Fibromyalgia

Description

Lifestyle Changes

Many studies have indicated that exercise is the most effective component in managing fibromyalgia, and patients must expect to undergo a long-term exercise program. Physical activity prevents muscle atrophy, increases a sense of well being, and, over time, reduces fatigue and pain itself.

Graded Exercise. The basic approach used for fibromyalgia is called graded exercise, which typically uses strength training and regular low-impact aerobic exercise. Both are very important for raising the pain threshold, although it may take months to perceive benefits.

For example, in a well-conducted 2002 study, 35% of patients who engaged in graded aerobic exercise reported much feeling better or very much better after three months. Only 18% of patients who performed relaxation and flexibility exercises reported the same results. At the end of a year, 55% of the exercise group was no longer diagnosed with fibromyalgia compared to only 34% of the relaxation group.

In general, graded exercise involves the following:

• Desirable exercises are walking, swimming, and using equipment such as treadmills or stationary bikes. Swimming and water therapy, which eliminate weight-bearing, appear to be excellent choices for getting started. In one 2002 study, patients who engaged in water exercise therapy for six months still reported improvements in symptoms and functioning two years after they had completed the program.
• The patient embarks on a very gradual incremental program of activity, beginning with mild exercise and building over time, is important to help patients comply with exercise. For example, in one successful exercise study, patients started with two weekly sessions that lasted for only six minutes each. By week 12, they were performing exercises that lasted 25 minutes each with sufficient intensity to produce some sweating while still allowing them to talk comfortably.
• Patients who attempt strenuous exercise too early actually experience an increase in pain and are likely to become discouraged and quit. It should be noted that even walking two or three times a week is helpful.
• Every patient must be prepared for relapses and setbacks, which are nearly universal, but this should not dissuade the patient from exercising. Patients who do not respond to one type of exercise might consider experimenting with other forms of physical activity.

Some patients are so disabled that they experience no benefits over time and some feel even worse even after many attempts and different programs. Such patients should not be discouraged.

Finding a physical therapist may be very helpful and may be covered by health insurance. One study suggests that physical therapy may reduce muscle overload, reduce fatigue from poor posture and positioning, and help condition weak muscles. Other treatments are available that can be very helpful, including medications and cognitive behavioral therapy.

Training Index. Some experts recommend the use of a training index for gauging progress and establishing a goal. This index is the product of three calculations:

• The duration of exercise in minutes.
• Number of days per week that the patient exercises.
• The percentage of maximum heart rate.

People just beginning an exercise program should start with an index of 10 to 25 and aim over time for at least 42. The following are some examples for determining these indexes using exercise goals.

• To achieve an initial index of 15 the patient strives for the following exercise goals: A maximum heart rate percentage of 60% (.60) during exercise performed for 5 minutes 5 times a week. (the index is calculated in such a case by multiplying .60 x 5 x 5).
• The later goal of an index of 42 could be achieved with the following a maximum heart rate percentage of 70% that occurs with 20-minute exercises three days a week (.70 x 20 x 3 = 42).

Stretching exercises should be performed for about 10 minutes before aerobic exercise, but they are not considered part of the total exercise time that the patient uses in calculating the index goal.

Establish Regular Sleep Routines

Sleep is essential, particularly since pain is aggravated by disturbed sleep. Improvement is low in those who are unable to sleep consistently and at night. Swing shift work, for example, is extremely hard on fibromyalgia patients.

Diet

Fibromyalgia patients should maintain a healthy diet low in animal fat and high in fiber, with plenty of whole grains, fresh fruits and vegetables. Although everyone should be careful about calories in fats, some are healthy.

Omega-3 Fatty Acids. Oils containing omega-3 fatty acids are of particular interest for arthritic pain. Such oils are found in cold water fish and can be purchased as supplements called EPA-DHA or omega 3.

Omega-3 fatty acids are a form of polyunsaturated fat that the body derives from food. Omega-3s (and omega-6s) are known as essential fatty acids (EFAs) because they are important for good health. The body cannot make these fatty acids on its own so omega-3s must be obtained from food. These different types of acids can be obtained in foods such as cold-water fish including tuna, salmon, and mackerel. Other important omega 3 fatty acids are found in dark green leafy vegetables, flaxseed oils, and certain vegetable oils. Omega-3 fatty acids have been found to be beneficial for the heart. Positive effects include anti-inflammatory and anti-blood clotting actions, lowering cholesterol and triglyceride levels, and reducing blood pressure. These fatty acids may also reduce the risks and symptoms for other disorders including diabetes, stroke, rheumatoid arthritis, asthma, inflammatory bowel disease, ulcerative colitis, some cancers, and mental decline.

Vegetarian Diet. Some studies then have suggested that a vegetarian diet may be helpful. For example, in two small studies a vegan diet was associated with improved symptoms including pain, stiffness, and quality of sleep. In addition, the diet was associated with lower weight and cholesterol levels. (A vegan diet has no meat, dairy, or eggs and includes uncooked fruits, vegetables, nuts, and germinated seeds.) A 2000 study found no significant decline in symptoms except some improvement in pain, but not as much as with a tricyclic antidepressant.

Elimination of Allergens. A very small 2001 study eliminated common food allergens (corn, wheat, dairy, citrus, soy, and nuts) from the diets of 17 fibromyalgia patients. After two weeks, half the patients reported significant improvements in pain and other distressing symptoms. The gradual reintroduction of these foods, one by one, coincided with the recurrence of pain, headache, and gastrointestinal distress. The most commonly offending foods were corn, wheat, dairy, citrus, and sugar. While this study does not prove any causal association, patients might try this elimination diet approach to see if it helps.

Elimination of Additives. One case report found that four patients experienced complete or near resolution of symptoms after several months by eliminating monosodium glutamate (MSG) and the artificial sweetener aspartame from the diet. These substances are sometimes called excitotoxins because they stimulate neurotransmitters and, in excess, may damage nerve cells. Better research is needed to confirm these findings, although there is no harm in eliminating the additives if patients include them in their diets.

Stress Reduction Techniques

Relaxation and stress-reduction techniques are proving to be helpful in managing chronic pain. There is certainly evidence that people with fibromyalgia have a more stressful response to daily conflicts and encounters than those without the disorder. A number of relaxation and stress-reduction techniques have proven to be helpful in managing chronic pain:

• Deep breathing exercises.
• Muscle relaxation techniques.
• Meditation.
• Hypnosis.
• Biofeedback.
• Massage therapy.

Biofeedback. Evidence suggests that biofeedback techniques may be helpful for fibromyalgia patients. During biofeedback, electric leads are taped to a subjects head. The person is encouraged to relax using any method that works. Brain waves are measured and an auditory signal is emitted when alpha waves are detected, a frequency that coincides with a state of deep relaxation. By repeating the process, subjects associate the sound with the relaxed state and learn to achieve relaxation on their own.

Meditation. Meditation, used for many years in eastern cultures, is now widely accepted in this country as an effective relaxation technique. A number of studies are reporting its benefits for fibromyalgia patients who practice on a sustained and regular basis. The practiced meditator can achieve the following physical benefits:

• Improvements in well being.
• Improved sleep. (Some research has reported an increase in melatonin levels in experienced meditators. This brain hormone is important in regulating the sleep-wake cycle.)
• Less pain, possibly from reductions in levels of cortisol, a stress hormone. (Stress is known to intensify the sensation of physical pain.)
• A reduction in heart rate, blood pressure, adrenaline levels, and skin temperature while meditating.

An important goal for both religious and therapeutic meditative practices is to quiet the mind, essentially to relax thought. This redirection of brain activity from thoughts and worries to the senses disrupts the stress response and prompts relaxation and renewed energy. A number of meditation techniques are available; some may be more or less useful for fibromyalgia.

• With the so-called fixed point meditation, practitioners focus on a fixed object, mental image (such as a candle flame), or internal sound (such as a mantra). When the mind begins to wander, the meditator gently brings concentration back to the central image or sound. This exercise promotes focus but it is often experienced as a thinking exercise. A popular variety of this type of meditation is known as transcendental meditation, or TM.
• Other meditative forms involve focusing on the present moment and observing (but not attending to or judging) ones thoughts. In one practice called breath meditation by many yoga practitioners one sits upright with the spine straight with the eyes closed. The subject begins to breathe regularly and continues to observe the outward (exhalation) of the breath. As the mind wanders, one simply notes the thoughts as a fact and returns to the breath. A variant of this technique called mindfulness meditation has been helpful for fibromyalgia patients. It involves focusing on the present moment and letting thoughts pass without the accompanying breathing exercises.
• One technique requiring little adaptation of the daily schedule has been termed mini-meditation. The method involves heightening awareness of the immediate surrounding environment. One should first choose a simple routine activity when alone. For example, while washing dishes concentrate on the feel of the water and dishes; allow the mind to wander to any immediate sensory experience, such as sounds outside the window, smells from the stove, or colors in the room. If the mind begins to think about the past or future, abstractions or worries, redirect it gently back.

New practitioners should understand that it can be difficult to quiet the mind and should not be discouraged by lack of immediate results. Some recommend meditating for no longer than 20 minutes in the morning after awakening and then again in early evening before dinner. Even once a day is helpful. (One should probably not meditate before going to bed, which causes some people to wake up in the middle of the night, alert and unable to return to sleep.)

Hypnosis. In one controlled study, hypnosis was more effective than physical therapy in improving function and reducing pain.

Massage Therapy. Massage therapy is thought to stimulate the parasympathetic nervous system, which slows down the heart and relaxes the body. In a 2002 study, patients who were given 30 minute sessions twice a week experienced lower stress and anxiety and less pain after five weeks compared to a group receiving an alternative therapy called transcutaneous electrical stimulation (TENS).

Alternative Treatments

Because of the difficulties in treating fibromyalgia, many patients seek alternative therapies. Everyone should be wary of those who promise a cure or urge the purchase of expensive but useless and potentially dangerous treatments. Major analyses have indicated that mind-body therapies, such as biofeedback or hypnosis, are more effective than no treatment at all but less effective than moderate to intense exercise. In one analysis, evidence was weakest on the advantages of so-called manipulative (hands-on) approaches such as massage and chiropractic treatments.

Acupuncture. The ancient Chinese practice of acupuncture may be effective for some patients. One 2001 study compared a group of fibromyalgia patients who received real acupuncture, in which needles were inserted into specific points on the body that practitioners believe promote the flow of healing energy or chi, to a group receiving sham acupuncture, with needles inserted at random locations. Those who received real acupuncture reported significant improvements in pain, depression, and mental health after a month, while those who received the sham acupuncture did not.

Click the icon to see an image of acupuncture.

Chiropractic or Osteopathic Manipulation. Chiropractic or osteopathic manipulation may also help some patients. In one study 21 patients improved after four weeks of chiropractic spinal manipulation compared to those receiving only medications. It may be less effective in older patients with severe symptoms. Other studies have reported pain relief and improved sleep with osteopathic manipulation. Osteopathic techniques may include manipulation of the spine or muscle tissue release. It should be noted that there is always some very small risk for adverse effects from any of these techniques. (For example, in rare cases manipulation of the neck has been known to cause stroke or damage to the arteries.)

Hydrotherapy and Similar Treatments. Hydrotherapy, also called balneotherapy, involves immersion in water, such as hot tubs, pools, or baths--either still or motion-based water--to help relieve pain. In one 2002 study, hydrotherapy using a daily 20-minute bath reduced tender-point pain.

One 1999 Italian study suggested that taking an antidepressant and undergoing mud-pack treatment may release natural steroids that reduce inflammation and relieve pain. Further research is needed to confirm any benefits.

Herbal or Natural Remedies. Some alternative agents are being investigated for fibromyalgia:

• S-adenosylmethionine (SAMe) is a natural substance that has antidepressant, anti-inflammatory, and analgesic properties. It has shown some benefit in controlled studies.
• Melatonin, a natural hormone associated with the sleep-wake cycle, may have benefits for some patients with fibromyalgia.
• In one 2000 study, collagen hydrolysat, a food supplement, significantly decreased pain in fibromyalgia patients with accompanying temporomandibular joint problems.

It is extremely important for patients to realize that any herbal remedy or natural medicine that has positive effects most likely has negative side effects and toxic reactions, just as any conventional drug does. Everyone is strongly advised to consult a physician before using any untested products or dietary supplements, and to discuss potential interactions with any medications being taken.