Upper Cervical Management of Primary Fibromyalgia and Chronic Fatigue Syndrome
Excerpts from the article published by
Today's Chiropractic. May 2000.
by William Amalu, DC.
The current scientific literature offers little with regard to published studies on chiropractic management of primary fibromyalgia and chronic fatigue syndrome.1 Reported here are clinical observations of 23 successive cases, along with a case presentation. Improvement in symptoms of 92 to 100 percent was achieved in both these syndrome subsequent to corrections of aberrant arthrokinematic function of the occipito-atlanto-axial complex.
A causal relationship between biomechanical faults in the upper cervical spine, abnormal central neurophysiologic processing, and subsequent peripheral neuropathophysiology, is suggested as the possible genesis of these two syndromes.
The initial patient profile of fibromyalgia syndrome (FMS) includes a history of widespread pain of at least three months' duration, both above and below the waist and including both sides of the body. The pain is described as deep aching, radiating, gnawing, shooting or burning. The overwhelming characteristic of fibromyalgia is long-standing pain at defined tender points. This disorder can appear in patients of all ages with an overall incidence of 9:1,000. FMS, however, has an increased frequency in women with the greatest incidence in the ages of 20 to 50 years.2-3
In 1990, the American College of Rheumatology released their criteria for the clinical classification of FMS. The criteria were drawn from the results of a prospective blinded investigation involving more than 550 fibrositis patients at multiple clinic and hospital outpatient settings across the U.S.4
A condition in which tender points are confined to a specific region, associated with specific muscles, and exhibit a characteristic pain referral pattern was referred to as myofascial pain syndrome (MPS). Patients with generalized tender points in the presence of widespread pain for at least three months, along with disturbed sleep, were classified as having FMS. Patients with FMS may have concomitant MPS, but not the reverse.
The study committee adopted specific definitions for use in making the diagnosis of FMS. Along with the previously mentioned widespread pain, tender points must be found in at least 11 of 18 sites, which include the occiput, lower cervical, trapezius, supraspinatus, anterior second rib, lateral epicondyle, gluteal, greater trochanter and knees. Palpatory pain elicited by 4 kg of pressure (measured by algometry) is considered positive at these tender points. Those with FMS tend to waken with body aches and stiffness. Pain generally improves during the day and often increases again during the evening. Symptoms flare-ups can occur with activity; cold, damp weather; anxiety, hormonal fluctuations (premenstrual and menopausal states), and stress. The majority of patients with FMS also report that they awaken unrested and complain of daily fatigue.
POSSIBLE CAUSES OF FMS
FMS can present as a constellation of symptoms. Therefore, other disease states must be ruled out before a diagnosis of FMS can be made. Conditions that can mimic the symptoms of FMS include: Rheumatoid arthritis, hypothyroidism, systemic lupus erythematosus, Lyme disease, primary sleep disorders, depression and HIV infection.
The primary clinical features of FMS, rated in percent of patients' experience, are as follows: 90-100 percent-generalized pain, fatigue, stiffness and morning fatigue; 70-90 percent-sleep disturbances, post-exertional malaise, headaches, swollen feeling in tissue, numbness and tingling, cognitive impairment, dizziness, sensitivity to noise and stress, dysmenorrhea and dry mouth; 50-70 percent-irritable bowel syndrome, blurred vision, affective lability, heart palpitations, cold extremities, feverous feeling and allergies; 15-50 percent-restless legs, muscle twitches, itchy skin, hearing disturbances, night sweats, migraines, breathing problems, infection proneness, skin manifestations, interstitial cystitis and temporomandibular dysfunction; below 15 percent-major depression (concurrent).
Current medical sources state that there is no known specific cause or prevention for FMS.2-3 However, it is suggested that there may be many different "triggering events" that precipitate the condition's onset. Possible events include physical trauma such as sports injuries, automobile accidents, falls, etc., or post-illness onset. Interestingly, it is thought that these triggering events do not cause FMS, but rather, they may awaken an underlying physiologic abnormality that is already present.
One hypothesis suggests that the disorder may be associated with changes in skeletal muscle metabolism, such as decreased blood flow, which could cause overall chronic fatigue and weakness. Another premise is that an infectious microbe, such as a virus, triggers the illness. At this point, no virus or microbe has been identified.The latest research is being directed toward investigating alterations in neurotransmitter regulation (particularly serotonin, norepinephrine, and substance P), immune function, sleep physiology, and hormonal control as a possible etiology of both FMS and chronic fatigue syndrome.
Repeated studies have found substance P to be elevated threefold in the CSF of patients with FMS. A defective neural feedback loop is thought to be responsible for this finding. Abnormal variations in two hormones, cortisol and GH, have also been found in some patients. A great deal of research is being spent on investigating alterations in normal sympathetic nervous system function. Patients with FMS and chronic fatigue syndrome have been found to have lower levels of sympathetically released neuropeptide Y. As it can be seen, the majority of current research is being directed toward investigating abnormal neurophysiology as the possible underlying cause of FMS and chronic fatigue syndrome.
POSSIBLE CAUSES OF CFS
Chronic fatigue syndrome (CFS), as previously mentioned, appears in 90-100 percent of patients with FMS. CFS usually surfaces sometime after the initial symptoms of FMS. However, CFS can appear in the early stages of FMS in many patients. Under current guidelines, it would be very difficult to find a FMS patient who did not meet the new CDC criteria for CFS. Research also suggests that CFS may actually be present in some patients before the symptoms of FMS. From this, it is proposed that patients with only chronic fatigue may have a dormant form of FMS, which may appear much later.
CFS can range from mild to incapacitating. The fatigue may be described as tiredness, a total drain of energy, heavy limbs, and/or poor concentration. The etiology of CFS encompasses some of the same factors as FMS, but also includes objective signs of EEG abnormalities. Most FMS patients exhibit an associated alpha-EEG anomaly sleep disorder. Studies show that most FMS patients can fall asleep without much trouble, but that their deep level (stage 4) sleep was constantly interrupted by bursts of alpha wave activity. Patients report that they awake feeling as if they have had little to no sleep. Two common sleep disorders that may also be present in FMS/CFS patients include restless leg syndrome and periodic limb movement during sleep.2-3
The most common medical treatments for FMS and CFS can include one or more antidepressants, non-steroidal anti-inflammatories, physical therapy, gentle stretching, low impact exercises, stress reduction, counseling, and lidocaine injections with or without hydrocortisone. Currently, the medical prognosis for FMS and CFS is not favorable. It is reported that as many as 40 percent of patients may significantly improve over time, but few are thought to completely recover.2-3
It is interesting to note that Masi and Yunus speculate that FMS and CFS are part of a larger spectrum of conditions, which they term Dysregulation Spectrum Syndrome.2,5 Yunus uses the term dysregulation to denote biophysiologic abnormalities, most likely in the neurohormonal system. This follows the latest research into the nervous system as the possible primary etiology of both FMS and CFS.
Over a five-year period, 23 cases of fibromyalgia syndrome with chronic fatigue syndrome were managed in an outpatient setting. All cases were followed for a minimum of one year to observe care effectiveness. The study group was composed of 5 males and 18 females, ranging from 11 to 76 years of age. Statistically, the subject group, consisting of 78 percent females with a mean age of 35, fits the published data on the most common patients with FMS and CFS.2-3
Of the 23 patients, 96 percent presented with an incoming medical diagnosis of both FMS and CFS. A thorough initial history and physical examination confirmed this diagnosis. The chronicity of this condition ranged from 2 to 35 years. The intensity of the presenting symptomatology varied from moderate (ADL interrupted) to severe (inability to work). Each patient's progress was assessed on every office visit by rating the intensity of his or her symptoms on a 1-10 VAS. All of the 23 subjects presenting symptoms fit the profile previously mentioned.
Upon stabilizing the upper cervical spine (determined by consistently presenting normal paraspinal infrared images-Tytron C-3000 Paraspinal IR System), improvement in the symptomatic profile of both FMS and CFS was 92-100 percent (VAS) for all 23 patients.
Every patient was able to resume normal activities, including full-time work. The total time of care to reach this point ranged from 3 to 7 months with a mean time of 15 weeks. The most common initial care frequency used was 3 times per week, with tapering frequency after 4-8 weeks. Total care visits ranged from 20 to 48 with a mean of 31 office visits to stabilization. All 23 patients reported maintaining their improvements at 1 to 1 ½ years or more of follow-up. Care consisted solely of corrections to aberrant arthrokinematic function of the occipito-atlanto-axial complex. The method of adjusting used was Applied Upper Cervical Biomechanics (International Upper Cervical Chiropractic Association.)
From the 23 subjects in this study, an average case has been selected for this report. The patient's presenting symptomatology, care profile and case outcome is representative of most of the patients in the group with the exception of chronicity.
A 55-year-old female was referred to our clinic with the chief complaints of constant bilateral neck, trapezius, mid-back, elbow, hip and foot pain, along with constant fatigue. She also experienced frequent bilateral upper extremity and right trapezius paresthesias. The patient advised that upon arising she felt sore, stiff and as if she never really slept. Cold temperatures and physical or emotional stress caused an increase in all her symptoms. She described her life as constant pain and perpetual fatigue.
The patient recalled that her symptoms began after a fall 35 years previously when she was employed as a gymnastic circus performer. Her symptoms gradually increased to a point, over the past 10 years, where she had been able to maintain only light part-time work (12-20 hours per week desk-work) when her condition permitted. She was currently on sick leave due to the severity of her FMS/CFS.
Approximately 15 years previously, a thorough medical workup yielded a diagnosis of primary FMS with accompanying CFS. Over the past 25 years, the patient had tried many forms of care, including physical therapy, massage, acupuncture, chiropractic and exercise, with little to no improvement.
At the initial consultation, the patient had been using a combination of light exercise when tolerated, muscle relaxants and a tricyclic antidepressant at bedtime for 10 years with limited success. She rated her FMS/CFS as being constant and at an intensity level between 7-9 (1-10 VAS). The patient advised that her life used to be filled with activity, exercise and happiness; now, it had been reduced to pain and very little else.
Upon examination, the patient presented with overall motions that were careful and deliberate. The patient was cooperative, but expressed that she was doubtful that care would be of benefit. Vital signs and ear, nose, and throat examinations were unremarkable.
An orthopedic examination revealed significant palpatory hypertonicity and tenderness of the paraspinal musculature from C0-T9 and including the trapezius, levator scapulae and anterior cervical musculature bilaterally. A marked increase in myohypertonicity and tenderness was noted in the right occipital region. Upon algometric examination, the patient tested positive for 14 of the 18 designated FMS tender points with 1-3 kg of pressure. Myofascial trigger points were elicited in the trapezius, levator, and infraspinatus musculature. A 40 percent overall decrease in cervical active and passive ROMs was noted along with paraspinal and trapezius pain in 4 of 6 ranges. Cervical orthopedic tests were found positive for facet joint irritation. Multi-axis articular end-range examination revealed biomechanical abnormalities in the cervical, costovertebral, and thoracic spine. The remainder of the patient's lumbosacral, lower extremity and upper extremity orthopedic evaluation was unremarkable.
Gross neurologic examination was also found to be unremarkable. A high-resolution paraspinal digital infrared imaging analysis was performed in accordance with thermographic protocol (a Tytron C-3000 paraspinal imaging system was utilized).6-8
A continuous paraspinal scan, consisting of approximately 423 infrared samples, was taken from the level of S1 to the occiput. The data were analyzed against established normal values and found to contain wide thermal asymmetries indicating abnormal autonomic regulation of neuropathophysiology.9-12
Since the cervical spine displayed highly abnormal thermal asymmetries, a focused scan was performed with approximately 81 infrared samples taken from T1 to the occiput. For the purpose of ruling out other pathologies, and to further characterize this condition, a computerized high-resolution infrared camera study was also performed in accordance with accepted protocols.6-8 The scans included all surface aspects of the face, neck, upper extremities, and posterior thorax. The posterior neck and thorax image showed disruption of the normal thermal gradient, significant thermal asymmetries, large areas of hyperthermia, and focal zones of high infrared emissions. These images were indicative of abnormal sympathetic regulation and broad-based myohypertonicity interspersed with myofascial trigger points. As such, these findings are consistent with the clinical presentation of FMS/CFS.
A high suspicion of abnormal upper cervical arthrokinematics was also gained from this examination. Consequently, a precision upper cervical radiographic series was performed for an accurate analysis of specific segmental biomechanics.13 Neutral lateral, AP, APOM and BP films were taken using an on-patient laser-optic alignment system to precisely align the patient to the central ray. With this system, maintenance of precision patient alignment can be facilitated from the source of the x-ray beam rather than the bucky.
An analytical radiographic method of combined mensuration and arthrokinematics was performed.13 Biomechanical abnormalities were noted at the atlanto-occipital and atlanto-axial articulations.
From the accumulated degree of aberrant biomechanics found at the atlanto-occipital articulations, correction of the C1 subluxation was chosen as the first to be adjusted. Before care was rendered, the patient was advised that exacerbations in symptomatology might occur as part of the normal response to care due to the global impact on neural reintegration.
In order to insure proper segmental contact and LOD control, the patient was placed on a specially designed knee-chest table with the posterior arch of atlas as the contact point. An adjusting force was introduced using a specialized upper cervical procedure.14 The patient was then placed in a post-adjustment recuperation suite for 15 minutes as per thermographic protocol.6-8 Correction of the subluxation was determined by resolution of the patient's presenting neuropathophysiology on the post-adjustment paraspinal infrared scans.
All subsequent office visits included an initial cervical paraspinal scan, and if care was rendered another scan was performed to determine if normal neurophysiology was restored. Since the patient's care was focused in the upper cervical spine, only cervical paraspinal infrared scans were taken during normal visits with full spine paraspinal scans performed at 30-day re-evaluation intervals.
During the first week of care, no change in pain was noticed. A definite decrease in fatigue, however, was reported by the end of the week. The patient began to notice a reduction in neck and trapezius pain, along with decreased paresthesias during the second week of care. Significant reductions in the patient's symptoms began during the third week of care. She noted that, for the first time in over 10 years, she could lift her head without assistance after having her hair shampooed in a salon. The intensity and frequency of her neck and trapezius pain, along with the paresthesias, continued to decrease. Her mid-back and elbow pain was also beginning to improve. She noticed that her level of sleep seemed to be improving. The patient reported that her stress levels had increased over this week and was very surprised that there were little to no effects on her symptoms.
By the end of the fourth week of care, the patient was noting that there were times when she was experiencing no neck or trapezius pain. Pain in the elbows and midback region were also continuing to decrease. Her paresthesias were becoming mild and infrequent. She was also beginning to report improvements in her hips and feet. The patient noticed that she was now waking feeling more refreshed.
A re-evaluation was also performed at this time. The patient noted a 65 percent overall improvement in her condition. At this time, she was reporting a pain intensity level of 4 (1-10 VAS). The examination revealed significantly decreased overall palpatory myohypertonicity and tenderness. The patient tested positive for only 8 of the 18 FMS tender points with 2-4 kg of pressure on algometry. All of the previously found myofascial trigger points were markedly reduced. Cervical active and passive ROMs were found to be normal with mild paraspinal and trapezius stiffness in 2 of 6 ranges. Mild cervical facet joint irritation remained positive upon testing. Six-axis palpatory spinal joint examination noted residual biomechanical abnormalities in the cervical and thoracic spine. A full-spine paraspinal infrared scan was performed at this time, noting total resolution of the patient's presenting neuropathophysiology.
Weeks five and six showed a consistent, but slower, improvement. The patient noted a mild continued decrease in pain, including her hips and feet. Her paresthesias remained mild and infrequent. Upon waking, she continued to feel more rested and started to notice that her daily fatigue levels were reducing. With this in mind, she began to slowly decrease her sleep medication under the guidance of her medical doctor. Her progress, however, reached a plateau at week six. The normalization usually seen on her post-adjustment paraspinal scans was waning. LOD changes were made on C1 with little to no improvement in her scans. By week seven, it was decided to change her listing to C2. The post-adjustment infrared scans showed an immediate return to normal with a corresponding improvement in the patient's symptomatic profile.
By the end of week 8, a significant improvement was noted upon re-evaluation. The patient rated her current pain levels at a 2 (1-10 VAS) with an intermittent frequency. She reported an overall improvement of 80 percent in her condition. All her examination findings continued to improve. The majority of the myofascial trigger points were resolving. Algometric testing revealed only 4 of the 18 FMS tender points with 4-6 kg of pressure. The frequency in which the patient was presenting with normal paraspinal infrared scans indicated that stabilization of the upper cervical joint complex was occurring. Consequently, a decrease in frequency to two office visits per week was made at this time. Working with her medical doctor, she continued to decrease her sleep medication and began reducing her muscle relaxants. Her daily level of fatigue had significantly reduced to the point where she began to increase her activities along with gardening for the first time in 10 years. Based upon her current symptom level, she decided to return to work part-time.
Over the next four weeks, the patient continued to improve. Her pain and paresthesia levels continued to decrease in intensity and frequency. Work duties and stresses had not caused any exacerbation in her condition. The patient continued to wean off her medications were termination by week 11. Physical examination noted complete resolution of her myofascial trigger points and FMS tender points. She noted that her sleep had normalized and upon awakening she felt refreshed and pain free. Her daily energy continued to improve with complete resolution of her chronic fatigue. By the end of this time, the patient had taken up bike riding and a gym-based exercise program. A high-resolution computerized infrared camera re-evaluation was performed with the images, indicating a return of the thoracic thermal gradient and normalization of autonomic neurophysiology.
The patient continued to improve over the next few weeks with complete resolution of her FMS and CFS. The patient returned to full-time work during this time and experienced only two minor temporary exacerbations in her condition. Over the past two years, the patient has been seen on a check-up basis of four times per year. She remains FMS and CFS free with only an occasional sore neck due to long deskwork hours.
- Taylor MR. Fibromyalgia Syndrome: Literature Review. Proceedings 1991 International Conference on Spinal Manipulation, Arlington VA: Foundation for Chiropractic Education and Research, 1991, 207-9.
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- Masi AT, Yunus MB. Concepts of illness in populations as applied to fibromyalgia syndrome. Am J Med 1996; 81: 1-25.
- Thermography protocols, International Thermographic Society, 1997.
- Thermography protocols, American Academy of Thermology, 1984.
- Thermography protocols, American Academy of Medical Infrared Imaging, 1997.
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- Amalu W, Tiscareno L. Precision radiology: module 1 and 5- Applied Upper Cervical Biomechanics Course, International Upper Cervical Chiropractic Association, 1993.
- Amalu W, Tiscareno L. Precision multivector adjusting: module 3 and 7- Applied Upper Cervical Biomechanics Course, International Upper Cervical Chiropractic Association, 1993.