Fibromyalgia Syndrome: Is There Any Effective Therapy?
By Source: Consultant. Jun. 1996; 36(6) •
June 1, 1996
Abstract: Fibromyalgia syndrome (FMS) can be treated using a variety of nonpharmacologic and pharmacologic therapies. A warm empathetic attitude on the part of the physician is critical for building rapport. For mild cases of FMS, patient education, exercise, physical therapy, simple analgesics and tricyclic antidepressants can be effective. In more severe cases, higher doses of drugs in combination with tricyclic agents and serotonin uptake inhibitors may be required. Acetaminophen and low-dose codeine may also be necessary for recalcitrant symptoms or acute flare-ups.
While the management of fibromyalgia syndrome (FMS) is more of an art than a science at this time, a better understanding of this potentially disabling condition has been reached in recent years. We now know that FMS is not simply stress or depression, and that psychological factors are only one component of this syndrome.
In fact, many different factors interact to cause symptoms, and their relative importance varies from patient to patient.1 Thus, FMS requires both a multifaceted and an individualized approach to treatment. Although most patients with FMS continue to have chronic pain, appropriate management can improve function and quality of life for many.
The Components of Therapy
The most important elements of the management of FMS are shown in Table 1.
Table 1: Components of Therapy for Fibromyalgia Syndrome
A positive and empathetic physician
Reassurance that the pain is real but does not cause tissue damage
Individualized therapy, considering severity and relative contribution of aggravating factors
Addressing psychological factors (anxiety, stress, and depression); referral to a mental health professional in difficult cases
Behavior modification through cognitive behavior therapy, focusing on positive attitude and self- responsibility
Improvement of sleep quality
Gradual increase of physical activities to achieve physical fitness
Physical/occupational therapy, including flexibility and muscle-strengthening exercises
Other nonpharmacologic approaches (electromyographic biofeedback, meditation, hypnotherapy, electroacupuncture)
Simple analgesics (acetaminophen and low-dose NSAIDs)
Serotonergic/noradrenergic (mostly antidepressant) medications; anxiolytic drugs (in patients with significant anxiety)
Myofascial therapy, including injection of symptomatic tender points with a local anesthetic
Multidisciplinary approach under "one umbrella," incorporating cognitive behavior therapy, physical fitness exercises, relaxation techniques, and other forms of therapy
A Positive and Empathetic Physician
The management of FMS begins with your first contact with the patient. A warm, empathetic attitude is readily discerned by the patient and builds rapport immediately. Many patients with FMS are defensive because of unpleasant experiences with previous noncaring physicians, so it is particularly important that you reassure them that you understand their suffering and are willing to help.2
FMS can be reliably diagnosed by clinical characteristics alone. Clearly convey the certainty of your diagnosis and do not imply that the problem is "all in the patient's head." This does not mean minimizing significant psychological problems, if present, but depicting them as aggravating factors.
Patient education is an integral part of management. A patient information sheet or booklet is always useful. Use layperson's language to explain what is known about the biophysiologic mechanisms and contributory factors of FMS. Neuroendocrine dysfunction, which includes a deficiency of serotonin and an excess of substance P, may be simply explained as "chemical imbalance." Explain that this imbalance is different from that in psychiatric illnesses, such as depression.
Encourage patients to accept that their pain is likely to remain chronic. They should focus on being as functional and active as possible, rather than focusing on symptoms. Tell them that their active participation in therapy is vital to their success.
Many patients are concerned about having a serious illness, such as SLE or cancer. This is often caused by a "positive test result," such as the presence of antinuclear antibodies. These patients need special reassurance. I usually tell my patients "I fully understand your genuine suffering, but please be assured that fibromyalgia will not cripple you or cause tissue damage." Avoid using the term "benign pain"; this term is particularly objectionable to patients who have disabling pain.
The severity of symptoms and aggravating factors vary from patient to patient. Consequently, "one-size treatment" does not fit all patients. Carefully evaluate these factors in each patient, and address the pertinent ones. Most patients need counseling on physical fitness and sleep; however, FMS can occur in physically fit persons and in those with no sleep difficulties.
The concomitant presence of another disease, such as RA, migraine, irritable bowel syndrome, or hypothyroidism, may augment symptoms and should be appropriately managed. Psychological factors are very important in some patients with FMS and require special attention.
Make every attempt to keep the patient employed. A working patient has less time to focus on pain, and employment provides a sense of self-worth, which is particularly important in patients with chronic illness. Job modifications, changes in ergonomics, and a reduction in work hours may be necessary, however. When appropriate, work with the patient's supervisors, educating them about FMS and discussing aggravating factors, such as shift work. Patients are more likely to stay employed if they perceive that their physician and employer are working together to help them.
Walking and stretching for a few minutes after sitting for 2 to 3 hours helps alleviate pain and stiffness. Recommend against frequent bending and weight lifting. "Return to work" centers often provide a valuable service by evaluating ergonomic factors, teaching proper body mechanics, and instituting a program of gradual work hardening for the same or a modified job. It is important that you closely interact with these centers.
Addressing Psychological Factors
Pain, irrespective of its cause, is significantly influenced by psychological factors and is accentuated by anxiety, stress, and depression. While these factors are better evaluated by validated questionnaires,1 simple questions can provide valuable information. You might ask: "Are you an anxious person or do you have worries?" "Do you have mental stress?" "Do you feel depressed, sad, or low in spirits?"
Significant psychological distress can be helped by emotional support coupled with pharmacologic agents, such as antidepressant and anxiolytic drugs. While the pain of FMS usually responds to low doses of serotonergic/noradrenergic medications, the presence of significant depression requires higher doses. Only a minority of patients need referral to a psychologist or psychiatrist.
Not all patients with severe pain or fatigue have significant psychological problems. Many of them, however, have poor coping skills; they wrongly believe that their symptoms will cripple them and that they have no control. These patients may particularly benefit from cognitive behavior therapy.
Cognitive Behavior Therapy
Advise your patient that behavioral changes are essential to the successful management of any chronic condition. In patients with severe symptoms, cognitive behavior therapy may be helpful. This can be provided by a psychotherapist -- either individually or in a group. In a group format, the therapist usually meets weekly with 10 to 12 patients for 3 to 6 months, with attention to individual needs (including psychotherapy). Such therapy can reduce pain, decrease mental stress, augment coping skills, enhance physical functioning, and improve overall quality of life.3,4
The goal of cognitive behavior therapy is to encourage a positive, "I can help my condition" attitude in patients and impart a sense of optimism and control. This approach minimizes the passive role of the patient. Such therapy also helps change negative perceptions about physical exercise, such as the belief that exercise will worsen pain.
Although several models of cognitive behavior therapy have been described,3-6 all involve patient education to change negative perceptions and behaviors. Patients are taught to set realistic goals, to relax (through electromyographic biofeedback, meditation, and/or counseling to reduce stress), and to remain physically fit. Coping skills are learned through techniques such as self-talk and distraction. Physical activities and social interactions are gradually increased.
Improving Sleep Quality
Most patients with FMS sleep poorly because of pain; psychological distress; endogenous arousal; or an associated sleep disorder, such as restless legs syndrome, periodic limb movement disorder or, perhaps, sleep apnea. Nonrestorative sleep contributes to pain, fatigue, and poor physical and mental performance.
The management of sleep disturbance is therefore important and includes both nonpharmacologic and pharmacologic approaches. Nonpharmacologic measures include going to bed early and at the same time every day, sleeping in a quiet room without distraction, avoiding alcohol and coffee before bed, exercising regularly during the day or early evening, and using relaxation techniques.
Tricyclic antidepressants, taken in low doses (10 to 50 mg after supper or at bedtime), are generally effective. Zolpidem (10 mg at bedtime) has been reported to improve sleep as well as daytime energy in a controlled study.7 An anxiolytic medication, such as alprazolam (0.25 to 0.5 mg in the evening or at bedtime), may also be helpful, particularly in anxious patients.
Routinely ask your patient about the presence of symptoms of restless legs syndrome or periodic limb movement disorder. These conditions require specific therapy, such as clonazepam and L-dopa.8 I have also found zolpidem useful in this setting.
Controlled studies have demonstrated that cardiovascular fitness training can reduce symptoms in patients with FMS.9 Some patients do not experience diminished pain but report enhanced well-being.
Many patients with FMS have muscle deconditioning.5,6 Deconditioned muscles use excess energy for a given task and may therefore contribute to fatigue. These muscles may also be susceptible to microtrauma, thus aggravating pain.6 The challenge is to get patients to do aerobic and muscle endurance exercises. Since symptoms are often aggravated afterward, reassure your patients that a moderate degree of pain following exercise is not harmful.
The types of exercises used are individualized, depending on personal choice and pain severity. Poorly motivated patients tend to do better in a group. Others benefit from brisk walking, swimming in a warm pool, and bicycling. The key is to start exercising at a low level for 5 to 10 minutes and build up to 30 to 40 minutes daily to attain a heart rate of 130 to 150 beats per minute. I ask my patients to use a graph to keep track of their progress in exercise tune and symptoms. This provides them with useful feedback.
Physical and Occupational Therapy
No controlled studies have shown the efficacy of physical therapy in FMS. Anecdotally, however, one or more forms of physical therapy provide relief in some patients. Different types of physical therapy are shown in Table 2. Patients should not concentrate on passive modalities, such as massage, heat, and electric stimulation. Active involvement in physical fitness and endurance programs is vital.
Table 2: Physical and Occupational Therapies Commonly Used in Managing Fibromyalgia Syndrome(*)
Heat therapy: hot packs; hydrotherapy
Cold therapy: cold packs
Myotherapy: massage; manipulation; stretch and vapocoolant spray
Stretching exercises, including range of motion
Muscle-strengthening and aerobic exercises
Use of proper posture and body mechanics
Transcutaneous electric stimulation
*It is important to combine a home program of physical therapy with the therapy at an institution. Patients should not completely rely on passive modalities, such as massage, heat, and electric stimulation.
Effective therapists provide encouragement; are persistent but not "pushy"; and stress the importance of aerobic exercise, stretching, muscle strengthening, correct posture, and proper body mechanics in carrying out daily tasks. The technique of stretching and spraying with a vapocoolant (fluoromethane) may provide temporary relief for some patients.10 The therapist should teach physical therapy modalities to both the patient and a family member, to help ensure daily compliance at home. An occupational therapist or rehabilitation specialist may teach patients to conserve energy, use appropriate splints if necessary, and minimize tissue trauma.
Other Nonpharmacologic Approaches
Controlled studies have demonstrated electromyographic biofeedback, electroacupuncture, and hypnotherapy to be useful in patients with FMS.11 An open study concluded that meditation is also helpful.12 Some of these nonpharmacologic approaches may have their beneficial effects via changes in neurohormonal status.
Acetaminophen and low-dose NSAIDs are effective in some patients, particularly when combined with a centrally acting medication, such as amitriptyline.11 Avoid NSAIDs in those with a history of peptic ulcer, hepatic disease, or renal disease.
These are the most useful agents in the management of FMS but should be used only in conjunction with the nonpharmacologic measures outlined above. I refer to these agents as "serotonin builders" rather than "antidepressants," because most patients with FMS are not depressed and feel hesitant, even indignant, about taking an antidepressant. Moreover, not all serotonergic and noradrenergic drugs shown by controlled studies to be effective in FMS have an antidepressant effect (cyclobenzaprine, for example).11
I explain that the low doses used in FMS help pain and sleep, but not depression. I add that a drug has many forms of action -- for example, an anti-malarial agent may be effective in RA.
Double-blind, controlled studies have shown the efficacy of amitriptyline and cyclobenzaprine.11 The efficacy of other tricyclic agents in patients with FMS has not been reported. Clinical experience suggests that selective serotonin re-uptake inhibitors (SSRIs) alone are ineffective unless they are used specifically for depression.
The combination of fluoxetine and amitriptyline is more effective than either of these drugs alone.13 When combined with an SSRI, a tricyclic agent has increased toxicity (drowsiness and anticholinergic effects), so keep the tricyclic dose low (such as 10 to 50 mg of amitriptyline). Also give SSRIs in low doses initially. SSRIs are taken in the morning because they may disrupt sleep.
These agents should be used in the lowest doses that produce the desired effect and given for at least 4 to 6 weeks before changing therapy. Because the biochemical profile is likely to vary from one patient to another,1 it is reasonable to prescribe a predominantly noradrenergic drug, such as desipramine, for a patient who has not responded sufficiently to the optimal dose of two or more predominantly serotonergic medications, such as amitriptyline and doxepin.
Patients with FMS seem to be unusually susceptible to the side effects of these medications, particularly to the antihistaminic effects (sedation and morning grogginess) of the tricyclic drugs. Urinary retention and cardiovascular side effects, such as tachycardia, arrhythmia, and hypotension, may occur -- albeit rarely -- especially in elderly patients taking tricyclic agents.
Starting at a low dose (10 mg) and taking the medication earlier in the evening often help mitigate these side effects, which tend to diminish after 2 to 3 weeks. Mild or moderate dry mouth can usually be managed with frequent sips of water.
My colleagues and I have used tramadol with impressive results in some patients with FMS. This unique analgesic has its effects on opioid receptors, and it inhibits the reuptake of both serotonin and noradrenaline. Because of tramadol's weak affinity for (Mu)-opioid receptors, addiction is rare. However, a combination of tramadol and a seratonergic agent has been reported to cause seizures; therefore, avoid this combination, particularly in patients with a history of seizures.
Since both serotonin and noradrenaline deficiency have been demonstrated in patients with FMS,1 newer antidepressants, such as venlafaxine and nefazodone, may be beneficial. Other serotonergic/noradrenergic drugs may be appropriate as they become available. Controlled trials of these drugs in patients with FMS are necessary.
Injection of Tender Points
The injection of tender points is an extremely valuable adjunctive therapy.9 It probably works by activating encephalinergic neurons in the spinal cord.
Injection of tender points is particularly useful if the patient can localize one to four areas that are most bothersome. With the patient's help, I first identify the most tender spot. I then inject this site with 1 mL of 1% lidocaine or a mixture of 0.75 mL of lidocaine and 0.25 mL of triamcinolone diacetate suspension, using a 27-gauge needle. (No data demonstrate an added benefit of the lidocaine-corticosteroid mixture.) As the needle penetrates the subcutaneous tissue (the medial fatty pad of the knee, for example) or into a muscle belly, the pain is sometimes exacerbated.
After the injections, ask the patient to gently stretch the injected tissues and refrain from using the injected areas for 24 to 48 hours. This minimizes postinjection flare, which is further curtailed by local use of ice for several hours after injections. The benefit of this treatment lasts 2 to 4 months. I rarely inject a patient's tender points more frequently than every 2 to 3 months.
A Multidisciplinary Approach
Acomprehensive "package" of patient education, cognitive behavioral therapy, physical fitness, physical/occupational therapy, and psychological counseling, while clearly beneficial for patients with FMS,3,5,6,14 is not always reimbursed by third-party payers. Consequently, my colleagues and I select various components of the program according to the patient's needs. For example, some patients are motivated to pursue a physical fitness program on their own, while others need a group format.
Tailoring Treatment on the Basis of Symptom Severity
Most mildly symptomatic patients respond to education about FMS, reassurance, home physical therapy, brisk walking exercises, simple analgesics and, sometimes, low-dose amitriptyline, cyclobenzaprine, or trazodone. Patients with severe FMS require cognitive behavior therapy and serotonergic/noradrenergic medications in higher doses. The injection of tender points can be carried out at any stage of illness.
I manage periodic and severe exacerbations of FMS with reassurance, physical therapy three to five times a week, relative rest, and injection of tender points, as well as by increasing the dose of a centrally acting medication. A short course (2 to 3 weeks) of acetaminophen with low-dose codeine (15 or 30 mg) may help some patients who have recalcitrant symptoms. Anxious patients also benefit from a bedtime or evening dose of an anxiolytic drug, such as alprazolam, lorazepam, or buspirone, for 2 to 8 weeks. These drugs may be used for a longer period, provided the dosages are kept low and the patient is not at risk for addiction. The underlying cause of a flare -- for example, a stressful event or an infection also needs to be addressed.
With the individualized and multifaceted approach described above, you can help most patients with FMS. Most patients require ongoing therapy and psychological support by an empathetic physician.
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2. Masi AT. An intuitive person-centered perspective on fibromyalgia syndrome and its management. In: Masi AT, ed. Bailliere's Clinical Rheumatology: Fibromyalgia and Myofascial Pain Syndromes. London: WB Saunders Company; 1994:957-993.
3. Burckhardt CS, Bjelle A. Education programs for fibromyalgia patients: description and evaluation. In: Masi AT, ed. Bailliere's Clinical Rheumatology: Fibromyalgia and Myofascial Pain Syndromes. London: WB Saunders Company; 1994:935-955.
4. Nielson WR, Walker C, McCain GA. Cognitive behavioral treatment of fibromyalgia syndrome: preliminary findings. J Rheumatol. 1991; 19:98-103.
5. Bennett RM, Burckhardt CS, Clark SR, et al. Group treatment of fibromyalgia: a 6-month outpatient program. J Rheumatol. 1996; 23:521-528.
6. Bennett RM, Campbell S, Burckhardt C, et al. A multidisciplinary approach to fibromyalgia management. J Musculoskeletal Med. 1991; 8(11):21-31.
7. Moldofsky H, Lue FA, Mously C, et al. The effect of zolpidem in patients with fibromyalgia: a dose ranging, double blind, placebo controlled, modified crossover study. J Rheumatol. 1996; 23:529-533.
8. Krueger BR. Restless legs syndrome and periodic movements of sleep. Mayo Clin Proc. 1990; 65:999-1006.
9. McCain GA. Treatment of fibromyalgia and myofascial pain syndrome. In: Rachlin ES, ed. Myofascial Pain and Fibromyalgia: Trigger Point Management. St Louis: Mosby; 1994:31-44.
10. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore: Williams & Wilkins; 1983.
11. Simms RW. Controlled trials of therapy in fibromyalgia syndrome. In: Masi AT, ed. Bailliere's Clinical Rheumatology: Fibromyalgia and Myofascial Pain Syndromes. London: WB Saunders Company; 1994:917-934.
12. Kaplan KH, Goldenberg DL, Galvin-Nadeau M. The impact of a meditation-based stress reduction program on fibromyalgia. Gen Hosp Psychiatry. 1993; 15:284-289.
13. Goldenberg DL, Mayskly M, Mossey C, et al. The independent and combined efficacy of fluoxetine and amitriptyline in the treatment of fibromyalgia. Arthritis Rheum. 1995; 38:S229. Abstract.
14. Nies KM. Treatment of the fibromyalgia syndrome. J Musculoskeletal Med. 1992; 9(5):20-26.
Dr. Yunus is professor of medicine in the section of rheumatology at the University of Illinois College of Medicine at Peoria. He is well known for his research, patient care, and teaching on fibromyalgia syndrome.
Copyright * 1996 Cliggott Publishing Company. Copyright * 1997 Information Access Company.
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