Download Preview the material

Fibromyalgia: Chronic Pain
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical
author. He graduated from Ross University School of Medicine and has completed his clinical
clerkship training in various teaching hospitals throughout New York, including King’s
County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed
all USMLE medical board exams, and has served as a test prep tutor and instructor for
Kaplan. He has developed several medical courses and curricula for a variety of educational
institutions. Dr. Jouria has also served on multiple levels in the academic field including
faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter
Expert for several continuing education organizations covering multiple basic medical
sciences. He has also developed several continuing medical education courses covering
various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the
University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an emodule training series for trauma patient management. Dr. Jouria is currently authoring an
academic textbook on Human Anatomy & Physiology.
ABSTRACT
Fatigue, insomnia, cognitive problems, memory problems, and psychological
distress are some of the symptoms associated with fibromyalgia and other
causes of chronic pain. Particularly with fibromyalgia, the exact cause of the
pain may not be entirely known or understood, which may make treatment
significantly more difficult but no less desired. Two types of treatment for
fibromyalgia and chronic pain are pharmacology and alternative therapies.
Pharmacology relies on modern science to provide medications that treat the
root of the disorder; alternative treatments seek to relieve the symptoms by
addressing the whole body. Most cases of fibromyalgia and chronic pain
require a multi-faceted approach with a combination of the two techniques
to provide patient relief.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
1
Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 3 hours. Nurses may only claim
continuing nursing education credit commensurate with the credit awarded
for completion of this course activity.
Pharmacology content is credited for 1 hour (60 minutes).
Statement of Learning Need
Fibromyalgia is one of the most common chronic pain conditions. To
understand fibromyalgia as a syndrome nurses require knowledge of chronic
pain and how to recognize the clinical presentation and support patients to
experience improved outcomes.
Course Purpose
To provide nurses knowledge about chronic pain syndromes and medical and
alternative treatments as it relates to fibromyalgia.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
2
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD; William S. Cook, PhD; Douglas Lawrence, MA;
Susan DePasquale, CGRN, MSN, FPMHNP – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP.
Release Date: 1/1/2016
Termination Date: 5/28/2017
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
3
1. _____ receptors are located in the brain and the spinal cord
and are often involved in pain sensation and management.
a. Kappa
b. Delta
c. Theta
d. Mu
2. A nurse is counseling a patient who has started taking an MAOI
for managing fibromyalgia symptoms. Which food should the
nurse tell the patient to avoid?
a. Steak
b. Sauerkraut
c. Eggs
d. Salmon
3. In 2007, the U.S. FDA approved the first drug specifically for
fibromyalgia management. It is called:
a. gabapentin.
b. tramadol.
c. duloxetine.
d. pregabalin.
4. Which of the following is an example of an opioid antagonist?
a. Zolpidem
b. Triazolam
c. Nalaxone
d. Celecoxib
5. The most commonly used type of acupuncture in the United
States is based on:
a. Korean hand acupuncture.
b. Myofascial release
c. Auricular acupuncture
d. Traditional Chinese medicine.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
4
Introduction
Chronic pain can be extremely difficult to manage and control and many
people suffer through symptoms of chronic pain without ever truly finding
relief. Some disorders cause chronic pain and other negative symptoms,
including fibromyalgia, a disorder that also leads to fatigue, insomnia, and
depression, among a host of other symptoms. There are many options for
pain control and management of other symptoms of fibromyalgia so that
people suffering from chronic conditions can find hope for resolution of some
of their symptoms.
Fibromyalgia: A Chronically Painful Condition
A chronically painful condition, fibromyalgia occurs as pain and tenderness
throughout the body, particularly in the muscles and tendons, as well as
chronic sleep difficulties and overwhelming fatigue. Fibromyalgia affects up
to four percent of people in the United States; although most of those
affected are women, fibromyalgia can develop in men as well.4 It most
commonly occurs between the ages of 20 and 60 years, although some
people can develop fibromyalgia during childhood or late in life. There is not
one specific test that can diagnose fibromyalgia; rather, many people seek
treatment for pain and must then have testing to rule out other health
conditions.
The exact cause of fibromyalgia is unknown, but may be associated with a
history of certain conditions, such as depression, anxiety, or chronic pain
that are all capable of triggering symptoms.10 Fibromyalgia may develop
slowly without obvious symptoms, which can make it difficult to identify. It
has been known to develop following an illness, such as a viral infection, or
it may also show up right away after an injury or traumatic event, such as a
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
5
motor vehicle accident. Most patients suffer from some symptoms all the
time, although there may be times when symptoms are worse. Fibromyalgia
symptoms tend to be exacerbated by stressful situations.57
The pain associated with fibromyalgia may be heightened by a factor known
as central sensitization. This phenomenon impacts the perception of pain in
some people and there may be a genetic component behind it. Central
sensitization occurs when the nervous system remains in a high state of
reactivity to pain and other stimuli. This continued, heightened sense might
cause chronic pain to exist, even if an injury that originally caused pain in
the first place has already healed. People with central sensitization may have
higher levels of anxiety because they are aware of their reactions to pain
and may fear even small stimuli that could cause a pain reaction. They may
feel depressed if they believe they cannot live normal lives because of fear of
pain; they may also feel judged or crazy because others have trouble
believing that they could be experiencing so much pain.44
Central sensitization is also associated with poor concentration, memory
problems, fatigue, and malaise. People that have this heightened sense of
pain can also be more sensitive to other factors that affect the senses, such
as sight, smell, or taste.44 For example, a person with central sensitization
may need to wear sunglasses almost constantly because of increased
sensitivity to sunlight, or she may become nauseated or may vomit in the
presence of routine smells, such as food cooking. Central sensitization has
also been seen among patients who suffer from painful disorders similar to
fibromyalgia, such as chronic fatigue syndrome, as well as those who
regularly suffer from chronic migraine headaches and those who have
irritable bowel syndrome. People who have family members with these
conditions are at an increased risk of developing fibromyalgia themselves.26
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
6
People with fibromyalgia complain of pain and tenderness at any part of the
body, most commonly in the muscles and joints, the neck and shoulders,
and the middle and lower back. These painful locations where pain is most
often felt are known as tender points. The pain is persistent, and may be
more intense on some days and mild on others, but it is almost always
present to some degree.
People with fibromyalgia complain that the pain feels aching, burning, or just
as generalized soreness. They may have the feeling of muscle stiffness, as if
they overexerted themselves, and they may complain of joint pain or the
feeling of swollen joints, even though there is no physical markers that
would cause joint pain.26
Fibromyalgia also causes other symptoms, including gastrointestinal
disturbances, the most common being irritable bowel syndrome. In this
situation, the patient may suffer from abdominal pain, and diarrhea,
constipation, or a combination of both. Urinary symptoms include pain with
urination and feelings similar to a urinary tract infection, including urinary
frequency and urgency. Some patients have also developed chronic
headaches or migraines and problems with the neck and jaw.26 The chronic
pain associated with the condition, as well as difficulties with identifying the
cause of the pain and a lack of identifiable factors that are the source of
pain, can all be stressful and debilitating for the affected patient.4
Although fibromyalgia leads to chronic pain and tenderness at various points
in the body, people suffering from the disorder also may have problems with
sleeping, complaining of difficulties with falling asleep, staying asleep, or
awakening without feeling refreshed. As a result, fatigue is a common
problem and fatigue may be present to the point that lack of energy disrupts
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
7
the person’s abilities to carry out daily activities. Lack of restful sleep also
leads to problems with concentration or memory, as well as a feeling of
being distracted, sometimes referred to as the fibro fog.
Depression is present in approximately 30 percent of cases, and it often
coincides with anxiety.26 Unfortunately, people suffering from depression,
whether or not they currently have fibromyalgia, may be more sensitive to
pain. Fibromyalgia sufferers who have depression may report greater
feelings of pain related to their conditions, which could coincide with
depression and anxiety.3 Anger is also a common element among people
with fibromyalgia, with one study showing 85 percent of patients with the
condition feeling some amount of anger at the situation. Unfortunately,
chronic anger can lead to increased levels of perceived pain, making the
situation worse for many. Additionally, people who are very angry about
handling their conditions may be less likely to commit to therapy or to find
solutions to manage the situations, making it very difficult to find
therapeutic treatment regimens that work over a long period of time.57
Other symptoms that may be seen among patients with fibromyalgia include
restless leg syndrome, painful menses, sleep apnea, numbness or tingling in
the extremities, and increased sensitivity to changes in temperature.
Fibromyalgia may exist as a syndrome on its own or it may manifest
alongside other painful conditions, including painful autoimmune disorders,
such as rheumatoid arthritis. When fibromyalgia exists with another
chronically painful condition, it is referred to as secondary fibromyalgia.10
Unfortunately, fibromyalgia tends to take on a cyclical, cause-and-effect
relationship between symptoms and their effects on activity. For example, a
person with fibromyalgia suffers from pain and muscle tension, making
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
8
exercise and certain activities difficult and painful. However, exercise often
helps fibromyalgia sufferers and is a solution for managing some of the pain.
The patient may be less likely to engage in exercise and may develop a
more sedentary lifestyle because of the pain. The lack of exercise and
activity can further lead to depression, which can cause sleep disruption and
further isolation, which only continues to prolong the misery.
Additionally, fibromyalgia may be considered by some to be a made up
condition, in which affected patients are sometimes judged or criticized for
trying to find help for a disorder that has no obvious cause of the pain. This
can lead to isolation and decreased social interactions with others who do
not understand the difficulties of trying to find relief from continuous pain
and insomnia.10
There is not one exact cause of fibromyalgia and, although many theories
have been suggested, there are a number of factors that are related to the
symptoms, such as the increase in central sensitization among many people
with the condition. Some patients with fibromyalgia have been shown to
have lower levels of serotonin, a neurotransmitter in the brain responsible
for promoting sleep, reacting to pain, and maintaining feelings of well being.
Decreased levels of serotonin have been associated with depression,
gastrointestinal conditions such as irritable bowel syndrome, and headaches,
which are all common symptoms of fibromyalgia as well.
Fibromyalgia may also develop as a result in changes in some types of
hormones, including growth hormone or the release of stress hormones. The
symptoms are also often similar to those of autoimmune disorders, such as
rheumatoid arthritis or systemic lupus erythematosus, however, patients
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
9
with fibromyalgia typically do not show laboratory changes of autoimmune
inflammatory responses that are seen with these diseases.
Some patients with fibromyalgia have also been shown to have
abnormalities with their muscles that could be the cause of fibromyalgia
symptoms. For example, a patient may experience more muscle contractions
or tight muscles if calcium levels are not regulated in the muscle cells.
Adenosine triphosphate (ATP) has some responsibility in regulating this
calcium, but if a patient has low levels of ATP, he/she might have more
muscle stiffness and pain.33
The diagnosis of fibromyalgia is performed through the exclusion of other
conditions that could be causing the painful symptoms. Because of this,
fibromyalgia is not classified as a disease, but rather as a functional somatic
syndrome.14 Often, patients seek help or treatment for pain but must first
rule out the possibilities of other conditions, a process that can take years
for some. There are some conditions that may manifest in manners similar
to fibromyalgia and these conditions should be ruled out as part of the
diagnostic process. Examples include rheumatoid arthritis, which is an
autoimmune disorder that results in inflammation, swelling, and deformity of
the joints; osteoarthritis, in which degenerative joint changes cause pain and
swelling in the joints; polymyalgia rheumatica, which typically affects people
over the age of 50 years, causes inflammation of large arteries, and results
in pain and inflammation most commonly in the joints and hips; and,
ankylosing spondylitis, an inflammatory disease that involves the joints of
the spine.26
Although testing may involve x-rays and blood tests to determine the cause
of symptoms, many testing results return as completely normal and there
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
10
are no obvious causes for the pain of fibromyalgia. For example, when
comparing symptoms of fibromyalgia to other types of autoimmune
disorders, laboratory tests often reveal no signs of inflammation in patients
with fibromyalgia, even though the symptoms may be the same as other
inflammatory disorders. In order to better help patients seeking help and
treatment for fibromyalgia, providers should perform a thorough physical
exam, which involves assessing the points on the body that cause the most
pain.
An assessment using mild pressure can identify tender points, as many
patients may react strongly to pain when gentle pressure is applied.45 A
comprehensive history is also important and should include the length of
time experiencing symptoms, a history of other physical or psychological
illnesses, and other issues that could be contributing to the condition, such
as sleep disorders or the presence of an autoimmune disease.26
In 1990, the American College of Rheumatology developed a set of criteria
for patients to diagnose fibromyalgia by determining the amount of severity
of symptoms of patients including fatigue, disturbed sleep, cognitive
changes, and other general symptoms. Patients were also asked to
determine the location of painful sites on the body, with 18 different sites
included as part of the analysis. The scale was developed with specific
criteria, including presence of widespread pain, which was defined as “pain
in 3 out of 4 quadrants including pain in left- and right-sided and upper- and
lower-segment pain, and axial pain”.38 Additionally, if a patient had at least
11 tender points out of the 18 listed and had been suffering for symptoms
for at least three months then he/she was diagnosed with fibromyalgia.21
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
11
In 2010, the American College of Rheumatology (ACR) modified its approach
to diagnosis and eliminated the tender point scale, instead using the
widespread pain index (WPI), which assesses areas where the patient is
feeling pain and asks him or her to rate the amount of pain. Each rating is
awarded a certain number of points, which helps clinicians determine
whether a diagnosis of fibromyalgia can be made based on the points
outcome. Additionally, the patient typically must have been suffering from
symptoms for at least three months before diagnosis.10,21 The approach was
updated to allow for the use of the criteria in the primary setting, to simplify
the process, and to recognize the various other symptoms that can
accompany fibromyalgia in addition to pain.38
In 2011, the diagnostic criteria became modified again and were to be used
for surveys and other studies, and the data obtained came entirely from the
patient without using physician assessment. The physician does not estimate
the amount of pain the patient is having, but instead the symptoms are self
reported. The WPI was again modified to create a fibromyalgia symptom
(FS) scale, which measures symptoms on a scale of 0 to 31. Because the
system uses patient input and removes the physician’s physical assessment
from the diagnostic picture, there may be more cases of fibromyalgia
incorrectly diagnosed. Research continues in this area to find the best
method of diagnosis.31
Although the American College of Rheumatology (ACR) established
diagnostic criteria that uses patient input and can be utilized more in
primary care practice, there may be other methods of assessment that are
easier and that consider more criteria. A 2014 study by Bennett, et al.,
studied another approach to diagnosing fibromyalgia that might be easier to
use and implement into clinical practice. A set of criteria, known as the 2013
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
12
AltCr, were developed based on symptom findings from a couple of different
questionnaires used in the diagnosis of fibromyalgia: the Symptom Impact
Questionnaire, a pain location inventory questionnaire, and a version of the
ACR’s modified criteria.58
After developing the study, researchers tested it against the 2011 modified
ACR criteria and found that the 2011 criteria found fibromyalgia more
commonly among patients but had more false positive diagnoses when
compared to the 2013 AltCr. Additionally, the 2013 AltCr was found to be
easier to use for diagnosis and included three symptoms that were not
regularly used as part of the ACR criteria; environmental sensitivity,
tenderness to touch, and stiffness.58 Keeping this in mind, clinicians who
must consider diagnosis of fibromyalgia should know that they may use
more than one questionnaire or set of criteria when making assessments,
and the 2013 AltCr is an option. Making choices between types of surveys
and questionnaires may provide more comprehensive data upon which to
base a diagnosis and may be faster and simpler to use as well.88
Nurses caring for patients with fibromyalgia must take a non-judgmental
stance and provide assurance for their patients that their symptoms have
meaning. Many patients with fibromyalgia experience isolation and loss of
relationships because friends or family do not understand the pain or how
much it impacts daily life. Significant others often grow tired of hearing
complaints about symptoms without having any answers. Social isolation
further adds to patient depression, anxiety, and feelings of inadequacy and
loneliness. Part of the nurse’s role is to ensure the patient that she believes
that the symptoms are real and to provide information to family and friends
about the devastating effects of fibromyalgia on daily life. After showing
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
13
support and empathy for the patient’s situation, the nurse can then help the
patient to focus on strategies that will improve symptoms and find relief.
Other Types of Chronic Pain
Chronic pain is classified as pain that lasts at least 3 to 6 months and the
pain may be constant or intermittent.5 Even when the cause of chronic pain
has been identified and treated, pain may continue if tissue damage has
occurred. Chronic pain must be treated in a manner different from acute
pain. Acute pain often occurs as a result of tissue damage and typically has
an identifiable cause, such as a traumatic event or surgical procedure.
Alternatively, the chronic pain may not be obvious, although pain is present.
Some people have no idea why they are having chronic pain, while others
can attribute the pain to a certain cause that was never entirely resolved.11
People who suffer from chronic pain can also develop higher levels of
tolerance for pain overall.
Taking medications over a long period of time to treat pain may result in an
increased tolerance of pain medication and may require larger doses of
medicine to achieve the same relief. Additionally, those with chronic pain
may develop depression or sleep issues because of living for so long without
finding relief. Stress and depression associated with chronic pain may make
pain feel worse and make it difficult for the affected patient to cope with
everyday stressors.11
Part of the goals of treatment of chronic pain and fibromyalgia is to help
patients learn to cope with pain and discomfort, to reduce the pain to a
tolerable level, and to continue to live full lives even if the pain is not
entirely resolved. This may mean incorporating various therapies and
pharmacologic treatments that can suppress the pain to some extent but not
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
14
entirely eliminate it. Unfortunately for many people with chronic pain,
identifying the exact cause in order to completely eradicate the pain is not
possible. Further, knowing this can be challenging and depressing for the
patient who may feel extremely helpless in the face of pain.
Pain is a very personal, individual experience and a person who is suffering
from pain may respond in a completely different method than someone else
that is also suffering. In other words, pain is perceived differently among
people. When working with patients in pain, the nurse must remember that
pain is whatever a patient says it is, and exists whenever the patient says it
does.5 The nurse cannot impart her own experiences with pain onto a patient
because he/she would experience pain differently.
Because a patient in pain will often have a different experience with coping
than the nurse, it is important to develop a sense of trust between the nurse
and the patient. The nurse needs to know that his/her efforts at assisting
with pain management are helping the patient; and, the patient needs to
know that the nurse believes him/her about being in pain and is trying to
help the patient manage pain. The nurse must consider not only the physical
effects pain has on a person, but also the psychological, social, and cultural
factors that impact the situation. All of these factors must be considered
when treating pain and evaluating the success of pain management efforts.
Additionally, the pain that a patient experiences that is classified as acute or
chronic may then further be sub-classified into different types of pain,
depending on the source of the pain and how the body interprets and
responds to pain messages. This is elaborated on in the section below.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
15
Nociceptive Pain
Nociceptive pain occurs with stimulation of nerve fibers that transmit pain
messages. Nociceptive pain can occur from injuries or short-term harm that
results in acute pain, or it may develop in situations that cause chronic pain.
Nociception occurs as a series of steps in which the body responds to a
painful stimulus and ultimately, the message of pain reaches the brain,
where the person then understands that he is feeling pain. When a painful
stimulus occurs, sensory nerve fibers known as nociceptors respond and
send signals to the spinal cord, which then travel to the brain where the
person perceives the sensation of pain.5
Various receptors in the central nervous system and in different tissues of
the body are responsible for the perception of pain. Kappa and delta
receptors are located in peripheral tissues in the body, in the brain, and in
the spinal cord. Mu receptors are located in the brain and the spinal cord and
are often most involved in the pain sensation and management.5,17 The
number of mu receptors that a person has affects his/her perception of pain.
The mu opioid receptor gene controls the amount of mu receptors that a
person has in their body. Consequently, if a person has a large number of
mu receptors, his/her sensitivity to pain is lower than if they had a low
number of mu receptors.5
Nociceptive pain can be classified as somatic pain, which develops in the
skeletal muscles, the joints, and the ligaments or tendons; and, visceral
pain, which develops from smooth muscle tissue and internal organs. Pain
may be easier to treat when the source of the pain is known; however,
among patients with fibromyalgia and chronic pain, the exact source is not
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
16
always known because an injury or tissue damage cannot always be
identified.5
A theory of pain transmission known as the gate control theory can better
explain how the brain perceives pain that occurs in the body. When a painful
event occurs, the body releases a number of substances in response,
including prostaglandins, histamine, and serotonin. When these substances
are released, nerve impulses are set off in the distal ends of the nociceptors.
The impulses travel along the nociceptors to reach the dorsal horn of the
spinal cord, where pain receptors are then activated. At this point, the gate
control theory suggests that gates in this location control whether pain
impulses are sent on to the brain to allow a person to perceive pain, or
whether they are stopped.
When the gates are open, the pain impulses are sent to the brain, but when
they are closed, the impulses are stopped. Whether the gates are open or
closed is dependent on nerve fibers known as A fibers and C fibers. The A
fibers are larger in size and are responsible for closing the gate and thus
preventing the transmission of pain sensation to the brain. Alternatively, the
smaller-sized C fibers are responsible for opening the gate and allowing the
pain impulses to get through to reach the brain.5
Neuropathic Pain
Neuropathic pain develops when central or peripheral nerves are damaged
or otherwise do not work as well as they should, resulting in pain. The
International Association for the Study of Pain defines neuropathic pain as
“pain initiated or caused by a primary lesion or dysfunction of the nervous
system”.39 Instead of nerves transmitting messages to the brain to
communicate pain signals, as what occurs with nociceptive pain, neuropathic
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
17
pain involves injury or damage to peripheral or central nerves such that they
become the cause of the pain themselves.
Neuropathic pain may be classified as central or peripheral, depending on
the location of the nerve injury. Central neuropathic pain syndromes include
post-traumatic spinal cord injury, pain associated with Parkinson’s disease or
multiple sclerosis, and post-ischemic myelopathy. Alternatively, examples of
peripheral neuropathic pain conditions include diabetic peripheral
neuropathy, trigeminal neuralgia, phantom limb pain, and post-herpetic
neuropathy following shingles.
Neuropathic pain can be manifested in a number of ways. Its intensity can
range from mild to excruciating and it can be constant or intermittent. A
person experiencing neuropathic pain may also have paresthesia and
increased sensitivity to pain overall. The person may be extremely sensitive
to external stimuli, such that even mild sensations, such as light touches,
can be very painful. This condition is known as allodynia and may be a
frequent symptom associated with neuropathic pain.
Hyperalgesia is defined as an increased sensitivity to pain and is also
common with neuropathic pain, and, it may be classified as a primary or
secondary condition. Primary hyperalgesia occurs when an area is injured
and sensitization to the pain develops at the site. Secondary hyperalgesia
occurs in the areas surrounding the injury, even if they are not injured. In
addition to these symptoms, people with neuropathic pain may also suffer
from other issues, such as weakness and changes in reflexes.39,41
While fibromyalgia is technically not classified as a neuropathic pain
syndrome, its symptoms may manifest in methods similar to those types of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
18
peripheral syndromes. Several studies have been conducted that have
examined skin samples to look at nerve fibers among patients with
fibromyalgia. The results of the studies showed reduced innervation of nerve
fibers that carry pain messages. Additionally, many test subjects reported
pain symptoms that were similar to neuropathic pain, including pain
described as burning or tingling.
Although fibromyalgia is not classified as a neuropathic pain disorder, the
presence of these types of symptoms may occur as a result of damage to
peripheral nerves. Because fibromyalgia symptoms can manifest in so many
different ways, the concept of peripheral nerve involvement is just one more
supportive idea that the exact causes and triggers of the condition remains
difficult to pin down.40
Pharmacological Treatments
Because of the varied symptoms of fibromyalgia, management of the
condition involves trialing different therapies that will work to improve
comfort and quality of life. Most people have the best results with a
combination of therapies, which often include one or more types of
pharmacological treatments as well as supplements or other therapeutic
interventions. There are a number of pharmacological treatments used to
manage fibromyalgia and chronic pain symptoms, most of them are
considered off label use, which means that they are designed to treat or
manage some other disease or condition but their use has shown benefits in
symptom management for pain as well.
When managing fibromyalgia it is important to consider the most prominent
symptoms that are causing distress and focus on managing those, rather
than attempting to control every sign or symptom. For instance, if a patient
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
19
is experiencing pain, insomnia, lightheadedness, muscle stiffness, and
irritable bowel syndrome, but the most prominent symptoms are pain and
muscle stiffness, he/she should try to focus on managing those symptoms to
the best of their ability instead of treating everything. Managing the most
painful and debilitating symptoms of fibromyalgia can improve a person’s
quality of life as well as help them to handle other, minor symptoms
somewhat more easily.
It should also be noted that taking large numbers of medications to treat
various symptoms of fibromyalgia is probably not a good idea. While there is
not one medication that can usually treat all symptoms and most patients
find better relief by combining one or more medications or therapies, taking
too many medications to control symptoms can be confusing and even
dangerous. For example, if a patient takes four different medications to
control pain, insomnia, muscle stiffness, and anxiety, and then develops
significant side effects that become intolerable, it may be difficult to pinpoint
which medication is causing the side effects. The patient may not be able to
stop taking one or more of the medications because of a return of
symptoms. Similarly, there are a number of medications that negatively
interact with each other, such as through causing the medication to
metabolize too quickly or having the effect of canceling each other out.
Combining medications can be effective, but should be managed through the
help of a healthcare provider.
Antidepressants
Antidepressants, while primarily designed for the treatment of major
depression, can be effective methods of pain control for patients
experiencing chronic pain. The impact of antidepressants is on
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
20
neurotransmitters in the brain - supporting the overall levels of
neurotransmitters and preventing their reabsorption.
Neurotransmitters communicate many different messages throughout the
body by sending messages through nerve signals, such as telling the body to
perform different functions, including regulating heart rate and digestion.
Neurotransmitters also impact mood and feelings of well being among
people, and it is much of these effects that are affected by antidepressants.
Medications such as antidepressants can improve not only mood but can also
regulate sleep and impact how much pain a person perceives. There are a
number of different types of antidepressants currently used effectively to
manage symptoms of fibromyalgia, such as amitriptyline and fluoxetine.
Antidepressants and other drug categories are discussed in more detail in
the section to follow.
Tricyclic Antidepressants (TCAs)
Tricyclic antidepressants (TCAs) are medications that at one time were the
most commonly prescribed antidepressant for treatment of major
depression. This is no longer the case, but these drugs are still prescribed
for treatment of depression and may also be used for management of
symptoms of fibromyalgia. Tricyclic antidepressants were the first drugs that
were considered for management of fibromyalgia symptoms.33 These drugs
affect the central nervous system by extending the activity of certain
neurotransmitters, including serotonin and dopamine, and preventing their
reuptake.2
Serotonin impacts several body systems, such as by improving mood,
controlling appetite, and improving sleep. People who have low levels of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
21
serotonin may be more irritable, anxious, and may have more difficulties
with sleeping. Additionally, dopamine helps a person to feel more energized,
active, and focused on what he is doing. By reducing the uptake of these
neurotransmitters, TCAs prevent their levels from falling too low, which
further prevent the irritability, anger, sleep difficulties, and depression that
can come from such decreased levels.
Tricyclic antidepressants may also help to improve and can have a relaxing
effect, which can help with stress and tension associated with chronic pain.9
Effects of TCAs may take between 2 and 4 weeks to develop but those who
use these drugs for depression have reported improved feelings of mood and
increased feelings of being alert, with better concentration.2 Tricyclic
antidepressants may be used effectively in combination with other types of
medications, such as analgesic medications or other types of
antidepressants, such as selective serotonin reuptake inhibitors.
Often, TCAs are started at very low doses for treatment of fibromyalgia
symptoms, with the slowing of dosage increasing with consistent use. Many
patients begin taking doses between 10 and 50 mg to start and usually take
their doses at bedtime.22 Studies have shown that up to 45 percent of
patients with fibromyalgia have had significant improvements in symptoms
when using tricyclic antidepressants as a form of treatment.26
Tricyclic antidepressants can have some side effects that make their use
unpleasant. Even in very small doses, people have complained of side effects
that can make using these drugs difficult. Side effects associated with these
drugs include constipation, dry mouth, and heart arrhythmias.9 Many people
have had greater relief when using TCAs when they take their doses at
bedtime where they may not experience as many side effects. Additionally,
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
22
the relaxing effect of the drugs can promote improved sleep and muscle
relaxation.26 Some types of TCAs used in the treatment of fibromyalgia
include amitriptylene (Elavil®) and doxepine (Sinequan®).8
Selective Serotonin Reuptake Inhibitors (SSRIs)
Selective serotonin reuptake inhibitors (SSRIs) are the most commonly
prescribed antidepressant used for the treatment of depression. SSRIs work
by preventing the reuptake of serotonin, which occurs as the
neurotransmitter is reabsorbed into the nerve cells in the brain. Preventing
this reuptake then causes the neurotransmitter to remain in the synaptic gap
between the nerves to maintain communication between nerve cells and to
derive benefits of the neurotransmitter for a longer period. As discussed,
serotonin impacts mood, appetite, and sleep, and low levels of this
neurotransmitter can cause increased anxiety, depression, and insomnia.
Serotonin selective reuptake inhibitors often work to improve sleep and to
reduce the impact of depression among people diagnosed with fibromyalgia,
however, these drugs may not have as significant an effect on symptoms of
pain.33 SSRIs may have fewer side effects when compared to TCAs, but they
still may cause some uncomfortable side effects that can make early use of
these drugs difficult. Some of the most common side effects include nausea,
diarrhea, loss of appetite, irritability, anxiety, weight gain, headaches, and
dizziness. Ultimately, these side effects seem to fade after using the drugs
for a few days.9,34
Individuals may sometimes have better results of fibromyalgia symptoms
with a combination of SSRIs and TCAs to cover both pain and insomnia.
SSRIs should be taken in the morning because they could cause insomnia if
taken immediately before bed.22 The combination of using an SSRI in the
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
23
morning and a TCA in the evening has worked for many people, although the
decision of which drugs to combine is best discussed with a healthcare
provider.
Unlike TCAs, the starting dose of SSRIs is similar to that which is prescribed
for depression. Unfortunately, using SSRIs can impact liver function,
preventing the breakdown of other substances in the body, including some
medications. If this happens, SSRIs can then negatively interact with some
medications by causing a buildup of these medications in the body if the liver
cannot break them down adequately. Some medications that may interact
with SSRIs include alprazolam (Xanax®), warfarin (Coumadin®),
theophylline, phenytoin (Dilantin®), and some antidepressants such as
monoamine oxidase inhibitors (MAOIs).34 Any patient who wants to try
SSRIs for fibromyalgia treatment should discuss all other medications that
they are taking with their healthcare provider before starting on this type of
pharmacological therapy.
Fluoxetine (Prozac®) is one type of SSRI that has been studied extensively
for its benefits to patients with depression. Studies of Prozac have shown
that it can successfully decrease pain and insomnia in patients with
fibromyalgia; however, not everyone will respond in the same method or
have the same results. Other SSRIs that may be used in the treatment of
fibromyalgia include paroxetine (Paxil®), citalopram (Celexa®),
escitalopram (Lexapro®), and sertraline (Zoloft®).8,34
Dopamine Reuptake Inhibitors (DRIs)
Another type of drug, the dopamine reuptake inhibitor (DRI) prevents the
body from reabsorbing the neurotransmitter dopamine, thereby keeping it at
higher levels within the body. Dopamine is responsible for improving mood
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
24
and feelings of wellbeing. Dopamine reuptake inhibitors are most often
prescribed for patients with attention deficit hyperactivity disorder (ADHD)
or among patients with Parkinson’s disease. However, their off-label use
may also be available for patients with fibromyalgia and chronic pain, as
they have the ability to reduce depression and anxiety.
Dopamine reuptake inhibitors often work well when combined with other
types of medications, including SSRIs, which can then help to control
feelings of pain in addition to mood changes. DRIs have some side effects,
which may be similar to some other types of antidepressants. Because they
support dopamine levels, patients who take these drugs on a regular basis
may be more likely to have feelings of elevated mood and euphoria. Some
people may have difficulties with sleeping and may suffer from insomnia
because they are too alert and awake after taking the drugs. Other side
effects include nausea and tremor.
Because DRIs produce feelings of pleasure and elevated mood, they are at
higher risk of being abused by some patients. If they are combined with
some other substances, such as alcohol or some types of illicit drugs, they
can cause serious or even life-threatening side effects. Use of DRIs to
control depression and fibromyalgia symptoms in affected patients must be
carefully controlled and monitored by a healthcare provider to avoid the risk
of abuse in these medications.49
Norepinephrine-Dopamine Reuptake Inhibitors (NDRIs)
Norepinephrine-dopamine reuptake inhibitors (NDRIs) work in a similar
manner to NRIs, but they also prevent the reuptake of norepinephrine in the
body as well as dopamine. These drugs are classified as stimulants and may
not be the first choice for management of fibromyalgia, but they can be
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
25
effective for some people, particularly among those who have not had
success with other types of medications.
An example of a type of NDRI that may be used among some people is
bupropion (Wellbutrin®). Because they are stimulants, NDRIs can cause
some unpleasant side effects, including weight loss, sweating, tremor, dry
mouth, anxiety, and tachycardia.50
Monoamine Oxidase Inhibitors (MAOIs)
Monoamine oxidase inhibitors (MAOIs) are a class of antidepressants that
were the first true type of antidepressant and were once quite popular. The
first antidepressant ever developed was iproniazid, which was an MAOI that
was introduced in the 1950s. It was later followed by other drugs of various
classes and then was later removed from the market because of its potential
for liver toxicity. However, other MAOIs were subsequently developed and
for many years they were viable options for treatment of depression.43
The use of MAOIs is no longer as common, often because of their potential
to cause harmful side effects. Still, MAOIs can be effective in treating
depression and pain in some patients, and as of this writing, they are a third
or fourth choice of antidepressant medication treatment for major depressive
disorder. There are also patients with major depression who have specifically
benefitted from MAOIs when their depression cannot be otherwise treated
because it is resistant to other types of medications.43
Monoamine oxidase inhibitors work by interrupting the work of monoamine
oxidase, which is an enzyme that normally breaks down major
neurotransmitters such as serotonin, norepinephrine, and dopamine.42
Monoamines are further broken down into two different types: isoenzyme A
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
26
(MAO-A) and isoenzyme B (MAO-B). MAO-A is mostly found in the liver,
gastrointestinal tract, and adrenal glands. Its major function is to metabolize
norepinephrine and serotonin. Most of the monoamine oxidase in the
gastrointestinal tract is of the MAO-A type and it can also break down
tyramine, a compound found in certain foods. Many people have heard of
dietary restrictions associated with MAOIs, and it is because of this
breakdown that occurs due to MAO-A.43
Monoamine oxidase inhibitors antidepressants are also classified as to
whether they are selective or non-selective, as well as if they are reversible
or non-reversible. An MAOI is either selective or non-selective for MAO-A or
MAO-B. Whether a drug is selective or not is determined by the subtype of
monoamines it inhibits. Whether it is reversible means whether its effect is
permanent or not. Irreversible MAOIs can completely switch off monoamine
oxidases, and it can take a while for these enzymes to return, even after the
drug is discontinued.42,43 Selectivity can make a difference in how a drug is
used, as well as some of its side effects. For example, a drug that is
selective for MAO-B does not require the dietary restrictions common with
MAOIs because it works with MAO-B that is found in the brain and liver and
not with MAO-A, which is found in the intestinal tract and can break down
tyramine.43
Many MAOIs are prescribed as oral pills, although there is a transdermal
patch that is also available. Oral medications can cause side effects of
dizziness, orthostatic hypotension, drowsiness, and nausea. As is commonly
known, people who take MAOIs should avoid eating certain foods that
contain tyrosine or tyramine because of the reaction to the MAO-A in the
body. The U.S. Food and Drug Administration (FDA) has developed a list of
restricted foods for patients who are taking MAOIs. Some of these types of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
27
foods include aged cheeses, draft beer, sauerkraut, pickled foods, or red
wine. Ingesting these foods can cause a drastic rise in blood pressure that
can be life threatening.42,43
Many people do not want to make the dietary restrictions required with
MAOIs, choosing to take medications that have fewer limitations. Even if
someone has taken an MAOI for a prescription, he or she should wait at
least 14 days before consuming foods with tyramine because a reaction
could still occur.
The transdermal patch that is available has caused some renewed interest in
MAOIs. Developed and then marketed in 2006, the patch is called the
selegiline transdermal system (Emsam®). It does not require the dietary
restrictions that some other MAOIs do, and, because it is worn as a patch, it
can be easier to use than taking a daily dose of medication and has been
positively received.
The patch is the first transdermal system approved by the U.S. FDA for the
treatment of depression. The patch is placed on the skin once a day and the
medication is absorbed through the skin over the course of 24 hours. Doses
are available between 6 and 12 mg doses delivered over 24 hours.43
The transdermal patch is normally not affected by the dietary restrictions
often needed through other oral MAOIs. This is because it is absorbed
through the skin and not the gastrointestinal system where most MAO-A is
located. The dietary restrictions are not necessary for patients taking the
lowest doses of the medication, the 6 mg patch. However, dietary
restrictions are recommended in larger doses of 9 mg or 12 mg that are
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
28
available to protect against the larger doses of the medication affecting the
tyramine in the gut.43
The most common side effects associated with using the transdermal patch
include a rash or reaction at the site of the patch placement, headache,
insomnia, dry mouth, upset stomach, and orthostatic hypotension. Patients
may have some success with skin reactions by rotating the sites of where
they place the patch when they apply it. For those who have trouble sleeping
while using the transdermal system, it may help to apply the patch in the
morning and then take it off before going to bed, applying a new patch again
in the morning.43 Additionally, the patch can be expensive with a
prescription and individual insurance plans may vary as to coverage of the
cost.
Monoamine oxidase inhibitors can also have unsafe interactions with other
medications, potentially causing serotonin syndrome, a condition that results
from too much serotonin in the body. Drug-drug interactions with MAOIs
that should be avoided include SSRIs, SNRIs, TCAs, Demerol, and St. John’s
wort. Combining MAOIs with some types of cough medications or cold
preparations can also cause problematic symptoms and should be avoided.43
Monoamine oxidase inhibitors are effective in treating major depression,
particularly when other medications have been ineffective, or in cases in
which some patients have very negative side effects from other drugs that
make their use too difficult. Patients with atypical depression benefit from
using MAOIs; the criteria for a condition being classified as atypical
depression includes mood changes associated with depression and a
combination of significant weight gain; hyperphagia, or eating too much;
hypersomnolence, or leaden paralysis.43 Some examples of MAOIs that may
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
29
be available include isocarboxazid (Marplan®), phenelzine sulfate (Nardil®),
and tranylcypromine sulfate (Parnate®).
Additionally, MAOIs have been shown to improve some symptoms of
fibromyalgia among patients who take these types of drugs. Studies of
patients taking MAOIs for fibromyalgia have shown that people most often
report a decrease in pain and muscle stiffness, with a lower number of
tender points overall. The MAOIs do not necessarily cause changes in a
person’s ability to sleep or in improving physical function.56
Norepinephrine Reuptake Inhibitors (NRIs)
Norepinephrine reuptake inhibitors (NRIs) are sometimes prescribed for pain
associated with fibromyalgia in patients who do not necessarily suffer from
depression. These drugs inhibit the reuptake of serotonin and
norepinephrine in the body. Norepinephrine is a neurotransmitter that is also
prevented from being absorbed due to the action of NRIs. Norepinephrine is
responsible for attentiveness and focus, and it helps to improve mood and
sleep. Norepinephrine also plays a role in the circulatory system, in which it
can cause the heart to beat faster and the blood vessels to constrict, which
can impact blood pressure.
Norepinephrine inhibitors can make people feel more alert and energized. On
the other end of the spectrum, they can also cause insomnia and can make
users feel restless or irritable. These medications are not as effective in
treating the pain of fibromyalgia as some other types of traditional
antidepressants, but they can be helpful in fighting fatigue and the fibro fog
(described earlier) that sometimes develops with the condition.42
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
30
Because NRIs do not have much impact on serotonin, there is less of a risk
of serotonin syndrome developing when these drugs are combined with
other types of antidepressants. Consequently, they may be used as part of
combination therapy with other medications to treat fibromyalgia symptoms
where the NRI treats fatigue and another medication handles the pain. NRIs
may also be beneficial because they do not have as significant side effects as
some other types of antidepressants. While some other medications can
cause weight changes, fatigue, or changes in sex drive, norepinephrine
reuptake inhibitors typically do not cause these effects, which can make
them a positive choice for patients who are otherwise struggling with side
effects of different medications already. An example of a NRI that may be
used is atomoxetine (Strattera®).42
Non-steroidal Anti-inflammatory Drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) are a non-narcotic
analgesic that may work well in managing chronic pain. When a person
develops pain, the body releases prostaglandins from damaged cells,
resulting in an increase in prostaglandins within the affected tissues.
Prostaglandins affect the nerve endings in the body that are responsible for
transmitting pain messages to the brain. The messages notify the brain
about the pain’s location and severity. The work of NSAIDs is to reduce
prostaglandin synthesis.
This process happens by the NSAIDs interfering with specific enzymes that
are involved in prostaglandin production, cyclo-oxygenase 1 (COX-1) and
cyclo-oxygenase 2 (COX-2). COX-2, in particular, plays a role in pain and
inflammation. When NSAIDs interfere with COX-2, they may be referred to
as COX-2 inhibitors and can diminish the amount of pain a person
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
31
experiences because of inhibiting the ability of nerve endings to send pain
messages to the brain.9
Non-steroidal anti-inflammatory drugs can have side effects associated with
gastrointestinal irritation. The increase in experiencing side effects from
these drugs also increases with age and among those who have previously
experienced gastrointestinal bleeding, such as with ulcers. COX-1 is
associated with proper kidney and liver function. There was a time when all
NSAIDs available inhibited both COX-1 and COX-2, which might have
controlled pain, but could also lead to kidney or liver damage. Other NSAIDs
are now available that only inhibit COX-2, decreasing the impact on the
kidneys and reducing certain side effects, as well as kidney damage that can
occur.9
COX-2 inhibitors can be used for treatment of chronic pain and inflammation
associated with certain conditions. There have been some COX-2 inhibitors
that have been developed and marketed, but also later recalled. Celecoxib
(Celebrex®) is currently the only COX-2 inhibitor available for treatment of
pain and inflammation. Not all NSAIDs are COX-2 inhibitors, although
traditional NSAIDs can also provide relief from chronic pain. These traditional
NSAIDs work to inhibit both COX-1 and COX-2 and are often effective for
pain control.
Many patients with fibromyalgia do not exactly benefit from using NSAIDs
because these drugs are typically designed to control inflammation. Although
fibromyalgia patients may feel pain similar to that of inflammation or may
feel joint pain and stiffness similar to some autoimmune disorders that result
in inflammation, laboratory tests and studies usually show no inflammation
present. Therefore, if a fibromyalgia patient is taking NSAIDs to treat the
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
32
pain of inflammation, these drugs as well as other medications used to
combat inflammation such as corticosteroids may not be very helpful.
Alternatively, a patient with fibromyalgia who also suffers from other types
of pain such as headaches or who has a concurrent inflammatory condition
such as osteoarthritis may benefit from using NSAIDs. Examples of NSAIDs
that may be used for management of pain associated with other types of
chronic pain conditions include ibuprofen (Advil®, Motrin®), and naproxen
(Aleve®).9
Anti-epileptic Drugs (AEDs)
Anti-epileptic drugs (AEDs), also called anticonvulsants, are prescribed not
only for the control of seizure activity but also to manage symptoms of
fibromyalgia.
In 2007, the U.S. FDA approved the use of an anticonvulsant called
pregabalin (Lyrica®) for the treatment of fibromyalgia. While other drugs
are commonly used to treat symptoms of fibromyalgia, pregabalin was the
first drug ever approved specifically for fibromyalgia management. Before
being approved for fibromyalgia management, pregabalin was also approved
for use to control nerve pain associated with diabetic neuropathy in 2004.
Anticonvulsants work by slowing the work of neurons in the brain and spinal
cord, which can reduce feelings of pain in some people. Anticonvulsants also
work to improve sleep in some people who have chronic pain or to improve
mood, such as by decreasing anxiety in people with mood disorders.
Anticonvulsants are prescribed for treatment of fibromyalgia symptoms
because it is believed that patients with the condition are more likely to have
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
33
increased levels of brain activity and stronger reactions to external stimuli,
which causes more pain and difficulties with sleeping.35
Results of studies to determine the effectiveness of pregabalin on symptoms
of fibromyalgia showed a reduction in pain and fatigue, as well as a decrease
in side effects from medications, specifically dizziness. Pregabalin can cause
some negative side effects, which may cause some people to avoid using the
medication. The most common side effects include drowsiness, weight gain,
vision disturbances, and difficulties with walking.35
Another type of anticonvulsant called gabapentin (Neurontin®) may also be
used in management of fibromyalgia symptoms. Gabapentin has been
approved for use in patients suffering pain from post-herpetic neuralgia that
occurs with shingles. However, it also can be effective on the pain of
fibromyalgia, and patients who have taken gabapentin have reported an
increase in pain management as well as improved sleep and reduced
fatigue.33 Although gabapentin is not technically approved for fibromyalgia
and it is considered an off-label medication for this purpose, it is chemically
similar to pregabalin and works in much the same manner. A 2007 study
showed that fibromyalgia patients who took gabapentin for 12 weeks had a
significant reduction in symptoms of pain and fatigue and were able to sleep
better.36
Sedative-Hypnotics
Sedative and hypnotic drugs are those that are used to provide a calming
effect, to promote relaxation, and to induce sleep. These drugs may be
classified as sedatives, which are medications that are calming and reduce
irritability; and hypnotics, which induce sleep when they are taken.
Sedative-hypnotics are those drugs that work as both sleep-inducing and
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
34
calming drugs. Sedative-hypnotics are further classified as benzodiazepines,
barbiturates, and miscellaneous.36
Many sedative-hypnotics are also referred to as sleeping pills. While it might
seem logical for a person with fibromyalgia to take a sleeping pill for
difficulties with sleep, using some sedative-hypnotic medications could be
counterproductive to managing fibromyalgia symptoms. The use of sedativehypnotics to improve sleep, even those that are available without a
prescription, should be reviewed with a healthcare provider.
The issue with some sedative medications is that they change the levels of
depth of sleep for some people who use them. People need deep sleep in
order for their bodies to release a chemical that helps restore tissue damage
that has occurred during the day. Too little of this deep sleep and decreased
restoration can lead to muscle pain and stiffness. Some sedative medications
used to promote sleep may put the person using them into only lighter
stages of sleep, reducing the chance to achieve deep, restorative sleep. In
this way, sleeping pills can actually be counterproductive in some
situations.22 The prolonged interruption of deep sleep because of sedative
hypnotics reduces the overall amount of REM sleep that a person achieves,
which is a state called REM interference.36 Therefore, it is extremely
important for people with fibromyalgia to find the right type of medication to
use as a sedative-hypnotic to promote sleep.
Benzodiazepines depress activity in the central nervous system. These drugs
were once the most commonly prescribed types of sedative-hypnotic drugs,
but this is no longer the case. Benzodiazepines may be classified as either
sedative-hypnotics or anxiolytics, the latter being used to treat chronic
anxiety and provide a calming effect. Benzodiazepines depress some activity
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
35
of the hypothalamus, thalamus, and limbic systems. These drugs can also be
effective because they are not as disruptive to deep sleep so patients taking
them can still achieve restorative sleep. An example of a medication in this
category approved for use by the U.S. FDA to treat insomnia is eszopiclone
(Lunesta®).36
Benzodiazepines can be used to treat anxiety or depression, and they
promote sleep and can cause muscle relaxation. All of these indications can
be useful among patients with fibromyalgia and chronic pain. They are also
effective when they are combined with other types of medications,
particularly with analgesics. Patients who use these drugs should utilize
them on a short-term basis if possible and they should be well controlled
because of their potential to cause addiction.
Numerous side effects can be caused by benzodiazepines, most notably the
feeling of having a hangover after using them. Patients who take them
regularly are also at higher risk of withdrawal symptoms when they attempt
to stop. Some types of benzodiazepines include midazolam (Versed®),
diazepam (Valium®), and temazepam (Restoril®).36
There are some sedative-hypnotic benzodiazepine medications that can be
effective in promoting sleep among patients with fibromyalgia. One study of
patients who took 10 mg each night of zolpidem (Ambien®) reported falling
asleep faster, decreased awakenings during the night, and decreased
evening sleepiness. Ambien may also be an option for people who suffer
from fibromyalgia and restless legs syndrome, as the latter condition seems
to develop more commonly among patients with fibromyalgia.22
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
36
Barbiturates are another class of sedative-hypnotic medications that can be
used to induce sleep, control pain, and improve relaxation among people
with chronic pain. Barbiturates were discovered over 100 years ago and
many different types of these drugs were used for several years. Currently,
there are much fewer types of barbiturates that are prescribed for patients
because of their potential for harmful adverse effects, including the potential
for overdose and enzyme induction.
Barbiturates are central nervous system depressants and inhibit nerve
impulses in the cerebral cortex of the brain. The desired effect of these
drugs, whether for calming or to induce sleep is determined by the amount
prescribed. In other words, different amounts are prescribed based on the
desired end-effect. Barbiturates can cause drowsiness and induce sleep;
they are also used as anticonvulsants among patients who suffer from
seizures. Unfortunately, they impact rapid eye movement (REM) sleep
enough that restorative effects are not always attained, which may make
them less of an option for sleep issues associated with fibromyalgia. In fact,
people who consistently use barbiturates and who suffer from a lack of
adequate REM sleep may encounter a rebound effect when they stop using
the drugs, which leads to a much greater increase in REM sleep, including
many more vivid dreams and frequent nightmares.36
Barbiturates may also impact the utilization of some other medications by
the liver because they act as enzyme inducers. This means that they
stimulate enzymes in the liver to break down medications more quickly, and
the effects of the medications may not last as long. This can be problematic
for some types of medications, particularly those where long-term use is
needed and the effects must last for a long period of time. Finally,
barbiturates combined with some other substances, such as alcohol, can
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
37
cause significant central nervous system depression, which can lead to
altered levels of consciousness, coma, or even death if too much is used.
Patients who use barbiturates for treatment of pain must carefully monitor
their activities to ensure they are not combining medications or other
substances with these drugs that could cause adverse or harmful effects.
Examples of barbiturates that may still be prescribed include pentobarbital
(Nembutal®) and phenobarbital.36
Despite the number of sedative-hypnotics available for use, few have shown
to have very positive effects on promoting sleep in patients with fibromyalgia
and chronic pain. The most significant effects of these drugs were in
improvement of sleep habits and increases in restorative sleep; however,
their use to control pain or fatigue in fibromyalgia patients is limited.
Although sedative-hypnotics may be used in combination with other
therapies for management of sleep problems, these drugs are not typically a
first choice for controlling fibromyalgia symptoms.21
Muscle Relaxants
Because of the pain, tenderness, and muscle tension associated with
fibromyalgia and many other chronic pain conditions, muscle relaxants may
be beneficial as part of treatment. People who experience chronic pain can
develop muscle tension as the body’s response to pain or tenderness when
being touched. Muscle tension may also develop as a result of inflammation
or because of stress due to chronic pain. When a person experiences muscle
tension, the affected muscles become tight and contract; they do not move
as well and the patient may have even more pain. Muscle contraction
reduces the amount of blood flow to the affected areas.9
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
38
Muscle relaxants work through an increase of the blood flow to the muscles
that have tensed and constricted. The increased blood flow can then help to
relieve some of the pain or inflammation.9 Muscle relaxants have been
shown to improve symptoms of muscle pain among patients with
fibromyalgia, although the exact mechanism of how they improve symptoms
is not entirely clear.
It may be due to their relaxing effect on the muscles or the loosening of the
muscle tissues that can relieve some of the pain. Some studies have also
shown that using muscle relaxants can improve sleep, and the relaxation of
muscle groups may help patients to sleep longer and to suffer from less
fatigue.22
Muscle relaxants can be effectively used for fibromyalgia treatment when
combined with other practices or therapies, including physical therapy. The
combination of stretching exercises, increasing range of motion exercises,
strengthening and flexibility that can result from physical therapy along with
muscle relaxant use can be beneficial in managing muscle pain and stiffness
for many people.22
Like most other medications, muscle relaxants can have negative side
effects that cause some people to discontinue their use. Anyone who wants
to stop taking muscle relaxants after regular use should contact a healthcare
provider to slowly reduce the amount of medication they are taking, as
immediately stopping treatment can have negative effects. Side effects of
using muscles relaxants include an increase in sleepiness or daytime
drowsiness; taking the medications in the evening when the patient is
planning to go to bed often best controls this. People who take muscle
relaxants should determine the effects of these drugs on their bodies. If the
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
39
medication consistently causes drowsiness, it will need to be modified in
terms of the timing of the dosages and certain activities will need to be
avoided that can be unsafe, such as driving.
Other side effects of muscle relaxants that have been reported include
nausea, dizziness, light-headedness, unsteady gait, confusion, vision
disturbances, dry mouth, and muscle weakness. The muscle weakness that
can develop as part of using muscle relaxants can work against other types
of therapies, such as physical therapy. A patient who wants to take muscle
relaxants as well as undergo physical therapy for fibromyalgia should notify
his/her doctor to adjust the dose. In some cases, using muscle relaxants
counteracts the effects of physical therapy, so concurrent use with both
types of therapies must be monitored.22
Muscle relaxants may be used alone or in combination with other types of
medication to achieve the desired effects of pain control and improved sleep.
A healthcare provider should be made aware of any other medications the
patient is taking and when prescribing muscle relaxants for fibromyalgia
symptoms, the provider should determine the most prominent symptoms
the patient is experiencing and work to prescribe a combination of
medications and therapies that will best provide relief, which may include
muscle relaxants. Some types of muscle relaxants that may be prescribed
for management of fibromyalgia include carisoprodal (Soma®) and
cyclobenzaprine (Flexoril®).8
Opiates and Opioids
Opiates and opioids are medications used to manage moderate to severe
pain. Opiates are types of narcotic analgesics that originally come from the
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
40
opium poppy, known as Papaver somniferum. Examples of opiates include
codeine and morphine.
Alternatively, opioids bind to opiate receptors in the tissues and include
synthetic drugs, as well as opiates that are derived from the poppy plant.
For example, morphine is classified as an opiate and an opioid, but another
drug such as fentanyl, is only classified as an opioid. The two terms are
often used interchangeably, although there are differences between the two.
Opioids may be classified as agonists, antagonists, and agonist-antagonists.
Opioid agonists may be further classified as being mild or strong. Codeine is
an example of a mild opioid agonist, while morphine or oxymorphone are
considered strong agonists. Opioid agonists bind to receptors in the brain
and reduce the sensation of pain, which is known as an analgesic response.5
An agonist-antagonist, which may also be referred to as a partial agonist,
does not produce as much of an analgesic response as an agonist drug. An
agonist-antagonist drug binds to both mu and kappa receptor sites. These
medications are not always used for severe pain but may be a choice among
some people who have opioid dependency. Antagonist medications do not
produce analgesic responses in the body and are not used to treat pain.
They do, however, bind to pain receptor sites and compete with the agonist
medications. An example of an antagonist is nalaxone (Narcan®), which
may be given to some patients who develop respiratory depression as a
result of oversedation from opioid medications.5
Tolerance for opioids is one negative impact of regular use of these types of
drugs. Tolerance develops when changes in the body’s receptors make them
less susceptible to the effects of opioids over a period of time. Consequently,
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
41
the patient may require larger doses of opiates to achieve the same effect.5
Breakthrough pain may also occur with regular opioid use and increased
tolerance for these drugs. Only a certain amount of opiates can be given at
certain intervals as directed by the physician in order to be safe and reduce
negative effects, such as respiratory depression.
When opioid tolerance develops, the patient may require larger doses of
these medications to achieve the same effect, but may also suffer
breakthrough pain when the medication wears off. If it is too soon to safely
give another dose of the medication, the patient may then suffer from
breakthrough pain. Often, adjuvant drugs such as NSAIDs or corticosteroids
can be helpful with opiates to achieve pain control without adding to the
narcotic effects of the opiates.
The consistent use of opioids for treatment of pain associated with
fibromyalgia is controversial.33 Many patients who have severe pain from the
condition need more medications for pain relief but consistent use of these
drugs can cause tolerance, which may require greater amounts of the drugs
to achieve the same effect, as well as dependence, in which the patient
physically or psychologically needs the drug to continue functioning in the
same capacity.
In a situation such as fibromyalgia in which the goal is to manage symptoms
instead of completely cure the condition the regular use of opioid
medications may start something that cannot necessarily be finished. In
other words, if a patient is using opioids to control the pain of fibromyalgia,
but not using other methods of pain control, and is unable to find a
treatment that will stop the pain entirely, the use of opioids must continue,
which can be detrimental and dangerous over a long period of time.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
42
Other unwanted effects that may occur with the use of opiates and opioids
include flushing, itching, and rash. These effects may occur as a result of
histamine release when the drugs are administered and are not classified as
true allergic reactions. Some patients complain of constipation or nausea,
which are considered to be negative side effects.
Additional Pharmacologic Treatments
In addition to the many different types of pharmacologic treatments
available to manage fibromyalgia symptoms, there are still others to list that
can also be beneficial. Two more drugs have been approved specifically in
the treatment of fibromyalgia symptoms: duloxetine and milnacipran
(further discussed below), which are serotonin-norepinephrine reuptake
inhibitors.
The approval and use of duloxetine and milnacipran constitutes another
breakthrough in finding methods of symptom management for fibromyalgia.
Serotonin-norepinephrine reuptake inhibitors (SNRIs) inhibit the uptake of
both serotonin and norepinephrine neurotransmitters in the brain and spinal
cord. These drugs may be better tolerated and have fewer side effects than
tricyclic antidepressants.21
Duloxetine (Cymbalta)
The U.S. FDA approved Duloxetine (Cymbalta®) as the second drug to be
used in the treatment and management of fibromyalgia symptoms.
Duloxetine is a type of serotonin-norepinephrine reuptake inhibitor that was
originally created and used for the treatment of depression and diabetic
peripheral neuropathy.
Individuals that use duloxetine may have improved symptoms of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
43
pain and feelings of wellbeing because the medication improves levels of
serotonin and norepinephrine in the brain. The most common side effects
associated with duloxetine are dry mouth, nausea, dizziness, and
constipation. Duloxetine may also increase the risk of suicidal ideation in
some people, in particular when the drug is used for the treatment of
depression.37
Milnacipran (Savella)
Milnacipran (Savella®) is another type of serotonin-norepinephrine reuptake
inhibitor that has been approved for the management of fibromyalgia
symptoms. It works in a manner similar to duloxetine and also has similar
side effects to other antidepressants, but unlike duloxetine or pregabalin,
milnacipran was not originally developed as a type of medication used to
treat another condition. It was instead developed and approved specifically
for management of fibromyalgia. Milnacipran has been shown to reduce
pain, improve physical activity, and improve overall symptoms of
fibromyalgia, making it a viable option for control of symptoms for many
people.37
Acetaminophen
Acetaminophen is one of the most common analgesics used in the U.S.
Acetaminophen has many benefits, including having fever-reducing
properties and fewer side effects than some other types of medications,
including NSAIDs. Tylenol® is a well-known brand of acetaminophen, which
can be purchased over the counter, although it is also available in larger
strengths, which require a prescription from a healthcare provider.
Acetaminophen works by increasing the pain threshold, so the person taking
the drug has to experience more pain before he/she begins to feel it. The
drug can be taken on a regular basis, although the maximum amount
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
44
recommended is no more than 4,000 mg in 24 hours. This is the equivalent
of taking two 325 mg tablets of Tylenol every 8 hours. People who use
acetaminophen on a regular basis must monitor for side effects, which are
few, but too much of the drug over time can lead to liver damage.9,36
Acetaminophen is also commonly combined with other medications, which
further increases its therapeutic benefits. For example, acetaminophen may
be combined with codeine, which provides the pain relief of opioids as well
as fever-reduction properties. Acetaminophen has no anti-inflammatory
properties, but for patients with fibromyalgia who do not have inflammation
or swelling anyway, this should not matter. Taking acetaminophen can be
very beneficial in the management of chronic pain, allowing the person in
pain to experience some relief while using other therapies to control
symptoms as well.
Tramadol (Ultram)
Tramadol (Ultram®) is a type of pain reliever that has a weak opioid effect,
and has many of the pain-relieving properties of acetaminophen. It does not
have anti-inflammatory properties, nor is it classified as an NSAID. It works
in a manner similar to acetaminophen but with the stronger properties of
opioids to effectively control moderate to severe pain. Tramadol has been
prescribed for patients with fibromyalgia and is a good option for pain relief
because it is not habit-forming.
Tramadol, as well as a drug that contains a combination of tramadol and
acetaminophen (Ultracet®), are not technically classified as opioids, even
though they can treat severe pain. Instead, they seem to have properties
similar to selective serotonin reuptake inhibitors, and they are classified
separately. Tramadol also has the added benefit of providing extended relief,
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
45
so that dosages are required less often to achieve the same effect of pain
relief.21
While used primarily as an expectorant to reduce the amount of mucous in
people who have colds, some people also use Guaifensin for the treatment of
fibromyalgia. Paul St. Amand developed the Guaifenesin Protocol after
determining that medications used for gout could help symptoms of
fibromyalgia. The gout medications are no longer in use for this purpose but
some practitioners changed to prescribing guaifenesin as a treatment
instead because it had the same effects and is safer to use.
Essentially, the guaifenesin theory states that people with fibromyalgia who
use the medication have increased levels of excreted phosphate, oxalate,
and calcium in the urine. The theory states that people with fibromyalgia
might retain larger amounts of these substances instead of normally being
excreted by the kidneys. It is thought that the abnormally high levels of
phosphate, oxalate, and calcium levels in the bodies of people with
fibromyalgia are part of the cause of their many symptoms. If taking
guaifenesin can increase excretion of these substances, then people with
fibromyalgia should no longer suffer from its debilitating symptoms.52
There are people who state that using guaifenesin has changed their lives
and some providers claim to have “cured” patients of fibromyalgia using this
medication.52 However, there are many others who recommend staying
away from this idea, saying that it is useless and does not work. The
research and science of how guaifenesin might work to counteract the
effects of fibromyalgia and to develop it as a valid form of symptom
management continue. Patients who wish to try this protocol should speak to
their healthcare providers about its efficacy.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
46
Integrative Treatment For Fibromyalgia
Because chronic pain management can be a complex process, many patients
benefit from a combination of both pharmacologic and nonpharmacologic
treatments. In addition the drug therapy, there are many other types of
supplements and integrative (complementary) treatments that can
effectively work with medications to help control chronic pain.
Other types of treatments that are not classified as medications include
dietary supplements and mind-body work such as chiropractic manipulation
or massage. These other treatments work by improving the levels of
chemicals in the body that can cause fibromyalgia symptoms when they are
low. They may also physically impact the body so that it responds, such as
by using the immune system’s protective properties or increasing circulation.
A method of chronic pain management known as the rehabilitative model
combines techniques to treat chronic pain and discomfort as well as to teach
the patient coping strategies and other methods for handling the pain when
it does not completely resolve. Healthcare providers who use the
rehabilitative model may come up with a set of treatments and therapeutic
interventions that the patient with fibromyalgia or chronic pain can
implement that will help symptoms. Additionally, the rehabilitative method
also helps the patient to cope with his/her symptoms in order to continue to
live life fully while managing symptoms.
In addition to pharmacological treatments, many therapies exist that are
extremely beneficial in promoting comfort and relaxation and can be used
alongside medications. Other treatments that are not pharmacological in
design can be very effective in controlling pain, improving feelings of mood
and well being, and increasing sleep for many people who are suffering from
chronic pain.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
47
Dietary Supplements
The market for herbs and dietary supplements has exploded in recent years
with so many products to choose from available on shelves in pharmacies
and grocery store aisles. Many of these products are not regulated by the
U.S. FDA and an unsuspecting person who wants to find help by using
supplements could find or use the wrong type that may not work or could be
a waste of money. However, there are also many supplements available that
can improve symptoms of pain and fibromyalgia and have been studied
through research and shown to be effective.
Supplements, when carefully chosen and monitored with help from a
healthcare provider, can be beneficial, particularly when used alongside
other conventional therapies. Some are discussed in the section below.
5-Hydroxytryptophan
Referred to as 5-HTP, 5-hydroxytryptophan is a dietary supplement that
may be used to control pain and other negative symptoms among people
with fibromyalgia and chronic pain syndromes. 5-HTP is created in the body
through the conversion of the amino acid tryptophan, which is found in some
foods.13 However, 5-HTP cannot be ingested through diet alone; larger doses
than what the body makes must be taken in through supplements.
Tryptophan is an amino acid that is found in some foods, such as turkey,
milk, chicken, and potatoes. Tryptophan is first converted into 5-HTP in the
body, and following this conversion, the 5-HTP is then further converted into
serotonin. Ultimately, increased levels of 5-HTP are thought to increase
overall levels of serotonin in the body, leading to better regulation of
moods.13
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
48
Because some people with fibromyalgia may have lower levels of serotonin,
5-HTP could be used as a supplement to increase serotonin levels and to
help manage the syndrome. There have been three studies that have shown
5-HTP to improve symptoms of fibromyalgia, including pain and tenderness,
sleep difficulties, morning stiffness, and fatigue among people suffering from
the disorder.13 It is thought that 5-HTP may have a similar effect as
antidepressants in the body and may therefore serve to better manage
fibromyalgia symptoms. However, not all people with fibromyalgia have had
relief with 5-HTP supplements and studies are ongoing to determine its
benefits.
5-hydroxytryptophan may also help with people who have sleep difficulties,
whether it is due to chronic pain or other conditions. People who take 5-HTP
supplements may be more likely to fall asleep faster and to sleep more
deeply when compared with those who do not take the supplement. 5-HTP
has also been compared with some antidepressants as far as its
effectiveness in reducing symptoms of depression. In one study, 5-HTP was
compared with the antidepressant fluvoxamine and found that those who
took 5-HTP had just as many positive effects as those who took the
antidepressant. Because the study population was small, more research
studies are needed to assess the effectiveness of 5-HTP when compared to
antidepressants.13
People who take 5-HTP must use it as a dietary supplement, which can be
purchased over the counter. The supplement comes from a plant in Africa
called Griffonia simplicifolia. The typical dose is 50 mg, taken up to three
times daily in adults.13 Patients who take 5-HTP for fibromyalgia should talk
to their healthcare providers about possible side effects and any interactions
the supplement may cause with other medications or supplements.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
49
Tryptophan, while available in certain foods, is not available as a dietary
supplement. When created and marketed as a supplement, it was later
discovered that it contained a contaminant called Peak X that caused a
connection with the development of eosinophilic myalgia syndrome, a
disorder that significantly impacts the skin, muscles, and blood and that can
be fatal. Because supplemental tryptophan caused the severe side effects in
some people, it was eventually taken off the market.13
Because 5-HTP can increase levels of serotonin in the brain, it should not be
used with other antidepressants that also have the same effect. The
potential for excess levels of serotonin caused by both the supplement and
the antidepressant may cause serotonin syndrome, a condition that results
in tachycardia, high blood pressure, increased body temperature, and
hypereflexia. In some cases, the condition can be life threatening.
In particular, 5-HTP should not be used with SSRI antidepressants because
of the effects on serotonin, however, it can also negatively interact with
other types of antidepressants, including tricyclic antidepressants and
monoamine oxidase inhibitors.13 Patients with fibromyalgia who would like to
manage their chronic pain, depression, and sleeplessness with 5-HTP should
carefully consider its risks and benefits and speak with a healthcare provider
before starting to determine the appropriate dose.
S-Adenosyl-L-Methionine
Also referred to as SAMe, s-adenosyl-l-methionine is available as a
supplement that may be useful in the treatment of depression and
osteoarthritis. SAMe is produced in the body and is found in many different
tissues and body fluids. SAMe normally is involved with maintenance of cell
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
50
membranes, it helps to support the immune system, and it is involved with
production of certain neurotransmitters such as serotonin.
S-Adenosyl-L-Methionine is created in the body by the amino acid
methionine, and adenosine triphosphate (ATP), which is a source of energy.
It is also available as a supplement, but it is not found in food. Some people
may have a SAMe deficiency if they have other conditions that reduce their
levels of vitamin B12, folate, or methionine.25 To take in more SAMe than
the body already creates requires the use of supplements.
The amount to take of each supplement varies, depending on the condition
being managed. Patients who use SAMe for treatment of fibromyalgia
symptoms may take 400 mg of the supplement 2 times per day for 6 weeks.
Other conditions require different dosages. For example, management of
osteoarthritis typically requires 600-1200 mg daily in divided doses, while
the treatment of depression may need 800-1600 mg per day, divided
between morning and afternoon.24
There have been limited studies as to the effectiveness of controlling
fibromyalgia symptoms with SAMe. Of the studies that found SAMe to be
effective, the symptoms that were best controlled were morning stiffness,
pain, fatigue, and depression. SAMe has also been studied in the treatment
of osteoarthritis symptoms and supplements that may help to reduce pain
and joint inflammation. One study showed that SAMe was just as effective in
controlling chronic pain from osteoarthritis as NSAIDs. Finally, SAMe may
also be effective in the management of mild to moderate depression. Some
studies have shown that SAMe may be as effective in treating depression as
some antidepressants, and, that it works more quickly and has fewer side
effects.24
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
51
There are some drawbacks to the idea of using SAMe to solve the problem of
fibromyalgia symptoms. For one, many of the studies conducted on the
efficacy of the supplement were tested using injectable forms. Because most
people take oral preparations to take supplements, the benefits of SAMe
through an injectable form may not be as realistic for people who do not
take it in this method. Studies of the effects of SAMe when given as an oral
supplement are still ongoing.24 Another drawback of using SAMe as a
supplement is that it can be quite expensive. The cost of using is can be
prohibitive for many patients with fibromyalgia and chronic pain who must
also pay for other types of therapies and treatments.25
People who want to use SAMe for management of depression should only
attempt to treat mild or moderate depression. For those with severe
symptoms or activities that involve self-harm, other medications, including
antidepressants, are usually necessary. SAMe may also interact with some
types of antidepressants, including SSRIs, MAOIs and tricyclic
antidepressants.25
The interactions of SAMe with SSRIs, MAOIs and tricyclic antidepressants
could lead to serotonin syndrome due to excess release of the
neurotransmitter.24 Patients with fibromyalgia and severe depression should
not rely only on SAMe to control their symptoms and should seek to use this
type of supplement alongside other treatments as well. Anyone who wants
to use SAMe as a form of symptom management for pain, depression, or
fibromyalgia should consult with a physician before starting.
Magnesium
Magnesium is a mineral found in various foods, but it can also be consumed
as a supplement. Magnesium serves several important functions in the body,
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
52
including regulating muscle and nerve function, adjusting stress response,
and for energy production. It is also essential for regulating heart rhythm
and is required for the synthesis of an antioxidant in the body known as
glutathione.
Most magnesium in the body is contained within the bones and soft tissues.
A small percentage of body magnesium is in the bloodstream, which can
make testing for magnesium levels difficult. Testing the blood — serum
concentrations — even though the majority of magnesium is elsewhere in
the bones and tissues, covers most types of testing for magnesium levels.
Although there are other methods of testing magnesium, which may include
testing urine or saliva, there is not a general consensus on the best method
of determining the most accurate magnesium level.18 Testing serum levels is
a simpler method and can be done as part of routine laboratory testing, but
performing an adequate clinical assessment to determine signs or symptoms
of low magnesium is also important when checking serum levels of the
mineral.
The recommended daily intake of magnesium for adults is 400 mg daily for
men and 310 mg for women age 19 to 30 years, climbing to 420 mg daily
for men and 320 mg daily for women over age 31. Many Americans do not
take in enough magnesium in their daily diets; however, a true magnesium
deficiency is not common because the kidneys control how much is excreted
through the urine.18 However, inadequate amounts of magnesium can be
associated with chronic pain, including migraine headaches and possibly
symptoms of fibromyalgia.16
Because magnesium plays a role in the body’s stress response, as well as
how the muscles turn fuel into energy, inadequate amounts of magnesium in
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
53
the body could then contribute to fatigue and pain associated with increased
stress and decreased energy. Although dietary intakes of magnesium may
not be enough, most people are not chronically low in magnesium, except in
in cases where gastrointestinal issues prevent its absorption or in other
situations, such as alcoholism.18 However, among people who do have lower
than normal levels of magnesium due to illness or lack of dietary intake,
problematic symptoms can develop.
A study published in Rheumatology International showed that there may be
a connection between decreased magnesium and increased tender body
points, fatigue, sleep issues, headaches, and gastrointestinal
disturbances.16,19 Magnesium deficiency can also impact how well
neurotransmitters are released in the brain and may cause vasoconstriction.
Both of these situations can lead to increased amounts of pain and other
symptoms associated with fibromyalgia. Increasing intakes of magnesium
through diet or supplements has been shown to be effective in preventing
some types of chronic pain, including headaches.18
Magnesium is available in many foods, particularly those that are high in
fiber. Examples of foods that are good sources of magnesium include:18

dark-green vegetables such as spinach or broccoli;

nuts, including almonds and cashews;

beans and legumes, apples, carrots, and fortified cereals;

grain products that have been refined, such as white bread or white
rice where the outer bran has been removed, often have much lower
levels of magnesium when compared to whole grains and should be
avoided.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
54
Magnesium may also be found in water, although some brands of bottled
water may have more magnesium than others or from that of tap water.
Magnesium is available as a dietary supplement. It comes in different forms,
including magnesium oxide, citrate, and chloride. Depending on the form in
the supplement, the absorption of the nutrient may vary. Some studies have
found that magnesium citrate and magnesium chloride are absorbed more
readily when compared to magnesium sulfate or magnesium oxide. Some
products can also interfere with absorption of magnesium, so monitoring for
these interactions is important to gain enough of the nutrient to derive
benefits. Magnesium is also available in some medications, particularly
laxatives or those used for heartburn, including Phillips’ Milk of Magnesia®
and Rolaids®, respectively.
Some of these products can contain very large amounts of magnesium,
which could result in toxicity if too much of the medication is consumed.
However, much of the magnesium may not be absorbed in some cases, such
as when taken with laxatives, because a percentage of the magnesium may
just be eliminated from the body.18 Patients who want to help their
symptoms of fibromyalgia by increasing intake of magnesium should
carefully consider the effects of too much of the mineral.
In most cases, a person does not take in too much magnesium through diet
alone. Alternatively, magnesium through supplements and even through
medications and antacids may provide too much. Magnesium toxicity can
result in nausea, vomiting, and urinary retention, and could lead to
hypotension and cardiac arrest.18 Magnesium supplements may also
interfere with certain medications, which may impact some patients.
Magnesium has been shown to affect absorption of some types of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
55
medications, such as those taken for osteoporosis and some antibiotics. An
individual that wants to take magnesium supplements should discuss it with
his/her healthcare provider to determine the risks and benefits for its use in
the treatment and prevention of chronic pain.
Magnesium could pose benefits for some people. Increasing magnesium
intake, particularly through dietary sources, can increase the amount of the
mineral in muscle tissues, improve energy, and potentially improve stress
responses. Magnesium supplements used to treat symptoms of fibromyalgia
may be more effective when combined with other treatments, such as
antidepressants.16 The combination of dietary supplements such as
magnesium with pharmaceutical treatment often helps many people in the
management of their condition.
Melatonin
There is some evidence that taking melatonin supplements may help to
improve sleep that is disrupted as a result of fibromyalgia and chronic pain.
Melatonin is a hormone that is normally produced by the pineal gland in the
brain in response to changes in the amount of light in the environment and
the circadian rhythms affiliated with sleep. Most people naturally become
sleepy and fall asleep when it is dark at night, and then are awake during
the day.
During the day when there is more light in the environment, the body
produces very little melatonin. During the evening when the light in the
environment becomes dimmer and the time for sleep is approaching, the
body begins to produce more melatonin through the pineal gland. This
increase in melatonin production often occurs around 9 pm and levels tend
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
56
to remain elevated for approximately 12 hours. As the levels of melatonin
increase in the blood, the person starts to feel sleepy.
In order for melatonin to work properly, the surrounding environment must
be dark or at least have less light than that of the daytime. Bright lights, use
of electronics late in the day, and sunlight can restrict the effect of
melatonin, even when it is the body’s normal time for sleep. The brain may
know that it is a normal time for sleep based on the time of day or evening,
but the pineal gland will not produce melatonin unless the person is actually
in a darker environment.15
The body regulates its response to light and dark through certain pathways
that control hormones and other processes that make a person feel sleepy or
awake. As light enters the eye, a nerve that runs from the retina at the back
of the eye to the hypothalamus is stimulated. An area in the hypothalamus
called the supra-chiasmatic nucleus (SCN) is then stimulated to signal the
brain to react by producing substances and stimulating parts of the body to
respond to the light.15
The SCN works to control sleep and wakefulness in response to light through
such mechanisms as stimulating the release of stress hormones such as
cortisol or raising body temperature. The SCN can also prevent the release
of melatonin until a more appropriate time of day, such as when it is getting
dark and becoming a natural time for sleep.15
Sleep disturbance is a common issue for patients who suffer from
fibromyalgia. A person with fibromyalgia often has difficulty falling asleep or
staying asleep, and his/her sleep patterns may be disrupted throughout the
night, which may cause awakening with a sense of not feeling rested. Lack
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
57
of sleep also leads to other issues as well, as increased fatigue can cause
difficulties with memory and concentration. Chronic sleep deprivation is also
associated with depression and anxiety.15
Several studies have indicated that people with fibromyalgia may have lower
levels of melatonin in the bloodstream during periods when the body would
normally excrete the hormone to induce sleep.15 Decreased levels of
melatonin can then worsen sleep issues and might be the cause of some
sleep problems to begin with that are affiliated with the condition.
Melatonin is available as a supplement and can be purchased without a
prescription for use to induce sleep. It is often used very effectively among
people who perform shift work or those suffering from jet lag. However,
melatonin supplements may help to induce sleep among patients with
fibromyalgia and chronic pain, thereby not only improving sleep patterns,
but potentially reducing some levels of associated pain and fatigue.
While melatonin can be purchased over the counter and many people have
used it successfully, there is not one exact dose that has been found to be
beneficial. Additionally, since it is sold as a dietary supplement (because it
can be found in some foods), the U.S. FDA does not regulate it and the
amount of melatonin that is within the package may or may not be what is
found on the label. In other words, there is not one specific amount of
melatonin dosage that works for all people, and the exact amount to take to
induce sleep may vary from person to person. Additionally, even taking one
pill that contains a melatonin supplement may cause significant increases of
the hormone within the body. Unfortunately, the person taking melatonin
has little control over how much he/she actually ingests when taking each
supplement.15
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
58
Melatonin can cause some side effects among those who use it as a sleep
aid. The most common side effects are dizziness, a reduction in sex drive,
vivid dreams, headache and irritability. It has also been shown to increase
symptoms in people who have been diagnosed with clinical depression. Low
doses of melatonin may be as effective as higher doses of the supplement,
and many people have just as much success with achieving sleep by taking
smaller doses as with the larger amounts. This may be difficult to regulate,
depending on the amount available on the package, so reading the package
before purchase can indicate how much to buy to start out.21
Ultimately, a patient with fibromyalgia may benefit from using melatonin
supplements and should seek the advice of her healthcare provider for
directions on its use. When taken as a supplement, melatonin must be taken
at a normal time to induce sleep or a person’s body clock and sleep rhythm
may be thrown off. For example, if a person takes a dose of melatonin first
thing in the morning and remains in a darkened area, he/she may feel
drowsy or be able to sleep at that time, but that person’s internal clock of
the appropriate time to sleep may be reset, which could lead to later sleep
difficulties.
There are many people who have found relief from sleep issues by using
melatonin supplements and there are few, if any, cases of reported overdose
of melatonin.15 For an individual that is looking for relief of sleep difficulties,
melatonin may be a solution for improving sleep.
St. John’s Wort
A supplement that derives from a shrub that blooms with yellow flowers, St.
John’s wort is one of the most popular herbal preparations available without
a prescription. The herb is known as Hypericum perforatum and it is taken
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
59
from a plant that is found growing in the western portion of the United
States, as well as parts of Europe, Asia, and Africa. The typical time of
bloom is said to be the end of the month of June, coinciding with June 24,
which is traditionally the birth date of St. John the Baptist.20
St. John’s wort has been studied extensively and has been shown to have an
impact on psychological effects such as mood, but it may also be helpful as
an antibacterial or antiviral agent. The herb has been associated with
successful management of several conditions, including treatment of minor
burns and wounds, management of symptoms of premenstrual syndrome
and menopause, and treatment of seasonal affective disorder.20
Despite its use to treat or manage a number of medical conditions, St.
John’s Wort may be most commonly affiliated with the control of symptoms
of depression. Various studies have shown that St. John’s wort may be
helpful in controlling mild to moderate depression, which is not only a
serious mood disorder that can lead to many physical difficulties, but is also
a common component found in people who suffer from fibromyalgia.
A chemical component called hypericin is found in St. John’s Wort, which
may have an effect on neurotransmitter levels in the brain that are
responsible for regulating mood and behavior. Although hypericin may be
the best-known component of St. John’s wort, the chemical may not actually
be responsible for altering neurotransmitters to impact mood. St. John’s
wort does contain other components that are also being studied extensively
for their action, such as flavenoids. In short, scientists are not sure exactly
what component of St. John’s Wort causes changes that help to treat
depression, therefore, studies continue to be performed as to the action of
its properties.20
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
60
St. John’s Wort works on neurotransmitters to treat depression, and there
are studies that show that the herb has similar effects on depressed mood
as antidepressants such as selective serotonin reuptake inhibitors (SSRIs).20
Depression is a major element of fibromyalgia, and antidepressants are a
common pharmaceutical method of treating the condition. People with
fibromyalgia may feel depressed as a symptom of having the condition.
Additionally, the pain and tenderness, fatigue, and sleep difficulties
associated with fibromyalgia may lead to symptoms of depression,
particularly when it is very difficult to diagnose the condition and there are
no outward symptoms that show a cause.
St. John’s Wort can be used to help improve a depressed mood among some
patients suffering from fibromyalgia. It is available as a supplement and can
be purchased without a prescription. St. John’s Wort can be taken as a
tablet, steeped in tea, applied as a lotion, or consumed as a liquid extract. A
standard form of the preparation contains a 0.3 percent hypericin extract as
part of the solution. Most adults take approximately 300 mg as a dose, three
times each day. It can take a minimum of 4 weeks for a patient to start to
feel the effects of St John’s Wort.20,21
St. John’s Wort may cause some unpleasant side effects, including nausea,
dizziness, dry mouth, headache, and fatigue. Another negative effect that
seems to occur with some people taking the supplement is an increased
sensitivity to sunlight, requiring them to cover bare skin while in the sun and
avoid tanning beds or sunlamps.21 St. John’s Wort may also interact with
some medications, and patients should notify their healthcare providers that
they are taking the supplement to ensure that it does not interact with
anything else. For patients who take antidepressants for the treatment of
fibromyalgia, St. John’s Wort may cause an increase in side effects and an
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
61
increased risk of developing serotonin syndrome. St. John’s wort has also
been shown to interact with other medications such as antihistamines, cough
medicines, cardiac medications such as digoxin, as well as birth control pills,
some sedatives, and some medications used specifically to treat migraine
headaches.20
Severe forms of depression should not be treated alone with St. John’s Wort.
For a person who has a severe enough case of depression such that he/she
is unable to get out of bed, perform activities of daily living, or has plans of
self-injury or suicide, it is not safe practice to try to manage these negative
symptoms alone with St. John’s Wort. Patients who have significant
symptoms of depression, with or without a concurrent diagnosis of
fibromyalgia, should see their health care provider about recommended
forms of treatment, rather than relying on an herbal preparation.
Capsaicin
Capsaicin comes from Capsicum chili peppers and may be used as a pain
management method for some types of pain. The Capsicum family includes
such vegetables as red peppers, bell peppers, paprika, and cayenne
peppers.1 Capsaicin is taken out of the chili peppers and is known as the
specific alkaloid within the peppers that makes them hot. Capsaicin may be
available as an over-the-counter product or by prescription.
Capsaicin works by decreasing the amount of substance P in the body; the
substance responsible for sending pain signals to the brain from the nerve
endings. Initially, when capsaicin is applied, the body responds by increasing
release of substance P because of the burning effects of the pepper. The
body releases the substance P because it believes that it has been injured.
As a person continues to apply capsaicin on a regular basis, a tolerance
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
62
gradually builds, and the body no longer releases substance P in response.
In fact, substance P is actually reduced in the affected tissues where the
capsaicin has been applied.1 A reduction in substance P reduces the amount
of pain the affected patient feels and applying capsaicin cream to tender
points has been shown to have an effect of pain relief. People who suffer
from fibromyalgia or other chronic pain conditions, such as rheumatoid
arthritis, trigeminal neuralgia, or shingles, have found relief from applying
capsaicin cream to painful points on the body.6
Capsaicin is typically available in cream form; and, its often available in
more strength than one. The capsaicin cream approved for use by the U.S.
FDA is called Zostrix® and is primarily intended for people suffering postherpetic neuralgia following an attack of shingles.1
People who use capsaicin take a small amount of the cream and apply it to
the painful points on the body with their fingers, rubbing it into the skin. Its
application must be repeated several times per day to maintain effective
pain relief. Some people who use capsaicin may have rapid pain relief, but it
is capsaicin’s overall effect of reducing substance P in the body that provides
prolonged relief. Therefore, there are many times when relief through
capsaicin may take several weeks as the cumulative effects of substance P
are gradually reduced. It must also be taken on a regular basis to maintain
the positive effects. A disruption in the regular application of capsaicin cream
can slow the effects of pain relief.6
Because capsaicin comes from hot peppers, many people who use it for pain
relief also complain of a feeling of burning or tingling at the site of
application. The stinging sensation may be more prominent at first use, but
with regular application, this negative side effect diminishes. Although it may
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
63
be tempting to wash off the cream for relief from the painful side effects,
washing will remove the cream and the user will not get the benefits of
capsaicin. Instead, the individual needs to be informed that these side
effects should diminish shortly.6
Acupuncture
Acupuncture is a traditional form of Asian therapy that can help to improve
health, reduce chronic pain and promote sleep among some patients.
Acupuncture originated in China and is used to stimulate the flow of energy
through the body. Acupuncture dates back over 2,200 years ago in China.
While it started within China, the practice quickly moved west through trade
routes with Arab countries. The practice stayed within areas of Eastern
medicine and was not well known in the United States until the 1970s.23
Chinese practitioners believed that the body’s energy, or qi, flowed through
channels in the body known as meridians. Each meridian has a
corresponding body area, such as a certain organ or area of tissue. Qi is
related to the concept of yin and yang, which are opposites that complement
each other and describe everything in nature in the Eastern theory of
wellness.
When a person’s qi is out of balance, the yin and yang are also out of
balance, and it is believed that he/she can then develop illness or pain.
Either too much or too little qi can cause pain and illness in the theory of
Eastern wellness. Stimulating the energy flow along certain points in the
meridian, is believed to bring the qi back into balance, restore good health,
and improve some negative symptoms, including pain.22 Acupuncture uses
needles along certain meridians that run close to the surface of the body and
are just under the skin to stimulate energy flow and restore balance.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
64
Research has shown that acupuncture can be quite effective in the
management of symptoms of fibromyalgia and pain. One study showed that
patients with fibromyalgia who underwent several weeks of acupuncture
therapy had a significant decrease in tender points, decreased total pain,
and increased feelings of well being overall when compared to a break
period when they were not receiving acupuncture therapy.22
Acupuncture involves inserting small, very thin needles into the skin along
certain points in the body that are along the meridian for the flow of energy.
The acupuncturist is familiar with the normal sites to insert the needles and
can determine the correct locations based on initial assessment. Some
people say that the insertion of the needles — called needling —cannot be
felt and causes no pain, while others have noted a slight amount of pain,
such as the feeling of a skin prick in the beginning, which quickly dissipates
after the needle is in place. The patient usually lies on a procedure table for
the acupuncture and once the needling is complete, usually remains in the
same place for up to an hour afterward.23 The time after needling has been
described as restful and relaxing. Following the rest period, the
acupuncturist removes the needles and the session is complete.
At one time, acupuncture was discounted as a valid form of therapy for
health issues for various reasons. Some practitioners did not believe in the
concept of qi, while others may have disregarded the practice because it
differed from Western medicine. Acupuncture continues to gain ground as an
acceptable practice in the treatment of various disorders, such as pain,
nausea and vomiting, or hypertension. Understanding about the concept of
acupuncture also continues to evolve as scientists recognize that the process
has more of a biological basis than originally thought. In 1997, the National
Institute of Health officially recognized acupuncture as a valid form of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
65
treatment for a number of health conditions, particularly those that cause
pain, sleeping difficulties, and anxiety.23
The theory is that acupuncture works because insertion of the needles into
different points in the body actually stimulates the release of endorphins.22
Endorphins are neurotransmitters released by the body that work to help
control pain by binding to opioid receptor sites and decreasing the amount of
pain impulses that are sent through the spinal cord to the brain. Endorphins
work in a manner similar to opioid analgesics to control pain.5 Release of
greater amounts of endorphins through acupuncture may be a reason why
the method works to improve pain control.
There are a number of different forms of acupuncture available. Patients
seeking treatment with acupuncture should talk with practitioners who
perform the different methods to determine the best type for their
conditions. The most commonly used type of acupuncture in the U.S. is
based on Traditional Chinese Medicine (TCM). This method uses the concept
of balance between yin and yang and other theories of complementary
concepts, such as hot and cold.23
Korean hand acupuncture focuses on application of acupuncture needles in
specific areas of the hands and feet, with the belief that these locations have
higher concentrations of qi. Auricular acupuncture involves applying needles
to the ear with the belief that there are points on the ear that impact certain
body areas and organ systems. Auricular acupuncture may be used in
particular among patients who are recovering from addiction. Myofascial
acupuncture involves applying needles to points on the meridians that are
tender, and, this type of acupuncture is sometimes also practiced by
physical therapists. It involves an initial assessment to determine areas that
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
66
are most tender to know where to place the needles. It is believed that the
areas of tenderness indicate the imbalance in energy.23
Acupuncture can be used in conjunction with medications for treatment of
fibromyalgia, as it does not cause changes in the body that can significantly
interact with pharmacological therapy. However, some acupuncturists may
also prescribe certain herbs to go along with acupuncture therapy and to
continue treatment of pain, anxiety, or insomnia. In these cases, patients
should speak with their healthcare providers about any herbs they are taking
to determine if they will interact poorly with current medication therapy.
Acupuncturists in the U.S. should be licensed and follow specific procedural
guidelines for practice, including using disposable needles to avoid the
transmission of infectious diseases between patients. In general, most
patients with fibromyalgia who have sought treatment through acupuncture
have found the most relief when combining this type of therapy with other
forms of treatment, including pharmacological treatments, increased levels
of activity and exercise, and following a healthy diet.22
Chiropractic Manipulation
Chiropractic manipulation is a method of making adjustments to the spine to
reduce pain and negative symptoms associated with disease, as well as to
increase feelings of well being. The practice of chiropractic manipulation first
began in the late 18th century by a man named Daniel David Palmer, who
focused most of his work on spinal manipulation and adjustments. Since that
time, many chiropractors have also started using other methods
concurrently with spinal manipulation, such as prescribing herbs or
promoting certain vitamins.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
67
The concepts of chiropractic care focus on holism, in which the whole person
is considered as part of treatment, rather than just focusing on one area or
part of the body that might be affected. The idea is that all parts of the body
work together to achieve a balance for health and wellbeing.59 Therefore,
although many of the visits with a chiropractor will focus on treating and
managing certain aspects of chronic pain or fibromyalgia, the practitioner
will also offer guidance for other types of therapy that will also help to
balance the entire body toward good health, including increasing exercise,
promoting stress reduction techniques, and improving nutrition.
A chiropractor is a licensed professional who has the capacity not only to
perform adjustments and provide treatment for certain conditions, but can
also assess, diagnose, and refer cases that are not in the scope of practice.
A chiropractor can also take x-rays and order some types of laboratory tests.
The focus of their exams is typically on orthopedic, musculoskeletal, or
neurological function.58 Thus, a patient who is seeking treatment for nonspecific symptoms of fibromyalgia can effectively work with a chiropractor to
come up with a treatment plan based on symptoms and assessment.
The theory behind chiropractic manipulation is that the vertebrae of the
spine move out of position to block some of the sensory flow of nerves. This
blockage can lead to pain in various areas of the body, including the
muscles, the back, and the neck, in addition to other negative symptoms,
such as chronic headaches. Among patients with fibromyalgia, this
interference with nerve functioning can make fibromyalgia symptoms much
worse.22 Chiropractic manipulation is used as a treatment for a variety of
conditions, including back or neck pain, tension headaches, migraine
headaches, anxiety, high blood pressure, painful menses, and premenstrual
syndrome.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
68
During a chiropractic visit, a patient lies on a table and the chiropractor
performs adjustments, which is another reference to spinal manipulation. If
the vertebrae have shifted and are impeding the sensory flow of the nerves
to cause negative symptoms, this adjustment is meant to move the
vertebrae back into their proper place. The shifting of the vertebrae is called
subluxation. The technique typically uses short, forceful thrusts to move the
vertebrae back into position. This process is often done by hand, but there
are some techniques that use mechanical devices for assistance with
adjustments.
Whether the adjustment of the spinal vertebrae produces relief from chronic
pain because it restores the work of the nervous system or if symptom
management occurs due to other reasons is not entirely clear. Some
researchers believe that the adjustment process simply relaxes the
vertebrae and the surrounding supportive musculature that may have
become tight due to muscle stiffness and back pain. This loosening effect
may have an impact on pain relief as well.
Chiropractors use a diagnostic process during the early stages of treatment
to best determine how the patient can benefit from manipulation. They may
use x-rays or neurological testing to formulate diagnoses for their patients.
In addition to adjustment of the vertebrae of the spine, manipulation may
involve aligning joints and bones to help improve flexibility and range of
motion.22
There have been some studies that have shown that chiropractic
manipulation is effective in treating certain conditions, including back pain,
neck pain, tension headaches, and pain in the upper extremities. One
research study that showed some of the most statistically significant results
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
69
was the success of chiropractic manipulation to manage symptoms of
chronic migraines. The study showed that research participants with
migraines benefitted and found more relief through chiropractic manipulation
when compared to using a placebo.27
Chiropractic care is also helpful for patients suffering specifically from
fibromyalgia. One study showed that research participants with fibromyalgia
found improvement in their symptoms of pain, fatigue, and insomnia while
undergoing 30 sessions of chiropractic manipulation. The improvements
remained for up to a month even after the chiropractic care had ended
during the study.22
Patients with fibromyalgia may need more treatment measures than
chiropractic care alone, however, this type of therapy does free some
patients to engage in other forms of symptom management to be used in
conjunction with manipulation therapy. Chiropractic manipulation may lessen
symptoms of fibromyalgia enough to a point that a patient is then able to
engage in exercise or perform other activities of daily living; endeavors that
might have been almost impossible before because of pain, stiffness, and
fatigue.
Chiropractic manipulation can be costly for some patients who use this as a
form of treatment. Patients may have some insurance coverage provided for
chiropractic therapy, but it can be limited, requiring some people to then pay
for services out of pocket or discontinue therapy altogether, which can cause
a return in painful symptoms. The efficacy of treatments is also difficult to
determine, as research studies may have difficulties coming up with
placebos to use to compare with chiropractic manipulation. Study results can
be skewed, particularly when participants have an idea of what type of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
70
treatment they are receiving and if they believe that it can help them with
their pain.
Patients seeking chiropractic care for management of symptoms of
fibromyalgia and chronic pain should work with a licensed care practitioner
who has experience working with patients with fibromyalgia. Using an
unlicensed person for help with treatment or attempting to make
adjustments through the help of friends or others who are not properly
trained in this therapy could cause injury and could make fibromyalgia
symptoms much worse. When using the right practitioner who has
experience and who understands the adjustments needed to help with
chronic pain, a patient with fibromyalgia or other painful conditions can
experience some relief by using this therapeutic regimen.
Massage Therapy
It is well known that touch is essential to health and well being and that the
use of massage techniques can provide relief from muscle tension and
release of stress and anxiety. At one time, massage was reserved for highend populations through health clubs and expensive spas as a type of
luxury. While these options are still available, in more recent years, massage
has been used as a method of treatment for various health conditions and,
when used regularly, can be effective in controlling negative symptoms
associated with many illnesses and chronic conditions.
Massage can cause two different types of responses by the body as a result
of pressure that is applied during the session. A mechanical response is one
in which the body physically responds to the pressure when a massage
practitioner manipulates the tissues by rubbing, pulling, or kneading. An
example of how the body may demonstrate a mechanical response to
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
71
massage is when blood flow increases to the affected site. Alternatively, the
body may also respond to massage through a reflexive response. In this
way, massage stimulates the nerves, resulting in more generalized changes
in the nervous system, such as by causing a state of relaxation or
decreasing blood pressure.31 Both types of responses can be beneficial in
reacting to the pressure of massage to produce therapeutic results.
There are several different forms of massage available, and patients may
visit practitioners to determine what kind of massage may best provide the
benefits for their symptoms. The most common type of massage is Swedish
massage, in which the therapist uses longer strokes and circular movements
on the skin and muscles. Swedish massage may also incorporate kneading
of muscles and tissues as well as other stimulating exercises, such as
vibration. Deep tissue massage is another common form of this therapy.
Deep tissue massage is slower than Swedish massage and works at a deeper
level in the muscle tissues to target the muscles and connective tissues. This
type of massage may be helpful for patients who are recovering from muscle
injuries.32 There are many other forms available as well, including sports
massage; trigger point therapy, which targets certain painful points in the
body that have been injured or used too much; reflexology, and craniosacral
therapy.
During a massage therapy session, a patient may wear loose clothing or
may undress down to a level of comfort and lie on a table. The massage
therapist may test several points on the body to determine painful areas and
to decide how much pressure is needed without causing pain or tissue
injury. Some massage therapists use oil or some type of lotion to reduce
skin friction and to make the massage session more pleasant.32 Additionally,
the surrounding environment is typically calming and relaxing, with gentle
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
72
sounds, such as music therapy, and aromatherapy combined that can be a
source of stress relief for the patient and that puts him/her in a more
relaxed state for the session.
Patients who seek massage therapy as a form of symptom management of
fibromyalgia and chronic pain should only see licensed massage therapists
who have been specially trained in the techniques of muscle and tissue
manipulation. While mild massages from well-meaning friends or loved ones
may result in some stress relief or mild symptom relief, tissue manipulation
that is associated with massage, including the kneading and maneuvering of
muscles and soft tissues can be damaging if not performed properly by a
trained therapist. It is also important to use a licensed and experienced
professional because he/she often has more ability to pinpoint locations that
are causing the most pain and stress, and the therapist may be familiar with
fibromyalgia symptoms from previous clients and will know best what
maneuvers to use that can cause symptom relief.
Myofascial release therapy is a specific form of massage therapy that targets
the myofascial tissue that surrounds the muscles to improve circulation, and
promote relaxation of the muscles and overlying tissues. Myofascial release
therapy is one type of massage therapy that has been used successfully in
patients with fibromyalgia. Research in this specific area has shown that it
makes a difference in symptoms. One study indicated that patients with
fibromyalgia who used myofascial release therapy for 20 weeks showed
significant improvements in symptoms of pain, quality of life, depression,
anxiety and sleep quality. Even after six months from completion of the
study, many participants still had improved sleep quality.28
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
73
Massage therapy has many powerful benefits that serve a large number of
areas in the body. It is not regulated to affecting only the skin and the
underlying muscles, but massage therapy effects are far reaching
throughout the body, even to some systems that may be surprising.
Massage therapy improves circulation when pressure from massage causes
the body to increase blood flow to the affected site. Blood vessels dilate,
promoting greater circulation and improving venous return of blood to the
heart. This blood vessel dilation can also have an impact on blood pressure,
lowering levels and potentially helping those who have hypertension.
Increased circulation also promotes increased oxygen to the body’s tissues
when red blood cells with hemoglobin molecules are better able to circulate,
provide more oxygen, and reduce the risk of tissue ischemia.31
Massage has also been shown to help reduce anxiety, depression, and
stress. It can impact the work of the neurotransmitters in the brain,
including dopamine and serotonin, leading to greater feelings of wellbeing.
Because depression can increase a person’s sensitivity to pain, using
massage as part of a comprehensive plan to manage depression may reduce
the amount of pain an affected patient feels overall. Massage therapy can
also inhibit the release of cortisol, a stress hormone that comes from the
adrenal glands. Increased levels of cortisol in the body can impact immune
function, placing a person with high levels of stress and cortisol at greater
risk of illness. By reducing cortisol levels and improving relaxation as a
response to stress, massage therapy can also support immune function.31
Massage therapy stimulates the body to release endorphins, which are
endogenous painkillers that can effectively reduce some chronic pain. It can
also have a significant impact on pain by promoting muscle relaxation and
controlling muscle spasms. There are a number of other positive effects that
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
74
massage has on the body in various locations and body systems. It has been
shown to improve muscle flexibility, improve respiratory function, relieve
gastrointestinal disturbances, reduce fatigue, improve feelings of well being,
improve energy levels, and improve sleep.31 Obviously, the numerous effects
of massage make this type of therapy a beneficial option for some patients
with fibromyalgia and chronic pain syndromes. Studies have indicated that
patients with fibromyalgia who sought massage therapy as a form of
treatment or management of symptoms eventually showed improvements in
feelings of depression and anxiety; reduced pain, stiffness, and fatigue, and
improvements in sleep patterns.31
Because there is not a complete cure for fibromyalgia, healthcare providers
simply must focus on symptom management and control. As discussed, the
many benefits of massage therapy certainly do work in controlling
symptoms. The type of massage and the schedule of sessions should be
determined by the patient and the massage therapist. The therapist can
conduct an assessment to best determine the patient’s needs, determine
which areas to focus therapy, and ensure that there are no contraindications
to treatment, such as the presence of blood clots, open sores, or in some
cases of patients with concurrent rheumatoid arthritis.32
In addition to the physical responses of the body as a reaction to massage
techniques, many patients benefit from massage because of other factors as
well. For instance, a patient who attends a massage therapy session typically
spends time before and after the massage in a quiet room that is designed
to be soothing and comfortable. The time spent in a relaxing environment
can add to stress relief that occurs with the massage.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
75
Part of massage therapy also includes providing education to patients about
positive changes they can make in their health, such as following a healthy
diet and increasing exercise and activity levels. Patients with chronic
conditions such as pain and fibromyalgia may need ongoing massage
therapy in order to effectively control their painful symptoms for a long
period of time. As with many other types of therapy, massage must be
practiced on a regular basis in order to best derive benefits. Most patients
cannot attend a few massage therapy sessions and expect to gain long-term
benefits of reduction in fibromyalgia symptoms. However, regular massage
therapy, combined with exercise, adequate fluid intake, and a healthy diet,
can be beneficial for patients with chronic conditions who need ongoing
support for symptom management.31
Some components of massage may also involve relaxation techniques that
can either be incorporated with massage or may be used in separate
settings. Patients can be taught some relaxation techniques so that they can
not only use them during therapeutic procedures, but also at any time when
they are feeling pain, fatigued, or overwhelmingly stressed. Stress-relief
techniques, such as hypnosis, meditation and relaxation, and cognitivebehavioral therapy (CBT), are other forms of complementary and alternative
medicine (CAM) that have been shown as excellent augmentation strategies
to improve fibromyalgia symptoms.
Augmentation strategies for stress relief
Cognitive behavioral therapy has been the best-studied form of stress-relief
therapy that uses mind-body techniques. Recent clinical guidelines do
recommend the use of CBT alongside other components of treatment to
successfully manage symptoms of fibromyalgia.57 CBT teaches patients how
to manage some of their symptoms by helping them develop a greater belief
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
76
in their abilities to deal with stress and pain. It teaches patients how to
recognize factors in their lives that are causing negativity, such as pain.
Through CBT, individuals learn to view negative factors in their environment
and physical condition in a different light and learn to live with it differently.
For example, instead of seeing insomnia associated with fibromyalgia as
something that is completely disruptive and that negatively controls so many
aspects of life, a patient is taught through CBT to challenge their negative
thinking patterns and to replace negative thoughts about insomnia with
more positive ways of thinking. By changing their negative thinking, patients
can find more success in controlling some of their symptoms and having
more power over their own lives.33
Hypnosis is another type of relaxation technique that can be beneficial, in
which a person is placed into a trance, which is a different state of
consciousness than being awake and may be similar to dreaming while
asleep. When a person is hypnotized, the therapist can make suggestions
that speak to the patient’s subconsciousness and he/she may be more likely
to follow through with changes that were made as part of suggestions when
returning to a normal, awake state.26
Alternative and complementary therapies have been shown to be successful
for managing fibromyalgia when combined with other techniques, such as
patient education, exercise, and medication. As previously discussed, a
multimodal approach of combining several types of therapy, supplements, or
medications, may be most beneficial in successfully managing fibromyalgia
and chronic pain.57
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
77
Before starting any therapy, patients need to understand their own feelings
of self-efficacy. Self-efficacy beliefs are those that a person thinks or feels
about him- or herself and the abilities to overcome adversity. If self-efficacy
beliefs are low at the beginning of treatment, the patient may be less likely
to follow through with therapy or to have as positive an outcome when
compared to someone who has higher levels of self-efficacy. Additionally,
people with lower levels of self-efficacy report higher levels of pain intensity
and greater numbers of tender points. Promoting self-efficacy and positive
feelings about the self are very important fundamental beliefs that should be
promoted before starting CBT and hypnosis, or any other types of therapy,
for fibromyalgia treatment.57
Sleep
It is well known that many people with fibromyalgia and chronic pain can
suffer from disrupted sleep. The symptoms of fibromyalgia cause a difficult
cycle of pain, lack of sleep, and fatigue. An affected patient may have
difficulties sleeping because of pain, and many nights of poor and disrupted
sleep result of fatigue and exacerbation of painful symptoms, leading to
further struggles with sleep. People who are in pain may have more
difficulties experiencing restful sleep because of discomfort, and chronic pain
then leads to chronic sleep problems.
Improving sleep among people with fibromyalgia is easier said than done.
Not only is sleep disrupted due to pain and muscle stiffness, people with
fibromyalgia may be more likely to suffer from other conditions that can also
impact sleep, including restless legs syndrome and sleep apnea. Restless
legs syndrome (RLS) is a condition in which an affected person feels a
sensation of crawling, prickling, or tingling in the legs and feet. The
sensations are felt underneath the skin where they cannot be reached,
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
78
resulting in significant discomfort. The person with RLS also has a strong
urge to move his/her legs, sometimes in an effort to find relief from the
distracting symptoms. Patients with RLS suffer from disrupted sleep because
the tingling or crawling sensations may make falling asleep very difficult;
additionally, they may move their legs frequently enough that sleep cycles
are disrupted and they are unable to attain deep sleep.3
Sleep apnea may also be more likely in some patients with fibromyalgia.
The condition may occur as either central or obstructive sleep apnea. With
central sleep apnea, the breathing center of the brain fails to tell the person
to take a breath on a regular basis once he/she has fallen asleep. The
patient may fall asleep but then enter a period of apnea, which is a complete
lack of breathing for at least 10 seconds, followed by an awakening in which
the person begins to breathe again. Obstructive sleep apnea also causes
periods where the affected person does not breathe for short periods of
time, but it is caused by some type of obstruction in the airway, such as
extra fat tissue around the neck or enlarged tonsils, that block the flow of air
and cause the apnea.
People with obstructive sleep apnea are more likely to snore regularly and
wake up frequently to correct their apneic episodes, although they may be
unaware of it. Studies have shown that some people with sleep apnea can
awaken hundreds of times during a night of sleep, yet they are not fully
conscious and remain unaware. However, the frequent awakenings do
negatively impact sleep and result in disrupted sleep cycles, an inability to
attain levels of deep sleep, awakening without feeling refreshed, and
overwhelming fatigue.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
79
Sleep is essential for human life and most people enter a period of sleep at
night when the external environment is dark. Feelings of sleepiness, being
tired, or feeling fatigued all typically appear before descending into sleep.
Although a person is unconscious while sleeping, sleep differs from other,
more severe states of unconsciousness, such as a coma, because the
sleeping person can become aroused and alert.
Although the body is asleep and often quiet during sleep, the brain continues
its activity during this time. Scientists have shown that physiological factors
such as body temperature, breathing rate, and heart rate change while
asleep, but brain activity remains active. The body goes through different
stages of sleep that result in changes in muscle and brain activities. Rapid
eye movement (REM) sleep, as explained earlier on, is a period where a
person is unconsciousness and still; the muscles are often tight and
paralyzed during this stage and this is the point at which a person has
dreams. Non-REM sleep is a resting state in which there are few internal
thoughts and no dreams. Non-REM sleep is further classified into four stages
from N1 to N4, where N1 is the lightest type of sleep and N4 is a very deep
sleep.4
People with fibromyalgia often complain of disrupted sleep, light sleep,
difficulties falling or staying asleep, or awakening not feeling refreshed. The
pain and other sleep difficulties associated with fibromyalgia often prevent
these patients from achieving the deep, restorative sleep that their bodies
truly need. Studies have shown that patients with fibromyalgia have more
pain because of a lack of deep sleep required to restore tissues and damage
in the body that takes place while awake. During the deep stages of sleep,
the body releases somatotropin, a growth hormone that is necessary to
repair muscle tissues while the body is resting. If a patient cannot
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
80
consistently achieve deep sleep for long enough periods of time for the body
to make repairs with somatotropin, he/she may be more likely to have
increased muscle pain because of a lack of repairs.22
Adjusting lifestyle habits and introducing pharmacologic interventions may
help people with fibromyalgia and chronic pain to sleep better and
experience more restfulness that comes from adequate sleep. There are
many types of sleep aids available as medications; some can be purchased
over the counter, while others require a prescription. A patient with
fibromyalgia should speak with his/her healthcare provider to determine the
most effective course of treatment through medication and if this option is
reasonable to the situation.
Some patients have achieved better sleep using medications, while others
may use them for a while but then find that their bodies have adjusted or
have developed a tolerance for the medicines so that they are not as
effective. It may take a period of trial and error for some patients to
determine the best type of sleep aids that will help them achieve better
sleep. Some examples of medications that can help induce sleep or help a
person to stay asleep include the supplement melatonin; antihistamines,
such as diphenhydramine (Benadryl®), and other medications such as
zolpidem (Ambien®) and triazolam (Halcion®).4
Lifestyle changes, whether or not they are combined with sleep aids and
medications, can also improve sleep among people with fibromyalgia. While
lifestyle changes are not a complete cure, they can greatly improve sleep for
people who have chronic pain and they often only require minor changes
that involve little cost.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
81
It may seem obvious that people who want to improve sleep should ensure
that the sleeping environment is quiet, comfortable, and dark. This may
mean adding shades to windows that make a room darker, using eyewear to
reduce incoming light, or utilizing white noise, such as a fan, to eliminate
extraneous noises. The bed should be comfortable, and some people find
that using certain pillows or purchasing comfortable and soft sheets and
blankets can improve sleep a little because these items may promote
relaxation and can be soothing.
Some people have success by using distraction techniques, such as
meditation or praying, to help them fall asleep. While it may seem cliché,
counting can actually provide enough of a distraction that some people are
able to better fall asleep, hence the reason for the suggestion of counting
sheep. Establishing a regular routine is also imperative for improving sleep.
People do not sleep as well when they have irregular bedtime routines and
fall asleep or wake up at different times of day. Improved sleep occurs when
a person sets a regular bedtime and a regular time for waking up. It may be
tempting to sleep late or take daytime naps, especially with significant
fatigue, but these patterns can be disruptive to nighttime sleep. Many people
find that by eliminating daytime sleep, or naps, they have an easier time
falling asleep at night.
A regular bedtime routine is also helpful in promoting sleep, particularly for
falling asleep. This varies for people in terms of what some may find
comforting while others may have difficulty maintaining in terms of a
routine. For example, some experts recommend avoiding a meal after a
certain hour in the evening, as late snacking may disrupt sleep.
Alternatively, there are some people who cannot sleep if they are hungry
and avoiding eating in the evening only makes them feel worse.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
82
Establishing a positive bedtime routine works for each individual according to
ritual and comfort. This may mean taking a shower or a bath in the evening,
having a light snack, reading quietly before bed, or listening to music while
falling asleep. It may help to avoid certain activities before falling asleep,
such as drinking large quantities of liquids or consuming caffeine, which can
be disruptive.29
People who have restless legs syndrome or sleep apnea should seek
treatment for their conditions to help improve their sleep. No amount of
sleep aids or bedtime routines will make up for the lack of sleep caused by
these medical conditions, and sleep can be elusive for people who suffer
from these conditions in addition to fibromyalgia. Some individuals with
restless legs syndrome have had success managing their conditions by a
combination of improving their sleeping environments and sleep habits as
well as using pharmacological intervention. Medications that impact
neurotransmitters in the brain to alter sensory stimulation, such as ropinirole
(Requip®), may be prescribed, as well as other medications that can induce
sleep, including sedatives.
Patients with sleep apnea and fibromyalgia can and should seek treatment
for their conditions to improve sleep. Sleep apnea is often treated with the
use of continuous positive airway pressure (CPAP), which involves using a
machine that provides a steady stream of air into the nose and mouth.
The person using CPAP wears a mask to bed at night and receives this
gently pressurized air throughout the night while sleeping. The air keeps the
airways open and reduces periods of apnea while asleep. Consequently, the
person no longer has multiple periods of awakening during the night because
of apnea.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
83
Even if other medical conditions are not concurrently present, trying to sleep
while suffering from symptoms of fibromyalgia can be very difficult. The
problem with trying to sleep is that many people who think about and
actively try to sleep may be less likely to actually fall asleep. The act of
trying to sleep may lead to greater feelings of stress when the person cannot
achieve sleep. He or she may feel greater anxiety and worry about being
tired.
It may take practice, changes in lifestyle habits, and medications to better
control sleep, but improved sleep is possible for people with fibromyalgia
and chronic pain. Once a system of better sleep has evolved, the patient
with fibromyalgia can experience more relief from fatigue and exhaustion,
helping him/her to be more active and have a better quality of life.
Hormone Balance: Stress Related Disorders
Hormones play a significant role in the body, affecting virtually every body
system in one way or another. Hormones are chemicals that act as
messengers between the tissues. They are created by endocrine glands,
such as the thyroid, pituitary, and adrenal glands, and the pancreas.
Hormone imbalance is responsible for many serious medical conditions,
including diabetes, hypo- or hyperthyroidism, adrenal insufficiency, and
polycystic ovary syndrome (PCOS), among others. Many of these conditions
cause significant fatigue, weight changes, growth problems, issues with
metabolism, sleep disturbances, and mood changes. Because hormones play
an important role in many body systems, research has studied their effects
on producing symptoms of fibromyalgia and chronic pain. If fibromyalgia is
caused or worsened by hormone imbalances, it only makes sense to correct
the hormone imbalance to better manage symptoms.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
84
Whether fibromyalgia symptoms develop as a result of hormone imbalance
or whether the chronic pain, sleep disruption, and stress lead to fluctuations
in hormone levels remains unanswered. Research continues to investigate
the effects of hormone levels on fibromyalgia symptoms. Some people with
fibromyalgia may have disregulated autonomic nervous systems, which
impacts how hormones are released in the body when a person becomes
stressed. Some researchers believe that people who suffer from chronic
conditions such as fibromyalgia may release stress hormones in a different
manner than the general population. These stress hormones can impact how
a person perceives pain and the person may feel a heightened sense of pain
or react to painful stimuli more strongly.45
Cortisol is a hormone that is released by the adrenal glands, which are the
small, triangle-shaped glands that sit on top of the kidneys. Cortisol is
considered a stress hormone and is associated with the fight or flight
mechanism. When a person feels fear or stress, the adrenal glands are
stimulated to release cortisol in response. In some cases, elevated cortisol
levels in the body can be detrimental and cause problems with memory,
heart disease, weight gain and decreased immune function.
Alternatively, too low of amounts of cortisol can also cause problems and
some symptoms of low cortisol are similar to those experienced among
people with fibromyalgia, including fatigue, weakness, muscle and joint pain,
depression, and loss of appetite. Some former studies that have measured
cortisol levels in patients with fibromyalgia have shown lower than average
levels of the hormone in both serum concentrations and within the urine.
Additionally, fibromyalgia patients showed blunted cortisol responses to
stressful stimuli, which should normally cause a rise in overall cortisol levels.
This suggests that there may be an issue with the hypothalamic-pituitary-
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
85
adrenal axis (HPA), which is the mechanism for sending messages from the
hypothalamus and pituitary glands in the brain to the adrenal glands by the
kidneys to tell them to release cortisol in response to stress.14,51
People with fibromyalgia may be more likely to have underlying disorders
related to stress, such as depression, anxiety, or posttraumatic stress
disorder (PTSD), which also indicates a potential problem with the HPA.
Stress can exacerbate symptoms of fibromyalgia, but managing symptoms
of the condition on a regular basis can also cause increased levels of stress
in people, particularly when they are having trouble managing symptoms or
finding hope of relief. This chronic state of stress among people with
fibromyalgia can also be the cause of the blunted cortisol response to
stressful situations: people with fibromyalgia are often burned out so much
from stress that their bodies no longer respond in a normal fashion.57
Too low of cortisol levels can be replaced in some patients if the levels are
the true cause of the fatigue and pain. Cortisol replacement can be done by
a prescription for steroids, such as hydrocortisone or dexamethosone.
Because these replacements are corticosteroids, there can be many
unpleasant side effects associated with taking them, and regular monitoring
through a healthcare provider is important to manage symptoms and to
achieve therapeutic success. Some side effects of corticosteroids include an
increased risk of infection, weight gain, high blood glucose levels, fluid
retention, insomnia, and an increased risk of osteoporosis. Patients who take
corticosteroids as a replacement for low cortisol levels should not abruptly
stop their use, as serious side effects can occur. Instead, the dose should be
tapered until the patient is ready to stop taking them completely. This
process requires the help and guidance of a healthcare provider.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
86
Some patients may also have symptoms of fibromyalgia in relation to low
levels of growth hormone. A clinical study tested levels of serum insulindependent growth factor-1 (IGF-1) among 197 women and 49 men who had
symptoms of fibromyalgia. IGF-1 is a by-product of adult growth hormone.
Of those studied, 180 of 197 women and 40 of 49 men had low levels of
IGF-1, which was defined as less than 90 percent of ideal levels. The
average level for the women was 140 ng/ml, when a normal average level is
supposed to be 238 ng/ml. For the men, the average level obtained was 132
ng/ml when the average normal level was supposed to be 223 ng/ml.53
The people in the study who had low levels of IGF-1 went through hormone
replacement therapy with subcutaneous human growth hormone. After
treatment, the patients who received hormone replacement stated that they
had noticeably improved quality of life, and improved energy levels and
symptoms of pain. Overall, 85 percent of participants stated that their
quality of life had improved with human growth hormone replacement.
Deficiency in human growth hormone seems to have many similar symptoms
to fibromyalgia, including pain, memory problems, sensitivity to hot and cold
temperatures, and fatigue.53 Based on the results of this study, deficiency of
adult human growth hormone should be considered among fibromyalgia
patients as a possible cause of symptoms.
Growth hormone is a type of protein hormone that is made up of amino
acids and is secreted by the pituitary gland in the brain. It is essential for
human growth and metabolism. A major role of growth hormone is to
stimulate the liver to secrete IGF-1, which is actually used to stimulate
growth of the bones and muscles. Growth hormone also stimulates protein
metabolism, assists with utilization of fat molecules, and plays a role in
regulating blood glucose levels.54 Because many patients with fibromyalgia
are lacking the deep sleep that is required to restore tissue damage and to
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
87
provide rest and relief from fatigue, it stands to reason that these patients
would be lacking in human growth hormone. Growth hormone is also known
as somatotropin, which is released during stage 4 of sleep when the most
restoration occurs.
Another study that administered daily injections of human growth hormone
to women with fibromyalgia over the course of nine months resulted in
reports of significant improvements in muscle pain and other symptoms, as
measured by the Fibromyalgia Impact Questionnaire and tender point
scoring. Testing levels of IGF-1, taking a thorough patient history, and
performing a physical exam, can help to determine a diagnosis of growth
hormone deficiency. A patient with laboratory testing results of growth
hormone levels less than 200 ng/ml may benefit from growth hormone
supplements as a trial treatment for fibromyalgia symptoms.54
Clinicians have also considered low levels of thyroid hormone as part of the
issue of fibromyalgia. Some patients may have too little levels of thyroid
hormone in their bodies, either due to the body’s inability to produce enough
of the hormone or its inability to use thyroid hormone properly.
Many patients with thyroid problems such as hypothyroidism have
symptoms similar to those with fibromyalgia, including pain and tenderness,
cold intolerance, depression, poor memory, muscle stiffness, headaches, and
sleep disturbance. The thyroid gland, located in the neck, plays a major role
in metabolism throughout the body. The gland secretes two types of thyroid
hormones: T4, which is also called thyroxine, and T3, which is known as
triiodothyronine.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
88
A major responsibility of T4 is to create T3. T4 may be called the storage
form of thyroid hormones while T3 is the active form. Some people,
including people who have fibromyalgia, may be unable to convert T4 into
T3. While testing and supplementation may replenish levels of T4 in the
body, such as by using synthetic thyroid replacement, supplements of T4 do
not matter if the body is unable to convert it to T3.55
There are usually smaller amounts of T3 in the body when compared to T4,
but T3 is the hormone that plays a larger role in body metabolism. People
with fibromyalgia may have issues with the hypothalamus, the part of the
brain that stimulates the thyroid gland to create and release thyroid
hormones. If a person cannot transform T4 into T3, metabolic processes are
disrupted and he/she may begin to suffer from negative symptoms.
Unfortunately, many patients who are tested for thyroid problems do not
always show low levels of thyroid hormone. Additionally, the main type of
thyroid testing is for thyroid stimulating hormone (TSH), which cannot
indicate if a problem exists with hypothalamic function.55
People with fibromyalgia may need to have their thyroid hormone levels
checked, in particular T3. If thyroid hormone levels are low, thyroid
replacement therapy can be initiated to help with symptoms. Armour Thyroid
is a natural formulation that is one option that might be used by patients
with fibromyalgia to improve thyroid symptoms. Armour Thyroid is natural
and is considered to be desiccated thyroid, which is another word for
ground-up thyroid gland. Some other preparations of thyroid replacement
are synthetic and only will replace T4.45,55 After taking thyroid replacement
for a period of time, a patient should have his/her levels checked by a
physician. The amount of time to wait to check levels depends on symptoms,
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
89
but it may be beneficial to check again in six weeks after starting
replacement therapy.55
Good Nutrition
Diet plays a significant role in controlling symptoms of fibromyalgia and
chronic pain; however, there are few studies that have extensively
investigated the effects on dietary intake in relation to pain and that offer
clear recommendations for diet. Overall, many patients are told to “follow a
healthy diet” in which it is understood what that statement means; however,
there are also many people who do not understand the specifics of a healthy
diet and for people with fibromyalgia, intake of some nutrients may take
priority over others.30
The pain and muscle stiffness that occurs during fibromyalgia or other
conditions that cause chronic pain can lead to changes in body chemicals,
including altered levels of glucose in the bloodstream and increased release
of the stress hormone cortisol. Additionally, some medications, such as
those used to manage pain, can cause weight gain and can impact the
amount of glucose in the bloodstream as well.30 Many people who are
suffering from negative physical or psychological symptoms look for comfort
foods, which are often those that contain sugar and high levels of
carbohydrates. While carbohydrates are not problematic in controlled
amounts, too much intake of these types of foods can lead to weight gain,
increased cravings for sugar and sweets, and decreased protein intake
because foods that normally contain protein have been replaced with
carbohydrate-rich foods.
Protein is necessary to strengthen muscle mass and to provide energy.
Proteins also play a role in many other body processes, including cell
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
90
formation, tissue repair, antibody production, increased neurotransmitter
production, and support of the hormonal system.48 Carbohydrates may
provide energy but they are used by the body more quickly than the slower
release of energy from foods that contain more protein or those with a good
blend of protein and carbohydrates. Foods that contain protein also support
creation of endogenous chemicals that help to control pain in the body, such
as endorphins and serotonin. Additionally, many foods that contain protein
as well as important vitamins and minerals may have compounds that help
to control inflammation and should be added to the regular diet.30
Patients should be encouraged to avoid diets that contain high amounts of
carbohydrates as the major components of meals and try instead to eat
foods that contain a blend of carbohydrates, proteins, and fats. Patients
should also avoid foods and drinks that are taken in between meals, such as
regular sodas, fruit juices, and sports drinks, as these products can contain
high amounts of sugar that contribute to changes in glucose levels and
weight gain.
Fats can be good for the body and are actually essential for some body
processes, such as protecting the myelin sheath that covers the nerves.
Some types of fat should be increased through diet, while other types should
be significantly reduced or eliminated entirely. Patients should take in more
unsaturated fats, such as monounsaturated fats and polyunsaturated fats,
and fewer trans fats or saturated fats in the diet. Monounsaturated fats are
found in some products such as avocadoes; nuts, such as hazelnuts,
almonds, and pecans, and pumpkin or sesame seeds, as well as certain
cooking oils, including olive oil. Polyunsaturated fats can be found in foods
such as oily fish, and sunflower, canola, corn, soybean, or flaxseed oil.46
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
91
Alternatively, trans fats are found in many commercially prepared products
that use large amounts of oil or margarine. Examples of these foods include
french fries, onion rings, cookies, potato chips, and some crackers. They are
also in the cooking oils and the margarine themselves, so foods made with
partially hydrogenated vegetable oil and large quantities of margarine should
be avoided. Additionally, saturated fats are found in fatty animal sources,
such as red meat and whole fat dairy products, such as whole milk or
cheese.45,46
Omega-3 fatty acids are types of fats that are necessary for normal body
functioning and can improve health. Omega-3 fatty acids include
docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA) and alpha linolenic
acid (ALA). They are not made in the body, so they must be taken in
through certain foods. These fatty acids have been shown to provide a
number of health benefits, including improving neurological and vision
development, reducing joint pain, improving mood, and curbing
inflammation. DHA, EPA, and ALA are found in many foods but are also
available as supplements. Foods that contain these fatty acids are items
such as oily fish, including tuna, salmon, anchovies, and herring; as well as
other foods, such as walnuts and canola or olive oil.
Supplements that may be available include fish oil or algae oil.45 Before
purchasing supplements of fish oil, patients should carefully check the
packages to ensure that no mercury exists within the supplement, which is a
potential risk of increasing intake of fish. Fish oil naturally has a ‘fishy’ odor
as well, which some people find unpleasant, but starting with a small dose
and increasing as necessary may help adjust to this.21
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
92
Many people have found success in managing fibromyalgia symptoms by
avoiding or eliminating certain foods from their diets. Eliminating foods such
as chocolate, alcohol, coffee, and other beverages that contain caffeine
seems to make a difference in symptoms for some people. Some patients
should also be tested to determine if food allergies are present, as ingesting
certain foods while unaware that an allergy exists can cause many negative
symptoms that can impact the entire body. Some patients have sensitivities
to certain foods such as gluten found in wheat, corn, soy products, or food
preservatives, but the sensitivities do not manifest as typical allergies.
However, they can still suffer from physical or psychological disturbances
when the body cannot tolerate these foods.45 Allergies known as sub-clinical
allergies or food sensitivities can manifest as fatigue, pain, or insomnia.48
Individuals suffering from fibromyalgia may want to consider testing for food
sensitivities or try an elimination diet, in which they stop eating certain foods
to determine if some of their symptoms abate. For example, they may try
eliminating all wheat and products containing gluten to see if they have any
improvement in symptoms. If after several weeks of eating gluten free
meals have not produced changes in any symptoms, individuals may try
eliminating another source of food sensitivity, such as products containing
corn. It is important not to move too fast in this process by eliminating
everything all at once, or a person may not be able to determine which type
of food is causing the sensitivity.
Talking with a dietitian or nutritionist may help some patients with
fibromyalgia to come up with diet plans and menus for foods that they
should eat that can help them with their symptoms. While it is important to
increase protein intake in the diet, more protein intake must be kept in
relation to carbohydrate intake as well. Some people try to follow high-
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
93
protein, low-carbohydrate diets in efforts to quickly lose weight. However,
carbohydrates are an important component in the diet to some extent
because they are quickly changed into glucose after digestion to give the
body more rapid energy. Although strengthening muscle is important, very
low-carbohydrate diets are not ideal.
Protein in the diet not only helps to support muscle, but it can also promote
healing of the body’s tissues. Some types of foods that are good sources of
protein include meats, such as lean beef; poultry, including chicken or
turkey; nuts, eggs, peanut butter, and tofu. When choosing carbohydrates
to incorporate with protein sources, patients should try to choose complex
carbohydrates that still provide the benefit of being carbohydrate sources
while digesting a little bit more slowly and avoiding rapid spikes of glucose in
the bloodstream. Some examples of carbohydrate foods that might be good
choices for energy include whole grains, such as whole wheat, pumpernickel,
or rye bread, beans, lentils, brown rice, oatmeal, and couscous.
Alternatively, there are some foods that should be limited or avoided
altogether. These foods can be high in sugar and can cause rapid spikes in
blood sugar. The roller coaster effect of increased and then decreased blood
glucose levels can lead some people to feel some energy, followed by a
crash when blood sugar levels drop. Combined with the fatigue and sleep
deprivation of fibromyalgia, these fluctuations in blood sugar can cause
many patients to feel worse. Some examples of foods to limit or avoid
include sugared cereals, pastries, such as donuts, muffins, and cake,
sugared soda, candy, cookies and other sweets, white bread or white rice,
and fruits packed in heavy syrup.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
94
One method of controlling rapid fluctuations in blood glucose levels is by
monitoring the glycemic index of certain food. The glycemic index describes
the rate at which a food is digested after eating. Foods with a high glycemic
index are digested and absorbed rather rapidly, which can cause the blood
sugar to rise rapidly and require a quick release of insulin to manage the
higher glucose levels. The rapid influx of insulin is quickly used when
responding to the larger glucose levels. Over time, if a person gets most of
his/her foods from those that are considered to be high on the glycemic
index, the pancreas may have to work harder to continuously provide rapid
releases of insulin in response to blood glucose spikes. This increases the
risk of insulin resistance, in which the cells become resistant to the insulin;
or diabetes, in which the pancreas is no longer able to secrete enough
insulin. Examples of foods that are considered to be high on the glycemic
index are those with a rating of 70 or higher and include such items as white
potatoes, white bread, bagels, pretzels, and sugared cereals.43
Alternatively, foods that have a low glycemic index are absorbed more
slowly and have much less impact on blood glucose levels and insulin. While
blood sugar levels can still rise after eating low glycemic index foods, they
do not cause such a rapid spike in blood glucose or the roller coaster of up
and down levels. Foods that are considered to have a low glycemic index are
those with a rating of less than 50.43 Some examples include beans,
chickpeas, flax seeds, oats, rye, mushrooms, peaches, strawberries, and
mangoes.
Vegetables typically do not cause rapid fluctuations in blood glucose levels,
and they contain many essential vitamins and minerals that may be lacking
in some people with fibromyalgia. Additionally, there are many vegetables
that contain powerful phytochemicals and antioxidants that can help with
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
95
fighting disease. Fibromyalgia patients can improve their diets by increasing
intake of vegetables, particularly dark-green leafy vegetables such as
spinach or kale, asparagus, broccoli, radishes, lettuce, eggplant, tomatoes or
cabbage.
Fruits are good sources of vital nutrients that provide vitamins, minerals,
and other chemicals that can protect body processes and support the
immune system. Fruits are often low in calories, particularly when they are
eaten raw, and they also have low levels of sodium and virtually no
cholesterol. They are naturally sweet so that many people find pleasure in
simply eating them. Many fruits also contain fiber, which is important for
health, including decreasing the risk of heart disease, lowering blood
cholesterol levels, and improving elimination by reducing constipation, which
could be a problem for some patients with fibromyalgia. The best sources of
fiber from fruit are to eat fruits whole, rather than drinking fruit juice. Whole
fruits offer more benefits of fiber than using only the juice extracts; some
juice preparations may also contain added sugar and so should be avoided.
Fruits that are good sources of fiber include apples, blackberries, pears,
raspberries, blueberries, bananas, kiwi, oranges, and plums.
Many fruits and vegetables contain antioxidants that can positively impact
health. Antioxidants are chemicals that can inhibit cell damage that could
lead to negative physical symptoms. Some common antioxidants are
lycopene, selenium, and beta-carotene. Studies have shown that some
people with fibromyalgia are chronically low in antioxidant capacity.14
Antioxidants are also available as supplements, but taking large supplements
to gain the positive effects of antioxidants has not been shown to prevent
disease. It is better to gain the effects of antioxidants by consuming foods
that contain large amounts, as most of these foods also contain vitamins and
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
96
minerals that can also promote health. Examples of foods that contain
antioxidants include tomatoes, blueberries, kale, bell peppers, cherries, and
spinach.45
Antioxidants are available through some vitamins, which can be found in
food as well as well as through some vitamin supplements. Vitamins that are
antioxidants include vitamins A, C, D, E, and B vitamins.45 Studies have
demonstrated that some patients with fibromyalgia have low levels of
vitamin D, which can lead to fatigue, muscle pain and cramping, joint pain,
poor concentration, and headaches.14
One defining aspect of vitamin D is that it can be taken in through sunlight.
Spending time outdoors and soaking up some sunlight can help low levels of
vitamin D, although it is also available through several foods and in
supplements. Foods that are sources of vitamin D include salmon, mackerel,
tuna, fortified milk, beef liver, and eggs.
There are also several minerals found in foods that can have positive effects
on symptoms of fibromyalgia and that are sources of antioxidants as well.
Minerals also impact metabolism in many ways, which can ultimately impact
energy level and cell function.
Many people are deficient in minerals because of not eating enough
vegetables, and not managing stress, which can impact how the body uses
nutrients. Eating more foods that contain these minerals can improve health
and increase the work of antioxidants involved. Minerals that are considered
to be antioxidants are magnesium, calcium, and zinc.45 Examples of foods
that are good sources of these minerals include seeds such as pumpkin or
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
97
sesame seeds, beans, lentils, spinach, avocadoes, dairy products, and
bananas.
Green tea also has antioxidant properties and may be beneficial in helping
some symptoms with fibromyalgia;45 it has been shown to have the benefits
of improving circulation, improving memory, maintaining weight loss,
increasing metabolism, lowering cholesterol, and providing a calming
effect.47 Increasing green tea intake to no more than 4 cups daily can
provide some benefits for people and could be an easy switch from
caffeinated or sugary drinks. Also, drinking green tea on a regular basis does
not have to be time consuming or expensive and can be easily incorporated
into someone’s lifestyle without resorting to major changes.
People with fibromyalgia who also have irritable bowel syndrome may
benefit from taking probiotics to support gastrointestinal health. Probiotics
are live microorganisms that a person can ingest through certain foods or
supplements that provide health benefits and protection from some types of
infections. They have been used therapeutically in illnesses affecting the
gastrointestinal tract with positive results, including illnesses such as
Clostridium difficile colitis, inflammatory bowel disease, diarrhea caused by
antibiotic use.51
People with fibromyalgia may have higher risks of developing irritable bowel
syndrome, which is characterized by abdominal pain, frequent diarrhea,
frequent constipation, or a combination of all. Irritable bowel syndrome
(IBS) can be caused by several factors, including changes in motility of the
bowel, increased overgrowth of bacterial microorganisms in the gut, lowgrade inflammation extending through the small and large intestines, and
poor pain tolerance for the intestinal distention.51
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
98
Probiotics may work in the gastrointestinal system through several factors.
They may improve a person’s immune system function so that he/she is
better able to fight off infections from viruses, fungi, or bacteria; they may
also reinforce the mucosal barrier of the intestine, and can suppress the
growth of bacteria. Some of the most common types of probiotics are
Lactobacillus and Bifidobacterium. Several studies have shown that using
these types of probiotics can reduce abdominal pain and bloating and can
improve stool frequency in patients with IBS.51
All people naturally have bacteria in their intestines; some of the bacteria
are healthy and considered to be helpful, while other types have the
potential to cause disease. Intake of probiotics can then increase the amount
of beneficial bacteria versus disease-causing bacteria in the intestine.
Probiotics can be taken as supplements or they can be taken in through
food. Supplements are available without a prescription and can be added to
a daily regimen for gut health. Probiotics are available in doses called
colony-forming units (CFUs); doses can range from one billion CFUs to 50
million CFUs each day. Higher amounts of CFUs may be necessary for severe
symptoms of IBS, but the dose can be tapered down as symptoms start to
abate.21
Foods that naturally contain probiotics that can be incorporated into the
daily diet include yogurt, miso soup, soymilk, sauerkraut, cow’s milk, dark
chocolate, pickles, and olives. Patients with fibromyalgia that have
concurrent IBS may want to consider incorporating probiotics into their daily
diets to determine if these foods or supplements have an effect on
symptoms.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
99
Dehydration can be a problem that causes increased fatigue, headaches, and
generalized malaise. Unfortunately, many people are unaware that they are
chronically dehydrated when they do not drink enough water. Because
coffee, tea, sports drinks, and energy drinks are so pervasive within society,
people often believe that by constantly sipping these drinks that they are
avoiding dehydration. However, these types of drinks with added sugar or
caffeine do not contribute much to the overall hydration of the body’s cells.
Instead, patients should focus on drinking more water or decaffeinated
drinks that have little or no sugar. Water helps to flush toxins and excess
waste from the body, so focusing on remaining well hydrated can be another
step toward better health and feeling better overall.46
Weight Control
Weight can be problematic, as excess weight places more stress on the
joints, which can further contribute to pain. Some patients with fibromyalgia
have an improvement in symptoms by losing weight because they have less
weight to carry on their bodies. This can be difficult, however, as weight loss
requires healthy eating and exercise, which may be painful and difficult to
incorporate into daily life when constant pain is present.
For patients who need to lose weight, weight loss can be slow, but
maintaining healthy habits and not giving up will go a long way toward
reaching a weight goal. Patients who need to lose weight to help their
symptoms can start with setting a weight loss goal. When large amounts of
weight loss are necessary, it helps to set something realistic instead of trying
for a drastic weight reduction. By setting small goals and reaching them one
at a time, a person can slowly lose the weight needed and keep it off
permanently.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
100
Methods of weight loss include not only incorporating a healthy diet and
exercise into daily life, but also practicing certain habits that will promote
eating less calories overall. People can achieve weight loss by monitoring not
only what foods they eat, but by also monitoring the overall amounts of food
eaten as well. This may mean controlling portions and not finishing every
bite of each meal. Portion sizes can be quite large, particularly in restaurants
and eating establishments, and people have become accustomed to eating
larger amounts of food at each sitting. It may help to visually inspect the
food before just digging in; cut the amount of a meal in half, serve the food
on a smaller plate, or practice leaving some of the food behind.
Paying attention to what and how a person eats is also important to control
food intake and weight. People who often eat meals quickly and do not pay
attention to what or how much they eat may be more likely to have trouble
losing weight. Studies have shown that paying attention to what is eaten can
better control intake and cut back on the total amount of food. This may
mean eating in more social settings to truly enjoy the conversation and the
company, rather than focusing on taking in large portions; taking time to eat
slowly and truly enjoy the food, savoring every bite, can reduce intake
because the body has time to catch up and recognize that it is getting food
and is no longer hungry; and, avoiding mindless eating, which can be eating
in front of the TV or computer and not paying attention to volume. Eating
only when hungry and stopping when satisfied—instead of stuffed—can also
go along way toward reducing intake, controlling calories, and losing excess
weight.46
Following a healthy diet and losing weight can improve feelings of wellbeing
and can eventually improve energy levels. Although it may be difficult for
some individuals to start exercising and eating right, health providers can
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
101
help by emphasizing the benefits of improved symptoms of fibromyalgia and
a reduction in chronic pain.
Exercise
Regular exercise can be very beneficial to people suffering from fibromyalgia
and chronic pain. Exercise improves circulation by increasing the heart rate
and causing the heart to pump blood more rapidly. It increases blood flow to
the skeletal muscles, increases flexibility, and improves muscle metabolism.
It can also increase activity tolerance and endurance; improve feelings of
stress, anxiety, and depression, and help people to sleep better.12 Exercise
also can improve feelings of wellbeing and those who engage in regular
exercise may find benefits of performing activities that they enjoy or being
with others who share a common interest.
Unfortunately, people with fibromyalgia and chronic pain may be quite wary
of performing exercise. A common belief is that with so much pain to begin
with, exercise may cause further damage to the joints or muscles, which
would only increase the pain even further. People who suffer from chronic
pain may have a difficult time getting past the increase in activity levels
required for exercise because it is simply too painful and too difficult to
maintain a regular routine. Instead, they decrease their levels of activity and
avoid exercise to protect themselves from further pain; however, this only
compounds symptoms because of inactivity, leading to muscle stiffness and
activity intolerance.10
For those who are fearful of an exercise program or who are unaccustomed
to working out on a regular basis because of painful symptoms, it may be
beneficial to begin increasing activity levels in small increments. The nurse
may help the patient in pain to come up with small goals to increase
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
102
exercise by doing enjoyable activities that will still provide physical benefits.
Walking and swimming are two types of exercise that are low impact and
enjoyable for many, yet still can provide physical and emotional benefits.10 A
patient with fibromyalgia who suffers from severe pain and who has very
little activity tolerance may be able to set a goal of walking for five minutes
at a time, every other day, until the activity is tolerable. She may then
slowly increase the amount of time that she walks or the intervals at which
she takes walks, ultimately attempting to reach a goal of 30 minutes of
walking each day.
Setting small goals to increase exercise has many benefits. After possibly
months or years of inactivity due to pain, small amounts of exercise for
short periods to start out reconditions the muscles to adjust to increase
activity levels. The patient may also be more likely to stick with a shorter
exercise program because it is not as difficult as starting out with a complex
and painfully long exercise routine. Achieving small goals leads to increased
confidence, which may help the patient to feel better about his-/herself and
to derive greater benefits of pain and symptom relief. Other exercises that
are beneficial to patients with fibromyalgia and chronic pain include yoga,
which focuses not only on stretching and muscle strengthening, but also
relaxation and meditation; and bicycling, which strengthens the muscles in
the legs and improves circulation as a good form of aerobic exercise. Water
exercises, such as swimming or water aerobics are good forms of aerobic
exercise without being too hard on the joints. Water is also soothing to the
muscles and can be a pleasant activity in addition to improving
cardiovascular fitness.12
Many patients benefit from working with a physical therapist to learn an
exercise program or stretching exercises. A physical therapist can teach
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
103
patients about how to use their muscles to improve range of motion,
flexibility, and strength without pushing them too far, which could cause
over fatigue of the muscles. Physical therapists also have access to other
types of therapies that can be included along with regular exercise and
stretching, such as the use of hot and cold therapies, mild electrical
stimulation of certain muscle groups, and mild massage.57
Biofeedback
Another method of controlling pain as well as tension and the effects
associated with chronic pain or fibromyalgia is biofeedback. This process
uses special techniques that teach people how to control their body’s
responses to events, typically considered involuntary, such as increases in
heart rate, elevated blood pressure, or muscle tension. When a person with
chronic pain experiences many of these involuntary body reactions, it can
result in increased or prolonged pain and other negative symptoms.
Biofeedback teaches a person to control some of these symptoms and
therefore suffer from less negative outcomes of chronic pain and tension.
During a biofeedback session, a patient is connected to a monitor that
displays results such as heart rate or blood pressure. The patient meets with
a biofeedback practitioner, which is someone trained in the specific mental
exercises used for the process. Often, the mental exercises involve
relaxation techniques, included guided imagery or mindfulness techniques,
that when used consistently, can exert greater control over the involuntary
responses caused by some health conditions. As the patient is going through
the mental exercises, he can see the results on the monitor that is
connected to the electrodes. Eventually, the patient will be able to control
his or her responses without seeing the results on the monitor.7 This is an
important part of treatment; if the patient is able to learn how to use certain
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
104
techniques to control certain responses, he can incorporate these techniques
into everyday activities when he would not normally be connected to a
monitor. Learning these techniques then gives patients the freedom to utilize
them any time they need to, such as when they are feeling anxiety and an
increase in heart rate, for example, instead of only using them within the
biofeedback session.
There are three common forms of biofeedback therapy, each of which
measures different responses from the patient. Neurofeedback, also called
electroencephalography, measures the activity and responses of brainwaves;
electromyography measures amounts of muscle tension, and thermal
energy, which measures skin temperature. Many people who have high
levels of stress and who suffer from conditions or illnesses that have been
brought on by increased stress tend to benefit from biofeedback procedures.
Although the stress can be detrimental to body processes, biofeedback can
be calming and the patient is able to watch results on the monitor during a
procedure that are caused by his own efforts, which helps the patient to feel
more confident.7
According to the University of Maryland Medical Center, electromyography
biofeedback, which involves measuring muscle tension, has been used
effectively in treating the painful symptoms of fibromyalgia. Biofeedback is
also helpful in reducing insomnia in some people. Other chronic conditions
that may benefit from biofeedback include tension headaches, back pain,
and muscle spasms.7 As biofeedback techniques are learned, patients can
slowly learn to control a response to chronic pain, thereby reducing the
amount of negative symptoms that may be experienced. In order to have
continued success with biofeedback, patients must use the therapy on a
regular basis for a series of several sessions. The biofeedback practitioner
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
105
prescribes how many sessions and how often the patient needs to return,
based on patient outcomes of relief from pain and other negative symptoms.
Regular sessions, one to two times per week, for a series of several weeks
are often necessary to achieve results biofeedback to control chronic pain.
Summary
Fibromyalgia is a syndrome within the spectrum of chronic pain conditions.
Health professionals have a key role to help individuals suffering from
fibromyalgia make sense and understand the often confusing cycle of pain
that they experience. Diagnostic theories and screening tools exist to help in
the diagnosis of fibromyalgia. A family history and patient self-report of
triggers and symptoms of pain onset and recurrence support the diagnosis.
Patients have options in the treatment of fibromyalgia chronic pain, which
include pharmacological and complementary approaches to stress relief that
may alleviate pain and improve outcomes.
There are many options for people suffering from chronic pain and
fibromyalgia, both through pharmacologic medications and nonpharmacologic therapies, which can significantly reduce painful symptoms.
The goal is not to expect to completely alleviate all symptoms of
fibromyalgia or chronic pain, but rather to find the most severe symptoms
that are debilitating and to work on their management to find hope and
relief in their daily life.
Please take time to help NurseCe4Less.com course planners evaluate
the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
106
1. Which best describes central sensitization?
a. A decrease in the levels of dopamine in the bloodstream
b. When the nervous system remains in a high state of reactivity to
pain and other stimuli
c. The stimulation of nerve fibers that transmit pain messages
d. When central or peripheral nerve fibers are damaged and do not
work as well as they should
2. _____ receptors located in the brain and the spinal cord are
often most involved in the pain sensation and management.
a. Kappa
b. Delta
c. Theta
d. Mu
3. Which statement is true regarding tricyclic antidepressants?
a. Tricyclic antidepressants were the first drugs that were considered
for management of fibromyalgia symptoms.
b. Tricyclic antidepressants should be taken in the morning because
they could cause insomnia if taken immediately before bed.
c. Tricyclic antidepressants are most often prescribed for patients with
attention deficit hyperactivity disorder (ADHD)
d. Tricyclic antidepressants are beneficial because they do not have as
significant side effects as some other types of antidepressants.
4. A nurse is counseling a patient who has started taking an MAOI
for managing fibromyalgia symptoms. Which food should the
nurse tell the patient to avoid?
a. Steak
b. Sauerkraut
c. Eggs
d. Salmon
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
107
5. In 2007, the U.S. FDA approved the first drug specifically for
fibromyalgia management. It is called:
a. gabapentin.
b. tramadol.
c. duloxetine.
d. pregabalin.
6. Which of the following is an example of an opioid antagonist?
a. Zolpidem
b. Triazolam
c. Nalaxone
d. Celecoxib
7. Which describes the process of how 5-HTP may work to help
fibromyalgia?
a. 5-HTP is eventually converted to serotonin, which can increase
levels of the neurotransmitter
b. 5-HTP causes increased levels of excreted phosphate, oxalate, and
calcium in the urine
c. 5-HTP regulates calcium levels in the muscle cells
d. 5-HTP creates adenosine triphosphate to use as a source of energy.
8. St. John’s Wort contains a chemical component called ______ ,
which may have an effect on neurotransmitter levels in the
brain that are responsible for regulating mood and behavior.
a. eszopiclone
b. hypericin
c. selegiline
d. ropinirole
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
108
9. The most commonly used type of acupuncture in the United
States is based on:
a. Korean hand acupuncture.
b. Myofascial release
c. Auricular acupuncture
d. Traditional Chinese medicine.
10. A patient with fibromyalgia complains of sleeping problems
secondary to restless legs syndrome. The medication or therapy
most likely to be prescribed for this patient would be:
a. melatonin.
b. amitriptylene.
c. ropinirole.
d. magnesium.
CORRECT ANSWERS:
1.
B
2.
D
3.
A
4.
B
5.
D
6.
C
7.
A
8.
B
9.
D
10. C
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
109
Helpful Link:
Psycheducation.org is a helpful website focused on bipolar, anxiety and
related mood disorders written for the layperson to understand, which
includes a section on fibromyalgia. It includes tools that the nurse may
introduce to patients to help them trend their mood and, in particular, their
sleep. There are other helpful teaching aids and resources on hormones,
mood regulation and sleep in this website, including medication, light
therapy and lifestyle recommendations that have been raised in this course
with respect to fibromyalgia treatment. Fibromyalgia and ongoing studies on
how the condition affects mood can be reviewed through the site search
within Psycheducation.org: http://www.psycheducation.org/.
References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
1.
NYU Langone Medical Center. (2013, Aug.). Cayenne. Retrieved from
http://www.med.nyu.edu/content?ChunkIID=21645
2.
Willihnganz, C. (2013). Basic pharmacology for nurses (16th ed.). St.
Louis, MO: Elsevier Mosby
3.
National Sleep Foundation. (2013). Fibromyalgia and sleep. Retrieved
from http://sleepfoundation.org/sleep-disorders-problems/fibromyalgiaand-sleep
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
110
4.
Harvard Medical School. (2007, Dec.). The characteristics of sleep.
Retrieved from
http://healthysleep.med.harvard.edu/healthy/science/what/characterist
ics
5.
Lilley, L., Collins, S., Snyder. (2012). Pharmacology and the nursing
process (7th ed.). St. Louis, MO: Elsevier Mosby
6.
DermNetNZ. (2014, Mar.). Capsaicin. Retrieved from
http://www.dermnetnz.org/treatments/capsaicin.html
7.
University of Maryland Medical Center. (2013, May.). Biofeedback.
Retrieved from
http://umm.edu/health/medical/altmed/treatment/biofeedback
8.
Jacob, Elliot (Ed.). (2012). Medfocus guidebook on: Fibromyalgia.
Princeton, NJ: Medfocus.com, Inc.
9.
Koenig, H. G. (2012). Chronic pain: Biomedical and spiritual
approaches. New York, NY: Taylor & Francis Group
10. Ryan, S. (2013, Nov.). Care of patients with fibromyalgia: Assessment
and management. Nursing Standard 28(13), 37-43.
11. D’Arcy, Y. (2011). Compact guide to acute pain management: An
evidence-based approach. New York, NY: Springer Publishing, LLC
12. Collins, A. (2007, Jun.). What can exercise do? Retrieved from
http://www.fmaware.org/what-can-exercise-do.html
13. University of Maryland Medical Center. (2013, Jun.). 5Hydroxytryptophan (5-HTP). Retrieved from
http://umm.edu/health/medical/altmed/supplement/5hydroxytryptopha
n-5htp
14. Kotsirilos, V., Vitetta, L., Sali, A. (2011). A guide to evidence-based
integrative and complementary medicine. Chatswood, NSW: Elsevier
Churchill Livingstone
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
111
15. National Sleep Foundation. (2014, Jan.). Melatonin and sleep. Retrieved
from http://sleepfoundation.org/sleep-topics/melatonin-and-sleep
16. Deans, E. (2012, Sep.). Is fibromyalgia due to a mineral deficiency?
Retrieved from http://www.psychologytoday.com/blog/evolutionarypsychiatry/201209/is-fibromyalgia-due-mineral-deficiency
17. Vanderah, T. (2010, Jan.). Delta and kappa opioid receptors as suitable
drug targets for pain. Clinical Journal of Pain 26(10), s10-s15.
doi: 10.1097/AJP.0b013e3181c49e3a
18. National Institutes of Health Office of Dietary Supplements. (2013,
Nov.). Magnesium. Retrieved from
http://ods.od.nih.gov/factsheets/Magnesium-HealthProfessional/
19. Bagis, S., Karabiber, M., As, I., Tamer, L., Erdogan, C., Atalay, A.
(2013, Jan.). Is magnesium citrate treatment effective on pain, clinical
parameters and functional status in patients with fibromyalgia?
Rheumatology International 33(1), 167-172.
doi: 10.1007/s00296-011-2334-8
20. University of Maryland Medical Center. (2011, May). St. John’s wort.
Retrieved from http://umm.edu/health/medical/altmed/herb/st-johnswort
21. Mitchell, D. (2012). The complete guide to healing fibromyalgia. New
York, NY: St. Martin’s Press
22. Foy Digeronimo, T. (2010). New hope for people with fibromyalgia:
Your friendly, authoritative guide to the latest in traditional and
complementary solutions. New York, NY: Random House
23. University of Maryland Medical Center. (2011, Dec.). Acupuncture.
Retrieved from
https://umm.edu/health/medical/altmed/treatment/acupuncture
24. University of Maryland Medical Center. (2011, Jun.). Sadenosylmethionine. Retrieved from
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
112
http://umm.edu/health/medical/altmed/supplement/sadenosylmethioni
ne
25. NYU Langone Medical Center. S-adenosylmethionine (SAMe). Retrieved
from http://www.med.nyu.edu/content?ChunkIID=21460
26. Goldenberg, D. L. (2014, Apr.). Fibromyalgia. Retrieved from
http://www.uptodate.com/contents/fibromyalgia-beyond-the-basics
27. EBSCO. (n.d.). Chiropractic. Retrieved from
http://therapy.epnet.com/nat/GetContent.asp?siteid=EBSCO&chunkiid=
37431
28. Massage Therapy Foundation Contributor. (2011, Nov.). Patients with
fibromyalgia find comfort in massage myofascial release therapy.
Massage Today 11(11). Retrieved from
http://www.massagetoday.com/mpacms/mt/article.php?id=14498
29. Campbell, B. (n.d.). Solutions for sleep. Retrieved from
http://www.cfidsselfhelp.org/library/solutions-sleep
30. Tennant, F. (2011, Jul.). A diet for patients with chronic pain. Practical
Pain Management 11(6). Retrieved from
http://www.practicalpainmanagement.com/treatments/complementary/
diet-patients-chronic-pain
31. Salvo, S. (2012). Massage therapy principles and practice (4th ed.). St.
Louis, MO: Elsevier Saunders
32. Mayo Clinic Health System. (n.d.). Massage: Get in touch with its many
health benefits. Retrieved from http://www.mayoclinic.org/healthyliving/stress-management/in-depth/massage/art-20045743
33. New York Times Health Guide. (2013, Jul.). Fibromyalgia: In depth
report. Retrieved from
http://www.nytimes.com/health/guides/disease/fibromyalgia/in-depthreport.html
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
113
34. Ostalecki, S., Tamler, M. S. (2010). 100 questions & answers about
fibromyalgia. Sudbury, MA: Jones & Bartlett Publishers
35. Üçeyler, N., Sommer, C., Walitt, B., Häuser, W. Anticonvulsants for
fibromyalgia. Cochrane Database of Systematic Reviews 2013, Issue
10. Art. No.: CD010782. DOI: 10.1002/14651858.CD010782.
36. Lilley, L., Collins, S., Snyder. (2012). Pharmacology and the nursing
process (7th ed.). St. Louis, MO: Elsevier Mosby
37. Slim, M., Calandre, E. (2013, Dec.). Management of fibromyalgia:
Current pharmacologic therapies and recommendations for therapeutic
optimization. OA Musculoskeletal Medicine 1 (3): 30.
38. Garg, N., Deodhar, A. (2012, Feb.). New and modified fibromyalgia
diagnostic criteria. Retrieved from
http://www.rheumatologynetwork.com/fibromyalgia/new-and-modifiedfibromyalgia-diagnostic-criteria
39. Sutherland, S. (2013, Nov.). Multiple studies, one conclusion: Some
fibromyalgia patients show peripheral nerve pathologies. Retrieved from
http://www.painresearchforum.org/news/33529-multiple-studies-oneconclusion-some-fibromyalgia-patients-show-peripheral-nerve
40. Richeimer, S. (2000). Understanding neuropathic pain. Retrieved from
http://www.spineuniverse.com/conditions/chronic-pain/understandingneuropathic-pain
41. Haavisto, M. (2008). Reviving the broken marionette: Treatments for
CFS/ME and fibromyalgia. Raleigh, NC: Lulu.com
42. Wimbiscus, M., Kostenko, O., Malone, D. (2010, Dec.). MAO inhibitors:
Risks, benefits, and lore. Cleveland Clinic Journal of Medicine 77(12),
859-882. doi:10.3949/ccjm.77a.09103
43. Institute for Chronic Pain. (2013, Dec.). Central sensitization. Retrieved
from http://www.instituteforchronicpain.org/understanding-chronicpain/what-is-chronic-pain/central-sensitization
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
114
44. University of Maryland Medical Center. (2013, May). Fibromyalgia.
Retrieved from
https://umm.edu/health/medical/altmed/condition/fibromyalgia
45. Paul, M., Smith, M., Segal, J. (2014, Feb.). Healthy eating: Easy tips for
planning a healthy diet and sticking to it. Retrieved from
http://www.helpguide.org/life/healthy_eating_diet.htm
46. Rawlings, D. (2012). Foods that fight fibromyalgia: Nutrient-packed
meals that increase energy, ease pain, and move you toward recovery.
Lions Bay, BC: Fair Winds Press
47. Chudler, E. (n.d.). Amphetamines. Retrieved from
https://faculty.washington.edu/chudler/amp.html
48. Arlt, W. (2011). What do I need to know about adrenal insufficiency?
[Patient brochure]. Retrieved from
http://www.endocrinology.org/policy/docs/1103_adrenal%20insufficiency.pdf
49. Muhich, K. (2011, Apr.). Why guaifenesin for fibromyalgia and chronic
fatigue syndrome. Retrieved from
http://stetsonchiropractic.com/fibromyalgia/why-guaifenesin-forfibromyalgia-and-chronic-fatigue-syndrome/
50. Romano, T. (2009, Nov.). Adult growth hormone deficiency in
fibromyalgia. Retrieved from
http://www.practicalpainmanagement.com/pain/myofascial/fibromyalgi
a/adult-growth-hormone-deficiency-fibromyalgia?page=0,1
51. Growth Hormone Treatment of FM and CFS. (n.d.). Retrieved from
http://willomedispa.com/aesthetic-blog/wpcontent/uploads/articles/GHTreatment.pdf
52. Bowen, R. (2006, Dec.). Growth hormone. Retrieved from
http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/hypopit/gh.
html
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
115
53. Teitelbaum, J. (2013). The fatigue and fibromyalgia solution: The
essential guide to overcoming chronic fatigue and fibromyalgia, made
easy! New York, NY: Penguin Group
54. Turk, D. (2009, Feb.). Fibromyalgia syndrome: A guide for the
perplexed. Retrieved from http://www.psychiatrictimes.com/cognitivedisorders/fibromyalgia-syndrome-guide-perplexed/page/0/6
55. Baron-Faust, R. (2014, Feb.). Alternate criteria for fibromyalgia
diagnosis shown better, easier. Retrieved from
http://www.psychiatrictimes.com/fibromyalgia/alternate-criteriafibromyalgia-diagnosis-shown-better-easier
56. Bergmann, T., Peterson, D. (2010, May). Chiropractic technique (3rd
ed.). St. Louis, MO: Mosby Elsevier
57. Greb, P. (2000, Oct.). Soy, whey, protein diet. Retrieved from
http://www.ars.usda.gov/is/graphics/photos/oct00/K9093-1.htm
58. Bennett, R., Friend, R., Marcus, D., et al. Criteria for the diagnosis of
fibromyalgia: Validation of the modified 2010 preliminary ACR criteria
and the development of alternative criteria. Arthritis Care & Research
(2014) DOI: 10.1002/acr.22301 [accepted article]
The information presented in this course is intended solely for the use of healthcare
professionals taking this course, for credit, from NurseCe4Less.com.The information is
designed to assist healthcare professionals, including nurses, in addressing issues
associated with healthcare.
The information provided in this course is general in nature, and is not designed to address
any specific situation. This publication in no way absolves facilities of their responsibility for
the appropriate orientation of healthcare professionals.
Hospitals or other organizations using this publication as a part of their own orientation
processes should review the contents of this publication to ensure accuracy and compliance
before using this publication. Hospitals and facilities that use this publication agree to
defend and indemnify, and shall hold NurseCe4Less.com, including its parent(s),
subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use
of this publication.
The contents of this publication may not be reproduced without written permission from
NurseCe4Less.com.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
116