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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 e-module 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.

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 and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of 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.

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

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.

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.

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 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

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 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 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 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 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

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 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 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 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.

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 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 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 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 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 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 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, 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 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 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 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 (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 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 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 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

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 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 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 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 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 sedative-hypnotics 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 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

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 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

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 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 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, 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.

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

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 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, 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.

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.

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

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.

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 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

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, 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 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.

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 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 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 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

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

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

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 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 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 post-herpetic 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 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.

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 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 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.

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 non-specific 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.

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 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 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 high-end 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 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 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

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 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.

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 cognitive-behavioral 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 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

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, 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.

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 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.

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.

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.

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.

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-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.

Some patients may also have symptoms of fibromyalgia in relation to low levels of growth hormone. A clinical study tested levels of serum insulin-dependent 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 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.

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, 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 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

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

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-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.

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 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 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 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, low-grade inflammation extending through the small and large intestines, and poor pain tolerance for the intestinal distention.51

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.

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.

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 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 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 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 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 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 non-pharmacologic 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 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.

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

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

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

Helpful Link:

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 : .

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.

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