Soft Tissue Approach to Fibromyalgia
A new treatment protocol combining chiropractic with the Trigenics® technique

By Christian Guenette, BSc, DC, RTP, FIIT(c)
Canadian Chiropractor-Vol 8, No 1, February 2003

Fibromyalgia (FM) and chronic fatigue syndrome (CFS) are two major health problems which are gaining the attention of medical doctors and chiropractors. Both are known as multi-system illnesses with a significant impact on the musculoskeletal system, including widespread muscle pain and fatigue. Patients also experience various other symptoms which mimic an autonomic nervous system dysfunction. Although chiropractic theory allows us to predict that we can positively affect the symptoms associated with dysautonomia, DCs may find that adjustments alone yield limited results.

Due to the exaggerated “muscular” involvement in CFS and FM patients, I suggest that chiropractic care along with a soft tissue technique will yield better results than chiropractic alone. This article will focus on the Trigenics® soft tissue technique which is a synergistic blend of Eastern and Western manual medicine that can be used to treat any neuromuscular disorder. (1)

SYMPTOMS

According to the American College of Rheumatology, the criteria for FM includes a history of widespread pain, and more specific pain in 11 of the 18 tender point sites on digital palpation. Other systemic symptoms which may also be associated with the disease include: fatigue, disturbed sleep, restless leg syndrome, irritable bowel syndrome, irritable bladder syndrome, cognitive dysfunction, cold intolerance, dizziness, and others.

For a diagnosis of CFS the patient must have a clinically evaluated, unexplained persistent or relapsing chronic fatigue that is of new or definite onset (not lifelong), is not the result of ongoing exertion, is not substantially alleviated by rest, and results in substantial reduction in previous levels of occupational, educational, social, or personal activities. As well as concurrent occurrence of four or more of the following symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern, or severity; un-refreshing sleep; and post-exertional malaise lasting more than 24 hours. (2)

Since about 75 per cent of patients who meet the criteria of CFS also meet the criteria for FM, (3) this article consider these disorders as interchangeable.

ETIOLOGY

The cause of these conditions is unclear, however there appear to be several common ‘”triggering” events that may precipitate the onset of the symptoms. These may include viral or bacterial infection (6,7,8,9), overwhelming physical trauma (10), overwhelming emotional trauma, or the concurrent development of another disorder such as rheumatoid arthritis (11), lupus (12) or Sjogren’s (13). Others would claim that these syndromes are a result of an underlying condition, such as immune deficiency (7,14), autonomic nervous system dysfunction (dysautonomia) (15) or traumatic brain injury. (16)

TESTING AND TREATMENT

When treating FM or CFS patients, a multi-disciplinary approach is always suggested. Initial studies on chiropractic therapy alone have shown some promise (17,18,19), however given the multi-system involvement of these disorders, a more holistic approach is suggested.

However, I’ve found combining chiropractic adjustments with Trigenics® soft tissue therapy to address the musculoskeletal symptoms has shown tremendous results.

In my experience there appears to be a distribution of symptoms that are worsened with weight-bearing exercise. Running, walking or standing for prolonged periods often exacerbates the physical pain and fatigue associated with FM and CFS. Testing proprioceptive awareness and postural strength will often reveal weaknesses in both of these areas.

The initial screening procedure is done in a standing position. A standing strength test of the anterior deltoids bilaterally is an easy screening tool for postural strength. The patient stands with his/her arms extended at the elbow (arms straight), with the shoulders flexed to 90 degrees, such that the arms are in front of the body, parallel to the floor, level with the height of the shoulders. An eccentric load is applied to the distal aspect of the forearms, directed toward the floor. If the patient cannot provide immediate and adequate resistance to this load, this is considered a positive test for weak anterior deltoids bilaterally. (Fig. A.)

The patient is then tested in a seated position. (Fig.B.) If this test is also positive, then there is a primary weakness in the shoulder and upper back. If there is a positive finding standing, but the patient is strong in a seated position, then there is a secondary weakness in the upper back and shoulders due to proprioceptive weakness originating in the feet, pelvis or lower back (since the body is in the same position from the waist up in both tests).

Having the patient stand on a sample pair of orthotic inserts, we stimulate the proprioceptors located in the joints of the feet, and move the subtalar joint in the ankle more towards a neutral position (if the patient has the tendency to over-pronate, which is the most common aberrant position). If this results in a more stabilized result in the above standing test, then we may assume that there is a biomechanical instability of the metatarsal and/or longitudinal arches of the feet, and therefore prescribing custom orthotics for these patients is an important first step in creating a strong base of support for their postural system.

Then we begin using the Trigenics® procedures to ensure that the muscles of the feet and lower legs are functioning properly. Muscle testing of the tibialis posterior and anterior, fibularis longus and brevis, plus the gastrocnemius and soleus are paramount. It’s also helpful to palpate for hypertonicity in the plantar fascia, and motion palpate for proper movement and position of the subtalar joint, cuboid and navicular. A quick scan of muscle testing for lower leg dysfunction would include inversion, eversion, plantar and dorsiflexion challenges. Weaknesses in any of these areas would be an indication for the application of Trigenics® Strengthening (TS) procedures (21). Observing an abnormal static position of the foot (excessive plantar flexion, inversion, etc.), or a persistent weakness after application of the TS procedure, would indicate a need for Trigenics® Lengthening (TL) procedures (21) to help facilitate a better neutral position of the foot.

The next is the knee-pelvis. Watch for the gluteals, iliopsoas, adductors and tensor fascia latae (TFL). Challenging the patient in external and internal rotation, abduction and adduction, plus flexion and extension (of the hip), is a basic scan for pelvic stability. More specific tests may be performed for the iliopsoas and the TFL, as these are often involved in chronic postural dysfunction of the pelvis. Appropriate TS and/or TL procedures are used to effectively strengthen and balance these areas (21).

Persistent weakness of the pelvic musculature after Trigenics® applications would indicate a structural adjustment using the chiropractic technique of choice in a specific area indicated by the muscles tested.

On the lower back the erector spinae, multifidi, and quadratus lumborum (QL) muscles are primary targets for the Trigenics® treatment of these patients. Since most patients with chronic neuromuscular conditions such as FM and CFS will often have paraspinals that will go into spasm when muscle-testing these areas, static palpation for hypertonicity and contracture would be more appropriate as an indicator for appropriate TS and/or TL procedures, in addition to the necessary chiropractic adjustments. In addition to these muscles, important myopoints known as “miracle points” and “euphoric points” may be treated for their analgesic effects in these patients (22).

Higher regions of the back will include the scapular stabilizers. This is a common area of weakness in FM and CFS, in addition to any other patient that has chronic postural complaints. In particular, the rhomboids and lower mid-trapezius are most often in a lengthened, yet weakened state. This has been coined the “rhomboid decelerator dysfunction syndrome,” and has been successfully treated using the TS procedures (23).

Conversely, when the lower trapezius and rhomboids no longer function properly, the upper trapezius and levator scapulae muscles are commonly found in a facilitated and shortened state. When this happens, the scapulae are unable to be stabilized in a neutral position. Consequently, the shoulders tend to rotate anteriorly with the humerus in a more pronated position, decreasing the efficiency of the rotator cuff muscles, making them prone to strain and fatigue. If left in a “rounded shoulder” position, the pectoralis, latissimus dorsi, subscapularis and teres major muscles will all eventually shorten passively, making conditions worse and postural correction more difficult. Each of these potentially shortened muscles should be tested for proper range of motion, and stretched accordingly, preferably with the TL protocol.

The rotator cuff may also be tested, and the weakened external rotators may be assisted by the TS procedures (24). Chiropractic adjustments in the appropriate areas will facilitate proper biomechanical function in the thoracic region, which is crucial in maintaining the integrity of this area, as well as the muscles that depend upon the mechanical stability of the scapulae to function properly.

Finally, the cervical paraspinals, both anterior and posterior, are examined for proper muscular balance. These will include the suboccipital group of muscles. Once again, given the susceptibility to reactive spasm, eccentric muscle loading is usually contraindicated when the patient is more sensitive. Muscle-testing may cause spasm, and therefore thoroughly palpating these muscles and observing cervical range of motion should give the examiner sufficient information to address the musculature in this area. Most commonly affected are the upper trapezius, splenius cervicis and capitis, plus the suboccipitals and scalenes. Resetting the proper resting tone of these muscles using the appropriate TS and TL protocols (22) will allow for a more balanced and “lighter” feeling around the neck and shoulders.

The postural strength of each area of the body in a standing position will depend upon the stability of the area directly below it. Thus, the Trigenist will plan his treatments such that he or she will work from the most caudad to the most cephalad areas of the body. Knowing that all muscles will not be addressed in each treatment session (due to time constraints), working from the “feet-up” allows for the therapist to ensure that the patient’s “base of support” is always in a more balanced state, which then contributes to a stronger postural position when weight-bearing.

CONCLUSION

As a soft-tissue technique, Trigenics® is becoming well-known for its broad scope of application. It combines the benefits of acupressure, patient visualization and breathing techniques, and neuromuscular reflex physiology to optimize the resting and dynamic length-tension relationships of the muscular system to enhance proper biomechanical function of the entire neuromusculoskeletal system.

My FM and CFS patients say they feel stronger, less pain and more energy. They can perform more physical exercise allowing them to increase their strength and feel a sense of achievement and well-being. Overall it helps enhance their outlook on life.

References:

Austin AO. Trigenics. Theory 2002. The Trigenics Institute of Neuromuscular Medicine.
Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A, and the International CFS Study Group. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Annals of Internal Medicine 1994; 121: 953-959.
Goldenberg DL, Simms RW, Geiger A, Komaroff AL. High frequency of fibromyalgia in patients with chronic fatigue seen in a primary care practice. Arth.Rheum 1990; 33: 381-384.
Sigal LH. Persisting complaints attributed to chronic lyme disease: possible mechanisms and implications for management. Am J Med 1994; 96: 365-367.
Simms RW, Ferrante N, Craven DE. High prevalence of fibromyalgia syndrome (FMS) in human immunodeficiency virus type 1 (HIV) infected patients with polyarthralgia. Arth.Rheum 1990; 33(9): S136.
Barkhuizen A, Schoeplin GS, Bennett RM. Fibromyalgia: a prominent feature in patients with musculoskeletal problems in chronic hepatitis C: a report of 12 patients. J Clin Rheum 1996; 2: 180-184.
Leventhal LJ, Naides SJ, Freundlich B. Fibromyalgia and parvovirus infection. Arth.Rheum 1991; 34: 1319-1321.
Buskila D, Neumann L, Vaisberg G, Alkalay D, Wolfe F. Increased rates of fibromyalgia following cervical spine injury. A controlled study of 161 cases of traumatic injury. Arth Rheum 1997; 40: 446-448.
Urrows S, Affleck G, Tennen H, Higgins P. Unique clinical and psychological correlates of fibromyalgia tender points and joint tenderness in rheumatoid arthritis. Arth Rheum 1994; 37: 1513-1515.
Bennett R. The concurrence of lupus and fibromyalgia: implications for diagnosis and management. Lupus 1997; 6: 494-498.
Bonafede RP, Downey DC, Bennett RM. An association of fibromyalgia with primary Sjogren’s syndrome: a prospective study of 72 patients. J.Rheumatol 1995; 22: 133-135.
Harrison, R. Understanding Chronic Fatigue & Understanding Fibromyalgia. www.gethealthyagain.com.
Martínez-Lavín M. A Novel Holistic Explanation for the Fibromyalgia Enigma: Autonomic Nervous System Dysfunction. Fibromyalgia Frontiers 2001; 10(1).
Author unknown. Post-Traumatic Fibromyalgia: A New Paradigm. Fibromyalgia Frontiers (Sept/Oct 1999 & July/Aug 1998). www.fmpartnership.org.
Blunt KL, Rajwani MH, Guerriero RC. The effectiveness of chiropractic management of fibromyalgia patients: a pilot study. J Manip Physiol Ther 1997; 20(6): 389-399.
Hains G, Hains F. A combined ischemic compression and spinal manipulation in the treatment of fibromyalgia: a preliminary estimate of dose and efficacy. J Manip Physiol Ther 2000; 23(4): 225-230.
Berman BM, Swyers JP. Complementary medicine treatments for fibromyalgia syndrome. Baillieres Best Pract Res Clin Rheum 1999; 13(3): 487-492.
Austin AO. Trigenics. Module II – Extremity Procedures 2002. The Trigenics® Institute of Neuromuscular Medicine.
Austin AO. Trigenics. Module I – Spine and Thorax Procedures 2002. The Trigenics® Institute of Neuromuscular Medicine.
Pisarek S. Trigenics: A new paradigm in soft tissue therapeutics. Canadian Chiropractor 2001; 6(1): 18,41.
Guenette C. Treatment of rotator cuff tendonitis: An application of the Trigenics® technique. Canadian Chiropractor 2002; 7(1): 10, 12-13.