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• Imaging studies reveal that fibromyalgia patients are hypersensitive to all sensory stimuli, including sensory pressure and auditory, heat, cold, and electrical stimuli.

• Fibromyalgia patients demonstrate an increased sensitivity, or gain, to painful pressure.

• Those with fibromyalgia show elevated cerebrospinal fluid levels of pronociceptive neurotransmitters such as substance P, gluta-mate, nerve growth factor, and brain-derived neurotrophic factor and decreased levels of serotonin, norepinephrine, and dopamine.

• CSS patients show a strong genetic and familial predisposition.

• CSS patients do not experience significant pain relief with endogenous opioids.

• CSS patients may possess a metabolic or nutritional deficiency.

• A multifaceted approach to treatment should be pursued, consisting of pharmacological therapy, education, mild to moderate exer-cise, cognitive behavioral therapy, and PRT.

My clinical experience with fibromyalgia patients suggests that many of them fall some-where on the somatic dysfunction spectrum with varying degrees of symptomology and impairment.

Moreover, many CSS patients report an early trauma in life that caused what they believe is a spreading of pain throughout the body. However,

some patients also report an underlying disease condition that they believe may have caused the condition, such as Lyme disease or irritable bowel syndrome. Typically, CSS patients fall into one of two prognostic categories: those whose somatic dysfunction resolves with treatment and those whose condition does not resolve but their quality of life does with treatment. The disease or somatic condition of people in the latter category often does not resolve because of an underlying trigger or disease condition that cannot be treated, such as an autoimmune dysfunction. Therefore, when working with CSS patients or those diagnosed as having fibromyalgia, clinicians should perform a thorough investigation into the factors that may have precipitated the condition as well as its maintenance.

CLINICIAN THERAPEUTIC INTERVENTIONS

Fibromyalgia

• Perform a thorough history and diagnostic workup to identify causative or perpetuating factors for the patient’s condition.

• Consider requesting a blood chemical profile to identify any nutritional deficiencies.

• Assess and document the patient’s quality of sleep and pain and fatigue levels throughout the assessment and treatment process.

• Use a multimodal treatment approach con-sisting of manual, behavioral, nutritional, and pharmacological therapy coupled with progressive therapeutic exercise and stress management interventions.

• Assess and treat the patient’s somatic dys-function according to the area of concen-tration and the level of intensity. However, also consider the 18 designated fibromyalgia tender point locations identified in the 1990 ACR criteria as key areas for treatment.

• Palliative modalities such as heat, cold, and light massage may be helpful for those who cannot tolerate deep manipulative stimuli.

For patients who cannot tolerate these pal-liative modalities, focus on the application of PRT until pain and sensory amplifica-tion has diminished; then implement these complementary modalities for further pain control and healing.

Summary

Although PRT is a safe, nonpainful, and passive modality for the treatment of somatic dys-function, each patient and special population requires modifications to the application of the therapy. More important, internal and external factors must be taken into account such as age, level of physical activity, surgical history, body composition, disability, and underlying disease or comorbidities because they may affect the assessment and treatment of the condition. Some underlying disease states may not be remedied through therapeutic, surgical, or pharmacological interventions, but many of the somatic conditions discussed in this chapter possess underlying triggers or mechanisms that, if addressed, will help to resolve the patient’s condition. A prime example is obesity. It is accepted that being overweight or obese perpetuates a host of injury and disease conditions (Ellulu et al. 2014). For example, the obese are at greater risk for the development of knee osteoarthritis (Blagojevic et al. 2010), type 2 diabetes (Toivanen et al.

2010), headache (Chai et al. 2014), breast cancer (Jemal et al. 2011), rheumatoid arthritis (Finckh and Turesson 2014), and chronic pain (Vincent et al. 2012). If the therapist can help the patient address his obesity, then many of the associated conditions will also be addressed.

However, by the time chronic pain patients seek treatment, they often possess widespread pain and a poor quality of life, typical of the ACR 1990 definition of fibromyalgia. These patients are often in too much pain to engage in exercise, even of light intensity, as a result of worn-out joints, pain, weakness, or fatigue. The balancing act the clinician must perform is to reduce the patient’s somatic dysfunction with PRT and complementary therapies while addressing underlying disease(s) and trigger(s) without further aggravating the condition.

The list of special populations that may benefit from PRT presented in this chapter is not exhaustive. However, all typically show signs of pain and sensory amplification resulting from central sensitization that negatively affects their quality of life. What may first be a simple ankle sprain may over time develop into fibromyalgia, resulting in widespread pain, fatigue, and sleep disturbance. The clinical presentation of fibromyalgia may be one of many somatic dysfunctions on a spectrum of chronic pain disorders that share a similar pathogenesis among all populations and age groups irrespective of diagnosis. With this in mind, clinicians must address somatic dysfunction early and correct structural and mechanical abnormalities as well as precipitating factors such as nutritional, hormonal, and physical activity issues to prevent somatic dysfunction from becoming widespread.

PART II

PRT Techniques by