Fibromyalgia

Chronic pain is defined as pain that lasts longer than 3 months. That’s the main symptom of Fibromyalgia: widespread muscle pain that lasts longer than 3 months. Widespread pain is defined as pain both above and below the waist and on both the right and left sides of the body.

Some Fibromyalgia sufferers describe their pain as “all over” or “everywhere.” For some people, the pain and stiffness are worst when they wake up. Then it improves during the day. Symptoms may increase again at night. But other people have all-day, nonstop pain. This could include combinations of neck pain, arm pain, shoulder pain, back pain, hip pain, knee pain, feet pain, and pain in just about every other body part.

These tips from the National Fibromyalgia Association may help you get started.

  • Start slow. If you’re moving more today than yesterday, that’s progress
  • Listen closely to your body. It’s important not to overdo it. Don’t increase your activity too quickly
  • Start with just a few minutes of gentle exercise a day. Then work your way up
  • Walking is a great form of exercise
  • Stretch your muscles before and after exercise
  • Track your progress. Note the exercise you’re doing and how you feel both during and afterward
  • Post-exercise soreness will decrease over time. But respond to your body’s signals and pace yourself
  • Sleep

If you find that you are sleeping poorly, you’re not alone. With Fibro, pain and poor sleep happen in a circle. Each worsens the other. Fortunately, there is a lot you can do to help yourself sleep better. The National Fibromyalgia Association, the National Pain Foundation, the National Sleep Foundation, and other expert organizations recommend the following steps to help people sleep:

Stick to a sleep schedule. If you go to bed at the same time every night, your body will get used to falling asleep at that time. So choose a time and stay with it, even on weekends

Keep it cool. When a room is too warm, people wake up more often and sleep less deeply. According to the National Sleep Foundation, studies show that you’re likely to sleep better in a room that’s on the cool side. So try turning down the thermostat and/or keeping a fan on hand

As evening approaches, cut out the caffeine. Caffeine has a wake-up effect that lasts. It’s best to avoid it well before bedtime. That includes not just coffee, but also tea, colas, and/or chocolate

Avoid alcohol before bed. That “nightcap” may make you sleepy at first. But as your blood alcohol levels drop, it has the opposite effect. You may find yourself wide awake

Exercise in the afternoon. Afternoon exercise may help you sleep more deeply. But exercising before bedtime can make it harder to fall asleep

Nap if you need to, but be brief. If you’re so tired that you must take a nap, set the alarm for 20 minutes. Snooze any longer and you may have trouble falling asleep at night · Make your room a relaxing refuge. Treat yourself to comfortable bedclothes and snugly pajamas. A white-noise machine or fan may help you fall asleep to a soothing background sound

Develop a relaxing bedtime routine. Reading helps some people fall asleep. So does listening to soft music. Do whatever works for you. But try to follow the same routine every night to signal your body that it’s time for sleep

Fibromyalgia Diet

So what about your diet? There’s a lot of information on the Internet about “Fibromyalgia diets.” But many researchers say there is no perfect eating plan for Fibromyalgia relief. Talk to your doctor about what is right for your needs and your lifestyle. Let your doctor know if you have eliminated any foods from your diet. Also, be sure to tell your doctor if you are taking any nutritional supplements. They can possibly interact with any medications you may be taking.

Symptoms

  • Pain
  • Anxiety
  • Concentration and memory problems — known as “fibro fog”
  • Depression
  • Fatigue
  • Headaches
  • Irritable bowel syndrome
  • Morning stiffness
  • Painful menstrual cramps
  • Sleep problems
  • Tender points
  • Urinary symptoms, such as pain or frequency
  • Numbness, and tingling in hands, arms, feet, and leg

A healthy and active lifestyle may help you decrease your Fibromyalgia symptoms. Studies show that second to medication, the actions most likely to help are light aerobic exercises (such as walking or water exercise to get your heart rate up). But always check with your doctor before you start any exercise program.

Resources

Resources

  • Arnold LM (2006). “Biology and therapy of fibromyalgia. New therapies in fibromyalgia”. Arthritis Res Ther. 8 (4): 212. doi:10.1186/ar1971. PMC 1779399. PMID 16762044.
  • Holman AJ, Myers RR (August 2005). “A randomized, double-blind, placebo-controlled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications”. Arthritis & Rheumatism 52 (8): 2495–505. doi:10.1002/art.21191. PMID 16052595.
  • Jaschko G, Hepp U, Berkhoff M et al. (September 2007). “Serum serotonin levels are not useful in diagnosing fibromyalgia”. Ann Rheum Dis. 66 (9): 1267–8. doi:10.1136/ard.2006.058842. PMC 1955138. PMID 17693607.
  • Russell IJ, Michalek JE, Vipraio GA, Fletcher EM, Javors MA, Bowden CA (January 1992). “Platelet 3H-imipramine uptake receptor density and serum serotonin levels in patients with fibromyalgia/fibrositis syndrome”. Journal of Rheumatology (J Rheumatol.) 19 (1): 104–9. PMID 1313504.
  • Russell IJ, Vaeroy H, Javors M, Nyberg F (May 1992). “Cerebrospinal fluid biogenic amine metabolites in fibromyalgia/fibrositis syndrome and rheumatoid arthritis”. Arthritis Rheum. 35 (5): 550–6. doi:10.1002/art.1780350509. PMID 1374252.

Treatments

As with many other medically unexplained syndromes, there is no universally accepted treatment or cure for fibromyalgia, and treatment typically consists of symptom management. Developments in the understanding of the pathophysiology of the disorder have led to improvements in treatment, which include prescription medication, behavioral intervention, exercise, and alternative and complementary medicine. Indeed, integrated treatment plans that incorporate medication, patient education, aerobic exercise and cognitive-behavioral therapy have been shown to be effective in alleviating pain and other fibromyalgia-related symptoms.  In 2005, the American Pain Society produced comprehensive guidelines for patient evaluation and management. More recently, the European League Against Rheumatism (EULAR) issued updated treatment guidelines.

A meta-analysis of 1,119 subjects found “strong evidence that multicomponent treatment has beneficial short-term effects on key symptoms of FMS.” A 2010 systematic review of 14 studies reported that CBT improves self-efficacy or coping with pain and reduces the number of physician visits at post-treatment, but has no significant effect on pain, fatigue, sleep or health related quality of life at post-treatment or follow-up. Depressed mood was also improved but this could not be distinguished from some risks of bias. A multidisciplinary approach, often including CBT is sometimes considered to be the “gold standard” of treatment for chronic pain syndromes such as fibromyalgia.

  • Cognitive behavioral therapy (CBT) and related psychological/behavioral therapies are treatments which have been shown to be have a small to moderate effect in reducing symptoms of fibromyalgia in randomized controlled trials.  The greatest benefit occurs when CBT is used along with exercise.

There are three medications that have been approved by the FDA for treatment of fibromyalgia.

  • Pregabalin was approved in June 2007, duloxetine was approved in June 2008, and milnacipran was approved in January 2009. Pregabalin and duloxetine have been shown to reduce pain in a substantial number of patients with fibromyalgia, but there were others who did not benefit. Placebo-controlled trials involving a total of over 2000 patients have shown milnacipran to be significantly more effective than placebo in treating both pain and the broader syndrome of fibromyalgia. The use of NSAIDs is not recommended as first line therapy. It can take up to three months to derive benefit from the antidepressant amitriptyline and up to six months to gain maximal response from duloxetine, milnacipran, and pregabalin. Some medications have the potential to cause withdrawal symptoms when stopping so gradual discontinuation may be warranted particularly for antidepressants and pregabalin.
  • Antidepressants are “associated with improvements in pain, depression, fatigue, sleep disturbances, and health-related quality of life in patients with FMS.” The goal of antidepressants in fibromyalgia should be symptom reduction and if used long term, their effects should be evaluated against side effects. The SNRIs duloxetine and milnacipran as well as the selective and reversible MAOI drug moclobemide have proven effective against fibromyalgia syndrome with the tricyclic antidepressants particularly amitriptyline and nortriptyline possibly being the most effective against pain, fatigue, and sleep problems, but tricyclic antidepressants may have more side effects due to interaction with adrenergic, cholinergic or histaminergic receptors, and sodium ion channels. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have lower side effects.
  • The anti-convulsant drugs gabapentin (Neurontin) and pregabalin (Lyrica) have been tested in fibromyalgia. Gabapentin is approved for use in treatment of neuropathic pain but not in fibromyalgia. Pregabalin – originally labeled for the treatment of nerve pain suffered by diabetics – has been cleared by the US Food and Drug Administration for the treatment of fibromyalgia. A randomized controlled trial of pregabalin at a dose of 450 mg/day found that 6 patients is the number needed to treat (NNT) for one patient to have a 50% reduction in fibromyalgia-related pain. A Cochrane Database analysis of pregabalin use in chronic pain concluded that “A minority of patients will have substantial benefit with pregabalin, and more will have moderate benefit. Many will have no or trivial benefit, or will discontinue because of adverse events.” A meta-analysis of four trials of pregabalin in fibromyalgia found that, for patients who did respond to pregabalin, there was a reduction in their time off work of greater than 1 day per week.
  • Due to the limited data supporting the use of tramadol in fibromyalgia and the absence of any data supporting the use of other weak opioids, the Association of the Scientific Medical Societies in Germany makes no recommendation against or in favor of their use, but strongly advises against using strong opioids; the European League Against Rheumatism, based mainly on expert opinion (due to the insufficient data) recommends tramadol but not strong opioids; and the Canadian Pain Society says that opioids, starting with a weak opioid like tramadol, can be tried but only for patients with otherwise intractable moderate to severe pain, and that strong opioids are discouraged, only to be used by patients who show ongoing improved pain and function. Healthcare providers must monitor patients on opioids for ongoing effectiveness, side effects and possible unwanted drug behaviours. The combination of tramadol and paracetemol has demonstrated efficacy, safety and tolerability for up to two years in the management of other pain conditions without the development of tolerance. It is as effective as codeine plus paracetamol but produces less sleepiness and constipation.
  • The narcolepsy medication sodium oxybate has been studied in those with fibromyalgia, with moderate improvement in sleep, fatigue and pain symptoms. However, this medication was not approved by the FDA for the indication for use in fibromyalgia patients due to the concern for abuse.
  • The muscle relaxants cyclobenzaprine and tizanidine are sometimes used off-label to treat fibromyalgia. A small clinical trial of very low doses of cyclobenzaprine taken at bedtime demonstrated improved musculoskeletal pain, fatigue, tenderness and depression in FM patients.
  • Dopamine agonists (e.g. pramipexole (Mirapex) and ropinirole (ReQuip)) resulted in some improvement in a minority of patients, but numerous side effects, including the onset of impulse control disorders like compulsive gambling and shopping, have led to concern about this approach.
  • Evidence exists that fibromyalgia is a neuro-immuno-endocrine disorder. Elevations in substance P, IL-6 and IL-8 as well as corticotropin-releasing hormone have been found in the cerebral spinal fluid of fibromyalgia suffering individuals. Increased numbers of mast cell numbers have been found in skin biopsies of some individuals with fibromyalgia. Quercetin, a pharmacologically active natural product which possesses anti-inflammatory in addition to mast cell inhibiting properties may be a useful treatment.[126]
  • Exercise improves fitness and sleep and may reduce pain and fatigue in some people with fibromyalgia.  In particular, there is strong evidence that cardiovascular exercise is effective for some patients. Long-term aquatic-based exercise has been proven beneficial as it combines cardiovascular exercise with resistance training. However, due to the cold sensitivities of people with fibromyalgia syndrome, aquatic therapy must take place in a warm pool. Not only that, but the air temperature outside of the pool must also be heated to prevent fibromyalgia patients from getting chills and aches when out of the water. This involves a specialized pool facility, which makes this therapy more expensive and less accessible than regular swimming exercise.

 

Sue Ingebretson

Rebuilding Wellness

http://rebuildingwellness.com/blog/

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