Fibromyalgia: An Environmental Scan
Table of Contents
No single drug or group of pharmacologic agents has shown efficacy in treating fibromyalgia patients as a whole (Abeles, M., Solitar, B., Pillinger, MH. et al. 2008). As with many other soft tissue and rheumatological organic disorders, there is no cure for fibromyalgia, but some treatment options are available. Often individuals try many different treatment approaches from traditional allopathic treatments, complementary and alternative therapies in order to effectively manage fibromyalgia. Fibromyalgia is a syndrome that may dramatically change from one day to the next and flares up under a variety of circumstances. Goals of treatment are to control pain, thereby improving well-being, and daily functioning (Peterson, EL. 2007). Treatment is focused on reducing pain and alleviating other non-pain symptoms using pharmacological agents, cognitive behavioural therapy, exercise, self-management strategies and education along with a variety of other treatment modalities (Carville, S.F., Arendt-Nielsen, S., Biddal, H. et al. 2008).
184.108.40.206 Pharmacological Treatment (Antidepressants, Pain Killers, Anticonvulsants, Muscle Relaxants and Sleep Modifiers)
Neurotransmitters, for example serotonin, are chemicals that carry messages to and from the brain such as pain messages. Researchers believe that serotonin is either in lower than normal amounts or is not being used properly by the body in people with fibromyalgia. It is thought that low levels of neurotransmitters may be a factor in fibromyalgia and that raising the level of neurotransmitters reduces pain by facilitating the effective use of serotonin (Arnold, Lesley M. 2000). Typically the antidepressants used in the treatment of fibromyalgia are: tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors and selective serotonin reuptake inhibitors (SSRI’s) (See Appendix I for common pharmacological treatments, which may or may not be used in conjunction with alternative therapies). The presentation and severity of an individual’s symptoms along with their tolerance to the side effects dictates which specific antidepressant medication is chosen and when to use antidepressants in order to improve sleep and overall mood along with decreasing pain. Some individuals receive traditional pain killers: paractamol, codeine, tramadol which have shown effectiveness in treating fibromyalgia. More severe pain can be treated with chronic opioid analgesic therapy (COAT) that uses a combination of narcotics with acetaminophen. This particular treatment modality is reserved for patients, who do not respond to other methods of pain management or have more severe pain. Using narcotic medication over the long-term has inherent risks such as dependency; however, for more severe pain it may be necessary. The literature surrounding effective pain management for chronic pain syndromes in general illustrates that various opioid treatments are available; however, clinicians are often hesitant to prescribe these pharmalogic agents because of possible dependency issues surrounding prescribing and follow-up patterns along with potential abuse patterns.
Anticonvulsant medication is proving effective for alleviating anxiety, depression and sleeping disturbances. Pregabalin (known as Lyrica) is an anti-seizure medicine that has been found to be effective in treating several fibromyalgia symptoms. Anticonvulsants are increasingly used to treat chronic pain such as migraines and neuropathy. Additionally, anticonvulsants can also relieve fatigue, cognitive dysfunction, irritable bowel syndrome, bladder problems, restless legs and multiple chemical sensitivity. Known side effects are earaches, dizziness and vision impairment; therefore, some people tolerate anticonvulsant medication better than others. The broad spectrum of symptoms anticonvulsants are able to treat is promising in the area of chronic pain treatment. Finally, concerning pharmacological agents, muscle relaxants directly target stiffness and spasms which also often improve sleep disturbances such as restless leg syndrome and pain. When more specific sleep disturbances require treatment, sleep modifiers such as herbal supplements or sedatives are used. As with narcotic medication for pain, sedatives for sleep problems must be used carefully as there is an inherent risk of dependency.
220.127.116.11 Non-Pharmacological Treatment: Complementary and Alternative Therapies
Complementary and alternative therapies may also relieve fibromyalgia symptoms and primary types of these therapies include but are not limited to:
- Cognitive Behaviour Therapy (CBT)
- Physical Therapy
- Occupational Therapy
- Massage Therapy
- Aquatic Therapy
- Other Complimentary and Alternative Therapies
A specific type of CBT, biofeedback is a series of feedback cues, both visual and auditory, used to train the mind and body to control and normalize the way pain is interpreted and is used in combination with various relaxation techniques. The goal of CBT is to ‘train’ the brain so that both the perception and processing of pain is altered in a positive way to assist the patient in pain management. Other specific types of physical therapies are also used to treat fibromyalgia. In general, the goal of physical therapy is to maximize function, reduce impairment and limit disability in patients. Physical therapists use manipulation, stretching, posture training and functional activity. For people with chronic pain conditions and certainly fibromyalgia, it can be difficult to find the right balance between exercising enough for the benefits without over-exerting, which can cause a worsening of symptoms. A physical therapist can help establish the correct balance to an exercise program while also providing a variety of treatments such as heat or ultrasound therapy between exercise sessions that can assist patients managing their fibromyalgia symptoms.
Additionally, receiving occupational therapy helps people regain and acquire skills important to maintaining their independence. Individuals with fibromyalgia experience challenges both physically and mentally. The widespread chronic pain and often accompanying depression can make it difficult for fibromyalgia patients to compete simple daily tasks. The occupational therapist can assist in promoting independence and daily activity improvement by examining the environment, supporting caregivers and investigate what areas of the patient’s daily life are either contributing to their healing or causing further suffering. Each occupational therapy program is customized specifically for the patient by considering elements of their medical history, scope of their syndrome and the environment the patient lives and/or works in to systematically address issues that can reduce pain and add to an overall quality of life.
An important aspect of treatment for fibromyalgia is exercise. Aerobic and strength-training activities along with other forms of exercise have been associated with significant improvements in pain, tender points and sleeping patterns in individuals with fibromyalgia. For example, Yoga is an exercise choice that assists in improving breathing techniques, increasing flexibility and reducing stress all geared toward increasing the ability to self-manage and physical abilities to reduce symptoms of fibromyalgia. Unfortunately, adherence in exercise program remains low. A recent Cochrane review in 2008 of exercise in the treatment of fibromyalgia showed that research done to date demonstrates that exercise training can include aerobics, strength training and stretching. Specifically, moderate intensity aerobic training for a minimum of 12 weeks showed some overall improvement to well-being and physical function, whereas there was no difference in pain or tender points. Whether or not exercise can improve other symptoms such as difficulty sleeping, fatigue, stiffness and depression is not well understood.
There are different types of massage therapy approaches from a relaxing massage that helps rejuvenate a person to a pressure point therapy where relief is found by applying pressure on certain locations. Massage therapy is known to lower blood pressure and help to increase endorphins, which are natural pain killers reducing the pain felt by the individual. A specific massage known as myofascial release is recommended for fibromyalgia patients, which helps in subsiding severe pain along with restoring motion. Massage also aids in detoxifying the entire system. Furthermore, massage therapy increases blood flow to tissues and is described as soothing muscles along with an ability to reduce stress. Commonly, individuals with fibromyalgia who have massage therapy for treatment of their symptoms require a lighter touch with very gentle pressure. There is insufficient research into the efficacy of massage therapy in the treatment of chronic pain, it is commonly studied in conjunction with other therapies, and thus it is difficult to assess the impact in treating fibromyalgia. Finally, aquatic therapy can prove quite beneficial to individuals with chronic pain and specifically fibromyalgia. The nature of chronic pain disorders in general makes adhering to an exercise program challenging for many people. An advantage to aquatic therapy is the buoyancy provided by the water. The buoyancy assists the patient in supporting their body weight by decreasing the amount of weight on particular joints, thereby, decreasing joint stress. It is easier and less painful to perform exercises and in some instances allowing individuals to either simply complete the exercises or exercise more frequently.
18.104.22.168 Other Complementary and Alternative Therapies
Across a variety of studies, acupuncture has shown effectiveness in decreasing tender point pain. Treatments vary from weekly to intermittent treatments over months. More vigorous research using larger study populations is required to better understand the true efficacy of acupuncture as a treatment for chronic pain and specifically fibromyalgia. Hypnosis is derived from using altered state of consciousness to provide suggestive messages. For chronic pain, messaging is directed at training the patient to alter their pain perception and better manage their chronic pain. Breathing techniques are aimed at relaxing the body and taking the mind off pain and reducing stress. Slow, steady relaxation breathing can relax tense muscles and allows a patient to create a calmer environment and is an important skill for the self-management of chronic pain. Homeopathy uses a non-toxic approach to promote physical healing. The main tenant of homeopathic medicine is the ‘law of similar’ used to create a natural healing response of the body to cause a healing response. A particular substance is given in a very dilute concentration that ultimately causes a disease symptom which then causes the body to provide a natural healing response (See Appendix J: Common Supplements for Fibromyalgia and Chronic Fatigue Syndrome, which may or may not be used in conjunction with pharmacological agents).
An important aspect of managing fibromyalgia is learning to manage stress levels. Simply managing chronic pain over time in conjunction with events over the life course contributes to overall stress level for someone with fibromyalgia. Stress can be managed with or without medication; various complementary and alternative therapies are effective in reducing stress. Therefore individuals with fibromyalgia require access and support to various programs and learning opportunities to incorporate stress management techniques into their treatment regimes. A significant area for individuals with fibromyalgia to focus on is their self-management strategies. Given there is no cure, managing the syndrome must incorporate learning to moderate activity at optimal levels, processes in handling stress effectively and dedicated to managing pain. For many having social networks and social support such as support group can provide a necessary source of information and support.