Fibromyalgia Treatment & Management
- Author: Chad S Boomershine, MD, PhD; Chief Editor: Herbert S Diamond, MD more...
The physician should inform the patient that no cure exists for fibromyalgia but that education, lifestyle changes including regular physical activity, and proper medications can help the individual to regain control and achieve significant improvement. 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 Web sites, 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.
Therapeutic recommendations for fibromyalgia can now be based almost entirely on evidence from well-designed randomized controlled trials. Models of pain behavior that interrelate biologic, cognitive, emotional, and behavioral variables form the basis for cognitive-behavioral and operant-behavioral approaches to pain management. Wood published a useful summary of therapeutic approaches to central sensitivity syndrome (CSS) comorbidities in fibromyalgia.
The first crucial element in the treatment of pain, fatigue, and other diverse symptoms in patients with fibromyalgia is for the clinician to validate the patient’s illness through empathetic listening and acknowledgment that the patient is indeed experiencing pain.[26, 32, 97, 98, 99, 100, 101, 102, 103] Comments such as "it’s all in your mind" or "I cannot find anything wrong with you" only add to the patient's frustration.
Avoid excessive use of physical therapy modalities after minor trauma, excessive activity limitation, and overly liberal work release. Be aware of confounders to recovery, such as pending litigation or compensation claims.
The overall approach for chronic pain in fibromyalgia involves a multifaceted treatment plan that incorporates various adjuvant medicines, aerobic and resistance exercise, and psychological and behavioral approaches to reduce distress and promote self-efficacy and self-management (eg, relaxation training, activity pacing, visual imagery, distraction).
If significant nociceptive pain coexists with the diffuse chronic pain of fibromyalgia, manage it pharmacologically with non-narcotic medications such as antidepressants, anticonvulsants, or muscle relaxers. For associated regional chronic pain syndromes (eg, temporomandibular disorder), referral to an experienced specialist who advocates nonsurgical approaches is recommended.
In a systematic review by Häuser of 1119 patients in 9 randomized controlled trials, multicomponent treatment (at least 1 form of educational or other psychological therapy plus at least 1 form of exercise therapy) yielded short-term benefits for the symptoms of pain, fatigue, depression, and quality of life. They found no evidence that these symptomatic benefits were durable in the long term, but strong evidence suggested that multicomponent therapy conferred a long-term benefit to maintenance of physical fitness.
Poor sleep is virtually universal in fibromyalgia and contributes importantly to pain, depression, and fatigue. Accurate diagnosis and pharmacologic and nonpharmacologic management are essential.[105, 106, 107]
Trigger point injections, acupuncture, chiropractic manipulation, and myofascial release are usually well received by patients and can be beneficial, but results are not long lasting. In addition, patients may not be able to afford long-term therapy since these are sometimes not covered my insurance.
A possible etiologic link between Chiari malformation and fibromyalgia has been suggested. However, no generally accepted evidence indicates that skull surgery for correction of Chiari malformation is of benefit in patients with fibromyalgia and screening all fibromyalgia patients for Chiari formation is not recommended.
Treatment of Children
Fibromyalgia in children responds to a combination of psychotherapy, exercise, relaxation techniques, and education. Pharmacotherapy is generally not indicated. Stephens et al conducted a 12-week randomized controlled trial of exercise intervention in children with fibromyalgia and found that both aerobics and qigong yielded benefits in terms of fibromyalgia symptoms, pain, and quality of life in this population. Aerobics were found to be advantageous in several measures.
For more information, see Juvenile Primary Fibromyalgia Syndrome.
Patients should learn to identify the factors that trigger flare-ups (although, on occasion, no trigger can be identified) and what measures to take to decrease their symptoms. Tips for avoiding and managing flare-ups include the following:
Treat infections 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 unavoidable situations that have caused flare-ups in the past (eg, arrange for an increase in sleep medication or for help with housework and child care)
Encourage patients to pace their activities and know their limits
Psychological and Behavioral Therapy
Depression, anxiety, stress, sleep disturbance, pain beliefs and coping strategies, and self-efficacy all are central to the pain experience in many patients and frequently determine the outcome of chronic pain. Depression must be treated aggressively.
Unless psychosocial and behavioral variables are recognized and approached, strictly pharmacologic interventions are of limited benefit. Cognitive-behavioral therapy (CBT) and operant-behavioral therapy (OBT) both effect clinically meaningful improvements in pain intensity and physical impairment in approximately one third to on half of patients with fibromyalgia.
Pretreatment patient characteristics are important predictors of response to nonpharmacologic therapies. High levels of affective distress, poor coping skills, few pain behaviors, and unsolicitous spouse behavior predict response to CBT. Prominent pain behaviors, high levels of physical impairment, catastrophizing, and solicitous spouse behavior predict response to OBT.
Other useful strategies include the following:
Written emotional disclosure
Instruction in proper sleep hygiene
Depression in fibromyalgia may be treated with a regimen that includes nonpharmaceutical therapies. Treating depression alone does not cure fibromyalgia. Antidepressants may help, but the clinician also should address other symptoms, such as fatigue or pain. Modifying diet and practicing good sleep hygiene are crucial. Starting a rehabilitation exercise program is important. Behavioral modification techniques and stress management may also be used.
A meta-analysis by Häuser et al of randomized controlled clinical trials found strong evidence to show that antidepressants reduced pain, fatigue, depressed mood, and sleep disturbances and improved health-related quality of life in patients with fibromyalgia. The study included analysis of tricyclic and tetracyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), serotonin and noradrenaline reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors in 1427 participants.
Physical Therapy/Physical Modalities
Because many patients with chronic pain fear that activity will worsen their pain and fatigue, they become deconditioned. In fact, limitations on activity, including work release, should generally be avoided. Graded aerobic exercise (eg, low-impact aerobics, walking, water aerobics, stationary bicycle) is an integral part of optimum treatment in patients with fibromyalgia. However, exercise programs should start gently and progress gradually to endurance and strength training. Patients should avoid prolonged, overly strenuous physical exercise before reconditioning is established. The benefits of exercise for patients with fibromyalgia include improvement in subjective and objective measures of pain and in an overall sense of well-being.[103, 112, 113]
In a randomized controlled trial, Munguía-Izquierdo and Legaz-Arrese found that unfit women with severe fibromyalgia symptoms benefitted from aquatic therapy (in a warm pool) 3 times per week for 16 weeks. This approach also resulted in greatly improved adherence to exercise in the study participants.
Heat, massage, and other treatments are useful. Diffuse and regional pain is improved by strategies such as saunas, hot baths and showers, hot mud, and massage. However, excessive dependence on administration of physical therapy and modalities by another person may confound the patient's efforts to achieve self-efficacy for pain control.
Encouragement and positive reinforcement can improve compliance. Obesity, poor posture, and overloading activities at work and at home should be addressed.
Poor sleep worsens and perpetuates symptoms, so intensive 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.
Dietary and behavioral changes that may be helpful include avoiding 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.
It may be helpful for the patient to keep a sleep diary for 2 weeks before starting any new medications. The sleep diary provides useful information for choosing medications. The diary should include the following:
Time at which the patient went to bed
Approximate time of falling asleep
Number of awakenings
Number of times the patient got out of bed
General description of how rested the patient felt
Consider comorbid illnesses that may be present, such as restless legs syndrome, periodic limb-movement disorder, or sleep apnea. If these disorders are suspected, a sleep study may be needed.
Medications to improve sleep
If proper education and instruction on sleep hygiene and dietary changes fail to provide adequate improvement in the patient’s sleep, consider using appropriate medications. Sleep problems may be treated with the following:
Antidepressants (eg, trazodone, serotonin-selective reuptake inhibitors [SSRIs], dual-reuptake inhibitors [SNRIs], tricyclic antidepressants)
Anticonvulsants (eg, clonazepam, gabapentin, tiagabine)
Nonbenzodiazepine hypnotics (eg, zolpidem, zaleplon, eszopiclone)
Muscle relaxants (eg, cyclobenzaprine, tizanidine)
Dopamine agonists (eg, pramipexole)
Sleep-maintenance disorders are more difficult to manage than are sleep-onset problems. In general, antidepressants are most commonly used because of their effect on serotonin. Tricyclic antidepressants have the strongest evidence for efficacy. The criterion standard is amitriptyline, but many patients cannot tolerate this drug.
Trazodone is inexpensive, well-tolerated, and effective. The starting dose is 25 mg, and it should be taken at 8 pm. If necessary, the dose can be slowly titrated upward. If the patient is not staying asleep, adding an SSRI may be helpful.
If the patient has concomitant restless legs syndrome or mitral valve prolapse, clonazepam may be the drug of choice. The starting dose is 0.125 or 0.25 mg taken at 8 pm. Titrate the dose to the lowest effective dose.
Tiagabine increases sleep efficiency with a marked increase in slow-wave sleep in healthy elderly patients. Tiagabine titrated from 2 mg to 12 mg may improve sleep maintenance in some patients.
Gabapentin is being studied. It may also aid in sleep maintenance.
The dopamine agonist pramipexole (Mirapex) is approved by the US Food and Drug Administration (FDA) for the treatment of moderate to severe restless legs syndrome. This medication may aid in sleep maintenance in patients with fibromyalgia and restless legs syndrome. It is also under investigation as a treatment for fibromyalgia pain.[116, 117]
Patients with fibromyalgia are generally interested in diet and are influenced heavily by information that promotes complementary and alternative approaches to this disorder; therefore, promote sound general nutrition, appropriate vitamin supplementation, bone health, and weight reduction, if needed.
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.
Poor diet worsens the symptoms of fibromyalgia, possibly as a result of impaired glycolysis and carbohydrate metabolism. Dietary changes are essential to improving symptoms, but they are 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.
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; however, a patient with stable symptoms 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 starchy food with a food containing fiber or fat. Advise patients 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.
Deficiency of 25-hydroxyvitamin D is very common in patients with rheumatologic conditions and chronic pain and should be routinely sought. Low levels of vitamin D are not associated with chronic pain, however, and treatment with vitamin D does not reduce pain.
Consultation with a rheumatologist experienced in the diagnosis and treatment of fibromyalgia is appropriate. In addition, a rheumatologist can assist in the differential diagnoses of chronic pain and fatigue syndromes and in the assessment of comorbid rheumatologic disorders.
Referral to a neurologist, dentist, or other specialist may be beneficial in patients with prominent regional pain disorders that coexist with fibromyalgia. Psychological counseling is useful. If a psychiatric disorder is suggested, consult a psychiatrist.
Follow-up care in patients with fibromyalgia is greatly facilitated by the following:
Encouraging compliance with exercise regimens
Paying attention to current psychological and physical stressors
Obtaining ongoing self-report questionnaire information that provides semiquantitative data concerning the patient's function, levels of pain and fatigue, and global self-assessment of how the patient is doing
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