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How to Ease Symptoms with Informed Massage

By Charlotte Michael Versagi

Originally published in Massage Bodywork magazine September/October 2011. Copyright 2011. Associated Bodywork and Massage Professionals. All rights reserved.

Fibromyalgia has been described as a deep and superficial, soft tissue aching pain of at least three months' duration, characterized by specific tender points in 11 of 18 locations. This is a perfect definition for this painful condition, which can be profoundly affected by intelligent and thoughtful massage therapy.

Fibromyalgia in Review
Affecting anywhere from 3-6 million Americans, fibromyalgia syndrome (FMS) is categorized as either primary or secondary. A primary diagnosis means the cause is unclear--the existing evidence suggests it may be a neuroendocrine dysfunction.1 Secondary FMS, the form most MTs will see, is caused by traumatic physical or psychological insult; therefore, it is important to understand these insults as a factor in cause and care. The condition's duration is measured in years, and lifetime involvement is common. It occurs in children and adults of all ages and socioeconomics levels, with a strong prevalence in females aged 35-55.2 FMS occurs more frequently in families who share a history of depression, alcoholism, childhood physical and sexual abuse, drug abuse, or eating disorders. There may also be a genetic predisposition for FMS.3

The syndrome often mimics similar diseases, and several diseases that occur simultaneously with FMS can contribute to a confusing clinical picture. Associated conditions of FMS include anxiety, bowel difficulties, chronic fatigue syndrome, depression, headaches, insomnia, menstrual difficulties, myofascial pain syndrome, noncardiac-related chest pain, peripheral neurogenic pain, temporomandibular joint (TMJ) dysfunction, and some forms of arthritis.

The Symptomatic Picture
The severity of FMS fluctuates, and complications often occur that affect the person's quality of life. Symptoms of the chronic condition can be exacerbated by depression, extreme weather changes, insufficient sleep, long periods of immobility, overexertion, stress, and the presence of simultaneous infectious illnesses. The pain is pervasive, and the condition can endure for decades. However, it is not progressive, does not deteriorate the joints or organs, and is not fatal.

After years of labeling FMS as a psychological aberration or a nonexistent condition, clinicians have now narrowed the pathophysiology to a probable central nervous system and/or endocrine disorder. Those with FMS have hypersensitive pain (which signals activity in the brain) and a dysfunction in the muscle's pain receptors. The brain of a fibromyalgia patient reacts differently than those of nonsufferers while reporting pain, and FMS clients can show sensitivity to light touch as well as measurable abnormalities in nonpainful stimulus tests.

According to criteria established by the American College of Rheumatology,4 the clinical diagnosis depends on confirmation of at least 11 of 18 tender points on the body (see Tender Point Map 37), but laboratory tests, MRIs, and muscle biopsies to determine the presence of FMS are usually nondiagnostic. Overall signs and symptoms include:
- Allodynia (a normally nonpainful stimulus perceived as painful).
- Pain lasting at least three months.
- Pain and/or tenderness palpable in at least 11 of 18 points.
- Generalized muscular aching.
- Lack of restorative sleep, unrelated to the number of hours slept.
- Pain and depression exacerbated by insomnia.
- Pain exacerbated by exertion.
- Moderate to profound fatigue.
- Generalized stiffness, worse at the beginning and end of the day and after periods of immobility.
- Distal paresthesia (numbness, tingling, burning, and stinging in the hands and feet).
- Cold intolerance.

Through massage therapy, allodynia can be addressed with careful desensitization techniques, including decreasing the perception of pain with general Swedish massage. Insomnia and its attendant anxiety and irritability can be addressed by placing the client in a deep parasympathetic state. Generalized stiffness can be relieved with respectful and thorough range of motion (ROM). ROM exercises, combined with gentle joint stretches, are essential. Breathing restrictions, which typically accompany chronic pain and stress, can also be addressed during the massage therapy and homework sessions.

Massage Therapy Assessment
The initial assessment of an FMS client is based on excellent history taking, not on the therapist's manual evaluation--the verbal assessment could last at least half of the initial hour-long session. The client will have had many medical misdiagnoses, and her frustration may need to be vented to a compassionate massage therapist. Trust must be built, and knowledge gained, before the client is palpated. During this process, there are some important things to consider, including an understanding of tender points, the ability to set reasonable therapeutic goals, and proper preparation.

Trigger Point Vs. Tender Point[for the therapist]
When approaching your work with the fibromyalgia client, there is a clear clinical difference between a trigger point and a tender point, and the effective treatment of the FMS client depends on the therapist's understanding of significantly different approaches for each.

The therapist should keep the following in mind: FMS tender points are bilateral, and are typically found in the areas indicated in the Tender Point Map. FMS tender points are transient, and pain or discomfort is not strictly localized. These points should not be deeply palpated directly and must be approached gingerly for effective, pain-free treatment.

While trigger points can be bilateral, they are often unilateral and have a different character of pain in that they are deeply aching and constantly present. Trigger points also cause referred pain--pain that travels to another area of the body as a result of the myofascial compromise at the locus of the trigger point. Trigger points can be palpated and worked aggressively with an expected amount of discomfort, and can be treated with direct heat or cold and ROM exercises at the proximal or nearby joint. Trigger-point work is rarely performed on a client with fibromyalgia because the deep insult could produce post-session pain.

Reasonable Therapeutic Goals
It is not reasonable to develop specific therapeutic goals when treating FMS. Pain that seems intolerable and diffuse during one session can disappear completely by the next session, when the client's primary complaint might be profound fatigue secondary to nonrestful sleep. The only reasonable goal in treating FMS is to attempt to relieve one or two presenting complaints. Each therapy session, however, should address the client's overall compromised physiologic state. For best results, the ideal frequency of massage is weekly, with sessions lasting 30-60 minutes and continuing for the duration of the condition.

Before the Work BeginsClearly understand your client's chief complaint before the session begins. Have warm packs and plenty of pillows ready. Allow your client to lead the way, yet remember that the most beneficial session includes addressing only one or two tender regions, increasing circulation, helping the client breathe more efficiently, and stretching stiff limbs.

How to Treat a FMS Client [for the therapist]
If you bring to mind your last bout of the flu, you will have some idea of the energy-sapping state your FMS client deals with each day. The pain, tenderness, and fatigue are unrelenting--and yet many of the suggested therapeutic modalities demand that she move her body when all she wants to do is lay on the couch. Your deep compassion must be combined with your responsibility to get her moving again. The pain-spasm-pain cycle must be stopped, and circulation must be increased. Thorough charting is essential for mapping progressions and digressions. Deep-breathing exercises are critical for maintaining thoracic capacity and preventing pneumonia and other infectious diseases. Pretreatment heat, or rotating the presence of a hot pack around the body during the session, can provide great comfort and prepare an area for treatment. (Cold is typically not applied to FMS sufferers.) Soothing, light-to-moderate pressure (you will rarely apply deep pressure) will help gain the client's trust while easing her into a parasympathetic state and increasing circulation. Over my years of working with fibromyalgia clients, I've developed a protocol suitable for the many levels of pain with which they present. For brevity's sake, the protocol described here focuses on two bilateral points of tenderness (although it can be applied to all of the client's tender points), as well as deep-breathing exercises, stretching, and ROM techniques. Once the recipe has been tried and tested, seasoned therapists will most likely adapt the protocol to meet their and their clients' needs.

Treatment Options
There is no cure for fibromyalgia. However, in addition to massage therapy, interdisciplinary and self-treatment regimens, which include exercise, lifestyle changes, medications, physical therapy, and talk therapy, can effectively manage the condition. Although the standard treatment is largely pharmaceutical, the suggested medications typically have long-term side effects, and the wise client should not rely on medication alone to relieve her symptoms.

Acupuncture, biofeedback, and chiropractic manipulations have met with some success, physical therapies are reported as helpful, and aerobic exercise, combined with flexibility and strength training, is especially effective when not undertaken too aggressively. Psychological approaches to FMS include cognitive behavioral therapy, hypnotherapy, and meditation, while alternative treatments include dietary supplementation, homeopathy, and a vegan diet.

Contraindications and Cautions
Deep work or aggressive overstretching is usually contraindicated for FMS, and therapists should modify pressure based on the client's medication intake. Sleep may be induced as a result of the massage therapy session, so be sure driving arrangements have been made for the possibly-groggy client postsession. Some research indicates a parallel between FMS and joint hypermobility. When facilitating stretching, be aware if the client moves too easily into hyperextension or hyperflexion, and adjust ROM and stretches accordingly.

Conclusion
As massage therapy finds its place in the health-care field, intelligent, careful, well-read therapists will find themselves at the forefront of primary care of some of the most complicated medical conditions. Fibromyalgia, and all its attendant symptoms, lends itself perfectly to the disciplines and compassion of massage therapy. The constantly suffering client can, indeed, find relief in the oasis of thoughtful massage therapy.

Charlotte Michael Versagi is the author of the new textbook Step-by-Step Massage Therapy Protocols for Common Conditions (Lippincott Williams and Wilkins, 2011). This article was adapted from an excerpt from that textbook, which explores treatment of more than 40 medical conditions. Contact Versagi at 623-208-3898.

Rita Woods, BS, LMT, is a columnist, public speaker, and massage teacher. She has worked on massage therapy book projects for both Lippincott Williams Wilkins and McGraw Hill publishers. She manages Darien Lourde, Inc., a massage therapy continuing education company. Contact Woods at
706-482-0122 or darienlourde@yahoo.com.


Notes
1 O. Altindag et al., "Neuroendocrine Dysfunction in Fibromyalgia," Turkish Journal of Rheumatology 24 (2009): 98-102.
2 "Fibromyalgia," accessed July 2011, www.medicinenet.com/fibromyalgia/article.htm.
3 "Questions and Answers about Fibromyalgia," National Institute of Arthritis and Musculoskeletal and Skin Diseases, accessed July 2011, www.niams.nih.gov/Health_Info/Fibromyalgia/default.asp.
4 F. Wolfe, H.A. Smythe, M.B. Yunus, et al., "The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia: Report of the Multicenter Criteria Committee," Arthritis Rheumatology 33: 160-72.




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