Advance magazine seems to always be in the my mailbox alongside local, small town coupons.   Unlike the latter, this magazine is usually pretty good. The articles are usually clinically based and easy reading for hot, new topics and events.

Dawn Westfall, PT, MPT recently wrote a good column on Fibromyalgia, the Invisible Pain.  She went through diagnosis, physiology, therapeutic interventions and modality usage with what available evidence supports it.  I’m not going over that now, but you can read the article here.

I know most of us “sigh” in disgust and wonder how bad the evaluation will be with the Dx of Fibromyalgia walks in the door.  Its true…unfortunately.   I think these patients can be some of the most deserving of what we have to offer.  At times, I have us (meaning healthcare professionals) to blame for patients getting into this state.  Maybe we should start blaming ourselves instead of blaming the painful patient.

They are usually over-medicated and under-educated about their condition.  We can be of considerable service.

Each patient can and will present differently just like any other condition so prescribing the correct treatment will always vary.  Some points I look into:

-Graded pain-free ROM of the proximal joints and especially the spine are the most direct to start obtaining mobility and decreasing pain.

-Aquatic therapy can also be of benefit if it is available but still rare in most clinics.

-Exercise is absolutely necessary but not always the best route initially.

-Fibromyalgic syndromes typically have changing symptoms over short period of time.  These type of symptoms and individuals are usually resistive to exercise.  We need more to offer them than just modalities until we can obtain the critical proper pain-free range of motion.

-Manual therapy (of course, the main reason for this blog!) in my opinion, can really separate you from not only other physical therapists, but other professions.  It can give great results with this subset of patients.

Manual therapy hasn’t been conclusively stated in research to be greatly beneficial (but really, what has?).

Pain relief through manual means followed by low level exercise = results and increased function.

Considering pain is “wide-spread” (11 of 18 designated areas), where do we start??  Everywhere hurts!

I find it not only time-efficient but effective in addressing the spine; in particular, the junctions.  Meaning cervicothoracic & thoracolumbar junctions.  I address this with exercise and manual therapy. But from my knowledge, there is no evidence to back this claim.  Its evidenced-informed…but not evidenced-based.  Meaning, nothing confirms or invalidates it.

C7-T3 Prone HVLAT
Prone C7-T3 HVLAT
Flexed T10-L2 HVLAT Long-sitting

P.S.  After looking at the pictures, the techniques may seem brutal but really is more comfortable than it looks!

What are your thoughts on treating Fibromyalgia?  Do you think it is a scientific syndrome or just psychological? Do you find most relief from modalities, exercise &/or manual therapy?


  1. Yes, Fibro can be the mystery diagnosis. Janet Hulme, PT has done some great work in this area and her book Fibromyalgia – a handbook for self care & treatment is great and offers a lot of info into some of the systemic possible causes as well as some of the physical issues you addressed in your post. I also wonder how much of the persistent pain is not more of a nervous system issue than a true muscle system issue. I wonder if the work by Butler and Moseley “Explain Pain” and Butler’s “Sensitive Nervous System” isn’t a lot of the issue these patients are dealing with. Great post, I do agree about your points about needing to mobilize the spine and have seen better results with these patients when I do. But that brings to the thought that research shows us that maybe the mobilization/manipulation technique may more of an activation of the nervous system.

    1. Kory,
      Thanks for the comment and further info. I will have to check our more of Janet’s work and the other books you mentioned. I do agree that most of it does arise from neurological system, rather than musculoskeletal. It just does not behave as we would typically see with solely musculoskeletal issues.

  2. People with fibromyalgia probably don’t need a high content of the manual aspect of physical therapy intervention as you seem to suggest. The brain has chemical changes which most rhuematologists treat with various medications which are usually aimed at maintaining serotonin levels in the brain. Besides chemical issues within the brain, it is highly likely that brain changes also occur – the way the various parts of the brain interact with each other. The book, Making a Good Brain Great is quite interesting in describing the neuroplasticity of the brain. Exercise has relevancy in actually changing the brain.

    So… reality – skip the modalities. Spend time educating. Manipulation is maybe enhancing a “human” connection, creating a neuroinhibition, or is a placebo effect. No one knows. In the long run, anything that can change the probable central changes within the brain will be beneficial. Exercise IS something that centrally changes the brain. Move into exercise as quickly as possible with a graded approach.

    1. SnippetPhysTher,
      I appreciate you reading the blog and having great comments. I will have to delve more into the chemical changes that exercise does with the brain as this is something I don’t know much about. Seems to be just another reason why our profession can really help people. Our bodies were made to move even if it just low level activities. I hate to say it but I think other syndromes such as fibromyalgia will arise as our society moves more into inactive lifestyles at work and home.
      I know medication is needed in some people but I really dislike how over-medicated some are, even with some painful syndromes such as fibromyalgia. I know you have heard pts say how great they feel once they have been able to get rid of pain medication, neurontin, etc. It really does fog their mind. Did we alter the connection, such as neuroinhibition as you speak of…I’m not sure but is very interesting topic.


    2. To all,
      Sorry about the ALL CAPS in the comment section. It took me awhile to figure it actually was all caps. I can see comments from another view. I am working on that now!

      Stay tuned.


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