Case study

Her business survives but she has

had to employ one full-time and one
part-time person to handle the 95% of
the work she can no longer do, and in
order to achieve this she has had to
sacrifice almost all the profit from
the venture and undertake debts
with the bank which she is having
difficulty servicing. She is fearful
that she will lose everything. Her
GP is sympathetic but feels unable to
assist beyond offering low dosage
antidepressants (which did not help at
all but dulled her faculties even more
and which she has now stopped) and
pain-killing prescriptions (which do
not help more than marginally).
Jenny was referred to a Consultant
Rheumatologist at the local hospital
who diagnosed fibromyalgia
syndrome (FMS) some 18 months ago.
She was then referred to a pain clinic
at the hospital where she was given
10 sessions of electro-acupuncture,

which provided short-term relief of

the neck symptoms but not to any of
her other symptoms or general pain.
She reports that she became very
tearful during acupuncture treatment.
She was subsequently offered a neck
support which she uses at times
when she feels she cannot sustain
the weight of her head. She was also
advised to 'learn to live with the
problem'.
Jenny has no allergy history; her
periods are, and always have been,
normal, and her diet is balanced. She
developed thrush after the accident
which lasted for some 6 months,
having been treated with antifungal
medication by her GP.
Her attitude is determined but
despairing, as her marginal degree of
progress to date is so slow. She
presents as a tense, intense individual,
making a heroic effort to concentrate
on what she is saying and what is

being said. She talks slowly and

deliberately, weighing each word
before speaking. Her shoulders are
held high and tense, in a posture of
anxiety, or defence. Her breathing is
very much in the upper chest.
The clinical perspective exercise
this month will pose the following
questions, of different health care
providers (an osteopath/naturopath;
a chiropractor; a psychologist expert
in cognitive behaviour therapy and
a massage therapist). What would
your approach be to this case if
Jenny consulted you? What tests or
evaluations would you want, and for
what reason, and depending upon
the results and evidence obtained,
what treatment might be offered,
with what expectations? What
manual approaches (if any) would
you consider appropriate, with what
objective and what anticipated
outcome?

Fibromyalgia: osteopathic- naturopathic approach

L. Chaitow
In the case of Jenny there seems
to have been a specific traumatic
incident that triggered the start of her
symptoms, having enjoyed 'perfect'
health prior to the whiplash incident.
However, over the years during which

Leon Chaitow ND DO
c/o Centre for Community Care and Primary Health,
University of Westminster, 115 New Cavendish Street,
London WIM 8JS, UK
Correspondence to: L. Chaitow
Tel: +44 171 224 4220; Fax: +44 171 486 1241
Received May 1998
Accepted June 1998

Journal of Bodywork end Movement Therapies (1998)

2(4), 195-199
Harcourt Brace & Co. Ltd 1998

her health has declined a variety of

associated symptoms have emerged,
and a strategy is needed to evaluate
which of these can be modified
or eliminated, while trying to
understand what mechanisms might
be maintaining her symptom picture
(Goldstein 1996).
Where a condition (such as
fibromyalgia syndrome (FMS) or
chronic fatigue syndrome (CFS))
involves multiple interacting features
it makes clinical sense to try to reduce
the burden of whatever factors are
imposing themselves on the defence,
immune and repair mechanisms of the
body. At the same time, it is important
to do all that is possible to enhance
immune and repair functions without
creating excessive demands on a

patient's adaptive capacity and current

vitality (Figs 1 and 2). It is therefore
vital to:
Get the diagnosis right. Many
rheumatic-type problems produce
widespread muscular pain,
e.g. polymyalgia rheumatica.
Laboratory and other tests can
identify most non-FMS conditions
and these should be eliminated
from the picture (Yunus 1989)
(Fig. 3).
Carefully evaluate Jenny's neck
and cranial status to see whether
the whiplash has left any residual
and treatable dysfunctional patterns
(Buskilla 1997).
Identify associated myofascial
trigger-point activity and treat these

0
J O U R N A L OF B O D Y W O R K A N D M O V E M E N T T H E R A P I E S

OCTOBER

1998

Chaitow

Allergic and autoimmune

conditions

Possible nutrient
deficiencies
vitamins
minerals
- EFA's
-

Neural and/or limbic !ii

system malfunction li~.

Acquired toxicity
- pesticides etc
- heavy metals
- petrochemicals
- self-generated
via infection
-

Lifestyle factors
- poor sleep patterns
inadequate or excessive exercise
- alcohol, tobacco usage
social and medical drugs
- poor food choices
-

- i a t e r o g e n i c

influences etc
Emotional distress
personality traits
- powerlessness
anxiety
- depression
issues
-

Infections
bacterial
- fungal
viral
parasitic etc
-

- i n t e r p e r s o n a l

Bowel dysbiosis
Organ dysfunction
(liver, kidneys) etc
Endocrine imbalance

Genetically inherited tendencies

- hypermobility
genetic inscription influences
on hormonal function
-

Multiple current symptoms:

pain, fatigue, insomnia, IBS,
digestive, allergic, recurrent
infections, genito-urinary etc

Fig. 1

Functional problems
- hyperventilation
digestive enzyme
deficit etc

Trauma - physical
+/or psychological

Fibromyalgia in context - the multiple stressors.

appropriately, possibly
incorporating aspects of bodywork,
analgesic injection (xylocaine etc.),
acupuncture, nutrition,
hydrotherapy, postural and/or
breathing re-education, relaxation
methods etc. (Sandford Kiser 1983;
Travell & Simon 1983, Deluze et al
1992, Baldry 1993).
Provide appropriate soft-tissue
manipulative treatment plus
teaching gentle self-help methods
(Box 1)(Rubin etal 1990, Jimenez
et al 1993, Stoltz 1993).
Assess and treat (or refer elsewhere)
associated conditions such as

allergy, anxiety, hyperventilation,

yeast or viral activity, bowel
dysfunction, underactive thyroid,
sleep disturbance, depression etc.
(Holti 1966, Joly 1991, Paganelli
1991, Moldofsky 1993, Timmons
1994, Clauw 1995, Lowe 1995,
Tuncer 1997).
* Gradually, and in consultation with
Jenny, introduce constitutional
('whole body') health enhancement
methods such as: breathing
retraining, deep relaxation methods
(e.g. autogenic training), graduated
exercise programmes, regular
(weekly or fortnightly)

detoxification (fasting) days,

hydrotherapy for anxiety/pain and,
perhaps, progressive cold bathing
for circulation, plus regular nonspecific massage and acupuncture
for 'energy balancing' and pain
control (Ferraccioli 1989, Barelli &
1994, Bland 1995).
* Offer appropriate nutritional advice
(herbs and supplements), relying on
those for that have a research-based
validity (magnesium, malic acid,
manganese glycinate, methionine,
N-acetyl cysteine (NAC), vitamin
B 1 (thiamine), DLPA etc) as well
as amino acids for growth hormone

JOURNAL OF BODYWORK AND MOVEMENT THERAPIES OCTOBER 1998

Osteopathic - naturopathic approach

drugs (very low dosage) may offer

short-term benefit (Goldenberg
1986, Hudson 1996).
- Encourage Jenny to join support
groups, to read about the condition
and health enhancement; and to
take control of the condition even
if progress is apparently slow.
Suggest stress, or general,
counselling or behaviour
modification approaches which
may help in the learning of coping
skills and lead to stress reduction
(Goldenberg 1991, Fry 1993,
Waylonis 1994, Yunus 1994).

The interacting influences of a biochemical, biomechanical and psychosocial nature do not

produce single changes. For example:
a negative emotional state (e.g. depression) produces specific biochemical changes, impairs
immune function and leads to altered muscle tone
-- hyperventilation modifies blood acidity, alters neural reporting (initially hyper and then hypo),
creates feelings of anxiety/apprehension and directly impacts on the structural components
of the thoracic and cervical region - muscles and joints
-- altered chemistry affects mood; altered mood changes blood chemistry; altered structure
(posture for example) modifies function and therefore impacts on chemistry (e.g. liver
function) and potentially on mood
--within
these categories - biochemical, biomechanical and psychosociat- are to be found
most major influences on health.
--

Fig. 2 Three major categories of health influence interacting with the individual's unique
inherited and acquired characteristics defence, repair, immune function (homeostasis).

production enhancement (arginine,

ornithine). Specific herbal help to
enhance circulation to the brain
(e.g. Ginkgo biloba) may be useful
since studies show circulatory
deficit in the brain stem which
may be aetiological. Other herbal
products can be used for their pain
reducing properties (e.g. Boswellia)
or for relaxation properties
(kava kava, valerian etc). One
homeopathic remedy (Rhus tox 6C)
has been shown to be useful in

FMS (Fisher et al 1989, Jacobsen

1991, Yunus et al 1992, Kacera
1993, Sahley 1996).
Advise on regular exercise within
tolerance - if possible including
cardiovascular training and
stretching movements (yoga and/or
T'ai chi) (M'Cain et al 1988).
Possibly, if herbal and nutritional
methods fail to achieve the desired
result, suggest medication - under
medical supervision - to enhance
sleep. In this respect, antidepressant

Recovery from FMS is slow at best

and it is easy to make matters worse
by over-enthusiastic and inappropriate
interventions, or by introducing too
many quite appropriate changes too
rapidly. Patience is required by both
the health care provider and the
patient, avoiding raising false hopes
while realistic therapeutic and
educational methods are used that
do not make matters worse and that
offer ease and the best chance of
improvement.
I would anticipate that a broad, and
slowly unfolding, approach such as
that outlined above would lead to
progress, albeit slowly. Jenny could
come to understand her condition
better and, as her associated symptoms
modified (allergy, irritable bowel,
fatigue) and as her pain became
something she could do something
about herself (self-help positional
release methods for example) (Fig. 4),
her functioning would improve;
something approaching normal life
could resume. This progression,
however, would almost certainly be
erratic, with set-backs when inevitable
life stresses or infections once more
overloaded her adaptive capacity.
Within the framework of such a
programme the bodywork component
should be seen to be supportive, and
not primary, since FMS is not
primarily a musculoskeletal problem,
but one in which, while the major pain
symptoms manifest in the muscles, the

JOURNAL OF BODYWORK AND MOVEMENT THERAPIES OCTOBER 1998

Chaitow

'"/

"\\t

!j~i/
/

/
_.;_.,.,

)
\

~I'.

;J

...........
...........4
...}..::...~/
/

/:' iI

,/'2. )

I".......................!

"!

/i

""....

Fig. 3 The 18 bilateral tender point sites used in establishing a fibromyalgia diagnosis. Eleven of
the 18 need to be reported as painful on application of 4 kg pressure (see Box 1).

J O U R N A L OF B O D Y W O R K AND M O V E M E N T T H E R A P I E S

Fig. 4 Strain/counterstrain self-treatment of a

tender point in the 2nd costal interspace.
Patient applies sufficient pressure to cause
discomfort and then positions head, neck,
trunk until pain in tender point reduces by at
least 70%. This is held for up to 90 seconds to
enhance circulation and reduce pain.

OCTOBER 1998

Osteopathic - naturopathic approach

cause lies deeper in the body

chemistry and psyche.
This is an ideal condition for
collaborative inter-professional
dialogue and cooperation.

REFERENCES
Baldry P 1993 Acupuncture, Trigger Points and
Musculoskeletal Pain. Churchill Livingstone,
Edinburgh
Barelli P 1994 Nasopulmonary physiology.
In: Timmons B (ed). Behavioural and
Psychological Approaches to Breathing
Disorders. Plenum Press, New York
Bland J 1995 Medical food-supplemented
detoxification program in management of
chronic health problems. Alternative
Therapies 1:62-71
Bowles C 1981 Functional technique - a
modern perspective. Journal of American
Osteopathic Association 80(3): 326-331
Buskilla D 1997 Increased rate of FMS
following cervical spine injury. Arthritis and
Rheumatism 40(3): 446-452
Chaitow L 1991 Soft Tissue Manipulation.
Healing Arts Press, Rochester, Vermont
Clauw D 1995 Fibromyalgia: more than just a
musculoskeletal disease. American Family
Physician 1 September
DeLuze C et al 1992 Electroacupuncture in
fibromyalgia. British Medical Journal 21
November: 1249-1252
Ferraccioli Get al 1991 EMG-Biofeedback in
fibromyalgia syndrome Journal of
Rheumatology 16:1013-1014
Fisher P e t al 1989 Effect of homoeopathic
treatment of fibrositis (primary fibromyalgia),
British Medical 32:365-366
Fry R 1993 Adult physical illness and childhood
sexual abuse. Journal of Psychosomatic
Research 37(2): 89-103
Goldenberg D et al 1986 Randomized
controlled trial of Amitripyline anproxine
in treatment of patients with fibromyalgia.
Arthritis and Rheumutism 29:1371-1377

JOURNAL

Goldenberg D et al 1991 Impact of

cognitive-behavioural therapy on
fibromyalgia. Arthritis and Rheumatism
34(supp19): S190
Goldstein J 1996 Betrayal by the Brain. The
Neurological Basis of CFS and FMS and
Related Neural Network disorders. The
haworth Medical Press, New York
Holti G 1966 Candida allergy. In: Winner H,
Hurley R (eds). Symposium on Candida
Infections. Churchill Livingstone, Edinburgh
Hudson J 1996 The relationship between FMS
and major depressive disorder. Rheumatic
Disease Clinics of North America 22(2):
285-303
Jacobsen S 1991 Oral S-adenosylmethionine
in primary FMS. Scandinavian Journal of
Rheumatology 20(4): 294-302
Jiminez C et al 1993 Treatment of FMS with
OMT and self-learned techniques. Report in
Journal of American Osteopathic Association
93(8): 870
Joly E 1991 Viral persistence in neurons
explained by lack of major histocompatibility
class 1 expressions. Science 253:1283.-1285
Kacera W 1993 Fibromyalgia and chronic
fatigue - a different strain of the same
disease? Canadian Journal of Herbalism 9(3):
20-29
Lederman E 1998 Harmonic Technique.
Churchill Livingstone, Edinburgh
Levin S 1990 Massage effects on stress
response. Thesis, University of North
Carolina (Greensboro)
Lewit K 1985 Manipulative Therapy in
Rehabilitation of the Motor System.
Butterworths, London
Lowe J 1995 T4 induced recovery from FMS
by a hypothyroid patient resistant to T4 and
dessicated thyroid. Journal of Myofascial
Therapy 1(4): 21-30
McCain Get al 1988 Controlled study of
supervised cardiovascular fitness training
program. Arthritis and Rheumatism 31:
1135-1141
Moldofsky H 1993 Fibromyalgia, sleep disorder
and chronic fatigue syndrome. CIBA
Symposium 173:262-279

OF BODYWORK

AND MOVEMENT

THERAPIES

Paganelli R 1991 Intestinal permeability in

patients with chronic urticaria-angiodema
with and without arthralgia. Annals of
Allergy 66:181-184
Rubin B e t al 1990 Treatment options in
fibromyalgia syndrome. Report in Journal of
American Osteopathic Association 90(9):
844-845
Ruddy T 1962 Osteopathic rapid rhythmic
resistive technique. Academy of Applied
Osteopathy Yearbook: 23-31
Sahley B 1996 Malic Acid and Magnesium
for FMS. Pain and Stress Publications,
San Antonio, Texas
Sandford Kiser R et al 1983 Acupuncture relief
of chronic pain syndrome correlates with
increased plasma metenkephalin
concentrations. Lancet ii: 1394-1396
Schiowitz S 1990 Facilitated positional release.
Journal of American Osteopathic Association
90(2): 145-156
Stoltz A 1993 Effects of OMT on the tender
points of FMS, Report in Journal of
American Osteopathic Association 93(8): 866
Timmons B (ed) 1994 Behavioural and
Psychological approaches to breathing
disorders, Plenum Press, New York
Travell J, Simons D 1983 Myofascial Pain and
Dysfunction, Vol 1. Williams and Wilkins,
London: 364-365
Tuncer T 1997 Primary fibromyalgia and
<.~
allergy. Clinical Rheumatology 16(1): 9-12
van Why R 1994 'Fibromyalgia and Massage'
symposium notes
Waylonis G 1994 Post-traumatic fibromyalgia.
American Journal of Physical Medicine and
Rehabilitation 73(6): 403-412
Yunus M 1989 Fibromyalgia and other
functional syndromes. Journal of
Rheumatology 16 (supp. 19): 69
Yunus W e t al 1992 Plasma tryptophan and
other amino acids in primary FMS. Journal of
Rheumatology 19:90-94
Yunus M 1994 Psychological aspects of FMS a component of the dysfunctional spectrum
syndrome. In: Masi A (ed). Fibromyalgia and
Myofascial Pain Syndromes. Bailliere,
London

OCTOBER

1998