J Manipulative Physiol Ther 2006 (Sep); 29 (7): 524—528 ~ FULL TEXT
Ilkim Çitak-Karakaya, PT, PhD, Türkan Akbayrak, PT, PhD,
Funda Demirtürk, PT, PhD, Gamze Ekici, PT, PhD,
Yesim Bakar, PT, PhD
Mugla School of Health Sciences,
OBJECTIVE: The aim of the study was to evaluate the short-term and 1–year follow-up results of connective tissue manipulation and combined ultrasound (US) therapy (US and high-voltage pulsed galvanic stimulation) in terms of pain, complaint of nonrestorative sleep, and impact on the functional activities in patients with fibromyalgia (FM).
METHODS: This is an observational prospective cohort study of 20 female patients with FM. Intensity of pain, complaint of nonrestorative sleep, and impact of FM on functional activities were evaluated by visual analogue scales. All evaluations were performed before and after 20 sessions of treatment, which included connective tissue manipulation of the back daily, for a total of 20 sessions, and combined US therapy of the upper back region every other session. One-year follow-up evaluations were performed on 14 subjects. Friedman test was used to analyze time-dependent changes.
RESULTS: Statistical analyses revealed that pain intensity, impact of FM on functional activities, and complaints of nonrestorative sleep improved after the treatment program (P < .05).
CONCLUSION: Methods used in this study seemed to be helpful in improving pain intensity, complaints of nonrestorative sleep, and impact on functional activities in patients with FM.
From the Full-Text Article:
This observational prospective cohort study examined the results of a physiotherapy program including a manual technique and a combined electrotherapy approach in patients with FM. Although the present study did not include a control group, it can be said that CTM and combined HVPGS and US seemed to provide benefits in patients with FM in aspects of pain relief, restoration of sleep, and improving the impact of FM on functional activities, which was maintained for a mean duration of 6 months after the program.
Brattberg  investigated the effect of CTM on FM. In that study, it was presented that CTM was a treatment giving pain relief, decreasing depression, and increasing quality of life in patients with FM. It was reported that the analgesic effect appeared gradually with the first 15 treatments (1–2 per week) and positive effects decreased gradually after the last treatment session.
Almeida et al,  who performed the first study investigating the effects of a combined electrotherapy approach in FM, pointed out that combination of interferential current and pulsed US was more effective than each of them separately, and this combination provided an effective pain treatment with consequent sleep improvement in FM. They also suggested that sleep disorder in FM might be due to a presleep pain condition; thus, the improvement in sleep could lead to less pain in the morning.
Parallel to the findings of Almeida et al,  although not supported with comparison to each other or with sham techniques, our study also indicates that combination of CTM, HVPGS, and US leads to improvements in disease consequences such as pain, sleep disturbance, and impaired functional activities. As mentioned in the introduction section, current concepts about pathophysiology of FM are mainly about autonomic and central nervous system dysregulation. Therefore, improvements achieved in this study may be thought mainly due to the effects of CTM including the regulation of autonomic responses, producing general body relaxation, and increasing plasma ß-endorphins.  In addition, the previously presented effects of the methods on reducing muscle tension, relieving connective tissue tenderness and pain, increasing microcirculatory muscle blood flow, and augmentation of muscle strength [15, 24–30] might have played role in improving the disease symptoms such as muscle tenderness and tension rather than directly regulating the suspected underlying mechanisms of FM, although these parameters are not included as the findings.
When the design of this study is considered, it is difficult to say which modality led to improvement in investigated parameters, and if suggestions directed to maintain the gains from the treatment program in the follow-up period played role in the long-term results. Missing follow-up values of 30% of the cases are a limitation of this study, and it is difficult to comment if their values would change the results positively or negatively. However, it can be concluded that combination of the methods used in this trial seemed to be helpful in patients with FM, although placebo effect or natural history cannot be ruled out.
CTM, HVPGS, and US seemed to be helpful in improving pain intensity, complaints of nonrestorative sleep, and impact on functional activities in patients with FM. Effectiveness of these methods is thought to be worthy of investigation in further studies, including comparisons with other methods or sham/controlled protocols.