Fibromyalgia (FM) affects more than 3 million Americans every year. This chronic condition causes widespread muscle pain and increased sensitivity to stimuli that often lead to pain and difficulty sleeping, among other symptoms. Treatment is varied, but some of the current research indicates that massage therapy can be effective in helping to relieve some of the discomfort.
But FM is a complex disorder, and so working with clients who have FM is no different than working with clients with other chronic or pre-existing health conditions: you need to have a better-than-average understanding of how the condition affects the client, as well as when massage therapy can be helpful. Following, you will find information on what recent research is saying about FM and the role massage therapy can play in helping people better deal with some of the symptoms.
What is Fibromyalgia?
Fibromyalgia is a disorder characterized by widespread muscle pain and tenderness. Other common symptoms associated with FM include fatigue, tension headaches, cognitive difficulties and irritable bowel syndrome.
Interestingly, more of the research on FM is starting to suggest that the condition is actually a central nervous system disorder, even though muscle pain is one of its primary symptoms. More specifically, evidence points to the idea that FM is a disorder of central nervous system pain processing pathways instead of a primary auto-immune disorder of the peripheral tissue, as once believed.1 “There were studies that showed the association between stressors and FM,” explains Stephen Perle, Professor of Clinical Sciences at Bridgeport University. “For example, fMRI has shown that people with FM, when exposed to non-painful stimuli, have activation of the brain in areas that are normally activated only by painful stimuli.”
Accordingly, central nervous system involvement may explain why people with FM are often hypersensitive to all sorts of stimuli, not just mechanical pressure or touch. Dr. Michael Schneider, Associate Professor at the University of Pittsburgh and the author of multiple studies on FM, provides more insight: “The classic fibromyalgia patient just isn’t tender to the touch and can’t submit to mechanical pressure,” he explains. “They’re sensitive to light, sound, [may have] multiple food allergies, multiple chemical sensitivities, and they don’t tolerate heat and cold real well.”
Who Develops Fibromyalgia?
The short answer to this question is that women are much more likely than men to develop fibromyalgia—but it is more complicated than that. The likelihood that someone will develop FM isn’t well-known, but there are two variables that seem to be related: genetics and personal trauma. Genetics is fairly straightforward. FM tends to run in families.
Trauma, however, is a bit more complex. There seems to be a link between FM and post-traumatic stress disorder, though one does not necessarily cause the other. A 2001 study of 600 participants with FM showed “an extremely high prevalence of past emotional, physical and/or sexual trauma associated with the onset of FM symptoms.”2 Schneider’s review of the FM research literature suggests that the connection between personal trauma and FM may be that trauma often causes a person’s limbic system to go into overdrive, contributing to the central nervous system hypersensitivity.1 Remember, not everyone with FM is going to have experienced trauma, but you should keep the possibility in mind when working with clients with this condition. “There’s a high association with trauma, and people need to be aware of that when they’re treating these patients,” says Schneider.
Treatment for Fibromyalgia
There is no one pill or treatment that cures fibromyalgia or even relieves all of the symptoms, so many people with FM deal with this condition using multiple approaches. Most will likely be taking medication prescribed by their primary care physician, so be sure you do a thorough intake and understand how any medication they are taking may affect the massage therapy session. Remember that for these clients, self-care is crucial to being able to better control the major symptoms of FM. Therefore, focus on how massage therapy can help them reduce stress, for example, or get better sleep.
Along with massage therapy, these clients may be using other complementary approaches, such as acupuncture and yoga. When combined, Schneider sees real benefit from both traditional and complementary treatment. “These patients are best treated with a team approach,” he says.
Massage Therapy and Fibromyalgia
Of all the alternative therapies available, more and more research is showing that massage therapy provides real benefits to people dealing with a number of health conditions, including fibromyalgia. A study in 2011 showed that massage therapy caused reductions in sensitivity to pain at tender points in patients with FM, as well as lowering anxiety levels and increasing quality of sleep.3 Another study from 2014, which systematically reviewed nine other studies about massage therapy and FM, found that massage therapy had immediate beneficial effects on improving pain, anxiety and depression in patients with FM.4
According to this same study, massage therapy is particularly effective when it is administered to soft and connective tissues because this improves muscle flexibility, as well as modulating local blood and lymph circulation.4
There is not one specific technique that is more effective with FM than others, although myofascial release has been shown to be somewhat helpful.5 “To new massage therapists who would like to work with FM clients, I would tell them to fill their proverbial tool box with as many techniques as they can,” says Joseph Swinski, a massage therapist from Rhode Island who regularly works with clients with chronic conditions such as FM. “When working with the FM population, it is not one size fits all.”
For many clients, using the right amount of pressure is going to be imperative, so it is important to clearly communicate with the client both before and during the session and adjust when necessary. Remember that deep pressure will likely be too much for these clients. “If they’re hypersensitive, then the idea is you’re going to have to go really light with them and kind of coddle that client and be a little more gentle with them,” says Schneider. This idea holds true for all aspects of the massage session. “Speak in a lower voice to them, and that person’s going to like the dim room with some nice relaxing music,” he adds.
Flexibility is also a key ingredient to success when working with people with FM. “The most important thing I could hope to impress on a new massage therapist working with a client with FM is to be patient, not in a hurry and as observant as possible during the actual session,” says Erika Crisafulli, a massage therapist with the Texas Health Harris Methodist Hospital in Fort Worth. “Be compassionate. We all know what it is like to deal with physical ailments that we cannot get a hold of on our own.” Crisafulli knows this better than most, as she herself has had to deal with symptoms of FM. “Trying to control the symptoms so you can still live a full life is challenging, but not impossible if you are willing to help yourself,” she says. “It is so important to practice what you preach. If I don’t take care of myself, how in the world can I take care of my clients, something I love to do so much?”
Checking in with a client after a massage therapy session is also a good idea, and that sometimes means following up a few days later. “You may need to change your approach to massage after the first visit,” says Swinski. “This is why I contact my clients after the massage. If the results were not what we expected, I reassure them that there are other approaches that we could take in their next visit.” Again, you need to be aware that clients with FM are going to have different needs. What works for some may not work for others, so listen and be willing to adjust the massage therapy session when appropriate.
Although FM is a complex condition, research is showing there are a variety of ways massage therapy can help clients feel better. From better sleep to reduced stress, massage therapy is showing real promise in helping people better handle the symptoms of FM.
Does Your Client Really Have Fibromyalgia?
For many people, getting a diagnosis of fibromyalgia is a long, complicated process. Still, because FM is a complex, misunderstood condition, overdiagnosis is an emerging problem.
In a 2006 study titled Differential Diagnosis of Fibromyalgia Syndrome, Dr. Michael Schneider, Associate Professor at the University of Pittsburgh and the author of multiple studies on FM, found the condition often being used as a catchall diagnosis. “There is a problem with the current conceptual model of FM as one grandiose syndrome into which all patients with unexplained widespread pain are categorized,” the study concludes.
The complicated nature of FM diagnosis means you could encounter clients who may have been misdiagnosed. So, what does that mean for massage therapists who have clients with FM? The truth is, even if a client has been misdiagnosed, massage therapy can be effective—and massage therapists need to let the client lead.
“So the question is, is the massage helpful or not? If that client comes back next week for another massage and [says], ‘Oh, I feel great after that first massage.’ Excellent, let’s do it again,” says Schneider. “If that’s the expectation of the patient—to get some temporary relief—and they are, what’s the difference? They’re still getting relief.”
Massage & Fibromyalgia Research
The Study Question:
Fibromyalgia affects 2 to 3 percent of the population worldwide and is a condition commonly treated by massage therapists. Although the condition is diagnosed based on self-reported muscular pain, recent evidence points to the source of the pain as originating from the nervous system, via the process of central sensitization—the abnormal amplification of pain signals in the spinal cord. Is one massage therapy approach more effective in relieving fibromyalgia symptoms of general and localized muscular pain compared to another?
This article presents the results of a pilot study conducted at Oregon Health & Sciences University in Portland, Oregon, that compared myofascial release (MFR) to Swedish massage. While Swedish massage is often used by massage therapists to address fibromyalgia symptoms, the fascia surrounding skeletal muscle tissue is highly innervated and contains fibroblasts that can regulate inflammation. The researchers hypothesized that these pain-generating characteristics of fascia might play a role in maintaining fibromyalgia symptoms, and they reasoned that a technique that specifically targets fascia, such as myofascial release, might show greater benefits in reducing symptoms compared to a more general Swedish massage. A secondary goal of this pilot study was to see whether it was possible to measure improvement in localized areas of pain in conditions that result in widespread pain and central sensitization—conditions that include fibromyalgia, low back pain and temporomandibular disorder.
The Study Methods:
The study authors recruited a convenience sample of 12 women between 21–50 years of age who had a verified diagnosis of fibromyalgia. The participants were allowed to continue any existing treatment, either pharmacological or nonpharmacological, as long as they had been on it for the previous three months and agreed to not make any changes to the existing treatment during the study period. Exclusion criteria were concurrent pain conditions such as diabetic neuropathy, cervical or lumbar disc disease, or severe depression. People who were already receiving any form of manual therapy—including massage, Rolfing, chiropractic or physical therapy—were also excluded, as were those who preferred not to be touched, or who were involved in any litigation or applying for disability. Measures were assessed at baseline, before each session and at two weeks post treatment. All participants received 90-minute sessions once a week for four consecutive weeks. Eight women received MFR and four women received Swedish massage. The method of allocation to the type of massage therapy participants received was not specified.
The primary outcome measure was the Fibromyalgia Impact Questionnaire-Revised (FIQ-R), a 21-item self-report instrument that assesses primary symptoms of fibromyalgia, physical functioning and quality of life. Higher scores indicate more severe symptoms and decreased physical functioning and quality of life. A secondary measure, the Nordic Musculoskeletal Questionnaire (NMQ), was used to measure localized pain in seven body regions: the neck, shoulders, upper and lower back, arms, and upper and lower legs. Higher scores on a 0–3 scale indicate greater pain. All outcomes were measured by a single examiner who was blind to treatment group.
The study intervention consisted of either Swedish massage applied to the back, neck, arms and legs with moderate pressure stroking, or MFR performed on the same regions, using prolonged assisted stretching applied to painful areas. Three different licensed massage therapists delivered the intervention, and each had prior experience working with people with fibromyalgia using both techniques. The therapists also had received advanced training in MFR.
There were no pre-existing demographic or baseline differences between the two groups. The majority (90 percent) had tried Swedish massage previously and 70 percent reported some immediate but short-term improvement as a result of prior massage, generally lasting a few hours. Five of the eight participants in the MFR group reported clinically significant improvement in their FIQ-R scores, compared to one participant in the Swedish massage group. NMQ scores improved in both groups, but showed consistent improvement in the neck and upper back regions for the MFR group, while no local areas of improvement were observed in the Swedish massage group.
Limitations of the study:
The sample size was small, so the study did not have sufficient statistical power to estimate an effect size or determine efficacy, and participants were not randomized to the two treatment groups. The dose of massage was relatively small when compared to other studies of massage and fibromyalgia, and the longer-term effects were not measured. The sample was also limited to only women, so the results cannot be generalized to men, minorities or severely depressed people with fibromyalgia. However, it was designed as a pilot for a larger study.
Implications for evidence-informed practice:
Previous research shows that Swedish massage can provide at least temporary relief of general pain for people living with fibromyalgia. At the same time, addressing local muscle pain is a critical therapeutic goal in working with people with fibromyalgia. The results of this study are intriguing because they suggest a possible mechanism for how MFR might reduce pain, and hold some promise for further investigation of MFR as a longer-lasting treatment for reducing localized pain and tenderness in fibromyalgia. MFR may also have potential as an intervention to address central sensitization, but this hypothesis will require more research to determine. Practitioners who frequently see patients or clients with pain conditions involving central sensitization may want to consider adding MFR to their therapeutic repertoire.
Ian McCafferty, November 25, 2015