Fibromyalgia Management

Because there is currently no "magic pill" for Fibromyalgia, treatment aims at managing FMS symptoms to the greatest extent possible. Just as individual manifestations of Fibromyalgia vary from patient to patient, so do successful forms of treatment (e.g., what works for one patient may not work for another). In addition, medical practitioners often have different preferences as to treatment. Among the most commonly used treatment strategies, used alone or in combination, are the following:

Medication: Although a number of medications are now available to treat Fibromyalgia syndrome, two drugs, amitriptyline (Elavil) and cyclobenzaprine (Flexeril) remain the most popular and are helpful to many patients. Both have the advantage of having undergone extensive clinical testing for effectiveness in the treatment of Fibromyalgia syndrome. The tricyclic agent amitriptyline works on the serotonin deficiency present in FMS patients and has the added benefit of helping to promote sleep and control pain. Although also commonly prescribed in higher doses for depression, amitriptyline is most useful to Fibromyalgia patients at lower dosages. The medication cyclobenzaprine is a muscle relaxant which has proved helpful in the treatment of FMS muscle pain and spasm. For those patients who do not tolerate these drugs well, many other similar-acting medications are available.

A relatively new group of medications (used largely to treat clinical depression which sometimes occurs with FMS) are the Selective Serotonin Reuptake Inhibitors (SSRI’s). These include: fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), among others. Because their side effects may include nervousness or insomnia, they are often prescribed along with sedating medications.

Non-steroidal, anti-inflammatory drugs (or NSAIDS, for short) are another class of medications which can be helpful in taking the edge off of Fibromyalgia pain. NSAIDS include aspirin, ibuprofen (Motrin), and naproxen sodium (Aleve), available in both prescription and non-prescription form. Caution must be exercised when using these drugs over long periods of time since they can cause bleeding, gastrointestinal ulcers. Fibromyalgia patients can take heart, however, because an innovative new form of NSAID known as a COX-2 inhibitor has recently appeared in the marketplace, at least in prescription form. The drug carries the brand names of Celebrex (Searle Pharmaceuticals) and Vioxx (Merck). Unlike its predecessors, this NSAID blocks only one of the two cyclooxygenase (COX) enzymes which control the production of prostaglandin's--the "bad" one (COX-2) produced in the event of trauma which generates high levels of the prostaglandin's that cause inflammation and pain. Furthermore, this COX-2 inhibitor works without causing any known side effects! The "good" enzyme, COX-1, which keeps the stomach, platelets, kidneys, and other tissues in good shape (and when blocked causes the potentially dangerous side effects associated with traditional NSAIDS) is unaffected by the drug.

Another group of medications, analgesics like acetaminophen (Tylenol) or stronger narcotic analgesics containing codeine, can also be effective in treating chronic pain. However, the latter are prescribed less frequently due to their potentially addictive qualities and are often reserved for FMS patients who are experiencing painful flare-ups or who do not respond well to other pain medications. A newer drug, tramadol (Ultram), has proven popular and effective as a pain reliever for many patients in recent years. Individuals using Ultram should be aware that this drug may sometimes cause allergic reactions in persons sensitive to codeine medications. A small number of patients have also reported having seizures after taking it.

Benzodiazepines like diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin) are often used in conjunction with low levels of ibuprofen to treat the anxiety as well as the muscle spasms that many FMS patients experience. Clonazepam, in particular, is often very helpful in treating restless legs syndrome. These drugs act as mild tranquilizers and have muscle relaxant properties. Like the narcotic analgesics, benzodiazepines can cause physical dependency and must be administered with care.

Although regular sleep medications are not generally used on a long-term basis for FMS patients because of their habit-forming properties, the drug zolpidem tartrate (Ambien) is sometimes prescribed for short intervals to persons having severe sleep problems and is thought to be less habit-forming.

Other classes of prescription medications may be administered as treatment for other symptoms or conditions associated with fibromyalgia (irritable bowel syndrome, for example). However, the aforementioned drugs remain the mainstay of general Fibromyalgia treatment.

Physical Rehabilitation: A wide variety of hands-on "bodywork" therapies are available to individuals with FMS. Some can only be provided by trained physical rehabilitation professionals familiar with Fibromyalgia syndrome; others may be practiced at home, particularly under the supervision of a professional. Among the most widely used therapies are the following:

Massage: Often combined with ultrasound and/or the application of hot/cold packs, massage may be performed in a number of ways and is useful in soothing and increasing blood circulation to tense, sore muscles. It can also help remove built-up toxins like lactic acid and re-educate muscles and joints which have become mechanically misaligned.

Trigger Point Therapy: A technique designed to break up trigger points (hyperactive spots in the muscles where the nervous system is overly active). Sustained pressure is usually applied by the therapist. When trigger points can not be broken up via this therapy, patients may be sent to a physician for trigger point injections.

Craniosacral Therapy: Developed by Dr. John Upledger, craniosacral therapy is "a gentle, non-invasive method of evaluating and enhancing the function of the craniosacral system, the environment in which the brain and spinal cord function...this manual therapy encourages the body's natural healing mechanisms to improve the operation of the central nervous system, dissipate the negative effects of stress, enhance health, and strengthen resistance to disease". Patients can perform one type of craniosacral therapy at home using a "still point inducer", a product which can be purchased commercially or fabricated by tightly stuffing two tennis or racquet balls into a sock. The inducer is placed on the back of the head at the line of the ear, and the patient rests on it for five to 20 minutes.

Flexyx Neurotherapy: A brand new FMS treatment stemming from the research of Dr. Stuart Donaldson, Flexyx Neurotherapy essentially "resets" the brains of FMS patients who show signs of "EEG Slowing" (see Section 5 of this document) using a non-light emitting diode which is transmitted to the brain, drawing power from the slowest brain waves up to the fastest waves. Once the brain enters a flexible new state, effective neuromuscular re-education, including trigger point therapy, myofascial release, and micro exercises can be instituted.

Chiropractic: "Chiropractic philosophy recognizes that the nervous system via the brain, spinal cord, and nerves connects to every part of the body and controls all bodily functions." Chiropractic care works to remove misalignments in the vertebrae, "unchoke" nerves, and allow the body to heal naturally.

Osteopathy: A system of therapy founded by Andrew Taylor Still, osteopathy proposes that the body is often able to effectively cope with disease on its own as long as it is in a normal structural relationship, has a favorable environment, and suffers no nutritional deficits. Osteopathy uses generally accepted physical, medicinal, and surgical methods of diagnosis and therapy while placing chief emphasis on the musculoskeletal system. FMS patients may receive manipulation (bodywork) as part of a comprehensive treatment plan.

Stretching: Gentle stretching can be performed by physical therapists or practiced by patients at home. Several videotapes have been specially designed for Fibromyalgia patients for this purpose. Stretching is important because it helps to relieve muscle tension and spasm. In difficult to treat areas, "spray and stretch" techniques can be used to apply a spray coolant to sore muscles, deadening pain while the muscles are stretched. The coolant is available by prescription and may be applied at home by patients (and/or their family members) who have been trained in its use. Patients can also perform stretching exercises using a "theraband", a long elasticized strip which is manipulated in a number of ways, or an oversized, inflatable "Swiss ball" over which they can extend themselves in different ways to stretch and strengthen tight chest and abdominal muscles.

Aerobic Exercise: Low-impact aerobic exercise is very important for Fibromyalgia patients to prevent muscle atrophy (wasting), to promote the circulation of blood containing oxygen and other nutrients to muscles and connective tissue, and to build strength and endurance. Examples of low-impact exercise include walking, warm water walking/exercise, and the use of treadmills or cross-country ski machines. More and more, gentle exercise programs designed specifically for Fibromyalgia and other chronic pain conditions are being offered through local health/recreation centers, the Arthritis Foundation, and by videotape. A cardinal rule for Fibromyalgia patients is to start very slowly and conservatively and build up exercise tolerance in increments. Most medical professionals also suggest that patients find a form of exercise they like so that they will stick to it on a regular basis. However, if a FMS patient finds that exercise repeatedly causes high levels of pain, a consultation with a physical rehabilitation therapist (i.e., physical therapist, chiropractor, etc.) may be indicated. These professionals can help restore normal physiological relationships between muscles and joints, thereby paving the way for successful exercise.

Complementary Therapies: A number of other approaches have proven useful in the management of Fibromyalgia syndrome:

Postural Training: While the various forms of bodywork described previously can help patients reduce pain and relax muscles, posture or movement training is often required to undo lifelong bad habits which can increase pain and to re-educate muscles/joints that have become mechanically misaligned. Physical therapists can help with posture while professionals trained in the "Alexander Technique" can provide movement training. Fibromyalgia patients who have significant problems with foot pain resulting from poor posture or body mechanics may also benefit from special shoe inserts (orthotics) prescribed by a podiatrist.

Occupational Therapy: When job-related tasks contribute to pain (i.e., repetitive movements, uncomfortable work stations, etc.), an occupational therapist can help by suggesting/designing improvements. Increasingly, literature is also available on this subject. For example, for Fibromyalgia patients who work at a computer, ergonomic keyboards, chairs, and other products may provide significant relief.

Relaxation Therapy: Not surprisingly, the pain and related symptoms of Fibromyalgia cause significant stress to the body. Ironically, new research suggests that physiologically FMS patients simply do not manage stress well. Thus, effective stress management programs are important. Among those used for Fibromyalgia are: biofeedback, watsu, meditation, breathing exercises, progressive relaxation, guided imagery, and autogenic training. Patients need to receive initial training in biofeedback and watsu but can then often continue practicing the concepts they have learned on their own. Books, audio tapes, and classes which teach meditation, breathing exercises, and relaxation techniques are usually readily available.

Nutrition: Nutritional therapy for Fibromyalgia can be helpful in counteracting stress, ridding the body of toxins, and restoring nutrients which have been malabsorbed by or robbed from the body. Simple approaches may include the use of antioxidant vitamin supplements (containing vitamins, A, C, and E) to combat stress and support the immune system. Some patients also benefit from taking magnesium supplements which help the muscles. Nutritionists commonly urge Fibromyalgia patients to limit the amount of sugar, caffeine, and alcohol they consume since these substances irritate muscles and stress the system. More sophisticated nutritional programs using diet, toxin cleansing, and supplementation are, of course, possible, but they usually require a nutritionist familiar with FMS who first runs tests to determine the particular nutritional needs of a patient. As with other Fibromyalgia treatments, a specifically designed nutritional plan that works well for one patient may prove disastrous for another.

Acupuncture: While a number of alternative remedies have been offered for FMS management, very few have been rigorously studied in clinical settings. Acupuncture, a treatment which involves the insertion of very small needles at specific anatomical points identified as conducive to energy, has received more scrutiny. In November 1997, the National Institutes of Health convened a Consensus Panel on Acupuncture which issued a statement indicating that (1) pain from musculoskeletal conditions and (2) nausea were the entities most successfully treatable with acupuncture.30 In February 1998, the NIH Office of Alternative Medicine, along with NIAMS and several other institutes/offices announced the "Acupuncture Clinical Trial Pilot Grants" designed to increase the quality of clinical research evaluating the efficacy of acupuncture for the treatment or prevention of Fibromyalgia and several other diseases/conditions.

Cognitive/Behavioral Therapy: As trite as it may sound, attitude is often one of the strongest predictors of how well a patient will be able to manage Fibromyalgia. Patients who are not actively engaged in taking charge of their illness simply aren't as likely to get better. Those who unknowingly adopt maladaptive illness behaviors (i.e., hopelessness, victim mentality) are less likely to aggressively seek help through exercise, physical therapy, or medications. Those who need help in combating negative thinking can find help via classes and/or audio tapes on cognitive/behavioral therapy or via counseling.