deep breaths (30-90 seconds), in specific alignment that follows the myofascial meridians. Additionally, one is required to slowly warm up the fascia for at least 20 minutes in static postures before beginning any dynamic, strength-oriented asana. This is important because it allows time for the fascia to warm up. In fact, other practitioners have confirmed the importance of the slow warm-up for alleviating pain. Ben Benjamin, PhD, in Sports Medicine outlines protocols for warm-up in his book Exercise Without Injury (1979).
Nutrition
Diet and correctly-designed nutrition for the individual is critical in managing the inflammatory process to help alleviate the symptoms of widespread pain. As structural integrators, nutrition counseling is not within our scope of practice, so it is useful to be able to refer to a qualified professional.
Study Methods
I will be conducting a study to determine the outcomes of managing fascial health with a clinical trial of five to ten clients for three months beginning March 2014. I will seek clients through the local health network who have been diagnosed with FM. The study method will include:
Structural integration bodywork (90-minute sessions) at least once a month for three months.
The Widespread Pain Index (WPI) will be used to assess the individual clients before and after treatment to measure the effectiveness of the treatment, not as a diagnostic measure. The expected outcome is reduced scores on the WPI indicating that managing fascial health reduces widespread pain symptoms of FM. The final results will be available after the clinical practicum.
. . . managing widespread pain must include treatment of the fascia, as we are structured determined systems, and to decrease pain is to invite change in the structure through the fascial matrix . . .
Discussion
In the literature review and research, I have not been able to find a clear source that directly correlates the outcomes of managing fascial health and fibromyalgia. The intent of my upcoming study is to show clearly that managing widespread pain must include treatment of the fascia, as we are structured determined systems, and to decrease pain is to invite change in the structure through the fascial matrix in order to have a correlating change in the central nervous system. In this way we restore homeostasis for the client.
References
Al-Allaf, A. W., Dunbar, K. L., Hallum, N. S., Nosratzadeh, B., Templeton, K. D., & Pullar, T. (2002). A case-control study examining the role of physical trauma in the onset of fibromyalgia syndrome. Rheumatology, 41(4), 450-53.
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