Could Fibrositis be Making a Comeback?

Introduction

As I perused the abstracts for the upcoming 4th International Fascial Research Congress (September 2015), I came upon one that made me stop and think. It related to a half-day post-conference workshop by Kirstie Segarra – Managing Fascial Health for Individuals in Fibromyalgia:

To demonstrate clearly that managing widespread pain must include treatment of the fascia as we are structured determined systems, and to decrease pain is to invite change in the structure through the fascial matrix in order to have a correlating change in the central nervous system. In this way we restore homeostasis in the client.

Could pathology within fascia have been overlooked in the search for a peripheral source of nociception in this condition? Well, it appears that this is no longer the case.

Pathophysiological considerations

Liptan [1] hypothesized that fibromyalgia could be seen as a “bodywide fasciitis,” comparable to situations characterised by more focal fasciitis (e.g. plantar fasciitis).

The culprit appears to be chronic tension within the fascia responsible for causing micro-injuries (i.e. tears) in those with a “dysfunctional” healing response. Such a response is said to result from insufficient growth hormone release consequent upon inadequate deep sleep.

In summary, Liptan argued that: “Fascial dysfunction and inflammation may lead to widespread pain and central sensitization seen in fibromyalgia.”

She explained the tender points as possibly reflecting “areas that suffer the greatest microtrauma and mechanical stress from daily activities, and thus have higher levels of fascial inflammation.”

The main evidence put forward in support of her hypothesis derived from “recent biopsy studies [which] have found increased levels of collagen and inflammatory mediators in the fascia of fibromyalgia patients.”

But is this a novel hypothesis? In the Background section of her paper, Liptan harks back to the early 1900s when the aetiology of “muscular rheumatism” was indeed a hot topic.

Muscular rheumatism

In speculating upon the pathophysiology of low back pain, the great British neurologist, William Gowers [1904] coined the term “fibrositis” and thus championed the central role of the fascia in this condition:

In all parts it seems it seems the most susceptible to the influence we call “rheumatism” … The relation of lumbago to rheumatism would alone, make us expect to find it an affection of the fibrous tissue of the muscles, the tissue in which the spindles are situated, rather than of these alone … important proof that the malady is an affection of fibrous tissue; it may spread, and it spreads by continuity of this tissue.

Gowers postulated both focal and generalised forms of “fibrositis”:

We are thus compelled to regard lumbago in particular, and muscular rheumatism in general, as a form of inflammation of the fibrous tissue of the muscles.

The pathological findings

Ralph Stockman [1913], a Scottish pathologist, soon announced:

The essential lesion is a chronic inflammatory hyperplasia of white fibrous tissue in patches and as fibrous tissue is spread throughout the body the lesions may also be widely spread or may affect only a single limited area.

But after other researchers had repeatedly failed to find biopsy evidence of fibrous tissue inflammation, the “fibrositis” construct was eventually superseded by that of “fibromyalgia” [Hench, 1976] and classified in the nebulous category of non-articular rheumatism [Atkinson, 1981].

Treatment

As did Gowers, Liptan [2010] ascribed a limited role to anti-inflammatory drugs (NSAIDs and corticosteroids), which should be used only during the initial phase of injury repair.

According to Liptan [2010] “only slow and sustained pressure will effect changes in the fascial tissue” and she recommended manual therapy techniques that “don’t cause further injury and inflammation, but rather gently break apart existing fascial restrictions and adhesions to promote tissue healing.”

She wondered whether techniques said to target the fascia, which included “Rolfing” (a technique of deep tissue manipulation) and “myofascial release,” could “help define the role of fascia in producing fibromyalgia pain.”

Based upon Liptan’s hypothesis, a pilot trial was undertaken comparing Swedish massage with myofascial release therapy (MFR), each administered over 90 minutes a week for 4 consecutive weeks [Liptan et al. 2013]. The former technique utilized moderate pressure stroking of the neck, back, arms and legs, whereas MFR consisted of “prolonged assisted stretching of painful areas of soft tissue” in the same regions.

The rationale given for MFR manoeuvres is that they are designed to “break up fascial adhesions” presumed to be the consequence of tissue injuries occurring in the fascia of patients with fibromyalgia [Liptan et al. 2013]. That for Swedish massage is to increase circulation and promote general relaxation.

Although numbers were small, both forms of treatment were found to be “safe, tolerable and acceptable” with MFR producing better symptom reduction.

By contrast, the mainstay of treatment recommended by Gowers was complete rest:

Not even passive movement should be employed until it causes no pain, and then it should be most gentle. The avoidance of pain should be made the standard for all local measures.

Gowers observed that counter-irritation (cautery being the most effective form) sometimes lessens the pain, as does deep hypodermic injection of cocaine, repeated daily for 2-3 weeks.

Other treatment strategies worth trying included a Turkish bath, mild aperients and, in the most acute cases, medicinal agents such as salicylates, nitrous ether, colchicum and perchloride of mercury.

Looking ahead

Gowers conceded: “we are without any direct evidence of the real nature of these affections” but he did hope that opportunities for pathological research would be seized upon:

We cannot wonder at our ignorance, still less complain of it, for it is only quite recently that the minute structure of the sensory elements of muscle and tendon has been clearly perceived, and much of the normal structure remains obscure.

But over a century later, direct histological evidence to support the related concepts of “fibrositis” and “fascial adhesions” is still lacking.

Nonetheless, Liptan [2010] calls for the use of existing methods of in vivo microdialysis to investigate the chemical composition of fascial interstitial fluid for evidence of inflammation, as well as for evidence of activation of fibroblasts removed from fascial tissues. She did not canvass the possibility that any such inflammation might in fact be “neurogenic” [Julius & Basbaum, 2001].

As for the role of manual therapy, Liptan et al. [2013] hope that various measurement tools being developed “may provide insight into which symptom of function domains are most malleable to various types of massage intervention.”

Conclusion

To date, the search for underlying peripheral musculoskeletal pathology in fibromyalgia has not been fruitful.  Yet, a recently published book – Fascial Dysfunction: Manual Therapy Approaches (2014) – is being advertised to manual therapists with this rather astounding claim appearing in the blurb:

Fascial dysfunction is now recognized as one of the main underlying causes of musculoskeletal pain leading to impaired and reduced mobility.  [Link: http://www.amazon.com/Fascial-Dysfunction-Manual-Therapy-Approaches/dp/1909141100]

Could Gowers have been right after all? Should we now discard the term fibromyalgia and revert to his “fibrositis” model? It seems a most unlikely possibility but a critical review is urgently needed to once and for all resolve this important question.

References:

Atkinson MH. Nonarticular rheumatism. Can Fam Physician 1981; 27: 254-258.

Gowers WR. A lecture on lumbago: its lessons and analogues. Brit Med J 1904; i: 117-121.

Hench PK. Nonarticular rheumatism, 22nd rheumatism review: review of the American and English literature for the years 1973 and 1974. Arthritis Rheum 1976; 19(suppl): 1081–1089.

Julius D, Basbaum AI. Molecular mechanisms of nociception. Nature 2001; 413: 203–210.

Liptan GL. Fascia: a missing link in our understanding of the pathology of fibromyalgia. J Bodywork Mov Ther 2010; 14: 3-12.

Liptan G, Mist S, Wright C, Arzt A, Jones KD. A pilot study of myofascial release therapy compared to Swedish massage in Fibromyalgia. J Bodywork Mov Ther 2013; 17: 365-370.

Stockman R.  Discussion on fibrositis. Proc R Soc med 1913; 6: 36-39.

 

7 Comments

  1. Thank you for that lucid and interesting summary. You have accessed literature which is not as familiar to rheumatologists. Who among us, at least in the US, even knows of these journals and some of the notable efforts published there … e.g. from Guelph, Ontario: PP Purslow, Muscle fascia and force transmission, Journal of Bodywork and Movement Therapies 2010; 14: 411-417 .

    I am pleased by your lookback to the 1904 Gowers lecture on “Lumbago: Its Lessons and Analogues.” Gowers is the bete noire of CNS-focused fibromyalgia proponents because he unflinchingly sought biomechanical pathology for lumbosacral pain disorders, brachial pain (likely rotator cuff disease), thoracic cage pain, neck pain, etc. Many cases, he felt, were due to trauma, including awkward posture, in vulnerable individuals. He speculated on causation in the microscopic muscle spindles and their nerves, and also put emphasis on the tendinous attachments to bone via tissues we’d regard as fascia. Every time I read his lecture I enjoy those curious things which illuminate the medical perceptions of his time .. for instance, as you say, he critiques a variety of treatment modalities, including “free perspiration,” non-painful exercise, rest, avoidance by women of raising arms behind the head to groom hair, Turkish baths, “frequent hot fomentations,” massage, gentle electrical current, various liniments and wraps, saline laxatives, counter-irritation with cautery or with deep injections of cocaine, each method tuned to the early or late stage of the pain disorder. Gowers was skeptical of “medicinal agents” but in accepted a trial of salicylates, and of nitrous ether, citrate of lithia, and colchicum, with an option to add a small dose of perchloride of mercury in severe cases. Odd stuff, but not as odd as Lyrica and the suppositions underlying its use.

    As to the modern perception of causation in patients labeled as “fibromyalgia” sufferers, I favor looking at the underlying bio-neuro-mechanical features of each localized source of pain (including those features attributable to all locomotor system components, among them fascia). We owe our patients this much — especially in view of the scientific failure of the CNS theory — a failure so disastrous that its survival depends on shared illusions — particularly based around the fallacy of the normal control group.

  2. Dr Lampman, I share with you a great admiration for WR Gowers as a pioneer in clinical neurology. His paper on neuralgia is particularly remarkable for its clear descriptions of the various clinical presentations and for its prescience on possible central mechanisms involved in nerve pain [1].

    In my article, I was tempted to include these apt observation from Elliott [2]: “We have seen that there has been a progressive reduction in the number of conditions which can be attributed to fibrositis, and that the application of rigorous clinical discipline coupled with new technical methods threatens to continue the process of dismemberment … This thesis does not seek to shut the door on fibrositis as a clinical entity, and it would be unfortunate if the hypothesis of myofascial inflammation were to be replaced, at this stage, by a facile generalization that muscle tenderness is always due to spasm of skeletal muscle.”

    References:
    1. Gowers WR. Neuralgia; its etiology, diagnosis, and treatment. Wood’s Medical and Surgical Monographs 1890; 5(1): 3-56.
    2. Elliott FA. Aspects of “fibrositis”. Ann Rheum Dis 1944; 4: 22-25.

  3. “As to the modern perception of causation in patients labeled as “fibromyalgia” sufferers, I favor looking at the underlying bio-neuro-mechanical features of each localized source of pain (including those features attributable to all locomotor system components, among them fascia).”

    Dr Lampman, you may be interested to learn that there are others who seem to share your views, although they have extended them to medical conditions that are way beyond fibromyalgia, as we rheumatologists understand it.

    Here are some excerpts taken from an article by a prominent physical therapist, John F Barnes: “What is fibromyalgia really? What do fibromyalgia, chronic fatigue syndrome, chronic pain, headaches, pelvic/menstrual pain and dysfunction, and PMS have in common? These are simply different labels of a common denominator, unrecognized myofascial restrictions. Myofascial restrictions do not show up in all the standard tests that are now performed, nor have most health professionals been taught how to recognize them.”

    Having once identified the particular myofascial restriction in each case, Barnes claims that “Myofascial release is utilized for the treatment of menstrual pain and/or dysfunction, back and pelvic pain, and other inflammatory disorders. It can treat the unpleasant and/or painful symptoms of pregnancy and childbirth, recurrent bladder pain and infection, painful intercourse, sexual dysfunction, elimination problems, coccygeal pain, painful episiotomy scars and the list goes on.” He is confident that “these problems can in many cases be substantially alleviated or eliminated by myofascial release, nontraumatically and gently.”

    Myofascial release evidently has the added benefit of relieving the emotional pain associated with past unpleasant events or traumas. According to Barnes: “The painful memories or emotions from beatings, rapes, molestations, or miscarriages seem to be stored in the body’s memory … As myofascial release frees the adhered tissue, the trapped emotions and painful memories fade away leaving the person with a sense of peace.”

    Link: http://www.myofascialrelease.com/downloads/articles/Fibromyalgia.pdf

  4. Dr. Quintner, you are at your best in employing understatement and wry humor in handling Dr. Barnes’ Freud-like claims.

    As for me, I gained a “sense of peace” and fading of “trapped emotions and painful memories” some ten years ago when I shed concerns with the mystic weight of chronic widespread pain, finding solace in knowing that each limb or axial pain originated in rationally understood anatomic issues sculptured into the human form.

  5. Dr Lampman, the only connection I could find with Sigmund Freud (1856-1939) relates to his views on neurasthenia (a 19th century label for the fibromyalgia symptom cluster) as a “masturbation neurosis”:
    “Neurasthenics merge into anxiety neurosis in consequence of masturbation as soon as they refrain from this manner of sexual gratification.” [From Ch. VI. Selected Papers on Hysteria and other Psychoneuroses, 1912.]

    Barnes derives his inspiration from contemporary cellular biology, which does indeed include “anatomic issues sculptured into the human form”.

    I will briefly enlarge upon this matter, as rheumatologists may wish to have some knowledge and understanding of the various types of physical treatment on offer to their patients with fibromyalgia, and to be in a better position to help them discern what may be useful and what may be a waste of their time and money.

    In Massage Magazine, Barnes (2014) gives more than a passing nod to science and describes his work as “restoring the body’s microenvironment,” which he rightly sees as “critical to our health”. Barnes’ focus is solely upon fascia, which he describes as “truly the architecture of life”:

    “The cells’ cytoskeletons are influenced by the extracellular matrix, i.e. the fascia, which are in a constant tug of war. Balance is important to health.” [Barnes, 2014]

    Biologists accept that a fundamental requirement of cells is their ability to transduce and interpret their mechanical environment in response to physical forces and that this ability contributes to regulation of growth, differentiation and adaptation in many cell types [Ingber, 1997; Palmisano et al. 2015]. This is not a new concept:

    “The ancient Greek philosopher Aristotle considered shape as the soul of all living entities. Cell biologists are beginning to see the profound role of shape in a more modern sense. Shape exerts a powerful influence on life: on the one hand, it affects how cells build and repair organs, and on the other hand, it can become malevolent, undermining health. As we refine our understanding of the power of shape, we may be able to bend it to help people.” [Piccolo S, 2014]

    According to Barnes, physical treatment of patients with fibromyalgia is to be targeted at fascial “restrictions,” which can only be detected by well-trained therapists (Barnes has instructed more than 100,000 therapists worldwide in his Myofascial Release Approach):

    “In the practice of Myofascial Release, we focus on finding the restrictions in the individual, generating the proper amount of pressure, and waiting a sufficient amount of time-five minutes or longer-for a number of important physiologic processes to occur. These include piezoelectricity, mechanotransduction and ultimately, resonance, which is another word for the release we hope to help our clients achieve.” [Barnes, 2014]

    So patients with fibromyalgia could well harbour a multitude of “myofascial restrictions,” and be completely unaware of them. How well do Barnes’ theories translate into clinical practice?

    Surprisingly, the important question of inter-observer reliability in detecting Barnes’ “restrictions” is yet to be addressed.

    Nevertheless, two controlled trials of “myofascial release therapy” in fibromyalgia have been published by Spanish researchers [Castro-Sánchez et al., 2011 (a); Castro-Sánchez et al., 2011 (b)].

    In the former study, those in the experimental group attended twice-weekly for treatment administered according to a strange protocol that included: “release of the falx cerebri by frontal lift, release of tentorium cerebelli by synchronization of temporals, deep fascia release in temporal region, suboccipital release, compression–decompression of temporomandibular joint, global release of cervicodorsal fascia, release of pectoral region, diaphragm release (transverse slide), transverse diaphragmatic plane, lumbosacral decompression, release of psoas fascia and release of fascia of the lumbar square.”

    The investigators did not address the question as to whether “restrictions” actually existed at any or all of these disparate anatomical sites.

    In the latter study, the experimental group underwent release of their “myofascial restrictions” for 90 minutes weekly. Treatment was specifically directed at the sites of the 18 “painful points” reported by the American College of Rheumatology. Presumably the therapist spent 5 minutes treating each of these sites in turn. Neither study documented the number of myofascial “restrictions” detected in the respective control groups.

    Both studies, which are not really comparable in design, concluded that these techniques of manual therapy administered regularly for 20 weeks produced better outcomes at one and six months than sham therapy with a disconnected “magnotherapy” device.

    The main conclusion I draw is that there does seem to be quite a large credibility gap to bridge between Barnes’ theory of “myofascial restrictions” and its translation into clinical practice, at least for patients with fibromyalgia.

    However, it appears there are still those who believe that pathological changes reside in the region of the “tender points” once said to be associated with fibromyalgia. But of that there is no evidence!

    Yes, fibrositis never really disappeared and is definitely making a strong comeback.

    References:

    Barnes JF. Therapeutic insight: The John F. Barnes’ myofascial release perspective – how mechanotransduction may affect cells. Massage Magazine, October 23, 2014. http://www.massagemag.com/therapeutic-insight-the-john-f-barnes-myofascial-release-perspective-how-mechanotransduction-may-affect-cells-27154/

    Castro-Sanchez AM, Matarán-Peñarrocha GA, Morales MA, et al. Effects of myofascial release techniques on pain, physical function, and postural stability in patients with fibromyalgia: a randomized controlled trial. Clin. Rehabil 2011 (a); 25 (9): 800-813.

    Castro-Sánchez AM, Matarán-Peñarrocha GA, Granero-Molina J, et al. Benefits of massage-myofascial release on pain, anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia. Evidence-based Complementary and Alternative Medicine 2011 (b), Article ID 561753, 9 pages. doi: 10.1155/2011/561753.

    Ingber DE. Integrins, tensegrity, and mechanotransduction. Gravitational and Space Biology Bulletin 1997; 10(2): 49-55.

    Palmisano M, Bremner SN, Hornberger TA, et al. Skeletal muscle intermediate filaments form a stress-transmitting and stress-signaling network. Journal of Cell Science 2015; 128: 219-224.
    Piccolo S. Twists of fate. Scientific American, October 2014: 75-81.

  6. Try being diagnosed with this, I have no reason to think that it is anything organic and in the past have always thought that it was a disease (?) of neurotic women. Now I have to live with the d@mn diagnosis and am not in the least bit happy about it.

  7. It is not surprising that Dr Ginevra Liptan* has endorsed (but with considerable reservation) use of the FasciaBlaster. She claims, “… we know that the buildup of scar tissue creating adhesions and painful knots in the fascia plays an important role in many chronic pain conditions, including fibromyalgia, low back pain and tendonitis” and, in relation to the FasciaBlaster, she gives this advice, “from my experience it is too intense for most fibromyalgia patients and requires really good technique to get benefits and not harm.” Link: http://www.drliptan.com/blog/2017/3/10/can-the-fasciablaster-help-with-fibromyalgia-pain

    Yes, in the total absence of any supporting scientific evidence, the “fascia” mythology lives on regardless!

    *Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You…And Your Doctor

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