Introduction

The condition in question, known as Fibromyalgia (FM), or Fibromyalgia Syndrome, is a chronic rheumatic disorder characterized by widespread musculoskeletal pain. The multiplicity of symptoms with which it manifests itself has so far made its identification and classification almost impossible, based on the following two definitions accepted by the scientific community:

1 – “Fibromyalgia is a chronic rheumatic disease characterized by widespread muscle pain, asthenia and stiffness, with which systemic symptoms may be associated (sleep alterations, anxiety or depression, headache, thyroid disorders, gastroesophageal reflux, temporomandibular joint (TMJ) disorders, irritable bowel syndrome, dysmenorrhea, restless legs syndrome, and many others […]).”

2 – “Fibromyalgia is a form of generalized extra-articular rheumatism, characterized by chronic pain, stiffness, asthenia, as well as tension in muscles, periarticular tissues, and tendon insertions; it is accompanied by increased and marked painful sensitivity at specific anatomical sites, termed tender points” [Grieco, 2022, p. 24].

In the test subjects, Fibromyalgia has already reached an advanced stage, originating as a result of trauma, sensory overstimulation, stress or other unknown factors.
From a technical point of view, the above events increase the acidity of the extracellular matrix, within which this excess of acids prompts the immune system to activate inflammation, which over time becomes chronic. Vasoconstriction due to irritation of the peripheral nerves, together with blockage of the lymphatic system, progressively prevents the disposal of acids from the ECM, which, by releasing hydrogen ions, in turn irritate the nociceptors.
This whole process leads to activation of the fight-or-flight defense mechanisms, and bioelectrical short-circuits throughout the Nervous System, which originate from the metameres (sets of tissues and organs innervated by a spinal nerve and connected to the CNS through the spinal ganglia). For this reason, Dr. Grieco defined Fibromyalgia as “Neurometameric Dysfunction” (NMD).

The study participants were selected by ensuring demographic representativeness and variety of FM experiences, while excluding the most severe cases, unable to move at all. The average age of the 4 female participants was 46 years; during the first cognitive meeting, in June 2023, they showed different manifestations and extent of symptoms, as well as different family experiences and work and housing backgrounds (each of the participants was interviewed about her clinical and personal history). One of the participants (Mrs. MBM) joined the group at the end of August.

Two questionnaires and a presentation form were used for data analysis:
1. The Italian version of the Revised Fibromyalgia Impact Questionnaire (RFIQ), designed and applied in hospital settings to assess the extent of FM and its impact on health and daily activities;
2. A monthly self-assessment chart consisting of 22 questions designed to assess the extent of symptoms, environmental conditions, habits, consistency in practicing assigned exercises, and more.

1 – Revised Fibromyalgia Impact Questionnaire

This questionnaire is divided into 3 sections:

• PHYSICAL FUNCTION (9 questions);
• GENERAL HEALTH CONDITION – OVERALL IMPACT (2 questions);
• SYMPTOMS (10 questions);

The answers to the 21 questions are represented by a scale of values from 0 to 10, with 10 indicating the highest severity. The final result is the sum of the results of the 9 questions about physical function divided by 3, plus the
sum of the 2 questions about general health status, plus the sum of the 10 questions about symptoms divided by 2.

In this context, the absolute value of the result was not assessed against previously collected clinical data and medical benchmarks, but rather the evolution of the results over the 7-month study period, comparing any improvements or worsening of the 4 cases
under observation with each other and against the clinical and personal history of each subject.

2 – Monthly self-assessment form

3 – Presentation sheet

Last but not least, this personal form was added to the initial interviews to provide a complete clinical picture and collect demographic and anamnestic information in order to identify key variables such as any traumas (possible causes of symptom onset), previously experienced therapies and their effects, emotional-familial conditions, and expectations regarding treatment, which may have determined the effectiveness of some practices over others.

PROTOCOL

Following the canons of Traditional Chinese Medicine (TCM), it was required to distribute the exercises of the daily practice hour as follows:

• 20 minutes in the morning of soft Qi Gong (Zhan Zhuang or other free sequences), or a nature walk;
• 20 minutes in the afternoon, at the peak of Yang energy, devoted to Ba Duan Jin or other more intense exercises (brisk walking or training, if physical conditions permit);
• 20 minutes in the evening reserved for meditative practices: guided visualization, motor imagery training.

A light, general joint warm-up sequence is always recommended before each session. Follow- ing medical guidelines [Grieco, 2022], magnesium intake and an alkalizing diet are suggested. It is also advisable to maintain steady diaphragmatic breathing, and to try to improve one’s emotional relationships (as noted, the emotional aspect has a major bearing on the success of “therapy”).
Throughout the duration of the study, practitioners were required to perform the above exercises daily, and to participate in a one-hour online class each week.
A total of 22 online meetings were conducted, in which not all of them participated regularly.
Respectively: MD – 19 attendance, SG – 16 attendance, BM – 15 attendance, MBM – 13 attendance.

Progression of exercises

Participants were taught the exercises to practice following this progression:

1. Diaphragmatic breathing and joint gymnastics;
2. Proprioceptive exercise of “mental brushes”;
3. First postures of Zhan Zhuang, with related visualizations;
4. Ba Duan Jin Qi Gong;
5. Visualization and practice of the “Small Cyclic Heaven” meditation, or “Microcosmic Circulation”;
6. Theory and practice of the Tibetan meditation technique “Sci-ne”;
7. Other more complex meditation, relaxation and guided visualization exercises.

Description of exercises

Qi Gong
“Internal energy work” that teaches coordination of breath and movement, developing the sense of touch and perception of self and one’s psychophysical state (proprioception or “bioperception”). Through Qi Gong we identify emotions, states of anxiety and depression on a physical level, while improving psychophysical balance and the immune system.
Consistent practice also helps to loosen muscle stiffness and restore biorhythms. [Yuefang, 1996; Yáng, 2022]

Ba Duan Jin
Eight dynamic Qi Gong exercises to stretch and loosen muscles, tendons and meridians. [Montorsi, 2021]

Zhan Zhuang
The practice of “Standing Pole” is a static Nei Dan Qi Gong exercise that improves posture and structural muscles. It also helps to coordinate the sympathetic NS with the parasympathetic NS, decrease the flow of information directed to the cerebral cortex, and thus dispose of accumulated acids in the cerebral ECM through improved sleep quality. [Xuanjie, 2018; Xiang Zhai, 2017; Grieco, 2022].

Motor Imagery Training
It is a mental practice that consists of visualizing certain motor processes or actions, aimed at improving the execution of a technical gesture.
In our specific case, it is combined with the static postures of Zhan Zhuang to restore the bioelectric and nervous balance of the system through “will projection” techniques in specific postures that respect the six harmonies of traditional Chinese martial arts.
[Xuanjie, 2018; Xiang Zhai, 2017; Yáng, 2022; Wong, 1992]

Guided Visualization – Meditation
Practices that inhibit the cerebral cortex in order to achieve a state of mental stillness and “listening” (alpha waves). This predisposition promotes perception of one’s state of health and analysis of trauma and other past experiences that may have contributed to or
caused the onset of pathology. [Chögyam, 1986; Yuefang, 1996; Yáng, 2022]

RESULTS
Descriptive statistics from the analysis of the collected data follow.

Regarding the monthly self-assessment form, significant improvements were observed in the areas of pain, movement coordination, concentration (“fibro-fog”), dizziness, anxiety and depression. In the latter three parameters, one of the participants (Mrs. MD) achieved 100% improvement, with total disappearance of symptoms.

DISCUSSION

The results of this pilot study were certainly influenced by the difficulty of finding candidates among FM patients. What is more, since we had no way to work in the presence, it was impossible to evaluate and certify the actual performance of the exercises assigned to the participants. It was also difficult to correct the movements in the individual exercises and the “standing pole” postures. Finally, it was also not possible to assess the coordination between breath and movement, which is fundamental in the discipline of Qi Gong.
[Yuefang, 1996; Yáng, 2022; Montorsi, 2021]:

Considering the starting conditions, some curves on the analyzed graphs are in line with what is expected, some are not [Yuefang, 1996; Yáng, 2022; Montorsi, 2021]:
• The level of pain has not decreased as much as hoped;
• Mrs. MBM’s curves seem to run counter to all the others: the reason may lie in the precariousness of her current family situation, and her late inclusion in the program;
• In contrast, anxiety and depression levels have dropped extraordinarily, especially in the case of Mrs. MD;
• Coordination has improved, while fibro-fog has had an initial improvement, only to rise again;
• Outdoor environmental conditions did not seem to affect the extent of symptoms much, while housing transfers did.

The results show that the practices reserved for the body need more constancy, especially in the initial stages of acquiring the techniques, in order to be able to observe concrete results, which directly affect the perception of fatigue and pain.
Breathing techniques are essential for calmness and mental stillness, but in the face of the results obtained on anxiety, we can say that they have had their effect.
I personally guided the visualization and meditation techniques online, later sending a pdf file with vocal tracks to be recorded and listened to again before sleep. The beneficial effects manifested immediately, although it was hypothesized that increased awareness of the body, breath and one’s own bioelectric state could have considerably increased the effects of what “was being guided by the mind”
(motor imagery techniques).
Movement coordination can be improved through the practice of Ba Duan Jin and other joint mobility exercises and soft Qi Gong.
The lack of improvement in the sense of tiredness and fatigue can be attributed to the lack of consistency in the practice of Zhan Zhuang and walks.