Nonpharmacologic Care of Patients With Fibromyalgia
Larry Culpepper, MD, MPH
Department of Family Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
AV 1. Fibromyalgia and the Chronic Illness Framework (00:56)
The primary care physician who has diagnosed and evaluated fibromyalgia can provide definitive care for the majority of patients with this condition. The first step in managing a patient who has been diagnosed with fibromyalgia is educating that patient and engaging him or her in accepting the diagnosis and treatment plan. Fibromyalgia is best understood and explained using a chronic disease model (). Although no cure is currently available, it can be managed and treated to obtain both significant reduction in symptoms and improvement in functioning.1,2 As part of this initial patient engagement, the physician can build rapport with the patient by developing an understanding of his or her priorities and goals for treatment. At the same time, the physician must convey that the symptoms which the patient experiences are real, that treatment goals must be realistic to reduce symptoms and improve outcomes, and that a “cure” may be elusive at best.3–5 A key long-term goal for patients is for them to become experts in understanding their own symptoms and responses to further the successful self-management of their fibromyalgia.
Three Primary Aspects of Nonpharmacologic Therapy
AV 2. Minimal Nonpharmacologic Strategies for Patients With Fibromyalgia (00:19)
After these first steps, the minimum nonpharmacologic therapy for fibromyalgia should include encouraging the patient to (1) have a realistic, positive attitude and outlook; (2) engage in a regular, paced program of physical activity and exercise; and (3) adopt positive sleep hygiene practices ().2,6,7
CBT can help patients achieve a positive yet realistic outlook since it challenges defeatist or fear-based internal thoughts and self-imposed limitations, blaming, and related behaviors. It also can help patients evaluate their life circumstances and make realistic long-term plans as well as improve coping strategies and responses to daily challenges.1,2,8,9 Support groups can often be helpful in this regard as well.
Helping a patient with fibromyalgia develop an exercise program presents its own challenges. Many patients with fibromyalgia have been sedentary for years by the time of diagnosis and may be severely deconditioned.10,11 The physician should evaluate the level of deconditioning by assessing the patient’s type and amount of routine activity (eg, distance walking, stairs climbing) and take the results of such an assessment into account when planning a program to mobilize the patient and establish a regular exercise program. Initial goals should be modest, and the physician and other members of the treatment team should provide frequent encouragement and monitoring with nonjudgmental acceptance of the expected lapses in adherence. Often of considerable long-term value is for the clinician to determine the type of exercise a patient is willing to engage in and then help that patient establish progressive goals. Enlisting family or social support in the patient’s exercise plan can be helpful (for example, encouraging the patient and spouse to walk around the block after meals). Moderation in exercise is important to prevent fatigue and pain from overexertion.10,11
Good sleep hygiene can help manage the sleep dysfunction often associated with fibromyalgia, although additional pharmacologic care is often needed. Control of the sleep environment, regular bed and awakening times, and relaxation techniques all might be of benefit. Insomnia is often associated with mood disorders as well as fibromyalgia, and control of the mood disorders can then be helpful in alleviating sleep problems. For patients with comorbid depression, integrating regular monitoring of mood states using instruments such as the PHQ-9 can be helpful in encouraging the patient to collaborate with the physician in managing pharmacotherapy for depression.12 CBT in addition to medication can be helpful in treating depression and anxiety in patients with fibromyalgia, which may have a positive impact on sleep dysfunction, and specific CBT techniques also are available for treating insomnia.2
Complementary and Alternative Therapies
AV 3. Alternative Treatments and Patient Involvement in Fibromyalgia Care (00:41)
AV 4. Levels of Evidence for Nonpharmacologic Treatments for Fibromyalgia (00:19)
One of the important functions of the physician is guiding patients with fibromyalgia as they inevitably consider complementary and alternative therapies. A number of these therapies have been evaluated objectively, but others need additional research. For example, acupuncture and biofeedback have been evaluated in several studies; unfortunately, the quality of these studies is poor and few data support these techniques.13 However, if a patient finds these techniques to be of benefit, they can be part of the therapeutic package. 5 - Hydroxytryptophan, a precursor in the metabolic pathway of serotonin, may be of help in treating fibromyalgia, but again, few data support its use.14 Massage therapy has been found to be of benefit, although massage machines have not been found to be effective
(). In fact, a recent review15 that included chiropractic therapies categorized levels of evidence for varying nonpharmacologic treatments for fibromyalgia ().
For Clinical Use
- Provide education and support to help your patients with fibromyalgia develop a realistic, positive attitude and outlook
- Work with your patients to help them plan and engage in a regular, paced program of physical activity and exercise
- Address sleep dysfunction in your patients by encouraging them to adopt positive sleep hygiene practices and by treating comorbid mood disorders
CBT = cognitive-behavioral therapy
FDA = Food and Drug Administration
PHQ = Patient Health Questionnaire
All videos are derived from the Webcast "Debates and Directions in Fibromyalgia: Recognizing Signs and Selecting the Appropriate Paths, Part 2," held in March 2010 by the University of North Texas Health Science Center and featuring Larry Culpepper, MD, MPH, Boston University Medical Center, and Raymond Pertusi, DO, Harvard Vanguard Medical Associates. © 2010 University of North Texas Health Science Center, Fort Worth.
- Arnold LM, Bradley LA, Clauw DJ, et al. Multidisciplinary care and stepwise treatment for fibromyalgia. J Clin Psychiatry. 2008;69(12):e35.
- Hassett AL, Gevirtz RN. Nonpharmacologic treatment for fibromyalgia: patient education, cognitive-behavioral therapy, relaxation techniques, and complementary and alternative medicine. Rheum Dis Clin North Am. 2009;35(2):393–407.
- Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004;292(19):2388–2395.
- Chakrabarty S, Zoorob R. Fibromyalgia. Am Fam Physician. 2007;76(2):247–254.
- Boomershine CS, Crofford LJ. A symptom-based approach to pharmacologic management of fibromyalgia. Nat Rev Rheumatol. 2009;5(4):191–199.
- Buckhardt CS, Goldenberg D, Crofford L, et al. Guideline for the Management of Fibromyalgia Syndrome Pain in Adults and Children. Clinical Practice Guideline, No 4. Glenview, IL: American Pain Society (APS); 2005. http://www.guideline.gov/summary/summary.aspx?doc_id=7298&nbr=004342. Accessed March 7, 2010.
- Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008;67(4):536–541.
- Burckhardt CS. Nonpharmacologic management strategies in fibromyalgia. Rheum Dis Clin North Am. 2002;28(2):291–304.
- Russell IJ. Fibromyalgia syndrome: approach to management. Prim Psychiatry. 2006;13(9):76–84.
- Busch AJ, Schachter CL, Overend TJ, et al. Exercise for fibromyalgia: a systematic review. J Rheumatol. 2008;35(6):1130–1144.
- Jones KD, Clark SR. Individualizing the exercise prescription for persons with fibromyalgia. Rheum Dis Clin North Am. 2002;28(2):419–436.
- Lowe B, Kroenke K, Herzog W, et al. Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9). J Affect Disord. 2004;81(1):61–66.
- Mayhew E, Ernst E. Acupuncture for fibromyalgia: a systematic review of randomized clinical trials. Rheumatology (Oxford). 2007;46(5):801–804.
- Caruso I, Sarzi Puttini P, Cazzola M, et al. Double-blind study of 5-hydroxytryptophan versus placebo in the treatment of primary fibromyalgia syndrome. J Int Med Res. 1990;18(3):201–209.
- Schneider M, Vernon H, Ko G, et al. Chiropractic management of fibromyalgia syndrome: a systematic review of the literature. J Manipulative Physiol Ther. 2009;32(1):25–40.