Principles of Treating Fibromyalgia

Robert Bennett, MD

There is currently no cure for fibromyalgia and fibromyalgia patients may be symptomatic for many years with a reduced quality of life and varying levels of dysfunction. However engagement in a productive lifestyle and minimization of dysfunction can usually be achieved by paying attention to 4 major areas : pain, exercise, sleep and psyche.

Pain. The use of NSAIDs in fibromyalgia patients is usually disappointing; it is unusual for fibromyalgia patients to experience more than a 20% relief of their pain, but many consider this to be worthwhile. Narcotics ( propoxyphene, codeine, morphine,oxycodone, methadone) may provide a worthwhile  relief of pain in a small subgroup of severely afflicted patients, but fibromyalgia patients seem especially sensitive to opioid side effects (nausea, constipation, itching and mental blurring) and often decide against the long term use of these drugs. The oft quoted problem with addiction seldom occurs when narcotics are used to treat chronic pain.. Tramadol (Ultram), a recently introduced analgesic seems to provide partial, but significant, pain attenuation in many fibromyalgia patients – it is currently undergoing controlled trials. The severity of pain and the location of "hot spots" typically varies from month to month, and the judicious use of myofascial trigger point injections and spray and stretch is worthwhile in selected patients, but should be viewed as an aid to active participation in a regular stretching and aerobic exercise program.

Evaluation by an occupational and physical therapist often provides worthwhile advice on improved ergonomics, biomechanical imbalance and the formulation of a regular stretching program. Hands-on physical therapy treatment with heat modalities is reserved for major flares of pain, as there is no evidence that long term therapy alters the course of the disorder. The same comments can be made for acupuncture, TENS units and various massage techniques.

Exercise. A gentle program of stretching and aerobic exercise is essential to counteract the tendency for deconditioning that leads to progressive dysfunction in fibromyalgia patients. Prior to stretching, muscles should be warmed either actively by gentle exercise or passively by a heating pad, warm bath or hot tub. Stretching will aid in the release of the often tightened muscle bands and when properly performed will provide pain relief. The amount of the stretch is important. Stretching to point of resistance and then holding the stretch will allow the Golgi tendon apparatus to signal the muscle fibers to relax. Stretching to the point of increased pain will precipitate a contraction of additional fibers and have a deleterious effect. The stretch should be gentle and sustained for 60 seconds. Often patients must work up to this amount of time and start with 10-15 seconds on and then 10-15 seconds off. There is good evidence that fibromyalgia patients benefit from increased aerobic conditioning, but many are reluctant to exercise on account of increased pain and fatigue. However, most patients, can be motivated to increase their level of fitness if they are provided realistic guidelines for exercise and have regular follow-up. Exercise prescription should emphasize non-impact loading exercise such as use of walking, stationary exercycles and water-therapy. The eventual aim is to exercise 3 to 4 times a week at 60 to 70% of the maximal heart rate for 20 to 30 minutes. Most fibromyalgia patients cannot start out at this level but need to establish a regular pattern of exercise. I have found that an acceptable initiation for most patients is to start with two or three daily exercise sessions of only 3-5 minutes each. The duration should then be increased until they are doing three 10 minute sessions, then two 15 minute sessions and finally one 20 to 30 minute session performed 3 times per week.

Sleep. All fibromyalgia patients complain of fragmented non-refreshing sleep. A treatable cause for the sleep disturbance should always be sought. For instance, a small number of patients have sleep apnea and benefit from continuous positive airway pressure therapy. Other patients have nocturnal myoclonus associated with a restless leg syndrome and may often be helped by the prescription of clonazepam (Klonopin), 0.1 mg at bedtime or carbidopa-levodopa (Sinemet), 10/100 at bedtime. In 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 consequent to a whiplash injury may cause a persistent sleep disruption, which eventually leads to the appearance of widespread musculoskeletal pain consistent with the fibromyalgia syndrome; this transition from regional pain to widespread pain typically occurs over a period of 6 to 18 months. In some patients, trochanteric bursitis or subacromial bursitis/tendinitis causes a sleep disruption every time the patient turns over onto that side, and appropriate treatment of the bursitis (see previous section) may lead to a more restorative sleep pattern. In many fibromyalgia patients, the sleep disturbance may be helped by the judicious prescription of a low-dose tricyclic antidepressant (TCA). The doses required to promote restorative sleep in fibromyalgia are not in the range required to treat depression. Currently there seems to be no logical way of knowing which TCA to prescribe. The ideal medication would produce restorative sleep with a feeling of being refreshed on awakening with no side effects. In reality, some patients are excessively sensitive to TCAs and have a severe sense of "morning hangover"; this may be helped by switching from one of the more sedative agents to a more stimulant TCA. Other patients find TCAs unacceptable owing to anticholinergic side effects, such as tachycardia, dry mouth, and constipation. Most TCAs cause some weight gain, but in certain patients this may amount to 20% of their initial body weight and is thus unacceptable. The author often initiates TCA therapy with a trial of four medications taken for 6 days each with a 1-day washout between. Patients can be advised to start medication on a Friday evening to minimize the inconvenience of a possible hangover the next morning. If the patient has not taken a TCA before, the following drugs and dosages can typically be used: amitriptyline (Elavil, Endep), 10 mg at bedtime; doxepin (Sinequan, Adapin), 10 mg at bedtime; nortriptyline (Pamelor, Aventil), 10 mg at bedtime; trazadone (Desyrel), 25 mg at bedtime and cycobenzaprine (Flexeril) 10mg at bedtime – cycobenzaprine has a TCA structure and is also a muscle relaxant. Unless the patient has a concomitant major depressive illness, the author does not routinely advocate selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), because they may exacerbate insomnia and causes agitation. When SSRIs are used in patients with concomitant major depression, the author usually prescribes a low-dose TCA, such as trazadone 50 mg at bedtime. Some fibromyalgia patients are very intolerant of TCAs due to a persistent daytime hangover effect. In such cases the author uses zolpidem (Ambien) 10mg at bedtime, with instructions not to use it more than 3 times a week.

Psyche. Patients with chronic pain often develop secondary psychological disturbances, such as depression, anger, fear, withdrawal and anxiety. Sometimes these secondary reactions become the "major problem", however it is a common mistake to attribute all of the patients symptomatolgy to an aberrant psyche. The prompt diagnosis and treatment of these secondary features is essential to effective overall management of fibromyalgia patients. Some patients develop a reduced functional ability and have difficulty being competitively employed. In such cases the treating physician needs to act as an advocate in sanctioning a reduced or modified load at work and at home. The overall philosophy of treating fibromyalgia patients, however, is to provide them with realistic expectations of what can be done to help and de-emphasize the role of medications. Frequent visits to physical therapists, masseurs, and chiropractors or a dependence on repeated myofascial trigger point injections should be discouraged. Unless the patient has an obvious psychiatric illness, referral to psychiatrists is usually non-productive. Psychological counseling, particularly the use of techniques such as cognitive restructuring and biofeedback, may benefit some patients who are having difficulties coping with the realities of living with their pain and associated problems.