Fibromyalgia Treated by Biofeedback
by Desiree Morgan

	Fibromyalgia Syndrome, FMS, a debilitating condition affecting millions of 
people, is characterized by chronic wide-spread pain, sleep disturbances, fatigue and 
depression, though these are just a few of the symptoms.  Goldenberg, author of 
Fibromyalgia, explains that FMS has been designated as a syndrome because it has no 
known cause or defined pathology (25).  Because sufferers experience such a wide 
variety of symptoms, treatment modalities are equally varied.  The American College 
of Rheumatology (ACR) has only recently developed standards for determining a 
diagnosis for FMS, beginning with a process of elimination for other known 
conditions with similar symptoms, such as arthritis.  In 1990. The ACR established 
criteria for a definitive diagnosis (209): 
1.	History of wide-spread pain ( a minimum of three months):  [in]
	all four body quadrants, as well as the axial skeleton - cervical spine or anterior chest 
or thoracic spine or lower back  - AND - 
2.	Pain in eleven of eighteen tender points sites on digital palpitation: force 
4kg. located at those specific points on the body (bilateral).  (ACR 1990)
		Goldenberg emphasizes an important fact about these tender points: 
Characteristic tender points where muscles attach to bones are the only helpful 
physical finding in FMS.  [They] do not represent muscle inflammation or structural 
damage (15). 	The percentages of FMS suffers within the United States are 
surprising.  According to  Goldenberg:  FMS affects 3% - 5% of women and 1% - 2% 
of men, women outnumbering men eight to one, totaling approximately 4 million 
people in the United States; further, among sufferers, the percentage rises to 7% of 
women ages 60 B70 (9).  Goldenberg adds that the prevalence in England, Australia, 
Netherlands, Sweden, Norway, Germany, Italy, Israel and Mexico are comparable to 
U. S. statistics (9).  Staud and Domingo's statistics agree: approximately four million 
Americans, primarily adult women, most of whom are in their reproductive years are 
affected. 
	Treatment of FMS is generally symptomatic (Okifuji and Turk 130) and often 
highly individualized, following a clear understanding of an individual=s symptoms 
(Goldenberg 10).  Pain - chronic, acute, and wide-spread - is the greatest complaint of 
FMS patients.  Pain processing in the brains of FMS patients, the psychological 
affects of being in constant pain, and successful pain management are, in fact, the 
major topics of Fibromyalgia, All About Fibromyalgia, and innumerable medical 
studies.  In 1998, the brain's method of processing pain was studied by Bradley, et al. 
as reported in Arthritis Rheumatology and summarized by Staud and Domingo.  
Bradley=s study suggests chronic pain states are associated with reduced thalamic 
blood flow (212).  A recent, more detailed study of pain processing was reported in 
Arthritis and Rheumatism, May 2002, as explained in Harvard Women's Health Watch: 
When FMS patients received the amount of pressure they considered to be painful, 
blood flow increased in 12 brain regions, [whereas] the same pressure activated only 
two locations in the brains of control subjects (2).  In addition, this study states that 
FMS sufferers required half of the pressure required by the control participants to be 
considered painful (2).  This study of the mechanics of brain function suggests that a 
biological mechanism contributes to FMS suffers= increased sensitivity to pain (2).  
Therefore, the study explains that FMS sufferers experience and interpret pain more 
readily than non-FMS sufferers B twice as readily, and suggests a biological factor.  
	The 2002 study and report offer an additional consideration:  Differences in 
the areas of blood flow in the brain proved significant. Blood flow to the anterior 
cingulated increased only in the control group which suggests that FMS sufferers are 
so used to chronic pain that they respond less emotionally to it that people 
unaccustomed to pain.  Ironically, however, according to McBeth, et al. in their study 
of risk factors for pain, pain is associated with distress, affecting sufferers 
psychologically:  Persistent chronic widespread pain was strongly associated with high 
psychological stress and fatigue (95-101).  The relationships between the myriad of 
FMS symptoms, including the effects of chronic pain and psychological distress, and 
the mechanical and chemical contributors to symptoms are intricate and complicated, 
and as a result, are challenging to manage.
	According to Wallace and Wallace, understanding the contributing 
exacerbating factors is a key to applying appropriate management modalities (119).  
Currently, contributing risk factors vary among reports; Staud and Domingo 
summarize: previous history of emotional stress, infection, physical trauma, and 
female gender contribute (209).  Types of emotional stresses range from poor coping 
skills to childhood sexual abuse, and a history of abuse (209).  Wallace and Wallace 
clarify: Severe emotional stress or trauma frequently triggers and aggravates [FMS] 
(19).  Okifuji and Turk add: Many patients with FMS report that both physical and 
psychological stress exacerbate their symptoms (133).  Goldenberg's report of 
Harvard Medical School's 1998 study of the brain=s hormonal response to stress 
concurs.  Goldenberg explains that E. N. Griep, et al., including Dr. Gail Adler, tested 
15 of his FMS patients to check the status of their HPA axis and found that the 
patients had a weaker response of their stress axis compared to healthy controls (13).  
Goldenberg explains that this report is an important part of the Fibromyalgia puzzle, 
and may explain causes of fatigue, joint pain, muscle pain, sleep disturbances, 
cognitive disturbances, and gastrointestinal complaints (13).  Goldenberg concludes 
the FMS chemical issue simply: It is logical to think that many of the symptoms 
involved in [FMS] could be related to alterations of this stress-activated hormonal 
system@ (13).  Weissbecker, et. al. agree:  Fibromyalgia has been characterized as a 
>stress-related > disorder (297).  Therefore, Okifuji and Turk advise: 
Psychophysiological interventions, focusing on normalization of the stress reactivity, 
have potential to fill in important missing pieces of the [treatment] puzzle (137). 
Easing pain and managing stress, therefore, are critical factors to helping a 
FMS sufferer.  Weissbecker, et. al. promote Stress management skills (299);  
Goldenberg, and Wallace and Wallace agree and promote biofeedback as a viable 
relaxation technique to reduce stress.  Goldenberg: AStress responses can be modified 
by relaxation techniques including biofeedback@ (118 - 119).  Wallace and Wallace: 
Biofeedback works ... to achieve relaxation and pain relief (143); they add: it is no 
surprise that recent studies have proven that biofeedback can be effective in some 
Fibromyalgia patients (232).  A study by Flor and Birbaumer clarify: AOverall, the 
data of this study indicate that EMG-BFB may be a superior treatment method for 
patients with chronic musculoskeletal pain who are not severely impaired by their 
pain problem (658). 
As individual sufferers require individual treatments, Goldenberg and Wallace 
and Wallace suggest further modalities: anti-depressants, anti-inflamatories and 
analgesics, sleep medications, anxiety medications, exercise and physical therapy, 
lifestyle adaptations, counseling, and [additional] non-medical alternatives, such as 
acupuncture, massage, and meditation (Goldenberg 120-150).  Goldenberg 
summarizes coping with FMS frankly: Auntil a root cause is found, patients are 
encouraged to be as proactive as possible in self-management: (130-139).  A study of 
chronic pain by Burns et al. underlines the most broad approach: The way in which 
chronic pain is perceived and handled influences psychological and physical 
adjustment@ (81).  A 1993 study by Pastor, et al. states: AFMS patients believed 
that their symptoms depended on uncontrollable events and that they could not 
influence their disease by themselves (484-489).  This, then may reveal a key to 
treating FMS patients - an individual=s belief in her/his ability to positively affect 
self-management.  In fact, the Burns et. al. study offers this encouragement: The 
severity and debilitating effects of chronic pain should be reduced as a patient comes 
to view pain and discomfort less as an overwhelming catastrophe and more as a 
controllable and manageable condition. Thus, Burns et. al. continue, Aa presumed 
active and critical ingredient of multidisciplinary programs with cognitive-behavioral 
therapy is the process of cognitive change (81).  An FMS individual=s involvement in 
behavioral therapies, therefore, affects positive change in a sufferer=s mental and 
physical health.  In fact, Flor and Birbaumer=s study found reassuring results:  At the 
six and 24-month follow-up, only the biofeedback group maintained significant 
reductions in pain severity, interference, affective distress, pain related use of the 
health care system, stress-related reactivity of the affected muscles, and an increase in 
active coping self-statements@ (653).
			References:
The American College of Rhuematology:  http://www.rheumatology.org
Burns, J. W. & Kubilus, A., Bruehl & Harden, N., Lolfand, K. ,  Do changes in 
cognitive factors influence outcome following multidisciplinary treatment for chronic 
pain? A cross-lagged panel analysis.  Journal of Consulting and Clinical Psychology 
2003;71:81-91.
	Flor, H., Birbaumer, N.  Comparison of the efficacy of Electromyographic 
biofeedback, cognitive-behavioral therapy, and conservative medical interventions in 
the treatment of chronic musculoskeletal pain.  Journal of Consulting and Clinical 
Psychology 1993;61:653-658.
	Goldenberg, D. L.  Fibromyalgia.  New York:  The Berkeley Publishing Group, 
2002. 
	McBeth, J., et al.  Risk factors for persistent chronic widespread pain:  a 
community-based study.  Rheumatology 2001;40:95-101. (via The New England 
Journal of Medicine website.)
	The New England Journal of Medicine:  http://content.nejm.org
	Okifuji, A. , Turk, D. C.  Stress and psychophsiological dysregulation in 
patients with fibromyalgia syndrome. Applied Pschophysiology and Biofeedback 
2002;27:129-141.
            Oxford Journal Online B Rheumatology: 
http://www.rheumatology.oupjournals.org
	Pastor, M. A., et al.  Patient' beliefs about their lack of pain control in primary 
fibromyalgia syndrome.  The British Journal of Rheumatology 1993;32:484-489. (via 
The New England Journal of Medicine webcite)
	Robb-Nicholson, C.  Fibromyalgia pain visible on brain scans.@  Harvard 
Women's Health Watch, 2002;10:2. 
	Staud, R., Domingo, M.  A Evidence for abnormal pain processing in 
fibromyalgia syndrome. Pain Medicine 2001;2:208-215.
	Wallace, D., Wallace, J.  All About Fibromyalgia.  New York:  Oxford 
University Press, 2002.
	Weissbecker,I., et. al., Mindfullness-based stress reduction and sense of 
coherence among women with fibromyalgia.  Journal of Clinical Psychology in 
Medical Settings. 2002;9:297-305.     
	Wolfe. F., et al.  The Amercian College of Rhuematology 1990 Criteria for the 
Classification of Fibromyalgia:  Report of the Multicenter Criteria Committee. 
Arthritis and Rheumatism 1990;33:171.

Copyright © 2003, Dr. John M. Morgan, All rights reserved - This page last edited April 23, 2003
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