Fibromyalgia Information Foundation (FIF)

(www.myalgia.com)

Principles of Treating Fibromyalgia

Robert Bennett, MD There is currently no complete cure for fibromyalgia, but most FM patients can be substantially helped by paying attention to 4 major areas: pain, exercise, sleep and psyche. Pain. The use of NS !"s in fibromyalgia patients is usually disappointing# it is unusual for fibromyalgia patients to experience more than a $%& relief of their pain, but many consider this to be 'orth'hile. Narcotics ( propoxyphene, codeine, morphine,oxycodone, methadone) may pro*ide a 'orth'hile relief of pain in a small subgroup of se*erely afflicted patients, but fibromyalgia patients seem especially sensiti*e to opioid side effects (nausea, constipation, itching and mental blurring) and often decide against the long term use of these drugs. The oft +uoted problem 'ith addiction seldom occurs 'hen narcotics are used to treat chronic pain. Tramadol (,ltram), a recently introduced analgesic seems to pro*ide partial, but significant, pain attenuation in many fibromyalgia patients - it is currently undergoing controlled trials. The se*erity of pain and the location of .hot spots. typically *aries from month to month, and the judicious use of myofascial trigger point injections and spray and stretch is 'orth'hile in selected patients, but should be *ie'ed as an aid to acti*e participation in a regular stretching and aerobic exercise program. /*aluation by an occupational and physical therapist often pro*ides 'orth'hile ad*ice on impro*ed ergonomics, biomechanical imbalance and the formulation of a regular stretching program. 0ands1on physical therapy treatment 'ith heat modalities is reser*ed for major flares of pain, as there is no e*idence that long term therapy alters the course of the disorder. The same comments can be made for acupuncture, T/NS units and *arious massage techni+ues. Exercise. gentle program of stretching and aerobic exercise is essential to counteract the tendency for deconditioning that leads to progressi*e dysfunction in fibromyalgia patients. 2rior to stretching, muscles should be 'armed either acti*ely by gentle exercise or passi*ely by a heating pad, 'arm bath or hot tub. Stretching 'ill aid in the release of the often tightened muscle bands and 'hen properly performed 'ill pro*ide pain relief. The amount of the stretch is important. Stretching to point of resistance and then holding the stretch 'ill allo' the 3olgi tendon apparatus to signal the muscle fibers to relax. Stretching to the point of increased pain

'ill precipitate a contraction of additional fibers and ha*e a deleterious effect. The stretch should be gentle and sustained for 4% seconds. 5ften patients must 'or6 up to this amount of time and start 'ith 7%178 seconds on and then 7%178 seconds off. There is good e*idence that fibromyalgia patients benefit from increased aerobic conditioning, but many are reluctant to exercise on account of increased pain and fatigue. 0o'e*er, most patients, can be moti*ated to increase their le*el of fitness if they are pro*ided realistic guidelines for exercise and ha*e regular follo'1up. /xercise prescription should emphasi9e non1impact loading exercise such as use of 'al6ing, stationary exercycles and 'ater1therapy. The e*entual aim is to exercise : to 4 times a 'ee6 at 4% to ;%& of the maximal heart rate for $% to :% minutes. Most fibromyalgia patients cannot start out at this le*el but need to establish a regular pattern of exercise. ! ha*e found that an acceptable initiation for most patients is to start 'ith two or three daily exercise sessions of only :18 minutes each. The duration should then be increased until they are doing three 7% minute sessions, then two 78 minute sessions and finally one $% to :% minute session performed : times per 'ee6. Sleep. ll fibromyalgia patients complain of fragmented non1refreshing sleep. treatable cause for the sleep disturbance should al'ays be sought. For instance, a small number of patients ha*e sleep apnea and benefit from continuous positi*e air'ay pressure therapy. 5ther patients ha*e nocturnal myoclonus associated 'ith a restless leg syndrome and may often be helped by the prescription of clona9epam (<lonopin), %.7 mg at bedtime or carbidopa1le*odopa (Sinemet), 7%=7%% at bedtime. !n the majority of patients, the sleep disturbance seems to be rooted in psychological distress or due to pain itself. For instance, a regional myofascial pain syndrome conse+uent to a 'hiplash injury may cause a persistent sleep disruption, 'hich e*entually leads to the appearance of 'idespread musculos6eletal pain consistent 'ith the fibromyalgia syndrome# this transition from regional pain to 'idespread pain typically occurs o*er a period of 4 to 7> months. !n some patients, trochanteric bursitis or subacromial bursitis=tendinitis causes a sleep disruption e*ery time the patient turns o*er onto that side, and appropriate treatment of the bursitis (see pre*ious section) may lead to a more restorati*e sleep pattern. !n many fibromyalgia patients, the sleep disturbance may be helped by the judicious prescription of a lo'1dose tricyclic antidepressant (T? ). The doses re+uired to promote restorati*e sleep in fibromyalgia are not in the range re+uired to treat depression. ?urrently there seems to be no logical 'ay of 6no'ing 'hich T? to prescribe. The ideal medication 'ould produce restorati*e sleep 'ith a feeling of

being refreshed on a'a6ening 'ith no side effects. !n reality, some patients are excessi*ely sensiti*e to T? s and ha*e a se*ere sense of .morning hango*er.# this may be helped by s'itching from one of the more sedati*e agents to a more stimulant T? . 5ther patients find T? s unacceptable o'ing to anticholinergic side effects, such as tachycardia, dry mouth, and constipation. Most T? s cause some 'eight gain, but in certain patients this may amount to $%& of their initial body 'eight and is thus unacceptable. The author often initiates T? therapy 'ith a trial of four medications ta6en for 4 days each 'ith a 71day 'ashout bet'een. 2atients can be ad*ised to start medication on a Friday e*ening to minimi9e the incon*enience of a possible hango*er the next morning. !f the patient has not ta6en a T? (Sine+uan, before, the follo'ing drugs and *entil), 7% mg at bedtime# dosages can typically be used: amitriptyline (/la*il, /ndep), 7% mg at bedtime# doxepin dapin), 7% mg at bedtime# nortriptyline (2amelor, tra9adone ("esyrel), $8 mg at bedtime and cycoben9aprine (Flexeril) 7%mg at bedtime cycoben9aprine has a T? structure and is also a muscle relaxant. ,nless the patient has a concomitant major depressi*e illness, the author does not routinely ad*ocate selecti*e serotonin reupta6e inhibitors (SS@!s) such as fluoxetine (2ro9ac), because they may exacerbate insomnia and causes agitation. Ahen SS@!s are used in patients 'ith concomitant major depression, the author usually prescribes a lo'1dose T? , such as tra9adone 8% mg at bedtime. Some fibromyalgia patients are *ery intolerant of T? s due to a persistent daytime hango*er effect. !n such cases the author uses 9olpidem ( mbien) 7%mg at bedtime, 'ith instructions not to use it more than : times a 'ee6. Psyche. 2atients 'ith chronic pain often de*elop secondary psychological disturbances, such as depression, anger, fear, 'ithdra'al and anxiety. Sometimes these secondary reactions become the .major problem., ho'e*er it is a common mista6e to attribute all of the patients symptomatolgy to an aberrant psyche. The prompt diagnosis and treatment of these secondary features is essential to effecti*e o*erall management of fibromyalgia patients. Some patients de*elop a reduced functional ability and ha*e difficulty being competiti*ely employed. !n such cases the treating physician needs to act as an ad*ocate in sanctioning a reduced or modified load at 'or6 and at home. The o*erall philosophy of treating fibromyalgia patients, ho'e*er, is to pro*ide them 'ith realistic expectations of 'hat can be done to help and de1emphasi9e the role of medications. Fre+uent *isits to physical therapists, masseurs, and chiropractors or a

dependence on repeated myofascial trigger point injections should be discouraged. ,nless the patient has an ob*ious psychiatric illness, referral to psychiatrists is usually non1producti*e. 2sychological counseling, particularly the use of techni+ues such as cogniti*e restructuring and biofeedbac6, may benefit some patients 'ho are ha*ing difficulties coping 'ith the realities of li*ing 'ith their pain and associated problems.

Treatment of Fibromyalgia for Health Care Providers

Robert Bennett MD

!f you are reading this you probably ha*e a common syndrome of chronic musculos6eletal pain called fibromyalgia. This chronic pain state is no' appreciated to be caused by abnormalities of sensory processing 'ithin the spinal cord and brain. s such you 'ill usually experience a be'ildering (both to you and your doctor) array of bodily and psychological problems that can seldom be BcuredC. 0o'e*er, armed 'ith both patience and 6no'ledge, many fibromyalgia patients can be helped to li*e 'ith less pain and be more producti*e. !n my o'n e*ol*ing experience of dealing 'ith this problem ! can identify ; aspects of management that are of importance for your doctor to successful manage your fibromyalgia. My d*ice to "octors 'ho care for Fibromyalgia 2atients 1. 2. #. &. (. ). *. Realize that FM patients are going to be a chronic challenge. Be non-ju g!ental an prepare to be an a "ocate. $n erstan the pathophysiological basis %or sy!pto!s. 'nalyze an treat pain co!plaints in a syste!ic approach. Recognize an treat psychological proble!s at an early stage. Recognize associate syn ro!es o% isor ere sensory processing. +n"ol"e all FM patients in a progra! o% stretching an gentle aerobic exercise.

Treatment of pain in fibromyalgia 2ain is the primary o*er1riding problem for most of you. Many of the problems you experience are largely a secondary conse+uence of ha*ing chronic pain. Ahen pain is e*en partly relie*ed, fibromyalgia patients experience a significant impro*ement in psychological

distress, cogniti*e abilities, sleep and functional capacity.

total elimination of pain is currently s a

not possible in the majority of fibromyalgia patients. 0o'e*er 'orth'hile impro*ements can nearly al'ays be achie*ed by a careful systematic analysis of the pain complaints. generali9ation fibromyalgia related pain can be di*ided into general pain (i.e. the chronic bac6ground pain experience and focal pain (i.e. the intensification of pain in a specific region usually aggra*ated by mo*ement). The latter is probably a potent dri*ing force in the generation of central sensiti9ation. ttempts to brea6 the pain cycle, to enable patients to be more functional are especially important. !n general, most FM patients do not deri*e a great deal of benefit from NS !" preparations or acetoaminophen, although NS !"s are *ery useful in the treatment of associated joint pain problems such as osteoarthritis. 2rednisone and other steroids ha*e been sho'n to be ineffecti*e in the long term treatment of fibromyalgia. General Pain. The use of NS !"s (e.g. ibuprofen, aspirin etc.) is usually disappointing# it is unusual for FM patients to experience more than a $%& relief of their pain, but many consider this to be 'orth'hile. Narcotics (propoxyphene, codeine, and oxycodone) often pro*ide a 'orth'hile relief of pain. !n most patients, concerns about addiction, dependency and tolerance are ill founded. ,ltram (Tramadol) and ,ltracet (tramadol D Tylenol), are the most useful pain medications in many patients. They both ha*e the ad*antages of ha*ing a lo' abuse potential and is not a prostaglandin inhibitor# tramadol reduces the epileptogenic threshold and it should not be used in patients 'ith sei9ure disorders. ?urrently opiates are the most effecti*e medications for managing most chronic pain states (Friedman 52 7EE%, 2ortenoy 7EE4) . Their use is often condemned out of ignorance regarding their propensity to cause addiction, physical dependence and tolerance (Mel9ac6 7EE%, 2ortenoy et al 7EE;, Aall 7EE;) . Ahile physical dependence (defined as a 'ithdra'al syndrome on abrupt discontinuation is ine*itable) is ine*itable, this should not be e+uated 'ith addiction (2ortenoy 7EE4). ddiction is a dysfunctional state occurring as a result of the unrestrained use of a drug for its mind1altering properties# manipulation of the medical system and the ac+uisition of narcotics from non1medical sources are common accompaniments. ddiction should not be confused 'ith .pseudo1addiction.. This is a drug1see6ing beha*ior generated by attempts to obtain appropriate pain relief in the face of under1treatment of pain. 5piates should ne*er be the first choice for pain relief in fibromyalgia, but they should not be 'ithheld if less po'erful analgesics ha*e failed. !n my experience many fibromyalgia patients

'ant to try opioid medications, but then gi*e up on them due to unacceptable side effects, such as mental fog, increased tiredness, di99iness, constipation and itching. Local Pain. lthough you are experiencing 'idespread body pain 11 a manifestation of central sensiti9ation 11 you 'ill also ha*e multiple areas of tenderness in muscles 1 so called .myofascial trigger points.. The se*erity of pain and the location of these .hot spots. typically *aries from month to month, and the judicious use of myofascial trigger point injections and spray and stretch (see section on focal pain) is 'orth'hile in selected patients. !t is often 'orth'hile for your physician to identify the most symptomatic points for myofascial therapy. The steps in*ol*ed in the injection of trigger points are: 7) ccurate identification of the trigger point. $) !dentification and elimination of aggra*ating factors. :) The precise injection of the myofascial trigger points 'ith 7& procaine (a local anesthetic). 4) 2assi*e stretching of the in*ol*ed muscle after the local anesthetic has ta6en effect# this is often aided by spraying the o*erlying s6in 'ith an ethyl chloride spray. !n most FM patients, this myofascial therapy needs to be repeated o*er a period of se*eral 'ee6s and occasionally o*er se*eral months. ,nresponsi*eness is usually due to failure to eliminate an aggra*ating factor, imprecise injection of the trigger point, or failure to inject satellite trigger points. Trigger points are usually injected 'ith : to 8 ml of 71& procaine. 2lease note that these are not Bsteroid shotsC. 2erforming Bmyofascial spray and stretchC often enhances the efficacy of trigger point injections immediately after the injections. Spray and stretch consists of an application of a *apocoolant spray, such as ethyl chloride o*er the muscle 'ith simultaneous passi*e stretching. fine stream of the spray is aimed to'ard the s6in directly o*erlying the muscle 'ith the acti*e trigger point. fe' s'eeps of the spray are passed o*er the trigger point and the 9one of reference. This is follo'ed by a progressi*ely increasing passi*e stretch of the muscle. /*aluation by an occupational and physical therapist often pro*ides 'orth'hile ad*ice on impro*ed ergonomics, biomechanical imbalance and the formulation of a regular stretching program. 0ands1on physical therapy treatment 'ith heat modalities is reser*ed for major flares

of pain, as there is no e*idence that long1term therapy alters the course of the disorder. The same comments can be made for acupuncture, T/NS units and *arious massage techni+ues. Treatment of Sleep Disorders. Non1restorati*e sleep is a problem for most of you and contributes to your feelings of fatigue and seems to intensify their experience of pain. /ffecti*e management in*ol*es (7) ensuring an adherence to the basic rules of sleep hygiene, ($) regular lo' grade exercise, (:) ade+uate treatment of associated psychological problems (depression, anxiety etc.) and (4) the prescription of lo' dose tricyclic antidepressants (amitryptiline, tra9adone, doxepin, imipramine etc. Some fibromyalgia patients cannot tolerate T? s due to unacceptable le*els of daytime dro'siness or 'eight gain. !n these patients ben9odia9opine1li6e medications such as disorder, 'hich re+uires speciali9ed management. mbiem (9olpidem) are usually *ery useful. Some fibromyalgia patients suffer from a primary sleep bout $8& of male and 78& of female fibromyalgia patients ha*e sleep apnea. ,nless specific +uestions about this possibility are as6ed sleep apnea 'ill often be missed. 2atients 'ith sleep apnea usually re+uire treatment 'ith positi*e air'ay pressure (?2 2) or surgery. Fy far the commonest sleep disorder in fibromyalgia patients is restless leg syndrome. This can be effecti*ely treated 'ith G1 "opa=carbidopa (Sinemet 7%=7%% mg at suppertime) or clona9epam (<lonipin %.8 or 7.% mg at bedtime). Exercise for Fibromyalgia Patients Fibromyalgia patients cannot afford not to exercise as deconditioned muscles are more prone to microtrauma and inacti*ity begets dysfunctional beha*ioral problems . 0o'e*er, musculos6eletal pain and se*ere fatigue are po'erful conditioners for inacti*ity. ll fibromyalgia patients need to ha*e a home program 'ith muscle stretching and gentle strengthening, and aerobic conditioning. There are se*eral points that need to be stressed about exercise in FM patients: (i) /xercise is health training, not sportHs training. (ii) /xercise should be non1impact loading. (iii) erobic exercise should be done for :% minutes each day. This may be bro6en do'n into three 7% minute periods or other combinations, such as t'o 78 minute periods, to gi*e a cumulati*e total of :% minutes. This should be the aim 11 it may ta6e 417$ months to achie*e this le*el. (*i) Strength training should emphasi9e on concentric 'or6 and

a*oid eccentric muscle contractions. (*ii) @egular exercise needs to become part of the usual lifestyle# it is not merely a :14 month program to restore them to health. Suitable aerobic exercise includes: regular 'al6ing, the use of a stationery exercycle or Nordic trac6 (initially not using the arm component). 2atients 'ho are *ery deconditioned or incapacitated should be started 'ith 'ater therapy using a buoyancy belt ( +ua1jogger). Recognition and treatment of psychological distress s you suffer from chronic pain there is a distinct possibility that you may de*elop secondary psychological disturbances, such as depression, anger, fear, 'ithdra'al and anxiety. Ahen Ban e*entC is associated 'ith the onset of the fibromyalgia you may adopt the role of a .*ictim.. Sometimes these secondary reactions become the .major problem. for some patients. The prompt diagnosis and treatment of these secondary features is essential to effecti*e o*erall management of fibromyalgia patients. Some fibromyalgia patients de*elop a reduced functional ability and ha*e difficulty being competiti*ely employed. !n such cases your doctor 'ill hopefully act as an ad*ocate in sanctioning a reduced or modified load at 'or6 and at home. ,nless you ha*e a se*ere psychiatric illness (e,g, major depressi*e illness or a psychosis), referral to psychiatrists is usually non1producti*e. 2sychological counseling, particularly the use of techni+ues such as cogniti*e restructuring and biofeedbac6, may benefit some patients 'ho are ha*ing difficulties coping 'ith the realities of li*ing 'ith their pain and associated problems. Fibromyalgia associated syndromes !t is not unusual for fibromyalgia patients to ha*e an array of bodily complaints other than musculos6eletal pain. !t is no' thought that these symptoms are a result of the abnormal sensory processing - as described in the pre*ious section. @ecognition and treatment of these associated problems are important in the o*erall management of your fibromyalgia. Non-restorative sleep ognitive dysf!nction hronic fatig!e old intolerance Restless leg syndrome "!ltiple sensitivities #rritable bo$el syndrome Di%%iness #rritable bladder syndrome Ne!rally mediated hypotension hronic fatig!e' The common treatable cause of chronic fatigue in fibromyalgia patients

&.

are: (7) inappropriate dosing of medications (T? s, drugs 'ith antihistamine actions,

ben9odia9apines etc.), ($) depression, (:) aerobic deconditioning, (:) a primary sleep disorder (e.g. sleep apnea), (4) non1restorati*e sleep (see abo*e) and (8) neurally mediated hypotension (see belo'). ne' drug called 2ro*igil is of some help 'hen used intermittently for management of fatigue. (. Restless leg syndrome' This strictly refers to daytime (usually maximal in the e*ening) symptoms of (7) unusual sensations in the lo'er limbs (but can occur in arms or e*en scalp) that are often described as paresthesia (numbness, tingling, itching, muscle cra'ling) and ($) a restlessness, in that stretching or 'al6ing eases the sensory symptoms. This daytime symptomatology is nearly always accompanied by a sleep disorder 1 no' referred to as periodic limb mo*ement disorder (formerly nocturnal myoclonus). Treatment is simple and *ery effecti*e - "52 = Ge*odopa (Sinemet) in an early e*ening dose of 7%=7%% (a minority re+uire a higher dose or use of the long acting preparations). ). #rritable bo$el syndrome' This common syndrome of 3! distress that occurs in about $%& of the general population is found in about 4%& of fibromyalgia patients. The symptoms are those of abdominal pain, distension 'ith an altered bo'el habit (constipation, diarrhea or an alternating disturbance). Typically the abdominal discomfort is impro*ed by bo'el e*acuation. "ue to abnormal sensory processing these symptoms may be +uite distressing to fibromyalgia patients. Treatment in*ol*es (7) elimination of foods that aggra*ate symptoms, ($) minimi9ing psychological distress, (:) adhering to basic rules for maintaining a regular bo'el habit, (4) prescribing medications for specific symptoms# constipation (stool softener, fiber supplementation and gentle laxati*es such as bisacodyl), diarrhea (loperamide or diphenoxylate) and antispasmodics (dicyclomine or anticholinergic = sedati*e preparations such as "onnatal). *. #rritable bladder syndrome' This is found in 4%14%& of fibromyalgia patients. The initial incorrect diagnoses are usually recurrent urinary tract infections, interstitial cystitis or a gynecological condition. 5nce these possibilities ha*e been ruled out a diagnosis of irritable bladder syndrome (also called female urethal syndrome) should be considered. The typical symptoms are those of suprapubic discomfort 'ith an urgency to *oid, often accompanied by fre+uency and dysuria. !n a sub1population of fibromyalgia patients this is related to a myofascial trigger point in the pubic insertion of the rectus abdominus muscles - and may be helped by a procaine myofascial trigger point injection). Treatment' in*ol*es (7) increasing inta6e of 'ater, ($) a*oiding bladder irritants such as fruit juices (especially cranberry), (:)

pel*ic floor exercises (e.g. <agel exercises) and the prescription of antispasmodic medications (e.g. oxybutinin, fla*oxate, hyoscamine). +. ognitive dysf!nction' This is a common problem for many fibromyalgia patients. !t ad*ersely affects the ability to be competiti*ely employed and may cause concern as to an early dementing type of neurodegenerati*e disease. !n practice the latter concern has ne*er been a problem and patients can be reassured. The cause of poor memory and problems 'ith concentration is, in most patients, related to the distracting effects of chronic pain and mental fatigue. Thus the effecti*e treatment of cogniti*e dysfunction in fibromyalgia is dependent on the successful management of the other symptoms. ,. old intolerance' bout :%& of fibromyalgia patients complain of cold intolerance. !n most cases this amounts to needing 'armer clothing or turning up the heat in their homes. Some patients de*elop a true primary @aynaudHs phenomenon ('hich may mislead an un6no'ing physician to consider diagnoses such as SG/ or scleroderma. Many fibromyalgia patients ha*e cold hands and feet, and some ha*e cutis marmorata (a lace li6e pattern of *iolaceous discoloration of their extremities on cold exposure). Treatment in*ol*es: (7) 6eeping 'arm, ($) lo'1grade aerobic exercise ('hich impro*es peripheral circulation), (:) treatment of neurally mediated hypotension (see belo'), and (4) the prescription of *asodilators such as the calcium channel bloc6ers (but these may aggra*ate the problem in1patients 'ith hypotension). -. "!ltiple sensitivities' 5ne result of disordered sensory processing is that many sensations are amplified in fibromyalgia patients. !n general fibromyalgia patients are less tolerant of ad*erse 'eather, loud noises, bright lights and other sensory o*erloads. Treatment in*ol*es being a'are that this is a fibromyalgia1related problem and employing a*oidance tactics. .. Di%%iness' !s a common complaint of fibromyalgia patients. Fefore this symptom is attributable to fibromyalgia a thorough for other causes should be pursued (e.g. postural *ertigo, *estibular disorders, >th ner*e tumors, demyelinating disorders, brain stem ischemia and cer*ical myelopathy). !n many cases no ob*ious cause is found, despite sophisticated testing. Treatable causes related to fibromyalgia include: (7) propriocepti*e dysfunction secondary to muscle deconditioning, ($) propriocepti*e dysfunction secondary to myofascial trigger points in the sterno1cleido1mastoids and other nec6 muscles, (:) Neurally mediated hypotension (see belo') and (4) medication side effects. Treatment is dependent on ma6ing an accurate diagnosis. !n

patients in 'hom no ob*ious cause is found a trial of physical therapy, concentrating on propriocepti*e a'areness may pro*e 'orth'hile. /. Ne!rally mediated hypotension' Patients $ith this problem !s!ally have a lo$ blood press!re that does not go !p normally on standing or on exercise. diagnosis. lthough such patients often ha*e a lo' ambient F2 'ith postural changes, these findings are not a prere+uisite for tilt table test 'ith the infusion of isproterenol is the most reliable 'ay to confirm this diagnosis. Treatment in*ol*es: (7) education as to the triggering factors and their a*oidance, ($) increasing plasma *olume (increased salt inta6e, prescription of florinef), (:) a*oidance of drugs that aggra*ate hypotension (e.g. T? Hs, anti1hypertensi*es), (4) pre*ent reflex (prescribe I1adrenergic antagonists or disopyramide) and (8) minimi9e the efferent limb of the reflex (prescribe J$1adrenergic agonists or anti1cholinergic agents).