Sunday, August 26, 2007

Physical Therapy for Fibromyalgia

A Primer on Physical Therapy for Fibromyalgia Patients 8/25/07

This information is excerpted from the book Fibromyalgia: The Complete Guide from Medical Experts and Patients (May 2007, Jones and Bartlett), by Dr. Sharon Ostalecki, PhD.*

Loren DeVinney, an Orthopedic Manual Physical Therapist, explains: The mechanics of therapeutic heat and cold, ultrasound, and stretching exercises. An easy way to identify your maximum heart rate and stay within the exercise envelope thats beneficial for you. Two types of manual therapy - joint mobilization and soft tissue mobilization. And how to find/choose a knowledgeable body worker such as a massage or physical therapist.

Muscle Abnormalities

Fibromyalgic muscles are tender, painful, or both. Research shows structural abnormalities in the muscle fibers, which are primarily due to not enough oxygen (hypoxia). [Figure 15.1: Pain cycle due to abnormal Fibromyalgia muscles - shows a circle of symptoms starting with abnormal FM muscles and cycling through seven other abnormalities, each of which contributes to pain and is exacerbated by pain. These are poor posture, poor body mechanics, strain on muscles, micro trauma (injury) to muscles, muscle guarding, disuse due to fear of movement, and poor movement patterns - coming back full circle to abnormal FM muscles.]

Physical Therapy Treatments Heat and Cold

Heat applied with a moist or electrical heating pad relaxes muscles, increases blood flow, and facilitates healing. Cold inhibits blood flow (while applied) and blocks pain (numbs), leading to relaxation of the painful area by inhibiting the withdrawal reflex. Heat is frequently applied for 20 to 30 minutes. Cold, using a frozen gel pack wrapped in a towel, is applied for 10 to 15 minutes. Ice rubbed directly onto the skin is applied for about 5 minutes. Too much heat for too long can lead to swelling or burning and more pain. Too much cold can lead to frostbite. The heat packs sold in drug stores for one-time use (activated by exposure to air or by twisting them) can be used longer, because they aren't as warm as heating pads. Hot whirlpools can expose your whole body to heat. This helps when your whole body is sore. A temperature of about 104 degrees Fahrenheit for 10 to 15 minutes seems best for maximizing the benefits. If you want to soak for longer periods at home, the temperature should be no higher than 90 degrees or so.

Therapeutic Ultrasound

Ultrasound therapy is the application of high frequency sound waves to the body. Ultrasound treatment sets up a high frequency vibration in the muscle/tendon or ligament, generating a deep heat. This brings blood to the area, relaxing the muscles and facilitating healing. Most patients find ultrasound to be a comforting experience.

Stretching Exercises

There are hundreds of strengthening philosophies and techniques. Concentric contraction is less stressful to muscle fibers than eccentric contraction. In concentric contraction the muscles shorten; in eccentric contraction they lengthen, as for example when you lower a weight. A program that emphasizes concentric contractions with light weights is tolerated best by Fibromyalgia patients. General non-painful movement strengthens the muscle by re-educating it to work more efficiently. The number of repetitions is kept low, in the 10 to 20 range so as not to overstress one muscle. It is best to strengthen several muscle groups at a time, dividing the stress on the body more evenly. The physical therapist targets the muscles found to be weak on physical examination to determine what strengthening exercises are most appropriate. With moderate to severe pain, strengthening before complete muscle relaxation is obtained will trigger more pain. In those cases, the physical therapist may focus on relaxing the painful muscles while strengthening those that can tolerate strengthening exercise.

Aerobic Exercise

Getting enough aerobic exercise is difficult even for those who do not have pain. It requires motivation, willpower, and the energy to do regular exercise. Due to the nature of the syndrome, Fibromyalgia patients frequently have pain and fatigue with exercise, so they have another hurdle to overcome in doing aerobics. To understand aerobic exercise, you need to know that the body has two systems to supply itself with energy during exercise. One system initially supplies the energy. If exercise continues, the other system takes over the task. When you start to exercise (e.g., ride a bicycle) the body burns sugar in the blood and/or muscles for energy, because sugar is the most accessible fuel. Burning sugar requires no oxygen, so exercise fueled by this process is called anaerobic exercise. As we prolong the activity, the body switches energy systems so as not to deplete the supply of sugar in the blood, and it begins burning the fat. Burning fat requires oxygen, so this exercise is called aerobic exercise. Nearly everyone wants to burn fat hence the popularity of aerobics. Aerobic exercise carries many benefits: cardiovascular improvement, increased feelings of well-being, a general strengthening, and the release of pain-relieving substances such as endorphins in the brain. Achieving these benefits is crucial to making Fibromyalgia patients feel better. But it's a significant challenge.

Clinically we find that Fibromyalgia patients have low endurance and little strength. We also find that activity causes pain. Their muscles are easily injured, so post-exercise pain is common. Their muscles are less efficient than normal muscle. Like everyone, they try to avoid pain and therefore frequently avoid exercise. The key to doing aerobic exercise is in not doing too much just enough to realize a benefit. For the FM patient, the initial goal involves finding out how to move without increasing pain.

You can figure a basic guideline to gauge how much is too much aerobic exercise. First estimate your maximum heart rate (MHR) by subtracting your age from 220. For example, a forty-year-old persons maximum heart rate would be (220 minus 40 equals) 180 beats per minute. When you exercise keep track of your heart rate. Determine what percentage of your maximum heart rate (MHR) you are exercising at. For example, if you ride a stationary bike at a heart rate of 108 beats per minute, that is 60 percent of 180, the MHR in this example. [You will need a heart rate monitor, which resembles a wristwatch, to track heart rate and know if youre nearing your maximum. Your training index (TI) is an estimate of how much work your body is doing in your exercise program. You figure this value by multiplying three things: The percentage of your MHR you exercise attimes The number of minutes you exercisetimes The number of times you exercise per week. To realize cardiovascular benefits from aerobic exercise, your TI should be above 40. To keep from aggravating Fibromyalgic pain, keep it below 90. For example, if you ride a bike for 30 minutes (not counting warm up or cool down) at 60 percent of your maximum heart rate four times a week, your TI would be: 30 x .60 x 4 = 72. Thats within the acceptable range of 40 to 90. So, let's summarize with the formula for calculating your training index: (Number of Minutes of Exercise x Percent of MHR x Number of Sessions Per Week = TI) It is important to have variety in your aerobic exercise program. Riding a bicycle for 30 minutes uses the same leg muscles repeatedly. This can aggravate leg pain. Its better to use several different activities and therefore spread the stress over many different muscles so one group isnt overworked. A typical routine to begin with is 5 minutes on a stationary bike with no resistance; 5 minutes on a treadmill at a slow, comfortable speed (1.5 to 2.0 miles per hour); and 2 minutes on an arm bike with the lowest resistance setting. Severe FM patients may need to start with more brief periods and a much slower pace. Generally, the goal is to get up to about 30 minutes of aerobic activity. That can take several weeks, months, or years (in severe cases).

Joint Mobilization

Joints can have normal movement, not enough movement, or too much movement. If a joint doesn't permit enough movement, it is said to be hypomobile. If it is loose and permits too much movement, it is said to be hypermobile. A stiff and hypomobile joint needs mobilization. Manually gliding or distracting the joint is the usual treatment. A joint that moves normally usually requires no mobilization unless it is painful. Then low-amplitude oscillations (by manually vibrating the joint) can decrease the discomfort. * Hypermobile joints are treated with stabilization exercises and sometimes braces. Manipulating a hypermobile joint just makes it looser and more painful. So, it is very important for therapists to evaluate joint movement before using joint mobilization techniques. For example, the relief you get from cracking your neck (usually by a quick movement) is mostly due to the quick stretch of the joint capsule with the concurrent reflexive muscle relaxation. There are beneficial and not-so-beneficial cracks. Cracking (manipulating) a stiff joint can loosen it, and that helps. But manipulating a hypermobile joint also produces a crack and reflexive muscle relaxation, which may do more harm than good because it makes the hypermobile joint even looser. If much effort is required to get a crack, you are probably manipulating a hypermobile joint and should avoid doing so. Fibromyalgia primarily affects the central nervous system and the soft tissue, so joint treatment is secondary. Joint stiffness most commonly occurs in the thoracic (mid-back) section of the spine. This area almost always requires joint mobilization to loosen tight spinal joints so the patient can sit and stand properly.

Soft Tissue Mobilization

Soft tissue is composed of muscle fibers, tendons, fascia, and ligaments. * Muscle fibers are like cables wrapped in fascia (connective tissue much like a nylon stocking) into bundles. These bundles of muscle fibers are themselves bundled within fascia to form a muscle. Muscles are attached to bone by tendons, which are elastic and can stretch. Bones are connected to other bones by ligaments. Ligaments are inelastic and not meant to stretch; they should limit the range of joint movement so that the connected bones dont come out of joint. Joint capsules are similar to an elastic bandage that holds bones together but allows them to move. Any of these structures can develop trigger points. Dr. Janet Travell defines a trigger point as a focus of hyperirritability.3 All these structures have pain-sensing nerve endings in them, so trigger points cause pain. Fibromyalgia patients are especially susceptible to developing trigger points in muscle. Trigger points can be caused by resting contraction, micro-injury, poor posture, poor movement patterns, disuse, and immobilization. Muscles and fascia can also develop knots or restrictions. These restrictions are caused by the connective tissue fibers sticking together and bunching up. Treatment requires soft tissue mobilization/massage to free up restrictions and restore blood flow. The challenge in treating Fibromyalgia is doing this without increasing pain.

The following are some guidelines for applying soft tissue mobilization/massage: * Whole-body massage is usually not tolerated because FM muscles have a hard time reabsorbing waste products (like lactic acid). Massage tends to stir up these molecules, keeping them undissolved so that they don’t get quickly washed away. Direct/deep pressure causes ischemia (lack of oxygen) in the muscle and usually creates more pain, because part of the problem with FM muscles is they are already ischemic. Soft-tissue work should start superficially. Once the top layers are loosened, deeper soft-tissue mobilization may be tolerated. A stroke that goes parallel to the muscle fibers is well tolerated. Strokes that go perpendicular to the soft tissue fibers are used after the parallel strokes have begun to loosen muscle tissue. Using a cream (to prevent pinching the skin) that has no scent and few ingredients reduces the chances that the patient will be allergic to it or have a bad reaction.

Choosing a Muscle Therapist

Most Fibromyalgia dysfunction involves the muscles. So, it is important to involve massage therapists as well as physical therapists in Fibromyalgia management. Finding a massage therapist or physical therapist who can help manage Fibromyalgia can be a challenging task. It may require trial and error. Asking fellow Fibromyalgia patients (at a support group, for example) may help you tap into a network of health care professionals who are a good fit for you.

The following are some guidelines for selecting a body worker: Are they certified or licensed to practice what they claim to practice? Do they really know what Fibromyalgia is a muscle and nervous system problem? How does their technique for treating Fibromyalgia differ from their technique for treating healthy individuals? Deep, vigorous massage usually aggravates moderate to severe Fibromyalgia symptoms. Full-body, one-hour sessions are usually too long. Direct pressure into trigger points tends to cause flare-ups. Myofascial release or stretching must be preceded by gentle soft-tissue massage.

[N.B.  Dr. Cheney has stated repeatedly that patients with fibro can do aerobic exercise, but patients with CFS absolutely should not do anything aerobic because it will make them sicker.  If you have CFS, stick to stretching, resistance, etc., and avoid anything that stresses your heart.  See ]

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