In this article I will give a short overview on the evidence for nonpharmacological treatments for fibromyalgia (FMS). As stated before, FMS is a syndrome due to different causes which makes research and treatment complex. Since FMS is chronic, pervasive and affects different areas of physical health it’s necessary to approach it in a multicomponent therapy plan. The three best studied therapies are education, exercise and cognitive behavioral therapy incl. relaxation techniques:
1. Patient Education
Understanding the nature of FMS: It’s a real illness! There are changes in perception and processing of pain with abnormalities in neurohormones that can be proven (see my first to article for more about this). But it’s not a deforming, deteriorating or life-threatening condition, nor is it infectious or autoimmune. The great majotity of people with FMS live normal and active lives. Symptoms will wax and wane but pain and fatigue generally persist. There’s a role of physical and emotional stress incl. mood disorders that should be understood as precipitating or aggravating factors. Despite pain during activity, exercise is not harmful and in fact can be helpful. The role of sleep hygiene, maladaptive illness behaviors and the importance of self-management are essential.
Exercise is fully recognized as an important part of FMS treatment. Beneficial effects are seen in graded aerobic exercise like walking, biking, swimming and require a minimum of three times 30 min per week. Improvement is seen in pain, general well-beening and physical function. There is also some evidence of benefit from strength training. Most important is individualization of the training program and a graded increase over time. Studies assessed the effect after a minimum of 8 weeks with most benefit after 6 months(1).
In real life, exercise in FMS often leads to an increase in pain and is therefore discontinued. The benefit doesn’t come over a short period and one cannot expect to train away FMS, it’s not a muscular disorder. Not over doing it on good days and remaining active on bad days is important.
3. Cognitive Behavioral Therapy (CBT) / Pain Management
CBT is based on identifiying dysfunctional thoughts, beliefs and attitudes that affect both emotion and behavior. A therapist helps you understanding your current thought patterns.
Errors in thinking such as overgeneralizing, magnifying negatives, minimizing positives and catastrophizing are challenged and replaced with more realistic and helpful thoughts, thus decreasing emotional distress and self-defeating behavior. More specific to FM, catastrophizing, or the belief that the worst possible outcome will occur, has been associated with pain severity and emotional distress in FMS. In cognitive therapy, catastrophic thoughts like “My pain is awful and there is nothing I can do about it” are reframed to “As bad as my pain might get there are things I can do to make it at least a little better.”
Behavioral techniques used include activity pacing, reducing pain behaviors, sleep hygiene (identifying, then changing behaviors know to disrupt sleep), and learning relaxation techniques to lower stress.
The primary goal of CBT is to increase self-management which includes moving toward the ability to cope with and control pain and other symptoms, as well as taking action to decrease FMS symptoms and stress resulting in increased functioning. You can find more about CBT here:
4. Relaxation techniques
Because psychological distress and dysfunction of the stress response systems have been observed in subgroups of FM patients, stress management is a target of treatment. Progressive muscle relaxation (PRM), autogenic training (AT) and mindfulness meditation (MBSR) are the most used behavioral interventions for chronic pain (2) .
- PRM involves the systematic tightening and relaxing of various muscle groups with the goal of decreasing muscle tension overall and thus ameliorating anxiety which was presumed to be linked to muscle tension. In FMS, PMR has the added benefit of emphasizing to the patient the difference between muscles that are tense and those that are relaxed since many patients persistently tense their muscles unknowingly which can contribute to their pain.
- AT involves repeating phrases such as, “My arms are heavy and warm” and visualizing heaviness and warmth in the arms. The exercise invokes images associated with a relaxed state while moving the focus from one body area to the next. It includes elements of guided imagery. Even guided imagery alone involving engaging all senses in experiencing pleasant places or circumstances has proven to be helpful for some with FM. Guided imagery enhances muscle relaxation and can serve as a powerful distraction from pain.
- Mindfulness-based-stress-reduction (MBSR) focuses on direct perception of body awareness, mainly breath, with a non-judgmental attitude and openness for all forms experience. Detachment of thoughts and feelings and continued observation of perception are the core. It has it’s origin in eastern buddhist Vipassana mediation and is a powerful tool to gain calmness and self-awareness. Personally, it's my favorite intervention and can be learned more deeply in a 8-week MBSR course. A sample specifically for chronic pain can be found here:
To cut along story short: stay active, learn all about your condition and focus on what you can control. Be aware of your thought and behavioral patterns as well as your stress level and keep sharing your experiences. There are lots of other non-drug therapies out there.
Feedback is always welcome
Marc Fouradoulas, MD
1 Thomas, Eric N., and Francis Blotman. "Aerobic exercise in fibromyalgia: a practical review." Rheumatology international 30.9 (2010): 1143-1150.
2 Hassett, Afton L., and Richard N. Gevirtz. "Nonpharmacologic treatment for fibromyalgia." Rheumatic Disease Clinics of North America 35.2 (2009): 393-407.