Understanding the fibro behind myalgia

By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS

Introduction
Muscle aches and pain are common in all of us, despite the type of work, activity
or the cumulative activities we do. Once thing is for certain, as an experienced physical
therapist, I have seen something unique. Patients who complain with an increase in pain, and
trigger points present, despite if they had surgery, trauma, increased stress in their lives or
have been suffering from chronic pain. One of the most common types of pain is
fibromyalgia. This article will review the background on fibromyalgia, clinical presentation &
pathology, the medical and physical therapy treatment approach. Provide the latest
evidenced based research on treating fibromyalgia, but more importantly, how to work with
a fibromyalgia client using effective programming and periodization training principles
guiding the personal trainer to help the client reach optimal goals safely and based on
science.
Background
The literal translation of fibromyalgia comes from fibro meaning fibrous tissues (such as
tendons and ligaments), my meaning muscles, and algia meaning pain. Fibromyalgia
syndrome (FMS) has an estimated prevalence in North America and Europe of 0.5% to
5.8%. According to the criteria of the American College of Rheumatology (ACR), FMS is
defined as chronic widespread pain and tenderness at a minimum of 11 of 18 points, defined
as tender points, that last longer than 3 months in duration(Huser, W., et al, 2009).
What is Fibromyalgia?
Pathophysiology: Individuals suffering from fibromyalgia display enhanced sensitivity to a
wide array of stimuli, such as heat and cold, as well as to mechanical and ischemic pressure.
Trigger points are areas of where the muscle shortens, which clinically we call adaptive shortening.
There trigger points are areas of hyperexcitability, which contain irritants (bradykinin, substance p,
cytokines) that are stored within the trigger point. These irritants develop by stress, trauma, poor posture,
just to name a few. Physiologically the muscle fibers actin and myosin become shortened, and less
efficient to move and slide within the muscle, thus affecting movement.

Figure 1. Stiffness associated with pain

Contributing factors: Factors contributing to the pathophysiology of fibromyalgia include

abnormal function of the autonomic and neuroendocrine systems, genetic influences, and
other triggers such as stress, anxiety, fear, anger and other emotional variables(Bradley, L,
2009).
Sign and symptoms: According to the criteria of the American College of Rheumatology
(ACR), fibromyalgia syndrome (FMS) is defined as chronic widespread pain and tenderness
in at least eleven of 18 defined tender points (Huser, W., et al, 2010). FMS is frequently
associated with fatigue, sleep disorder, mental and physical disorders, as well as disability and
diminished quality of life. With fibromyalgia, a person will have feel stiff and achy,
particularly in the morning that improves during the day and is sore by the end of the day.

Figure 2. Common locations of tender points associated with Fibromyalgia8

Associated symptoms: Patient may present with central sensitization. Central sensitization is
when persistent nocioceptive input leads to increased excitability in the dorsal horn neurons
of the spinal cord. Other symptoms of FMS are fatigue and disrupted sleep.
Medical mgmt.: Several high level randomized control trial articles, have shown there is
Strong evidence that anti depressants reduce pain. However, there are other interventions
that are very effective per the research(Huser, W., et al, 2009).
Cognitive therapy is based on the premise that modifying maladaptive thoughts results in
changes in both affect and behavior. High level research or meta-analysis has shown that
cognitive behavioral therapy (CBT) has significant effectiveness in treating associated

symptoms of depression, and anxiety, which is common with patients who suffer from
Fibromyalgia. In addition, research shows that relaxation techniques have also proven to be
helpful for FM symptoms include, but are not limited to, progressive muscle relaxation,
autogenic training, guided imagery and meditation(Hassett, A., & Gervirtz, R., 2009).
The term Qigong generally describes a number of traditional Chinese therapies and
exercises all believed to facilitate the flow of vital energy or chi.
Physical therapy: Patient education is the most important element in helping a fibromyalgia
patient. Understanding that utilizing a comprehensive approach is the most effective and a
must, to manage and improve ones quality of life.
Manual therapy is one of the most effective approaches to address the stiffness a
fibromyalgia patient presents with by using a manual therapy approach. Myofascial release
and soft tissue massage are two manual therapy approaches that not only relax the patient,
but enable the therapist to improve the elasticity of the muscle, whereby effecting the actin
and myosin to improve Their ability to contract and lengthen during functional movements.
Stretching the upper trapezius, lumbar, specifically the quadratus lumborum, the iliotibial
band, legs and calves are Important to restore optimal muscle length for movement.
Aqua therapy is very effective per the research. In a study by Diego, I., & Legaz-Arrese, A.,
(2008), wanted to evaluate the effects of a 16-week exercise therapy in a chest-high pool of
warm water through applicable tests in the clinical practice on the global symptomatology of
women with fibromyalgia (FM) and to determine exercise. The intervention was a 16-week
aquatic training program, including strength training, aerobic training, and relaxation
exercises. Results: those patients who were involved in the strength training, aerobic
training and relaxation group, showed significant deficiencies compared with the healthy
subjects. The group had significant decrease in the tender point, improving sleep quality,
cognitive function, and physical function.
Massage can very effective to compliment physical therapy reducing tension, trigger points,
whereby improving relaxation to the body. Cross training such as hiking and walking are all
part of the organic approach to help the FM patient achieve optimal wellness.
Recommendations for training:
Training a FM client should involve mild intensity and as always, should be specific to the
goals of the client. Strength training should focus on weaker phasic muscles such as; glute
maximus, glute medius/minimus and hamstrings>quadriceps. The choice of exercise and
type of equipment depends on several factors; the clients experience with exercise, time,
body type, goals and whether or not the client had or underwent surgery.

Figure 3. Stretching upper trapezius

Figure 4. Stretching thoracic area

Stretching should focus on upper trapezius and neck musculature where the tender points
typically are in the upper torso as seen in figure 3 and 4. Strengthening should focus on
strengthening the weaker rhomboids(through mid row exercise), low trap pull downs, seated
reverse flyes and targeting weaker glute medius, glute minimus and glute maximus muscles.
A simple beginning exercise is the horizontal leg press, which targets the hamstrings and
glute maximus primarily. This can be progressed to diagonal lunges, which target the weaker
glute medius and glute minimus musculature.

Figure 5. Horizontal leg press machine

Core stabilization training should focus on weaker phasic external oblique, quadratus
lumborum and multifidi. Exercises such as bridging with ball, standing trunk rotation with
cable or medicine ball, progressed to partial lunge with trunk rotation with medicine ball is
ideal. Cross training with yoga and pilates can not only improve flexibility and breathing but
core strength in multi directions and progressed as appropriate. Swimming also can serve to
compliment training due to the buoyancy principle and how relaxing it can feel.

Figure 6. Trunk rotation w/medicine ball with in place lunge

Summary:
Fibromyalgia(FM) can be devastating to deal with. Throughout my career as both a physical
therapist and personal trainer, I have treated a large amount of patients with mild, moderate
to severe fibromyalgia. I use a personalized approach treating patients with FM similarly to
training clients with FM.
Fibromyalgia is a chronic musculoskeletal pain syndrome that is associated with a wide
variety of symptoms, significantly affecting daily function, making exercise very discouraging.
Fitness professionals can make a significant positive impact on a client with fibromyalgia. It
first begins with understanding the science behind the dysfunction, listening, observing,
modifying and designing programs that are based on science. Utilize appropriate
programming and periodization training principles is fundamental. Training a client should
focus on reducing stress, improving flexibility, strengthening that is client specific and
including core training and cross training that is upbeat and delivers sound results.
Chris is the CEO of Pinnacle Training & Consulting Systems(PTCS). A continuing
education company, that provides educational material in the forms of home study courses,
live seminars, DVDs, webinars, articles and min books teaching in-depth, the foundation
science, functional assessments and practical application behind Human Movement, that is
evidenced based. Chris is both a dynamic physical therapist with 15 years experience, and a
personal trainer with 19 years experience, with advanced training, has created over 10
courses, is an experienced international fitness presenter, writes for various websites and
international publications, consults and teaches seminars on human movement. For more
information, please visit www.pinnacle-tcs.com.





REFERENCES

Bradley, L, 2009, Pathophysiology of Fibromyalgia, American Journal of Sports Medicine,

vol. 22, issue 12, pp. 1-9.
Diego, I., & Legaz-Arrese, A., 2008, Assessment of the Effects of Aquatic Therapy on
Global Symptomatology in Patients With Fibromyalgia Syndrome: A Randomized
Controlled Trial, Archive of Physical Medicine Rehabilitation, vol. 89, pp. 225-2256.
Hassett, A., & Gervirtz, R., 2009, Nonpharmacologic, Treatment for Fibromyalgia: Patient
Education, Cognitive-Behavioral Therapy, Relaxation Techniques, and Complementary and
Alternative Medicine, Rheum Disorders Clinical North America. Vol. 35, issue 2, pp. 393407.
Huser, W., et al, 2009, Treatment of Fibromyalgia Syndrome With Antidepressants: A
Meta-analysis, vol. 301, issue 2, pp. 198-209.
Huser, W., et al, 2010, Review Guidelines on the management of fibromyalgia syndrome
A systematic review European Journal of Pain, Issue 14, pp. 510.
Sanchez, A., et al., 2011, Effects of myofascial release techniques on pain, physical function
and postural stability in patients with fibromyalgia: a randomized controlled trial, vol. 25,
issue 9, pp. 800-813.