An Osteopathic Approach to Fibromyalgia
An osteopathic approach to the patient entails viewing all aspects of health (physical, mental, emotional, and spiritual) as a combination of coordinated body functions that make up that unique individual patient. It is a patient-centered focus, emphasizing health- oriented principles of patient care and adds the osteopathic touch—i.e., hands on manual diagnosis and treatment to address mechanical dysfunctions that impede normal motion throughout the body. Joint motion is essential in each body region as it facilitates vascular and lymphatic drainage from the region back to the general circulation. The osteopathic philosophy is founded on core beliefs about health, disease and patient care that can be summarized in four basic tenets that stem from the sciences of anatomy and physiology:1,2
- The human being is a dynamic unit of function.
- The body possesses self-regulatory mechanisms that are self-healing in nature.
- Structure and function are interrelated at all levels.
- Rational treatment is based on these principles.
Though we learn anatomy and physiology in parts and systems, the first tenet recognizes that the person is a dynamic unified whole, not the mere compilation of unrelated anatomical parts or physiologic systems. The patient with fibromyalgia has wide spread pain that is bilateral, involving all body regions. Although signs on physical exam manifest as select tenderpoints in the musculoskeletal system, other body systems are involved. Common complaints often include gastrointestinal and nervous system dysfunctions. Additionally, what is going on in the person’s environment, social life, diet and nutrition, drugs used or abused, sleep patterns, emotions, beliefs and other behavioral factors play a role in the generation and recovery from fibromyalgia. All of the body’s systems are working together as a coordinated unit, helping the patient adapt to environmental and social challenges.
The second tenet stresses that the body is capable of self-regulation, self healing, and health maintenance. This capability is inherent, but at times may require assistance in the form of osteopathic manipulative treatment (OMT), surgery, exercise, nutritional advice, medications, or counseling. The third tenet states that structure and function are inter-related at all levels. Altered form leads to altered function; altered function leads to altered form. This is true at the molecular, cellular, tissue and organ levels. In assessing the patient, a search for areas of altered form and function within the neuromusculoskeletal and other systems will help identify entry points for treatment using OMT and other therapies. The fourth tenet, that rational treatment is based upon the three previous principles emphasizing the need to consider the unity of the human body, mind and spirit, the patient’s self-healing and regulatory capabilities, and the inter-relationship between structure and function in developing a management plan.
E.D. is a 46-year-old female that complains of three years of progressive widespread pain including her arms, legs, neck, back, and head that is not alleviated by non-steroidal anti-inflammatory medications or acetaminophen. Symptoms have been worse in the past six months to the point of interfering with her work. She has missed 10 days in the past two months due to the pain and fatigue. She has had difficulty working lately, with poor concentration and stamina, getting tired easily. Symptoms are better with rest and worse with prolonged sitting or standing and repetitive activities. She has irritable bowel symptoms, non-restorative sleep and difficulty falling asleep at night, but falls asleep sometimes while sitting at her computer at work during the day. She has been suffering from a depressed mood for several months, loss of interest in hobbies and fun activities, is not doing any exercise, seeks solitude, has poor appetite at times, though has not lost weight, and denies suicidal ideations. She has not sought psychiatric help nor taken antidepressants and has no history of psychiatric treatment or hospitalizations.
Although she has no history of organic diseases, she has had three automobile collisions in the past twenty years, rear ended twice, that have caused her considerable neck and back pain. She denies social problems at work or home. She denies using illicit drugs. However, she does smoke a pack of cigarettes a day for the past 25 years. On physical exam, she not only has bilateral tender points in each body region, 14 of the 18 classic points ascribed to fibromyalgia syndrome,3 but also has generalized allodynia—light touch anywhere on the left arm, for instance, elicits shooting pain into the limb not in a dermatome distribution. Neck motion is significantly limited: extension is only to 45 degrees and neck flexion is to two fingerbreadths above the chest. The neurologic exam is otherwise unremarkable and non-lateralizing.
There were spinal motion restrictions at several cervical, thoracic and lumbar vertebral joints. Cervical radiographs displayed degenerative bone and disc disease and a follow up MRI showed a moderate to severe spinal stenosis between C3-C5. A sleep study diagnosed severe sleep apnea. Her diagnoses are cervical spinal stenosis, depression, fibromyalgia, somatic dysfunction, irritable bowel syndrome and sleep apnea.
The question at hand is whether these six conditions all stem from one primary problem, i.e., fibromyalgia?4 Or are they co-morbidities with separate and distinct etiologies? Is fibromyalgia the end result of the conglomerate of these other disorders? Each condition affects the nervous and musculoskeletal systems. In this instance, to restore normal functionality, rational treatment would consist of OMT to alleviate the somatic dysfunction, exercises, medications, C-PAP at night, counseling and nutritional advice. Alleviating somatic dysfunction using OMT and exercises improved her efficiency of motion, decreased neural irritability and facilitated self-healing and recovery. Aerobic exercises, counseling, nutrition and medications, such as pregabalin, duloxetine or milnacipran, along with C-PAP, may help further decrease neural irritability, improve restorative sleep, and stabilize emotions.5
As fibromyalgia involves muscle pain and dysfunction, it is helpful to look at the roles the musculoskeletal system plays in restoring and maintaining health and well-being. The musculoskeletal system is integral in five basic integrated and coordinated body functions that aid healthful adaptation to life and its circumstances: