The Treatment of a Client Diagnosed with Fibromyalgia Syndrome Utilizing Integrative Manual Therapy™
Author: Tammy S. Koch, M.P.T., I.M.P., C and Laurie Lunn, P.T.
Abstract: This article is a case study on a 46 year old woman with complaints of total body pain and diagnosis of Fibromyalgia Syndrome (FMS). This study illustrates the benefits of Integrative Manual Therapy (IMT) on a client with FMS. The woman was treated with IMT with a focus on the immune system and lymphatic drainage. The woman was also treated with Endermologie. After therapy was completed, the woman had significant improvement including a decrease in her medications and a significant improvement in levels of fatigue.
Key Words: Fibromyalgia Syndrome, Chronic Pain, Sleep, Fatigue, Endermologie
Introduction
Modern healthcare has succeeded in markedly reducing the mortality of the
U.S. population. While primary healthcare research has focused on decoding
the genetic mystery which defines chromosomal predisposition to disease, all
aspects of healthcare continue to look for answers to the chronic diseases
and disorders which now account for 80% of all deaths and 80% of all morbidity.
(1) Some of the most challenging chronic disease patients who visit healthcare
providers are diagnosed with fibromyalgia syndrome (FMS).
FMS was first recognized in the mid 19th century when physicians noted exaggerated
tenderness to palpation in patients. (2) In the early 1900’s, physicians
noted inflammation in microscopic examination of connective tissue. Unable
to determine the etiology of this inflammation, physicians thought the disease
was a result of neurosis or hysterical disorders. (3) This appears to be the
beginning of a long history of misunderstanding clients diagnosed with FMS.
Fibrosis and psychogenic rheumatism were the terms used to describe clients
with this disorder prior to the1980’s. In the early 1980’s, the
term “Fibromyalgia Syndrome” was coined by Hench. (4)
Today, FMS is the third leading diagnosis of those clients visiting the rheumatologist’s
office. (5) The American College of Rheumatology states that it is 7 times
more prevalent in women than men. (6) The onset of FMS is common between the
ages of 20-40 and diagnosed at a median age of 34-53. (7) There is some speculation
that there is a genetic basis to this disease because of the familial patterns
noted, however, there is no genetic discovery to date which substantiates
this speculation.
Symptoms of FMS vary widely. Musculoskeletal symptoms reported include: aches,
stiffness, swelling (in soft tissue, articular and/or periarticular areas),
tender points (in the neck, shoulders, upper chest wall and lower back), and
muscle spasms or nodules. (8) Other symptoms and/or concomitant diagnoses
include: excessive fatigue, nonrestorative sleep, tension and migraine headaches,
chest pains, irritability, dysmenorrhea, parasthesia, Raynoud’s Phenomenon,
bowel/bladder irritability, anxiety, depression, extremity swelling and numbness,
total body weakness, mitral valve prolapse, temporomandibular joint (TMJ)
dysfunction, cognitive problems, vertigo, irritable bowel syndrome, tinnitus,
bursitis, reticular skin discoloration, tachycardia, rheumatoid arthritis,
sciatica and lupus. (9, 10, 11)
In 1990, the American College of Rheumatology concluded that fibromyalgia
would be diagnosed by a history of widespread pain occurring longer than 3
months, in combination with pain in at least 11 of 18 specified bilateral
tender points primarily in muscular tissue origin. (12) Tenderpoints are palpated
using a 4 kg/cm2 pressure at these points. (13) Grading of pain occurs according
to Reeves, et al. Index (14) of the following:
0 = no tenderness with no withdrawal
2 = tenderness and withdrawal
3 = tenderness and exaggerated withdrawal
4 = untouchable
The etiology of FMS is currently unknown, although, several postulates abound. Current theories regarding the etiology include the following:
Even today as researchers try to understand the causes of FMS, many openly
dispute whether or not this chronic disease is a psychogenic disorder or the
somatic expression of a major psychologic disorder. Debate remains as to the
causal effect of any psychologic abnormality vs. the onset of psychologic
disorders, mainly depression, which may manifest due to dealing with the life
altering affects of FMS.
Treatment of FMS is multidimensional. Typical treatment includes: education,
stress-management, energy conservation, and cognitive training. Many FMS clients
depend on mounting varieties of medication to address pain control, sleep
disturbances, and depression. Exercise is also a primary treatment approach.
The exercise focuses mainly on low impact and low-level cardiovascular exercise,
such as walking or aquatic therapy. In the past year, physicians have investigated
the prevalence of Arnold Chiari Syndrome and spinal stenosis, which impinge
on the brainstem. As a result, surgeons are doing radical surgery of skull
decompression to relieve pressure on the brainstem. (20) This radical surgery
has to date no good long-term data to suggest it has been beneficial to clients
who have undergone the procedure.
While the treatments described above are varied, there is no treatment or
combinations of treatment, to date, which successfully treat FMS.
The objective of this case study is to document the efficacy and efficiency of using Integrative Manual Therapy™ (IMT), which may be used by any health professional whom has attended formal training approved by Dialogues in Contemporary Rehabilitation, and Endermologie, a form of manual lymph drainage, (45) to successfully address a client with FMS. The treatment rationale for using IMT is that treating the structural components of the body and improving lymph drainage will improve the detoxification process of the body, positively affect the autonomic nervous system, and thereby improve the client’s function and quality of life. The anticipated outcome was twofold: 1) subjective reports of decreased pain with improved function, and 2) objective improvements documented in range of motion, posture, gait, and cardiovascular endurance.
Case Description: The client was a 46 year old female who came to our facility with complaints of total body pain in the face, neck, back, chest/rib cage, bilateral shoulders, bilateral upper extremities, abdomen, low back, hips, buttocks, bilateral lower extremities, and bilateral feet. She also complained of abnormal sleep patterns and low endurance to any type of activity. Her medical history was significant for FMS, Bell’s Palsey and dental work. She had a history of traumatic injury with a fractured right arm at 9 years old; four major falls at 21 years of age and a fall 2 years ago on ice. She is employed 35 hours per week as a librarian. Although she was completing her work duties, she was experiencing significant pain and fatigue making the completion of those duties difficult. She had a long history of total body pain. On evaluation, she was taking the following medications: Talaren, Baclofen, Oxycontin, Celebrex, Neurontin, Trazodon e, Tylenol 3, Prilosec, Sulcralfate and Paxil. Treatment this client had used in the past included a traditional physical therapy exercise program, ju jit su, massage and bodywork. While these treatments seemed to pallitively decrease symptoms, she had not seen an overall improvement in her condition and had not seen changes lasting longer than a few days previous to our intervention.
Evaluation
A comprehensive evaluation was performed on the client by a physical therapist certified in IMT. Significant findings included the following:
Posture: severe forward head and neck, bilateral shoulder protraction and elevation, decreased lumbar lordosis
Biomechanics and Joint Mobility: mobility testing revealed hypomobility
at the pelvic joints, lumbosacral junction, intervertebral joints of the lumbar,
thoracic, and cervical spine and OA/AA joints. Bilateral shoulder and knee
joints exhibited moderate limitations in range of motion (ROM) on all planes.
The bilateral hip and ankle joints exhibited severe limitations in ROM on
all planes.
Spinal Limitations in ROM: (True, uncompensated ROM)
Lumbar motion limited by:
flexion - 95 %
extension - 95%
right lateral flexion- 90%
left lateral flexion - 90%
right rotation - 90%
left rotation - 90%
Cervical motion limited by:
flexion - 75%
extension - 75%
right rotation - 75%
left rotation - 75%
right lateral flexion - 70%
left lateral flexion - 70%
Soft Tissue Flexibility: Fascial dysfunction, with limited soft tissue mobility and pain on palpation was present in the following areas: neck, suboccipital region, posterior soft tissues of the neck/thorax/lumbar spine, shoulder girdles, rib cage, abdomen, pelvis/buttocks, upper and lower extremities, and feet. This soft tissue dysfunction appeared to be contributing to the limitation in ROM of the spine and extremities. Protective muscle spasm was also found in the following areas: craniofascial region, neck, sub-occipital musculature, paravertebral muscles of the neck/thorax/lumbar spine, bilateral shoulder girdles, rib cage, abdomen, pelvis/buttocks, bilateral upper and lower extremities and feet. This protective muscle spasm also appeared to be contributing to the pain and limited ROM.
Clinical Neurology: Light touch sensation was within normal limits.
The brachial plexus showed signs of being compromised at the scalenes on both
the left and right sides.
Strength: Gross muscle strength for the trunk and all 4 extremities
was within functional limits, however, was painful with testing.
Function/ADLs: The following activities, as reported by the client,
were noted to be painful and difficult: lying on her stomach, back, or left
side; moving from lying to sitting, sitting to standing, and standing to sitting;
sitting; driving; sitting in a car; walking; bending; lifting; reaching; work
activities. The client also noted sports and leisure activities were compromised.
The client reported both pain and low endurance/quick fatigue were limiting
factors in these activities.
Gait: Decreased reciprocal movements at bilateral upper extremities
and trunk; decreased stride length bilaterally. The client noted she could
only walk short functional distances secondary to a significant increase in
severe and prolonged total body pain following the activity.
Girth Measurements: Waist/Umbilicus: 53 inches
Right thigh: 26 inches
Left thigh: 26 inches
Myofascial Mapping: (21) Significant Mapping noted over lymph tissue,
abdomen, and thorax.
Intervention
After a full explanation of the objective findings to the client, she was further educated on IMT, the various treatment techniques and rationales and her responsibilities as our client towards her improved health and recovery. Throughout the course of treatment, the client was continually educated regarding the treatment and its rationale.
Treatment goals included: decreased pain, improved biomechanical and joint dysfunction, decreased protective muscle spasm, increased soft tissue flexibility with decreased fascial dysfunction and increased ROM; return to previous activities and functional level with normal endurance and no pain.
The treatment plan was developed after reviewing the evaluation and included multiple techniques from the Integrative Manual Therapy approach. With significant Myofascial Mapping noted over the lymph tissue, thoracic and abdominal regions, Disruption of Membrane technique (22) was completed over areas of the kidneys, inferior vena cava (IVC), superior vena cava (SVC), thoracic duct, sigmoid colon, portal system and liver. Superior and inferior vena cava syndromes (23) were also completed. Lymph node Advanced Strain and Counterstrain techniques (24) were done in areas of major lymph nodes and near major organs. Aberrant motilities in the lower extremities, abdomen and thorax were addressed to include Immune Deficiency Motility (25) and Eruption Motility. (26) Endermologie was completed 7 times over the total body to enhance lymph drainage throughout the body. Compression Syndromes (27) were done on the lower extremities and the Bone Bruise technique (28) was used on the femur, tibias, ribs, cranium, ilia and the spine. Advanced Neural Tissue Tension Techniques (29) to sensory nerves of the upper extremities and cranial base was utilized. Muscle Energy and ‘Beyond’ Techniques were used to address pelvis and sacrum mechanics. All of the above mentioned techniques were completed in approximately 33 visits. During the course of treatment, the client asked her physician for assistance in safely decreasing her medications according to his guidelines.
Functionally, the client was educated in completing a walking program beginning with 2-5 minutes of walking. She was then instructed in adequate progression of this program.
Neurofascial Process homework was issued to the client for self-treatment. (30) Imagery was used to help the client with psycho/social/emotional issues which arose during the course of treatment.
Outcomes
Following completion of the aforementioned treatment, the client subjectively reported the following:
Objective findings were noted as follows:
|
in inches
|
||
| waist/umbilicus |
53
|
48
|
| bilateral thighs |
26
|
24
|
|
Percentage Limitation
|
||
| lumbar flexion |
95
|
50
|
| lumbar extension |
95
|
75
|
| lumbar sidebending |
90
|
65
|
| cervical flexion |
75
|
60
|
| cervical extension |
75
|
70
|
| cervical rotation |
75
|
50
|
Discussion
The results of this single case report using Integrative Manual Therapy techniques
and Endermologie suggest that the anatomical specific identification of pathoanatomy
can successfully be used to provide favorable outcomes for clients with FMS.
A review of the literature has determined that while the American Association
of Rheumatology has determined basic guidelines for diagnosis, there is no
effective treatment aimed at uncovering the pathoanatomy and etiology unique
to each individual’s case. Therefore, developing a treatment plan aimed
at treating the possible pathoanatomical causes behind the symptoms of FMS
had not been developed until the evaluation and treatment techniques of IMT
were introduced. IMT evaluation and treatment techniques allow for specific
and successful clinical diagnosis of pathoanatomical landmarks and treatment
of each individual client’s situation.
Roger Williams, Ph.D., the author of Biomechanical Individuality, states that
anatomy and biochemistry are always intimately related, even though the two
disciplines may be regarded as quite dissimilar. (31) While Dr. Williams saw
anatomical variations rooted primarily in heredity, the theory of IMT would
support the hypothesis that the anatomical variations between individuals
is, in part, due to breakdown of tissue secondary to antigens and protective
mechanisms facilitated by the brainstem. These would, in turn, affect the
efficiency and function of the anatomical structure, thereby affecting the
body’s biochemistry.
This case study treatment plan considered several anatomical systems to assist
the client’s body in detoxifying and healing. The lymphatic system was
a major focus of the treatment plan. It was addressed through treatment of
lymph nodes with Advanced Strain and Counterstrain Technique, Disruption of
Membrane Technique, and Endermologie treatment. All were used to enhance lymph
drainage. Ingrid Kurz, MD, states that lymph drainage activates inhibitory
cells whose function is to dampen the sensation of pain. (32) Furthermore,
she states that lymph drainage has immunological benefits assisting the body
in inactivating antigens by mobilizing the function of the lymph system. (33)
These things said, we can then hypothesize by extrapolation that treatment
of the lymph system assists in function of this system, thereby assisting
the body’s healing, detoxification, and pain relief.
Lymphatic drainage was completed using Endermologie. This treatment was performed
to the entire body and at times focused on areas of congestion such as the
lower extremities. Dr. Vodder reports that the effects of lymph drainage are
to not only improve the immune system and drainage effectiveness of the system,
but that lymph drainage has a stimulating effect on the parasympathetic nervous
system with resultant subject calmness and relaxation. (42) This is important
in a world that continually challenges the sympathetic nervous system through
daily stress, bringing it to a heightened state of resting potential. In an
individual whose body is doing its best to survive, one may expect the sympathetic
nervous system to be at a heightened state of alert. Lymphatic drainage starts
the process of balancing the autonomic nervous system. This attempt at balancing
the autonomic nervous system was further supported through Neurofascial Process
homework and imagery.
Dr. Vodder also reports that lymph drainage has a tonic effect on smooth muscles
of the blood vessels. (43) Once the sphincters of these vessels close, the
capillary pressure drops. (44) As a result, there is improved edema reduction
and reabsorptive capacity of the capillaries. Therefore, the capillaries become
a more efficient means of drainage throughout the tissue system. This will
also impact the amount of blood delivered to the muscles with activity. Functionally,
the impact will allow increased tolerance to exercise.
Dr. W. Giammatteo reports that both the IVC and the SVC are important for
effective lymphatic drainage to occur. (35) Furthermore, she reports that
the IVC is clinically more significant than the SVC for lymphatic drainage
due to its importance in gastrointestinal lymphatic drainage. (36) This client
had significant and thorough IMT work done to focus on both the IVC and SVC.
The theory being that both would again enhance the lymphatic drainage and
improve detoxification. Dr. Kurtz reports in her book, Introduction to Dr.
Vodder’s Manual Lymph Drainage, that while the arterial network is the
supply system to the tissues, the venous and lymph systems network the drainage
systems. (37) The venous system has the task of removing small molecules from
the connective tissue and transporting them. (38) The lymph system removes
larger molecules and water from tissue and transports them. (39) According
to Vodder, lymph obligatory load, those substances which must be removed by
the lymph system, includes the protein molecules, immobile cells, cell fragments,
waste product, bacteria, viruses, inanimate substances, surplus water and
large molecular fats. (40) When in a protective mode due to injury or an infectious
process, the IVC is not capable of maximizing the detoxification process potential.
Toxins will remain in the system with the expected inflammatory response occurring,
thus impacting the client’s function. The SVC receives lymph flow from
all areas except the right thoracic inlet, abdominal region and bilateral
lower extremities. Dr. W. Giammatteo reports that restrictions in the SVC
flow will cause congestion with subsequent impact on the immune system and
the cardiac system. (41) Impact on both the immune and cardiac systems will
therefore decrease function of each system via decreased ability to fight
antigens and decreased cardiovascular endurance.
IMT techniques for the liver and portal system were completed: structural
work was done on these anatomical parts to improve the function of the system
and therefore further assist the body’s ability to detoxify. Phase I
activation and Phase II conjugation are functions of the liver which remove
exogenous and endogenous toxins from the body through detoxification. (34)
Functional biochemical tests to determine the effectiveness of these detoxification
processes would have been of interest pre and post treatment with IMT to objectively
determine improvement in this client’s ability to detoxify.
In attempts to decrease the client’s pain, Bone Bruise technique and
Advanced Neural Tissue Tension of the sensory nerves were completed in areas
of intense discomfort. By completing these techniques, the body was able to
maximize healing potential, and pain receptors were subsequently quieted.
The client was able to decrease her medication dramatically secondary to improved
comfort.
As soft tissue protection was relaxed through the aforementioned techniques,
the biomechanical range of motion potential was maximized through Muscle Energy
and ‘Beyond’ Technique of the pelvis, sacrum and spine. This allowed
for improved ease and comfort with function, which was evident in ROM testing
pre and post treatment.
Conclusion
This single study case study has demonstrated the successful use of Integrative Manual Therapy techniques to evaluate and treat the diagnosis of fibromyalgia syndrome efficiently and effectively. Clearly, it shows that the treatment of FMS occurs most effectively when the theory of toxicity is considered, and attempts are made to assist the body in healing and detoxification by focusing on the pathoanatomical landmarks of multiple systems. With IMT, each client’s condition is unique, and subsequent treatment plans which focus on the pathoanatomical landmarks involved in that client’s condition can help to improve their health, and ultimately, their quality of life.
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