WHAT TREATMENT SEEMS MOST EFFECTIVE IN TREATMENT OF FIBROMYALGIA
Because examination of a particular method is included in this review it should not be taken as a recommendation for its use this discussion is an exercise in reporting what is being claimed in what appear to be responsible publications, by a wide range of therapists and practitioners, however there is no absolute ‘quality control’ or ability to adequately compare the accuracy of the reports on which these discussions are based.
Cardiovascular exercise is stated to be helpful in rehabilitation from Fibromyalgia.
The guidelines most commonly given involve the patient performing active aerobic exercise three times weekly (some say four times) for at least 20 (some say 15) minutes during which time they are required to achieve between 60 and 85% of their maximum predicted heart rate. The methods of exercise best suited to Fibromyalgia patients are said to be cycling (static cycle) walking or swimming.
Appropriate warm-up and warm-down periods are suggested and a slow incremental program is needed to reach the prescribed length and frequency of exercising. The release of hormone-like substances (endogenous endorphins) during aerobic exercise is thought to offer the means whereby pain relief and well-being are enhanced, along with the obvious increased self-esteem and psychological boost which comes with increased fitness.
A study involving 34 patients with Fibromyalgia had some of the patients perform aerobic exercise (cycle exercise which was designed to achieve a heart rate of 150 per minute) or flexibility exercises (achieving no more than 115 beats per minute) three times a week for 20 weeks. At the end of this period those patients doing the aerobic routines achieved far greater reduction in pain than the flexibility group.
People with CFS(ME) may be unable to do any exercise at all in some stages of their illness.
See the discussion below on cognitive/behavioral treatment in which tasks and routines (which have been agreed and negotiated between the CFS patient and the therapist) are performed daily with slight increments over time, whatever the patient feels (and whether they are having a good day or a bad day) always staying without strain.
Acupuncture in general and electroacupuncture in particular has an excellent track record in treatment of pain.
One of the leading experts in use of acupuncture in pain relief is Dr.P.Baldry after asserting categorically that acupuncture is certainly the treatment of choice for dealing with Myofascial Pain Syndrome or trigger point problems states:
” The pain in Fibromyalgia, which would seem to be due to some as yet unidentified noxious substance in the circulation giving rise to neural hyperactivity at tender points and trigger points takes a protracted course and it is only possible by means of acupuncture to suppress this neural hyperactivity for short periods”.
As is clear there are other ways, however if acupuncture is used for Fibromyalgia Baldry believes that it is necessary to repeat treatment every 2 to 3 weeks for months or even years, which he regards as unsatisfactory, “but nevertheless some patients insist that it improves the quality of their lives”.
Relief from pain for weeks on end and an enhanced quality of life would seem quite a desirable objective, perhaps helping ease the pain burden while more fundamental approaches are dealing with constitutional and causative issues.
A Swiss research team in Geneva has examined the effectiveness of electro-acupuncture in treating Fibromyalgia. 70 patients (54 women) who all met the American College of Rheumatology criteria for Fibromyalgia received either sham acupuncture (‘wrong’ points used) or the real thing. Various methods were used for patients to record their level of symptom activity and the amount of medication they used before and after treatment. Sleep quality, morning stiffness and pain were all monitored.
Over a three week period the electroacupuncture treatment was administered with only the doctor giving the treatment knowing whether or not the needles were being placed correctly and whether the amount and type of electrical current being passed through the needles was correct.
Seven out of the eight measurements showed that only the acupuncture group and not the placebo (dummy acupuncture) group had benefits (as in all such studies a few minor improvements are always noted in the dummy or placebo group, but these were only slight).
The acupuncture group, after treatment, required far more pressure on tender points to produce pain while use of pain killing medication was virtually halved as was these patient’s assessment of regional pain levels. There was also a significant increase in quality of sleep. The length of time morning stiffness was experienced only improved a small amount.
Around 25% of the treated group did not improve significantly while all the others showed a remarkable amount of improvement with some having almost complete relief of all symptoms.
The duration of the improvement was noted to be ‘several weeks’ in most patients which seems to be in line with Dr.Baldry’s observation of it being necessary to repeat treatment every few weeks.
The fact that there are virtually no side effects from electroacupuncture make it attractive when compared with pain killing and/or antidepressant medication.
Dry Needling and Injection into Trigger Points
There have been few clinical trials involving bodywork in treating Fibromyalgia however there is abundant evidence of the successful use of various methods for treating trigger points including injection of saline of procaine or even of simply ‘dry needling’ the trigger points. In one study 46% of those people with MPS treated found that this approach offered them the longest lasting relief of symptoms compared with other forms of treatment they had received. 69% required less medication for some time afterwards.
There is a mass of anecdotal reporting of benefit from use of chiropractic in treatment of Fibromyalgia and CFS(ME). Few clinical studies support these claims but since the manipulative methodology of osteopathy and chiropractic have become ever closer, and since the methods of osteopathy which focus on muscles notably Strain Counterstrain and Muscle Energy Technique are now widely used by massage therapists, and since there are indeed clinical studies involving osteopathic manipulative therapy (OMT) and massage, see below, it is safe to assume that the anecdotal claims are accurate. Those forms of chiropractic which focus on muscles, such as Morter Bio Energetic Synchronisation Technique (BEST) are more likely to be helpful in Fibromyalgia cases than the more active adjustment methods although these do have their place when joint restrictions are a feature.
It is generally agreed that the difference between CFS(ME) and Fibromyalgia are marginal at best and that many, probably most, patients in each category could just as easily be diagnosed as having the other condition/diagnosis.
One model of these conditions suggests that whatever the trigger (trauma, viral infection, toxicity etc) there need also to be perpetuating factors such as emotional stress, inadequate rest patterns, concurrent depression etc. The treatment approach suggested would tackle the behavioral and cognitive aspects, using agreed (between therapist and patient) targets for changing the behavior pattern which has become established by the illness.
Careful planning and preparation are required with a lot of attention to engaging the patient in the process of recovery. The patient is not led to believe that this is all there is to treatment but is encouraged to see that while underlying factors (viral or yeast infection etc) are being dealt with the perpetuating factors can begin to be modified. A gradual increase in activity is the aim with equally gradual reduction in rest periods and time. The key to success is not to do too much too soon, staying within what is a manageable level for the patient. A structured schedule evolves via negotiation and discussion over 20 to 30 sessions. The same degree of activity is suggested on good and bad days, with perhaps no increase in activity initially but a structured pattern emerging. Very gradually activity increases and responsibility for what happens is transferred fully to the patient. Does it work? Some claim it does but it takes dedication on everyone’s part.
There have been no clinical trials involving herbal treatment of Fibromyalgia however at least one very well researched herb is being used clinically to help circulation to the brain: Ginko biloba (see above).
In addition leading herbalists are on record as claiming benefits from an approach which tries to ‘support the nervous system with herbal nerve tonics and adaptogens’ (substances which help the body cope with stress). Additionally herbal methods try to help the defense mechanisms by using known immune system enhancers such as echinacea, astragalus and ginseng. Various nervine herbs would also be included in a combination aimed at helping normalize sleep disturbances.
A herbal combination formula is suggested which consists of:
• 2 parts Panax quinquefolium (American Ginseng)
• 2 parts Astragalus mongolicus
• 2 parts Angelica sinensis (Dong quai)
• 1 part Ginko biloba
• 1 part Cimicifuga racemosa (Black cohosh)
• 1/2 part passiflora incarnata (Passion flower)
• 1/2 part Betonica officinalis (Wood betony)
• 1/2 part Matricaria chamomila (Chamomile)
• 1/2 part Zizyphus sativa (Jujube red dates)
This formulation is claimed to be a tonic which will support people with chronic weakness, anxiety, headaches, sleep disturbances and general fatigue as well as diminished blood flow to the extremities. The person who needs this will probably have a weak pulse, weak digestive system, have headaches and will be fatigued. A dose of between half and one teaspoon (infusion) two or three times daily taken between meals is suggested.
Several studies have looked at the effects of a specific homoeopathic remedy Rhus Tox in treating Fibromyalgia and ‘fibrositis’ with varying results.
Although treatment of painful rheumatic conditions by homeopathy often involves the use of Rhus tox it is therefore not suitable for all people with such conditions, but only those with the profile of the medicine.
The ideal person for using Rhus tox is :
Restless, continually changing position, having a great deal of apprehension especially at night and finds it difficult to stay in bed. The head will feel heavy, and the jaws may be noisy, creaking, with TMJ pain.
The tongue tends to be coated except for a red triangular area near the tip and there is a frequently bitter taste in the mouth and a desire for milky drinks. There is often a drowsy feeling after eating.
There may be a nagging dry cough and a sense of palpitation most noticeable when sitting still. The back tends be stiff and normally feels better for moving about; limbs are stiff and any exposure to cold makes the skin feel sensitive or painful.
Cold, wet weather makes symptoms worse as does sleep and resting. What helps most as far as symptoms are concerned is warm, dry weather, movement, rubbing the uncomfortable areas, warm applications and stretching. The remedy is Rhus tox in the 6C potency.
Trials – In Britain a study found that using the 6C dilution of Rhus Tox was effective in moderating the symptoms of patients with Fibromyalgia whereas a trial in the Australia, involving just three patients who fitted all the criteria including the profile for Rhus tox, there was no benefit when a 6X dilution was used.
The difference between 6X and 6C may seem unimportant, but the dilution difference if enormous.
With one study using Rhus tox 6C and claiming marked benefits for Fibromyalgia patients and one using Rhus tox 6X showing no benefit, the jury is still out. However since there is absolutely no chance of side effects with homeopathy there is little to be lost in trying, but try the 6C first.
In controlled trials it has been found that hypnotherapy helps more than physical therapy in those patients who do not seem to respond well to most other forms of treatment. Pain is reduced, fatigue and stiffness on waking is improved and general feeling of wellbeing better.
The most widespread treatment approach to Fibromyalgia involves the use of various pharmacological agents and it is useful to evaluate the results of studies as to their efficacy. Tricyclic antidepressant medications increases the amount of serotonin in the central nervous system and increases the delta-wave sleep stage and is found to consistently improve the symptoms of Fibromyalgia, though not by acting as an anti-depressant and not in all patients treated.
Studies involving various forms of antidepressant medication tend to support use of Amitripyline (25 to 50mg daily) with pain scores, stiffness, sleep and fatigue all improving on average but by no means in all patients.
In one study 77% of Fibromyalgia patients receiving Amitripyline reported general improvement after 5 weeks as against only 43% of those receiving placebo medication. Side effects from the antidepressant were however measurable with a selection of drowsiness, confusion, seizure, agitation, nightmares, blurred vision, hallucinations, uneven heartbeat, gastrointestinal upsets, low blood pressure, constipation, urinary retention, impotence and mouth dryness all being observed or reported.
When combined with osteopathic manipulative methods (mainly soft tissue techniques – see below) anti-depressant medication offered greater relief.
A study involving the use of systemic corticosteroids (prednisone 15mg daily) showed that there were no measurable improvements, and since side effects with such medication is usual this approach is clearly not desirable. Indeed if it were to produce an improvement it would be sensible to question whether Fibromyalgia was indeed the correct diagnosis. Some other rheumatic condition is a more likely to improve symptomatically with its use.
When muscle relaxants were tested in Fibromyalgia patients most were found to be useless but cyclobenzaprine was found to improve pain levels, sleep and tender point count (10 to 40 mg daily given at night to prevent daytime drowsiness) and this is thought to be because it has a chemical similarity to Amitripyline.
Many other drugs are currently being researched and tried in treatment of Fibromyalgia ranging from antiviral agents to substances which modulate the immune system. Various cocktails of antidepressant and sedative medications are being tried out as well. Even aspirin has been tried and is said to be mildly useful!
Osteopathic medicine, from which both SCS (Strain/Counterstrain) and Muscle Energy Technique (MET) derive, has conducted many studies involving Fibromyalgia, including:
Doctors at Chicago College of Osteopathic Medicine let by Drs. A.Stotz and R.Keppler measured the effects of osteopathic manipulative therapy (OMT – which includes SCS and MET) on the intensity of pain felt in the diagnostic tender points in 18 patients who met all the criteria for Fibromyalgia.
Each had six visits/treatments and it was found over a one year period that 12 of the patients responded well in that there tender points became less sensitive (14% reduction in intensity as against a 34% increase in the six patients who did not respond well) Most of the patients, the responders and the non-responders to OMT, showed that there tender points were more symmetrically spread after the course (using thermographic imaging) than before. Activities of daily living were significantly improved and general pain symptoms decreased overall.
Doctors at Texas College of Osteopathic Medicine selected three groups of Fibromyalgia patients, one of which received OMT, another had OMT plus self-teaching (learning about the condition and self-help measures) and a third group received only moist-heat treatment. The group with the least reported pain after six months of care was that receiving OMT, although some benefit was noted in the self-teaching group.
Another group of doctors from Texas tested the difference in results involving 37 patients with Fibromyalgia of using a/ drugs only (ibuprofen, alprazolam) or b/ OMT plus medication c/ a dummy medication (placebo) plus OMT or d/ a placebo only. The results showed that drug therapy alone resulted in significantly less tenderness being reported than did drugs and manipulation or the use of placebo and OMT or placebo alone.
Patients receiving placebo plus manipulation reported significantly less fatigue than the other groups. The group receiving medication and OMT showed the greatest improvement in their quality of life.
19 patients with all the criteria of Fibromyalgia were treated once a week for four weeks at Kirksville, Missouri College of Osteopathic Medicine using OMT. 84.2% showed improved sleep patterns, 94.7% reported less pain and most patients had fewer tender points on palpation.
Magnesium is often found to be deficient in people with Fibromyalgia/CFS(ME). In a study 15 patients with Fibromyalgia were supplemented with 300 to 600mg daily of magnesium and 1200 to 1400mg per day of malic acid.
Pain levels were greatly reduced. Benefits took some weeks or even months to be noticed.
This study replicates a previous study which showed that magnesium deficiency was a feature of many patients with CFS(ME).
Additional supplementation strategies which are recommended after clinical study include use of vitamin B3 and B6 which together with magnesium and tryptophan (obtainable from a good protein meal) are needed to manufacture serotonin.
The amino acids ornithine and arginine can be used to promote Growth hormone production. Calcium and zinc supplementation is commonly found to help sleep patterns return to normal.
General nutritional status support can usefully include supplementation with B-complex and vitamin C as well as essential fatty acids derived from flaxseeds or evening primrose.
Dr.Travell17 has confirmed that a variety of factors can all help to maintain and enhance trigger point activity: nutritional deficiency especially vitamins C, B-complex and iron; hormonal imbalances (low thyroid hormone production, menopausal or premenstrual situations); infections (bacteria, viruses or yeast); allergies (wheat and dairy in particular); low oxygenation of tissues (aggravated by tension, stress, inactivity, poor respiration).
Vibrational Therapy (Massage/Percussion Analgesia)
Rapid low level vibration has been shown to provide a speedy, safe and effective method for easing pain. A hand held vibrator is suitable for this purpose and may require firm pressure contact of the vibrator for up to half an hour before relief is strongly noticed. Vibration (100 to 200 cycles per second) should continue for 45 minutes at least. Relief of even chronic pain can last for many hours and in some instances for days. A high frequency works best (100Hz) if applied near to or below the area of pain (or according to Richard van Why to an antagonistic muscle or directly to a trigger point or reference zone).18
Manually applied vibration or rhythmic rocking (‘Harmonic Technique’19) is extremely soothing and helpful in chronic pain conditions with a tradition going back to the American Civil War where the method was used to help the pain of amputees.
Research at the University of California, Irvine, has show that when a range of physical methods were tested in treatment of myofascial pain including placebo ultrasound, spray and stretch, hydrocollator, real ultrasound and massage (ischemic compression/NMT) it was massage which came out ahead in providing immediate relief.20
1. McCain G Role of physical fitness training in fibrositis/fibromyalgia syndrome American Journal of Medicine 1986 (supplement 3A)pp73-77
2. Dr.P.Baldry Acupuncture, Trigger Points and Musculoskeletal Pain (Churchill Livingstone, Edinburgh, 1993
3. DeLuze C et al Electroacupuncture in Fibromyalgia British Medical Journal 21 October 1992 pp1249-1252
4. Sandford Kiser R et al Acupuncture relief of chronic pain syndrome correlates with increased plasma metenkephalin concentrations Lancet 1983;ii:1394-1396
5. Beck A et al Cognitive therapy in depression Guildford press New York 1979
6. Deale A Wessley S Cognitive-behavioral approach to CFS The Therapist 2(1)1994 pp11-14
7. Kacera W Fibromyalgia and chronic fatigue – a different strain of the same disease? Canadian Journal of Herbalism October 1993 Vol.XlV no lV pp20-29
8. Fisher P et al Effect of homoeopathic treatment of fibrositis (primary Fibromyalgia) British Medical Journal 32pp365-366 1989
9. Gemmell H et al Homoeopathic Rhus Toxicodendron in treatment of Fibromyalgia Chiropractic Journal of Australia Vol.21 No1 March 1991pp2-6
10.Haanen H et al Controlled trial of hypnotherapy in treatment of refractory Fibromyalgia Journal of Rheumatology 18pp72-75 1991
11. Goldenberg D et al Randomized, controlled trial of Amitripyline anproxine in treatment of patients with Fibromyalgia Arthritis/Rheum 1986;29:pp1371-1377
12. Clark S et al Double blind crossover trial of prednisone in treatment of fibrositis J Rheumatol 1985;12(5)pp980-983
13. Campbell S et al A double blind study of cyclobenzaprine in patients with primary Fibromyalgia Arthritis Rhem 1985;28:S40
14. Carette S et al Evaluation of Amitripyline in primary fibrositis Arthritis Rhem 1986:29pp655-659
15a. Stoltz A Effects of OMT on the tender points f Fibromyalgia Report in Journal of American Osteopathic Association 93(8)p866 August 1993
15b. Jiminez C et al Treatment of Fibromyalgia with OMT and self-learned techniques Report in Journal of American Osteopathic Association 93(8)p870 August 1993
15c. Rubin B et al Treatment options in Fibromyalgia syndrome Report in Journal of American Osteopathic Association 90(9)September 1990 pp844-5
16. Abraham G et al Management of Fibromyalgia – rationale for the use of magnesium and Malic acid Journal of Nutritional Medicine 3:49-59 1992
17. Travell J Simons D as cited previously
18. van Why R ‘Fibromyalgia and Massage’ symposium notes 1994
19. Lederman E DO Harmonic Tecnique Arnica House London
20. Hong C-Z et al Immediate effects of various physical medicine modalities on pain threshold of active myofascial trigger points. J Musculoskeletal Pain 1(2)pp37-53 1993.