(Fibromyalgia Interventions Continued)

Medications

Recent research advances highlight a critical role for aberrant central pain processing in FMS, and the first three drugs approved by the FDA for FMS over the past 2 years have a predominantly central mode of action.  The first drug, pregabalin, may counteract central pain transmission by inhibiting presynaptic release of excitatory neurotransmitters, including substance P and glutamate.  Duloxetine and milnacipran, serotonin-norepinephrine reuptake inhibitors, have been approved more recently and are believed to reduce pain by increasing serotonin and norepinephrine concentrations in descending inhibitory pain pathways.  Agents with multiple other mechanisms of action are in development and promise an assortment of therapeutic options for this complex disorder in the near future. 

Research-Based Massage Therapy for Fibromyalgia
Research has shown that therapeutic massage may reduce the pain, muscle spasms and stress associated with FMS.  In a 2002 study, researchers provided massage to subjects, who received 30-minute treatments twice weekly for 5 weeks.  Across the course of the study, only the massage therapy group reported an increase in the number of sleep hours and a decrease in their sleep movements.  In addition, substance P levels decreased, and the patients' physicians assigned lower disease and pain ratings and rated fewer tender points in the massage therapy group.(17)  In a more recent study, researchers used the Fibromyalgia Impact Questionnaire and a physical examination scoring tender points (number, pain intensity).  Evaluations at the screening visit, after 7 sessions of therapeutic massage, and after completion of 15 sessions of therapeutic massage.  At the end of the 15 sessions, most of the parameters (pain intensity, physical function, number of tender points) showed a significant improvement.(18)  In a recent systematic review of Complementary Alternative Medicine interventions for FMS, therapeutic massage provided benefit to patients in several studies reviewed.(19)  The most important thing to remember when providing massage therapy is that the patient may be hypersensitive to touch and pressure, and therefore the therapist should apply soft tissue techniques gently with an intention of relaxing the patient and increasing circulation to the involved tissues.  In a recent study on the effects of Craniosacral Therapy, an experimental, double-blind longitudinal clinical trial design was undertaken.  Eighty-four patients diagnosed with fibromyalgia were randomly assigned to an intervention group (craniosacral therapy) or placebo group (simulated treatment with disconnected ultrasound).  The treatment period was 25 weeks.  Anxiety, pain, sleep quality, depression and quality of life were determined at baseline and at 10 min, 6 months and 1-year post-treatment. State anxiety and trait anxiety and pain were lower in the intervention group while quality of life and Pittsburgh sleep quality index were significantly higher in the intervention versus placebo group after the treatment period and at the 6-month follow-up.  Approaching fibromyalgia by means of craniosacral therapy contributes to improving anxiety and quality of life levels in these patients.(25) In a study published in 2011, seventy-four fibromyalgia patients were randomly assigned to either the massage/myofascial release treatment group or a sham therapy group. The purpose of the study was to determine whether massage-myofascial release therapy can improve pain, anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia. After 20 weeks of massage/myofascial release therapy intervention, pain, anxiety, quality of sleep, and quality of life were all improved and stayed improved for 1 month. (32)

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Research-Based Hydrotherapy for Fibromyalgia
In multiple studies, balneotherapy and hydrotherapy have been shown to provide relief of pain associated with FMS.(19)  Spa therapies are some of the most commonly used non-pharmacological approaches for many rheumatic diseases.  Spa therapies consist of warm baths, hydrotherapy, warm mud wraps, aromatherapy wraps and other spa treatments that sooth the body and relax the mind.  In FMS, it may be useful for the reduction of chronic widespread musculoskeletal pain.  Because of the unknown etiology of FMS and the not clearly understood pathogenesis, there is no standard therapy regimen for FMS.  Muscle tone and pain intensity can be positively influenced by mud packs and thermal baths.  The review of international data from 2000 to 2007 confirms that spa therapy should be a valid tool in the multidisciplinary approach in the treatment of primary FMS.(20) One recent study examined the use of hydrotherapy on 60 female patients with fibromyalgia. All patients completed the following questionnaires: Fibromyalgia Impact Questionnaire (FIQ); Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale. Training sessions were performed twice a week for two months, each session lasting 60 minutes. Right after the hydrotherapy program, the patients improved the following aspects assessed by use of the FIQ: physical function, work absenteeism, ability to do job, pain intensity, fatigue, morning tiredness, stiffness (P < 0.0001), anxiety (P = 0,0013), and depression (P < 0.0001). Sleep quality (P < 0.0001) and daytime sleepiness (P = 0.0003) also improved. The researchers concluded that hydrotherapy improves sleep quality, physical function, professional status, psychological disorders and physical symptoms in patients with fibromyalgia. (33)

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Aerobic Exercise
There is strong evidence to support aerobic exercise in the treatment of FMS.(19)  The guidelines are to perform exercise 3 times per week for 20 minutes at an intensity of 50-75% of maximal Heart Rate.  At that intensity, the person should be able to talk while exercising without becoming out of breath.  There should be adequate warm up and cool down periods and a slow incremental increase in activity is recommended so as not to exacerbate symptoms.  The best types of exercise for patients with FMS are cycling, walking and swimming.  In one study, thirty women with fibromyalgia were randomly assigned to a water exercise group or a control group.  The impact of fibromyalgia on physical and mental health was assessed using the Fibromyalgia Impact Questionnaire and the anxiety state with State-Trait Anxiety Inventory.  Physical fitness was also measured.  After 8 months of training, the exercise therapy group improved compared with the control group in terms of physical function (20%), pain (8%), stiffness (53%), anxiety (41%), depression (27%), Fibromyalgia Impact Questionnaire total scores (18%), State-Trait Anxiety Inventory score (22%), aerobic capacity (22%), balance (30%), functional capacity for walking (6%), stair-climbing with no extra weight (14%) and stair-climbing 10 kg-weighted (25%).   Eight months of supervised exercise in warm water was feasible and led to long-term improvements in physical and mental health in patients with fibromyalgia at a similar magnitude to those of shorter therapy programmes.(21)  In a recent systematic review of clinical trials of exercise in the treatment of FMS, researchers found that in people with FMS:

  • moderate intensity aerobic training for 12 weeks may improve overall well-being and physical function; moderate intensity aerobic exercise probably leads to little or no difference in pain or tender points.
  • strength training for 12 weeks may result in large reductions in pain, tender points and depression, and large improvement in overall well-being but may not lead to any difference in physical function.
  • the exercise programs that were studied were safe for most. The intensity of aerobic exercise training should be increased slowly aiming for a moderate level. If exercisers experience increased symptoms, they should cut back until symptoms improve. If in doubt about adverse effects, they should check with a health care professional.
  • it is not known whether exercise training for more than 12 weeks improves other symptoms such as fatigue, stiffness or poor sleep.
  • Many people with FM do have difficulty staying on an exercise program. Strategies to help individuals exercise regularly were not measured in these studies.
  • it is not known whether flexibility training, programs combining types of exercise, and programs combining exercise with non-exercise strategies improve the symptoms of fibromyalgia.

In the studies, aerobic exercises were done for at least 20 minutes once a day (or twice for at least 10 minutes), 2 to 3 days a week.  Strength training was done 2 to 3 times a week and with at least 8 to 12 repetitions per exercise. The exercise programs lasted between 2 ½ to 24 weeks.  When compared to no exercising, aerobic exercise training may:

  • improve overall well-being by 7 points on a scale of 0 to 100.
  • improve ability to perform aerobic exercise; by using 2.8 ml/kg/minute more oxygen when walking on a treadmill.
  • increase the amount of pressure that can be applied to a tender point by 0.23 kgs/cm2 before the onset of pain.
  • reduce pain by 1.3 on a scale of 0 to 10.
  • have unknown effects on fatigue, depression or stiffness.(23)

Yoga for Fibromyalgia
Several studies have been conducted with yoga as an intervention for FMS. In one study, 22 women with FMS participated in two 75 minute yoga classes per week for 8 weeks. Pre and post questionnaires revealed decreased pain, improved pain acceptance, decreased catastrophizing and improved mindfulness. Pre-post saliva tests revealed increased cortisol levels, which is a positive sign due to the chronic low cortisol levels seen in most women with FMS. (30)

In another randomized clinical trial, Yoga of Awareness intervention was found to be effective for improving symptoms, functional deficits, and coping abilities in fibromyalgia. Researchers used the Fibromyalgia Impact Questionnaire Revised (FIQR) to investigate before and after effects of an 8 week yoga program. The FIQR Total Score improved across the participants by 31.9% and remained improved by 21.9% at 3 months. (31)

Cognitive and Behavioral Therapy
The pain of FMS is often accompanied by one or more other manifestations, such as affective moods, cognitive insecurity, autonomic dysfunction, anxiety or depression.  There is moderate evidence to support the use of psychotherapy to reduce the symptoms of FMS.(26)  Psychological treatments can include counseling, group therapy, stress management, biofeedback, relaxation techniques, and coping strategies.  In one clinical trial (Rucco et al 1995), researchers found that both autogenic training technique and progressive muscular relaxation techniques benefited patients in terms of decreased pain as long as the methods were performed regularly.  A study conducted in 2007 evaluated the efficacy of electromyography (EMG) biofeedback to reduce pain in patients with FMS.  A randomized controlled trial was conducted involving two groups of FMS patients, one receiving EMG biofeedback and the other a sham biofeedback.  The assessment tools included in the study were fibromyalgia impact questionnaire (FIQ), visual analogue scale (VAS), six-minute walk test (SMWT) and number of tender points; and tenderness of each tender point was done for both the groups.  After using biofeedback, the subjective analysis from both groups showed improvement in physical and psychological realms with statistical significance.  Biofeedback as a treatment modality reduces pain in patients with FMS, along with improvements in FIQ, SMWT and the number of tender points.(27)  New findings from brain imaging and polysomnography imply that FMS may be a disorder of premature neurologic aging.(24) 

Acupuncture
Although acupuncture has inconsistent results in the treatment of FMS, electro-acupuncture has been shown to be effective.   In a single-blinded randomized controlled trial conducted by a Swiss research team, patients underwent a 3 week treatment plan.  In seven out of eight measures for pain, tender points, decreased medication usage, improved sleep, and decreased morning stiffness, the treatment group showed significant improvement.(28) These effects lasted several weeks, which is consistent with other studies on the longevity of relief of FMS symptoms with acupuncture treatment.

Chiropractic
Many patients use chiropractic as a treatment of fibromyalgia and many chiropractors seem to be convinced that it is effective for that condition.  In one study, a systematic review was conducted of randomized clinical trials testing the effectiveness of chiropractic care for fibromyalgia.  Data extraction and validation were carried out by two independent reviewers.  Three studies met the inclusion criteria even though their methodological quality was poor.  They generated no evidence to suggest that chiropractic care is effective for fibromyalgia.  Currently, there is insufficient evidence to conclude that chiropractic is an effective treatment for fibromyalgia.(29)

Summary of Research for Fibromyalgia Syndrome
Fibromyalgia Syndrome (FMS) has been specifically defined by the American College of Rheumatology (ACR) for diagnostic purposes.  The ACR defines FMS as a clinical syndrome defined by chronic widespread muscular pain, fatigue and tenderness.  It affects between 2-4% of the U.S. population.  People with FMS may also have other conditions and symptoms that add to the complexity of this disorder.  There is no known cause of FMS, although there are many hypotheses as to how the syndrome develops.  In any case, FMS seems to affect many body systems and be a chronic disorder.  Due to the widespread effects of FMS, an interdisciplinary and integrated approach to treatment seems to be the most effective.  Patient education is an important part of the treatment of FMS because patients must often seek out help from a variety of healthcare professionals and use many self-care methods.  Medication is available for the treatment of FMS and has shown promise.  Massage and hydrotherapy are two treatments that massage therapists are trained in and both of these can provide relief from the chronic muscular pain associated with FMS.  Deep relaxation and other cognitive/behavioral therapy techniques have also been shown to reduce the symptoms of FMS.  Of all the interventions, aerobic exercise appears to have the strongest evidence supporting it as a treatment of FMS.  A combination of these treatments may be the best way to reduce the symptoms of FMS.  There is currently no cure for FMS and it tends to be a chronic condition that lasts for months or years in many people.  As part of the healthcare community, massage therapists are in a good position to provide efficacious care and educate patients with FMS.

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REFERENCES

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