Fibromyalgia Symposium Part III: Optimal Management of Fibromyalgia

It takes a village to raise a child and it takes a team to manage fibromyalgia: primary care providers, rheumatologists, pain specialists, rehab specialists, neurologists, psychologists, social workers and more. In Part III of the symposium Dr. Natalie Boileau spoke about non-pharmacologic treatments and Dr. Goldenberg followed up with an overview of medications for fibromyalgia.

"Medications alone are not enough in this situation."
~ Dr. Don Goldenberg

Dr. Boileau answers questions after the symposium

The Four Step Method to Manage FM:

1) Exercise - this is key!
2) CBT (Cognitive Behavioral Therapy) - psychotherapy that emphasizes the importance of thinking in how we feel
3) Education
4) Medication

General FM Management: avoid excessive invasive testing; regular psychosocial support; focus on the positive; education; partake in pleasurable activities; focus on activity rather than pain; regular exercise; healthy lifestyle; take control; supportive family; set realistic goals; pace yourself; improve sleep

Non-Pharmacologic Management of Fibromyalgia: Dr. Nathalie Boileau, MD
Rheumatologist

 Dr. Boileau presented an interesting slide that outlined non-pharmacologic FM treatments with strong, moderate and weak evidence of their efficacy. That is not to say that the "weak" treatments don't work, rather there is no compelling evidence to prove that they're effective.

Non-pharmacologic FM Strategies:
 
Strong evidence:

• Exercise: increased blood flow to brain improves cognitive abilities, lessens pain, improves sleep and mood
• Cognitive Behavior Therapy: improves pain, fatigue, and mood which can be sustained for several months
• Patient Education/self management: improves pain, fatigue, and quality of life

Modest Evidence:

• strength training, hypnotherapy, bio-feedback, baineotherapy (medicinal bathing), Tai-chi; yoga

Weak Evidence:

• Acupuncture, Chiropractic, Massage Therapy, Ultrasound

No Evidence:

•  Tender point injections, Flexibility exercises

Exercise: The Cochrane Review looked at 20 of 34 random control trials where patients exercised two times a week for twenty minutes in aerobics, strength training and flexibility. Aerobic exercise improved the pain threshold, well-being and physical function. Strength training worked but not as well as aerobic exercise. Dr. Boileau warned that pain intensity goes up when first starting to exercise but then goes down as conditioning improves.

Vicious Cycle: The pain cycle is induced by lack of exercise! First there is pain in the muscle or in other words a muscle spasm, which decreases blood flow and increases lactic acid. The lactic acid is a signal to the brain to increase the muscle contraction which then in turn increases the pain. Exercise increases the blood flow which washes out the lactic acid and breaks the cycle.

One problem with FM patients is the high drop out rate due to fatigue and pain. High intensity exercise creates a high drop out rate so moderate exercise, 55-75% maximum heart rate or MHR, two to four times a week is recommended for FM. To calculate MHR, subtract one's age from 220. Start slowly and gradually increase exercises such as walking, biking or water aerobics. I do water aerobics two to three times a week and it is a life saver!!!!

Yoga and tai chi are also excellent choices. The study showcased in the news about tai chi and FM patients at Tufts University was a study of Dr. Goldenberg's group.The participants were divided into two groups: one group took a one hour tai chi class once a week for 12 weeks and the second group had wellness education and stretching. The tai chi group improved more in overall function and other FM symptoms than the other group.

Cognitive Behavioral Therapy: counseling educates patients about coping strategies for pain and mood disturbances and reduces depression. It teaches patients about realistic goal setting, relaxation techniques, and re-framing thoughts in a positive manner.

Promising New Tool: Neurostimulation An electrical current is sent to the brain's pain centers which results in pain reduction in FM with very few side effects. But more research is needed.

Complimentary medicine, such as acupuncture and chiropractic, as well as supplements  have little evidence to support their benefit. Dr. Boileau suggested trying them to see if they bring relief. If it's not helping within a month, stop the therapy/supplement.

Overview of Fibromyalgia Management : Dr. Don Goldenberg, MD
Chief of Rheumatology, Newton-Wellesley Hospital 

Pharmacological FM Therapies:
 
Strong evidence:

• Antidepressants: tricyclic compounds (amitriptyline); SNRI's and NSRI's (duloxetine)
• Pregabalin

Modest Evidence:

• Tramadol, Gabapentin, SSRI's, Gamma hydroxybutyrate

Weak Evidence:

• Growth hormone, SAMe, Dopamine agonists, 5-HTP

No Evidence:

•  Opioids, corticosteroids, NSAID's, thyroid hormone, benzodiazepine and nonbenzodiazepine hypnotics, guanifenesin

Recommended: While not a cure, medications have shown to reduce pain from an eight to a four on a scale of 1-10. There is no strong evidence that SSRI's alone are helpful. Dr. Goldenberg recommended a combination of 20 mg of Prozac in the morning and 20 mg of Elavil at night, which is much better than either one alone. SNRI's, such as Cymbalta or Savella, are combination drugs that hit both serotonin and norepinephrine and help with pain and fatigue reduction, not just depression. However, they are equally important in FM patients with and without depression. Pregbalin, such as Lyrica, is an anti-sesuire medication but also helps with pain by affecting the nerve endings. These drugs are difficult to use because of side effects such as headaches, nausea, weight gain, edema and dizziness. Start slowly with a low dose and adjust as needed. Patients need to be patient in order to tolerate them.

Not Recommended: Anti-inflammatory drugs, like Advil, don't really work, but may take the edge off. Opioids can heighten pain and were not recommended. In 2008, most people were taking NSAID's, antidepressants and opioids to treat FM although there is no evidence that NSAID's or opioids actually work.

Typical outcomes in FM patients: Outcomes vary and often overlap with other conditions such as lupus, sleep apnea and chronic fatigue. 10-15% are disabled, most have some impingement on work and leisure and some FM clears up completely.

The Future of FM: increase knowledge; early diagnosis; unite multiple constituencies, such as patients, clinicians and administration; bridge specialties such as rheumatology, neurology and pain management; better understanding of pain pathways.