The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 2
Application of the concept of neural plasticity to fibromyalgia suggests that changes should be seen in both the peripheral and central nervous systems. It is through the application of surface electromyographic (sEMG) and electroencephalographic (EEG) assessment techniques that such changes may be seen. It is through the application of biofeedback, specifically multiple channel sEMG biofeedback-assisted neuromuscular therapy and EEG neurotherapy, that we can powerfully impact neuroplasticity.
Before proceeding with the sEMG assessment it is important that a comprehensive medical evaluation of fibromyalgia symptoms be conducted. Various systemic diseases as well as somatoform disorders must be ruled out before considering the diagnosis of fibromyalgia. Moreover, in every case the intensity and frequency of symptoms as well as the presence or absence of various secondary symptoms may differ. A detailed listing of all experienced symptoms is necessary. This includes: a) presence of symptoms; b) length of time each symptom has been present; c) intensity of symptoms; d) frequency of symptoms; e) worsening in either intensity or frequency in the presence or absence of treatment and environmental factors; f) improvement in either intensity or frequency in the presence or absence of treatment and environmental factors; g) listing of different treatments and symptomatic response in time; and h) overall symptom change from the beginning of the appearance of symptoms to the time of the evaluation or re-evaluation.100,101
The essential points of the evaluation, with special focus on fibromyalgia, myofascial pain syndrome, and other muscular painful conditions are as follows:
- History of the condition: description of the primary etiology of the condition, e.g. acute post-traumatic, chronic, post-repetitive motion injury, etc. The time span from the original initiation of the pain symptoms to the time of the evaluation has to be described in detail, especially with regard to the investigation, diagnostic process, treatment, and success rate of the rehabilitation102
- Review of systems, with special regard to any injury or condition, which may contribute to the maintenance or enhancement of the muscular type pain, fatigue, and concomitant symptoms of depression, anxiety, and especially sleep disorder
- Physical examination, with special focus on every system in terms of conditions that may contribute actively to the maintenance of the fibromyalgia or related symptoms. Such examination needs to contain a comprehensive questionnaire, especially involving the pain and emotional symptoms, history thereof, and treatment up to the point of the evaluation
- Review of all prescription and OTC medications as well as herbal remedies and nutritional supplements being taken by the patient, with particular attention paid to possible medication effects or adverse interactions that might actively contribute to the patient’s fibromyalgia or related symptoms. Computer software such as The Medical Letter’s Drug Interactions Program® can be very useful in this process
- Objective evaluation of the muscular pain components in terms of sEMG of all the affected muscles as well as muscles known to co-activate with the symptomatic muscles, goniometry to assess any changes in the joints range of motion, dynamometry to assess loss of strength, dolorimetry to assess the pain perception pattern, and other tests as necessary90,103-105
- Psychological tests related to the emotional component of the pain, including negative cognitions, anxiety, and depression. Some psychometric instruments that are commonly used in the evaluation of chronic pain patients are: Illness Behavior Questionnaire (IBQ),
McGill Pain Questionnaire,37 Minnesota Multiphasic Personality Inventory-2 (MMPI-2),107 Survey of Pain Attitudes (SOPA),108 Symptom Check List-90-R (SCL-90-R),109 West Haven-Yale Multidimensional Pain Inventory (WHYMPI)110
- Sleep studies where there is sleep disturbance, especially associated with lack of dreaming, early awakening, and sensation of sleepiness during the day. A disproportionate number of persons diagnosed with fibromyalgia also have such physiological sleep disorders as obstructive sleep apnea, restless leg syndrome, buxism, etc. These may be primary or secondary to the fibromyalgia but frequently play a significant role in maintaining the sleep disturbance that appears to lie at the heart of fibromyalgia and therefore, must be addressed.
Once basic medical and psychological investigations are completed then a sEMG evaluation can be conducted.104, 111-113 Surface EMG recordings provide a safe, relatively easy and noninvasive method of reliably and objectively quantifying the electrical activity of muscles both at rest and through their full range of movement. Multiple channel sEMG instruments can provide a method of examining the nervous system’s control of muscle function and may be utilized in differentiating pain due to myofascial causes verses pain due to fibromyalgia, or pain due to a combination thereof. Using sEMG, muscle dysfunction is primarily seen in four phenomena: a) increased electrical activity of the muscle at rest; b) increased electrical activity following movement or failure to return to normal resting baseline activity levels; c) excessive electrical activity during movement; and d) coactivation of muscles during movement that are normally inhibited.88,114
Excessive resting muscle electrical activity may be a direct consequence of improper posture, emotional dysfunction, or learned muscle guarding or bracing114 and is a common finding in myofascial pain patients, particularly in those muscles in body areas that are reported as painful. When muscles retain an elevated level of activity it is believed that fatigue and pain are induced through a disturbance in microcirculation and a subsequent build up of lactic acid.