Fibromyalgia and Myofascial Pain Syndrome

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Fibromyalgia and Myofascial Pain
The Science
Syndrome
Fibromyalgia syndrome (FMS) is a controversial syndrome
that was first recognized in 1987 by the American Medical
This article will explore our current understanding of fibro-
Association (AMA). It is a rheumatologic diagnosis with a
myalgia syndrome (FMS) from both traditional and alterna-
rather precise diagnostic criterion. FMS must be distin-
tive perspectives, and will offer management options that
guished from Myofascial Pain Syndrome (MPS) even
can substantially improve treatment outcomes of patients
though they share several characteristics: both are affected
suffering from this insidious condition. Understanding FMS
by cold weather and may involve increased sympathetic
is a tall order because there are so many possible causes for
nerve activity, resulting in conditions such as Raynaud’s
it, and because it can involve so many systems of the body.
phenomenon. They both have tension headaches and paraes-
There is usually a dysfunction in the regulation of the central
thesia as major associated symptoms (Donaldson et al 2001).
nervous, immunologic, and endocrine systems that is super-
Muscles (Chaitow ibid) that contain areas that feel like “a
imposed upon the malfunction of many organs. To make a
tight rubber band” are found in about 30% of patients with
long story short, however, conventional medicine does not
FMS, and in more than 60% of patients with MPS. Patients
understand either the etiology or the pathophysiology of this
with FMS have reduced muscle endurance than do patients
disease well enough to cure, or even manage it satisfactorily.
with MPS. Muscles in FMS patients tend to feel soft and
Consequently, physicians and patients alike have experi-
doughy as compared to the tense, taut bands felt in MPS.
enced continuing frustration resulting from the typically
FMS may be more of a systemic or medical disorder—possi-
poor treatment outcomes, as well as from the enormous eco-
bly a component of chronic fatigue syndrome; and about
nomic burden incurred by ongoing medical costs and lost
75% of patients of chronic fatigue syndrome meet the crite-
income. Even the insurance industry has been severely chal-
ria of FMS; however, substance P levels are normal in MPS
lenged by the mighty costs generated by this disease. This
and chronic fatigue syndrome and not in FMS. MPS is more
predicament has created the need to conceptualize a new
likely to be a musculoskeletal (orthopedic) condition. FMS
approach that can provide a better management of the mal-
occurs often as a development of chronic MPS, and 20% of
homeostasis (the body's physiologic adjustment to metabolic
MPS patients also have FMS. 72% of FMS patients have
abnormalities) that results from FMS, and causes its associ-
active trigger points (TPs) (Gerwin 1995). Patients with
ated symptoms. This has been done! A new paradigm of nat-
FMS often are hypermobile while patients with MPS are
ural healing has emerged that is based on supporting the
often hypomobile, at least at the affected region. This differ-
innate healing capacity of the body, and relies on nutrition
entiation is important, since the prognosis of each of these is
and natural therapies as its major tools. Unfortunately, con-
very different. Both MPS and FMS may be caused by a vari-
ventional medicine has not yet acknowledged this paradigm.
ety of conditions which include: endocrine disorders, aller-
This new “natural healing” paradigm is based on what is
gies, neoplasms, connective tissue diseases, infections,
called a “process oriented approach” (POA) to managing
nutritional, as well as joint and ligamentous dysfunctions.
disease. The objective of the POA is to create a healthier
MPS is a painful condition felt by some to be due to myo-
homeostasis by identifying and correcting metabolic imbal-
fascial trigger point activation, either by direct causes or as a
ances, and in responding to the specific increased metabolic
reactive mechanism to other dysfunctions. The pain of MPS
needs created by the disease process. While symptoms are
is better localized than the pain from FMS. The pain may be
often addressed by interventions that address the “disease
confined to a large area and involve several separate sites;
process” itself to effect a cure, the main goal is to initiate the
however, it is often unilateral with a defined pattern of distri-
innate wisdom of the body to heal itself thus allowing it to
bution. MPS is associated with focal tenderness; FMS is
restore a more functional homeostasis, which can then mani-
associated with widespread tenderness. MPS is seen equally
fest the healing process.
in males and females, whereas about 80% diagnosed with
Much of the basis for this concept is developed from the
FMS are females (Donaldson et al ibid). The patient is often
premise that if all your cells are healthy and functioning per-
awakened from sleep by pain in both MPS and FMS, but
fectly, how can you be sick. Each individual human cell is
chronic fatigue is not a common complaint in MPS patients.
analogous to a microscopic industrial plant. Without an ade-
MPS does not produce morning stiffness as often as FMS
quate supply of appropriate raw materials, it cannot be
does. Tension headaches are a common associated symptom
expected to manufacture all of its products properly. Simi-
in both. Prognosis for MPS is very favorable, and the condi-
larly, if it is supplied with the wrong raw materials, it will be
tion responds well to techniques described in this text. In the
unable to produce a product that is perfect. Put simply, we
MPS paradigm, emphasis is on short and tight muscles as
must consume all the nutrients (food) that our cells require,
causative factors of pain and dysfunctions. Table 11-1 com-
and avoid those that are not needed (and potentially toxic), if
pares FMS and MPS.
our cells are to manufacture everything required for perfect
function. (Saputo 1998).
Fibromyalgia Syndrome
According to a consensus document on fibromyalgia syn-

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Table 11-1: Fibromyalgia and Myofascial Pain Syndrome
SYMPTOMS AND SIGNS
FIBROMYALGIA
MYOFASCIAL PAIN
SYNDROME
MUSCLES WITH A TIGHT BAND FOUND IN
30% of patients with FMS
60% of patients with MPS
REDUCED MUSCLE ENDURANCE
more in with FMS
less in MPS
TENSION HEADACHES
same
same
PAIN AFFECTED BY COLD WEATHER
same
same
INCREASED SYMPATHETIC NERVE ACTIVITY,
more in FMS
less in MPS
RESULTING IN CONDITIONS SUCH AS
RAYNAUD’S PHENOMENON
SUBSTANCE P LEVELS
elevated in FMS
normal in MPS
ABNORMAL LEVELS OF NEUROTRANSMITTERS common
less common
AND HORMONE RESPONSES
CHRONIC FATIGUE
common in FMS
not common in MPS
HYPERMOBILITY
common
less common
HYPOMOBILITY
less common
more common
INTERNAL MEDICAL PROBLEMS SUCH AS:
common
less common
IRRITABLE BOWEL SYNDROME,
DYSMENORRHEA, INTERSTITIAL CYSTITIS,
DEPRESSION, ANXIETY, MITRAL VALVE
PROLAPSE, AND RESTLESS LEG SYNDROME
MYOFASCIAL TRIGGER POINTS
found in 72% of patients
found in 100% of patients
WIDE-SPREAD TENDERNESS AND PAINFUL SKIN found in 100% of patients
less common
ROLE
SLEEP DISORDER
very common
less common
ALLODYNIA AND HYPERALGESIA
common
not common
COGNITIVE DIFFICULTIES
common
not common
drome (FMS)—the Copenhagen Declaration (Jacobsen,
resent the end of a continuum of pain amplification rather
Samsoe, Lund, 1993)—FMS is a painful, non-articular con-
than a unique or discrete disorder. Most patients who meet
dition predominantly involving muscles, and is the common-
the criteria for FMS also meet the CDC criteria for CFS
est cause of chronic widespread musculoskeletal pain. FMS
(Clauw 1999). FMS, however, is a chronic disorder and is
affects an estimated 3-6 million persons in the US, most of
relatively unchanging, which most likely represents a dis-
whom are women between the ages of thirty and fifty (Gold-
tinct entity involving a disorder of the nervous system. FMS
enberg 1994), or about 2-3.3% of the North American popu-
can be a source of substantial disability (Kaplan, Schmidt
lation (Donaldson et al 2001). It was only in 1987 that FMS
and Cronan, 2000). This is especially true if the patient has
was recognized by the American Medical Association
had it for a long time without adequate medical support.
(AMA) as a distinct condition that is responsible for signifi-
Nearly everyone with FMS exhibits reduced coordination
cant disability. Many, however, still do not believe FMS to
skills and decreased endurance abilities, although some of
be a distinct condition. They consider it a “garbage diagno-
this may be due to co-existing chronic myofascial pain (Star-
sis” for many separate disorders, including “just being” a
lanyl and Copeland 2001). In FMS the pain often is bilateral,
variety of a chronic affective (somatization) disorder. Some
variable, and generalized (involving all four quadrants). The
also think that FMS and related disorders such as chronic
pain cannot be explained by peripheral mechanisms only,
fatigue syndrome (CFS) and irritable bowel syndrome, rep-
and neural plasticity with CNS sensitization and reduced

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pain threshold probably playing a major role. FMS has been
Liver-Blood and Liver-Qi), digestive symptoms of bloating,
described as widespread allodynia and hyperalgesia (Russell
gas, cramping, diarrhea and/or constipation (OM: Often asso-
1998). In allodynia, nonpainful sensations are translated into
ciated with Dampness or Qi-stagnation in FMS patients), palpita-
pain sensations. Hyperalgesia means that pain sensations are
tions, easy sweating or night sweats (OM: Often associated in
amplified. FMS and disorders such as restless leg syndrome,
FMS patients with Qi-Yin-Blood-deficiency or Damp-Heat), uri-
primary dysmenorrhea, migraines, tension headaches, post-
nary symptoms, respiratory symptoms, and allergic symp-
traumatic stress disorder (PTSD) etc., have been grouped
toms (OM: Often Kidney related in FMS patients). A reduced
under the name, “Central Sensitivity Syndromes,” or sensi-
threshold of the nervous system can result in sensitivity to
tivity within the spinal cord and brain.
odors, sounds, lights, and vibrations that others don’t even
Patients often complain of fatigue, poor quality of sleep,
notice (OM: often due to easy arousal of Yang, Wind or Phlegm in
morning stiffness, and increased perception of effort. Mus-
FMS patients).
cular pain increases during repetitive muscular activity and
Dellenbach et al (2001) have suggested that many women
usually eases on cessation. FMS is frequently associated
with chronic pelvic pain are suffering from what they call
with other medical conditions such as: irritable bowel syn-
pelvic-fibromyalgia. Pelvic pain is a frequent and difficult
drome, dysmenorrhea, headaches, subjective sensation of
problem because, despite the quality and diversity of diag-
joint swelling (Baldry ibid), interstitial cystitis, depression,
nostic procedures, no relevant etiology will be found in 30-
generalized anxiety, mitral valve prolapse, restless leg syn-
40% of all cases. It has been proposed that in many cases the
drome, chronic fatigue syndrome, and myofascial pain syn-
dominant pain is not visceral but parietal. In many of these
drome (MPS). Seniors (Starlanyl and Copeland ibid) are
patients, the pelvic envelope is more painful than the pelvic
more troubled by fatigue, soft-tissue swelling, and depres-
content. In these cases, one can evoke the diagnosis of pel-
sion. In younger people, discomfort after minimal exercise,
vic-fibromyalgia; it is quite similar to classic FMS. This
low-grade fever or below-normal temperature, and skin sen-
form of pain actually is the somatization of a past and diffi-
sitivity are also common (ibid).
cult issue that will be revealed very slowly and progressively
Common symptoms are: generalized pain that may be
in the realm of a multidisciplinary, i.e. simultaneous physical
dull, deep, achy, or at times sharp, throbbing, shooting—
and psychological approaches.2 In the majority of cases
especially if associated with other pathologies. There are
these women have a history of physical, moral, or sexual
often increased morning symptoms of stiffness, fatigue, and
trauma inflicted by family members or a third party. Taking
pain. (OM: Often these symptoms are associated with Dampness,
in to account the physical dimension of body pain at the
Cold/Yang-deficiency, and poor Blood circulation in TCM, in FMS
same time as psychotherapy will considerably enhance the
patients.) Other common symptoms are dizziness and/or
efficiency of treatment. In the experience of the study
light-headedness, “spaciness” or “brain fog” (cognitive diffi-
authors, 70% of all women will be “cured” using this
culties), which can be due to orthostatic hypotension and/or
approach.
hypovolemia (OM: Often these last symptoms are associated in
FMS caused by trauma or another precipitating event such
FMS patients with Phlegm, Central-Qi-deficiency with Clear-Yang
as serious (often infectious) illness tends to be more severe
not rising, Blood-deficiency, unstable-Yang or Wind),1 photopho-
and have a worse prognosis than idiopathic FMS (Romano
bia, ocular complaints (dry eyes, poor focus), stress intoler-
2000).3 Basal autonomic states of FMS patients are charac-
ance, depression, sleep disturbances (including early
terized by increased sympathetic and decreased parasympa-
morning awakening (OM: Often associated in FMS patients with
thetic tone with associated increased resting heart rate,
reduced heart rate variability (especially remaining-active-
at-night frequency domains, and cortisol or heart rate vari-
1. Some patients with FMS and up to 90% of patients with chronic fatigue
ability), deranged response to orthostatic stress,4 and a high
syndrome may suffer from a neurally mediated hypotension (NMH), a
incidence of Raynaud’s syndrome (Donaldson et al 2001).
condition characterized by an abnormal drop in blood pressure in
response to prolonged standing, exposure to warm environments, or
Thus, FMS may be a sympathetically mediated syndrome
vigorous exercise. These patients usually feel dizzy and may suffer
with alterations in the feedback loops interconnecting the
from syncope and palpitations. Some patients may feel muscle pains,
hypothalamus-pituitary-adrenal axis.
nausea, sweating, abdominal pain, blurred vision, or severe itching.
Assessment may need to be done with a head-up tilt table test
The prognosis of FMS is much less favorable than MPS,
performed by a cardiologist in a hospital. The patient is placed on a tilt
and patients often respond only temporarily to treatment.
table and brought up to seventy degrees for forty-five minutes. If no
Reeves (1994), however, reported that prolotherapy was suc-
significant drop in blood pressure occurs, an adrenalin-like drug is
given intravenously This usually brings out the latent positives. Some
cessful in resolving symptoms in more than 75% of his
patients can be diagnosed by an office orthostatic blood pressure test.
First, blood pressure and pulse are taken after lying flat. Then, after
standing against a wall for ten minutes without being stimulated, the
2. It is a common experience of acupuncturists and body-workers that
blood pressure and pulse are taken again. Fainting, extreme dizziness,
such histories are revealed during treatments.
or a fall in blood pressure (or marked increase in pulse rate) may
3. Information on treatment here reflects the author’s experience with
indicate the presence of NMH and treatment may be tried. Treatment
patients in this category.
usually includes increased salt and water intake to increase plasma
volume. Licorice, drugs, that reduce adrenaline receptor sensitivity, or
4. Usually low blood pressure and lightheadedness or “blacking out” on
medications that increase blood pressure may be needed (Bouch 2001).
standing.

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patients with “severe fibromyalgia.” OM and other natural
(1997) studied ten random fibromyalgia patients with blood
approaches, preferably in concert, can be very helpful.
testing to determine if viral infections could play a part in the
Cures, however, are few.
development of fibromyalgia. Screening volunteers for anti-
bodies to influenza type A viral antigen yielded positive
Mechanisms of FMS
results in nine of ten patients. Only three of ten patients with
FMS in a similarly aged and sex-matched group demon-
In general, FMS is thought to be a disorder of the nervous
strated positive responses to influenza type B. With the posi-
system involving activation of larger myelinated fibers,
tive results obtained, it appears that influenza type A viral
which are recruited (by chemical amplification in the spinal
infection, which primarily strikes the respiratory and auto-
cord) to rapidly transmit stimuli to the dorsal horn area of the
nomic nervous systems, might be involved in the develop-
spinal cord. Because these fibers are so large and transmit
ment of fibromyalgia. In the FMS cases tested, the patients
signals so rapidly, stimuli that are normally not painful are
related a history of upper respiratory infection along with
perceived as painful—allodynia (Russell 1999). Animal
associated neurological symptoms prior to the onset of fibro-
studies (Mense 1990) have shown that activity in central
myalgia symptoms. Retroviruses where also found in muscle
nociceptive neurons that receive input mainly from muscles
tissues at a higher rate in FMS patients than in controls.
are more under central inhibitory control than central nocice-
Bacterial overgrowth in the small intestine was evaluated
ptive neurons receiving input from the skin. This central
in 815 individuals using the lactulose hydrogen breath test.
inhibition may explain why treatment to the CNS with anti-
Of these, 152 individuals had the diagnosis of FMS, of
depressants often is helpful in FMS patients. Furthermore, a
whom twenty-nine, who had concurrent inflammatory bowel
review article presented by Henriksson at the Second World
disease, were excluded. Out of the 123 subjects with FMS
Congress on MPS and FMS states that there are a fairly large
syndrome, 96 (78%) tested positive for small intestinal bac-
number of studies that indicate that FMS patients either have
terial overgrowth as diagnosed by the lactulose hydrogen
a disturbance of pain modulation or a disturbed function of
breath test. Of those treated with antibiotics, 57% reported
other regulatory systems. He further cites studies that impli-
global improvement in their FMS symptoms. The data sug-
cate serotonin metabolism and deficiency, a marked increase
gested that bowel symptoms in FMS may be caused by small
of substance P in CSF, lower levels of cortisol,5 epinephrine
intestinal bacterial overgrowth. Associations have been
and norepinephrine following exercise by patients than in
made between FMS symptoms and the bacterial species,
control groups, enhanced pituitary release of ACTH, low
Chlamydia and Borrelia burgdorferi. In animal models,
metenkephaline levels, and lower levels of serum IGF-1.
small intestinal bacterial overgrowth can result in bacterial
Finally, Henriksson cites a few reports of immunological
translocation to mesenteric lymph nodes and can produce
disturbances in FMS, for example, a defect in the interleu-
systemic effects. These systemic effects are believed to be
kin-2 pathway. Elevated levels of nerve growth factors may
mediated by endotoxins from Gram-negative bacteria. These
account for high substance P in CSF (Russel ibid). Patients
endotoxin effects may explain the soft tissue hyperalgesia
with FMS (Bennett 1990) produced excessive lactic acid,
that is seen in FMS, since injections of the endotoxin into lab
which may add to their discomfort after exercise.
animals results in similar hyperalgesia. The authors conclude
Recently, information from PET scans has shown a dys-
that the intestinal symptoms of FMS patients may be related
function in thalamic activity. Compared to healthy individu-
to small intestinal bacterial overgrowth, and treatment of
als, FMS patients have significantly lower resting-state
small intestinal bacterial overgrowth can result in overall
levels of regional cerebral blood flow in the thalamus and
improvement in intestinal symptoms (Pimentel, Chow, Hal-
caudate nucleus (Mountz et al 1995, Kwiatek et al 1997).
legua, Wallace, and Lin 2001).
About twenty-two percent of all patients with FMS have a
Patients with genetic factors that predispose them to
deformity in which the cerebellum and medulla oblongata
hyper-coagulability may be especially susceptible to the
are impacted into the foramen magnum and upper spinal
effects of microbes. Abnormal coagulation can result in the
canal, known as Arnold-Chiari malformation (Russell ibid).
accumulation of soluble fibrin monomer (SFM) that leads to
Twenty-two percent of all patients that presented to the
the formation of a dense film that settles on the inner surface
emergency room with whiplash injury show symptoms of
of capillary walls. These deposits form a protective coat that
FMS within three months (Buskila et al 1997). This may be
covers microbes living in blood vessel walls, thereby making
due to the development of disturbances in CSF circulation
it difficult for the immune system to attack and destroy them.
and spinal canal size (and which may explain why many
SFM may also make it difficult for nutrients to pass through
such patients respond to cranial osteopathy).
thickened blood vessel walls to get into cells, as well as for
Because many fibromyalgia patients relate a history of
waste products to pass from the cells into the blood stream.
acute febrile and congestive respiratory episodes prior to the
This may explain why so many organ systems and regions
onset of their illness, a viral cause has been suggested. Tyler
are involved in FMS (Saputo 2004).
Some authors suggest that FMS is a somatization syn-
5. Licorice (Gan Cao) supplementation is often useful in these patients,
drome due to depression; however, research suggests other-
especially before exercise.
wise (Stiles and Landro 1995). Their data showed that the

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cognitive dysfunction that reflects a presumed compromise
of the right hemisphere (which is present in major depres-
sion) is not found in primary FMS. They concluded that this
finding would suggest that primary FMS and depression are
different conditions. Cianfrini observed SPECT brain imag-
ing during stimulation of tender points in FMS, chronic
fatigue patients, depressed patients, and a control group. He
found that both FMS and chronic fatigue patients (with
FMS) had significant increases in bilateral regional cerebral
blood flow in the somatosensory cortex and the anterior
angulate cortex following pressure stimulation at three right-
sided tender points. However, healthy controls and
depressed patients only showed significant regional cerebral
blood flow increases in the contralateral thalamus, soma-
tosensory cortex, and anterior angulate cortex. Croft et al.
(1994) have noted that many tender points are also found
Figure 1: Tender points in FMS
with depression, chronic fatigue, anxiety disorders, and other
patients.
symptoms of a somatic nature and not part of this list,
including pain. Other symptoms seen in both FMS and
depression include poor sleep, fatigue, morning stiffness,
poor concentration and poor immediate recall (Donaldson et
1. History of widespread pain, extending into the sides of
al ibid).
the body, and pain above and below the waist.
Other hypothetical candidates for causal factors in FMS
2. Axial skeletal pain must be present. Low back pain is
include: central neurotransmitter imbalances, thyroid hor-
considered lower segment pain.
mone resistance, stress-related physiological changes, psy-
chopathology, psychosocial factors, and disturbance of alpha
3. Pain must also be present in eleven of eighteen tender
stages of sleep (Donaldson et al ibid).
sites on digital palpation of an approximate force of 4kg.
In conclusion, any of the above causes of FMS are
At (fig-1):
thought by most authors to cause a disorder of the nervous
— The suboccipital muscle insertions
system involving CNS sensitization and the activation of
— Anterior aspects of the intertransverse spaces of C5-C7
larger myelinated fibers that are recruited (by chemical
— Midpoint of the upper border of the trapezius
amplification in the spinal cord) to rapidly transmit stimuli to
— Origins of supraspinous above the scapula
the dorsal horn area of the spinal cord. In CNS sensitization,
— Upper lateral aspects of the second costochondral
the nervous systems undergoes remarkable changes, often
junction
after an initial painful stimulus at the periphery (or after an
— 2 cm distal to the lateral epicondyle
emotional stress) so that subsequent stimuli, even if normal,
— The upper outer quadrants of the buttocks in the
registers as pain and/or altered sensations.
anterior fold of the gluteal muscle
— The posterior aspect of the trochanteric prominence of
the greater trochanter
Differential Diagnosis
— Medial fat pad proximal to the joint line of the knee.
Several conditions can mimic fibromyalgia. Some examples
The diagnostic criteria suggested by Yunus et al. 1981 and
include (Jacobsen, Samsoe and Lund 1993):
Moldofsky et al. 1975 are:
• Hypothyroidism
• Widespread aching of more than three months duration
• Widespread malignancy
• Cutaneous and subcutaneous sensitivity as demonstrated
• Polymyalgia rheumatica
by skin roll
• Osteomalacia
• Morning fatigue stiffness with disturbed sleep
• Generalized osteoarthritis
• Absence of laboratory evidence of inflammation or mus-
• Early Parkinson’s disease
cle damage
• Initial stage of various connective tissue diseases.
• Bilateral tender points in at least six areas.
Diagnostic Criteria
Fibromyalgia and Traditional Chinese Medicine
The American College of Rheumatology criteria for the clas-
Because fibromyalgia presents with a variety of symptoms
sification of fibromyalgia are:
and fatigue is a common complaint, the disorder often falls
within traditional Chinese medicine (TCM) internal medical

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and Painful Obstruction (painful conditions) classifications.
being the most common. The Lungs and Kidneys are
Stress, poor sleep quality, poor diet, insufficient rest, and
affected often, as well.
unresolved emotions (such as fear, anger, frustration, depres-
5. Trauma injuring Qi, Blood, and related tissues and
sion, anxiety) or trauma can influence Organ functions,
Organs.
deplete True-Qi (a type of vital energy and functions),
Blood, and Fluids, all of which may result in stagnation of Qi
6. Hemorrhage.
(energies and functions of organs) and Blood, formation or
FMS often begins following an infectious or other med-
retention of Dampness, Phlegm, Wind (types of pathologies
ical disease, which can lead to retained Pathogenic Factors.
in TCM), and symptoms and signs of FMS. Blood loss may
It may also result from trauma, blood loss, chronic stress, or
injure the Liver, Blood and Qi, which then may fail to nour-
chronic disease. Stress, trauma, and retained Pathogenic Fac-
ish the sinews (soft tissues). The muscles may tighten and
tors are said to result in obstruction (which almost always
loose their strength. FMS with a primary syndrome of
result in pain in TCM), and often secondary unstable Yang
Blood-deficiency is more commonly seen in females, as
(such as Yin-Fire, Empty-Heat, endogenous-Wind, and defi-
blood is lost with the menses. Blood-stasis may be seen in
cient-Yang rising). Unstable Yang can manifest as a facili-
chronic diseases and secondary to trauma.
tated sympathetic nervous system and depressed
Although FMS is not necessarily an externally contacted
parasympathetics. This autonomic nervous dysfunction often
disorder (one of the causes of disease in TCM), many FMS
manifests with increased pulse rate (both day and night) that
patients present with a history of infectious disease, injury,
tends to be variable at rest (frequent changes in rate strength
and/or severe medical conditions in which Pathogenic Fac-
and quality with little stimulation, which, in TCM, is often
tors often play a major role. FMS may be best described by
associated with weakness), wiry pulse (often with Shao
six TCM clinical presentations:6
Yang syndrome), decreased circulation with trophic edema,
1. Retention of Pathogenic Factors.
and increased red skin responses on various areas (the skin
remains red when scraped or when a needle is inserted, due
2. Latent Pathogenic Factors (a kind of hidden infection
to poor circulation from excessive sympathetic activity, or is
such as stealth virus).
red due to histamines), increased fascial tissue sensitivity
3. Pathogenic Factors between the Interior and Exterior
demonstrated by pinching or rolling the skin, tender muscles,
(Shao Yang) (an area of the body between the deeper
nodulations in muscles, hypochondriac tension (felt in
bodily functions such as the organs and the more
abdominal [Hara] evaluation), thoracic inlet/outlet tension
superficial tissues such as the muscles).
(felt at and around the SCM muscles), and reactions at the
Kidney/Chong channels (TCM meridians of circulation).
4. Part of Organic or other internal disorder with or without
The organs/Organs can become congested and dysfunc-
externally contracted Pathogenic Factors. General stress
tional. The patient is often oversensitive to stimulations such
depleting the Righteous (basic healthy functions) and
as noise, odors, light, and stress (often when Phlegm or Liver
Organs, resulting in Pathogenic Factors and Organic
disorders are seen).
disorders with Liver, Spleen, and Heart involvement
The main pathogenic factor seen clinically in FMS
patients is Dampness, often with underlying Deficiency.
6. Flaws and Sionneau (2001) state, that in their view the “core” disease
Transformative-Heat and Yin-Fire/unstable Yang are com-
mechanism of FMS is Liver-Spleen disharmony. They list the following
mon complicating factors. The severity of muscle aches is
patterns:
often related to the level of pathogenic Dampness or Phlegm.
Liver-Spleen disharmony, that they treat with Rambling Powder -+
With time, Blood-stasis and more severe and fixed pain can
(Xiao Yao San);
develop. There are five distinct risk factors for Dampness,
Damp-Heat, that they treat with Pinelliae Drain the Heart Decoction -+
Phlegm, and related conditions are: 1) Improper treatment;
(Ban Xia Xie Xin Tang);
2) Fever/Heat/Fire/Cold and other Pathogenic Factors; 3)
Qi and Yin-vacuity with Liver-depression and Fire Effulgence, that
Damage to the Spleen/pancreas and Liver; 4) Damage to the
they treat with Heavenly Emperor Supplement the Heart Elixir -+ (Tian
Wang Bu Xin Dan Jia Jian);
Lungs; 5) Kidney Yin, Yang, Essence or True-Qi-defi-
ciency. I will discuss each of these in turn.
Spleen-Kidney-Yang Vacuity with Liver-Depression, that they treat
with Supplement the Center and Boost the Qi Decoction (Bu Zhong Yi
1. Improper treatment.
Qi Tang), plus Restore the Right +- (You Gui Yin);
A common clinical iatrogenicity is due to excessive use of
Spleen-Qi and Yin and Yang vacuity with Heat and Liver-depression,
that they treat with Supplement the Center and Boost the Qi Decoction
tonifying methods in a patient with Pathogenic Factors.7
(Bu Zhong Yi Qi Tang) and Two Immortals Decoction +- (Er Xian
This is said to result in further penetration of Pathogenic
Tang);
Factors (often the development of Phlegm) and increased
Blood-stasis, that they treat with Body Pain Dispel Stasis Decoction +-
(Shen Tong Zhu Yu Tang);
Phlegm Nodulation, that they treat with Disperse Scrofula pills (Xiao
7. Many of the author’s patients were taking herbs such as Ginseng, either
Luo Wan) and Two Aged Decoction +- (Er Chen Tang).
self-prescribed or given by other health-care practitioners.

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7
symptoms of Deficiency, stagnation, and Heat. In such
area or point (fibrous tissue) within the muscular taught
cases, the proper treatment would be to eliminate
band (Kori), often at the motor points (usually at midpoint
pathogens. This may then result in the recovery of the
of muscle), and fixed pain that is worse at night or during
patients’ Righteous-Qi (vital strength). In some patients a
inactivity. If Phlegm and Blood-stasis combine and
combined approach is warranted.
stagnate, the patient may develop bony swellings, spurs,
Excessive or improper use of cold medicines or
and inflamed and hard calcified bursae. Insertional or
antibiotics is said to be capable of damaging the Spleen/
calcific tendinitis may develop.
Stomach and may result in Dampness and Phlegm. It may
Deficient-Yin patients may show a tight radial blood
drive Exterior Wind-Cold Pathogenic Factors (simple
vessel or a quick, thready-wiry pulse. A pounding pulse8
viruses, etc.) inside/Interiorly, which become hidden or
may be seen in both Deficient and Excess conditions with
turn into Heat. With hidden-Heat, the patient becomes ill
Pathogenic Factors. A significantly weak patient may
later, when another infection sets in or life stresses
present with a pounding pulse, which may be slow or fast.
increase. Latent-Heat disorder is said to be more common
The blood vessel wall tends to be tight in Excessive
in a patient with a Deficient constitution or condition,
conditions and softer in Deficient patients (at least in
especially Yin.
Yang-deficiency and Dampness). As the patient’s strength
Excessive or improper use of hot and spicy medicines or
is increased, the underlying (Organ) pulse may become
foods are said to thicken and consume Fluids that may
more evident. The tongue often shows signs of Dampness
transform into Phlegm and mucus, and lodge internally, or
and Phlegm. Signs of Blood-stasis may or may not be
within the joints and muscles. This may result in pain and
seen.
obstruction. Hot and spicy medicines are also said to be
capable of injuring Yin, resulting in deficient-Yin Empty-
3. Damage to Spleen/pancreas and Liver.
Heat and difficulties with sleep.
Pathogenic Factors may damage the Spleen/pancreas
The excessive use of Qi-moving medicines (or coffee
disturbing the transforming and transporting functions of
and some spicy foods) is said to be capable of injuring Qi
the Spleen. These patients may have digestive symptoms
and may result in stagnation due to lack of movement from
and may be sensitive to foods. They often feel bloated and
Qi-weakness. Qi-stagnation may then result in local
have epigastric or lower abdominal discomfort and gas.
transformative-Heat and inflammatory signs (local
The area around the umbilicus and between CV9-12 may
inflammation in a Cold and Deficient patient). Deficient-
be tight and sensitive. A pulse around the umbilical region
Qi may result in eventual weakness of Blood. The sinews
may be visible or palpable. The degree of Dampness or
(soft tissues) may tighten and the patient’s sleep become
Phlegm is often seen on the tongue coat, but not always.
affected with increased dreams. Because many Qi-moving
Similar presentations may be seen in patients with prior
herbs are spicy (or food such as curry), they can injure the
weakness of the Spleen/pancreas and a tendency to
Yin and Blood, as well.
develop or retain Dampness. This condition is often
The excessive use of Blood-moving medicines is said to
secondary to poor dietary habits and/or excessive stress.
be capable of injuring both the Qi and Blood, again,
Signs and symptoms are similar, but the patient has a long
resulting in obstruction due to lack of vitality.
history of weak digestion and/or fatigue. The patient, at
An inappropriate use of diuretics can injure Yin, Yang,
times, just reports fatigue or sleepiness after eating and
or True-Qi or drive Pathogenic Factors inside/Interiorly.
mild bloating. The tongue coat may be normal, but the
Pharmaceutical anti-histamines and some expectorants
tongue body is often swollen and pale. The right middle
can result in thickening mucus and Phlegm-Heat.
pulse tends to be soft or weak.
Spleen/pancreas weakness is also said to result in
2. Fever/Heat/Fire/Cold and other Pathogenic Factors.
deficiency of Blood, which then may weaken (“fail to
Any fever, Heat, and stagnation may damage the Fluids,
lubricate”) the Liver and may result in Liver Qi-
which congeal and thicken and do not flow. Excessive
stagnation/congestion. The Liver then may fail to nourish
Coldness from external or internal causes is said to be able
the sinews. The muscles and sinews may develop tension
to congeal the Fluids, as well.
and weakness. Liver-congestion Qi-stagnation may result
These common clinical presentations may result in the
in variable and poorly localized pains and leave the patient
development of “Trigger Points” (called Ashi-sensitive-
susceptible to emotional stress and aggravation. Because
Kori-tight bands in Oriental medicine) in muscles that
Qi (or Phlegm/Dampness) stagnation is said to slow
generally feel soft, soggy, and nodular with low general
circulation, Blood-stasis or transformative/congested-
tone. Dual Dampness and Yin-deficiency may develop.
Heat may develop. When Qi-stagnation becomes severe
Blood-stasis is a secondary complication seen frequently.
and rebels, swelling (usually not substantial or changing)
When Blood-stasis is significant, the patient may develop
may develop. Heat may congeal Fluids, which become
abdominal reactions at the left lower quadrant, visible
Phlegm. When Phlegm and Blood join, muscles may
darkened blood vessels, skin discoloration (especially lips
in early stage), choppy or slippery/wiry pulse, and a hard
8. Not a classical pulse description but seen quite frequently.

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8
become fibrotic and lose flexibility, possibly permanently.
with excessive pulsations palpable. Kidney points at or
With Qi-stagnation, the patient’s symptoms may
just below the umbilicus may be tight and tender. The
frequently change.
patient’s complexion may be dull, and, especially in
Liver-congestion is a common condition. Liver/wood
women, the area around the mouth and eyes may be green
congestion/stagnation is an Excessive condition and may
and dark. Tenderness and tightness/indurations may be
result in over-regulation of Spleen/earth (according to
felt especially at UB-52 (quadratus lumborum), CV4-6,
five-Phases theory). This disharmony is another risk factor
K-7, and K-3. Phlegm develops due to a lack of vitality.
of Spleen/pancreas failing to transform and transport,
This may be “unseen Phlegm,” affecting non-mucus
which may result in Dampness.
membranes and lacking many of the usual signs of Phlegm
such as a greasy and slimy tongue coat, especially in
4. Damage to the Lungs.
Kidney-Yin-deficient patients. The pulse at the proximal
Pathogenic Factors can disturb the Lung's descending
positions may reflect weakness.
function, which normally directs Fluids to the Kidneys
(often after respiratory infections). This results in dryness,
Latent Pathogenic Factors are said to be seen most com-
edema, and Qi-dysfunction: the Lungs are said to control
monly in Deficient patients who do not have a clear history/
Qi, which is the motive force behind Fluids and Blood.
onset of infectious disease. An insufficiency of the patient's
The failure of the Lungs to control Qi and vessels may lead
True-Qi, Kidney-Qi, Yin and Essence (i.e., Righteous or
to a pooling of Blood or Fluids in the lower body and may
basic functional strength) is said to result in Pathogenic Fac-
become visible as varicose veins or edema.
tors entering the Interior. This may be seen without the
These patients more commonly show signs of upper
development of superficial symptoms (due to the absence of
edema (Phlegm) under eyes (baggy eyes), face, and
a struggle between the weaken antipathogenic-Qi and the
sinuses, and tenderness/induration at Lu-1, GB-21, and
pathogens) or with only mild symptoms. Later, symptoms of
UB-13 (upper back) areas. Upper arm and shoulder
Heat, irritability, digestive disturbances, fatigue, and possi-
symptoms are common. Patients may or may not have
bly muscle pain may develop.9 Yin-deficient patients may
other respiratory symptoms. The tongue coat may show
tend to develop a complex syndrome with symptoms of
signs of Dampness/Phlegm and may also show Dryness at
Heat, Cold, and Dampness. Yang-deficient patients may
the root.
tend to develop a Cold syndrome with Dampness; however,
local Fire may be seen.10 In FMS patients, if treatments that
5. Kidney Yin, Yang, Essence, or True-Qi deficiency.
usually work in “latent-Heat” prove effective, the patients
The Kidneys are the source of Yin and Yang and can
may or may not show the classic syndrome of latent or
influence most of the bodily systems that may lead to
retained Pathogenic Factors (such as infection, irritability,
FMS. It is Kidney-Yang that is the origin of Spleen-Yang,
digestive symptoms and signs, etc.). Signs may be felt in the
the catalyst within the Spleen that is in charge of
tissue texture of muscles and joint end-feels. They usually
transformation and transportation (digestion and
include “rheumatic” type changes and little or no systemic
metabolism). The Kidneys are the root of Qi, and healthy
symptoms and signs.
functional breathing requires the Kidneys to accept and
Pathogenic Factors may be retained at the Shao Yang
root Qi. The Fire/force of the Heart and Triple Warmer
level (between the Exterior and Interior), especially in
come from the Kidneys. Therefore, both Blood and Fluid
stressed patients. The patient is said to be temporarily defi-
circulation are ultimately dependent on healthy Kidney
cient (from stress) and therefore unable to dispel the external
function. The Fluids that travel with Defensive-Qi (via
Pathogenic Factors. The Pathogenic Factors are often weak,
Triple Warmer) at the Cuo Li (the space between the skin
as well. The main manifestation is alternating or combined
and muscles/membranes/interstice) are rooted in
symptoms of Heat and Cold or cyclical symptoms (or chang-
Mingmen (Kidney-Yang), and therefore depend on the
ing symptoms and/or symptoms that are sometimes present
Kidneys for motility and warmth. The creation of Blood is
sometimes not). FMS patients with Shao Yang syndrome
also ultimately dependent on healthy marrow and
may not show the classic (Shang Han Lun) syndrome. They
Kidneys, because the Kidneys warm the Spleen/pancreas;
do not have to have Exterior symptoms or a history of exter-
they motivate, moisten and nourish the Liver; they root the
nal Pathogenic Factors. They do, however, often present
Lungs and warm the Heart. All of these functions are
with both Interior and Exterior symptoms and have relatively
needed to form Blood. The Kidneys are said to be in
strong, muscular physiques, but not always.11 They often
charge of Fluids; therefore, Dampness and other Fluid
complain of temperature disregulation, saying that “since
dysfunctions can result from Kidney disorders.
Patients with Kidney (Essence or True-Qi) weakness
may have a long history of poor health and general
9. Muscle pains are not classically among of the symptoms associated
physical weakness, especially poor physical and mental
with hidden-latent Pathogenic Factors. However, Latent/hidden
endurance. These may be due either to constitutional
Pathogenic Factors are said to “reside in the bones/marrow, Cou Li
factors or chronic illness. The lower abdomen of such
(membranes, space between the skin and muscles), and muscles.”
patients may be soft at the surface and tense deep inside,
10. These patients are treated mainly as Deficient Cold.

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9
they have been sick” their internal temperature has not been
meals for four hours, and exercise for six hours before sleep
right—sometimes they feel excessively cold or hot, or just
(Bennett 1999).
uncomfortable when external temperature is extreme. They
The standard of care (in the US) is treatment with antide-
often feel nauseous and have a bad taste in the mouth, espe-
pressant medication, despite a great deal of research showing
cially in the morning. They may feel relatively fine when
that in most instances depression is a result, rather than a
rested, but when fatigued or stressed they develop symp-
cause of the condition (Block 1993, Duna and Wilke 1993).
toms. Clinical experience (of the author) suggests that this
The effectiveness of this treatment has much to do with
condition is slightly more common in male patients. Second-
improvement in sleep. Possibly this treatment results in
ary Yin-deficiency, Liver-stagnation, and Blood-stasis may
reduced substance P formation by increasing serotonin con-
be complicating factors. The soft tissues, muscles, and joints
trol and by modulating pain in other ways. Lower doses are
of these patients have a tighter feel compared with the more
usually used than for depression. NSAIDs are of marginal
Deficient patient. The patient usually appears to be physi-
value, with propionic acid derivatives (Daypro, Orudis) pos-
cally strong. The subcostals and possibly the epigastric and
sibly the most effective12 of these drugs. Analgesics, espe-
right lateral abdomen areas may be tight, sensitive, and may
cially Tramadol, a drug that is a weak opioid and that also
show tight bands and indurations. (They often develop
inhibits reuptake of norepinephrine and serotonin, have been
extensive congestions that may be anywhere within the three
advocated. The muscle relaxants levodopa, carbidopa, and
Warmers.) The pulse is wiry.
quinine are sometimes used for restless leg syndrome or
muscle cramps (Bennett ibid).
Treatment
An alternative pharmaceutical treatment using the OTC
expectorant guaifenesin (Robitussin) has been suggested to
FMS is notoriously unresponsive to standard biomedical
be helpful for FMS and chronic fatigue syndrome by Dr.
treatment. The reductionistic approach of Western Medicine
Amand. The basic theory behind this protocol is that FMS is
is designed to primarily focus on the body as the major mal-
a manifestation of a genetic anomaly that affects the body’s
functioning factor that “needs fixing.” The inseparability of
ability to excrete phosphates (and perhaps other minerals)
body, mind and spirit is acknowledged, but not revered. No
effectively. Guaifenesin is said to excrete phosphates, and, to
healing therapy would be complete without honoring this
a lesser degree, oxalates and blood calcium. Progression is
holism. It is not surprising that there is scientific evidence
said to be cyclical, beginning with exacerbation of symp-
supporting the value of other disciplinary approaches such as
toms followed by good days, generally within a few months.
Tai Chi, Qi Gong, Ayurveda, Chinese Medicine, and a multi-
An average reversal rate is said to be about one year for
tude of others, where attention is paid to “balance and move-
every two months of the proper dosage. Dr. Amand recom-
ment” as reflected by breathwork, physical exercise, and
mends a starting dose of 300mg BID. Within a week, the
“mobilization of the life force.” It is especially important to
patient is said to feel significantly but tolerably worse, if the
work in collaboration with other disciplines when requested
patient is not taking salicylates. Salicylates must be avoided
by our patients, especially when what we are doing isn’t
in the form of any aspirin-related compounds including
working very well (Saputo 1998). An integrative approach is
herbs. Other NSAIDs and Tylenol are okay. This dosage suf-
therefor imperative.
fices for 20% of all patients. If there is no increase in symp-
Education is probably one of the most important aspects
toms in that time, the dose is increased to 600mg BID. This
in its management. The patient must understand that being
dose is maintained for three to four weeks. In 70% of the
out of condition contributes to myofascial pain. Therefore,
patients 1200mg/day suffices. The upper dose range is
an exercise program that includes stretching, strength build-
3600mg/day.
ing, and aerobic conditioning is extremely important. How-
Other treatments may include physical medicine proce-
ever, patients should not over-exercise and should conserve
dures such as acupuncture, manual therapies (especially
their energy. A one-day rest between exercise sessions may
muscle energy, functional, counter-strain and cranial tech-
be prudent. The patient’s sleep quality must be improved, as
niques), ultrasound, and heat. Internal intervensions such as
altered sleep patterns are probably the most important clini-
herbal and nutritional therapies are often helpful. Psycho-
cal facet of FMS. Patients should try to sleep at least eight
therapy (especially Cognitive Psychotherapy), biofeedback,
hours per day. Sleep hygiene is important. Having the patient
and other relaxation exercise techniques, and EEG biofeed-
observe regular bedtime hours and encouraging them to reg-
back may be helpful.
ulate their daily activities (such as rest and meals) can be
Osteopathic approaches have been shown to be helpful in
helpful. Patients should avoid caffeine for eight hours, large
treating patients diagnosed with FMS. Stotz and Kappler
(1992) treated patients using a variety of Osteopathic
11. Minor Bupleurum Decoction (Xiao Chai Hu Tang) in some Japanese
approaches. Goldenberg (1993) measured the effects of
traditions is used more for “weak confirmations.” This formula is then
used to strengthen the patient’s constitution and is taken for long
periods. In the author’s experience, many of the above FMS patients
12. Although recently, Wallace et al. has shown increased levels of three
respond to modifications of Xiao Chai Hu Tang or Da Chai Hu Tang
cytokines (inflammatory mediators): IL-6, IL-8, and IL-1Ra in FMS
and therefore may be categorized as Shao Yang.
patients.

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10
Osteopathic manipulative therapy (OMT) on the intensity of
treatment. These results suggest that acupuncture therapy is
pain reported from tender points in eighteen patients who
associated with changes in the concentrations of pain-modu-
met all of the criteria for FMS. Each patient had six treat-
lating substances in serum.
ments. Over a one year period, twelve of the patients
Sprott, Jeschonneck, Grohmann, Hein (2000) have
responded well, and their tender points became less sensitive
shown that, besides normalization of clinical parameters,
(14% reduction verses a 34% increase in the six patients who
acupuncture results in improvement in microcirculation
did not respond). Activities of daily living were significantly
above “tender points.”
improved, and general pain symptoms decreased. Lo et al
Zborovskii and Babaeva (1996) showed that 9.6% of 1240
(1992) studied nineteen patients with all of the criteria of
patients making complaints of osteomuscular pains had clin-
FMS. The patients were treated once a week for four weeks
ical signs of primary fibromyalgia (PFM). They suggested
using OMT. At the end of treatment 84.2% of the patients
therapies that combine the use of dimexide with NSAIDs
had improved sleep, 94.7% reported less pain, and most
and sessions of acupuncture to promote the normalization of
patients had fewer tender points on palpation. Rubin et al.
dysfunctions.
(1990), in a study involving thirty-seven patients with FMS,
Targino et al (2002), in a review of the literature on the
tested the differences resulting from using drugs only (ibu-
use of acupuncture as an adjunct or chief treatment for
profen, alprazolam), Osteopathic treatment (including strain-
patients with fibromyalgia, compared it with other clinical
counterstrain and muscle energy) plus medication, OMT
experience. He found that traditional acupuncture gives posi-
plus a placebo, and a placebo only. Drug therapy alone
tive scores in the Visual Analogue Scale, Myalgic Index,
resulted in significantly less tenderness than did drugs and
number of tender points, and improvement in quality of life
osteopathy, or the use of placebo and OMT, or placebo
based on the SF-36 questionnaire.
alone. Patients receiving placebo plus Osteopathic manipula-
Insomnia, depression, and Raynaud’s are common in
tion reported significantly less fatigue than the other groups.
FMS patients. These related symptoms can be treated. For
The group receiving medication and (mainly) osteopathic
example, Montakab (1999) has shown acupuncture to be
soft tissue manipulation showed the greatest improvement in
helpful for insomnia. Forty patients with primary difficulties
their quality of life. Jiminez et al. (1993) selected three
in either falling asleep or remaining asleep were diagnosed
groups of FMS patients, one of which received OMT,
according to TCM, assigned to specific diagnostic sub-
another had OMT plus self-teaching (study of the condition
groups, and treated individually by a practitioner in his pri-
and self-help measures), and a third group received only
vate practice. The patients were distributed at random into
moist-heat treatment. The group with the lowest level of
two groups, one receiving true acupuncture, the other nee-
reported pain after six months of care was the one receiving
dled at non-acupuncture points for three to five sessions at
OMT, although benefits were also noted in the self-teaching
weekly intervals. The outcome of the therapy was assessed
group.
in several ways: first by an objective measurement of the
Acupuncture has been shown to be helpful in FMS. Ber-
sleep quality, and second by polysomnography in a special-
man, Ezzo, Hadhazy, and Swyers (1999) conducted a search
ized sleep laboratory, performed once before and once after
for the key words “acupuncture” and “fibromyalgia.” They
termination of the series of treatments. Additional qualitative
selected all randomized or quasi-randomized controlled tri-
results were obtained from several questionnaires. The
als, or cohort studies of patients with FMS who were treated
objective measurement showed a statistically significant
with acupuncture. Seven studies (three randomized, con-
effect only in the patients who received the true acupuncture.
trolled trials and four cohort studies) were included; only one
Evaluation of the effects of a standardized acupuncture
was of high methodologic quality. The high-quality study
treatment in primary Raynaud's syndrome showed a signifi-
suggests that real acupuncture is more effective than sham
cant decrease in the frequency of attacks from 1.4 day-1 to
acupuncture for relieving pain, increasing pain thresholds,
0.6 day-1, P < 0.01 (control 1.6 to 1.2, P = 0.08). The overall
improving global ratings, and reducing morning stiffness of
reduction of attacks was 63% (control 27%, P = 0.03). The
FMS, but the duration of benefit following the acupuncture
mean duration of the capillary flowstop reaction decreased
treatment series is not known. Some patients report no bene-
from 71 to 24 s (week 1 vs week 12, P = 0.001) and 38 s
fit, and a few report an exacerbation of FMS-related pain.
(week 1 vs week 23, P = 0.02) respectively (Appiah, Hiller,
Lower-quality studies were consistent with these findings.
Caspary, Alexander, Creutzig 1997).
Sprott, Franke, Kluge, and Hein (1998) performed acu-
Acupuncture has been used successfully to treat depres-
puncture therapy on FMS patients and established a combi-
sion. For example, Allen et al (1998) treated thirty-eight
nation of methods to objectify pain measurement before and
women between eighteen and forty-five years of age. The
after therapy. Acupuncture treatment of patients with FMS
patients were randomly assigned to one of three treatments:
was associated with decreased pain levels and fewer positive
receiving specific acupuncture treatment (n=12), receiving
tender points as measured by Visual Analogue Scale (VAS)
nonspecific acupuncture treatment (n=11), or being on a
and dolorimetry (pressure sensitivity). They also showed a
waiting list (n=11). Patients who were in the nonspecific
decreased serotonin concentration in platelets and an
treatment group received eight weeks of nonspecific treat-
increase of serotonin and substance P levels in serum after
ment first, and then eight weeks of specific treatment.

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