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Fibromyalgia

Posted Feb 02 2009 12:00am
I just saw an advertisement in my local newspaper for a seminar a chiropractor was running on chiropractic treatment of fibromyalgia syndrome (FMS).
This is an issue that is dear to my heart because not only do I lecture on fibromyalgia but I have also published on this.
Schneider MJ, Brady DM, Perle SM. Commentary: differential diagnosis of fibromyalgia syndrome: proposal of a model and algorithm for patients presenting with the primary symptom of chronic widespread pain. J Manipulative PhysiolTher. 2006 Jul-Aug;29(6):493-501.
Our paper is available for free, click on the link above.
In our paper we basically deal with the fact that there are three classes of conditions that are commonly misdiagnosed as FMS.
  • Medical Conditions - a competent diagnostic work up must be done to rule out some other cause for the patients widespread pain for example: Hypothyroidism, anemia, rheumatoid arthritis, Lyme disease, rheumatic auto-immune disorders such as ankylosing spondylitis or scleroderma, multiple sclerosis, and occult malignancy
  • Functional Metabolic Disorders - these are subclinical disease states and disorders involving dysfunction of internal organs and metabolism, rather than true pathology
  • Musculoskeletal Disorders - various conditions while documented in the literature are not known universally, for example joint dysfunction (a name for the joint that causes symptoms which resolves after manipulation), myofascial trigger points or sclerotomal pain . Murphy et al present a good diagnosis-based clinical decision rule dealing with how to diagnose these conditions.
Now one might say that the last category should be within the competency domain of all chiropractors. For various reasons (e.g. where they went to school or their anachronistic beliefs about chiropractic) some are ignorant of all the potential conditions that may look like FMS but really only are these muscuolskeletal dysfunctions.
Now the point of this blog. There is compelling evidence at this time that FMS is not a condition of the musculoskeletal system. Clearly it is pain in the musculoskeletal system but that does not mean that there is anything wrong with the musculoskeletal system just that is how our brain interprets the symptoms.
For a good review of the pathophysiology of fibromyalgia see
Abeles AM, Pillinger MH, Solitar BM, Abeles M. Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med. 2007 May 15;146(10):726-34.
Abeles et al review on fibromyalgia is available free just click on the link above.
The basic problem with FMS is a change in how the brain perceives touch and interprets it as pain. Thus, treatments geared towards affecting any changes to the periphery (e.g., muscles, joints, ligaments) are not likely to benefit the patient with FMS. Aerobic exercise (which involves using these peripheral tissues) is beneficial because of its mood elevating effects.

The patient with "FMS" who finds that manipulation, massage, vitamins & other supplements is an effective treatment more than likely had successful treatment of some other condition that was misdiagnosed at FMS. I guess for that person they are lucky that the stumbled upon someone who mis-treated their misdiagnosed FMS. The real problem is the vast number of people with real FMS who stumble along between health care providers who haven't correctly diagnosed FMS or who have but offer inherently ineffective treatments.

SMP
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