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12 Articles in Volume 12, Issue #5
A-Delta Pain Fiber Nerve Conduction Study Benefits Patients With Spinal Pain
Chronic Pain Management of the Noncompliant Patient
Clinical Applications of Radiofrequency Lesioning for Back and Neck Pain
Current Understanding and Management Of Medication-overuse Headache
Fibromyalgia: An Overview of Etiology and Non-pharmaceutical Treatment Options
June 2012 Pain Research Updates
Junk The Term Narcotics—Call Them Opioids
Managing Adverse Drug Effects in Pain: Focus on Muscle Relaxants
Music Therapy for Pain Management
Perioperative Pain Management in the Opioid-tolerant Elderly Patient: Case Challenge
Practical Tips in the Treatment Of Osteoarthritis of the Knee
Sudden, Unexpected Death in Chronic Pain Patients

Fibromyalgia: An Overview of Etiology and Non-pharmaceutical Treatment Options

Due to the large number of symptoms that can be associated with fibromyalgia, a multimodal approach that treats the “whole” patient will tend to produce the best treatment outcome.

Fibromyalgia is a complex chronic pain disorder that can result in great personal1 and economic burden on the medical system,2 as well as strain on employers.3,4 The prevalence of fibromyalgia has been determined to range from 2% to 5% in the general population,5,6 with women seven times more likely than men to be affected.7 This article reviews the literature and examines the etiology, comorbid symptoms and disorders, and non-pharmacological treatment options for fibromyalgia.

Diagnostic Criteria
The 1990 American College of Rheumatology (ACR) criteria for diagnosing fibromyalgia includes the presence of chronic widespread pain for a minimum of three months and the presence of at least 11 of 17 tender points with a manual tender point assessment.8 Chronic widespread pain is defined as pain above and below the waist, on the left and right side of the body, with at least one point along the axial skeleton. In 2010, the ACR proposed new diagnostic criteria, which eliminate the manual tender point evaluation, assess widespread pain somewhat differently, and include the assessment of additional symptoms of unrefreshed sleep, general fatigue, and cognitive deficits.8,9

Fibromyalgia is associated with a number of other similar syndromes, including chronic fatigue syndrome, irritable bowel syndrome, migraine/tension headache, and temporomandibular joint disorder.10,11 Common symptoms of these related syndromes include pain, fatigue, poor sleep, cognitive deficits, headaches, anxiety, and depression.12 The prevailing theory is that the root etiology of all of these related syndromes, including fibromyalgia, can be attributed to abnormal pain processing in the central nervous system. Within this central sensitization theory, central nervous system neurons become hyperexcitable, and descending inhibitory pathways in the spinal cord become suppressed, resulting in hypersensitivity to both noxious and non-noxious stimuli.13-20

Recent research, employing neuroimaging of fibromyalgia patients, has focused on specific regions of the brain, including the amygdala, the dorsal cingulate, and the nucleus accumbens.21 Using positron emission tomography (PET), studies of fibromyalgia patients have shown reduced binding potential of μ-opioid receptors in these brain regions. Harris et al posit that this finding explains why prescribed opioids are not as effective in fibromyalgia patients for pain management.21 There is also evidence of altered peripheral pain mechanisms,22 hypoactivity of the sympathetic-adrenal system, and hyporeactivity of the hypothalamic-pituitary system23,24 in patients with fibromyalgia.

How Does Fibromyalgia Develop?
The factors that cause the development of fibromyalgia are currently not well understood, but some predictive variables have been identified. Because central sensitization can be produced by physical trauma and/or sustained pain impulses, it has been proposed that fibromyalgia might develop from an acute injury.25-27 An association between whiplash/cervical injury and fibromyalgia has been identified by several researchers.28-30 In fact, one study reported that fibromyalgia was 13 times more frequent following a neck injury in patients than following a lower extremity injury.30

However, a more recent prospective study conducted on patients in automobile accidents showed that there was no association between neck injuries and the occurrence of fibromyalgia.31 These results were confirmed in a 3-year follow-up study.32 However, another study found that patients with regional pain syndromes, such as chronic neck or low back pain, are at risk for developing central sensitization, chronic widespread pain, and fibromyalgia.33 The study reported that 22.6% of patients presenting with neck or back pain had developed chronic widespread pain 5 years later.25

Emotional trauma has also been found to predict the onset of fibromyalgia.34 A recent study in Israel found that 15% of train wreck survivors had developed fibromyalgia, in addition to a number of other psychiatric and physical symptoms, 3 years after the wreck.35 A link between childhood abuse/trauma and the later development of fibromyalgia has also been suggested.36-38 In one study, subjects indicating psychological distress were given manual tender point examinations in conjunction with assessments regarding childhood traumas; those subjects with a greater number of tender points were found to have reported more aversive experiences.39

Finally, other factors including genetic predisposition, infections, neuroendocrine dysfunction, and even vaccinations have been implicated as precipitating factors in the development of fibromyalgia.11,40

Psychosocial Links
It has been well documented that fibromyalgia is associated with increased psychosocial distress and psychiatric disorders, especially depression.41-44 The relationship between psychosocial distress and depression is bi-directional—as both a precipitating factor and a result of fibromyalgia.18

Stress has been suggested as a fibromyalgia symptom mediator. In one sample of fibromyalgia patients, 65% reported stress as a factor associated with their conditions. They demonstrated decreased reactivity to stress via the adrenal glands and the sympathetic nervous system, suggesting that fibromyalgia may be associated with a faulty stress-response system.24

Gracely et al investigated catastrophizing (ie, characterizations of pain as awful, horrible, and unbearable) in fibromyalgia patients.45 By using functional magnetic resonance imaging technology, patients with fibromyalgia reported elevated levels of catastrophizing and showed increased activation in multiple brain areas tied to the expectation of pain, concentration on pain, and the emotional facets associated with pain. Catastrophizing was seen to amplify the sensitivity to pain as a result of a heightened anticipation along with increased awareness of the pain source.

The Role of Sleep Disturbance
Fibromyalgia is highly associated with poor sleep quality and non-refreshing sleep. More than 75% of fibromyalgia subjects report disturbed sleep.46 A decrease in nighttime melatonin production and abnormalities in circadian rhythm of hormonal profiles and cytokines has been found in fibromyalgia subjects.47 Polysomnographic studies have confirmed that, compared to controls, fibromyalgia patients demonstrate more periodic limb movements and more superficial sleep, at the expense of deep sleep.48

Sleep deficits have been suggested not only as a symptom of fibromyalgia, but also as a possible causal factor in the development of fibromyalgia.49 In one study, healthy subjects who were subjected to disturbed sleep over consecutive nights in a sleep laboratory developed fibromyalgia symptoms, including multiple tender points.50 A separate longitudinal study found that sleep disturbance in a population of women without fibromyalgia predicted the development of fibromyalgia 10 years later.51 The authors reported a dose-dependent association between sleep problems and risk of fibromyalgia (P for trend<0.001), with an adjusted relative risk of 3.43 (95% confidence interval 2.26-5.19) among women who reported having sleep problems often or always, compared to women who never experienced sleep problems.

Non-pharmaceutical Treatments
Exercise and Physical Therapies
A variety of physical activities have been shown to improve fibromyalgia symptoms, such as walking, swimming, dance, and strength training.52 Patients with fibromyalgia may be reluctant to engage in physical activity due to the fear that pain may be exacerbated.53 Indeed, some increase in pain is expected upon the commencement of physical activity due to physical deconditioning. If a patient can overcome these fears, however, exercise has been shown to provide benefits to individuals with fibromyalgia. A recent meta-analysis of 33 studies on community-based exercise determined that exercise can result in improved pain and physical functioning for adults with rheumatic diseases, including fibromyalgia.54 A separate meta-analysis of five randomized controlled trials (RCTs), focusing specifically on fibromyalgia, found that exercise (including aerobic, strength training, or both) can result in a significantly improved sense of global well being.55 A meta-analysis by another group found that aerobic exercise resulted in positive effects on global well being and physical function; effects on pain and number of tender points was less conclusive.56 In this same review, muscle strengthening exercises were also found to be an important component of fibromyalgia treatment, but additional research is recommended.

Cognitive Behavioral Therapies (CBTs)
As an example of CBT, Turk and Sherman53 offered an extensive CBT program for individuals with fibromyalgia that included educating individuals about their condition; helping individuals accept the fact that they suffer from a chronic condition; helping individuals focus on improving their condition rather than curing it; helping patients set realistic goals; teaching patients self-management skills such as relaxation, imagery, and physical activity; and helping patients decrease the effects of the cognitive dysfunction, maladaptive thoughts, and stress associated with fibromyalgia.

Results of studies examining the effectiveness of CBT have been mixed. For example, a recent meta-analysis of 14 trials concluded that CBT was effective for reducing depression (P=0.004) and increasing pain coping skills (P=0.006), but was generally not effective for improving pain, fatigue, and sleep.57 An 18-hour psychoeducational intervention (over 2 months), including educational classes and autogenic relaxation training, resulted in improvements in physical impairment, fatigue, anxiety, and depression compared to a control group.58 In studying adolescents (ages 11-18 years) with juvenile fibromyalgia, both educational classes and CBT treatment resulted in reduced depression and functional disability, but CBT was significantly superior to education for reducing functional disability.59 In comparing CBT with patient education only, within an in-patient rehabilitation program, both groups showed positive effects on pain coping and self-reported health outcomes, but the CBT group showed significantly more improvement than the education-only group.60 Fibromyalgia patients with relatively high levels of psychological distress seem to get the most benefit from CBT.60

Complementary and Alternative Medicine (CAM) Treatments
A variety of CAM treatments have also been studied for the treatment of fibromyalgia. Although some positive results have been identified, there are few replicated studies, and the methodological quality of many of these studies has been relatively low.61,62 Even so, many CAM treatments have shown promise. For example, compared to a waitlist standard of care group, an 8-week yoga treatment group (which included gentle poses, breathing, meditation, education, and group discussion) demonstrated significantly greater improvements in pain, fatigue, mood, pain catastrophizing, and physical functioning than a waitlist standard care control group.63

A number of studies have examined the effectiveness of biofeedback training. An RCT evaluating surface electromyographic (SEMG) biofeedback compared with sham biofeedback found significant improvements in pain and number of tender points with SEMG. After using biofeedback, the mean visual analog scores and the mean number of tender points were found to be 3 out of 10 and 6 out of 18, respectively.64 A non-randomized pilot study of heart rate variability biofeedback (involving breathing training to increase variability in heart rate parameters) was found to be effective for reducing pain and depression.65 Fibromyalgia patients receiving neurofeedback training (electroencephalographic biofeedback) demonstrated significantly more improvement in measures of pain, fatigue, depression, and anxiety than a “treatment as usual” group (P<0.05).66 A separate study found that neurofeedback treatment subjects showed significant improvements in pain, fatigue, and visual attention when compared to a standard medical care control group.67

Relaxation techniques and Chinese/eastern medicine also have been studied. A review of 15 studies on mindfulness-based meditation for the treatment of a variety of chronic diseases concluded that this technique produced positive results in general, including improved coping, quality of life, and overall well being.68 Despite methodological problems (such as variability of forms and intensity), tai chi has been associated with significant clinical improvements with a variety of pain syndromes, including fibromyalgia.69 In a recent study, a tai chi group demonstrated greater self-reported improvements in function and quality of life compared to a wellness education and stretching control group.70Compared to a pharmacological treatment–only group, both a CBT group and a CBT with hypnosis group demonstrated better outcomes (including pain, psychological distress, and sleep); the addition of hypnosis enhanced the effectiveness of CBT, the authors found.71 A recent meta-analysis of 25 trials studying traditional Chinese medicine determined that acupuncture can result in reduced pain and number of tender points.72 A separate meta-analysis of seven acupuncture trials found significant effects for pain reduction, but the study concluded that the results were not clearly distinguishable from bias.73 A somewhat older meta-analysis of five acupuncture trials determined that there is some evidence for temporary positive effects but, in general, they concluded that acupuncture alone cannot be recommended for treatment of fibromyalgia.74

Multidisciplinary Approach Is Key
In multidisciplinary and interdisciplinary treatments, a combination of treatment approaches—usually combining physical therapies, education, counseling, and CBT strategies—are used in concert and most often evoke maximal improvement in a patient’s physical and psychosocial functioning. In one study, a 4-week interdisciplinary treatment program resulted in significant improvement in pain severity, fatigue, and depression for fibromyalgia patients.75 Bailey, Starr, Alderson, and Moreland found that a multidisciplinary program, which incorporated exercise, education, and one session of counseling, significantly improved impairment levels.76 Similarly, Wennemer et al found that an 8-week functional rehabilitation program, including educational sessions, exercise, and stress management training, improved physical functioning in a group of fibromyalgia patients.77 Also, such multidisciplinary treatment programs have demonstrated improvement in fibromyalgia symptoms for up to 1 year post-treatment.78

A recent meta-analysis of nine trials found that multi-component treatments resulted in significant improvements in pain, fatigue, depressive symptoms, physical fitness, and self-efficacy.79 A study comparing multidisciplinary treatments with and without a CBT education component (stress coping and lifestyle change) found that the addition of CBT had a significant impact on treatment outcomes (up to a 6-month follow-up), especially on patients with more fatigue.80Although fibromyalgia patients do tend to show gains in both physical and emotional well being with multidisciplinary treatments, there is evidence that treatment outcomes are poorer for this population compared with chronic pain patients without fibromyalgia.81

Summary
Over the past decade, a great deal of research has been dedicated to understanding fibromyalgia and how best to treat this disorder. Because fibromyalgia is a syndrome and a chronic condition, treatment must focus on management of these symptoms and not on “curing” the disease. Due to the large number of symptoms that may be associated with an individual fibromyalgia patient, and the physical deconditioning, emotional burden, and the effect on daily function that it can cause, it is clear that a multimodal approach—one that treats the “whole person” and targets a wide range of potential symptoms—will tend to produce the best treatment outcome. Based on the evidence of the clinical research shown to date, multidisciplinary treatment approaches are recommended by many experts on fibromyalgia.16,17,82-85

Treatment efficacy might also be enhanced by offering tailored treatment approaches at an early stage to patients who are at risk of developing chronic physical and psychological impairments.60 Because of the high prevalence of depression, and because poorer multimodal rehabilitation treatment outcomes are associated with comorbid depression in fibromyalgia patients,86 such patients should be evaluated for major depressive disorder, and treated accordingly with pharmaceutical and/or behavioral/psychosocial strategies.

Finally, because of the high incidence of sleep disturbance in this population, and because of the relationship between sleep disturbance and both the development and maintenance of fibromyalgia, insomnia should be evaluated and treated with available therapeutic strategies.

Last updated on: December 15, 2014
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