Fibromyalgia Meets Craniosacral Therapy

Fibromyalgia
The current criteria for making the diagnosis of fibromyalgia are based upon the scoring obtained from two subjective measures, the Widespread Pain Index and the Symptom Severity Scale, the results of which are then combined [Wolfe et al, 2010]. Fibromyalgia is therefore neither a distinct syndrome nor a specific disease, which is now being understood as an indication of polysymptomatic distress [Wolfe et al. 2013].

Complementary and Alternative Medicine
Practitioners who operate under the umbrella of Complementary and Alternative Medicine (CAM) have exploited this diagnostic uncertainty, as evidenced by a recent systematic overview of such therapies, which are utilized by many patients with fibromyalgia [Lauche et al., 2015].

Although some of the interventions appeared to be beneficial, in others the outcomes were either inconsistent or inconclusive. The investigators remarked upon the “methodological flaws limiting definite conclusions about their efficacy and safety” [Lauche et al., 2015].

Somewhat surprisingly, craniosacral therapy (CST) was not included in the systematic overview. However, this form of therapy is being confidently offered around the world to patients with fibromyalgia. [For example, see: http://www.fibromyalgia-symptoms.org/fibromyalgia_craniosacral.html]

The origins of craniosacral Therapy (CST)
CST is an approach that appears to have been modeled upon the remarkable theories of 18th century Swedish philosopher and scientist, Emanuel Swedenborg [Tubbs et al. 2011]. Because of his many prescient insights about the brain and nervous system, Swedenborg has been recognized as a neuroscientist who was well ahead of his time [Gross, 2009], and has been accorded a prominent place in the history of neurology [McHenry, 1969].

He gave an accurate account of the importance of the cerebral cortex as the seat of the higher psychical functions and was the first to suggest somatotopic organization of the motor cortex, as well as the importance and function of the pituitary gland (which he termed the “arch gland”).

Swedenborg was aware of the phenomenon of pulsation of the brain [Maier, 1994] and believed that it imparted a motion to the cerebrospinal fluid [Squires, 1940]. The movements of the brain and the central nervous system were said to be reciprocal to those of the lungs i.e., when the lungs expand, the brain contracts, and vice versa. During the expansile motion of the brain cerebrospinal fluid is expressed from the IVth ventricle into the subarachnoid space.

The pumping action of the brain forced “nervous fluid” through the nerves. The spinal ganglia were thought to help propel the fluid, which was eventually returned to the spinal cord and brain by way of the meninges [McHenry, 1969].

Swedenborg attempted to explain mental events in terms of minute vibrations or “tremulations”. These, and his other important contributions to neuroscience, were only recognized when his manuscripts were discovered, translated, and published in the late 1800s.

Swedenborg’s influence
Swedenborg’s ideas seem to have influenced William Garner Sutherland (1873-1954), an American osteopathic physician, who proceeded to elaborate upon them [Scarr, 2013].

Sutherland described five components of what he called The Primary Respiratory Mechanism, an intrinsic motion that expressed itself through the entire body and was held to be a “fundamental expression of life itself.”

Agreeing with Swedenborg, Sutherland observed that the brain and spinal cord undulate rhythmically, as does the cerebrospinal fluid. Moreover, this fluid was able to move throughout the body by passing along the spinal nerve sheaths and through extra-cranial lymphatics, thereby fulfilling a nutritive function. The movements of the brain and cerebrospinal fluid also became evident in the spinal membranes as a “dynamic shifting of tension” within them.

Sutherland believed that the dura mater was held under constant tension and could transmit external forces along its length. Because of its attachment to the cranial bones, this tissue was responsible for maintaining the structural integrity of the cranium.

Thus, excessive forces applied by the dura mater to the cranium could lead to distortion of its components, which although they grew to approximate each other, remained in constant motion. The cranial sutures were thus kept open by tiny movements, estimated to be of the order of 100ths of an inch.

Sutherland’s views were at odds with the conventional thinking of anatomists, which held that the bones of the skull fused in early life. But Sutherland interpreted the fusion of certain cranial sutures to be indicative of a pathological condition, said to follow cranial traumata.

The importance given to the sacrum is due to its role in anchoring the dura mater. Motility at the level of the occiput is transmitted to the sacrum. Any trauma to the sacrum could also have an effect on the cranium (e.g. be a cause of headache).

Sutherland also believed that the body’s connective tissues are subject to a cyclic change in tension and a small amount of motion, typically 2-14 times a minute [Scarr, 2103].

In summary, the “craniosacral system” comprises the bones of the skull, the cerebrospinal fluid flowing within the spinal meninges, and the anchoring sacrum.

Upledger’s contribution
The idea of cranial bone movement and a “dural pulse” were further developed in the 1970’s through research performed by osteopath John E. Upledger (1932-2012) and his associates at the University of Michigan.

A key part of the ‘cranial’ concept is that bones of the skull remain distinct throughout life and have a rhythmic motion that is palpable as the ‘cranial rhythmic impulse’ [Scarr, 2012].

This mobility allows the CST practitioner to palpate the pulse and at the same time to gently move the cranial bones in such a way as to remove any restrictions, in order to restore bodily balance, and relieve tension in fascial tissues throughout the body. Headaches, muscles spasm, and chronic pain are said to then be able to rapidly dissipate.

In contrast to Sutherland’s Primary Respiratory Mechanism Model, Upledger suggested that the cerebrospinal fluid pressure rhythmically fluctuates according to its cycle of production and resorption. It is this “pressurestat” mechanism that drives the ventricular system of the brain to dilate and contract rhythmically—rather than “some intrinsic contractile power of the brain tissue itself” [Upledger & Vredevoogd, 1983].

Upledger’s model centered upon the presumed existence of sensory nerves and receptors positioned within human sagittal sutures that are responsive to compression and stretch, acting as a signaling system between the respective suture and the choroid plexus.

When a suture expanded, stretch receptors were activated and the production of cerebrospinal fluid (CSF) decreased. As fluid was reabsorbed into the venous system, volume and pressure of CSF reduced, activating compression receptors within the suture and signaling the choroid plexus to resume production of CSF. According to Upledger [1995]:

“The brain, in turn, rhythmically tones and relaxes the myofascial system via the motor division of the nervous system. This effect is delicate and easily inhibited by connective tissue that is restricted and not able to respond to this gentle urging of the craniosacral system via the motor system. Hence, these restrictions are easily found by the skilled therapist practicing craniosacral therapy.”

Alaquel et al. [2006] reviewed the evidence that cranial sutures do respond to mechanical loads and believed that they function as a cushion between adjacent bones. The sutures can indeed be subject to compressive stress, tensile stress, and shear stress as the underlying brain expands during development and as forces are transmitted from the masticatory muscles.

But these forces are technically difficult to measure with accuracy. Alaquel et al. [2006] considered that additional research is needed to elucidate the mechanotransduction events by which cranial sutures respond to the application of mechanical force.

Inter-rater reliability of CST
When Wirth-Pattullo and Hayes [1994] tested the claim that craniosacral therapists are able to palpate changes in cyclical movements of the cranium, they found that inter-rater reliability was unacceptable for clinical decision-making and treatment. They also wondered about the very existence of craniosacral motion and whether the evaluators in their study might have imagined such motion.

In a lengthy response, Upledger [1995] affirmed the usefulness of his “pressurestat” model and argued that other factors needed to be considered besides an assessment of the rate, amplitude, symmetry, and quality of the craniosacral rhythmical activity, as palpated using the “vault hold” on the head.

Upledger [1995] argued: “we should not allow strict adherence to the rules of experimental design to fetter human intelligence, nor should we allow it to stifle our creativity.”

He then defended his position by calling upon therapists to factor in the “wisdom of the body,” or in other words, to harness the placebo response:

“Implicit in craniosacral therapy is the concept that the patient’s own body and craniosacral system know how best to correct the problem. Our goal as therapists is to tune into that inherent wisdom and assist and facilitate its self-corrective processes.”

Controlled trials of CST in fibromyalgia
In a randomized controlled trial of a 20-week programme using a CST protocol in patients with fibromyalgia, symptoms did improve but there was no comparable control group (i.e. patients receiving another form of manual therapy) [Cástro-Sanchez et al. 2011]. The same serious design fault was evident in another study performed by the same group of researchers [Mataran-Peñarrocha et al. 2011]. The control group in each of these studies had received disconnected magnetotherapy.

The complex treatment protocol administered by the researchers was aimed at “removing the restrictive obstacle and returning the system to its natural state.” But it is noteworthy that they failed to record the nature and site of any such obstacles they encountered in members of either group.

Conclusion
From the available scientific evidence, one can only agree with the conclusion of Rogers and Witt [1997] that the opinions or beliefs of practitioners of CST do not provide sufficient reasons to support its use as an effective treatment. At the very least this appears to be the case for those with fibromyalgia.

References:

Alaquel SM, Hinton RJ, Oppenehim LA. Cellular response to force application at craniofacial sutures. Orthod Craniofacial Res 2006; 9: 111-122.

Castro-Sánchez AM, Mataran-Peñarrocha GA, Sánchez-Labraca N, et al. A randomized controlled trial investigating the effects of craniosacral therapy on pain and heart rate variability in fibromyalgia patients. Clin Rehabil 2011; 26: 25-36.

Gross CG. Three before their time: neuroscientists whose ideas were ignored by their contemporaries. Exp Brain Res 2009; 192: 321-334.

Lauche R, Cramer H, Häuser W, et al. A systematic overview of reviews for complementary and alternative therapies in the treatment of the fibromyalgia syndrome. Evid Based Complement Alternat Med 2015, Article ID 610615, 13 pages.

Maier SE, Hardy CJ, Jolesz FA. Brain and cerebrospinal fluid motion: real time quantification with M-mode MR imaging. Radiology 1994; 193: 477-483.

Mataran-Peñarrocha GA, Castro-Sánchez AM, Garcia GC, et al. Influence of Craniosacral Therapy on Anxiety, Depression and
McHenry L, Jr. Garrison’s History of Neurology, revised and enlarged. Springfield: Charles C Thomas, Publisher, 1969: 107-108.

McHenry L, Jr. Garrison’s History of Neurology, revised and enlarged. Springfield: Charles C Thomas, Publisher, 1969: 107-108.

Rogers JS, Witt PL. The controversy of cranial bone motion. JOSPT 1997; 26: 95-103.

Scarr G. Palpatory phenomena in the limbs: a proposed mechanism. Int J Osteopath Med 2013; 16; 114-120.

Squires AW. Emanuel Swedenborg and the cerebrospinbal fluid. Ann Hist Med 1940; 2: 52-53.

Tubbs RS, Riech S, Verma K, et al. Emanuel Swedenborg (1688-1772): pioneer of neuroanatomy. Childs Nerv Syst 2011; 27: 1353-1355.

Upledger JE, Vredevoogd JD. Craniosacral Therapy. Seattle: Eastland Press, 1983.

Upledger JE [Letter]. Craniosacral therapy. Phys Ther 1995; 75: 328-329.

Wirth-Pattullo V, Hayes KW. Interrater reliability of craniosacral rate measurements and their relationship with subjects’ and examiners’ heart and respiratory rate measurements. Phys Ther 1994; 74: 908-916.

Wolfe F, Clauw DJ, Fitzcharles M-A, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res 2010; 62: 600-610.

Wolfe F, Brähler E, Hinz A, Häuser W. Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polysymptomatic distress: results from a survey of the general population. Arthritis Care Res 2013; 65: 777-785.

26 Comments

  1. At first, I thought that John Quintner’s article on Craniosacral therapy told me much more than I wanted to know about CST. It is not the kind of thing I want to spend much time on, a decision I made some years ago when I discovered the world was not flat. There are so many crazy ideas about fibromyalgia and so many crazy treatments. Quintner’s article taught me that CST was even crazier than I had thought. What I am always left with after reading such things is the question, “How can people believe this?”

    One of the references in the CST piece was to an article that had as an author a frequent co-author of mine, Winfried Hauser. The article, “A Systematic Overview of Reviews for Complementary and Alternative Therapies in the Treatment of the Fibromyalgia Syndrome,” concluded “Despite a growing body of scientific evidence of CAM therapies for the management of FMS systematic reviews still show methodological flaws limiting definite conclusions about their efficacy and safety.” But in the article, there was this: “In the current German guideline for the treatment of the fibromyalgia only meditative exercise techniques, that is, yoga, tai chi, or qigong, among others, received a strong recommendation followed by acupuncture with an open recommendation. All other complementary therapies were not recommended when used as monotherapies.” Sometimes systematic reviews give more credence to therapies than the “research” trials that are said to underlie the recommendations. From the Lauche article we learn that that there is ” growing body of scientific evidence of CAM therapies for the management of FMS,” even though, it would seems from the review – the opposite, that there is not a growing body of scientific evidence. One could read with amusement that the German guidelines strongly recommended “meditative exercise techniques, that is, yoga, tai chi, or qigong.” Had the systematic reviewers been aware of CST they probably would have concluded that they could not come to definite conclusions about its efficacy and safety. Still, Quintner makes it clear. We don’t need a systematic review for CST. Probably a good thing, too.

    • I would add the importance of prior plausibility. If a hypothesis must break known rules of physics or physiology, we should need a much higher standard of proof. In the real world of limited research resources, it is unconscionable to waste them on clinical trials of such hypotheses.

    • There is a growing body of research, but it does not translate to a growing body of evidence. There are CST palpation studies (not necessarily clinical treatment based) that are more current than the Wirth-Pattullo and Hayes [1994] study mentioned, but they do not counter the 1994 findings. Despite any methodological improvements in current studies the outcomes tend to generally agree with the 1994 findings. This collection of studies could constitute a body of evidence that CST reliability is ‘unacceptable for clinical decision-making and treatment.’

  2. Monica, I have since become aware of another important paper by Hartman and Norton that contains a damaging review of CST. They conclude: “Our own and previously published findings suggest that the proposed mechanism for cranial osteopathy is invalid and that inter-examiner (and, therefore, diagnostic) reliability is approximately zero. Since no properly randomized, blinded, and placebo-controlled outcome studies have been published, we conclude that cranial osteopathy should be removed from curricula of colleges of osteopathic medicine and from osteopathic licensing examinations.”

    Reference: Hartman SE, Norton JM. Interexaminer reliability and cranial osteopathy. The Scientific Review of Alternative Medicine 2002; 6(1): 29-34.

    PS Here is the complete reference to Mataran-Peñarrocha et al. that appears to be incomplete in the main article.

    Mataran-Peñarrocha GA, Castro-Sánchez AM, Garcia GC, et al. Influence of craniosacral therapy on anxiety, depression and quality of life in patients with fibromyalgia. Evidence-based Complementary and Alternative Medicine 2011, Article ID 178769, 9 pages. doi: 10.1093/ecam/nep125.

  3. CST can be filed under Possible Future Interest, next to chiari malformation (the fibromite and Ehlers-Danlos patient communities may be coming under the influence of chiropractic lobbyists?)
    CAM is intriguing. Holistic service providers have an ‘alternative’ view which theorises that mind, body and behaviour are all interconnected, and incorporates strategies that are thought to improve psychological and physical well-being, and aims to allow patients to take an active role in their treatment. Benefit would seem self-evident!
    The evidence base is confused, and opinions are in disarray. Recent Cochrane review CD001980 by psychologist Dr Theadom et al of mind&body CAM therapies for fibromyalgia endorsed psychotherapy, but a negative finding for mindfulness is at odds with an earlier Lauche & Langhorst et al (http://www.ncbi.nlm.nih.gov/pubmed/24290038) meta-analysis in 2013. Crucial to this 2015 decision was categorisation of Clauw et al ‘Sustained Pain Reduction Through Affective Self-awareness (ASA) in Fibromyalgia: A Randomized Controlled Trial’ as psychotherapy.
    Despite ASA delivered in a group setting by Dr H. Schubiner following Jon Kabat-Zinn teachings and incorporating mindfulness of breathing and meditative bodyscans. There’s a lot of politics in play.

  4. @FnMyalgia. Are you aware that SomatoEmotional Release (SER), which is being touted as a psychotherapeutic adjunct to CST, targets those with fibromyalgia who have become depressed? According to this theory, their emotions have become “stuck” and could in some way be creating more pain. SER consists of encouraging regions of “stuck” fascia to unwind and release any emotions that happen to be trapped within the offending tissue(s). Perhaps I am missing the point but I cannot see that either of these weird therapeutic approaches could be fairly categorised as being “holistic” (where the whole is greater than the sum of its parts).

    I found the paper by Clauw et al. to be quite confusing. The authors make mention of “pain disorders of central pain amplification” and also that they use a model of understanding pain as a “mind-body” syndrome. How is an intelligent reader expected to make any sense at all of these concepts?

      • Many well meaning people including those at NIH are mislead by something they read or they are grabbing at straws. Everyone wants to take credit for curing or reducing disc pain in the neck and low back, but there is little or no scientific evidence that anything works including intradiscal steroid. It would be interesting to see fibromyalgia exam results of a study from a spine surgery clinic comparing the pre and postoperative exam tender points or in those receiving complete pain relief.

        • John, I agree that intradiscal injections of a corticosteroid preparation in patients with localised cervical or lumbar spinal pain is an experimental form treatment which lacks a supporting scientific evidence-base. If, however, such injections are being offered to those who complain of persistent widespread pain (fibromyalgia syndrome) that, by definition, includes their spinal regions, then this would, in my opinion, constitute fraudulent practice. As an aside, and I am sure Professor Wolfe would be in agreement, a count of the number of tender points is a highly flawed means of assessing response to treatment of such patients.

  5. The US National Center for Complementary and Integrative Health within the NIH is non-judgemental, their classification isn’t an endorsement. Many therapies could be derided, although even crystals have their merits – offering more transparency than within our NHMRC!
    Daniel Clauw’s interest must surely fall under the ‘complementary’ umbrella, since his declared conflict-of-interest sponsorships and consultancies are inclusive of almost every pharmaceutical manufacturer. Although their ASA is clearly a monotherapy, as a cognitive-emotive tool adjunct to meds it’s shown promise through 21% experiencing halving of pain at 6month followup. Their UnlearnYourPain.com franchise is none too revealing of sufficient detail as to suit academic dissection. Omission of the psychometric standard FIQ as an outcome is also disappointing, because meta-analysis has revealed benefit (SMD) of about 1/3rd of a std deviation i.e. below Minimum Clinically Important Difference. These are early days.

  6. I am not at all enamoured of the concept of the “Tension Myositis Syndrome” pioneered by Dr John Sarno and since embellished by his followers, including Dr Howard Schubiner. I suspect that any academic dissection of the concept would take us back to Cartesian dualism, but I am happy to be proven incorrect in my prediction.

  7. Dear Fred, I have attached the link to an upcoming conference that appears to be quite prestigious. However, when one looks at the content of this conference it is clear that an “unholy alliance” has been forged between the “trigger point” aficionados (represented by Dr James Fricton of the International Myopain Society) and mainstream Rheumatology & Pain Medicine (as represented respectively by Drs Dan Clauw and Lynn Webster).

    The bottom line, no doubt, is the highly flawed proposition that “myofascial trigger points” are in some mysterious way able to initiate and then drive the central nervous system changes (“central sensitisation”) associated with the symptom cluster known as Fibromyalgia.

    This Conference could also be titled: “When the nebulous trigger point meets the innocent tender point: a potential disaster for medical science”.

    Link: http://www.fmcpaware.org/com-virtuemart-menu-users/announcing-2015-tap-chronic-pain-conference.html

  8. My post of Feb 20, 1916 The fibromyalgia examination is a fabulolus addition to the armamentarium of the medical provider seeing patients with musculoskeletal and headache complaints. When there is a successful interbody fusion at the level of the disc producing the pain there is pain relief, associated muscle spasm relief, and disappearance of any associated positive fibromyalgia syndrome findings. The ideal study would be in a surgical clinic performing interbody fusions(stop the motion stop the pain). To date I have not been able to find interest, but such will come in time. Two of my patients with only one painful disc in the lower neck and 5 or more positive points in the upper body had complete pain relief following successful fusion . Lower body exam was unchanged.

  9. John, you appear to be conflating chronic widespread pain (Fibromyalgia) with the phenomenon of regionally referred pain and mechanical allodynia (tenderness) arising from deep bodily structures – in this case the spine. I suspect that you have fallen into a logical error.

  10. The best I can determine it is all of disc origin particularly if the patient has neck or low back pain. The fibromyalgia exam is great in that it helps us further arrive at a correct diagnosis. Patient after patient can place their finger on the exact point of maximum tenderness over the anterior cervical spine and at most frequently the L5-S1 disc level in the low back. If the surgeon examines the anterior cervical spine before he operates he finds the point found by the patient is over the disc to be operated. The pain clinics are all giving steroid injections in these areas for the neck and low back pain.

    Another approach for the patient and physician seeking a most likely diagnosis is to send the patient to the experienced spine surgeon with his neck or low back pain and not mention fibromyalgia.

  11. John, is your comment meant to reflect upon the parlous state of pain management in your geographical area of practice? It is on this basis that I have listed my responses:

    (1) There is no such clinical entity as the “fibromyalgia exam”. As I explained above, the tender point count that was once an important criterion for the diagnosis/classification of fibromyalgia has been abandoned as it bore no relation whatsoever to the pain experienced by those with the presumed condition. I suspect that busy clinicians never actually performed such a count when confronted by a patient with chronic widespread pain.

    (2) That patients can identify points of maximum tenderness overlying their spine is an interesting observation but it is not one upon which a spinal surgical procedure should ever be undertaken.

    (3) If pain clinics in your area are “all giving steroid injections in these areas for neck and low back pain” I would advise those pain sufferers who are contemplating attending such clinics to avoid them like the plague. Such practice is as irrational as that of CST.

    (4) If patients complain of chronic widespread pain, why would you advise them to withhold such important information from a spine surgeon? In any case, in my opinion an experienced and ethical spine surgeon would be very loath to operate on a patient where the sole indication for such operation was spinal pain.

  12. John can I ask a question of you.

    Over the years I have read so much regarding Fibromyalgia (FM) and Myofascial Pain Syndrome (MPS), actually anything to do with widespread or regional chronic pain. Whilst there are obvious similarities there seems to be a difference in the treatment and the causal factors of these two complaints? Could you elaborate on this form me.
    I have had many and varied treatments to try and alleviate my pain symptoms and have been told I have many things over the past 16 years including FM and MPS, and agree with your thoughts relating to both CST and corticosteroidal injections (even dry needling) as a patient neither helped me. Injections of Botox helped to a small degree however not sufficient to warrant ongoing treatment. Recently I had trials and implants of neuro-stimulators in my cervical and lumbar spine as well as subcutaneous leads placed at the left and right iliac crest and right Supraspinatus.

    Although initially sceptical after some 15 years of chronic pain, these implants have assisted greatly in controlling my pain and right shoulder flexibility and movement range. The effects are dramatic and easily displayed just by turning the system on and off stops much of the pain, the most visual is stopping the muscle tremors in my right arm and hand. I still have some muscle cramping and sleep issues. Has there been any discussions relating to this treatment or is it likely that I didnt have FM or MPS in the first place and my pain stems from my cervical and lumbar disc problems? I realise both seem to be present in MPS but not FM patients?

    James

    • James, I am pleased to hear that you have obtained worthwhile pain relief at long last. To answer your question as directly as I can: (i) the theory of “trigger points” being responsible for MPS has been refuted. Yes, pain and tenderness can be referred into muscles from deep-seated spinal structures. In addition, some of the “trigger points” happen to overly major nerve trunks, which can also be tender in certain painful conditions. I can well understand your confusion! (ii) FM was initially conceived as a distinct syndrome (a set of clinical features running together) but in fact it was only ever a “symptom cluster” (a good analogy being the clusters or constellations of stars in the night sky. The stars in each cluster seem to be close together but in reality can be light years apart). Current thinking is that FM is not a single condition but rather a constellation of symptoms and signs that are indicative of human distress. They are features of dysregulated stress/sickness responses. Here is a link that you might find helpful: http://blog.apsoc.org.au/2015/05/18/this-train-is-bound-for-wholeville-a-travel-guide-for-the-perplexed/

  13. Thanks for the link John very much appreciated, I realise you cant make any specific comment relating individual conditions however is it therefore plausable for a miss diagnosis of patients labelled with MPS or to a lesser extent FM by medicos and specialist when in fact the cervical and lumbar spondylosis and foraminal stenosis could in fact be the root cause of much of the associated pain? As an Intelligence Analyst I always search for the cause and effect through a crictical thinking process when developing any hypothesis. In this process if Fibromyalgia and/or MPS are viewed as symtoms surely there is a cause whether this is a trauma either physical or mental, or even an underlying undiagnosed stressors, disease and/or illness, surely something disrupts the bodies normal process. I read two lines of thought in all resource material yet there is little evidentiary research as to the causal factors of both FM and MPS, surely we cannot exclude physical trauma as a causal factor when others can be excluded?
    Whilst Im not disabled greatly by my pain I have spent time at pain management centres as a live in patient where people cant even physically get out of bed. I cant imagine that sort of pain, I consider myself a resilent and logical person with a high pain threshold and have often used my past injuries as a pain assessment guide for referencing my nerve pain (including a stingray barb to my foot at a level 5 pain score out of 10) and during my time as an Army Medic.
    Thankyou for your opinions and feedback.

  14. James, the changes seen on x-ray correlate poorly with symptoms. One can be in severe spinal pain with unremarkable x-rays or have terrible looking x-ray films but no pain. As for the ultimate causes of persistent pain in so many people, we still have much to learn. What we know is that there may not be a straight forward relationship between cause and effect. I agree with you that traumata, physical and/or mental, cannot be excluded from the equation.

    • Unfortunately for me the assessing Rheumatologist has excluded trauma as a causal factor quoting a Dr Wolfe article stating that FM is not caused by physical trauma, following with ‘as MPS is a subset of FM therefore my shoulder injury and trauma (my compensable condition) is not linked to my chronic pain syndrome’, even after all other treating specialists and Rehabilitation Physician have stated otherwise over 16 years. As such they wont be covering my future implant maintenance nor associated pain management costs outside of my strained rotator cuff. 🙂
      I hope you dont mind, can I pass your link above to my GP.

  15. Ive just read your link battling through tears as I read lol, very well described I must say. That is one of the best articles I have read in 16 years Thankyou so much.
    I am truely blessed to have a wonderful GP.
    I wish you were closer to Melbourne?
    I thought I had reached Wholeville after my Workers compensation covered me for 16 years with 8 surgeries including my recent neuro stimulator implant (which is awesome) however after being reviewed by a Sydney based Rheumatologist for a permanent impairment assessment. Comcare have now decided that the weight of Medical Evidence no longer links my chronic pain condition (regardless of name) diagnosed as Right Hemi-Body Myofascial Pain Syndrome to my major shoulder trauma during combat defensive skills training as trauma doesnt cause FM and as MPS is a subset of FM my injury isnt the cause of my chronic pain, Im now back to being very confused.. This has massive impacts to my ongoing implant coverage, work hours capacity and ongoing medical coverage and upon me physically and mentally.
    I guess Im catching that train again to Wholesville?

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