Contemporary Chiropractic Care for a Veteran with Fibromyalgia: A Case Report

INTRODUCTION

Chronic widespread pain is characterized by diffuse musculoskeletal discomfort involving multiple body regions, persisting for at least three months, and is estimated to affect 10–15% of all adults.^1,2 Fibromyalgia is the most common cause of chronic widespread pain,^3,4 and is often accompanied by symptoms such as chronic fatigue, nonrestorative sleep, and cognitive dysfunction (commonly referred to as “fibro fog”).^5,6 Although the pain in fibromyalgia is frequently perceived as originating from musculoskeletal tissues, it is now understood to represent a nociplastic pain condition, characterized by heightened pain sensitivity involving both central and peripheral sensitization mechanisms.^7–11 The etiology of fibromyalgia remains incompletely understood but is believed to be multifactorial, involving a combination of genetic and environmental factors.^12–14 Identified risk factors include female sex, advancing age, poor sleep hygiene, physical trauma, adverse childhood experiences, sedentary behavior, and low socioeconomic status.¹⁵

Diagnosing fibromyalgia has long been considered challenging and is often reported to be underdiagnosed or recognized only after a significant delay.^16–18 This may reflect evolving diagnostic understanding over the past 4 decades. The first widely accepted diagnostic criteria were developed by the American College of Rheumatology (ACR) in 1990,¹⁹ with major revisions introduced in 2010,²⁰ and again in 2016.²¹ Diagnosing fibromyalgia should include a comprehensive health history, physical examination, consideration of relevant differential diagnoses, and application of the 2016 ACR criteria to help confirm the diagnosis (Figure 1).^21,22 Notably, the 2016 criteria emphasizes that “a diagnosis of fibromyalgia does not exclude the presence of other clinically important illnesses,”²¹ reinforcing the validity of the diagnosis even in the presence of comorbid conditions.

Figure 1.Modern Diagnostic Criteria for Fibromyalgia²¹

Once a diagnosis of fibromyalgia is established, management should follow a patient-centered, biopsychosocial approach grounded in evidence-based, multimodal care.^23–25 Current clinical guidelines consistently recommend nonpharmacologic interventions as first-line treatment, with aerobic exercise, cognitive behavioral therapy (CBT), and patient education serving as the foundation of effective management.³ Among these, regular exercise has the strongest evidence for improving function and reducing pain. Pharmacologic therapies such as duloxetine and pregabalin may be considered for select patients; however, their benefits are often modest and medication side effects should be taken into account.³ Additional supportive therapies such as acupuncture, mindfulness-based stress reduction, and spinal manipulation may also be incorporated into individualized treatment plans to address the multifactorial symptom burden of fibromyalgia.²⁶ From a chiropractic perspective, exercise prescription is a well-supported intervention that aligns with current guidelines and may serve as a key strategy for enhancing pain tolerance and promoting physical function. Although evidence supporting spinal manipulative therapy for fibromyalgia remains limited,²⁷ some individuals may benefit from this form of treatment when used as part of a broader interdisciplinary care model.²⁸ The purpose of this case report is to describe a multimodal course of chiropractic care for a Veteran with fibromyalgia within an integrated healthcare setting.

CASE REPORT

A 34-year-old male U.S. Veteran was referred by his primary care provider for chiropractic consultation at a Veterans Affairs (VA) facility for chronic widespread pain affecting the cervical, thoracic, and lumbar spinal regions, both shoulders and hips, and intermittent paresthesia in all four extremities. His symptoms had persisted at a consistent level since his time in military service, 7 years prior. Prior diagnostic workup included magnetic resonance imaging (MRI) of each spinal region and electrodiagnostic testing (EMG/NCV) of the extremities. Imaging was unremarkable aside from mild multilevel lumbar spondylosis, and electrodiagnostic testing revealed no evidence of peripheral neuropathy or radiculopathy.

At the time of referral, the patient was receiving chiropractic and massage therapy visits twice weekly via providers outside of the VA; these treatments were limited to full-spine spinal manipulative therapy and full-body Swedish massage, respectively. No self-care strategies or home exercise recommendations were included by either provider. Additionally, he was concurrently prescribed acetaminophen, diclofenac, tizanidine, and pregabalin for pain control. A review of his electronic health record revealed multiple comorbidities including major depressive disorder, attention-deficit hyperactivity disorder (ADHD), obstructive sleep apnea, adjustment disorder with anxious mood, irritable bowel syndrome, patellofemoral syndrome, and class I obesity. The referring provider described a longstanding history of “central pain” with limited response to his ongoing treatment (Table 1).

The patient reported constant, diffuse pain over the past 7 years, describing it as “aching, sharp, tight, and pinching.” He also noted pain-induced weakness in his legs, which required him to use a cane when walking. He also described intermittent non-dermatomal paresthesia in all 4 limbs, but denied any sensory loss, recent trauma, bowel or bladder dysfunction, or other red flag symptoms. He associated the onset of his symptoms with military service, including an electrical injury, and attributed his condition to an accumulation of physical traumas. Pain was aggravated by any type of movement or routine daily activity, with only mild and transient relief reported after manual therapies and medication use.^29–31

At intake, his average PEG score was an 8.7 out of 10,³² while his score on the 6-item University of Washington Concerns About Pain (UW-CAP) scale indicated pain-related distress (i.e., catastrophizing) above the 69th percentile of individuals with chronic pain. Fibromyalgia was also suspected; his score on the Widespread Pain Index was 16/19, his Symptom Severity Score was 12/12, and he reported longstanding pain in all five body regions for over three months, which confirmed the presence of fibromyalgia (Figure 1).

Physical examination revealed an antalgic gait with use of a cane and moderate pain behaviors with all transitions. There were no visible deformities, erythema, edema, or overt muscle atrophy. Cervical, thoracic, lumbar, shoulder, and hip ranges of motion were full but provoked increased discomfort and involved pain behaviors. Neural tension testing was negative, and strength, reflexes, and sensation were grossly normal. Light palpation of spinal and shoulder girdle musculature elicited exaggerated pain responses consistent with mechanical allodynia. Lumbar extension-rotation testing (i.e., Kemp’s test) and cervical extension-rotation testing (i.e., Spurling’s maneuver) reproduced regional axial spine pain bilaterally, but there was no directional preference with end-range loading.

We diagnosed him with fibromyalgia, with a secondary diagnoses of regional back pain (cervicalgia, thoracic spine pain, low back pain, and lumbar spondylosis). His widespread soft-tissue tenderness and non-dermatomal paresthesia were interpreted as characteristic manifestations of fibromyalgia.

The initial visit emphasized patient education, including a lay explanation of neuronal sensitization involved in nociplastic pain. Terms such as amplification and hyperexcitable were used along with phrases such as “hurt doesn’t equal harm” and “safe, but sore” to discuss neurophysiologic concepts related to nociplastic pain. Since he also had ADHD, an analogy was used describing how “fibromyalgia is like ADHD, but for pain” in an attempt to communicate the dysregulated neurophysiology associated with nociplastic pain. Evidence-based fibromyalgia management strategies were reviewed with the Veteran,³ and the importance of daily self-care was emphasized, while discussing the limitations associated with long-term reliance on passive treatments for chronic pain management. We also discussed the harms of long-term passive coping and fear-avoidance and the importance of managing relevant comorbid conditions (i.e., yellow flags like depression).^33–35

Treatment goals were identified at the initial visit and included 1) daily engagement in self-care and exercise, 2) reduced dependence on his assistive cane, 3) increased tolerance for walking (>10 minutes duration), and 4) reduced average pain intensity “by half” (i.e., from a 7/10 to a 3–4/10). Shared decision-making guided the development of a multimodal care plan, which incorporated the following: pain science education focusing on nociplastic pain, lifestyle counseling focusing on the pillars of Lifestyle Medicine,^36,37 engagement in graded activities using a cognitive functional therapy approach,³⁸ self-care and home exercise program instruction, and manual therapies. Manual therapies included lumbar flexion-distraction, soft-tissue treatment (e.g., VibraCussor massager, ArthroStim percussion, pin-and-stretch), and spinal manipulative therapy in the cervical, thoracic, and lumbopelvic regions.

Chiropractic care was provided over a 7-month period for a total of 11 visits. Each encounter reinforced principles of self-management and active engagement. Minor treatment variations occurred across visits, based on presentation and progress, but treatment always included patient education and encouragement, therapeutic exercise instruction (Table 2), spinal mobilization or low-force manipulation, soft-tissue therapy, and progress monitoring. Pain neuroscience education was reiterated using patient-centered language to support cognitive re-appraisal of his symptoms, to reduce fear-based avoidance behaviors and to reduce catastrophic thinking about his pain.

The patient demonstrated gradual but consistent improvements over the course of care. By visit 6, he reported increased tolerance for upright activity, reduced need for his cane when walking short-distances, increased ability to walk >10 minutes, and a greater sense of control over his condition. He also reported engaging with his recommended home exercise program “almost every day,” which included walking, chair yoga, and core strengthening exercises. At the final visit, he described a reduction in average pain intensity from 7/10 to 3/10 and improvements in both activity tolerance and emotional coping. His average pain-related PEG score decreased from an average of 8.7/10 to 4.3/10, and his UW-CAP score improved from a percentile rank of 69% to 44%, indicating a reduction in pain-related catastrophic thinking. Consistent with these functional and emotional improvements, he rated his overall progress as “much improved” on the Patient Global Impression of Change (PGIC) scale, reflecting a clinically meaningful perception of benefit following his trial of care (Table 3).

No adverse events from treatment occurred throughout his trial of chiropractic care and the patient described his chiropractic visits as relieving and emotionally validating. He expressed increased understanding of his condition and stated that his progress felt sustainable due to the emphasis on self-care and education. Manual therapy, including spinal manipulation, was described as helpful for facilitating movement, and he no longer viewed it as the primary treatment modality.

At his final chiropractic visit, he told us that his fibromyalgia symptoms persisted but were less frequent, less intense, and described as less consuming. He also noted greater consistency in sleep patterns and daily routines. We discussed discharge from treatment, during which we agreed to discontinue scheduled follow-up visits, with the option for the patient to self-schedule a follow-up as-needed. Four months have lapsed since this final visit and the drafting of this report, and he has yet to return for follow-up treatment in the chiropractic clinic. A recent chart review indicated that he has successfully completed a trial of aquatic physical therapy and remains engaged in ongoing care with VA pain psychology services.

DISCUSSION

Fibromyalgia remains a challenging condition to diagnose and manage,^16,18,40,41 particularly within complex patient populations such as U.S. Veterans.^42,43 Characteristic features of fibromyalgia include widespread chronic pain, fatigue, and sensory amplification, and these are often compounded by overlapping comorbidities and a history of prior treatments that have provided limited relief.^21,44,45 In this case, the patient’s clinical presentation was consistent with a nociplastic pain phenotype, and a diagnosis of fibromyalgia was confirmed using the 2016 ACR criteria (Figure 1).^10,29,30,46 Key clinical features included diffuse tenderness, non-dermatomal paresthesia, and pain behaviors that were not attributable to structural or neurologic pathology. The case highlights the clinical complexity of fibromyalgia and underscores the importance of patient-centered care models that reflect current evidence.^3,10,24 A central feature of the care process was the use of shared clinical decision-making to develop a multimodal treatment plan. The chiropractic care emphasized transitioning from long-term reliance on passive treatments for short-term pain relief, to a multi-modal approach that focused on improving functional goals, self-care, and graded physical activity (Figure 2).^24,28 Each of these strategies are supported by contemporary treatment recommendations for fibromyalgia.^{3,28,41,47,48}

Figure 2.Transition in Care from Passive to Active

Chiropractic services within the VA are included in the standard Medical Benefits Package, and utilization of these services by Veterans is expected to continue growing.^49,50 Compared to non-Veterans, U.S. Veterans experience a higher prevalence of severe pain, with spine-related pain and headaches being listed among the most commonly reported conditions.⁵¹ Fibromyalgia is also relatively common in this population, and chiropractic care has been reported to be integrated into fibromyalgia management in approximately 40% of cases.^48,52,53 While spinal manipulative therapy has traditionally played a central role in chiropractic practice,^54,55 this service alone has yet to establish efficacy for fibromyalgia management.²⁷ Instead, this case demonstrates how chiropractic care can be integrated into a broader, evidence-informed framework that prioritizes nonpharmacologic strategies such as pain neuroscience education, exercise instruction, and promotion of self-efficacy. These strategies align with clinical practice guidelines, which recommend nonpharmacologic therapies as the foundation of fibromyalgia treatment.^3,44–48 In this case, chiropractic care was integrated into a multidisciplinary treatment and complemented referrals to pain psychology and physical therapy, contributing to a more comprehensive management plan. The chiropractor’s role extended beyond the passive delivery of manual therapies to include education about fibromyalgia and nociplastic pain mechanisms, guidance in graded activity, and support for behavioral change, thereby reinforcing the goals of interdisciplinary care.

The improvements observed in this case are consistent with known therapeutic mechanisms relevant to the management of fibromyalgia and other nociplastic pain conditions. Multimodal care that includes education, lifestyle change, and graded activity has been associated with improved pain modulation, reduced pain catastrophizing, and enhanced self-efficacy.^6,10,24,36 While manual therapies such as spinal manipulation and soft-tissue techniques were used in this case, their use was intended to serve as a tool to support movement and comfort, rather than as curative interventions. The emphasis on patient empowerment and behavioral activation is believed to have contributed to this individual’s improved functional capacity, reduced pain intensity, and reduction of catastrophic thinking over the course of care. The patient’s transition to self-management and elective discontinuation of scheduled chiropractic visits supports the role of integrating chiropractic services into guideline-concordant care for those suffering from fibromyalgia.

Individuals with chronic pain are often faced with the burdensome reality of navigating a fragmented healthcare system,^56,57 in which patients become increasingly consumed by the demands of managing numerous appointments.⁵⁸ This burden of treatment can be overwhelming and is reflective of a healthcare model that often emphasizes pathoanatomic pathology over a holistic and coordinated approach to care. For patients with complex chronic pain conditions, such as fibromyalgia, the accumulation of diagnostic labels and referrals may inadvertently amplify distress, adding fuel to the chronic pain cycle. Strictly focusing on biomedical explaanations may miss the broader biopsychosocial contributors to chronic pain, reinforcing passive models of care that prioritize short-term symptom reduction over functional improvement. We encourage clinicians to view their role in chronic pain management not solely as fixers, but as facilitators of patient-centered change.³⁶ Despite good intentions, repeated passive interventions are likely to provide only transient relief while inadvertently reinforcing dependency, without fostering long-term self-efficacy or functional improvement. A more helpful paradigm shift involves guiding patients toward values-based goals and helping them reframe success not as the simple elimination of pain, but as the ability to meaningfully reengage in life. Lifestyle-based approaches, focusing on physical activity, provide not only analgesic benefit, but are also likely to help improve stress regulation, sleep, and dietary patterns, further supporting the broader rehabilitation process.^38,59,60

Limitations

As with all case reports, this manuscript is subject to important limitations. The patient’s improvement cannot be attributed to any single intervention, as care was delivered in a multimodal, outpatient setting over an extended period. Numerous uncontrolled variables, including concurrent treatments, natural symptom fluctuations, and psychosocial influences, may have contributed to the observed outcomes. Chronic pain is influenced by complex interactions among biological, psychological, and social factors,⁶¹ all of which likely shaped this individual’s experience and response to care. This report should not be interpreted as evidence of efficacy for chiropractic treatment of fibromyalgia. Rather, it illustrates the application of a multimodal, patient-centered approach in an integrated clinical setting.

CONCLUSION

This case describes a course of chiropractic care for a U.S. Veteran with fibromyalgia. Chiropractic management was incorporated into a multidisciplinary approach to his chronic pain management. He transitioned from a treatment approach limited to passive coping strategies to one that integrated regular self-care, active rehabilitation strategies, and patient education. He demonstrated lasting improvement of his widespread chronic pain, sustained functional gains, and reduced pain catastrophizing. He was eventually released from scheduled follow-up and transitioned to self-management and continuation with pain psychology. This case emphasizes the value of multimodal chiropractic care for a U.S. Veteran with fibromyalgia within an integrated care setting.

ACKNOWLEDGEMENTS

We acknowledge the use of OpenAI’s ChatGPT (model GPT-4o) for assistance in creating components of Figures 1 & 2 in this report.

AUTHORS’ CONTRIBUTIONS

CBR delivered clinical care, recorded outcomes, and developed the study design. CBR and AS drafted and edited the manuscript. Both authors met the criteria for authorship and approved the final version of this manuscript.

COMPETING INTERESTS & FUNDING

No funding was received for this work. CBR serves as a consultant on a “HEAL Initiative: Pain Research Enhancement Program (PREP)” NIH grant application. If funded, compensation for this consulting will total $6,000 over a period of 3 years, which breaks down to $2,000 per year. Additionally, CBR is the sole proprietor of Clinical Solutions, LLC. This LLC is a business structure, under which he is currently writing a book with future to publish. This book is still in development, with tentative plans to publish in 2025. To date, Clinical Solutions LLC has not engaged in any business transactions and CBR has received zero income from Clinical Solutions LLC. AS has no conflicts of interest to disclose.

DISCLAIMER

The content of this manuscript is that of the authors and does not necessarily reflect the positions or policies of the U.S. Government or the Department of Veterans Affairs.

CONSENT FOR PUBLICATION

The patient described in this report consented to publication both verbally and in writing. Documentation of his consent was provided to the Journal of Contemporary Chiropractic at the time of submission.