How To Manage Fibromyalgia

Posted on December 3rd, 2014

Speaker: Andrew J. Gross, MD - Director, UCSF Rheumatology Clinic

What is Fibromyalgia?

  • More common in woman
  • Widespread pain (stiffness) that gets worse as the day progresses. Gets worse in the evening
  • Fibromyalgia is the most common problem following low back pain, neck pain, and osteoarthritis. Rarely acknowledged problem
  • Fibromyalgia is primarily caused by how the central nervous system picks up the pain signals. Think of it as a thermostat that is out of tune
  • People with anxiety disorders are more likely to develop fibromyalgia symptoms
  • Fibromyalgia affects how people function in their daily life
  • Fibromyalgia has a spectrum of pain - some people experience more main than others

Fibromyalgia Symptoms

  • Difficulty getting a good night sleep due to constant tossing and turning
  • Moderate to severe fatigue
  • Headaches
  • TMJ pain
  • Chest Pain/Palpitations
  • Irritable bowel syndrome
  • Urinary Problems (feeling the need to pee a lot but nothing comes out)
  • Pelvic Pain
  • Numbness and tingling
  • Skin rashes and/or Skin sensitivity
  • Chemical sensitivity

How Do you Diagnose it?

  • Widespread pain for longer than three months.
  • Common symptoms: fatigue, disturbed sleep due to pain, and cognitive problems (difficulty thinking, concentrating, and remembering)
  • Characteristics - 18 tender points. However, tender points are not used as the only way to diagnose fibromyalgia
  • Lack of other disease or conditions that may contribute to pain or cognitive problems. Some of these problems include hyper-mobility syndromes, endocrine disease (thyroid), cancer, autoimmune disease (lupus), neurologic disease (multiple sclerosis), viral infections (HIV, hepatitis, EBV, influenza), or bacterial infections (lyme disease, syphilis)

Is it real? - Where does Pain Come From?

Pain does not come from structural or muscular problems.

People with Fibromyalgia experience pain differently from unaffected individuals. Subjective evidence indicate increased sensitivity to heat, cold, and pressure

People with Fibromyalgia are more sensitive to all kinds of pain symptoms including: irritable bowel syndrome, temporomandibular joint disorder (TMJ), cognitive problems, headache/migraine, multiple chemical sensitives, depression/anxiety, chronic fatigue syndrome, interstitial cystitis, restless legs, and chronic low back pain

What Causes It?

  • Genetic vulnerability
  • Physical trauma (e.g., infections, motor vehicle accident, injuries)
  • Emotional trauma (e.g., violence, stress, loss of a loved one)
  • However, there is no clear guide as to why people get Fibromyalgia
  • Making a definite diagnosis reduces unnecessary use of medical resources and reduces costs as well as reduces the likelihood of doing unnecessary procedures.

Prognosis - What can I expect?

  • One study suggested that most people, 12 years later still have symptoms
  • Another study suggested that people continue to experience some good and some bad months or years during their life with Fibromyalgia
  • Even though, Fibromyalgia may never go away, people can take measure to reduce their symptoms

What Can I Do to Teat It?

  • Combination of treatment: medicine, mind, and body
  • No single intervention is truly effective
  • The best treatment approach is a multidisciplinary approach

Medicine

  • Increase norepinephrine levels (fight or flight hormone) in the body to decrease pain levels
  • Tricyclic antidepressants mediation - Elavil.
  • Dual-reuptake inhibitors (SNRis): Cymbalta, Savella, Effexor.
  • These medications are often prescribed at levels lower than for people who experience depression.
  • Reasonably effective. However, people may experience side-effects.
  • People report experiencing approximately 25% improvement.
  • Medication is helpful in getting the pain under control initially. However, medication cannot be used as the only long-term solution.

Other drugs include Gabapentin (Neurontin) and Pregabalin (Lyrica). These drugs can be helpful (mostly for “burning” type of pain). Side effects include: being sleepy or foggy.

Tramadol - somewhat effective.

No evidence for efficacy for Fibromyalgia in general: NSAIDs (Advil, Mortin, Aleve), Corticosteroids (Prednisone), Benzodiazepenes (Ambien, Ativan), and Opioids. These drugs can provide temporary relief but built tolerance over time. Some people may get addicted to the point of not being able to sleep without taking the drug.

Most people prefer to avoid taking drugs and instead use alternative strategies.

Methadone can be helpful but over time, there is a risk of requiring higher dosage to get the same effect.

Body

  • Exercise regularly - improves sleep, mood, and overall functioning
  • Examples of exercise: walking, elliptical & bicycling, swimming or water aerobics, stretching, Tai chi or Qigong

Walking

  • Walking is the easiest strategy to implement into daily life
  • Walking around your house does not count
  • Walking should be a dedicated period of time during which you move and (ideally) increase your heart rate/perspiration
  • For people who are just starting out, it can be 5-10 minutes
  • However, 30-60 minutes are recommended. It can take several months to get to this level
  • Water aerobics are recommended at least several times per week

Stretching

  • Daily stretching is important for recovery. Ideally, stretching is done two times per day
  • Find a physiotherapist who is familiar with Fibromyalgia. Regular sports physiotherapists may not provide the right type of stretching and can make the person experiencing Fibromyalgia feel worse

Other

  • Tai Chi/Qigong - martial art based on isometric movement, stretching, and meditation
  • When starting any type of exercise, focus on gradually building up exercise intensity
  • Use a calendar and write daily what you will do today in terms of dedicated physical activity. Tracking will help you create more awareness and stick with your plan

Tips

Because fibromyalgia seems to exaggerate pain, make sure to:

Start out slow: Begin with only a few repetitions, move only so far (stay within “reasonable” pain boundaries), and do only 1 or 2 sets, maybe 5 minutes max of a particular maneuver. Remember, if you do too much and really hurt a lot afterwards, you may become afraid to exercise again and that’s the WORST thing that could happen!

Self-Massage, hot or cold: Consider light self-applied massage with or without moist heat for 15-20/hour. If pain is more intense, try ice after exercising, usually for 15-20 minutes/hour, to remove swelling.

Personalize: Because you’re unique, personalize your program so it becomes “yours.” Remember, you are not like the next person and you must design a program that “works” for you. Pick things you like to do so you look forward to doing it - bike riding, brisk walking, swimming, canoeing, hiking off road, weight lifting (emphasizing low weight/high reps), and so on. Pick some activities that you like to do!

Aerobic exercises: Consider starting with an aerobic (heart pumping) type of exercise. Many studies have reported that aerobics offer greater benefits compared to stretching for the FM patient. Start and with low impact cardiovascular exercise like walking. Even sitting on a gym ball and gently bouncing for 5 minutes gets the hear pumping quite nicely and, it’s fun! Swimming and bicycling are good, non-pounding types of exercises as well.

Don’t smoke - smoking makes pain worse!

Nutrition - Eat Healthy

  • There is no convincing data to indicate that one diet will help to reduce pain or improve energy levels
  • Higher body mass index (BMO) is associated with fibromyalgia
  • Weight loss is obese patients with Fibromyalgia is associated with improved function
  • Eating healthy in addition to exercise can improve overall health
  • Find a healthy well balanced diet that work for you

Get a Good Night Sleep

  • Sleep deprivation (or Stage 4 “delta-wave” sleep deprivation) is associated with development of widespread pain
  • Patients with Fibromyalgia commonly have disturbances in the sleep with periodic arousals
  • Improvement in restorative seep is associated with improvement in pain

In one study participants were taken out of their deep sleep stage through loud noises. Although, they did not fully wake up, they deep sleep was interrupted. After doing this for three days, the participants reported experiencing pain symptoms similar to Fibromyalgia. A similar study was completed with athletes and the researchers discovered that it was more difficult to pull athletes out of their deep sleep phase using the same loud noises. This is one of the many reasons why physical exercise is important for a good night sleep and overall health.

Tips For A Better Night’s Sleep

Do:

  • Establish and maintain a regular bedtime and wake-up time every day
  • Find the amount of sleep you need to feel consistently refreshed
  • Create a comfortable, quiet, clean and dark environment for sleeping. Your bed and the temperature of your bedroom should be comfortable
  • Establish a regular pattern of relaxing behaviors for 10-60 minutes before bedtime
  • Use the bed and bedroom for sleeping and sex only
  • Exercise on a regular basis (but not too close to bedtime)

Don’t:

  • Don’t nap during the day or evening
  • Don’t eat heavy meals or drink large amounts of liquid before bedtime
  • Don’t allow worrying, anger or frustration to keep you awake in bed
  • Don’t lie awake in bed for long periods of time. If not asleep within 20-30 minutes, leave your bedroom and do something relaxing until you feel sleep again
  • Don’t allow your sleep to be disturbed by your phone, pets, family, etc.
  • Don’t use alcohol, caffeine, or nicotine. Also please turn off TV, computer and cell phone at least 30-60 minutes before bed. All of these may worsen sleep

Courtesy of David Daman, MD, UCSF Sleep Disorders Center

Mind

  • Common belief - “It’s all on your mind. Pain does not exist.”
  • Emotional stress exacerbates pain and impairs functioning
  • The Vicious Cycle of Chronic Pain: Increased Pain -> Anxiety -> Sleeping Problems -> Not Coping -> Increased Pain…

Common worries that make the pain worse:

  • Worries about employment
  • General health worries
  • Medication worries
  • Family and relationship worries (sexual concerns)
  • Financial worries
  • Doctor’s and hospital visits (anger, frustration)
  • Lack of enjoyment

What would life be like if you could influence the way you think and feel? What you radiate outward in your thoughts, feelings, mental pictures, and words, you attract into your life” - Catherine Ponder

Cognitive Behavioural Therapy (CBT) Goals

  • Education about the nature of fibromyalgia
  • Realistic goal setting
  • Relaxation training
  • Identification of dysfunctional thought patterns and techniques to counteract negative automatic thoughts

Your physical responses influence your feelings, which influence your behaviors, which influence your thoughts, which influence your physical responses.

Pain symptoms can be decreased after approximately six weeks of CBT. Simply by talking to someone can reduce pain.

Work With People in Your Life

  • Fibromyalgia takes a toll on personal and social relationships
  • People with fibromyalgia often feel isolated (feeling invalidated by friends & family and society)
  • Receiving support (compassion) from other people is helpful
  • Work with people in your life to study fibromyalgia and become proactive
  • Educate your family members about fibromyalgia
  • Joining a good support group (positive thinking and not complaining) can be very beneficial

Non-Pharmacologic Therapies

Moderate Evidence for Efficacy

  • Aerobic Exercise (efficacy not maintained if exercise stops)
  • Cognitive Behavioral Therapy
  • Patient Education
  • Group Therapy

Weak Evidence for Efficacy

  • Strength training
  • Acupuncture (feeling comfortable with your acupuncturist is more important than where the acupuncturist places the needles)
  • Hypnotherapy
  • Biofeedback
  • Balneotherapy

Very Weak Evidence

  • Chiropractic therapy
  • Manual & Massage Therapy
  • Electrotherapy
  • Ultrasound

No Evidence for Efficacy

  • Trigger point injection (injecting steroids)

Goldenberg DL, Burckhardt C, Crofford L. JAMA 2004 Carville SF, et al, EULAR recommendations. Ann Rheum Dis 2008

Summary

  • Fibromyalgia represents a condition of central sensitization to pain
  • Systemic disease should be excluded in patients with fibromyalgia
  • Fibromyalgia is important to diagnose to limit unnecessary medical utilization
  • Fibromyalgia is manageable with a multidisciplinary approach (Non-pharmacologic and Pharmacologic)

Questions or comments? Send me an email