Treatment of Fibromyalgia: Managing a Multifactorial Syndrome
October 2, 2002
By Sherron M. Stonecypher
Fibromyalgia syndrome (FMS) is a chronic pain disorder that causes widespread pain, tenderness, and stiffness in muscles, as well as general fatigue.
Although there is currently no cure for fibromyalgia syndrome (FMS), management of its symptoms is possible. The management process begins with a thorough examination and diagnosis by a physician trained in tender point recognition. Once fibromyalgia and any accompanying conditions are diagnosed, the healthcare provider and patient can decide on the best approach for treatment.
Fibromyalgia is a multifactorial syndrome, making it challenging to treat. The most common goals in the management of FMS are to:
• break the pain cycle,
• restore sleep patterns, and
• increase functional activity levels (1).
Currently, no single intervention has led to long–term relief for the majority of people with FMS (2). Therefore, fibromyalgia is best managed using a multidimensional treatment approach. "Common treatments include lifestyle modifications to help conserve energy and minimize pain, anti–depressant or tricyclic drugs to help regulate sleep patterns, pain medications to control severe pain, a gentle exercise program, massage or similar physical therapies, dietary and environmental changes to keep the immune system in good shape, and relaxation therapy." (3) Using a multidimensional approach requires proactive involvement from health care professionals, family members, and the patient, working together as a team.
Medications are prescribed to FMS patients for primarily two reasons: reducing pain and improving restorative sleep. Medications that act as stimulants or disrupt sleep, as side effects, should be prescribed with caution. Blood test should be done on a regular basis to check for side effects of medications. As another precaution, medications should be safe for use by women in their childbearing years since this comprises a large percentage of the fibromyalgia population.
Fibromyalgia patients may take an average of three of the following medications: a nonsteroidal analgesic, an antidepressant, a muscle relaxant, benzodiazepine, and sometimes a narcotic analgesic (4). Tricyclic antidepressants are one of the most prevalent medications used by FMS patients because they "appear to lessen stage IV sleep disturbance and are thought to increase levels of brain serotonin and other neurotransmitters." (5) In addition to antidepressant drug therapy, "patients are instructed in sleep preparation and sleep habits to assist in maintaining restorative sleep patterns." (6)
New drug therapies continue to be evaluated on a regular basis. Based on recent studies, some researchers think growth hormone replacement therapy may be a promising treatment (7). Studies have also indicated that the use of medication, which blocks substance P receptors in the brain, may relieve fibromyalgia symptoms (8). But currently, no drug therapy alone has provided complete relief from fibromyalgia symptoms (9).
One of the most effective interventions for long term management of FMS is physical exercise. It has been shown that exercise increases time spent in deep sleep (10). This perhaps explains why aerobic exercise has therapeutic value in the treatment of FMS (11).
Based upon evaluation of tender points, pain, range of motion, and strength, physical therapists and physicians can prescribe an exercise program. "The key to initiating an appropriate exercise program should be an individualized regimen that respects the FMS patient's limitations but does not bow to them." (12) A program should consist of low–repetition strengthening; passive stretching; postural exercises; and low–impact aerobic exercise (cycling, swimming, walking) (13). To avoid exacerbating fibromyalgia symptoms, patients should never exceed existing pain limits when exercising and stretching (14).
Bennett and McCain advocate that people diagnosed with fibromyalgia follow these exercise guidelines:
• exercise three times a week,
• at a pulse rate of 85% of the target heart rate for age (for most adults, 120-150 beats per minute),
• for a duration of 40 minutes 15.
"Patients who are deconditioned should start out with just 3-5 minutes of exercise every day and gradually increase as tolerated." (16) Once a regiment is established, symptoms may amplify if the exercise routine is interrupted (17). This is a reminder that compliance is important. Patient compliance can perhaps improve with greater supervision, encouragement using a team approach and by making exercise a lifelong habit (18).
Patients should experiment with a variety of exercise activities to find what best suits them. Walking, bicycling, and various types of home exercise equipment are popular. Aerobic water exercise in heated water is often recommended for patients with injuries, who are overweight, or are sensitive to weight–bearing activities (19). Water exercise is particularly useful when patients are initially starting an exercise program (20). As tolerance increases, other forms of exercise can be implemented into the routine.
"Exercise is most effective if done in the late afternoon or early evening, perhaps because of its known effect on deep sleep." (21) One study found inconclusive evidence of the beneficial effects of aerobic walking on the symptoms of fibromyalgia (22). But other researchers have found that "regular physical exercise, rather than drugs or specific physical therapy approaches, correlated highly with low symptomatic FMS activity scores." (23)
There are many therapeutic treatment options for FMS patients. These options include physical therapy. "Physical therapy has provided many FMS patients relief from symptoms, objectively increased strength and endurance allowing them the subsequent ability to lead more productive and active lifestyles." (24)
To assist in stress management, patients and their family members may find it useful to participate in support groups, educational workshops, and psychological or psychiatric counseling. Meditation, spiritual aids, relaxation tapes, hypnosis, yoga, tai chi, and biofeedback are other therapeutic techniques fibromyalgia patients may find useful for stress reduction (25).
Fibromyalgia patients often pursue a variety of complimentary medical treatments. According to one study, chiropractors were consulted with the highest frequency, but FMS patients had the most satisfaction from massage therapy when a less rigorous massage technique was used (26). Acupuncture is another effective therapy. "Acupuncture, and especially electroacupuncture, when using traditional acupuncture sites for needle insertion as opposed to tender–point sites, has been shown to raise pain threshold levels by 70% in patients with FMS." (27) Although many patients benefit from complimentary medicine, patients should be cautioned not to substitute these interventions for traditional medical treatment without consulting a physician (28).
Nutrition specialists can recommend appropriate nutritional supplements such as "calcium and magnesium (1,000-1,500 mg per day, to be taken at night), B–Complex, or a good multi–vitamin" (29). Nutrition specialists can also educate patients about foods which have an effect on FMS symptoms. For instance, several patients experience improvement in their symptoms when they follow a low–fat diet (30). Foods that increase the body's level of serotonin (a neurotransmitter that may help induce sleep) may also be beneficial. Sugar and carbohydrates both enhance the production of serotonin; however, carbohydrates (when not consumed with a protein) increase serotonin for a longer duration (31). Use of caffeine, nicotine, and alcohol should be limited because these substances interfere with sleep patterns and energy levels (32).
In any chronic pain condition, education is an essential component that helps patients and their families develop appropriate expectations, understand limitations, and make informed treatment decisions. Education can also teach patients how to help themselves. Several "authors have suggested that patients should be educated in the FMS disease process and coping strategies, including stress recognition and management, sleep patterns, nutrition, energy conservation, pain management and cognitive–behavioral intervention programs, medication, and physical conditioning" (33).
Physical therapists can advise patients how to use heat (moist hot packs, heating pads, whirlpools, and warm showers or baths) to decrease muscle spasm, increase blood flow and diminish tension (34). "Physical therapists can also instruct patients in the proper use of cold modalities (ice packs, ice massage, and cool baths) to anesthetize localized areas of pain (tender points) and break the pain cycle." (35)
Education in energy–conservation techniques includes learning time–management skills. Fibromyalgia patients must learn not to physically overdo. Proper body mechanics, postural exercises, and the use of assistive devices can also reduce muscular energy requirements (36). When physically demanding tasks need to be completed, it is best if the tasks are completed over several days rather than in one block of time (37). Overexertion may trigger symptoms, and require bed rest for several days to recover. Patients who learn time–management skills and stop when they have reached their physical limits will lead more productive, balanced lifestyles (38).
1. S Krsnich–Shriwise, "Fibromyalgia Syndrome: An Overview," Physical Therapy 77, January (1997): 72.
2. Krsnich–Shriwise, "Fibromyalgia Syndrome."
DA Nye, "Fibromyalgia: A Physician's Guide," 4 November 1998, (4 May 1999).
3. FibroNorth, "FM Basics," 1998, (5 May 1999), Treatment.
4. Krsnich–Shriwise, "Fibromyalgia Syndrome."
5. DL Goldenberg, "Controversies in Fibromyalgia and Myofascial Pain Syndrome," In Evaluation and Treatment of Chronic Pain, Edited by GM Arnoff, (Baltimore, Maryland: Williams & Wilkins, 1992), 172.
6. Krsnich–Shriwise, "Fibromyalgia Syndrome," 73.
7. RM Bennett, "The Growth Hormone Connection," Paper presented at Oregon 1996 National Convention on Fibromyalgia: A New Era of Understanding; Oregon Convention Center, Portland, Oregon; 6-8 September, 1996. E Bagge, BA Bengtsson, L Carlsson, J Carlsson, "Low Growth Hormone Secretion in Patients with Fibromyalgia: A Preliminary Report on 10 Patients and 10 Controls," Journal of Rheumatology 25, January (1998).
8. RM Bennett, "A New Era of Understanding," Paper presented at the Oregon 1996 National Convention on Fibromyalgia: A New Era of Understanding; Oregon Convention Center, Portland, Oregon; 6-8 September 1996.
9. Krsnich–Shriwise, "Fibromyalgia Syndrome."
10. JA Hobson, "Sleep After Exercise," Science 162, no. 861 (1968).
11. GA McCain, DA Bell, FM Mai, PD Halliday, "A Controlled Study of the Effects of a Supervised Cardiovascular Fitness Training Program on the Manifestations of Primary Fibromyalgia," Arthritis and Rheumatism 31, September (1988).
12. C Sherman, "Managing Fibromyalgia with Exercise," The Physician and Sportsmedicine 20, no. 10 (1992): 169.
13. Sherman, "Managing Fibromyalgia."
Krsnich–Shriwise, "Fibromyalgia Syndrome."
14. Krsnich–Shriwise, "Fibromyalgia Syndrome."
15. RM Bennett, G McCain, "Coping Successfully with Fibromyalgia," Patient Care (1995).
16. Nye, "Fibromyalgia," paragraph 20.
17. Nye, "Fibromyalgia."
18. Bennett and McCain, "Coping Successfully."
19. Krsnich–Shriwise, "Fibromyalgia Syndrome." Nye, "Fibromyalgia."
20. Nye, "Fibromyalgia."
21. Nye, "Fibromyalgia," paragraph 22.
22. DS Nichols, TM Glenn, "Effect of Aerobic Exercise on Pain Perception, Affect, and Level of Disability in Individuals with Fibromyalgia," Physical Therapy 74, April (1994).
23. G Granges, P Zilko, GO Littlejohn, "Fibromyalgia Syndrome: Assessment of the Severity of the Condition 2 Years After Diagnosis," Journal of Rheumatology 21, (1994): 523.
24. KB McCoy, "Fibromyalgia," Paper presented at the Oregon 1996 National Convention on Fibromyalgia: A New Era of Understanding; Oregon Convention Center, Portland, Oregon; 6-8 September 1996.
25. J Kelly, R Devonshire, J Fransen, Taking Charge of Fibromyalgia: A Self-Management Program for Your Fibromyalgia, (Minneapolis, Minnesota: Abbott-Northwestern Hospital, Arthritis Care Program, 1993). Bennett and McCain, "Coping Successfully."
26. M Pioro–Boisset, JM Esdaile, M Fitacharles, "Alternative Medicine Use in Fibromyalgia Syndrome," Arthritis Care and Research 9, no. 1 (1996).
27. C Deluze, L Bosia, A Zirbs, A Chantraine, TL Vischer, "Electroacupuncture in Fibromyalgia: Results of a Controlled Trial," BMJ 305, no. 6864 (1992): 1250.
28. Nye, "Fibromyalgia."
29. Kelly et al., Taking Charge of Fibromyalgia, 48. (Return to text)
30. Nye, "Fibromyalgia."
31. Kelly et al., Taking Charge of Fibromyalgia.
32. Kelly et al., Taking Charge of Fibromyalgia.
33. Krsnich–Shriwise, "Fibromyalgia Syndrome," 72.
34. KM Nies, "Treatment of the Fibromyalgia Syndrome," The Journal of Musculoskeletal Pain 44, (1992).
35. Krsnich–Shriwise, "Fibromyalgia Syndrome," 74.
36. Krsnich–Shriwise, "Fibromyalgia Syndrome."
37. Nye, "Fibromyalgia."
38. Kelly et al., Taking Charge of Fibromyalgia.
(c) Sherron M. Stonecypher. All rights reserved. Source: http://www.lclark.edu/~sherrons/treatment.htm