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7 Articles in Volume 1, Issue #5
Accidentally Speaking
Breaking Down the Barriers of Pain: Part 5
Cancer Pain: Successful Management of Patients’ Fears
Emergency Medicine: Emergency Department Protocols
Magnets & Medicine
The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 3
Thinking About Pain

The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 3

The third installment of this series discusses sEMG and other treatment options for fibromyalgia.

The treatment of fibromyalgia follows directly from the assessment. The basic premise is to reduce the source(s) of pain in the periphery while simultaneously reducing the CNS dysfunction, without irritating or reinforcing the pain pathways. As one or several of these mechanisms may be involved in the maintenance of the dysfunction, a multi-faceted strategy is recommended. This should consist of: a) trying to calm the system with medication(s), naturopathic substances, and relaxation training techniques; b) alter the muscle, joint (peripheral) activity using different sEMG techniques, physical therapy, and massage therapy; and c) alter the CNS activity using EEG neurotherapy techniques.

Medication

Before discussing biofeedback and other treatments, a brief discussion of medications and the impact upon biofeedback is needed. In general it has been found that the use of medication(s) can both enhance and retard treatment. If the individual is in a significant amount of distress at the start of treatment, then medications can be used as a means of pain control, or to treat severe anxiety or depression that may prevent initiating other forms of treatment. However, as treatment progresses, medication(s) may retard progress, for as the treatment works the need for the medication decreases. When this happens the individual will start to show signs of being over medicated. It is important for the clinician to have an up-to-date and comprehensive pharmaceutical reference available in order to understand the interaction between treatment and medications and to support the patient.

The pain component cannot be treated specifically with just one type of medication. Different analgesic classes may prove useful in reducing pain intensity and/or frequency for a determined period of time. Combined classes of medicines may prove more useful, e.g. tramadol (Ultram), vicoprophen, etc., in that they may reduce pain by blocking different receptors. Opiates may be reserved for complicated cases, which have shown a poor response to pain treatment with other classes of analgesics. NSAIDs have generally not proven very effective in treating fibromyalgia.150 All pain medication must be prescribed and taken under clear guidelines and control. Recently, Jacob Teitelbaum (work in progress 1999) indicated that in a double blind study the application of a combination of medications and naturopathic substances significantly reduced fibromyalgia symptoms. Unfortunately, the authors do presently not know the exact nature of this combination and readers need to be cautioned that this work is preliminary and needs further review.

Where possible, substitution of herbal remedies and OTC nutritional supplements for pain medications should be considered. A number of herbal remedies have demonstrated some promise in alleviating musculoskeletal pain, including sangre de grado,151 capsaicin,152 and devil’s claw (harpagophytum procumbens). Similarly, the OTC nutritional supplements methyl-sulfonyl-methane (MSM),153 glucosamine,154,155 and S-adenosyl-l-methionine (SAMe) have all been shown effective in alleviating some types of musculoskeletal pain, including inflammatory and arthritic pain.

A recent commercial release of a combination herbal and nutrient remedy for fibromyalgia called FM Relief®† combines many of the ingredients that have shown clinical promise in relieving musculoskeletal pain (i.e., malic acid, salicin, magnesium hydroxide, methyl-sulfonyl-methane, glucosamine sulfate, chrondroitin sulfate, 5-HTP, curcumin, boswellia) and may be a useful adjuvant or even alternative to some of the pain medications commonly prescribed to people with fibromyalgia.156

There is also evidence that one important factor in musculoskeletal pain is low plasma magnesium levels157,158 and, moreover, that many medications commonly prescribed to people with chronic pain interfere with the body’s metabolism of magnesium.159 Calcium is also an important nutritional factor in muscle and bone health. Therefore, it is recommended that myofascial and fibromyalgia pain patients take a calcium and magnesium supplement at least four times per day (i.e., with meals and just before bedtime) to attain a total daily dose of approximately 1000-1500 mg of calcium and 600-800 mg of magnesium. Clinical experience shows that calcium and magnesium can be effective in reducing muscle spasming and tension as well as chronic headaches. A moderately large dose (200-400 mg) of magnesium can abort a migraine or tension headache, and high doses of calcium can be very effective in reducing some of the symptoms of PMS.160 Calcium and magnesium can also help induce sleep.

The anxiety/depression component may be controlled with adequate doses of anxiolytic/antidepressant agents. Different medications may be used in the same individual over time if the response is less than adequate. Dosing may differ according to the intensity of the anxiety/depression symptoms over time. Tricyclics such as amitriptyline (Elavil) have traditionally been used in low dosages (i.e., 10-25 mg hs) to enhance sleep, improve negative mood, and take the edge off chronic pain, but more recently, SSRIs (e.g., Paxil, Prozac, Zoloft, etc.) have been employed with a view to reduce depression and stabilize affective symptoms. While the older tricyclic antidepressants have proven themselves as moderately effective adjuvants to analgesics in treating chronic pain,161 the newer SSRIs may be less effective in this regard.162 Many physicians now combine a low bedtime dose of amitriptyline or trazodone with a moderate morning dose of an SSRI.

Research on the effectiveness of various medications in the treatment of fibromyalgia would appear to point to amitriptyline (Elavil) (10-50 mg hs) and cyclobenzaprine (Flexeril) (10-30 mg) as the most consistently beneficial.150

There is some evidence that mild depressive symptoms may respond well to herbal remedies such as St. John’s wort (hypericum), or certain OTC nutritional supplements such as S-adenosyl-l-methionine (SAMe), l-tryptophan or 5-hydroxy-tryptophan (5-HTP),163 whereas mild generalized anxiety may respond well to kava kava (piper methysticum) or valerian (valeriana officinalis).164 The problem of sleep inadequacy may be treated partially with the antidepressant medications described above, especially amitriptyline and trazodone. However, it may be relevant to consider the use of herbal remedies such as chamomile, lemon balm, kava kava, or valerian, or nutritional supplements such as melatonin,165 l-tryptophan, or 5-HTP163 before adding specific sleep medication, especially those of the benzodiazepine group which frequently cause more problems in the long term.

It is important to remember that once treatment is underway medications will often reduce the speed of recovery, as rebound effects and symptoms of an overdose will occur as the need for medication is reduced. Medications of the benzodiazepine group, steroids, and opiates tend to suppress the electrophysiological signal making treatment more difficult. It is also important to monitor what herbal supplements and medications patients are taking in order to avoid potential interactions.

Successful treatment requires all members of the team to know their part in the rehabilitation process and coordinating the treatments.

Other Forms of Treatment

It is important that the clinician recognize the role other forms of treatment have in treating these complex problems as sEMG and EEG neurotherapy cannot be used in isolation from other treatments.

The treatment of chronic pain is not a simple issue, nor is it well researched. Throughout North America there is a growing recognition that the treatment of chronic pain requires a multi-disciplinary approach integrating all the different disciplines.90 However this recognition goes beyond having a collection of individuals doing their own thing under the guise of a coordinated program.90

There is growing recognition that successful treatment of chronic pain requires awareness by clinicians that when they treat, they must be aware of their impact upon the entire system. Successful treatment requires all members of the team to know their part in the rehabilitation process and coordinating the treatments. For example, aggressive treatment that causes pain in an area, which for an extended amount of time is not diminished, will affect other parts of the system (i.e., the brain, sensory system) retarding rehabilitation. The different disciplines need to know how their work impacts the work of their colleagues.

The following section discusses adjunctive treatment techniques that have been integrated into the senior clinician’s clinic as part of a comprehensive treatment program. The materials are based upon the authors’ knowledge of them as they impact and relate to the biofeedback techniques. Techniques such as acupuncture and chiropractic are not included, as the senior author has no knowledge how they impact biofeedback techniques.

Overall Strategy

The overall strategy in treating chronic pain patients is to reduce problematic peripheral stimulation, maintain the activity of the sensory nervous system at a low level of arousal, and monitor and change if necessary the activity of the brain. Treatments may be divided into two categories — general and specific. General treatments refer to impacting upon the entire system (involving more than one physiological level — (i.e., muscles and CNS), while specific treatments refer to treating a localized area (i.e., muscles).

General Treatments

Relaxation Training. Relaxation training is considered a general treatment due to its diffuse impact upon the body. Virtually every bodily system can profit from reduced arousal and tension. Muscles, in particular, should show reduced tonus, thus reducing their need for oxygen and allowing an opportunity to eliminate lactic acid and other toxic waste. The cardiovascular system should also show improvement in blood flow as seen in increased peripheral temperatures. The nervous system, both peripheral and central, should show a decrease in activity and hopefully an increase in firing threshold level. Relaxation training may also be directly effective in reducing myofascial trigger point sensitivity that is possibly mediated by intrafusal muscle fibers via the sympathetic nervous system.166 Relaxation training may also reduce the background noise at the dorsal horn thereby reducing the secondary pain stimulus from this location. Finally, the brain should show an improvement in cognitive functioning (increased clarity, better concentration, and immediate memory) with general relaxation. However good the relaxation training is, it cannot be considered a cure as the PNS and CNS factors that caused the problem still need to be alleviated. Until this is done, relaxation training should be considered an important part of the package, but only a part.

As mentioned previously, autonomic nervous system imbalance has been implicated in the development of fibromyalgia.58 With the basal autonomic state of people with fibromyalgia characterized by increased sympathetic and decreased parasympathetic (vagal) tone with associated increased resting heart rate, reduced heart rate variability, and deranged response to orthostatic stress.59,60 An excellent biofeedback technique for restoring autonomic homeostasis is cardiovascular resonant frequency training whereby people are trained to alter the spectral pattern of heart rate data in a systematic way through controlled diaphragmatic breathing rates.167,168 Specifically, patients are taught to slow their diaphragmatic breathing to a rate that shifts the usual respiratory rhythm (RSA) down until it is superimposed on the baroreceptor rhythm at approximately 0.1 Hz (6 breaths/minute). This has the effect of maximizing the variability of the heart rate acceleration/deceleration with inspiration and exhalation while simultaneously minimizing the input of the autonomic nervous system on heart rate.

Physical Exercise. All chronic pain patients should be engaged in some form of physical exercise. Certainly, with respect to fibromyalgia, the evidence is clear that properly supervised aerobic exercise programs can be at least temporarily beneficial for a majority of patients.150 The exercises should be designed to improve cardiovascular activity, range of motion, and muscle tonus.169,170 This latter aspect is particularly important as it is believed that the greater the muscle tonus, the greater the ability of the muscle to tolerate muscle dysfunctions (see sEMG section for details). However, caution needs to be applied here. Exercising too aggressively will increase pain and may restrict mobility around a joint. If there is CNS involvement with the patient’s problems, then the pain signal will impact upon the nervous system increasing peripheral system irritability and brain (cognitive) dysfunction. Exercise needs to be treated as a double-edged sword that can be an important part of treatment but, if not applied judiciously, will increase pain and encourage the patient to drop out of treatment. Unfortunately, many chronic pain rehabilitation programs that apply a “work hardening” or “sports medicine” model fail to recognize this and, therefore, fail their patients.

All chronic pain patients should be engaged in some form of physical exercise.

Psychotherapy. Psychotherapy is included because individuals often demonstrate emotional reactions to pain that need to be resolved. Emotional reactions impact upon the biochemical “soup” which flows throughout the body altering the levels of various important neurotransmitters and hormones (e.g., serotonin, catecholomine, cortisol, adrenaline, noradrenaline, etc.). Tensing of the muscles is often a by-product of emotional agitation, and will cause increased muscle pain. Increased emotional activity may also increase the background noise in the receptor fields at the dorsal horn, increasing the probability of non-painful stimuli triggering a painful reaction.90 Psychotherapy should be used in conjunction with relaxation training in order to provide a cognitive understanding of the emotional component of the dysfunction while reducing hypersensitivity at the dorsal horn providing some physical symptomatic relief.171, 172

Massage. Massage is included when it is used primarily as a relaxation technique. All the usual benefits such as muscle relaxation, improved blood flow, and lymphatic drainage is expected. Tissue sensitivity (the ability of the tissue to tolerate pressure) is an important factor here, as there is a risk of flaring the tissue in the hypersensitive person. The massage therapist needs to be sensitive to how much pressure the tissue can tolerate because in a person with fibromyalgia it is considerably less then what can be tolerated by healthy tissue. Techniques that have shown great value with fibromyalgia patients in the authors’ clinics include: Hellerwork or connective tissue massage, craniosacral therapy (e.g., William Sutherland, John Upledger), myofascial release techniques,173 Ortho-Bionomy or positional release techniques,174,175 and Shiatsu.

Physiotherapy. Physiotherapy is included here for its use of electrical modalities to decrease the perception of the pain signal. Research has indicated that this use is primarily restricted to acute pain as the studies on chronic pain show a poor outcome with these modalities. More recently the use of microstimulation techniques has been introduced to the area of the treatment of chronic pain. Instruments such as the Alpha Stim®‡ have shown promise in the alleviation of symptoms.176

Another concern for physiotherapy is the impact of time upon muscle length. The longer the muscle(s) is in an altered position (shortened or lengthened), the more work will be required to modify and improve this problem. This is basic to most physical therapy so no further comment will be made here, except to alert the clinician to possible complications of excessive stretching irritating the neural systems (see specific treatments for more details).

Physiotherapy using muscle stabilization and balancing techniques177-179 can be very effective with fibromyalgia patients.

Occupational Therapy. The role of the occupational therapist is to adapt activities and/or behaviors to improve function and independence. The primary goal is to get patients as functional as possible within their limitations as soon as possible. Occupational therapy focuses on providing a balanced lifestyle of work/rest/leisure. Principles of energy conservation, work simplification, joint protection, and correct body mechanics are applied to activities of daily living. Concurrently, the patient is taught to cognitively break up co-contracted movement patterns while slowly and gently improving strength and range of motion — always working just below their pain threshold.

Specific Treatments

Physical or Manual Therapy. The manual therapist’s specific function here is to reduce or eliminate dysfunctions found in fascia, muscles, and joints. Without success here the underlying cause of the pain will remain, continuing the bombardment of the neural pathways with the pain signal. Great care needs to be taken not to flare the tissue for an extended period, as this will only retard progress in therapy. Use of vapo-coolants such as Fluori-Methane®‡† or ethyl chloride as part of a stretch and spray program is part of this method.87 Stretching can be used as appropriate, but care must be taken not to hold the stretch too long or forcefully since this may cause a pain signal to be sent back to the nervous system. Stretching is most beneficial when the stretch is done to just the edge of pain and held for approximately 30 to 90 seconds until a release is felt. If release is not felt, other areas need to be worked on first.

The occupational therapist’s specific role is to adapt activities of daily living to improve patient function.

Other types of manual therapy utilized in the authors’ clinics include various connective tissue manipulation and stimulation therapies that are collectively categorized as neuromuscular therapy techniques.169 Modern neuromuscular therapies are specifically designed to address somatic dysfunction, which may be defined as any impairment or altered function of related components of the body framework — i.e., skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements. These manual therapeutic techniques utilize physiological responses involving neurological mechanoreceptors, golgi tendon organs, muscle spindles and other proprioceptors in order to achieve the normalization of imbalances in hypertonic and/or fibrotic tissue, with a particular emphasis on deactivating focal points of reflexogenic activity such as myofascial trigger points or fibromyalgic tender points. Modern neuromuscular techniques, include not only effleurage, myofascial release therapies and craniosacral therapies, but also muscle energy techniques and various positional release techniques. These manual therapy techniques are gentle, yet effective in reducing peripheral involvement without irritating the CNS.

Positional release therapies include a number of different methods that all involve positioning of an area of the body, or the whole body, in its most comfortable, easy, and pain free position so as to evoke a therapeutically significant physiological response that helps to resolve musculoskeletal dysfunction.174 A particularly useful positional release technique, called Strain/Counterstrain (SCS) is thought to achieve its benefits by means of an automatic resetting of muscle spindles when the muscle housing the spindle is positioned “at ease” with subsequent reductions in excessive muscle tone and release of spasm.180 Muscle energy techniques involve fully or partially resisted muscle contraction to activate a physiologically induced post-isometric relaxation (or reciprocal inhibition) response, prior to passive stretching.181 Specific muscle energy techniques include isometric contraction with reciprocal inhibition, isometric contraction using postisometric relaxation without stretching, isometric contraction with postfacilitation stretching, isotonic concentric contraction, isotonic eccentric contraction, and isokinetic contractions.181

Myofascial release primarily treats the fascia. If any part of the fascia is deformed or distorted there may be negative stresses imposed on distant aspects and on the various structures that the fascia divides, envelops, enmeshes, and supports. This results in abnormal restrictions or pressures in any or all body components. Myofascial release techniques involve the application of manual friction and pressure to remove fascia restrictions, reduce adhesions between the fascia and underlying structures, to stretch and shift the fascia to reduce localized and distant stresses, and restore equilibrium.

Craniosacral therapy is helpful in reducing autonomic tonus (sympathetic activity), reducing general stress and anxiety, improving endocrine function, assisting postural balancing, and improving fluid exchange in the tissues.

These techniques have a more important role in situations with physical trauma as the primary cause of the fibromyalgia.

Massage. Massage therapy’s specific role in treating fibromyalgia patients is to help desensitize the patient to being physically handled through gentle relaxation massage techniques and to work on trigger points and taut bands. Included in this process is the use of topical anesthetics such as Biofreeze®‡‡ (a cryogel) or a capsaicin to reduce the pain. Other techniques such as stretch and spray87 may be used as well.

Occupational Therapy. The occupational therapist’s specific role is to adapt activities of daily living to improve patient function. Focusing on the area of rest, positioning is taught to encourage corcorrect alignment, protect joints, and decrease pain. Body mechanics are taught for getting in and out of bed without unnecessary strain to the neck or painful joints. Visualization and deep relaxation techniques are utilized to quiet muscle activity and negative thoughts, especially when applied to disruptive waking and rumination patterns.

Treatment Using Biofeedback Techniques

The basic premise of biofeedback is that the provision of timely information, which is normally outside the zones of awareness, is brought into awareness in order to induce change toward the restoration of correct or normal functioning. EEG neurotherapy and sEMG techniques facilitate this change either indirectly through the monitoring of the individual’s reaction to other forms of treatment or by directly impacting upon a neural system facilitating change. SEMG impacts fibromyalgia by: a) altering the afferent generated by the motor system thus reducing the irritation to the PNS and the CNS; and b) reducing the activity of the sensory system. Conversely sEMG can also document when a treatment is not working and is increasing irritation to the systems. EEG neurotherapy impacts directly upon the CNS by altering the patterns of brain wave activity.

sEMG as an Indirect Treatment Tool

Due to the flexibility of sEMG as a monitoring device, the efficacy of other forms of treatment can be established. When using other forms of treatment, it is important to first clearly establish what is the goal of the treatment. These goals may include an increase or reduction of muscle activity, a change of muscle tonus, and a return to baseline. It is impossible to accurately and in a timely manner monitor these changes without the use of sEMG.

Through the use of relaxation training techniques the levels of muscle tension in response to stress can be reduced and the outcome reported in an objective manner. There are a number of different methods of recording muscle activity for the purpose of documenting relaxation response, the selection of which is dependent upon the clincian’s training and goals. The methods of recording are defined by the area or part(s) of the body to be monitored. For example, Budzynski in the 1970s recommended the practice of monitoring frontalis muscle activity as this was thought to be associated with tension headaches182 This placement was thought to reflect the activity of the facial muscles, indirectly reflecting the level of activity of the autonomic nervous system. Subsequent research has shown this placement is no more efficacious than relaxation training in reducing tension headaches, but this placement appears to adequately reflect the muscle activity involving the facial muscles.183

Recently, Hubbard and his colleagues184 using needle electrodes demonstrated elevated electrical activity in trigger points in the upper trapezius. Activity in the trigger points increased when individuals were exposed to stressful stimuli. This activity was reduced with the administration of phentolamine and the application of deep breathing techniques. While this research appears to be promising, it is presently not known if all muscles with trigger points react to stressors in the same manner or if it varies from muscle to muscle. Flor65 recently demonstrated that traumatized muscle will react to a stressor with an increase in electrical activity, while the muscle immediately adjacent (which was not traumatized) failed to react. After placing sEMG electrodes over these muscles, the researchers asked patients to talk about their trauma (usually motor vehicle accidents). Muscles that were reported as sore immediately after the trauma showed increases in electrical activity, while those adjacent did not. This was interpreted as a form of muscle memory in which the muscle retains the memory of the trauma and reacts to it when placed under situations of stress. This phenomenon appears particularly relevant to individuals suffering from fibromyalgia as various studies15 indicate 70 percent of people with fibromyalgia report the onset of symptoms post-trauma — most frequently a motor vehicle accident.

Poor recovery of baseline refers to the condition in which a muscle after movement (contraction) does not return to its pre-movement resting EMG level. This shows up as an increased level of activity or hypertonus on sEMG. Resolution of this problem may be accomplished by providing the individual with the appropriate stretching exercises, which should show immediately as decreased activity of the sEMG signal. Also relaxation training may be utilized.

SEMG techniques can be utilized as a form of data collection to document the efficacy of the treatment undertaken. This can vary from physical therapies to psychological therapies. It clearly shows changes in electrical activity of the muscles allowing for a quick and objective measure of change. It allows the practitioner to note when a therapy has not been effective (little impact upon muscle activity) or too aggressive (increased muscle activity) so steps can be immediately taken to correct and/or minimize the impact upon the sensory nervous system.

sEMG as a Direct Treatment Device

One of the most important functions of sEMG as a biofeedback technique is when it’s used to directly change muscle activity. Surface electromyography (sEMG) techniques are designed to isolate a muscle and restore normal functioning of the muscle and consequently the myotatic units. In those individuals suffering from fibromyalgia, muscle dysfunction may be present in several forms. These include muscle imbalances (one partner of a homologous pair will show significant hyperactivity while the other will show hypoactivity) and inappropriate muscle activity known as co-contractions. As each of these conditions has a significant impact upon fibromyalgia their treatment will be discussed below in some detail.

One of the major uses of sEMG biofeedback is the restoration of muscle balance.115 Muscle imbalances are primarily associated with trigger point activity causing pain as described by Travell and Simons.87 Donaldson128 showed that trigger point activity was associated with significant muscle imbalances (at least 20 percent difference) that can be effectively reduced and result in eliminating the pain. In fibromyalgia this pain is usually reported as localized, variable in intensity, but always in the same spot.

Treatment involves placing the electrode over the hyperactive muscle (trigger point) and in the identical spot over the same muscle on the other side. While there are several different methods to reduce muscle imbalances most of the treatments focus on the hyperactive muscle, reducing the level of activity as described previously.

The use of the Donaldson Protocol© for the restoration of muscle balance is unique in that it targets the hypoactive muscle working to increase normal functioning and balance. Donaldson88 proposed the use of this technique on the basis of peripheral neural inhibitory processes, using normal inhibitory control mechanisms to reduce hyperactive muscles. The patient is taught to contract the hypoactive muscle until it is higher in activity than the hyperactive muscle, hold this contraction for 10 seconds, then release it, resting for 50 seconds. (See Donaldson84 for details of this protocol.) When done correctly this technique should be painless except for some slight soreness in the targeted (contracting) muscle, due to the increased physical activity. When done incorrectly this technique may induce pain due to muscle spasm, necessitating the use of pain control measures. This treatment is designed to gently reduce the muscle imbalances while avoiding irritation of the sensory systems.

Diffuse Muscular Coactivation (DMC) occurs when a muscle that is normally quiet and has no biomechanical involvement with the movement, (i.e., gluteus maximus during rotation of the head) demonstrates increased electrical activity during the movement, in a manner that is directly time linked to that movement. If the DMC is peripherally mediated then restoration of the muscle balance as described often eliminates this problem. For example, the restoration of the normal muscle balance of the C5/6 paraspinals will often eliminate the DMC evident in the forearm extensors. However, if the DMCs are centrally mediated this technique will not work. Presently it is not known how to differentiate or predict which neural mechanism is involved, so it is recommended that the clinician attempt to balance the muscles first, as no harm can be done to the patient. If the co-contraction persists, then EEG neurotherapy must be utilized. Resolution of the DMCs appears to be associated with reduction in pain as described in the next installment of this series.

Read Part 4 of this article series

Last updated on: January 6, 2012
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