• Highlights
• Introduction
• Causes
• Risk Factors
• Diagnosis
• Conditions with Similar Symptoms
• Prognosis
• Treatment
• Lifestyle Changes
• Behavioral Therapy
• Medications
• Resources
• References

Fibromyalgia

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of fibromyalgia.

Alternative Names

Fibromyositis; Fibrositis; Myofascial pain syndrome

Lifestyle Changes

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

Graded Exercise. The basic approach used for fibromyalgia is called graded exercise. Graded exercise means you slowly increase the amount of your physical activity. In a well-conducted 2002 study, 35% of patients who engaged in graded aerobic exercise reported feeling much better or very much better after 3 months. Only 18% of patients who performed relaxation and flexibility exercises reported the same results. At the end of a year, more than half of the exercise group no longer had symptoms of fibromyalgia, compared to only 34% of the relaxation group.

In general, graded exercise involves:

• Walking, swimming, and using equipment such as treadmills or stationary bikes are excellent choices for starting an exercise program. Swimming and water therapy are also good because they eliminate putting weight on joints. In one 2002 study, patients who engaged in water exercise therapy for 6 months still reported improvements in symptoms and functioning 2 years after they had completed the program.
• A very gradual program of activity, beginning with mild exercise and building in intensity over time, is important to help patients do their exercise as directed. For example, in one successful exercise study, patients started with 2 weekly sessions that lasted for only 6 minutes each. By week 12, they were performing exercises that lasted 25 minutes each, with enough intensity to produce some sweating. However, they were still able to talk comfortably.
• Patients should do stretching exercises before exercising. A daily stretching routine can also help relax tense muscles and prevent muscle soreness.

Patients who try hard exercises too early actually experience an increase in pain, and are likely to become discouraged and quit.

Every patient must be prepared for relapses and setbacks, but this should not be discouraging. Patients who do not respond to one type of exercise might consider experimenting with another form.

Physical therapy can be very helpful. Studies suggest that physical therapy may reduce muscle overload, lessen fatigue from poor posture and positioning, and help condition weak muscles.

Establishing Regular Sleep Routines

Sleep is essential, particularly since sleep disruptions make pain worse. Many patients with fibromyalgia have trouble getting a restful and healing night's sleep. Improvement in fibromyalgia is low in those who are unable to sleep consistently and at night. Swing shift work, for example, is extremely hard on fibromyalgia patients. Poor sleep habits can adds to sleep problems. Tips for good sleep habits include:

• Establish a regular time for going to bed and getting up in the morning. Maintain this schedule even on weekends and during vacation.
• Use the bed only for sleep and sexual relations.
• If you are unable to fall asleep after 15 or 20 minutes, go into another room and engage in quiet activity. Return to bed when you feel sleepy.
• Minimize light and maintain a comfortable, moderate temperature in the bedroom. Keep the bedroom well ventilated.
• Avoid naps, especially in the evening or late afternoon.
• Avoid exercising within 6 hours of bedtime.
• Avoid caffeine or alcohol within 4 - 6 hours of bedtime.
• Avoid drinking fluids directly before bedtime so that sleep is not disturbed by the need to urinate.
• Avoid large meals before bedtime. A light snack, however, may help promote sleep.

[For more information see In-Depth Report #27 : Insomnia.]

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 from 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. You can also purchase these oils as supplements called EPA-DHA or omega 3.

Vegetarian Diet. A vegan diet has no meat, dairy, or eggs and includes uncooked fruits, vegetables, nuts, and germinated seeds. In two small studies, a vegan diet was associated with improved symptoms including reduced pain, stiffness, and increased quality of sleep. In addition, the diet was associated with lower weight and cholesterol levels. However, a 2000 study found no significant decline in symptoms, except for some improvement in pain. This improvement was not as great as the one seen with a tricyclic antidepressant.

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 a biofeedback session, electric leads are taped to a subject's head. The person is encouraged to relax using any method that works. Brain waves are measured and an audio signal sounds when alpha waves are detected. Alpha waves are brain waves that occur with a state of deep relaxation. By repeating the process, people using biofeedback connect 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 continued 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. Melatonin is important in regulating the sleep-wake cycle.
• Less pain, possibly from reductions in levels of cortisol, a stress hormone
• A reduction in heart rate, blood pressure, adrenaline levels, and skin temperature while meditating

An important goal for both religious and therapeutic meditation 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. Several meditation techniques are available. Some may be more useful for fibromyalgia than others.

• Fixed point meditation involves focusing on a stationary 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.
• Breath meditation. Other meditative forms involve focusing on the present moment and observing (but not examining or judging) one's thoughts. During breath meditation, 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.
• Mini-meditation . This 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.

People who try meditation for the first time 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. A person should probably not meditate before going to bed, since it 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 5 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 quick cure or urge the purchase of expensive but 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. Studies continue to report conflicting results on acupuncture's ability to relieve pain. Several small studies suggest it offers some benefit, especially to those who can not take medicines because of their side effects. However, a large controlled study published in the July 2005 Annals of Internal Medicine found that inserting needles at fibromyalgia-related pressure points was no better at relieving pain for fibromyalgia than randomly inserting needles ("sham acupuncture").

Chiropractic or Osteopathic Manipulation. Chiropractic or osteopathic manipulation may also help some patients. In one study, 21 patients improved after 4 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. Note 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 caused stroke or damage to the large blood vessels in the neck.

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

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 who had temporomandibular joint problems. The temporomandibular joint connects the lower jaw to the skull.

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. You should consult a doctor before using any untested products or dietary supplements. You should also discuss with your doctor any potential interactions between the supplements and any medications you take.

Herbs and Supplements Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even deadly side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

• Review Date: 12/15/2006
• Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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