Fibromyalgia is widely viewed as a pain syndrome with an unknown cause. Sufferers will tell you a common truth though: it can be debilitating, distressing, and it’s very, very real. Sadly, the issue of how to treat this pain syndrome is no more straight-forward than finding its cause. Cognitive behavioural therapy, low-dose anti-depressants and mild exercise are often prescribed but “there is no permanent change associated with this form of treatment [1].” This often leaves sufferers feeling frustrated at the apparent permanence of their predicament.

Cranbourne North chiropractor Dr Shaun Beovich shares a case study found on the Australian Spinal Research Foundation Blog. For specific advice and care, family chiropractor Dr Shaun Beovich is experienced in dealing with Fibromyalgia. Cranbourne Chiropractic Centre services the Cranbourne North, Berwick Springs, Clyde North, Narre Warren South and surrounding areas. Book online here or call 9581 2624.

Case Reports Offer Strong Indications that Chiropractic Care May Help

A recent case study and literature review posted in the Annals of Vertebral Subluxation reveals some interesting observations on the matter. It reported on the structural and symptomatic improvements in a 40-year-old female who had suffered with the disorder for 8 years.

Hers is a demographic group that is no stranger to this disorder. It is said to affect between 2-5% of the population of the developed world. Interestingly, the vast majority of these sufferers are young to middle-aged women [2]. The symptoms of this diagnostic enigma include significant fatigue, musculoskeletal pain, cognitive disturbances and tenderness along with many other potential symptoms. Due to the fatigue elements of the disorder, many sufferers find themselves wearing a diagnostic label of ‘chronic fatigue syndrome’ though this fails to explain all their symptoms.

In the case study the patient’s symptoms included widespread musculoskeletal pain, fatigue, depression and headaches. The researchers used an initial SF 36 questionnaire to measure health-related quality of life, as well as checking her for structural misalignments or subluxations. The latter revealed an anterior head translation, left lateral head flexion, and a lateral cervical translation of 32.7mm when the ideal is 0mm. Significant segmental misalignments were noted at C3-C4, C4-C5 and C5-C6.

On her self-reported quality of life questionnaire (the SF 36), the patient’s highest scores were in the areas of role limitations due to emotional problems or physical health (50.9 and 47 respectively). When it came to general health, energy/fatigue, pain and physical functioning, she reported scores as low as 16.6, 3, 0 and 0 respectively. This illustrates the degree to which this disorder had impacted her life.

She received 44 sessions of chiropractic care over the course of 5 months using a combination of mirror image exercises, adjustments and traction.

Following the intervention, the patient’s films revealed significant improvements in subluxations. Her 32.7mm lateral cervical translation had dropped to 15.4mm and significant improvements were noted from C3-C6, restoring a lordosis to a spinal region in which she previously suffered kyphosis.

The interesting part of the case report was the quality of life scores post-intervention. The patient’s energy score had risen from 16.6 to 35. Her general health score lifted from 3 to 38. Pain and physical function rose from 0 to 38 and 36.7 respectively.

Fedorchuk et al point out that there are a number of case reports that look at fibromyalgia and chiropractic care. Their literature review, written into the case report, included details of ten other studies on the topic. In all instances, chiropractic care was employed as part of the care, and improvements were noted.

RCT Shows Upper Cervical Manipulative Therapy is Beneficial

Fedorchuk’s work, and the case reports that fed into the literature review, jog the memory back to a piece of work that may have escaped the eyes of many a chiropractor. Emerging from Cairo University and appearing in the journal Rheumatology International, the randomized controlled trial looked at the addition of upper cervical manipulative therapy to a multimodal program in treatment of fibromyalgia [3].

The study, authored by researchers Ibrahim Moustafa and Aliaa Diab, took a sample of 120 people with fibromyalgia and definite C1-2 joint dysfunction. These were randomly assigned to either a control group or an experimental group. Both groups benefited from a multimodal program involving exercise, education and cognitive behavioural therapy, whilst the experimental group also received upper cervical manipulative therapy.

The education aspect of the program included information about “typical symptoms, the usual course, medical conditions, potential causes of the illness, the influence of psychosocial factors on pain, current pharmacologic and non-pharmacological treatments, the benefits of regular exercise, and the typical barriers to behavioural change [3].” There were 12 sessions, delivered once a week in 2-hour blocks over the course of the intervention period. The same was true for the cognitive behavioural therapy aspect of the study, which concentrated on a combination of components including “educational, physical, cognitive and behavioural elements [3].” The exercise component of the program centred on a variety of relaxation techniques and stretches. All participants in the study took part in these three aspects.

The upper cervical manipulative therapy administered to the experimental group came in the form of a HVLA thrust described below:

“With the patient in the supine position, the therapist contacted the left posterior arch of the atlas with the lateral aspect of the proximal phalanx of the left second finger using a “cradle hold.” To localize the forces to the left C1-2 articulation, the secondary levers of extension, posterior– anterior shift, ipsilateral side-bend, and contralateral side- shift were used. While maintaining the secondary levers, the therapist applied a single HVLA thrust manipulation to the left atlantoaxial joint using the combined thrusting primary levers of right rotation in an arc toward the under- side eye and translation toward the table. This process was repeated using the same procedure but directed to the right C1-2 articulation.”

Additionally, the experimental group underwent low-velocity cervical joint mobilization techniques as described in Maitland [5].

The researchers used a number of outcome measures to report on baseline data and results. Outcome measures were taken after the 12-week intervention, and at 6 months and 1 year post-intervention respectively. Among the outcome measures were:

• A fibromyalgia impact questionnaire
• Rasterstereographic posture analysis
• A pain catastrophizing scale
• Algometric score
• Sleep quality
• The Beck Anxiety Inventory
• The Beck Depression Inventory

This is where it gets interesting: the results didn’t differ significantly between groups at the 12-week mark. In fact, the fibromyalgia management outcomes indicated that both of the programs were equally successful. Both groups saw some level of improvement in their symptoms, and this supported a meta-analysis showing that multicomponent treatment was effective for improving key symptoms of fibromyalgia.

However, at the one-year follow-up from this, there were “statistically significant changes that indicated that the FMS management outcomes of the experimental group exhibited continued improvement and that the control subjects’ scores regressed back toward the baseline values (i.e., the scores worsened) [3].”

The study’s authors went on to remark that, “the normalization of the afferent input of the upper cervical spine seems to offer an explanation for these one-year improved outcomes in the experimental group.” There are a number of possible explanations for the difference witnessed at the one-year mark. Among them is the possibility that the long-term effects of poor or flexed posture, or continuous asymmetrical loading and muscle imbalance may have a role – a hypothesis supported by previous research [7, cited in 3].

For a randomised controlled trial, the sample size may appear small. Given 20 of 120 people dropped out of the one-year follow up, this could appear more limiting. However, the authors indicated that this still gave them enough data for a statistically relevant change. Though not without its limitations, the results of the Cairo [fibromyalgia] study left its authors confident enough to state their belief that the results of the study should be used to introduce new guidelines for the treatment of fibromyalgia.

Although the intervention in the study was not directed specifically at subluxations, it does demonstrate the importance of a properly functioning nervous system.

How this changes the game

Up until the publication of the Cairo study, the most comprehensive literature on the matter was possibly the systemic review by Schneider et al, which was published in 2009. The lack of a comprehensive RCT left the authors of that study with the following evidence for the management of fibromyalgia: “Strong evidence supports aerobic exercise and cognitive behavioural therapy. Moderate evidence supports massage, muscle strength training, acupuncture, and spa therapy (balneotherapy). Limited evidence supports spinal manipulation, movement/body awareness, vitamins, herbs, and dietary modification [5].”

Later on, in 2011, another systemic review looked at complementary and alternative medicine in the treatment of fibromyalgia. Again, the lack of larger clinical trials left them with little evidence for spinal manipulation and other therapies like massage [6].

Moustafa and Diab’s work offers us the reliability of a clinical trial and, for the first time, statistically significant indications that the addition of upper cervical manipulative therapy can have a role. Although as with all things research-related cautious optimism is the order of the day, this study does offer a unique and valuable contribution to the evidence surrounding this condition.  We look forward to seeing further research of the impact of the subluxation on the health of those with fibromyalgia.

Read the full article at https://spinalresearch.com.au/fibromyalgia-case-study-shows-improvement-symptoms-cervical-alignments-quality-life/

References:

[1] Fedorchuk, C, Lightstone, D, Moser, J (2017), “Improvements in Symptoms, Cervical Alignment and Quality of Life in a 40-Year-Old Female with Fibromyalgia Following Chiropractic BioPhysics® Technigue: A Case Study and Selective Review of Literature,” Annals of Vertebral Subluxation

[2] Gumer, E, Littlejohn, G (2013), “Diagnostic Challenges, Fibromyalgia’ Australian Family Physician, Volume 42, No. 10, October 2013, pp 690-694, http://www.racgp.org.au/afp/2013/october/fibromylagia/

[3] Moustafa I, Diab A (2015), “The addition of upper cervical manipulative therapy in the treatment of patients with fibromyalgia: a randomized controlled trial,” Journal Rheumatology International,  https://link.springer.com/article/10.1007/s00296-015-3248-7

[4] Maitland GD, Hengeveld E, Banks K et al (2000) Maitland’s vertebral manipulation, 6th edn. Butterworth, London

[5] Schneider M, Vernon H, Ko G, Lawson G and Perera, J (2009), “Chiropractic management of fibromyalgia syndrome: a systematic review of the literature,” JMPT Vol 32, Issue 1, January 2009, pp. 25-40, https://doi.org/10.1016/j.jmpt.2008.08.012

[6] Terhost L, Schneider M, Kim K Goozdich L and Stilley C (2011), “Complementary and Alternative Medicine in the Treatment of Pain in Fibromyalgia: a systematic review of randomized controlled trials,” JMPT Vol 34, Issue 7, September 2011, pp. 483-496, http://www.sciencedirect.com/science/article/pii/S0161475411000959

[7] Mueller A, Hartmann M, Eich W (2000) Inanspruchnahme medizinischer Versorgungsleistungen. Untersuchung bei Patienten mit Fibromyalgiesyndrom (FMS) [Health care utiliza- tion in patients with bromyalgia syndrome (FMS)]. Schmerz 14:77–83 (German)

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