# The best way to treat fibromyalgia



## eric (Jul 8, 1999)

FYIHarvard HealthThe best way to treat fibromyalgiaIt may require more than one strategy, but you can get some pain relief and feel a lot better about life.Two to four percent of Americans have fibromyalgia, and about 90% of them are women. Itï¿½s second only to osteoarthritis as the condition most frequently diagnosed by rheumatologists.Fibromyalgia is characterized by chronic, widespread musculoskeletal pain and tenderness at specific points on the body. Aching often starts around the neck and shoulders and eventually involves the back, chest, hips, arms, and legs. The condition is usually accompanied by fatigue and sleep problems, and often by depression. Some women also suffer from other health problems, such as headache, chest pain, irritable bowel syndrome, irritable bladder, temporomandibular joint problems, premenstrual syndrome, chronic fatigue, and difficulty remembering or concentrating.Fibromyalgia can be disabling and a source of enormous frustration. Its cause is unknown, so we donï¿½t know how to prevent it. And because the symptoms vary so much, it can take a long time to diagnose. Some doctors argue that the diagnosis is harmful, because it may make people feel more disabled than they are. Others disagree, arguing that a fibromyalgia diagnosis puts to rest fears of a fatal or progressive disease and can point the way to effective therapies.Despite dozens of studies, researchers have found no single, universally effective treatment for fibromyalgia. Experts say the best approach is a combination of medication, stress reduction, exercise, and cognitive behavioral therapy. A cardinal rule is to learn as much as possible about the condition to help reduce distress and increase a womanï¿½s sense of control over her situation.What causes fibromyalgia?We know that fibromyalgia is not a muscle disease, as was once thought. Because it overlaps with so many other conditions, investigators have looked for shared causes at the level of hormones, brain functioning, and neurotransmitters ï¿½ the chemical messengers by which nerve and brain cells communicate. Many studies suggest that fibromyalgia results from a malfunction that increases the excitability of pain centers in the brain and possibly in the spinal cord. People with fibromyalgia have lower-than-average levels of the stress hormone cortisol, which reduces levels of the neurotransmitters serotonin and norepinephrine. This can make a woman more sensitive to pain, and, perhaps, to depression. Low serotonin has also been linked to increased substance P, a chemical that amplifies pain perception. The cerebrospinal fluid of people with fibromyalgia contains two to three times as much substance P as that of healthy people. In 2002, an imaging study published in Arthritis and Rheumatism showed for the first time that the brains of fibromyalgia patients experience pain at a relatively low level of pressure stimulation. Researchers have also found low levels of human growth hormone in people with fibromyalgia. This may be due to sleep problems, which can interfere with the pituitary glandï¿½s production of the hormone. A shortage of growth hormone can impede muscle maintenance and repair, contributing to weakness and fatigue.In combination, these factors produce a self-perpetuating cycle of pain, fatigue, and poor sleep. What sets it off is still unknown ï¿½ and could differ from person to person. Many patients report a viral disease or an emotional or physical trauma immediately before developing fibromyalgia. Some people may be more susceptible than others due to their genetic makeup and social environment.Chronic fatigue and fibromyalgia: Whatï¿½s the difference?Most people with fibromyalgia feel the weariness characteristic of chronic fatigue syndrome, and most people with chronic fatigue syndrome have fibromyalgiaï¿½s tender points as well. Doctors disagree as to whether these two illnesses are actually different, or the same thing under different names. In general, women with fibromyalgia have more pain; women with chronic fatigue syndrome are more likely to have sore throats, swollen lymph glands, and low-grade fevers. Diagnosing fibromyalgiaThe American College of Rheumatologyï¿½s criteria for diagnosis include persistent widespread musculoskeletal pain and excess tenderness in at least 11 of 18 specific anatomic sites known as ï¿½tender points.ï¿½ (Some doctors will make the diagnosis with fewer than this.) Before making a diagnosis, a physician may also perform tests to exclude other diseases, such as rheumatoid arthritis, osteoarthritis, and lupus. While fibromyalgia can be debilitating, it doesnï¿½t produce the kind of muscle, bone, and joint damage associated with these diseases.Fibromyalgiaï¿½s tender pointsï¿½Tender pointsï¿½ are places on the body that become painful when pressed. They often develop in people with fibromyalgia at the locations shown here. Tender points seldom occur in healthy people. Mind-body strategiesReducing stress can help ease pain, improve sleep and concentration, and alleviate depression and anxiety from fibromyalgia. Harvard Medical Schoolï¿½s Dr. Herbert Benson, who coined the term ï¿½relaxation response,ï¿½ recommends meditation and other relaxation techniques for relieving stress.Meditation is aimed at quieting the autonomic nervous system, which regulates heart, breathing, and metabolic rates. The goal is a calm mental state brought on by focused breathing, repetition of a word or phrase, and an effort to empty the mind of random thoughts. Another mind-body strategy, progressive muscle relaxation, involves tensing and relaxing muscles, one at a time. Some people prefer guided imagery, in which they learn how to travel in their minds to a comforting place, in response to pain.The importance of exerciseIf you have fibromyalgia, exercise may be the last thing you feel like doing, but it can provide huge benefits. Regular strength and aerobic training over a period of months can increase strength and endurance, reduce pain and stiffness, improve coping skills, and generally make you feel better. Physical activity also helps relieve depression, anxiety, and fatigue. Moderate-intensity aerobic exercise twice a week, for example, has been shown to reduce pain at tender points. It can also raise your pain threshold. Pool exercises are a good way to start, because they are low-impact and the warm water may reduce stiffness and pain. Muscle strengthening and flexibility training have also proved useful.Itï¿½s a good idea to tailor the type and intensity of exercise to your own situation, preferably with the help of a physical therapist or exercise physiologist. Working out too hard may increase pain and fatigue and make you want to quit. Start at a level that feels comfortable, and take time to rest as needed. Gradually increase the duration and intensity of the exercise, taking care not to escalate until youï¿½re ready. For low-impact aerobic exercise, such as biking, walking, and swimming, start with 20 minutes a day, two to three times a week, and work up to 30 minutes.Cognitive behavioral therapyUnrelenting pain and other symptoms can understandably lead to discouraging thoughts, such as ï¿½The pain is completely out of my control,ï¿½ or ï¿½Iï¿½ll never be able to enjoy life again.ï¿½ This type of thinking can spiral into depression, anxiety, and anger, which can exacerbate pain and other symptoms. Research suggests that cognitive behavioral therapy may be particularly helpful for chronic conditions such as fibromyalgia.Cognitive behavioral therapy teaches patients that their thoughts influence how they feel and behave. Its goal is to help them learn how to turn unproductive thought patterns into helpful ones. This may include, for example, learning how to shift focus from what they canï¿½t do anymore to activities they can still enjoy, or adjusting expectations to minimize disappointment.During cognitive behavioral therapy, fibromyalgia sufferers also learn how to adapt daily activities to prevent flareups caused by doing too much or lethargy caused by doing too little. This may help them maintain their routines, which can improve mood and reduce isolation. Cognitive behavioral therapy can be done in a group setting or in one-on-one sessions with a therapist.Psychotherapy can be helpful for people with fibromyalgia, but itï¿½s important to choose a therapist who will focus on the present pain and stresses in your life. An emphasis on past conflicts and the influence of childhood experiences or trauma hasnï¿½t been studied as a treatment for fibromyalgia.Medications used to treat fibromyalgia Medications Comment(s) Tricyclic antidepressants amitriptyline (Elavil), desipramine (Norpramin), others Can help relieve pain and depression. Side effects include anxiety, drowsiness, dizziness, dry mouth, and constipation. Selective serotonin reuptake inhibitors fluoxetine (Prozac), others Can help relieve pain and depression. Fewer side effects than tricyclic antidepressants. Serotonin-norepinephrine reuptake inhibitors venlafaxine (Effexor) May help relieve pain and depression. Not extensively tested in fibromyalgia. Muscle relaxants cyclobenzaprine (Flexeril), carisoprodol (Soma), others Can help relieve pain and restore normal sleep patterns. Analgesics tramadol (Ultram), acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) Tramadol provides pain relief but may be habit-forming. Acetaminophen and NSAIDs have limited effectiveness. Anticonvulsants gabapentin (Neurontin) Under study for relieving pain and improving sleep in fibromyalgia. Stay open to changeTo live well despite the limitations of fibromyalgia requires taking charge of treatment and remaining flexible. Some therapies work for some patients and not others. Other therapies are helpful only for people with a distinct array of symptoms. Approaches that target both physical and psychological factors appear to offer the best chance of relieving the greatest number of symptoms.Selected resourceAmerican Fibromyalgia Syndrome Association6380 E. Tanque Verde Rd., Suite DTucson, AZ 85715520-733-1570 (toll call)www.afsafund.org


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## Feisty (Aug 14, 2000)

Eric--thank you so much for posting this.


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## weener (Aug 15, 2000)

Thank you Eric for the article.


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## moldie (Sep 25, 1999)

Eric, that was an excellent article. Thank you for taking the time to post this for us. If I have one criticism of this article, it would be the reference to "women" and its exclusion of "men," as we do know that men can experience this syndrome as well. I really do think there is beginning to be more and more evidence of this complex condition though, with more credible health facilities out there supporting its existence. I took interest to one particular paragraph concerning cognitive behavior. This seems to be what I, and many others here, have to continually fight on occasion: "Cognitive behavioral therapy teaches patients that their thoughts influence how they feel and behave. Its goal is to help them learn how to turn unproductive thought patterns into helpful ones. This may include, for example, learning how to shift focus from what they canï¿½t do anymore to activities they can still enjoy, or adjusting expectations to minimize disappointment."It's kind of reminded me of the Serenity Prayer in a way that goes something like this: "Lord help me to accept the things I cannot change, give me the courage to change the things that I can, and grant me the wisdom to know the difference."M.


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## eric (Jul 8, 1999)

I am glad it helped.Sometimes they don't say much about men either in IBS or fibro or even cfs.This is on CBT for IBS just for the info on CBT.Dr Bolen wrote this for me for my IBS website.Barbara Bradley Bolen, Ph.D.bbolen###optonline.netSeptember 5, 2002COGNITIVE BEHAVIORAL THERAPY FOR IRRITABLE BOWEL SYNDROMEThere is an old saying that if you give a child a fish, you feed that child for a day, but if you teach a child to fish, they are fed for a lifetime. In accordance with this old proverb, Cognitive behavioral therapy (CBT) is a form of psychotherapy that strives to actively teach people skills and strategies that they can use to help themselves feel better. A considerable amount of research indicates that CBT is effective in helping to reduce the symptoms of Irritable Bowel Syndrome.Many people wonder how psychotherapy can help IBS if IBS is a physical disorder. One of the major triggers that can set off or exacerbate IBS is stress. In addition, IBS is a very stressful disorder to live with. CBT provides an individual with tools for combating stress, reducing the anxiety response and thus calming the GI system.The cognitive therapy part of CBT helps individuals to identify, challenge and replace unhealthy thought patterns. When we are thinking clearly, we are able to deal with the world in a calm, rational manner. However, our thinking often gets distorted, due to our personalities, our past history, our emotional state or lack of information. When thinking gets distorted it can lead to excessive emotional reactions. For an individual with IBS, these thought distortions may lead to an anxiety response that can trigger symptoms. For example, if a person with IBS thinks ï¿½My stomach is rumbling. Uh, oh! I know I am going to be sick. What if I canï¿½t make it to the bathroom? This is terrible!ï¿½, that person is going to experience anxiety and perhaps set off the very symptoms they are afraid of. If instead, the person thinks, ï¿½Just because my stomach is making some noise does not necessarily mean I am going to have symptoms. I will just focus on what I am doing and see what happensï¿½, that person will remain calm and be less likely to stimulate their digestive system.The behavioral aspect of CBT involves skill training. Relaxation techniques, including deep breathing skills and progressive muscle relaxation, help the individual to reduce the physiological symptoms of anxiety. An anxiety reaction can be likened to a home security alarm. Relaxation techniques send the message to the body that there is no emergency and that the alarm can be shut off. CBT for IBS may also include skill training in assertion and anger management, as research has shown that IBS patients often have difficulty in these areas.IBS can wreak havoc on a personï¿½s quality of life. CBT helps IBS sufferers to regain a sense of control over their life. With the skills gained in CBT, one no longer needs to be a passive victim of this disruptive disorder, but can now actively use strategies which are effective in reducing the frequency, intensity and duration of IBS symptoms. Barbara Bradley Bolen, Ph.D.bbolen###optonline.netAuthor of:Breaking the Bonds of Irritable Bowel SyndromeNew Harbinger Publications (2000)


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## Guest (Jan 9, 2004)

Good post, Shawn. I guess I do most everything you listed. I still have pain and fatigue, but the way I see it, it might be a whole lot worse if I didn't do all of those things. I think exercise is the hardest one of all to do... but as you know, I've chosen something that I love and that is a real plus because I don't have to try so hard....


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