"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
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
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:
- 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
- strength training, hypnotherapy, bio-feedback, baineotherapy (medicinal bathing), Tai-chi; yoga
- Acupuncture, Chiropractic, Massage Therapy, Ultrasound
- Tender point injections, Flexibility exercises
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:
- Antidepressants: tricyclic compounds (amitriptyline); SNRI's and NSRI's (duloxetine)
- Tramadol, Gabapentin, SSRI's, Gamma hydroxybutyrate
- Growth hormone, SAMe, Dopamine agonists, 5-HTP
- Opioids, corticosteroids, NSAID's, thyroid hormone, benzodiazepine and nonbenzodiazepine hypnotics, guanifenesin
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.