From patient to patient, you will have completely different problems presented. But there are some basic guidelines to follow.
Ignore the press from some of the articles and ads. Many of those will promote deep tissue or Rolfing for those with Fibromyalgia. Do that and you'll be peeling them off of the ceiling. NEVER approach a Fibromyalgia patient with the assumption that you're going deep. ALWAYS start light. Myofascial release, done at the lightest level is the best start for a fibromyalgia patient. It warms the tissue, stretches and warms the connective tissues, increase blood flow, decreases the cortisol and epinephrine, and increases the levels of seratonin. Yet it works, generally within the hedonic level of most fibros. Check in with the client. They may request deeper work, at which point, you can go to Swedish, deep tissue and even Rolfing. But, be aware that because you can do deep tissue on the right leg, doesn't mean that you can do the same on the left. Fibromyalgia flares may be systemic or regional.
Trigger point work is valuable when working with Fibromyalgia patients. Because of the chronicity of the pain, there are often numerous trigger points.
People who are suffering with FIbromyalgia, are in a constant state of heightened stimulation. They are in a sympathetic state (neurologically overstimulated) most of the time. Therefore, their brains are constantly on the go.
An anology is with cars. A normal car will idle at a fairly low RPM. This prevents excessive wear and tear on the car, plus allows the car to be put into gear with minimal stress on the components. A person with Fibromyalgia has a much higher idle speed. Thus, there's a greater strain on the body and mind, with less opportunity for repair. They are in a constant state of near exhaustion. It may only take a slight exertion for them to become exhausted. If we use the 1-10 scale for exhaustion where 10 is exhaustion, then for a normal, healthy person, we may be, on a daily basis at around the 1 - 5 range. This gives us a tremendous store of energy before exhausting ourselves. Patients with Fibromyalgia, may, on a daily basis, be running between 4-8+. This means that as MT's, we need to be very conscious of the ability of massage improve this range, but also be aware that the work may literally exhause the client rather than relax them.
Chronic hypertonicity, such as that found in people with Fibromyalgia, results in higher degrees of toxins in the tissue. When body work is applied to someone with Fibromyalgia, the sudden surge of toxins into the blood stream can literally make a Fibromyalgia patient feel exhausted and possibly even sicker than when they came in. Of course, with proper hydration, the effects of the toxins will pass, but this must be a very important consideration with working with a Fibromyalgia patient.
A safe protocol to use when working with a FIbro the first time would be:
Interview;
- Make sure to find out ALL of the symptoms that they are presenting.
- Medications. Many are on high levels of pain killers and may have just taken a dose of percocet on top of a double dose of oxicontin that they take daily. Hence, they will be unaware of the depth of the work and cannot warn if damage is occuring.
- Hedonic level. Ask them to describe how they feel on a normal day and how they feel today. Use a 1-10 scale. Although you will often get "Today, I'm a 12", Fibro's learn to relate to the scale quickly and will actually begin to greet you with "Hi, I'm a 5 today, but my right shoulder is a 7".
- Emotional state. Does the client appear to be agitated? Overly sedate? Distracted? Confused? Are they in a Fibro Fog?
- On the table (be aware that with Fibros, you may not and probably should not work full body at first. generally try to limit work to a third of the body at a time)
Protocol
* compression. use mild compression along the apendicular structure to feel the tonus of the tissue (skin as well as muscle). This helps you to evaluate the quality of the tissue as well as getting feedback from the client on the depth of work possible. It also begins the flushing process in the tissue of toxins. Note, in some cases, this will be the limit of the work for the first visit or two.
* Slow, light effleurage. Avoid overstimulation of the nervous system. Fibro's need more sedation that stimulation, generally.
* light level, myofacial stretch. Will probably need to be applied several times. Depending on the quality of the tissue, one stretch along the rectus femoris (front of leg), for example, may take as long as 2-3 minutes to have a positive effect.
* Petrissage. To stimulate reduced tonus in the tissue and toxin removal. If the client defines themself systemically as a 6, 7 or 8+, then do this on a limited basis. Their exhaustion quotient is pretty high and the additonal stimulation may be too much for them.
general effleurage.
* trigger point work as necessary
Be aware of the emotional state of the FM client at all times. Especially if doing any abdominal, gluteal or facial work. These areas are highly charged areas which have a deep impact on the emotional state of the client. (Fibro's do have a higher percentage of past abuse than the general population. But do not assume that just because they are an FM, that they were abused, you'll most likely be wrong).
---Closing the session
* Light tapotement is ok, but avoid overdoing it. If the client seems overly sedate at the end of the session, the the tapotement will help wake them up. If they do not seem sedate, then avoid tapotemnt except as a topical application for specific muscles or muscle groups.
* Use long, slow, light fingerstrokes along the anterior body. This and light compression, may be all that the client can handle in the first couple of visits. But the compression and light stroking can have a phenomenal effect on removal of toxins and reducing the sympathetic nervous activity.
As you work with the client, ask for feedback on the work and their hedonic level. If they want deeper, go deeper. But be aware, that you, as the therapist, are responsible for avoiding damage and injury for the client. If they ask you to go deeper, but you feel the muscles respond by tightening, then you must explain that you are currently working at the safe level for them. That going deeper could result in bruising or tissue exhaustion.
Keep in mind also, that there are Fibro's who only have occasional flairs. These people can be dealt with as normal unless in a flare.
Indications for massage. If they are Fibro, it's indicated.
Contraindications If they are systemically a 9 or 10 in pain level, you won't have any effect except to torture them. If they are on pain meds and have taken recent doses or are on high levels, use caution or ask for their doctors permission. Use caution when working on stretching or mobilization of joints, Fibros have a high incident of hypermobility.
Fibromyalgia work requires that you develop a high sensitivity to the client (their tissue as well as their behavior, posture, and emotional state).
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