Fibromyalgia – Treatment

It seems clear that, given the myriad and variety of symptoms, it is important for physicians and patients to work together to establish a multifaceted and individualized treatment approach. This is especially important since FM is a chronic disease whose symptoms wax and wane, thus requiring alterations in treatment strategies overtime (i.e., during a flare). Nonetheless, the comprehensive treatment of FM falls along 4 broad categories: education, symptom management, cognitive behavior therapy, and complementary approaches^{ref 3, 5}.

Education:

Providing information about the disease, normalizing and validating the patients’ experience is an essential FM treatment component. Perhaps the most important factors in improving the symptoms of FM is for the patient to understand the range of FM symptoms they may experience, the prospect for symptom flares, and to recognize the need for lifestyle adaptation as they attempt to manage their disease. This requires a physician and/or health care provider who is knowledgeable about the diagnosis and treatment of FM to listen and work closely with the patient to develop a treatment protocol that addresses the unique needs of the patient.

Symptom Management:

Conventional pharmacotherapy to address the range of symptoms is the cornerstone of treating FM. Over-the-counter or prescription medications may be essential in reducing symptoms and minimizing disability. Generally medications are used to manage pain, fatigue, and psychological distress, as well as to improve other health issues associated with FM (e.g., migraine headache, irritable bowel syndrome).

Antidepressant medications are the most frequently used and best studied drugs for the treatment of FM. A recent review of drug treatments for FM indicates that tricyclic antidepressants (TCA’s), including amitriptyline and doxepin, are effective in treating multiple FM symptoms including pain, sleep disturbance, fatigue, and depression^{ref 9}. However, tolerance to these medications is an important issue. Serotonin re-uptake inhibitors (Fluoxetine, Seratiline) are better tolerated and provide greater benefits on depressed mood than TCA’s, but less benefit on other FM symptoms. Tramadol has been shown in several trials to reduce pain but has little or no effect on other symptoms^{ref 9}. Interestingly, non-steroidal anti-inflammatory drugs (NSAIDS) and corticosteroids show no benefit on FM.

Apart from addressing the depression and pain, it is also important to minimize fatigue by promoting a healthy sleep regimen. This may involve simple behavioral strategies such as going to bed and getting up at the same time every day, making sure that the sleeping environment is conducive to sleep (e.g., a comfortable bed and room temperature), avoiding caffeine, or medications (e.g., zolpidem, zopiclone) to promote restful sleep^{ref 5}.

Cognitive Behavior Therapy (CBT):

CBT involves assisting persons with FM to self-manage their disease by learning and applying a range of cognitive and behavioral techniques. For example, techniques such as relaxation therapy, coping skills, cognitive pain management, and eliciting social support have been shown in several clinical trials to reduce symptoms and improve quality of life^{ref 3, 5}. In addition to formal CBT programs, many communities throughout the United States and abroad have organized FM support groups. These groups often provide important information and have guest speakers who discuss subjects of interest to the FM patient. Moreover, the Arthritis Foundation runs the Fibromyalgia Self-Help Group, a multi-session group intervention that provides information, support, and teaches many behavioral techniques to better manage the symptoms of FM.

Complementary Approaches:

There are literally dozens of complementary therapies to treat FM and its associated symptoms^{ref 5}. They include, but are not limited to: physical therapy, therapeutic massage, myofascial release therapy, water therapy, exercise and physical activity, acupressure, application of heat or cold, acupuncture, yoga, relaxation exercises, breathing techniques, aromatherapy, biofeedback, herbs, hypnosis, nutritional supplements, and osteopathic or chiropractic manipulation. Of these, exercise is the only treatment approach that has been tested in randomized controlled clinical trials and shown to improve fitness, self-assessment of improvement, and reduce tender point counts^{ref 10, 11}. Nonetheless, anecdotally persons with FM have reported significant improvements in symptoms with complementary approaches. Even if the benefits of such approaches derive from placebo effects, it is valuable to encourage persons with FM to explore the range of different treatments and thereby take an active role in the management of their disease.

References

1. Wolfe, F et al. Prevalence of characteristics of fibromyalgia in the general population. Arthritis and Rheumatism 38:19-28, 1995.
2. Guymer, E.K., & Clauw, D.J. Treatment of fatigue in fibromyalgia. Rheumatic Disease Clinics of North America28:367-378, 2002.
3. Burckhardt, C.S. (2001). Fibromyalgia. In: Clinical Care in Rheumatic Diseases. Atlanta, GA: American College of Rheumatology.
4. Boissevain, M.D., & McCain, G.A. Toward an integrated understanding of fibromyalgia syndrome: Psychological and phenomenological aspects. Pain45:239-248, 1991.
5. Millea, P.J., Holloway R.L. Treating fibromyalgia. American Family Physician October 1, 2000.
6. Burckhardt, C.S., Clark, S.R., & Bennett, R.M. Fibromyalgia and quality of life: a comparative analysis. Journal of Rheumatology20:475-479, 1993.
7. Fitzcharles MA, DaCosta, D., & Poyhia, R. A study of standard care in fibromyalgia syndrome: A favorable outcome. Journal of Rheumatology30:154-159, 2003.
8. Wolfe F., Smythe, H.A., Yunus, M.B. et al. The American College of Rheumatology Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis & Rheumatism33:160-172, 1990.
9. Rao, S.G., Bennett, R.M. Pharmacological therapies in fibromyalgia. Best Practice & Research Clinical rheumatology17:611-627, 2003.
10. Busch, A., Schachter, C.L., Peloso, P.M., & Bombardier, C. (2002). Exercise for treating fibromyalgia syndrome. The Cochrane Library, 3.
11. Richards S.C.M., & Scott, D.L. Prescribed exercise in people with fibromyalgia: parallel group randomized trial. British Medical Journal325:185-188, 2002.