Fibromyalgia Questions and Answers For The Massage Therapist

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© 2010 Susan Fisher Anderson All Rights Reserved

© RODUC©O
© J Fibromyalgia. Even the name evokes questions. hose questions remain
n long after the diagnosis is delivered. hey live and fester in the mind of the
t
patient, her family, and even her doctor on many levels. He wonders whether,
r
o in light of the fact that there are no diagnostic tests which confirm his diagnosis,
d he has made the right call. Or has he missed something? Has a clue escaped
u
his notice? Was there something else he should have considered before
c
t delivering to his patient what amounts to a life sentence of pain?
i
o
n
© J For her, the patient³and
and 80% to 90% of Fibromyalgia patients are
n women
women³it is finally an answer. ©t·s a reason for the pain she has been
t
experiencing, for perhaps years and years, with no help and nothing to
r
o indicate that the pain is anywhere other than ¶in her head.· But it·s also, finally,
d a real ¶medical diagnosis· with a fancy medical title: Fibromyalgia Syndrome
u
(FMS).
(FMS)
c
t
i
o
n
© J She has, by this point½tried everything the pharmacy has to offer her, both
n prescription and over-the-counter, often without anything but the slightest
t
improvement½and that short-
short-lived
r
o J She·s been to several physicians, probably, and at least one has referred
d
her to a psychiatrist. Every test has been ¶normal· and she·s nearing the
u
c conclusion that maybe she is crazy.
crazy And it·s been ten years (average, from the
t onset of her symptoms to diagnosis )«
i
o
n
© J Her family has grown weary of the constant look of distress on her face,
n feeling uncertain that it is pain, and not their own failures which cause that
t
r look of sadness
o
d
J hey have tried hard to be supportive and encouraging, while treating
u her with kid gloves and tiptoeing around in an attempt to avoid her on those
c inevitable ¶bad
bad days
days.·
t
i
o
n
© J So, as she leaves the doctor·s office with the packet of pamphlets in her
n
hand,, is she really any closer to an answer to her pain than when she walked
t
r in?
o
d J Does she understand her illness, how it happened, why it happened to her,
u and how to approach and conquer it?
c
t
i
o
n
© J Drobably not, because most medical professionals, doctors included, are
n
in the dark regarding the etiology and management of this baffling
t
r condition.
o
d
u
c
t
i
o
n
[ooking Ahead«
here has been much recent research What we will tackle in this course are
aimed at answering these questions. ©n the questions, and hopefully some of
this course, we·ll examine some of these the answers to the management of this
research projects and their conclusions illness. We·ll talk about how you, as a
in an effort to understand what is massage therapist, can help these
happening to these ladies who often clients whose conditions may change
turn to us, massage therapists, for help. not only from session to session, but
from day to day and even hour to hour
within those ¶good· and ¶bad· days.
[ooking Ahead«
Dealing with a FMS patient can be ©n fact, your assistance may be the
extremely challenging
challenging, but they are determining factor which will help your
also one of the most rewarding markets client retain her sanity as she lives out
you will find. her life sentence of pain.
hese are people who really need you
(probably forever), and whose
condition may be dependent on you to
manage its ups and downs.

Code [etter
umber One!
hroughout the lesson

you will come across
five letters. Write
them down, they form
a code you will need
to complete the
course
DAR ©: F©BROMYA[ ©A DEF© ED
Dart ©: Fibromyalgia Defined
Dart ©
F
J he first issue for a massage therapist providing services to a client with
i health issues is an understanding of the client·s condition. For FMS, this is harder
b than one might think. FMS is an often misdiagnosed,
misdiagnosed little-understood condition,
r D
even for doctors and other health professionals.
o e
m f
y i
a n
l e
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i
a © 2010 Susan Fisher Anderson All Rights Reserved
Dart ©
F
J he term, fibromyalgia, comes from the reek terms, fibro-referring to
i fibrous tissue, @ -meaning muscle, and meaning pain. So the term,
b literally, means pain coming from muscle and fibrous tissue. his could mean
r D
any type of muscle pain. However, this term is used for a specific set of
o e
m f symptoms, classically found together, defining Fibromyalgia Syndrome.
y i
a n
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i
Dart ©
F J here are three which all must be

i present for a FMS diagnosis, with a
b broad range of other symptoms which
r D
o e often are combined with those three
m f symptoms. he ¶B©
B© HREE· are: pain,
y i sleep disturbance and fatigue.
a n
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i
he Big hree: Dain
Dart ©
F
J ©n a FMS patient, pain is widespread Upper Upper
Right
[eft
i and often diverse. ©t also, by definition,
b presents in all four quadrants of the
r
[ower [ower
D
body: upper right, upper left, lower [eft Right
o e
m f right, lower left.
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a n
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i
he Big hree: Dain
Dart ©
F
J A positive symptom of tenderness in 12 of the classic 18 ¶tender points· is
i a major classifier of the problem as FMS, as opposed to other diagnoses which
b involve pain. We will be looking at these in a moment.
r D
o e
m f
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he Big hree: Dain
Dart ©
F
J ©t stabs her in the neck, grates in her shoulder joints, grabs her back and
i hips and won·t let go. ©t throbs in her elbows and knees.
b
r ©
D J t keeps her awake at night, and shoves its way into the front of her
o e thoughts at all hours of the day and night.
m f
y i J S
he can·t escape it, can·t drug it away³she·s tried, and nobody seems to
a n be able to give her a reason for it.
l e
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i
he Big hree: Dain
Dart ©
F
J Finally, in desperation
desperation, and with a little trepidation,
trepidation she makes an
i appointment with a rheumatologist.
b
r D J S
he is terrified of the diagnosis. Maybe it·s rheumatoid arthritis, and with
o e the pain will come a gradual crippling deformation of her joints. And the
m f prospect of complete loss of the use of her hands.
y i
a n J M
aybe it·s just ordinary Arthritis. But, isn·t she too young for that?
l e
g d
i
he Big hree: Dain
Dart ©
F
J And if it·s not that maybe it·s muscular.
i
b
J Droblem is, she can·t remember any physical activity that brought it on. She
r D didn·t hurt herself, had a fall, a traffic accident. Well, there was that accident,
o e but that was months or years ago. Surely it couldn·t be connected to that after
m f all this time?
y i
a n J One by one she counts off all the possibilities,
possibilities trying to fit her symptoms into
l e
the narrow range of a particular, defined, disease state.
g d
i
he Big hree: Dain
Dart ©
F
J She is struggling for answers to what it ©S©S, not what it ©S ·½she·s had plenty
i of that by this time.
b
r D J A
nd for many FMS sufferers, the diagnosis is many, many months³or
o e years³in coming. he average is 10 years, E YEARS of pain without knowing
m f why or how to get rid of it.
y i
a n
l e
g d
i
he Big hree: Dain
Dart ©
F
J According to Wikipedia: 1
i

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@
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m f
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i
a 1www.wikipedia.com/fibromyalgia
he Big hree: Dain
Dart ©
F
J According to Wikipedia:
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he Big hree: Dain
Dart ©
F
J So here she is. She hurts ©t comes and goes½but never completely
i disappears.
b
r D J S
ome days are worse, depending on whether it·s cold outside, or muggy, or
o e there·s a storm coming. Her family calls her ¶the human barometer· and it·s true,
m f she feels worse³much worse³on days when the weather is about to change.
y i
a
l
n J H
er headache is always present, like an unwelcome houseguest. ©t blurs her
e
vision and commands her attention, no matter what else is happening in her life.
g d
i Always½always, is the pain.
he Big hree: Dain
Dart ©
F
J ©n FMS, the pain is usually ¶widespread
widespread· meaning there is pain in all four
i quadrants of the body.
b
r D J
his pain is often identified by palpation of the classic eighteen ¶tender
o e points·
points of which eleven need to be positively identified as ¶tender· for the
m f diagnosis of FMS to be confirmed.
y i
a n
l e
g d
i
he Big hree: Dain
Dart ©
F [eft side Right side

above the above the Upper quadrant pain
i waist waist includes the upper
Upper Upper
b [eft Right extremity, the arm and
r D shoulder.
o e
[ower [ower
m f [eft Right [ower quadrant pain
y i [eft side Right side includes the lower
below the below the extremity, the leg
a n waist waist and hip.
l e
g d
i
he Big hree: Dain
Dart ©
F J ©n addition, the pain and tenderness of FMS is characterized as heightened

i sensitivity.
sensitivity
b
r D J M
ost massage therapists have run across a client who complains of
o e discomfort or too much pressure, when the therapist is thinking, ¶©·m
©·m barely
m f
y
touching her.·
her his hypersensitivity is classic in FMS sufferers and needs to be at
i
a n the top of the therapist·s mind when dealing with such a case.
l e
g d
i
he Big hree: Dain
Dart ©
F © @

i !

b
@ ©
r D
o e
m f
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a n
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i
he Big hree: Dain: Substance D
Dart ©
F
J Recent studies indicate that FMS patients often have an excess of
i ¶Substance D· in their bodies, even as much as double the level present in
b healthy subjects. 2
r D
o e J S
ubstance D is a mysterious neuropeptide found only in the brain and
m f spinal cord.
cord ©t appears to streamline the brain·s ability to sense pain signals
y i
a n
sent from the body. ©n fact, the
the Substance D level, the more efficient
l e the person·s ability to register pain stimuli.
g d
i 2Mc©lwain,H.H. and Bruce, D.F, he
Fibromyalgia Handbook, 3rd ed., Henry
a Holt and Co., ew York, Y, 2003, p. 17. © 2010 Susan Fisher Anderson All Rights Reserved
Dart ©
F
J First discovered in 1931,
1931 Substance D

i seems to be a factor in reconciling the
b body·s response to stress and anxiety as

r D

well as enhancing the pain sensation.
sensation
o e
m
y
f J
i
O
ther bodily functions upon which

a n
Substance D has an effect are connected

l e to sympathetic nervous system activities
activities:

g d
i
Dart ©
F J he increase in Substance D present in FMS sufferers may account for many
i of the associated secondary symptoms frequently presenting in clients. (We·ll
b discuss secondary symptoms a little later.)
r D
o
m
©
e J t definitely contributes to the client·s sensation of pain. We all have had
f
y
clients who seem ultra-sensitive to pressure.
i
a
l e
©
n J n fact, in encountering such a client, you may be the first medical
g d professional to suspect Fibromyalgia as a cause of her hypersensitivity to pain.

i
Dart ©
F @ ?

i
b
r D
o e
m f
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a n
l e
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i
Dart ©
F © @

i
b
r D
o e J ©f you suspect something of which your client might not be aware, your best
m f course of action is to refer her to a physician who can make a proper
y i
a n
diagnosis. his is to your benefit, since such a diagnosis might make your
l e services covered under your client·s major medical insurance.
g d
i
he Big hree: Dain: Serotonin
Dart ©
F
J ©n addition to increased levels of Substance D, there also appears to be a
i reduction of the neurotransmitter, serotonin.
serotonin
b
r D J
his vital chemical promotes the feeling of well-
well-being
being.
o e
m f

J his neurotransmitter is made from tryptophan and is a major factor in our
y i feelings of being happy.
a n
l e
g d
i
Dart ©
F
J Clinical depression occurs when there are chronic and clinical serotonin
i deficiencies, and many anti-
anti-depressants target this deficiency, not to
b chemically increase levels, but rather to prevent the body·s metabolism or
r D
uptake of serotonin which reduces its levels.
o e
m f
y i
a n
l e
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i
Dart ©
F
J ©n the clinically depressed, low levels of serotonin manifest as anxiety,
anxiety fear
fear,
i insomnia hypersomnia (sleeping too much, increased or decreased appetite,
insomnia,
b and fatigue.
fatigue
r D
o ©
e J n a FMS patient, reduced serotonin levels make her feel hopeless,
hopeless tired
tired,
m f and³note the insomnia effect
effect³
³it may contribute to sleep disturbances which
y i
a n
we·ll discuss shortly.
l e
g d
i
Dart ©
F
S J hese lowered levels of important neurotransmitters appear, in some
ie studies, to be stress-
stress-induced
induced.
br
r oD J ©n some cases there is a genetic predisposition to serotonin deficiencies and
o e Substance D excess.
mt f
yo i
an n
l e
gid
in
he Big hree: Dain: ender Doints
Dart ©
F J And the difficult thing about dealing with FMS is that the client·s perception
i of pain is very unpredictable.
unpredictable
b
r ©
D J t can change from session to session, and from location to location on the
o e client·s body.
m f
y i J
he therapist should be particularly aware of the classic ¶tender point·
a n locations, since the client will often feel the most discomfort in those areas.
l e
g d
i
he Big hree: Dain: ender Doints
Classic ender Doint [ocations:
Dart ©
F
i 1. Dosterior neck
b 2. Anterior neck
r D 3. Upper rapezius
o e 4. Upper Scapula
m f
y
5. Upper Chest
i
a n 6. Elbow Crease
Back
l e 7. Sacroiliac joint
g d 8. [ateral high
Front
i 9. Medial Knee
a http://www.coloradofibromyalgia.com
he Big hree: Dain: ©nflammation
Dart ©
F
J When we talk about pain, we also usually talk about inflammation.
inflammation ©t
i almost always accompanies, and is a source of pain.
pain
b
r D J B
ut, in a FMS sufferer, one of the most interesting factors is the [ACK of
o e inflammation. Hence, the problem seems to be originating in the nervous
m f system.
y i
a n
l e
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i
Dart ©
F
J Derhaps it·s a chemical reaction that sensitizes the nerves like the presence of
i inflammation does.
b
r D
J Why so much discomfort is present without inflammation is a mystery and yet,
o e when pain is described, often the first course of action for a physician is
m f prescribing pain medication, often anti-inflammatories., (Also known as SA©DS-
y i on-Steroid Anti-©nflammatory Drugs)
a n
l
g
e J
d
Y
et, in the absence of a proper diagnosis of FMS and testing to confirm the
i presence of inflammation, the administration of ¶anti-inflammatory· medications
a falls far short of solving the problem. © 2010 Susan Fisher Anderson All Rights Reserved
Dart ©
F
J For some, when inflammation is an issue, these drugs can be helpful. But,
i unknown to many patients, most of these medications must be taken consistently
b for at least 14 to 30 days before the serum level of the drug in the
r D
bloodstream is adequate to provide an anti-inflammatory effect. Rarely does
o e
m f this information accompany the prescription. Drior to the end of this 30 day
y i period, the client may feel some relief, but it is usually because of their
a n
analgesic effect (pain relief) not as anti-
anti-inflammatory.
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i
Dart ©
F
J his is a fact for most SA©DS including aspirin,
aspirin Excedrin (aspirin +
i caffeine), ibuprofen (Motrin), naproxen
naproxen(Aleve), and others.
others
b
r D
J While the pain-relieving properties may appear quickly after the pill is
o e swallowed, the actual anti-inflammatory properties don·t come until after at
m f least 2 weeks to 30 days of regular, daily use.
y i
a n J
hey also can have a disastrous effect on the stomach, especially with large
l e doses and prolonged use.
g d
i
Dart ©
F
i
J So, the lady in question finds herself popping pill after pill,
pill day after
b
day½which frequently do nothing more than extend the misery½without effect.
r
o
D
e
J Can you imagine taking medication three or four times a day without
m f much change for a month?.. At least
y i
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he Big hree: Dain
Dart ©
F

i
@

b

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o e
@

@ @

m f
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[ooking Ahead« he Big hree
Dart ©
F
i J So the first of the three
b necessary symptoms for a
r D fibromyalgia diagnosis is pain.
o e ext we will cover the second:
m f S[EED D©SURBA CE.
y i
a n
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Code [etter
umber wo!
he Big hree: Sleep Disturbance
Dart ©
F
J his is a very interesting aspect of FMS. ©n fact, early studies indicated that
i FMS pain symptoms could be reproduced in young, healthy college students
b merely by depriving them of deep,
deep non-
non-REM sleep.
sleep
r D
o e J H
owever, unlike the healthy college students in that study²whose symptoms
m f resolved when they satisfied their sleep deprivation²in an FMS patient, the sleep
y i disturbance becomes a major cause of her problem.
problem
a n
l e J A
s more and more is learned about this baffling condition, the true impact of
g d sleep disturbance becomes apparent.
i
Dart ©
F
J Here·s how it could present in your client:
i O She·s bought a new mattress, maybe more than one, but still she can·t sleep.
b
r D O he tiniest noise jostles her awake from the light sleep state she may have
o e finally achieved after hours and hours of watching , reading, playing
m f solitaire on the computer, until she finally drops off.
y i
a n O hen, the snoring of her spouse of the horn of the late-night train jolts her
l e awake again, not necessarily alert. Sometimes she wonders if she·s ever
g d
i completely alert, even in the middle of the day. And the process starts again.
Dart ©
F
J Maybe she·s abandoned her attempts at sleep and retreated to a hot
i bathtub. Some nights that relaxes her enough that sleep will come soon. But, not
b wanting to wake her spouse by running the tub, she avoids it until a last
r D
resort. She hates to wake him. He·ll ask how she·s feeling. And she·s tired³so
o e
m f very tired³of the same old answer, 0©·m hurting She loves it that he cares, but
y i she also knows it drives him crazy to be unable to fix it or even to help her in
a n any way.
l e
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i
Dart ©
F
J She·s tried drug after drug½in all sorts of combinations
i
b
J Elavil (amitriptyline), a prescription antidepressant designed to help
r D restore sleep patterns, Melatonin, a natural chemical to help restore her sleep
o e patterns. Aspirin, which makes her ears ring. ©buprofen, naproxen, which upset
m f her stomach, flexoril, which relaxes EERY muscle she owns, and yet nothing
y i
a n
touches the source of the pain
l e
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i
Dart ©
F
J You may ask how © know so much about how a FMS patient thinks and feels.
i ©·ve just described for you the first ten years of my own battle with this strange
b bedfellow, before © was finally diagnosed. (And most of the 30 years since my
r D
diagnosis.) ©·ve taken so much ibuprofen that ©·m now highly allergic to it.
o e
m f
y i
a n
l e
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i
Dart ©
J ot every FMS patient experiences the same symptoms, or progression, as
F
i © have. For some, pharmaceuticals are very effective.
b
r D J Your clients· experiences may be very different
o e
m f
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a n
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[ooking Ahead« he Big hree
Dart ©
F
i J ext we will cover the last of
b the main symptoms: FA© UE.
r D Well, wouldn·t you feel tired if you
o e didn·t get any sleep?
m f
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he Big hree:
hree: Fatigue
Dart ©
F
J he fatigue that FMS sufferers feel is often debilitating.
i
b
J ©t·s not just the ¶© need a nap· sort of fatigue that lots of people experience
r D in the ¶afternoon slump· period. ©t·s more than the normal drowsiness that hits
o e us all when the parasympathetic nervous system kicks in after a heavy meal.
m f o, it·s the ´© can·t drag myself off the couch to fix a meal or start a load of
y i
a n
laundry or play with my kidsµ sort of fatigue. ©t·s the kind of fatigue that
l e wraps her in a lead blanket and refuses to let go.
g d
i J And with the fatigue comes the pain.
he Bi hree:
hree: Fati ue
Dart ©
F J ©t·s often a vicious cycle: he can·t slee

i ecause of the ain
an not slee in akes
the ain orse .
r D
o e
f
y i
a n he ore she can·t he ore she hurts,
l e slee , the ore she the ore she can·t
hurts. slee an
i
a
© 2010 usan Fisher An erson All Rihts Reserve
he Big hree:
hree: Fatigue
Dart ©
F
J ©t·s important to note here that it is not a total lack of sleep at issue, but
i the fact that constant awakening diminishes deep, restorative non-REM sleep.
b
r D J S
leep studies of such clients show awakenings of several dozen per night.
o
m
e
f
S
J o even when she wakes in the morning, she doesn·t feel rested. And the
y i cycle begins again.
a n
l e
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i
he Big hree:
hree: Fatigue
Dart ©
F
J As you can see, the B© HREE are interconnected and feed on each
i other., like this:
b
r D
O She can·t wait to go to bed, yet dreads it, knowing she·ll not be able to
o e sleep once she gets there.
m f
y i O She goes to bed, tries to relax and her legs tremble
tremble, or pain shoots across
a n her back and hips, or down her leg, while her head pounds in time with her
l e heartbeat.
g d
i
he Big hree:
hree: Fatigue
Dart ©
F
J And, to make matters worse, FMS is often accompanied by Chronic Fatigue
i Syndrome as lack of restorative sleep weakens her immune system and makes
b
C her body more and more susceptible to infection.
F
hr D
or e
t
©
a J t is not unusual for a FMS sufferer to also suffer from [upus
[upus, Rheumatoid
m
o f Arthritis,
yn i Arthritis or a host of other ailments.
i
ai g
n
u
cl e
g e
d
i
he Big hree:
hree: Fatigue: HDA Axis
Dart ©
F
J Some of this may be the result of the HDA axis disruption, which is
i essentially a major hormonal imbalance.
bH
r DD J
he fact that women experience much greater fluctuations in their hormone
A
o e levels throughout their lives from puberty all the way through the end of their
m f lives, may account for why more women than men suffer from FMS.
A
y i
ax n
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gsd
i
he Big hree:
Dart ©
F
J he HDA axis refers to the way hormones are produced and regulated in
i the body, hypothalamus-pituitary-adrenal glands. hese three glands work
bH together to control hormone levels.
r DD
A
o e J ©f this cycle is disrupted, nearly all hormones of the body are affected.
m f
A
y i J D stands for pituitary, the Master land. From the pituitary come all sorts
ax n of hormones, including SH (thyroid stimulating hormone) H H (Human growth
l ie
hormone) and several which stimulate other glands to secrete hormones, like
gsd
i the adrenal glands, the A in our axis.
he Big hree:
Dart ©
F
J he H stands for hypothalamus,
hypothalamus which is the master of the Master land
i and the ultimate controller. he hypothalamus receives input from the body,
bH through the nervous system, to ascertain which hormones are needed for
r DD
A optimal homeostasis (internal balance). ©t then stimulates the pituitary,
pituitary which
o e
m f sends hormones to stimulate the adrenals, which produce cortisol, also known
A
y i as the stress hormone, to stimulate the sympathetic nervous system.
ax n
l ie
gsd
i
he Big hree:
Dart ©
F
J Cortisol levels must be maintained in a very delicate balance if the body
i is to function properly. ©ts levels directly affect the hypothalamus through the
bH nervous system. Unfortunately, if there is too much cortisol in the blood, the
r DD
A hypothalamus is more stimulated, turning on the pituitary which stimulates the
o e
m f adrenals to produce more cortisol, effectively putting the entire endocrine
A
y i system out of whack.
ax n
l ie
gsd
i
he Big hree:
Dart ©
J he pituitary then releases "hormone releasing factors", which stimulate particular glands, such as
F
i the thyroid gland and adrenal gland to release the appropriate amount of hormone into the
bH bloodstream. he adrenal gland is the final gland in the mix and is responsible for releasing
r DD
A cortisol. Cortisol is involved in many processes within the body and must be kept in perfect
o e
m f balance. Cortisol then loops back up to the hypothalamus, starting a new cycle. 3
A
y i
ax n
l ie
gsd
i
a 3http://www.coloradofibromyalgia.com/AllAboutFibromyalgia.html
he Big hree:
Dart ©
F
i
bH
r DD
A
o e
m f
A
y i
ax n
l ie
gsd
i
a http://www.niaaa.nih.gov/Resources © 2010 Susan Fisher Anderson All Rights Reserved
DAR ©©: OHER SYMDOMS
Dart ©©
J Well, now that we·ve defined FMS by the ¶Big hree·, lets talk about other
symptoms which can present in a FMS person. On the following page are some
S of the myriad of symptoms which are often present in FMS patients, there may
O y be a variety of others.4
t m
h p
e t
r o
m
s
4http://www.coloradofibromyalgia.com/AllAboutFibromyalgia.html © 2010 Susan Fisher Anderson All Rights Reserved

Headaches
Morning Anxiety
Stiffness
rigeminal Depression
euralgia
Restless [eg Door

Syndrome Any or all Memory
can be umbness
Muscle
Cramps
included. And ingling
©n he
Extremities
Chemical Cold Hands

Sensitivities And Feet
[owered ©rritable
©mmune Bowel
Function Brain Fog Syndrome
4http://www.coloradofibromyalgia.com/AllAboutFibromyalgia.html
Headaches
Dart ©©
J One of the interesting things about FMS, is that it can often be
accompanied by Myofascial Dain Syndrome (MDS) commonly known to massage
S therapists as the presence of rigger Doints.
O y
t ©
m J n fact, ravell and Simons indicate that the DR©MARY cause of headaches,
h p including and especially migraines, is MDS. hey also maintain that much
e t
fibromyalgia is misdiagnosed and may be, in fact, MDS instead. 5
r o
m
s 5Simons, D., ravell, J., and Simons, [.,
Myofascial Dain and Dysfunction: he rigger
Doint Manual, 2nd ed., Williams and Wilkins,
1999, Baltimore, MD, pps. 38-39. © 2010 Susan Fisher Anderson All Rights Reserved
Headaches
Dart ©©
J As we massage therapists know, trigger points are present in a large
H majority of the population and resist identification by other than a very skilled
eS hand.
Oa y
t dm J ©n other words, most physicians lack the tactile discrimination we have
h ap developed over many years of manual therapy. hey don·t identify the
ec t trigger points because they can·t feel them and, consequently may fail to
r ho
em consider MDS in their arrival at a diagnosis of FMS.
ss

Headaches
Dart ©©
J ©n the next section, we·ll discuss how to evaluate and manage trigger points
H when present in your Fibromyalgia client.
eS
Oa y
J Whether or not trigger points are a factor depends largely on the
t d m initiating event for the FMS.
h ap
ec t
r ho
em
ss

Headaches
Dart ©©
J Fibromyalgia often starts with an event, although the event may or may not
H be considered as a ¶major
major· life event by the client (patient).
eS
Oa y
©
J f she suffered an auto accident or fall, the resulting pain from muscle strain
t d m and the resulting trigger point formation is adequate to disrupt her sleep
h a p patterns enough to cascade into the FMS well of despair.
ec t
r ho
em
ss

Headaches
Dart ©©
J On the other hand, the event might be an emotional trauma, such as
H divorce, death of a close friend or relative, or physical or sexual abuse.
divorce abuse
eS
Oa y
J ©n those cases, the emotional trauma precipitates the sleep disturbance and
t dm triggers the FMS. Yet, even in mental trauma cases, there is very often a
h ap myofascial link.
ec t
r ho J Our bodies express what our mouths can·t or won·t. he neck tightens up,
em the rhomboids tense in a posture of defense and trigger points form in the
ss
muscles.
Headaches
Dart ©©

© @
H @

eS

Oa y
t dm
h ap
ec t
r ho
em
ss

Anxiety
Dart ©©
J As previously mentioned, FMS can be precipitated by an emotional
trauma or event.
AS
On y
B
J ut, even when the trigger event is a physical trauma such as an accident
t x m or fall, there is significant emotional distress arising from a condition
h i p producing constant pain, fatigue and lack of sleep.
ee t
©
r t o J don·t know about you, but when my kids don·t get enough sleep, it
y m disrupts their whole emotional balance.
s

Anxiety
Dart ©©
J ©t·s nearly impossible in light of the physical, mental and emotional
limitations of a chronic illness like FMS.
AS
On y
J Ours is a very stressful world, and women often have too much to do with
t xm too little time to get everything done: Manage a relationship, raise children,
h ip excel in her profession while balancing home and family with work and school,
ee t
maintain her weight, get proper exercise, fix meals, clean house, do laundry,
r to
ym pick up kids from soccer practice, on and on and on.
s

Anxiety
Dart ©©
J All with the constant, niggling thought that her body is
hurting and not
knowing what is wrong. ©s it any wonder that anxiety can accompany FMS?
AS
On y
J Added to her anxiety is that steady, nagging weight of constant pain.
t xm
h ip
ee t
r to
ym
s

Anxiety
Dart ©©
J [iving in pain produces an anxiety unique in all medical conditions.
AS
J Dain gnaws at one·s consciousness, demanding focus and attention, while
On y
defying dismissal.
t xm
h ip
E
J ven when forced to the back of your client·s mind, it is always there,
e e t unrelenting and persistent.
r to
ym
s

Depression
Dart ©©
J Dsychiatrists have known for years that low levels of serotonin and high levels
D of dopamine (neurotransmitters we talked about earlier) produce symptoms of
e
S depression.
p
O y
r
t m
e
J Clinical Depression caused by altered brain chemistry.
chemistry he feelings of
h p hopelessness, sadness, etc. which accompany and define depression result from
s
e t
s temporary or chronic imbalances in these critical neurotransmitters in the brain.
r o
i
m "Research over the past two decades has shown that depression is an important risk factor for heart disease
o
s
n along with high blood cholesterol and high blood pressure." -- ational ©nstitute of Mental Health

Depression
Dart ©©
J So, it becomes apparent how critical
D the chemical balance in the C S (central
e
S nervous system) is and how widespread the
p
O y effects of an imbalance such as we
r
t m
e described above in the HDA Axis loop can
h p
s
e t be; and how devastating and debilitating
s
r o the consequences are.
i
m
o
s
n
Door Memory
Dart ©©
D
J Studies show that when someone doesn·t get enough sleep, the F©RS thing
o that suffers is the ability to process information.
oS
Or y

J hese studies, specifically investigating the learning processes of school
t m children and adolescents, explain a lot about how memory can be affected
h Mp when FMS robs your client of good sleep patterns.
ee t
r mo
om
rs
y
Depression
Dart ©©
D
J ©n fact, poor memory is also another symptom of the effects of chemical
o imbalances in the C S.
oS
Or y
J [earning, memory, and in fact A[[ thought processing, are functions of the
t m C S (Central ervous System).
h Mp
ee t J When its chemicals are out of balance it isn·t surprising that MA Y of
r mo its functions are negatively affected, on the cognitive or thinking and feeling
om side as well as the sensory side.
rs
y
Emotional Distress
Dart ©©
J Another major component of chronic disease is worry. A mom worries
E about whether she·ll be around to raise her children. A businessperson worries
m D
S about promotions and how her physical condition may negatively affect her
O
o yi productivity at work. Add to that the headache that all this stress and anxiety
t ms
hi pt produces, and it·s a wonder she can even think at all. Keeping all the balls in
oe rt the air is difficult, in the best of circumstances.
nr oe
a ms J ot severe enough to be classified as ¶Clinical Depression· this emotional
l s distress can affect not only her body, but also her relationships.

Code [etter
umber
hree!
umbness & ingling in the Extremities
Dart ©©
J Here is another situation involving neurological symptoms. hese sensory
nerves, receiving and sending information to the arms and legs, belong to the
u
S somatic side of the D S (peripheral
peripheral nervous system)
system and are highly sensitive to
m
O yi proper levels of neurotransmitters.
b
t mn
n
h g J
p umbness and tingling in the hands and feet have been listed as symptoms
e
e tl often associated with Clinical Depression.
s
r oi
s
m ©
n J n addition to that, the chronic muscle tension and presence of untreated
gs
& trigger points can continue to create adhesions that bind up the sensory nerves all
up and down the arms and legs. © 2010 Susan Fisher Anderson All Rights Reserved
Dart ©©
Jow you have a multiple-system issue. he question becomes is the
depression creating the numbness and tingling, or are there other, myofascial
u
S issues that are disrupting proper function of the sensory side of the D S?
m
O yi
b
t
n
mn J Or is it a result of chemical imbalance of neurotransmitters,
h g
p
e
e
s
tl J Or maybe a result of dehydration, which can also affect nerve conduction?
r oi
s
mn
gs
&
Dart ©©
J Your job is to refer for the former (Clinical Depression) and use the
myofascial techniques you have learned²myofascial release, cross-fiber
u
S friction, etc. for the latter, after you have done a careful COMD[EE evaluation
m
O yi of your client·s muscles so you know which is which.
b
t mn
n
h
e ©
g J t is not an easy task! We·ll discuss this in more detail in the Drotocols
p
e tl
s section of this course.
r oi
s
mn
gs
&
Dart ©©
J he client also may need to be reminded to drink water to correct
dehydration issues. Refer to a competent physician for a serious, chronic case
u
S of dehydration.
m
O yi
b
t mn
n
h g
p
e
e tl
s
r oi
s
mn
gs
&
Cold Hands & Feet
Dart ©©
C J he hypothalamus gland is primarily responsible for maintaining homeostasis
o in the body, including vasodilation and vasoconstriction of peripheral blood
l
S vessels to regulate body temperature.
d
O y
t
H
m ©
F J f the HDA loop is all confused, some of these signals get lost in the shuffle.
h e
p
a
e
n
et J
he body, in an effort to conserve body temperature to the core, will pull
r ot blood from the extremities, leaving them cold.
d
m
s ©
s J t·s a natural protective mechanism which occurs when your body is exposed
& to cold, especially extreme cold which can be life-threatening.
©rritable Bowel Syndrome
Dart ©©
J One in four FMS patients also suffers from ©BS (©rritable Bowel
Syndrome)6. hat·s an alarming rate, yet it falls right in line with our discussion
S of Serotonin, that busy neurotransmitter.
O y
©
t © m J t turns out that serotonin is a major factor in peristalsis,
peristalsis the undulating
h B p motion the intestines do to move feces through the colon.
eS t
r o
m
s
6Wilke, WS, he Cleveland Clinic uide
to Fibromyalgia, Kaplan Dublishing, ew
York, Y, 2010, pps 113-115. © 2010 Susan Fisher Anderson All Rights Reserved
©rritable Bowel Syndrome
Dart ©©
J Serotonin receptors in the colon are stimulated when serotonin arrives.
hose receptors retard the peristalsis.
S
O y

J oo little serotonin, the peristalsis is excessive and there·s diarrhea; too
t © m much and there·s constipation. And with the constant use of pharmaceuticals to
h B p regulate the serotonin levels, it can be a horrible curse to bear.
eS t
r o
m
s

Brain Fog
Dart ©©
J Also called ´Fibro
Fibro Fog,µ
Fog there is a confusion of thought processes that
B affects many FMS sufferers.
rS
Oa y
J ©t is a hazy sort of mental state in which the FMS client feels disconnected
t im with life in general and current events specifically. Again, we·re talking about
h np C S function, which can be severely impaired by the issues we·ve already
e t
talked about.
r Fo
om
gs
J C S function in the pain reception arena is impaired along with general
thinking and thought processing centers which results in Fibro Fog.
Brain Fog
Dart ©©
J ©t seems there is no discrimination of impairment with respect to altered
B brain chemistry. ©t becomes an activity requiring tremendous effort on the part
rS of the FMS client to focus her attention on work, family activities, relationships,
Oa y etc.
t im
h np J Brain fog also can be part of the impairment symptoms resulting from
e t
chronic headaches, which we·ve already discussed.
r Fo
om
gs

[owered ©mmune Function
Dart ©©
[
o
J ©t is not uncommon for FMS sufferers to also be victims of other chronic
w diseases. ©mmune disorders such as [upus, another chronic illness characterized
e S by autoimmune issues, often accompany FMS.
F
Or uy
e
t
d
m
n J Constantly on the alert for problems, the immune system can become
h pc hypersensitive and its ability to fight infection actually reduced.
e© t
r
m
o
oi J FMS patients often find themselves more susceptible to chronic infections
m m and illnesses, such as allergies, colds, flu, etc.
u s n
n
e © 2010 Susan Fisher Anderson All Rights Reserved
Chemical Sensitivities
Dart ©©
S
J Heightened immune system sensitivity also can make the client more
e sensitive to chemicals in the environment, such as cleaning products, perfume
C Sn and fragrances, food additives, cigarette smoke, etc.
O h ys
e
t mi

m t
hi p "
@
i
ec vt
@

@
ra oi @ @
l m t
si
e
s © 2010 Susan Fisher Anderson All Rights Reserved
Muscle Cramps
Dart ©©
M
u

J hese are a common pain reaction of the body. ©t is well-known among
s practitioners of rigger Doint herapy that although Ds refer pain to other
c S areas and muscles, it is common if not expected that the muscles that live in the
O l y pain reference zone are subject to developing Ds of their own.
t em
h p
eC t
r ro
am
ms
p
Muscle Cramps
Dart ©©
M
u
J his results from the pain that is being projected there by other trigger
s points. For example, when Ds in the upper rapezius refer pain to the side of
cS the neck, the SCM (sternocleidomastoid
sternocleidomastoid muscle)
muscle responds by activating its own
Ol y Ds and creating a migraine headache. hus, spasm in one muscle refers to
t em
h p another, which goes into its own spasm.
eC t
r ro
am
ms
p
Muscle Cramps
Dart ©©
M
u
J W ith the deep, constant pain of FMS, it is not unusual for muscles all over
s the body to become tight and painful, the body·s natural response to pain.
cS
Ol y

J hese can occur without warning and create a further disruption in the
t e m FMS patient·s life. More pain, more spasm. Around and around the cycle goes. goes
h p
eC t
r ro
am
ms
p
Muscle Cramps
Dart ©©
M
u
@ @ @
s

cS @

Ol y
t em
© @
@

?
h p
eC t

@

r ro "
am
ms
p
Restless [eg Syndrome
Dart ©©
R J R[S is a sensation of pain, or sometimes just discomfort in the lower
e
extremities which can be extremely uncomfortable, especially when the client is
s
S trying to sleep. his need to shift the legs constantly makes relaxation difficult.
t
O y
l
t m
n
e
h p
d
s
e rt
s
r o
m
[
es
e
g
Dart ©©
R J According to the Restless [eg Syndrome Foundation the symptoms are these:
e O

@

@
s @ @
@ ?@

S
t

O y
l
t m
n O
? @@ @

e
h p
d @@
@

s
e rt
s
r o
O
? @@
@
@
m
[

es
e @

g
Dart ©©
R
O
? @@
@
@
e

s @

S
t
O y O
? @@

l
t m
n

e
h p
d ?

s O
e rt @ @

@ ?
s
r o @ @ @ ?

m

[
es ?
@

e
g
7www.rls.org
Dart ©©
R J Many of the medications prescribed to manage this syndrome are similar
e to those prescribed for FMS, though there are others which address the
s
S symptoms of R[S more specifically.
t
O y
l
t m
n
e
h p
d
s
e rt
s
r o
m
[
es
e
g
Dart ©©
R J ©n my opinion, more and more medications only serve to further upset the
e delicate chemical balance of the central nervous system, while underlying
s
S issues are often not addressed.
t
O y
l
t
e
n J
m Y
et the fact that many of the medications prescribed for these diseases
h p
d are antidepressants,
antidepressants one might agree with the conclusion that perhaps there is
s
e rt
s a psychological or emotional origin for these baffling disorders. We·ll talk
r o
m more about this in the next section.
[
es
e
g
Dart ©©
R J Many physicians recommend that when other defined syndromes present
e with FMS, medications to relieve those specific symptoms will help the FMS
s
S patient deal with her illness more comfortably.
t
O y
l
t m
n
e
h p
d
s
e rt
s
r o
m
[
es
e
g
rigeminal euralgia
Dart ©©
J is pain from the trigeminal nerve
nerve, which is the number (five) of the
cranial nerves and enervates much of the lower face and jaw.jaw
r
i
O
S
e J
y
B
ecause of the precarious balance of neurotransmitters in the brain and
g u
t m C S, it is not uncommon for cranial nerves to suffer from the imbalance.
e r
h p
m
e
i
a J
t
he origin is often traced to dental work,
work even to tongue piercing. ©t
l
r o may be another consequence of the hypersensitivity of the nociceptors (pain
n g
m nerves) of created by an excess of Substance D that we have discussed before.
a i
s
l a
rigeminal euralgia
Dart ©©
Wikipedia describes the social impact of , which is remarkable similar to FMS:

@@

S @ @

?@

O
@

y

@ @ @
t m
@ @ @
h p

e t @

r o

@

m

@
@
s @

8http://en.wikipedia.org/wiki/rigeminal_neuralgia
rigeminal euralgia
Dart ©©

? @@ @

@

? @
r
i
S @
e
O y
g u
t
e
h
m
m
r
p J Unfortunately for the client, many physicians are unaware of the
a
e t existence of trigger points, let alone their prevalence among the
i l
r o population and their ability to create painful sensations in all sorts of
n g
m
a i strange places. Be sure to check these muscles for Ds in your session.
s
l a
Morning Stiffness
Dart ©©
J his seems to be one of the classic symptoms of FMS, and is present in a
large majority of cases. ©t may be related to the sleep disturbance issues, or
S
M S from the fact that many of the medications prescribed for FMS are in the
t
o
O y narcotic family. hese meds can bring on a deeper sleep state that makes the
i
rt m
f tonic contractor (postural) muscles relax so much that the joints lose their stability.
hn p
f
ei t
nr
n J
o

he result can be a dead-weight sleep without normal sleep motion. Upon
e
g m arising, then, the joints feel stiff and sore, like recovery from a hangover. Even
s
s some of the antidepressants can cause this, along with some ¶natural·
s
supplements such as melatonin.
Morning Stiffness
Dart ©©
J Other chronic stiffness issues could be related to disuse of muscles.
M
S J
S
Muscles that hurt discourage a client to exercise and they often find
t themselves spiraling downward both in fitness level and motivation to exercise.
o
O y
i
hn
rt m J
f
p
[
ack of exercise is one of the main reasons stiffness in muscles occurs in
f ORMA[ people@
@ @ @ ?

ei t
n
nr o
e
g m
s
s
s
Dainful Exercise
Dart ©©
J A little movement does a world of good for the Client, both physically and
emotionally. ©t liquefies joint fluid
fluid, releases endorphins (the body·s natural pain
D SE killers), burns calories and increases blood flow in muscles and joints.
a
O xy
ti e J
m
here is a fine line, however, between adequate and appropriate exercise
hn pr and excessive, pain-exacerbating activity.
ef ct
ur oi
l m s
es

Dainful Exercise
Dart ©©
J For some FMS clients, ordinary walking falls into the latter category. Even
shopping for an hour at Wal-Mart can rob her of sleep for a day or two as her
S
M S hip muscles spasm.
t
o
O y
i
rt m J on-weight-bearing activities such as bicycling, or a short time on an
f
hn p elliptical trainer can substitute for activities which create more pain.
f
ei t
nr
n
o J
e
F
or these clients, gentle stretching during a massage session can help
g m counteract the detrimental effects weight-bearing exercise can have on the
s
s
s patient·s pain levels. We·ll discuss this more in the next section.
[ooking Ahead«
Dart ©©
We·ve spent quite a bit of time discussing the symptoms and

S characteristics of Fibromyalgia Syndrome (FMS). ©n this section, we·ll
O y explore what you, as a Massage herapist, can do to help these poor
t m folks who end up on your table.
h p
e t
r o
m
s

DAR ©©©: DROCEDURES A D DROOCO[S
Dart ©©©
D
r
©

o D
@

c r
@ @

e o
d t
u o
r c
e o
s l
s
& © 2010 Susan Fisher Anderson All Rights Reserved
Dart ©©©
D J Muscles have memory and remember each incident of an over-stretch, a

r fall, a car accident, sports activities and anything else that might have insulted
o D their delicate balance. ©t is your job to uncover these incidents and insults in
c r
e order to properly address and correct them.
o
d
u
t
o
J his might not happen in the first session²and in fact, it might be overly
r c traumatic to your client to recite a litany of her pain all at once. However, as
e o you work together, you should be inquiring into her history as she is able to
s l relate it, and as you encounter issues in her tissues.
s
Dart ©©©
D J She may not be aware of how falls, accidents, and even abuse can initiate
r trigger points and adhesions in her musculature that remain for years, or until
o D addressed specifically with an appropriate technique.
c r
e o J ©t takes a lot of courage for her to even make the call and come see you.
d t
Understand that; and enter into the client/therapist relationship with caution
u o
r c and respect for her wishes.
e o
s l
s
Dart ©©©
D J As a 40-year veteran of this illness, © have ¶managed· my pain by pushing it

r to the back of my mind and not letting it rule my life. A few years ago, ©
o D volunteered to be a model for an M class which was nearing graduation and
c r
e needed clients for practice and case studies. Darticipation as a client required
o
d t me to complete a 4-page intake form describing all my symptoms, head to toe.
u o ©t was the first time in many years that © listed everything, all at once. © was in
r c
tears by the time © finished it, totally overwhelmed by the magnitude of my
e o
s l pain. ©n my effort to ignore it, © was unaware of how pain had permeated
s every facet of my life.
Rules: Reduced Dressure
Dart ©©©
D J Here are some rules that will help you work more effectively with FMS
r clients:
o D
c r 1. Be aware that her tolerance for pressure may be greatly reduced from
e o what you consider ¶normal.· ©t doesn·t matter what you think, but only what
d t
she thinks. Her perception of pressure may be vastly different from what
u o
r c you consider ¶light· or ¶appropriate.· [isten to her! ive her what she thinks
e o she needs no matter whether you think the pressure is adequate or not.
s l
s
Rules: Be entle
Dart ©©©
2. Be entle!
D
r a)Begin your relationship with gentle Swedish strokes that will help you
o D examine her tissues more thoroughly. While more advanced techniques and
c r
e
protocols are extremely valuable in addressing and correcting myofascial
o
d t issues, this is not the time for that. rust is a B© issue for your client. She is
u o entrusting her body and her pain to your skilled hands. So, even if you feel
r c
like you·re barely touching her, that·s okay. You won·t be able to help her
e o
s l until she trusts you. And she won·t trust you if you hurt her!
s
Dart ©©©
D © am a massage instructor, but © rarely get massage from licensed therapists.

r
o D
Why? Because © can·t trust them to respect my limits. Most therapists ©·ve
c r encountered want to show off. hey want to impress me, a massage teacher,
e o with what they know. ©n the process of that excruciating session, my needs go
d t
u
right out the window. And it takes days, sometimes a week for me to recover.
o
r c Even though © continually request less pressure, they continue with what they
e o think is best to the detriment of my condition. ©t is extremely frustrating for
s l
me.
s
Dart ©©©
D Consequently, knowing how beneficial massage is for FMS, © have sought it

r
o D from my students, knowing that they are too intimidated by me to hurt me. As
c r a result, © have not benefited from advanced techniques that could erase my
e o trigger points and possibly relieve much of my pain.
d t
u o
r c
e o
s l
s
Rules: Be entle
Dart ©©©
D b)Remember²and be sure to inform your new client²that there may be

r some soreness arise the next day²or a few days²after your session. Assure
o D her that this is a normal reaction from the release of tissue toxins, which
c r
e happens during massage²especially the first one. Your goal for your first
o
d t session should be to soothe her, and to let her become accustomed to your
u o touch. his is not the time to dig into knots and poke your elbow into her
r c
gluts. ©n fact, if you cause her excessive discomfort, you·ll likely never see
e o
s l her again.
s
Rules: Be entle
Dart ©©©
D c) ote, as you work, areas of tension, issues in her tissues, places you·d like
r to address more completely as the relationship progresses. here will be
o D time for that, so be patient.
c r
e o
d t
u o
r c
e o
s l
s
Rules: Session [ength
Dart ©©©
D 3. [imit the length of your session. A full hour, or hour and a half, is probably
r more than her fragile nervous system can handle. he repercussions of your
o D work will be more severe than with your ¶normal· clients. She may not be
c r
e aware of that fact, but you, as the experienced therapist, should be.
o
d t
u o
r c
e o
s l
s
Rules: Session [ength
Dart ©©©
D a)You may want to start with a half hour on her back and neck. his is a
r particular area of FMS pain.
o D
c r b)©f she is insistent on the full hour, spend extra time on her hands and feet,
e o especially the feet. here are powerful reflex effects of foot work, and
d t
this may be an alternative way to address her painful areas without
u o
r c excessive trauma to them. (And be aware that even your light touch can
e o traumatize these sensitive areas.)
s l
s
Rules: Respect her Wishes
Dart ©©©
D 4. Respect her wishes, and watch her face for signs of discomfort.
r
a)here is a ¶no pain, no gain· mentality that permeates the sports and therapy
o D
c r industry. ´ othing is happening if it doesn·t hurtµ may be what your client is thinking.
e o Actually, the opposite is true. While an hour and a half may feel really good, and she
d t can ¶take it· when you press on a trigger point, the truth is that she may experience
u o
r c much increased discomfort over the next few days because of your work.
e o
b)A frown, grimace or even just a furrowing of her eyebrows indicates pain. So BACK
s l
s OFF!
Dart ©©©
D c)Watch for signs of resistance in her tissues. ©f her toes are curled and
r clenched, it may be a sign of resistance to the pressure you are applying.
o D Or, it may be a sign of her resisting the work itself. As © mentioned before,
c r
e there is a huge RUS issue with a FMS client, to even come in the door. ´My
o
d t body needs this, so ©·ll lie here and take it,µ may be what she·s thinking, too
u o intimidated to tell you that what you·re doing is painful. You may need to
r c
remind her to relax, or, you may need to define ¶too much pressure· to her.
e o
s l
s
Dart ©©©
D c) (
)
© tell my clients this,

!
r " ##

$
o D %& hat simple sentence goes a long way to help clients understand the
c r
e goal of your work. You are there to help, not hurt them.
o
d t
d)Your respect of her needs will go a long way to create a safe environment
u o
r c for your client to manage her illness, perhaps for the first time.
e o
s l
s
Rules: Flashback
Dart ©©©
D 5. Watch for signs of F[ASHBACK. he percentage of FMS patients who have a
r history of childhood sexual abuse is staggering³about 75%. hat·s huge.
o D And, anyone who has experienced abuse, especially sexual abuse, is very
c r
e vulnerable when entrusting her naked body to a stranger. Consequently, the
o
d t experiencing of flashbacks, and/or unexpected emotional response to touch is
u o not unusual.
r c
e o
s l
s
Rules: Flashback
Dart ©©©
D a)A client may ¶zone out,· tense-up, begin to cry for reasons unknown even
r to her, and possibly unrelated to what you are doing.
o D
c r b)A touch to a certain area of the body may trigger memories, both
e o conscious and unconscious, that elicit these types of responses.
d t
u o
r c
e o
s l
s
Rules: Flashback
Dart ©©©
D J ©f you encounter such reactions, head back to what you learned about
r dealing with this scenario. A person experiencing a flashback, or an extreme
o D emotional reaction to your massage may be totally shocked by her own
c r
e reaction. ©t·s up to you to put her at ease, and make sure she feels safe.
o
d t
u o
! ©
r c

e o
s l
s
Rules: Flashback
Dart ©©©
D J What you CA do is reassure her that she is in a safe place and that her
r reactions are neither unacceptable nor unwelcome.
o D
c r J Don·t rush to hand her a tissue if she·s crying; rather give her a voice by
e o asking her what she wants to do.
d t
u o
r c
e o
s l
s
Rules: Flashback
Dart ©©©
D J A person in this position feels extremely vulnerable and powerless. Your

r best response is to return power to her. Ask her if she wants to continue, or if
o D she wants you to stop.
c r
e o J Derhaps she is uncomfortable with you working in this particular body
d t
area (she may not have even known she was so sensitive there). And recognize
u o
r c ©·m not talking about physical sensitivity or specifically about pain sensitivity.
e o
s l
s
Emotional ©ssues: Flashback riggers
Dart ©©©
D J ©n abuse victims, touch can trigger flashbacks to the abuse situation.

Fr
ol D
J Someone who has been choked may become agitated and afraid if you
ac rr work across from one side of her upper chest to the other, a stroke many clients
es oi find very enjoyable.
dh gt
bu o
g J Areas of the body particularly subject to this kind of response may
ar ec surprise you, and it depends on the abuse this particular client suffered,
ec or
although the legs, buttocks and especially the abdomen are probably most
ks sl
s sensitive in most people.
Dart ©©©
D J Be careful with techniques that cause you to hold both wrists, or any
r movement which may make your client feel restrained.
o D
c r
@

@
e o

d t © @
@@
u o
©

r c
e o
s l
s
Dart ©©©
D J ©t is appropriate for you to refer her to someone who can help her. An
r approach © suggest to students is this:
o D
c r O ´You seem to be having a strong emotional response to this work, you
e o might want to talk to someone about it.µ
d t
u o J ©f you have a psychological/psychiatric referral list, this is the time to use it.
r c
e o O ´© can give you some names of professionals who work in this field, if
s l you like.µ
s
Dart ©©©
D J Be sure you give her at least two referrals.

r
o D
J his approach acknowledges her reaction without producing guilt or shame
c r in your client. ©t merely lets her know that you are there to help and not
e o condemn or criticize.
d t
u o J ©f you do not have a referral list, you can refer her to one of several
r c hotlines available in most cities for psychiatric counseling.
e o
s l
s
Dart ©©©
D J Another very interesting aspect of childhood sexual abuse is the fact that
r many, many victims completely block the abuse from their memories.
o D
c r J his is true especially when the abuse happened at a very early age.
e o When the abuse happens so early in life, the child is unable to understand and
d t
cope with the horrible things happening to her body, and in most children, the
u o
r c language skills are not developed enough to be able to report the abuse in a
e o coherent, accurate manner.
s l
s
Dart ©©©
D J Add to that the mistaken impression that since children make things up,
r adults can·t believe what they say, so anyone to whom she might report it will
o D likely dismiss her allegations as imagined.
c r
e o J [et me set the record straight on that: Children do not make up stories of
d t
sexual abuse. How can she imagine something about which she knows nothing
u o
r c and of which she is totally innocent? She can·t.
e o
s l
s
Dart ©©©
D J Sexual abuse of children is rampant and has been for centuries. ©t crosses all
r racial and cultural lines, and the perpetrator is usually someone the child loves
o D and trusts. And, the saddest thing is once the damage is done, scars remain
c r
e forever, leaving the little girl to cope in the only way she can.
o
d t
u o
r c
e o
s l
s
Dart ©©©
D J he feeling of powerlessness is devastating and often turned inward. Years

r later, the symptoms arise as
o D
c r Confusion Eating Autoimmune
Dromiscuity Drug Use of Sexual Addictions
e o ©dentity Disorders Diseases
d t
u o
and a host of other conditions that we never expect to be connected to that
r c
e o childhood violation of her innocence.
s l
s
Dart ©©©
D J Childhood sexual abuse also happens to boys, but normally not at such an
r early age. hey may rationalize it as ¶playing around· or ¶sexual
o D experimentation· but the effects are the same and the fallout similar. ©f the
c r
e violation is non-sexual such as bullying or being ridiculed, the child may have
o
d t better coping mechanisms and the results not as severe as when sexual abuse
u o occurs when the victims are very small²six or younger. his is discussed more in
r c
the next section.
e o
s l
s
Emotional ©ssues: icklishness
Dart ©©©
D J Be aware also of ticklishness, which is the next-door neighbor to pain and

r often results from previous injury or abuse.
o D
c ©
r J n cases where there has been physical injury, some people will report
e o ticklishness with light pressure, while a little more pressure elicits a pain response.
d t
Other times, ticklishness is the result of childhood abuse, which may have occured
u o
r c in the name of good fun.
e o
s l
s
Dart ©©©
D J he ticklish client may have deep, emotional trust issues as part of her touch
r issues. ©t is very common for a person who is ticklish in their trunk or torso to
o D have endured being tickled in childhood²often to the point of tears or loss of
c r
e bladder control. © consider this child abuse.
abuse
o
d
u
t
o
J [et me make myself clear. icklishness is a defense mechanism used by our
r c bodies as protection on a very deep level. You can·t tickle yourself, can you?
e o o, because you trust your own hands.
s l
s
Dart ©©©
D J ©t is abuse whenever a smaller, weaker person is subjected to stimulation

r over which they have no control, and can·t escape. Even if they laugh, it·s still
o D abuse. And, even years later, there is often the underlying sensation of pain in
c r
e the same area with a little more pressure.
o
d
u
t
o
J hat is why it·s so important to approach ticklishness with a firm, confident
r c and nurturing touch to break through emotional barriers.
e o
s l
s
Emotional ©ssues: ouch Rehab
Dart ©©©
D
J On the other hand, many abuse victims seek out massage services to help
r them come to terms with touch issues.
o D
c r
J hese astute clients, aware of their touch issues, will partner with you and
e o their psychotherapist to help them work through their difficulties and press on to
d t more normal lives.
u o
r c
e o
s l
s
Emotional ©ssues: ouch Rehab
Dart ©©©
D
©

r
o D @

c r @ @
e o
d t
u o
r c
e o
s l
s
Emotional ©ssues: Dsychosomatic Dain
Dart ©©©
D J [et·s face it. Dain is the body·s valuable and necessary response to noxious
r stimuli.
o D
c r J ©t·s the signal that something is terribly wrong. And, when the wrong is
e o emotional or psychological and when emotional or psychological response is
d t
restrained or not allowed, the body is very likely to respond with physical
u o
r c pain²called psychosomatic pain, literally mind pain felt in the body.
e o
s l
s
Dart ©©©
D J ©t is still real pain

pain, just psychological in origin, and manifesting in the
r somatic realm of the physical body.
o D
c r J And, sometimes it is necessary²even optimal²to deal with both the psyche
e o and the soma together, at the same time.
d t
u o
r c
e o
s l
s
Dart ©©©
D J his is particularly common when the abuse was suffered in childhood²

r when she was little, weak and unable to communicate on an adult level. ©f your
o D client wants to talk about her abuse with you, you may listen, but only listen.
c r
e And only as far as it doesn·t wound your own spirit in the process.
o
d t
u o
r c
e o
s l
s
Dart ©©©
D
@

r

@

o D
c r
e o
d t
u o
r c
e o
s l
s
Dart ©©©
D J ©n addition, your wearing both hats, that of massage therapist A

D
r counselor makes your client very vulnerable and borders on client abuse. Refer
o D her to a competent, qualified counselor to explore those issues.
c r
e o J Remember that not all FMS clients were victims of childhood sexual abuse,
d t
and it·s not your job as a massage therapist to ask them.
u o
r c
e o
s l
s
Emotional ©ssues
Dart ©©©
D J Just know, as you·re caring for her skin, there may be very real, very
r horrible places where her skin has been, and she may react to your hands in
o D unexpected ways (both to you and to her).
c r
e o J You can still be a part of her healing by providing non-sexual, nurturing
d t
touch and by caring for her in a way only you can.
u o
r c
e o
s l
s
Dhysical echniques
Dart ©©©
D J Hard to believe up to now we·ve spent so much time talking about how to
r deal with the emotional person on your table, now let·s talk about the physical
o D person.
c r
e o J When you dig into your tool kit for techniques to use on this new FMS
d t
client, the first choice, as © said, is gentle Swedish techniques. And not the deep
u o
r c work strokes such as cross-fiber friction and stripping. ©nstead use gentle
e o effleurage and very light pettrissage
pettrissage, with liberal use of vibration,
vibration both coarse
s l and fine.
s
Dhysical echniques: Effleurage
Dart ©©©
D
J Effleurage Should be gentle, with as broad a contact as possible for the
r area you·re working. With FMS clients, pain is a primary issue.
o
c
D
r
J he more localized the contact, the more painful your touch will be to your
e o client . So avoid ¶pokey· types of strokes.
d t
u o
r c
e o
s l
s
Dart ©©©
D
J Use your whole hand to contact as much skin as possible on each stroke. his
r will dissipate your pressure over a larger area of touch receptors and minimize
o D the discomfort to the client.
c r
e o
© @

d t
u o

@

r c @
e o
s l
s
Dart ©©©
D J hese long, broad strokes can do wonders both for you and for your client.
r Use them as evaluative strokes, to get as much information from your client·s
o D skin as you can.
c r
e o O How does it feel?
d t
u o O ©s it firm or doughy?
r c O Do you feel little knots or bumps which might indicate trigger points?
e o
s l O Does it feel stringy or leathery?
&
s J Each of these descriptions refer to a different type of tissue condition.
Effleurage: issue exture: Firm
Dart ©©©
D J Firm might be hypertonic, or tight muscles. hese could be overused

r muscles.
o D
c r J A little petrissage might be appropriate after the muscles are warmed
e o and more pliable. But be careful of doing too much, too soon. As © said, if you
d t
hurt her, you·ll never see her again.
u o
r c
e o
s l
s
Effleurage: issue exture: Firm
Dart ©©©
D J [ook for this type of muscle condition in the neck and shoulders, especially
r in someone who works at a computer or carries a heavy backpack or handbag
o D on her shoulders.
c r
e o J And remember, even though these kind of tissues are familiar to you, the
d t
person wearing them is not your average, ordinary client. Easy does it!
u o
r c
e o
s l
s
Effleurage: issue exture: Doughy
Dart ©©©
D J ©f you encounter doughy areas where your client complains of pain, be

r really careful. You may not find any of the expected tight tissues, Ds,
o D adhesions or knots in these areas.
c r
e o J Yet don·t tell yourself (or your client!) that she has no reason to feel pain
d t
here.
u o
r
e
c
o
J hese are the classic FMS tender points, where the sensory nerves are
s
hypersensitive.
l
s
Effleurage: issue exture: Doughy
Dart ©©©
D J ibration here may help soothe the nervous system, release holding
r patterns and promote relaxation. Your broad, nurturing effleurage here will
o D be comforting, but be careful of too much pressure.
c r
e o J Remember, just because if you don·t feel any issues, that doesn·t mean it
d t
doesn·t hurt.
u o
r c
e o
s l
s
Effleurage: issue exture: Knots and Bumps
Dart ©©©
D J hese are probably the classic evidence of adhesions or Ds.

r
o D
J ©t is okay to work them gently and cautiously, while always maintaining eye
c r contact with your client to be able to judge her level of discomfort.
e o
d t J Many, many FMS clients also have trigger points, in fact, probably most of
u o them. hese two syndromes often overlap and are misdiagnosed. 9 ©n fact,
r c Myofascial Dain Syndrome²MDS or rigger Doints²may be a causative factor
e o
s
for FMS.
l
s
& 9Simons and ravell, pps. 38-39 © 2010 Susan Fisher Anderson All Rights Reserved
Dart ©©©
DK J ©t is still necessary to approach this situation with care and caution. Do only
rn
as much as your client can tolerate. And you might want to avoid them
ooD
ctr altogether in the first few sessions.
eso
d/ t © @ © #
©
uBo

@ @

r c @ ?
u
e o
sm l
ps
&y © 2010 Susan Fisher Anderson All Rights Reserved
Dart ©©©
D J ©t is possible to subtly work D into your Swedish routine by pausing on the
r D for a few seconds. Use all fingers for a broad contact, with one finger
o D adding a little extra pressure on the D (7 to 10 seconds, no more) while
c r
e encouraging your client to breathe.
o
d
u
t
o
J Follow that with a good stretch of the particular muscle where you·ve
r c worked the D and you·re good to go.
e
s
o
l
J Don·t try to work more that 8 or 10 Ds in an hour session. Even a healthy
s client probably won·t tolerate it well.
Dart ©©©
D J otice also © said knots or adhesions.

r
o D
J hey are different and ©t·s very important for you to know the difference
c r between them and trigger points, and to address each correctly.
e o
d t
u o
r c
e o
s l
s
Dart ©©©
D
r
o D An adhesion is where
A knot is an area of something is stuck to
c r something else when
tight muscle fibers it·s not supposed to
e o
be stuck.
d t
u o
r c
e o
s l
s
J rigger points are another thing all together and need very specific care.
Dart ©©©
D J A knot might respond to pettrissage or effleurage, while an adhesion may

r need transverse friction or MFR to release it.
o D
c r J Know what you·re dealing with, and how to manage it properly.
e o
d t
u o
r c
e o
s l
s
Dart ©©©
D J ©t·s also critical that you know which muscle you·re dealing with so you know
r which direction the fibers are running, so you can apply your techniques
o D correctly.
c r
e o J he best massage therapists are those who know ! et your
d t
book out and keep learning.
u o
r c
e o
s l
s
Effleurage: issue exture: Stringy
Dart ©©©
D
J Here·s an area where you·re most likely to encounter Ds.
r
o D
J Buried within those taut bands of stringy muscle fibers is probably a trigger
c r
point just aching to be released. A little extra pressure (again buried within a
e o broad contact) will cause it to wilt or melt under your finger.
d t
u o
r c
e o
s l
s
Dart ©©©
D
J Of particular note here is the fact that trigger points are DA©
FU[. And you·re
r dealing with a client in a lot of pain, right? So you need to be ready to show them
o D a D chart, teach them what you are doing and why, and help them breathe
c r through the discomfort, making sure they recognize the sensation of relief when it
e o
d t releases.
u o
r c
e o
s l
s
Dart ©©©
D J And remember also, D without SRECH of the involved muscle is

r worthless. he whole purpose of your ischemic compression of that D (or the
o D spray and stretch, or ice and stretch) is to quiet the muscle so it will allow itself
c r
e to be stretched. he is what erases the D, not your pressure.
o
d t
u o
r c
e o
s l
s
Dart ©©©
D J Most doctors have little or no education in the science of D, or even

r know what a D is or what to do with it. Finding Ds in his patient·s body and
o D not knowing how to differentiate R© ER points from E DER points, he might
c r
e arrive at Fibromyalgia without considering MDS at all.
o
d
u
t
o
J he encouraging thing about working Ds in a FMS client is that the Ds
r c may be the source of much of the pain which is keeping her awake at night
e o and preventing her from living her life. hey may be the very things that
s l caused her doctor to arrive at his FMS diagnosis.
s
Dart ©©©
D J Your work with this client could be the difference between wellness and a
r lifetime of pain for her.
o D
c r J ake a rigger Doint class, if you haven·t done so already, so you·ll know
e o how to identify and manage these pesky issues in the tissues.
d t
u o
r c
e o
s l
s
Dart ©©©
D J Unfortunately for your client, a leathery patch usually means a long-

r standing injury to tissues with adhesions at several levels. his is the way muscle
o D scar tissue feels when it·s been there for quite a while.
c r
e o J his is not to say there·s nothing you can do about it. Quite the contrary,
d t
these tissues respond well to myofascial release techniques and transverse
u o
r c friction.
e o
s l
s
Effleurage: issue exture: [eathery
Dart ©©©
D J ©t is wise, however, to delay working on them until your relationship with

r your FMS client is well-established and you are comfortable enough with each
o D other to begin deeper work.
c r
e o J Don·t worry, though, most FMS clients have plenty to keep you busy for a
d t
long time, and they so desperately need quality, nurturing touch.
u o
r c
e o
s l
s
Dhysical echniques: ibration
Dart ©©©
D J his is a MA©C stroke for FMS clients. his is the stroke that soothes and
r sedates the nervous system, and it·s a hyperactive nervous system that is the
o D major culprit in FMS in general.
c r
e o J Deep, rhythmic rocking will relax tight muscles and release long-
d t
maintained holding patterns without the pressure that might cause your FMS
u o
r c client pain. USE © [©BERA[[Y!
e
s
o
l
J Use finer shaking or trembling for specific areas of knots and tight spots,
s where digging deep would only exacerbate your client·s pain.
Code [etter
umber Four!
Dhysical echniques: ibration
Dart ©©©
D J Since vibration works primarily with the nervous system, the residual
r soreness from massage is not as likely to appear the next day.
o D
c r J Dlease, don·t underestimate this powerful tool.
tool ©·ve known vibration to be
e o magical in all sorts of injury situations where the other strokes are
d t
contraindicated.
u o
r c
e o
s l
s
Dhysical echniques: Dettrissage
Dart ©©©
D J his is a stroke to save for later.

r
o D
J ©n your early work with an FMS client it may be too much for her to
c r tolerate when she·s just beginning to trust you.
e o
d t J ©ts benefit for increasing blood flow is undeniable, but it may be too
u o invasive for an FMS client unless done very gently and above all, S[OW[Y
S[OW[Y!
r c
e o
s l
s
Dhysical echniques: Friction
Dart ©©©
D J Again, this is a more invasive and stimulating stroke which also may be
r best saved for later in your relationship with this client.
o D
c r J ©f you find some definite adhesions which contribute to her condition in a
e o major way, use it sparingly and cautiously.
d t
u o J And follow up with soothing effleurage to apologize to the tissue you·ve
r c insulted.
e o
s l
s
Dhysical echniques: apotement
Dart ©©©
D J Many, many therapists never use tapotement in normal circumstances,

r which © think is a crime. Each of the five Swedish strokes is necessary and useful
o D in its own way.
c r
e o J ©n FMS clients is the only time © suggest eliminating this stroke from your
d t
routine. FMS clients already have a hard time falling asleep, and their tissues
u o
r c are already hypersensitive and over-stimulated. apotement will only
e o exacerbate this scenario.
s l
s
Dhysical echniques: Range of Motion
Dart ©©©
D J Also called Swedish ymnastics, these are one of the most commonly
r omitted and most useful elements of a classic Swedish massage.
o D
c r J entle passive stretching of the joints will help muscles regain their proper
e o memory of length without pain.
d t
u o J ©t mobilizes the joints and decreases viscosity of joint fluid.
r c
e o
s l
s
Dhysical echniques: Range of Motion
Dart ©©©
D J Be careful to work only within the tolerance levels of your client, she will
r benefit tremendously from a good stretch.
o D
c r J Since exercising is difficult for FMS sufferers and often exacerbates their
e o pain, many do not get the motion their joints need to retain their healthful
d t
natural state.
u o
r
e
c
o
J You can add this to their session and greatly improve their quality of life.
s
Be sure you stretch gently and, again, S[OW[Y, while reminding your client
l
s that comfortable stretch, not pain, is the goal.
Dhysical echniques: Hydrotherapy
Dart ©©©
D J his can be one of the most comforting and helpful modalities you can use.
r Clients respond well to heat therapy, especially moist heat, and it seems to be
o D greatly effective in reducing pain.
c r
e o J Of course you can also use ice, though ice is more appropriate when
d t
inflammation is present, which is rare in FMS.
u o
r
e
c
o
J Heat, however feels much more soothing and comfortable, encouraging a
s
warm, snuggly sensation that can be quite appealing to your client.
l
s
Hydrotherapy: ate Effect
Dart ©©©
D J ©n addition, the use of temperature invokes the ¶ ate Effect,· which is one
r of the primary advantages of Hydrotherapy.
o D
c r J he ate Effect is based upon the premise that chronic pain nerves and
e o temperature-sensing nerves follow similar pathways on their way to the spinal
d t
column and, once arriving at their destination, share a common sympathetic
u o
r c ganglion, where the information is passed on to the C S and, eventually, to the
e o brain.
s l
s
Dart ©©©
D J he key to the operation of the ate Effect, is that the temperature-sensing
r neurons are fast nerves, while the chronic pain neurons pass their message at a
o D much slower speed.
c r
e o J Consequently, when hydrotherapy is used to change the temperature, the
d t
temperature change message arrives at the C S first, blocking the pain
u o
r c information the chronic pain nerves are sending.
e
s
o
l
J So, the brain perceives heat (or cold) instead of the pain it was feeling.
s Compare this to using a heating pad to soothe low back pain so you can sleep. ©t·s
& the ate Effect that makes that work. © 2010 Susan Fisher Anderson All Rights Reserved
Dart ©©©
D J ©n FMS, chronic pain nerves are abnormally sensitized and constantly

r sending that message to the C S (brain). Use of temperature quiets that
o D constant racket of pain the brain is receiving.
c r
e o
d t
u o
r c
e o
s l
s
Dart ©©©
D J You can encourage your client to use moist heat at home. Use a heating
r pad
if it has an automatic shut-off switch. Using a heating pad and
o D sleeping with it on can DRODUCE inflammation where none was present
c r
e before.
o
d t
u o
r c
e o
s l
s
Dart ©©©
D J © recommend microwaveable heat packs (usually filled with grain such as rice,
r or barley) often with aromatic herbs such as lavender and peppermint²which have
o D their own relaxing effect. he added benefit of the grain filling is that, when
c r
e microwaved, moisture is released from the grain, providing the moist heat which is
o
d t so helpful for FMS sufferers.
u o
r c J hese microwaveable packs are warm for about 20-30 minutes, and then cool,
e o which makes them much safer to use than an electric heating pad.
s l
s
Dart ©©©
D
©

@
?
r
o D ?
@
c r ?
e o
d t J ©ce packs area also beneficial, and they lose their cool and have an added
u o
benefit of actually numbing the pain nerves, not just overriding them with the
r c
e o ate Effect.
s l
s
Dhysical echniques: Other Modalities
Dart ©©©
D J © don·t mean to imply that Swedish Massage is the only appropriate way
r to address Fibromyalgia. othing could be further from the truth.
o D
c r J ©n choosing a modality, opt for one that is:
e o
d
O Minimally invasive
t
u o O Relaxing rather than stimulating
r c
e o O One that is soothing to the nervous system
s l
s
Dhysical echniques: Other Modalities
Dart ©©©
D J As you and your client get to know and trust each other, other modalities
r can be added to suit you both.
o D
c r
e o
d t
u o
r c
e o
s l
s
Dh sil hniqus: Othr Mlitis
Drt ©©©
D J S rn tins r:

r
Utiliz r ckin n j stlin ti ns, hich r v r
D r r hniqus n fici l t th n rv us s st .
r
Uss l n , ntl str ks n j int nipul ti ns
Es ln M ss th t r vr rl xin .
t
u C n rss issus thr u h ut th ith ut
r Rflx l tu ll t uhin th p inful rs.

s l J As u n ur cli nt t t kn n trust ch th r, th r liti s
s
c n t suit u th.
&
© 2010 Susn Fishr An rsn All Rihts Rsrv

Dalpate, ©nvestigate and Assess
Dart ©©©
D J Whatever modality you choose to employ, be careful to use your hands

r to DA[DAE, © ES© AE and ASSESS your client·s tissues.
o D
c r J Use your knowledge of anatomy to ascertain exactly WH©CH muscles are
e o involved in the Ds, knots or adhesions you find, so you can address them
d t
specifically and confidently.
u o
r
e
c
o
J Don·t just go digging into your client·s tissue without a firm knowledge of
s
the problem and a specific plan of care.
l
s
Dlan of Care
Dart ©©©
D J ©t is wise to develop a specific plan so both you and your client will know
r how your relationship will proceed. ©t may be wise to see this client twice a
o D week to start, but, consider her relatively fragile state:
c r
1)[imit your sessions to half an hour until you develop a keen awareness of
e o
d t her tolerances.
u o
r c
e o
s l
s
Dlan of Care: Self Care
Dart ©©©
D 2)©nstruct her
on self-care. Stretches she can do between sessions, and
r general taking care of herself, which is a trait severely lacking in many,
o D many FMS clients who take care of everybody else before themselves.
c r
e o
d t
u o
r c
e o
s l
s
Dlan of Care: Hydrotherapy
Dart ©©©
D 3)©can·t stress this too much! Some doctors who specialize in FMS say that
r twice-daily moist heat is the single most powerful therapy for their FMS
o D patients to self-manage their condition. 10
c r
e o OUse your table warmer, hot packs, hot stone therapy³whatever you have
d t
available to youto help warm your clients tissues in preparation for the
u o
r c massage.
e o
s l
s
& 10Mc©lwain and Bruce, p. 72 © 2010 Susan Fisher Anderson All Rights Reserved
Dlan of Care: ime [imit
Dart ©©©
D 4)©tis very important that you put a time limit on your work together. his is
r to protect both of you.
o D
c r OA reasonable amount of time, such as two or three weeks of twice-weekly
e o sessions is long enough for you both to know whether you·ll be able to help
d t
her.
u o
r c
e o
s l
s
Dlan of Care: oals
Dart ©©©
D unconscionable to take someone·s money week after week after week

O©t·s
r when there is no improvement. So, set some parameters, define how you
o D each will know if your work is benefiting your client.
c r
e o OWhat are her goals³specifically³for your time together?
d t
u o OAre they being met?
r c
e o OHow will you know?
s l
s
Dlan of Care: Finances
Dart ©©©
D OBeopen and up front with her regarding financial issues. But be gentle
r about it.
o D
c r OMany FMS clients feel intimidated by people in authority (a result of
e o childhood abuse) and are reluctant to express their feelings³it·s one of the
d t
things that turned their anger inward and may have caused their condition.
u o
r c
e o
s l
s
Dlan of Care: Care eam
Dart ©©©
D J Consult regularly with her physician³with

physician her consent, of course.
r
her doctor know of your findings and her progression. Cooperation
O[et
o D
c r among health professionals serves to increase the benefit to the client.
e o
d OBe sure you check and correct spelling and grammar.
t
u o
ODon·t be intimidated to send him a report. (Remember, you know a whole
r c
e o lot about muscles and work with them all the time. He might not have
s l thought about them since medical school.)
s
FY©: Medications
Dart ©©©
D J Recently there have been several new drugs advertised on that are
r supposed to help FMS patients. Your client may be using them and you need to
o D know what they are.
c r
e o J here is some skepticism regarding any chemical solutions²drugs²having any
d t
long-term answer to the lifetime of pain FMS sufferers live with. However, in
u o
r c fairness to the traditional medical community (most of whom are sincere, caring
e o and very concerned about their patients· welfare) © wanted to give you some
s l information on the only three drugs which have been approved by the FDA for
s
& treatment of FMS.
FY©: Medications
Dart ©©©
D J ot being a pharmacist or even a nurse, the information ©·m providing has

r been quoted from the various websites, listed by the manufacturers of these
o D medications, who know how and when these drugs should be used, and the
c r
e respective cautionary statements.
o
d t
u o
r c
e o
s l
s
FY©: Medications
Dart ©©©
D J Of course, whenever using a drug²even natural substances, supplements

r and herbs²one must consider the benefits versus the detriments, or side effects.
o D One must ask, is it worth it? Does the benefit outweigh the hazards? And, as
c r
e usual with any pharmaceutical²to cover any liability issues²description of side
o
d t effects and cautionary statements predominate.
u o
r c
@
@

e o
@

s l
s
FY©: Medications
Dart ©©©
D J According to the [yrica website::

r
o D ©
@
c r @

e o
d t © @

u o
r c
e o
s l
s
FY©: Medications
Dart ©©©

r © @

o D

@
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e o @ @
d t @

?

u o

@
@
r c
e o @ @@ @
s l
s
FY©: Medications
Dart ©©©

r © @ @ ©
o D

@
c r
e o @ @@

d t @ @

u o

@ @@
r c
e o
s l
s
FY©: Medications
Dart ©©©
D J According to the Cymbalta website::

r
@ @
o D
c r @
@ @
e o
@ @ "
d t $ @ @
u o
r c @
@ @@
e o
@
s l
s
FY©: Medications
Dart ©©©

r

o D

?

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u o

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r c
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s l
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FY©: Medications
Dart ©©©

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o D
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d t

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u o
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s l @ @
s
&
FY©: Medications
Dart ©©©
D J According to the Savella website::

r ? @@ @
o D
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e o ?© @ @

@
d t

u o
r c @ %
e o @

s l
@
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s
&
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FY©: Medications
Dart ©©©
D J According to the Savella website::

r ?

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d t

% @

u o
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r c
e o @
s l
s
FY©: Medications
Dart ©©©
D J Most of the medications used to treat FMS, as you can see from the
r above, are employed to treat either the nervous system sensitivity, or to
o D compensate for the serotonin deficiencies the patients suffer. Both of these
c r
e difficult problems stem from chemical imbalance in the nervous system, a
o
d t problem which is usually addressed by trying to chemically supplement the low
u o chemicals through drug therapy. ©·m not convinced that is a helpful solution.
r c
e o
s l
s
CO C[US©O
J Fibromyalgia Syndrome is a baffling illness, both to physicians and those
C assigned to manage it, and to its victims. We·ve spent a lot of time talking
o
about both the physical and psychological origins and ramifications of this
n
c condition.
l
u J Hopefully, you should now have a greater understanding of the misery
s your clients are experiencing, and will be better able use your unique skills to
i help them.
o
n
J As we have discussed, the massage therapist is uniquely positioned to
C present a mechanical solution for issues such as trigger points, myalgic
o
adhesions (muscles stuck together), conditions which may exist in a large
n
c majority of FMS patients.
l
u J hese physiologic and anatomical issues can create the same types of pain
s and distress that many FMS patients suffer. ©n fact, as we mentioned, much FMS
i may be misdiagnosed and may actually be MDS (Myofascial Dain Syndrome,
o
n i.e. trigger points).

J ow, while ravell and Simons· textbook was published nearly 10 years ago,
C and there have been many FMS studies since, © believe they have a good case.
o
n J As a matter of fact, they postulate that the distress from the pain and
c misunderstanding a MDS patient lives with²increasing pain and dysfunction,
l
u difficulty sleeping due to pain, and the emotional trauma of being in pain and
s regularly dismissed by physician after physician²it·s not an unreasonable leap to
i wondering whether many FMS patients may not be suffering from FMS at all, but
o
n rather MDS, a mechanical condition, highly treatable and correctible physical
malady.
he Emotional and Dsychological Side of FMS
J Unfortunately, most of the literature seems to ignore or placate with
C medication the emotional and psychological side of FMS. What about the
o
bigger picture: the emotional and spiritual component of FMS.
n
c
l
J ©f, as has been suggested, such a large majority of FMS (and other
u autoimmune diseases and syndromes) are victims of childhood sexual abuse, it
s would seem to me that there is a major disconnect in the medical approach to
i these difficult illnesses.
o
n
J As massage therapists, we know that there is a powerful emotional and
C spiritual connection that is made when we touch someone. Yet, so much of
o
medicine treats only the body and leaves the mind, the psyche²the spirit²
n
c hanging.
l
u J Are we the only practitioners who even consider this ¶whole person·
s concept? ©t would seem to me that emotional and spiritual healing is an
i absolutely necessary part of the treatment of these conditions.
o
n
J ©n my own case, © have come a long way in my recovery from childhood
C sexual abuse, yet it has only been since © learned about the abuse component
o
of FMS that it occurred to me that there might be a correlation between the
n
c abuse © suffered and my struggle with FMS.
l
u
s
i
o
n
J As a Christian, © strongly believe that healing belongs in the hands of the
C Creator, and © believe it is His will that we all be whole and happy in all areas
o
of our lives. He who made us can fix us if we only ask. And it is by His strength
n
c and power that © have progressed so far in my emotional healing from the
l abuse.
u
s J ow that © am aware of the physical repercussions of abuse, ©·m ready to
i approach that journey with the same tools. © have been ignoring FMS too long,
o
n ©·m ready to be healed and whole.

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© 2010 Susan Fisher Anderson All Rights Reserved

© 2010 Susan Fisher Anderson All Rights Reserved

hroughout the lesson

F J here are three which all must be

i       

F  [eft side  Right side

F J ©n addition, the pain and tenderness of FMS is characterized as heightened

F          ©   @

g d professional to suspect Fibromyalgia as a cause of her hypersensitivity to pain.

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F J ©t·s often a vicious cycle: he can·t slee

4http://www.coloradofibromyalgia.com/AllAboutFibromyalgia.html © 2010 Susan Fisher Anderson All Rights Reserved

Restless [eg Door

Chemical Cold Hands

© 2010 Susan Fisher Anderson All Rights Reserved

© 2010 Susan Fisher Anderson All Rights Reserved

© 2010 Susan Fisher Anderson All Rights Reserved

© 2010 Susan Fisher Anderson All Rights Reserved

© 2010 Susan Fisher Anderson All Rights Reserved

© 2010 Susan Fisher Anderson All Rights Reserved

© 2010 Susan Fisher Anderson All Rights Reserved

© 2010 Susan Fisher Anderson All Rights Reserved

© 2010 Susan Fisher Anderson All Rights Reserved

© 2010 Susan Fisher Anderson All Rights Reserved

© 2010 Susan Fisher Anderson All Rights Reserved

© 2010 Susan Fisher Anderson All Rights Reserved

Wikipedia describes the social impact of , which is remarkable similar to FMS:

© 2010 Susan Fisher Anderson All Rights Reserved

We·ve spent quite a bit of time discussing the symptoms and

© 2010 Susan Fisher Anderson All Rights Reserved

D J Muscles have memory and remember each incident of an over-stretch, a

D J As a 40-year veteran of this illness, © have ¶managed· my pain by pushing it

D © am a massage instructor, but © rarely get massage from licensed therapists.

D Consequently, knowing how beneficial massage is for FMS, © have sought it

D b)Remember²and be sure to inform your new client²that there may be

D J A person in this position feels extremely vulnerable and powerless. Your

D J ©n abuse victims, touch can trigger flashbacks to the abuse situation.

D J Be sure you give her at least two referrals.

D J he feeling of powerlessness is devastating and often turned inward. Years

D J Be aware also of ticklishness, which is the next-door neighbor to pain and

D J ©t is abuse whenever a smaller, weaker person is subjected to stimulation

D J ©t is still real pain

D J his is particularly common when the abuse was suffered in childhood²

D J ©n addition, your wearing both hats, that of massage therapist A

D J Firm might be hypertonic, or tight muscles. hese could be overused

D J ©f you encounter doughy areas where your client complains of pain, be

D J hese are probably the classic evidence of adhesions or Ds.

D J otice also © said knots or adhesions.

D J A knot might respond to pettrissage or effleurage, while an adhesion may

D J And remember also, D without SRECH of the involved muscle is

D J Most doctors have little or no education in the science of D, or even

D J Unfortunately for your client, a leathery patch usually means a long-

D J ©t is wise, however, to delay working on them until your relationship with

D J his is a stroke to save for later.

D J Many, many therapists never use tapotement in normal circumstances,

D J ©n FMS, chronic pain nerves are abnormally sensitized and constantly

D J S rn tins r:

D J Whatever modality you choose to employ, be careful to use your hands

D unconscionable to take someone·s money week after week after week

D J Consult regularly with her physician³with

à

i

F [eft side Right side

F © @

F @ ?

F © @

F

D J S rn tins r:

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