Research-Based Interventions for Fibromyalgia Syndrome

No one treatment approach eliminates all of the symptoms of FMS or cures the condition.  However, various treatments applied in an integrated and interdisciplinary approach can provide relief from symptoms. 

Patient Education
Educating the patient on the nature of FMS, diagnosis, pain management and evidence-based treatment is the first step.  There are many written resources available in the form of books, brochures, newsletters and articles that educate healthcare professionals and patients about FMS.  The American College of Rheumatology is an excellent online resource at www.rheumatology.org
Below is patient education information from their website that can be used to educate clients with FMS.  This is not by any means an all-inclusive document.  There is much more information available about FMS.

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Patient Education (from the American College of Rheumatology)
Fibromyalgia is an often misunderstood, even unrecognized, disorder that causes widespread muscle pain and tenderness which tends to come and go, and move about the body. This common and chronic condition also can be associated with fatigue, sleep disturbances and memory problems.

Fast facts

  • Fibromyalgia affects 2 to 4 percent of the population, predominantly women.
  • There is no laboratory or other diagnostic test for fibromyalgia so it must be diagnosed based on patient symptoms and physical examination.
  • Medication, while important, is not the only treatment. Patient education, exercise, self-management skills and alternative therapies help treat fibromyalgia symptoms.

What is fibromyalgia?
Fibromyalgia is a clinical syndrome defined by chronic widespread muscular pain, fatigue and tenderness. Many people with fibromyalgia also experience additional symptoms such as morning tiredness, headaches, irritable bowel syndrome, irritable bladder, cognitive and memory problems (often called “fibro fog”), temporomandibular joint disorder, pelvic pain, restless leg syndrome, sensitivity to noise and temperature, and anxiety and depression. These symptoms can vary in intensity and, like the pain of fibromyalgia, wax and wane over time.

What causes fibromyalgia?
No one knows what causes fibromyalgia. However, we do know that people with fibromyalgia can have abnormal levels of Substance P in their spinal fluid, a chemical that helps transmit and amplify pain signals to and from the brain. For the person with fibromyalgia, it is as though the “volume control” is turned up too high in the brain's pain processing areas. Current studies are underway to examine how the brain and spinal cord (the central nervous system) process pain and the role Substance P and other nerve transmitters play.
Genetics also appear to play a role leading to a familial tendency to develop fibromyalgia. So does everyday life exposure to physical, emotional or environmental stressors that may trigger the initiation of fibromyalgia symptoms.

Who gets fibromyalgia?
While men and adolescents can develop fibromyalgia, this condition is more common in women. The disorder tends to develop during early and middle adulthood or during a woman's childbearing years. Those who have a rheumatic disease such as lupus, rheumatoid arthritis, or ankylosing spondylitis also are at risk for developing fibromyalgia.

How is fibromyalgia diagnosed?
Unfortunately, there are no what are called “objective markers”—evidence on X-rays, blood tests or muscle biopsies—for this condition, so patients have to be diagnosed based on the symptoms they are experiencing.
Because pain and tenderness are the defining characteristics of fibromyalgia, medical care providers focus on the features of the pain to distinguish it from other rheumatic disorders. For instance, hypothyroidism and polymyalgia rheumatica often mimic fibromyalgia. However, blood tests for TSH (thyroid stimulating hormone) and ESR (erythrocyte sedimentation rate) values can differentiate these diagnoses from fibromyalgia. Occasionally, fibromyalgia can be confused with other rheumatic disorders such as rheumatoid arthritis or lupus, but again there is a difference as these conditions cause inflammation in the joints and tissues.

How is fibromyalgia treated?

Fibromyalgia must be managed as a chronic condition, and should include both medication and non-medication treatments for symptoms.

Medications: Drug therapy for fibromyalgia is largely symptomatic (it primarily treats the symptoms). Current studies indicate the best pharmacologic treatment for treating pain (and improving disrupted sleep patterns) is low doses of tricyclic compounds including cyclobenzaprine (Flexeril, Cycloflex, Flexiban) and amitriptyline (Elavil, Endep). Positive results also have been shown with dual reuptake inhibitors (venlafaxine [Effexor], duloxetine [Cymbalta], tramadol [Ultram]) that work similarly.
Conversely, long-acting opioids are typically not recommended for the treatment of fibromyalgia unless patients are refractory (or resistant) to other therapies. This is not due to issues with dependence but rather because anecdotal evidence suggests these drugs are not of great benefit to most people with fibromyalgia. Likewise, although benzodiazepines such as clonazepam (Klonopin) and diazepam (Valium) may be useful for individuals with restless leg syndrome and severe sleep disturbances who do not tolerate tricyclic drugs, they are usually reserved for those who have not responded to other therapies.
In a few cases, fibromyalgia pain may be managed with analgesics such as over-the-counter acetaminophen (Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin) or naproxen (Aleve, Anaprox). However, this is atypical. It is particularly important to use these drugs if individuals have a "peripheral" (e.g., arthritis) pain syndrome in addition to fibromyalgia.
Your physician may prescribe SSRIs/antidepressants (possibly along with a tricyclic antidepressant) such as fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft), but sometimes these need to be used at doses higher than typically used for depression. Other antidepressants prescribed are trazodone (Desyrel, Trazon, Trialodine), bupropion (Wellbutrin, Zyban) and mirtazapine (Remeron).
Recently, researchers studying antiepileptics such as gabapentin (Neurontin) and pregabalin (Lyrica) have found that these drugs may prove promising for fibromyalgia.

Other Therapies: Complementary and alternative therapies can be useful in pain management for people with fibromyalgia, although these treatments have generally not been well tested.
Therapeutic massage to manipulate the muscles and soft tissues of the body may alleviate pain, discomfort, muscle spasms and stress. Similarly, myofascial release therapy which works on a broader range of muscles can gently stretch, soften, lengthen and realign the connective tissue to ease discomfort.

Living with fibromyalgia

Even with these therapeutic options, however, patient self-management is integral to a meaningful improvement in symptoms and daily function.

  • Schedule time to relax each day. Deep-breathing exercises and meditation will help reduce the stress that can bring on symptoms.
  • Establish a regular pattern for going to bed and waking up. Getting enough sleep allows the body to repair itself, physically and psychologically. Also, avoid daytime napping and limit caffeine intake that can disrupt sleep.
  • Exercise regularly. While difficult at first, regular exercise often reduces pain symptoms and fatigue—but “Start Low, Go Slow.” Begin with physical activity that fits into your lifestyle. For instance, take the stairs instead of the elevator, or park further away from the store, slowly adding daily fitness into your routine. Then push harder. Add in some walking, swimming, water aerobics and/or stretching exercises. Remember, it takes time to establish a comfortable routine so just get moving, stay active and don't give up!
  • Educate yourself. Nationally recognized organizations like the Arthritis Foundation and the National Fibromyalgia Association are excellent resources for information you can share with family, friends and co-workers.
  • Join a support group. These peers can offer coping strategies as well as reassurance that you are not alone.

Need some additional help with self-management? Cognitive behavioral therapy (CBT) can help redefine your illness beliefs and, through symptom reduction skills, change your behavioral response to pain.
Keep in mind, establishing healthy lifestyle behaviors in concert with medical treatment can reduce pain, increase sleep quality, lessen fatigue and help you cope effectively with fibromyalgia.

Points to remember

  • Look forward, not backward. Focus on what you need to do to get better, not what caused your illness.
  • As your symptoms decrease with medical treatment, begin increasing your activity and functions, by beginning to do things that you had originally stopped doing because of your pain and other symptoms. You can get better and live a normal life.

The role of the rheumatologist

Fibromyalgia is not a form of arthritis (joint disease) and does not cause inflammation or damage to joints, muscles or other tissues. However, because fibromyalgia can cause chronic pain and fatigue similar to arthritis, it may be thought of as a rheumatic condition. As a result, it is often the rheumatologist who makes the diagnosis (and rules out other rheumatic diseases), but your primary care physician can provide care and treatment for fibromyalgia.
The American College of Rheumatology has compiled this list to give you a starting point for your own additional research. The ACR does not endorse or maintain these Web sites, and is not responsible for any information or claims provided on them. It is always best to talk with your rheumatologist for more information and before making any decisions about your care.
Fibromyalgia Network
www.fmnetnews.com
National Institute of Arthritis and Musculoskeletal and Skin Diseases
http://www.niams.nih.gov/hi/topics/fibromyalgia/fibrofs.htm
National Fibromyalgia Association
www.fmaware.org
National Fibromyalgia Partnership, Inc.
www.fmpartnership.org
The American Fibromyalgia Syndrome Association, Inc.
www.afsafund.org

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