fibromyalgia from natural standard€¦ · and muscle ache. there is no cure for fibromyalgia....
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Fibromyalgia – from Natural Standard
Health 24 17 August 2011
Fibromyalgia - from Natural Standard Fibromyalgia is a complex, disabling, and chronic (long-term) condition characterized
by widespread long-term pain, fatigue, and stiffness in the muscles, ligaments, and
tendons, as well as multiple tender points (places on the body where slight pressure
causes pain). In addition to muscular pain and fatigue, fibromyalgia may also be
associated with sleep problems, depression, and an inability to think clearly.
BACKGROUND
Fibromyalgia is a complex, disabling, and chronic (long-term) condition characterized
by widespread long-term pain, fatigue, and stiffness in the muscles, ligaments, and
tendons, as well as multiple tender points (places on the body where slight pressure
causes pain). In addition to muscular pain and fatigue, fibromyalgia may also be
associated with sleep problems, depression, and an inability to think clearly.
The word fibromyalgia comes from the Latin term for fibrous tissue (fibro) and the
Greek words for muscle (myo) and pain (algia). Fibromyalgia may also be called
fibromyositis, fibrositis, chronic muscle pain syndrome, psychogenic rheumatism, and
tension myalgia. Although fibromyalgia is often considered an arthritis-related
condition, it is not truly a form of arthritis because it does not cause inflammation or
damage to the joints, muscles, or other tissues. Like arthritis, however, fibromyalgia is
considered a rheumatic condition, a medical condition that impairs the joints and/or
soft tissues and causes chronic pain.
The main symptom of fibromyalgia is chronic widespread musculoskeletal pain for
which no alternative cause, such as tissue inflammation or damage, can be identified.
Patients generally experience pain and stiffness throughout their bodies. Common
additional symptoms include: fatigue, sleep disturbances, irritable bowel syndrome
(IBS), headaches, facial pain, and increased sensitivity, depression, anxiety, difficulty
concentrating, chest pain, numbness or tingling sensations in the hands or feet, painful
menstrual periods, dizziness, as well as dry eyes, skin, or mouth. Not all people with
fibromyalgia experience all associated symptoms.
The cause of fibromyalgia is unclear. Fibromyalgia is believed to be the result of central
nervous system malfunction, resulting in amplification of pain transmission and
detection. Researchers believe that several factors, including sleep disturbances, stress,
family history of fibromyalgia, infection, injury, abnormalities in the nervous system,
and changes in muscle metabolism, may lead to the development of fibromyalgia. These
events, however, may or may not be present in individuals diagnosed with fibromyalgia.
The main risk factors that may predispose an individual to developing fibromyalgia or
its symptoms include middle age, female gender, family history of fibromyalgia, stress,
depression, rheumatic disease, and sleep disorders.
Some medical experts prefer the term fibromyalgia syndrome, arguing that fibromyalgia
is not its own disease due to lacking scientific consensus about its cause. They also argue
that there is a lack of abnormalities on physical examination and an absence of objective
diagnostic tests. A diagnosis may be based on a pain index, the presence of key
symptoms, and a measure of the severity of the symptoms. According to the American
College of Rheumatology guidelines, fibromyalgia patients must have moderate-to-
severe pain throughout the body for at least three months. Patients must also have at
least 11 tender points (out of a total possible of 18) that are unusually sensitive when
mild-to-firm pressure is applied.
Fibromyalgia is not a progressive disease and generally does not lead to other
conditions or diseases. It may, however, lead to pain, depression, and lack of sleep. The
problems associated with fibromyalgia may disrupt family or work relationships and
performance, which may cause frustration and depression. Other conditions that may
occur in fibromyalgia patients include gastroesophageal reflux disease (GERD), (IBS),
temporomandibular joint (TMJ) disorder, recurrent migraine or tension-type headaches,
and muscle ache.
There is no cure for fibromyalgia. However, some treatments are effective in reducing
symptoms, such as medications, behavioral interventions, support groups, patient
education, and exercise. In mild cases, a reduction in stress and certain lifestyle changes
may be enough to manage the disease. These changes may include participation in
counselling, regular exercise, physical therapy, healthy sleep habits, and stress
reduction.
Scientists at the National Institutes of Health (NIH) estimate that fibromyalgia affects
five million Americans age 18 years of age or older. The vast majority of fibromyalgia
cases (80-90%) are women in their mid-30s to late-50s. However, men and children can
also have the disorder. An estimate of the prevalence of fibromyalgia is as high as 3-5%
of the population in the United States. Fibromyalgia symptoms may never completely
resolve, and their intensity may vary. Although the symptoms of fibromyalgia may be
hard to live with, the condition is not considered progressive or life-threatening.
RISK FACTORS
General: Although the cause of fibromyalgia is not entirely clear, there are some factors
that may predispose an individual to developing fibromyalgia or its symptoms. These
main risk factors include: middle age, female gender, family history of fibromyalgia,
stress, rheumatic disease, and sleep disorders.
Age: Individuals between the ages of 20 and 60 are at the highest risk of developing
fibromyalgia, although it may occur at any age.
Gender: Although fibromyalgia may develop in men or women, statistics indicate that
women are seven times more likely to develop the condition than men. Nine of 10
fibromyalgia patients are women. An estimated 3.4% of American women have been
diagnosed with fibromyalgia. Women are more likely to develop fibromyalgia during
menopause than any other time. Generally, a woman's symptoms are more severe than a
man's symptoms.
Genetic factors: There is some indication that genetic factors may be involved in the
development of fibromyalgia. Studies have shown that individuals with family members
who have fibromyalgia are at a higher risk of developing it themselves.
Psychiatric illness: While the majority of individuals with fibromyalgia report a history
of psychiatric symptoms, such as depression or anxiety, many patients do not. There is
no clear evidence that psychiatric illness causes fibromyalgia.
Rheumatic disease: Patients with rheumatic disease, such as rheumatoid arthritis,
ankylosing spondylitis (spinal arthritis), or lupus may be more likely to develop
fibromyalgia.
Sleep disorders: Patients with sleep disorders, such as restless legs syndrome or sleep
apnea (pauses in breathing during sleep), may have a higher risk of developing
fibromyalgia.
Stress: People who have recently experienced a stressful physical or emotional event
(such as a divorce, car accident, or death of a family member) may be at a higher risk of
developing fibromyalgia.
Other: Changes in weather, cold or drafty environments, infections, allergies, and
hormonal fluctuations (premenstrual and menopausal states) may all contribute to the
development of fibromyalgia.
CAUSES
General: The causes of fibromyalgia remain unknown. The most current hypothesis is
that fibromyalgia is the result of central nervous system malfunction, resulting in
amplification (increase) of pain transmission and detection. Researchers believe that
several factors, including sleep disturbances, stress, family history of fibromyalgia,
infection, injury, abnormalities in the nervous system, and changes in muscle
metabolism, may lead to the development of fibromyalgia. These events, however, may
or may not be present in individuals diagnosed with fibromyalgia.
Abnormal pain transmission: There is some evidence that fibromyalgia patients have
abnormal pain transmission responses caused by defects in the central nervous system.
According to the central sensitization theory, patients with fibromyalgia may have a
lower pain threshold (the point at which pain begins to be felt) because of increased
sensitivity in the brain to pain signals. Possible causes for this include: abnormally high
levels of certain chemicals in the brain that signal pain and/ or an increased sensitivity
of the brain to pain signals. Abnormal pain processing may also be responsible for
symptoms experienced in several chronic pain disorders that many fibromyalgia
patients also experience, including irritable bowel syndrome (IBS), temporomandibular
joint disorder (TMJ), chronic low back pain, and other chronic pain disorders.
SIGNS AND SYMPTOMS
General: Symptoms of fibromyalgia may vary, depending on the weather, time of day,
physical activity, and stress levels. Patients generally experience pain and stiffness
throughout their bodies. Common symptoms include fatigue, sleep disturbances,
irritable bowel syndrome (IBS), headaches, facial pain, and increased sensitivity. Other
symptoms may include depression, difficulty concentrating, chest pain, numbness or
tingling sensations in the hands or feet (paresthesia), anxiety, painful menstrual periods,
dizziness, as well as dry eyes, skin, or mouth. Not all people with fibromyalgia
experience all associated symptoms.
Co-existing conditions: Fibromyalgia frequently occurs in patients with psychiatric
conditions such as depression and anxiety and stress-related disorders such as post-
traumatic stress disorder (PTSD). Fibromyalgia also occurs more often in patients with
endometriosis, lupus, osteoarthritis, or rheumatoid arthritis.
Fatigue and sleep disturbances: Fibromyalgia patients often do not feel rested, even
after getting sufficient sleep. It is possible that these patients are unable to reach the
deep restorative stage of sleep known as rapid eye movement (REM) sleep. Sleep and
fatigue disorders associated with fibromyalgia include restless legs syndrome, sleep
apnea, and chronic fatigue syndrome.
Gastroesophageal reflux disease (GERD): Gastroesophageal reflux disease (GERD), or
acid reflux, occurs in roughly 40-70% of fibromyalgia patients.
Headache: Recurrent migraine or tension-type headaches are seen in about 70% of
fibromyalgia patients.
Irritable bowel syndrome (IBS): Symptoms of IBS include fluctuations between
constipation and diarrhea, frequent abdominal pain, abdominal gas, and nausea.
Symptoms of IBS are found in roughly 40-70% of fibromyalgia patients.
Muscle ache: Patients with fibromyalgia usually experience an aching throughout their
bodies. Their muscles, including those in the face, may feel like they are pulled or
overworked or feel as if they are burning. Patients may wake up with body aches and
stiffness.
Pain: The most common symptom experienced by fibromyalgia patients is long-term,
body-wide pain and allodynia. Allodynia is pain caused by stimuli that are not normally
painful and may occur in an area other than in the area being stimulated. The pain is
usually in multiple locations and may be difficult to describe precisely. The pain
associated with fibromyalgia is usually described as a constant dull ache, typically
arising from muscles, tendons, and ligaments. The pain may also be described as
radiating, gnawing, shooting or burning. It ranges from mild to severe. In some patients,
the pain improves during the day and increases again during the evening, although
other patients experience unrelenting pain throughout the day. The pain may increase
with activity, cold or damp weather, anxiety, and stress.
Fibromyalgia is characterized by additional pain when firm pressure is applied to tender
points. Tender point locations include the back of the head, between the shoulder
blades, the top of the shoulders, the front sides of neck, the upper chest, the outer
elbows, the upper and sides of the hips, and the inner knees.
Temporomandibular joint (TMJ) disorder: Temporomandibular joint (TMJ) disorder
causes tremendous jaw-related face and head pain in one-quarter of fibromyalgia
patients.
Other: Other symptoms of fibromyalgia may include premenstrual syndrome (PMS) and
painful menstrual periods, chest pain, morning stiffness, cognitive or memory
impairment, numbness and tingling sensations, muscle twitching, difficulty with
swallowing, bowel and bladder abnormalities, swollen hands and feet, skin sensitivities,
dry eyes and mouth, palpitations, dizziness, reduced exercise tolerance, and impaired
coordination. Fibromyalgia patients are often sensitive to odors, loud noises, bright
lights, and sometimes even the medications that they are prescribed.
DIAGNOSIS
General: Fibromyalgia is a difficult condition to diagnose. A diagnosis may be based on a
pain index, the presence of key symptoms, and a measure of these symptoms and their
severity. Testing may be done to rule out other conditions that may be associated with
or have similar symptoms to fibromyalgia, such as cancer, cervical and low-back
degenerative disease, chronic fatigue syndrome, depression, HIV infection,
hypothyroidism, irritable bowel syndrome, Lyme disease, rheumatoid arthritis, and
sleep disorders.
American College of Rheumatology guidelines: The American College of Rheumatology
has established guidelines for diagnosing fibromyalgia. According to these guidelines,
patients must have aching pain throughout the body for at least three months. Patients
must also have at least 11 parts of the body (out of a total possible of 18) that are
unusually sensitive when mild-to-firm pressure is applied. The tender-point sites
include: fibrous tissue or muscles of the arms (elbows), buttocks, chest, knees, lower
back, neck, rib cage, shoulders, and thighs.
Blood tests: While there is no lab test to confirm a diagnosis of fibromyalgia, blood may
be drawn to rule out other conditions that may have similar symptoms. A test called an
erythrocyte sedimentation rate (ESR) test measures the rate at which red blood cells
settle to the bottom of a test tube containing blood. The ESR is increased when
inflammation is present. The level of creatine kinase (a normal muscle enzyme that
leaks out and is released into the bloodstream when muscle is damaged) may also be
tested. Levels of creatine kinase are increased when there is widespread and ongoing
destruction of muscle. Blood tests that are used to diagnose rheumatoid arthritis test for
the presence of rheumatoid factor or anti-cyclic citrullinated peptide (anti-CCP)
antibody in the blood. A blood test to identify autoimmune antibodies (antinuclear
antibodies) is helpful in ruling out systemic lupus erythematosus (lupus).
Other: Healthcare providers may also perform other tests, including X-rays, magnetic
resonance imaging (MRI), and computerized tomography (CT) scans to rule out other
conditions. X-rays are most valuable for detecting abnormalities in bone and are taken
to evaluate painful, deformed, or suspected abnormal areas of bone. X-rays may be
helpful in showing changes that confirm a person has a certain kind of arthritis (for
example, rheumatoid arthritis or osteoarthritis). X-rays do not show soft tissues such as
muscles, bursae (small, fluid-filled sacs that reduce friction between moving body
parts), ligaments, tendons, or nerves. CT scans and MRI give much more detail than
conventional X-rays. MRI is especially valuable for imaging muscles, ligaments, and
tendons.
COMPLICATIONS
General: Fibromyalgia is not a progressive disease and generally does not lead to other
conditions or diseases. It may, however, lead to pain and lack of sleep. These problems
may disrupt family or work relationships and performance, leading to frustration and
depression. Other conditions that may occur in fibromyalgia patients include
gastroesophageal reflux disease (GERD), temporomandibular joint (TMJ) disorder,
recurrent migraine or tension-type headaches, and irritable bowel syndrome (IBS).
Depression: Many fibromyalgia patients suffer from depression when the condition
interferes significantly with the patients' lifestyles, including causing pain. Individuals
and members of their family should consult their healthcare providers if they
experience feelings of sadness, low self-esteem, loss of pleasure, apathy, and difficulty
functioning for two weeks or longer with no known underlying cause. These may be
signs of depression.
Fatigue and sleep disturbances: Fibromyalgia patients often do not feel rested, even
after getting sufficient sleep. It is possible that these patients are unable to reach the
deep restorative stage of sleep known as rapid eye movement (REM) sleep. Sleep and
fatigue disorders associated with fibromyalgia include: restless legs syndrome, sleep
apnea, and chronic fatigue syndrome.
Gastroesophageal reflux disease (GERD): Gastroesophageal reflux disease (GERD), or
acid reflux, occurs in roughly 40-70% of fibromyalgia patients.
Headache: Recurrent migraine or tension-type headaches are seen in about 70% of
fibromyalgia patients.
Irritable bowel syndrome (IBS): Symptoms of IBS include fluctuations between
constipation and diarrhea, frequent abdominal pain, abdominal gas, and nausea.
Symptoms of IBS are found in roughly 40-70% of fibromyalgia patients.
Muscle ache: Patients with fibromyalgia usually experience an aching throughout their
bodies. Their muscles, including those in the face, may feel like they are pulled or
overworked or feel as if they are burning. These patients may wake up with body aches
and stiffness.
Pain: The most common symptom experienced by fibromyalgia patients is long-
standing, body-wide pain and allodynia. Allodynia is pain caused by stimuli that are not
normally painful, and by stimuli that may occur in an area other than in the area being
stimulated. The pain is usually in multiple locations and may be difficult to describe
precisely. The pain associated with fibromyalgia is usually described as a constant dull
ache, typically arising from muscles, tendons, and ligaments. The pain may also be
described as radiating, gnawing, shooting, or burning. It ranges from mild to severe. In
some patients, the pain improves during the day and increases again during the evening,
although other patients experience unrelenting pain throughout the day. The pain may
increase with activity, cold or damp weather, anxiety, and stress. Patients should stay in
close contact with their healthcare providers to ensure that their medications are
properly managing the pain; adjustments may be necessary.
Temporomandibular joint (TMJ) disorder: Temporomandibular joint (TMJ) disorder
causes tremendous jaw-related face and head pain in one-quarter of fibromyalgia
patients.
Other: Other complications of fibromyalgia may include: premenstrual syndrome (PMS)
and painful periods, chest pain, morning stiffness, cognitive or memory impairment,
numbness and tingling sensations, muscle twitching, difficulty with swallowing, bowel
and bladder abnormalities, swollen hands and feet, skin sensitivities, dry eyes and
mouth, palpitations, dizziness, reduced exercise tolerance, and impaired coordination.
Fibromyalgia patients are often sensitive to odors, loud noises, bright lights, and
sometimes even the medications they are prescribed.
TREATMENT
General: There is no cure for fibromyalgia. However, some treatments are effective in
reducing symptoms, such as medications, behavioral interventions, support groups,
patient education, and exercise. In mild cases, a reduction in stress and certain lifestyle
changes may be enough to manage the disease. These changes may include:
participation in counseling, regular exercise, physical therapy, healthy sleep habits, and
stress reduction.
The management of fibromyalgia usually requires a multi-disciplinary approach
combining pharmacological and nonpharmacological modalities (methods of
treatment). It is important to find a doctor who is knowledgeable about fibromyalgia
before beginning treatment. In addition to a family physician, medical specialists may be
consulted, such as a rheumatologist (specializes in conditions that affect the joints or
soft tissues), a physical therapist, a pain specialist, and others.
U.S. Food and Drug Administration (FDA) has approved three drugs for the management
of fibromyalgia: duloxetine (Cymbalta©), milnacipran (Savella©), and pregabalin
(Lyrica©). Other types of medications may also be prescribed to manage symptoms or
co-existing conditions. Such drugs may include: antidepressants, anti-seizure drugs,
benzodiazepines, muscle relaxants, and pain relievers. In order to properly manage
pain, individuals should take their medications as prescribed by their healthcare
providers. Patients should also tell their healthcare providers if they are taking any
herbs, dietary supplements, or other drugs (prescription or over-the-counter), because
they may interfere with treatment.
Antidepressants: Many individuals with fibromyalgia also suffer from depression. There
is evidence that antidepressants in low doses may decrease depression, relax
craniofacial and skeletal muscles, improve sleep quality, and release pain-killing
endorphins (compounds). Side effects of antidepressant medications include:
drowsiness, fatigue (excessive tiredness), reduced sex drive, increased risk of suicide,
increased blood pressure, constipation, dry mouth, and blurred vision.
Tricyclic antidepressants: When taken at bedtime in dosages lower than those used to
treat depression, tricyclic antidepressants may help promote restorative sleep in people
with fibromyalgia. They also may relax painful muscles and heighten the effects of the
body's natural pain-killing substances called endorphins. Examples of tricyclic
medications used to treat fibromyalgia include: amitriptyline hydrochloride (Elavil©,
Endep©), cyclobenzaprine (Cycloflex©, Flexeril©, Flexiban©), doxepin (Adapin©,
Sinequan©), and nortriptyline (Aventyl©, Pamelor©). Both amitriptyline and
cyclobenzaprine have been proven useful for the treatment of fibromyalgia.
Selective serotonin reuptake inhibitors (SSRIs): Another class of antidepressant that
may be prescribed is known as selective serotonin reuptake inhibitors (SSRIs). They are
usually prescribed for fibromyalgia patients in lower dosages than are used to treat
depression. By promoting the release of serotonin, these drugs may reduce fatigue and
some other symptoms associated with fibromyalgia. The group of SSRIs includes
fluoxetine (Prozac©), paroxetine (Paxil©), and sertraline (Zoloft©). Newer SSRIs such
as citalopram (Celexa©) or escitalopram (Lexapro©) do not seem to work as well for
pain as the older SSRIs. There is evidence that a combination therapy of the tricyclic
amitriptyline and the SSRI fluoxetine resulted in greater improvements in the study
participants' fibromyalgia symptoms than either drug alone. However, this combination
therapy is associated with an increased risk of serotonin syndrome.
Serotonin-norepinephrine reuptake inhibitors (SNRIs): SNRIs are a newer class of
antidepressants that raise levels of both serotonin and norepinephrine. Examples of
these medications include: venlafaxine (Effexor©), duloxetine (Cymbalta©), and
milnacipran (Savella©). In general, these drugs work better for pain than SSRIs.
Anti-seizure drugs: Medications designed to treat epilepsy are often useful in reducing
certain types of pain. Gabapentin (Neurontin©) is sometimes helpful in reducing
fibromyalgia symptoms. Patients with fibromyalgia may take an anti-seizure medication,
called pregabalin (Lyrica©). Although this medication is primarily used to prevent
seizures, the FDA has also approved the medication as a treatment for fibromyalgia.
Pregabalin has been shown to reduce pain caused by fibromyalgia. Side effects may
include: dizziness, sleepiness, difficulty concentrating, blurred vision, weight gain, dry
mouth, and swelling in the hands and feet; alcohol should be avoided while taking this
medication.
Benzodiazepines: Benzodiazepines are sometimes used in fibromyalgia patients to relax
tense, painful muscles and promote a deep sleep pattern. Benzodiazepines also may
relieve the symptoms of restless legs syndrome. Doctors usually prescribe
benzodiazepines only for people who have not responded to other therapies because of
the potential for addiction. Benzodiazepines include clonazepam (Klonopin©) and
diazepam (Valium©).
Cool compress or ice pack: Applying a cool compress or ice pack to the affected joint
during a painful flare-up may help reduce swelling and pain caused by a rheumatic
disease.
Counseling: In cognitive behavioral therapy, techniques for dealing with stressful
situations are learned and practiced. Individual or group therapy may be used. Support
groups are available for patients with fibromyalgia.
Diet: Eating a well-balanced diet and avoiding caffeine may reduce the severity of
fibromyalgia symptoms, including problems sleeping.
Drugs: Although other medications may be prescribed to manage symptoms associated
with fibromyalgia, only three medications, duloxetine (Cymbalta©), milnacipran
(Savella©), and pregabalin (Lyrica©), have been approved by the FDA for the treatment
of fibromyalgia. Cymbalta© was originally developed for and is still used to treat
depression. Lyrica© is an anti-seizure medication developed to treat neuropathic pain
(chronic pain caused by damage to the nervous system). Savella© is not approved for
any condition other than fibromyalgia.
Exercise/physical therapy: Studies have shown that fibromyalgia symptoms may be
relieved by aerobic exercise. Patients should consult with a physician before beginning
an exercise program. A physical therapist may be helpful in deciding those exercises that
are most appropriate. Specific exercises may help restore muscle balance and reduce
pain. Stretching techniques may also be recommended.
Heat: Applying a hot pack to affected joints may help reduce pain, relax muscles, and
increase blood flow to the joint. It may also be an effective treatment before exercise.
Alternatively, patients may take a hot shower or bath before exercise to help reduce
pain.
Irritable bowel syndrome (IBS) management: Symptoms of IBS are found in roughly 40-
70% of fibromyalgia patients. To manage this symptom, fiber supplements or laxatives
to relieve constipation or medications such as diphenoxylate/atropine (Lotomil©) or
loperamide (Imodium©) to relieve diarrhea may be used. A prescription medication
called alosetron (Lotronex©) is approved for the treatment of severe IBS with diarrhea
that does not respond to other treatment. Another drug, lubiprostone (Amitiza©), is
approved for the treatment of IBS with constipation.
Muscle relaxants: Muscle relaxants, such as cyclobenzaprine (Flexeril©), may help
reduce muscle pain and spasms associated with fibromyalgia. Patients usually take
these medications by mouth before sleep. Muscle relaxants should only be taken short-
term. The most common side effect of muscle relaxants is sedation. Patients should not
drive or operate machinery or consume alcohol while taking muscle relaxants.
Pain relievers: Over-the-counter pain relievers used in the treatment of fibromyalgia
include acetaminophen (Tylenol©). However, its effectiveness varies. Prescription pain
relievers, including tramadol (Ultram©), have also been used with or without
acetaminophen. Although tramadol does not reduce swelling, it has fewer side effects
than nonsteroidal anti-inflammatory drugs (NSAIDs). It is generally taken as a short-
term treatment to reduce symptoms of flare-ups. It is not used long-term due to the risk
of addiction.
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil©,
Motrin©, and others) or naproxen sodium (Aleve©, and others), are sometimes used in
conjunction with other medications to manage pain associated with fibromyalgia.
Commonly prescribed NSAIDs include diclofenac (Cataflam© or Voltaren©),
nabumetone (Relafen©), or short-term ketoprofen (Orudis©). NSAIDs are generally
taken long term to manage symptoms. NSAIDs treat inflammation. Although
inflammation is not a symptom of fibromyalgia, NSAIDs also relieve pain and may help
ease the muscle aches of fibromyalgia. They may also relieve menstrual cramps and
headaches associated with fibromyalgia. The frequency and severity of side effects vary
depending on the specific NSAID used. The most common side effects include: nausea,
vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, and
drowsiness. The most serious side effects include: kidney failure, liver failure,
gastrointestinal ulcers, heart-related problems, and prolonged bleeding after an injury
or surgery. About 15% of patients who receive long-term NSAID treatment develop
ulcers (open sores) in the stomach or duodenum.
For fibromyalgia patients with severe pain, narcotic medications may be prescribed.
However, there is no solid evidence showing that narcotics actually work to treat the
chronic pain of fibromyalgia in most people. Narcotic pain relievers are only used short-
term to treat flare-ups. Common side effects include: constipation, drowsiness, dry
mouth, and difficulty urinating. Narcotic pain relievers should be used cautiously
because patients may become addicted to them.
Sleep: Since patients with sleep disorders (i.e., restless legs syndrome, sleep apnea) may
have a higher risk of developing fibromyalgia, patient-specific therapies may be
recommended to improve the quality of sleep. These may include medications (such as
amitriptyline) and/or machines to assist in breathing during the night.
Stress reduction: Since physical or emotional trauma may trigger fibromyalgia, reducing
stress and improving coping skills may also help reduce painful symptoms. Approaches
may include using medications (such as sertraline (Zoloft©) or practicing relaxing
activities (such as yoga or meditation).
INTEGRATIVE THERAPIES
Good scientific evidence:
5-HTP: 5-HTP is the precursor of the neurotransmitter serotonin. It is obtained
commercially from the seeds of the plant Griffonia simplicifolia. There is a small amount
of research evaluating the use of 5-HTP for fibromyalgia, and early evidence suggests
that 5-HTP may reduce the number of tender points, anxiety, and intensity of pain and
may improve sleep, fatigue, and morning stiffness.
5-HTP may cause drug interaction with medications such as antidepressants and sleep
medicines. A potentially life-threatening condition called serotonin syndrome could
occur in patients who take 5-HTP in combination with antidepressants. 5-HTP is not
recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.
Acupuncture: There is evidence from several studies suggesting acupuncture may help
with pain relief in fibromyalgia. More high quality studies would help to confirm these
study results.
Needles must be sterile in order to avoid disease transmission. Avoid with valvular
heart disease, infections, bleeding disorders, medical conditions of unknown origin,
neurological disorders, or if taking anticoagulants. Avoid on areas that have received
radiation therapy and during pregnancy. Avoid electroacupuncture with irregular
heartbeat or in patients with pacemakers. Use cautiously with pulmonary disease (like
asthma or emphysema). Use cautiously in elderly or medically compromised patients,
diabetics, or those with a history of seizures.
Chlorella: A randomized controlled trial and one case series indicate that chlorella may
reduce the tenderness associated with fibromyalgia's tender points. Although the results
are promising, more high-quality studies are needed to confirm these studies' findings.
Avoid in patients with known allergy/hypersensitivity to chlorella, its constituents,
mold, or members of the Oocystaceae family. Use cautiously in patients with
hypotension, altered immune function, cancer, or those taking antihypertensives or
immunomodulators. Use cautiously in patients with photosensitivity, taking
photosensitizers, or exposed to the sun. Avoid long-term supplementation or with
manganese supplementation. Avoid in patients using warfarin or other anticoagulant
therapy.
Trigger point therapy: There have been several studies that addressed the therapeutic
potential of trigger point therapy (the practice of compressing small areas or trigger
points in a muscle from which pain is believed to radiate in that area or in unrelated
areas). The results of the higher-quality studies show slight, albeit not significant,
improvement of myofascial pain. Many of the medium-quality studies illustrate more
pronounced improvement and statistical differences. Overall, the studies indicate that
trigger point therapy may be effective for myofascial pain. However, future studies need
to be performed before any definitive conclusions can be drawn.
Use cautiously with local or systemic infection, anticoagulation or bleeding disorders, or
acute muscle trauma. Avoid aspirin ingestion within three days of injection. Avoid with
extreme fear of needles, large bruises, phlebitis, varicose veins, undiagnosed lumps, or
open wounds. Avoid if allergic to anesthetic agents (mainly caused by aminoester
agents). Use cautiously during pregnancy.
Unclear or conflicting scientific evidence:
Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship
between musculoskeletal structure (primarily the spine) and body function (as
coordinated by the nervous system), and how this relationship affects the preservation
and restoration of health. Further research is needed to determine if chiropractic
therapy is an effective treatment for hip pain, osteoarthritis, fibromyalgia, or
temporomandibular joint (TMJ) disorders.
Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable
spondylolisthesis (the slipping of a disc in the spine over the one beneath it), or arthritis.
Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue
after surgery. Avoid if pregnant or breastfeeding, due to a lack of scientific data. Use
extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions
that cause decreased bone mineralization, brittle bone disease, bone softening
conditions, bleeding disorders, or migraines. Use cautiously with the risk of tumors or
cancers.
Comfrey: A comfrey-containing cream has been applied on the skin to reduce pain
associated with myalgia (muscle pain). Improvements in pain at rest and in motion were
noted. Further studies are required before a firm recommendation can be made.
Avoid if allergic/hypersensitive to comfrey, its constituents, or members of the
Boraginaceae family. Avoid oral comfrey, due to hepatotoxic and carcinogenic
pyrrolizidine alkaloids; oral use has caused death. Avoid topical comfrey on broken skin,
due to hepatotoxic and carcinogenic pyrrolizidine alkaloids. Avoid topical comfrey in
individuals with or at risk for hepatic disorders, cancer, or immune disorders. Use
topical creams containing comfrey cautiously if taking anti-inflammatory medications or
cytochrome P450 3A4-inducing agents. Use extreme caution when using topical creams
containing comfrey for extended periods. Avoid if pregnant or breastfeeding.
Dehydroepiandrosterone (DHEA): Preliminary evidence suggests that DHEA
(dehydroepiandrosterone) may not offer benefit to individuals with rheumatoid
arthritis or fibromyalgia. Further research is needed in this area.
Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or
thyroid disorders or anticoagulants, or drugs, herbs or supplements for diabetes, heart
disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic
procedures with bleeding risk, and do not use immediately after these procedures.
Avoid if pregnant or breastfeeding.
Feldenkrais Method©: The Feldenkrais Method© uses gentle touch, movement, and
directed attention to increase self-awareness and body movement. In early studies of
patients with nonspecific musculoskeletal disorders, Body Awareness Therapy© and
Feldenkrais seemed to improve health-related quality of life. The Feldenkrais Method©
is popularly considered a useful treatment for chronic pain. However, clinical evidence
of the efficacy of Feldenkrais in fibromyalgia is limited. There is currently a lack of
available scientific studies or reports of safety of the Feldenkrais Method©.
Guided imagery: Guided imagery uses imagination to heal the body. Cognitive-
behavioral interventions for pain may be an effective adjunct to standard pharmacologic
interventions for pain in patients with osteoarthritis or juvenile rheumatoid arthritis.
Initial research for fibromyalgia also suggests possible reductions in pain and
improvements in functioning. Further research is needed to confirm these results.
Guided imagery is usually intended to supplement medical care, not to replace it, and
should not be relied on as the sole therapy for a medical problem. Contact a qualified
healthcare provider if mental or physical health is unstable or fragile. Never use guided
imagery techniques while driving or doing any other activity that requires strict
attention. Use cautiously with physical symptoms that can be brought about by stress,
anxiety, or emotional upset because imagery may trigger these symptoms. Speak with a
qualified healthcare provider before practicing guided imagery if feeling unusually
anxious while practicing guided imagery, or with a history of trauma or abuse.
Hypnosis, hypnotherapy: Although multiple trials report diminished pain levels or
requirements for pain-relieving medications after hypnotherapy (techniques that
bypass the conscious mind), there is limited research for rheumatoid arthritis pain
specifically. Other signs of rheumatoid arthritis, such as joint mobility or blood tests for
rheumatoid factor, have not been adequately assessed. There is inconclusive evidence
from preliminary research regarding use of hypnotherapy for fibromyalgia. Additional
study is needed before a firm conclusion can be drawn.
Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression,
multiple personality disorder, or dissociative disorders. Use cautiously with seizure
disorders.
Magnet therapy: Initial evidence has failed to show improvements in pain from
rheumatoid arthritis or osteoarthritis with the use of magnet therapy (using magnets to
produce static magnetic fields in the body for possible health benefits). However, due to
the methodological weaknesses of this research, the conclusions cannot be considered
definitive. The effectiveness of magnet therapy as an additive treatment for fibromyalgia
has been assessed in preliminary studies (including the use of magnetic sleep pads).
Results of recent research suggest that magnetic fields may not be helpful for this
condition. Better study is needed before a firm conclusion can be drawn.
Avoid with implantable medical devices like heart pacemakers, defibrillators, insulin
pumps, or hepatic artery infusion pumps. Avoid with myasthenia gravis or bleeding
disorders. Avoid if pregnant or breastfeeding. Magnet therapy is not advised as the sole
treatment for potentially serious medical conditions, and should not delay the time to
diagnosis or treatment with more proven methods. Patients are advised to discuss
magnet therapy with a qualified healthcare provider before starting treatment.
Massage: Massage may be of benefit for rheumatoid arthritis, but there is currently not
enough scientific data on which to base a strong conclusion for this indication. A small
number of studies report that massage may improve pain, depression, and quality of life
in fibromyalgia patients. Early evidence suggests that massage may reduce the number
and intensity of painful trigger points. More studies are needed regarding use of
massage for myofascial pain.
Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications
(such as heparin or warfarin/Coumadin©). Areas should not be massaged where there
are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds,
skin infections, recent surgery, or blood clots. Use cautiously with a history of physical
abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for
more proven therapies for medical conditions. Massage should not cause pain to the
client.
Meditation: It has been suggested that mindfulness meditation may help improve
symptoms in patients with fibromyalgia. Better quality research is needed before a
conclusion can be formed.
Use cautiously with underlying mental illnesses. People with psychiatric disorders
should consult with their primary mental healthcare professionals before starting a
program of meditation and should explore how meditation may or may not fit with their
current treatment plans. Avoid with risk of seizures. The practice of meditation should
not delay the time to diagnose or treat the condition with more proven techniques or
therapies. Meditation should not be used as the sole approach to illnesses.
Physical therapy: Several studies have indicated that treatment of rheumatoid arthritis
with physical therapy may help improve morning stiffness and grip strength. Some
experts have suggested a long-term, high-intensity exercise program. Beneficial effects
may last up to one year. Despite promising early evidence, better-designed studies are
needed to draw a firm conclusion. More research is also needed to determine if physical
therapy is an effective treatment for frozen shoulder, hip pain, joint problems (including
rotator cuff and sacroiliac joint dysfunction), or osteoarthritis.
Early research indicates that a self-management based program of pool exercises and
education may improve the quality of life of patients with fibromyalgia and their
satisfaction with treatment. In one study, physical therapy did not show better effects
when compared with hypnotherapy. Additional study is needed to make a firm
recommendation for use of physical therapy for myofascial pain.
Not all physical therapy programs are suited for everyone, and patients should discuss
their medical history with a qualified healthcare professional before beginning any
treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and
fractures of unknown origin have been reported. Physical therapy may increase the
duration of pain or cause limitation of motion. Pain and anxiety may occur during the
rehabilitation of patients with burns. Both morning stiffness and bone erosion have
been reported in the physical therapy literature although causality is unclear. Erectile
dysfunction has also been reported. Physical therapy has been used in pregnancy and
although reports of major adverse effects are lacking in the available literature, caution
is advised nonetheless. All therapies during pregnancy and breastfeeding should be
discussed with a licensed obstetrician/gynecologist before initiation.
Qi gong: There is mixed evidence regarding the usefulness of Qi gong (a Chinese system
similar to meditation or yoga, of physical and mental training for health, martial arts,
and emotional well-being) in treating fibromyalgia. More research is needed before a
conclusion can be made.
Qi gong is generally considered to be safe in most people when learned from a qualified
instructor. Use cautiously with psychiatric disorders.
Relaxation therapy: Limited preliminary research reports that muscle relaxation
training may improve function and well being in patients with rheumatoid arthritis.
Additional research is necessary before a conclusion can be reached. In a randomized
study of patients with osteoarthritis pain, Jacobson relaxation was reported to lower the
level of subjective pain over time. The study concluded that relaxation might be effective
in reducing the amount of analgesic medication taken by participants. Further well-
designed research is needed to confirm these results.
Relaxation has been reported to reduce fibromyalgia pain. However, results from other
studies are conflicting, and therefore further research is needed before a clear
recommendation can be made.
Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation
(flexing specific muscles, holding that position, and then relaxing the muscles) should be
used cautiously with illnesses like heart disease, high blood pressure, or
musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment
approach for potentially serious medical conditions, and should not delay the time to
diagnosis or treatment with more proven techniques.
S-adenosyl-methionine (SAMe): Since fibromyalgia is characterized by chronic pain and
depressive symptoms, there is an increased interest in studying S-adenosyl-methionine
(SAMe) for this indication. Current available evidence, however, does not appear to
show any benefit of SAMe over placebo in reducing the number of tender points and in
alleviating depression. Additional study is needed to confirm these findings.
Avoid if allergic or hypersensitive to SAMe. Use cautiously with diabetes and anxiety
disorders, or women in their third trimester of pregnancy. Avoid with bipolar disorder.
Avoid during first trimester of pregnancy or if breastfeeding.
Tai chi: There is not enough scientific evidence showing that tai chi (a system of body
movements and positions that aim to address the body and mind as an interconnected
system) reduces rheumatoid arthritis symptoms, although tai chi may help improve
range of motion of the lower extremities. A small trial in women with osteoarthritis
reported that treatment with tai chi significantly decreased pain and stiffness compared
with a sedentary lifestyle. Women in the tai chi group also reported fewer perceptions of
difficulties in physical functioning. More research is needed in this area. Tai chi may also
aid quality of life in fibromyalgia patients, but additional study is needed to make a
strong recommendation.
Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures.
Avoid during active infections, right after a meal, or when very tired. Some believe that
visualization of energy flow below the waist during menstruation may increase
menstrual bleeding. Straining downwards or holding low postures should be avoided
during pregnancy, and by people with inguinal hernias. Some tai chi practitioners
believe that practicing too long or using too much intention may direct the flow of chi
(qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should
not be used as a substitute for more proven therapies for potentially serious conditions.
Advancing too quickly while studying tai chi may increase the risk of injury.
TENS (transcutaneous electrical nerve stimulation): Preliminary studies of
transcutaneous electrical nerve stimulation (TENS) in patients with rheumatoid
arthritis, fibromyalgia, and temporomandibular joint pain (TMJ) report improvements
in joint function and pain. However, most research is not well designed or reported, and
better studies are needed before a clear conclusion can be reached.
Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion
pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like
neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.
Therapeutic touch: Preliminary research suggests that therapeutic touch (an adaptation
of several healing traditions in which the practitioner holds his/her hands above the
patient's body to detect the patient's energy field and correct any perceived imbalances)
may be an effective treatment option in relieving pain in patients with fibromyalgia.
Further research is needed before a recommendation can be made.
Therapeutic touch is believed to be safe for most people. Therapeutic touch should not
be used for potentially serious conditions in place of more proven therapies. Avoid with
fever or inflammation, and on body areas with cancer.
Fair negative scientific evidence:
Dehydroepiandrosterone (DHEA): Preliminary evidence suggests that DHEA
(dehydroepiandrosterone) may not offer benefit to individuals with rheumatoid
arthritis or fibromyalgia. Further research is needed in this area.
Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or
thyroid disorders or anticoagulants, or drugs, herbs or supplements for diabetes, heart
disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic
procedures with bleeding risk, and do not use immediately after these procedures.
Avoid if pregnant or breastfeeding.
PREVENTION
General: There is currently no known method of prevention for fibromyalgia. Patients
should take their medications exactly as prescribed and visit their healthcare providers
regularly to help prevent complications and ensure that symptoms are properly
managed. Lifestyle modifications may prevent symptoms associated with fibromyalgia.
Examples include dietary restrictions, regular exercise, occupational changes, setting
realistic expectations, getting proper amounts of sleep, and reducing stress levels.
Diet: Although no specific diet has been proven to influence fibromyalgia, food allergies
may be a contributing factor in fibromyalgia development. It may be advisable to
eliminate potential food allergens, including dairy (milk, cheese, and sour cream), eggs,
nuts, shellfish, wheat (gluten), corn, preservatives, and food additives (such as dyes and
fillers). If the individual is allergic to dairy products, calcium supplements are
recommended. Experts recommend avoiding refined foods such as white breads, pastas,
and sugar. Doughnuts, pastries, bread, candy, soft drinks, and foods with high sugar or
caffeine content may all contribute to worsening symptoms of fibromyalgia.
Exercise: Studies have shown that fibromyalgia symptoms may be relieved by aerobic
exercise. Patients should consult with a physician before beginning an exercise program.
A physical therapist may be helpful in deciding exercises that are the most appropriate.
Specific exercises may help restore muscle balance and may reduce pain. Stretching
techniques may also be recommended.
Occupational changes: Fibromyalgia patients may need to work fewer hours or switch to
a less physically demanding or less stressful job in order to manage their disease.
Occupational therapists may make suggestions that may help.
Realistic expectations: It is necessary for fibromyalgia patients to pace themselves and
not try to overdo activities. Stress may trigger symptoms associated with fibromyalgia.
Sleep: Since patients with sleep disorders (i.e., restless legs syndrome, sleep apnea) may
have a higher risk of developing fibromyalgia, patient-specific therapies may be
recommended to improve the quality of sleep. This may include medications (such as
amitriptyline) and/or machines to assist in breathing during the night.
Stress reduction: Since physical or emotional trauma may trigger fibromyalgia, reducing
stress and improving coping skills may also help reduce painful symptoms. Approaches
may include using medications or practicing relaxing activities, such as yoga or
meditation.
AUTHOR INFORMATION
This information has been edited and peer-reviewed by contributors to the Natural
Standard Research Collaboration (www.naturalstandard.com).
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