eMedicine Specialties > Physical Medicine and Rehabilitation > Muscle Pain Syndromes

Fibromyalgia: Follow-up

Author: Regina P Gilliland, MD, Department of Internal Medicine; Division of Rehab Medicine, Mobile Infirmary Medical Center
Contributor Information and Disclosures

Updated: Aug 13, 2009

Follow-up

Further Inpatient Care

  • A rehabilitation program for fibromyalgia is incomplete without psychological intervention.
  • Many patients with fibromyalgia have increased levels of stress and feelings of depression, anxiety, and frustration.
  • Several treatment options are available. According to Buckelew, cognitive behavioral therapy, relaxation training, group therapy, biofeedback, and stress management are some of the most useful options.34
  • Buckelew and colleagues found that patients receiving aerobic training plus biofeedback had significant improvements in tender-point pain, self-reported physical function, and self-efficacy for function, as compared with a control group.34

Further Outpatient Care

  • Cognitive behavioral therapy (CBT) techniques emphasize changes in thought patterns and behaviors.35 CBT can be performed in a one-on-one or group setting, with beneficial effects achievable in as few as 10 sessions. These techniques have been used in chronic pain treatment programs that manage patients with fibromyalgia. A study that reviewed the results of 13 programs using CBT found that generally, CBT provided improvements in pain-related behaviors, coping strategies, and overall physical function.36 However, providing CBT alone is not advantageous over group programs of exercise and/or education.

Complications

Symptoms of fibromyalgia vary as follows:

  • Patients may experience few symptoms one day and many the next.
  • Some investigators describe a flare-up as a time when the patient experiences an acute intense increase in symptoms that last more than a day. The pain may be amplified to such intense levels that the patient becomes bedridden.
  • Flares-ups usually are triggered by a stressor. The stressor may be infection, trauma, or changes in medication, sleep, or exercise. Onset of allergies, changes in diet, and a change in usual activity may bring on a flare-up.

Teach patients about the triggers of flare-ups. On occasion, no trigger can be identified. Patients must learn to identify their triggers and what measures to take to decrease their symptoms.35 Tips for avoiding and managing flare-ups include the following:

  • Educate the patient about flare-ups. (See Patient Education, below.)
  • Treat infection quickly.
  • Avoid changes in diet.
  • Exercise as prescribed (ask patients not to increase their routine without consulting a physician).
  • Moderate changes in activity.
  • Avoid unnecessary life changes.
  • Treat changes in mood or sleep early and aggressively.
  • Always start new medications at the lowest possible dose.
  • Prepare for situations that have caused flare-ups in the past (situations, for example, that may require an increase in sleep medication or help with housework and child care).
  • Encourage patients to pace their activities and know their limits.

Prognosis

  • Fibromyalgia is not a life-threatening, deforming, or progressive disease.
  • The symptoms of fibromyalgia are variable.
  • Without proper diagnosis and treatment, a patient with fibromyalgia may have the illusion of disease progression. This illusion does not occur as a result of disease but is instead caused by sleep deprivation and physical deconditioning.
  • Some investigators state that, with the proper treatment and a caring, informed physician, patients with fibromyalgia should be able to improve function and reduce pain.

Patient Education

  • History
    • Treatment of fibromyalgia begins with a detailed history and a thorough physical examination. Making a correct diagnosis is crucial, and patients need to know that a name exists for the mysterious symptoms that they are experiencing.
  • No cure
    • The physician should inform the patient that no cure exists for fibromyalgia but that education, lifestyle changes, and proper rehabilitation can help the individual to regain control and achieve significant improvement.
    • Although fibromyalgia has no cure, patients should be reassured that the illness is not life threatening. Some authors suggest explaining the chronic, fluctuating nature of this disorder to patients. When patients with fibromyalgia fully understand the nature of the disease, they are more likely to comply with treatment and to take an active role in managing the disease.
    • At the initial visit, give patients educational materials about fibromyalgia, including a list of resources, such as books, videotapes, newsletters, and brochures, related to the disease. Some authors recommend encouraging patients to attend their local fibromyalgia support group. Provide education and support to the patient's significant family members.
  • Sleep
    • Poor sleep worsens and perpetuates symptoms, so aggressive treatment is indicated. Most patients understand little about the nature of sleep; therefore, instruct them on the basics of sleep and proper sleep hygiene. Providing this education is one of the most helpful interventions.37
    • The present author suggests asking the patient to keep a sleep diary for 2 weeks before starting any new medications. The diary should include a list of medications taken during the 2 weeks, the time at which patients went to bed, the approximate time at which they fell asleep, the number of awakenings, the number of times they got out of bed, and a general description of how rested they felt. The sleep diary provides useful information for choosing medications.
    • Suggest a few helpful dietary and behavioral changes to the patient. Instruct the patient to avoid caffeine and large evening meals; avoiding alcohol is also helpful. Teach the patient basic relaxation techniques to use before bed. If urinary frequency is problematic, restrict fluids in the evenings.
    • Consider comorbid illnesses, such as restless legs syndrome, periodic limb-movement disorder, or sleep apnea, that may be present. If these disorders are suspected, a sleep study may be needed.
    • After proper education and instruction on sleep hygiene and dietary changes, consider using appropriate medications to improve the patient's sleep. (See Medications to improve sleep.)
  • Nutrition
    • Poor diet worsens the symptoms of fibromyalgia. One investigator suggests that this deterioration may be due to impaired glycolysis and carbohydrate metabolism.38 Dietary changes are essential to improving symptoms and challenging to achieve.
    • Although many dietary choices can be made, some may be no healthier than the patient's existing diet. While no dietary or nutritional approach is universally accepted, increasing evidence reveals that some nutritional changes may improve the symptoms of fibromyalgia. Choose an approach that is nutritionally balanced and safe. Help the patient to set reasonable and attainable goals.39
    • Have the patient keep a food journal for 2 weeks. Determine what foods the patient normally eats. Slowly wean the patient off caffeine, because abruptly stopping caffeine will increase fatigue and pain, headaches, anxiety, and sleep disturbance. Some suggest that all alcohol must be avoided for at least 6 months; if the patient's symptoms are stable, he/she may consume no more than 2 alcoholic drinks a day. Tobacco use should cease, as should the consumption of chemical-laden foods, refined sugars, white flour, aspartame, and monosodium glutamate (MSG). Case studies have shown worsening of symptoms in patients who were challenged with aspartame and MSG and have demonstrated patient improvement when these compounds were removed from the diet.
    • Most patients with fibromyalgia consume enormous amounts of carbohydrate-rich foods, which may contribute to their symptoms. Some suggest a diet high in fresh vegetables, fish, and fiber. Green, leafy, and yellow vegetables are preferred because of their low carbohydrate content. Choose fruits carefully; some are more glycemic than others. Fruits such as citrus fruits, apples, berries, cantaloupe, and peaches may be preferred. The rate of carbohydrate absorption decreases if the patient combines it a food containing fiber or fat. Ask the patient to avoid junk foods or processed snack foods, which usually contain large amounts of sugar or salt.
    • Patients with fibromyalgia produce more damaging free radicals than do healthy people, and they have a reduced antioxidant capacity. Normal cellular respiration produces free radicals that lead to oxidative stress. The antioxidant defense system normally keeps these free radicals in check. Dietary antioxidants consumed in foods are essential to increasing our antioxidant status and maintaining our antioxidant systems.

      Vitamins (eg, C, E), minerals (eg, selenium, zinc), and phytochemicals are important dietary antioxidants. Vegetarian diets improve some symptoms, in association with an increased intestinal bacterial profile and increased antioxidant status; however, they may be difficult to maintain long term. A vegetarian diet rich in a variety of fruits, vegetables, and nuts may be of some benefit. Moderation may be the key to long-term compliance.
    • Physicians must acquaint themselves with the available research on diet and metabolism. Investigate the trend diets and make informed recommendations to each patient on an individual basis. Help patients set attainable goals for dietary modification.
  • For excellent patient education resources, visit eMedicine's Muscle Disorders Center; Mental Health and Behavior Center; and Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education articles Fibromyalgia, Chronic Fatigue Syndrome, Chronic Pain, and Fatigue.
 


More on Fibromyalgia

Overview: Fibromyalgia
Differential Diagnoses & Workup: Fibromyalgia
Treatment & Medication: Fibromyalgia
Follow-up: Fibromyalgia
References
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Further Reading

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Keywords

fibromyalgia, myofascial pain, fibromyalgia symptoms, fibromyalgia pain, treatment fibromyalgia, symptoms of fibromyalgia, fibromyalgia syndrome, chronic fibromyalgia, fibromyalgia fatigue, interstitial myofibrositis, muscular hardening, muscular rheumatism, musculorheumatism, myofibrositis, myogelosis, myositism, nodular rheumatism, nonarticular rheumatism, rheumatic muscle callus, rheumatic muscle hardening, rheumatic myalgia, rheumatic pain modulation disorder, tension myalgia, fibromyositis, fibrositis, idiopathic myalgia

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Contributor Information and Disclosures

Author

Regina P Gilliland, MD, Department of Internal Medicine; Division of Rehab Medicine, Mobile Infirmary Medical Center
Regina P Gilliland, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Medical Association of the State of Alabama, and Southern Medical Association
Disclosure: Acorda Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Forest Honoraria Speaking and teaching; Solstice Honoraria Speaking and teaching; Allergan Honoraria Speaking and teaching

Medical Editor

Martin K Childers, DO, PhD, Associate Professor, Department of Neurology, Wake Forest University Health Services
Martin K Childers, DO, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Osteopathic Association, Christian Medical & Dental Society, and Federation of American Societies for Experimental Biology
Disclosure: Allergan pharma Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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