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Fibromyalgia – Nonpharmacological Treatments

Dec 04, 2015 3:57 PM

Dear Community,

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.

2. Exercise

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:

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

kind regards,

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.

Dec 06, 2015 7:38 PM

Thank you Dr Fouradoulas for sharing all this. I plan to check it out more, some of the things you shared. 🙏🌼

Dec 06, 2015 8:19 PM

I'm still in the acceptance phase as I was only dxed last year. Does it ever get any easier to accept that this is probably forever? I took CBT for panic attacks years ago and it helped wonderfully until this came along. Now suddenly panic attacks are jumping on full blown and rage and what I can only describe as temper tantrums.... How do I accept this? How do I move forward. Cuz right now, I'm awfully close to just curling into a ball and saying to hell with it.

Dec 07, 2015 2:28 PM

PhoenixRising, do you have a professional to talk this over? It's good to learn about coping skills, thought patterns and the degree you can control your condition. But this has limits too. And when you reach them and nothing seems to work, it may be better to just accept and retreat. Don't demand too much of yourself in that situation. Life is change and bad days are followed by better ones. Maybe you can find a pattern in your condition through the diary? Pain shows us our limits, but sometimes it can lead to insights and more understanding about ourselves. Acceptance and awareness are crucial. Mindfulness meditation is exactly about that. Training your mind to be with the present experience, nothing else. It can do wonders. I've had several patients with anxiety and panic that improved tremendously through meditation and finally got off their medication, like a phoenix rising ;-)
Take a look at this story as an example:
this helps

Dec 07, 2015 2:50 PM

I see a psychiatrist on the regular. Mainly dealing with medication. If I didn't keep a check she'd probably keep me in a stupor. I did have my pain specialist's PA tell me that if I was expecting more than 50% improvement I was dreaming. She told me the odds were slim that I'd get anywhere near 50%. Why would she tell a patient that?!?! I came very close to giving up right there. I did cry. I'm getting a new pain management doctor. I have tried meditation, it's very hard to stay focused. I keep trying, though

Dec 08, 2015 11:56 AM

Hi. I was diagnosed with FMS PTSD Panic n anxiety attacks. List of other health issues. Been in the hospital. N depression also. Am seeing internal specialist. Meds not really helping. One R.A told me it's in my head there's nothing wrong with me. I've been going through this for over 25 yrs. What other type of Dr do u recommend?

Dec 08, 2015 1:53 PM

Phoenix, no Dr wants to create unrealistic expectations. And chronic pain is about symptom management. Looking for a single cure leads to disappointments. Maybe you find a way around your pain, but expecting it from you Dr is not the way. That for we have the community here. Meditation needs regular practice, best in a group and with a course. Getting distracted is normal, just return to focusing.

Dec 08, 2015 4:35 PM

Probably the same thing we all want. Cessation of pain. Or at the very least acknowledgment.

Dec 08, 2015 9:09 PM

When referring to fibro it would be nice to have an answer as to why. A real concrete answer and not just blown off where everything is 'just fibro'.
It's really hard when someone asks why you are limping or favoring something or doing something in a way they think is odd and your only answer is 'my body hates me' because no one knows the why yet

Dec 09, 2015 5:50 AM

Yes, acknowledgment is important. But how would you expect the cessation to happen?

Dec 09, 2015 7:50 AM

Dr. I have ddd, but during my last visit to my pain management doc he told me about a new thing mabey you can elaborate on for all others. He said it is a device that goes behind the ear and somehow interacts with the Vegas nerve to basically reset the pain tolerance level in the body. I am not sure if it would work for or would even apply for fms but just thought I would bring it up. He also said that I would have to go to his office every day for 7 days.

Dec 09, 2015 2:33 PM

Wow, it's called vagus nerve stimulation and works through electrical stimulation of that nerve in your auricle. It creates a relaxation response in your body. Very new device, the studies are promising, though haven't seen it yet in real life. Give it a try and share you experience with the community.👍

Dec 10, 2015 6:02 PM

How do I delete this appt?

Dec 20, 2015 6:41 AM

I have fms for 9yrs & it is getting worse no medication i have tried has helped between the pain & fatigue i just feel i would like to curl up & give up.

Apr 07, 2016 6:03 PM

I was diagnosed with Fibromyalgia, RA, anxiety, depression and IBS 8 years ago. I saw a sleep specialist who put me on Xyrem. After a sleep study and diagnosis of idiopathic hypersomnia, the melatonin solution is real. I got my life back. I do still have to pace my activity and not overdo. Many doctors are scared of Xyrem. I would be shriveled in a ball in my bed on disability without it.
I wish I wasn't dependant on so much medication, but I am glad that I can still function most of the time.

Dec 08, 2016 2:05 PM

Dr. Have you read Dr. Ginevra Liptan 's Fibro Manuel? More info on hyperactive stress response & difficult getting deep restating sleep as the cause of fibro. The blame & control here does not rest with the patient alone & stigma of us all having psychiatric problems as cause debunked. I found your article full of the usual patient blame. Please read this book so you can stop alienating your fibro clients. A lot of promising research for an approach that brings hope not condemnation. Very sad for a supposed expert in your field. You are discouraging people with your exercise more & get therapy to stop catastrophizing your symptoms approach. You have not addressed the role fascia plays & gentle myofascial stretching and gentle warm up before any exercise. What about Integrative & Functional Medicine? Any who are discouraged please go to Dr. Liptan website & check out her book. The most

Dec 08, 2016 2:10 PM

I apologize for being blunt but I have had it with health practitioners who think they know about fibro but really don't & whole alienate us with there treatment plan. Please connect with Dr. Liptan. She is an MD. Has her own clinic in Oregon and steeps her knowledge in viable research.

Jul 11, 2017 11:53 PM

How do you know it's fibro. Why not to the urine, skin tests to ensure its not EDS I would love an excell doc with every differential diagnosis with symptom sign - tests. This could be given to us the other.

Mar 11, 2018 11:20 AM

Hi Dr thank you for this post. I am having trouble accepting my diagnosis of FMS and connective tissue disease so this information has benefitted me. I have recently discovered something called an ActiPatch - I would love to hear your thoughts on this if you have time. Thanks again Hayley

Jul 11, 2018 9:08 AM

i had stopped all prescription drugs about 4 years ago, I was doin g good for awhile got remarried went to work , I fel t happy I could move around without pain. But recently I have been dealing with a horrible painful nonstop flare up and discovered new pains with it in place that I never noticed, but it’s getting bad I where a wrist brace on my right arm cuz when I use it too much it feels like I’m going to break it, I find it harder to deal with this flare up I feel sick to my stomach can’t eat unless I force myself, my shin hurts when I shower it feel like razors cutting through me, baths feel like I sat in a pool of needles, both hips hurt so bad I can’t sleep very good my back feels like I’ve been beaten with a 4x4 post lights sounds, tempeture sensitivities anyways list goes on I tried different distractions non seem to help very long I’m ready to go back on pain meds cuz I’m becoming more sad and depressed no one at all understands what it’s like for me unless they have it, it’s a lonely place we live in , I’ll look into you article doc thank you

Aug 07, 2018 12:23 PM

Still don't believe I have fibro even through been dianosed by one rhumatolgist and a special environmental health program that treats several under its preview (fibro, ME, multiple chemical sensitivity and several others.
I'm active daily (walk my service dog twice a day for an hour plus [if we r not out all day working/running around] so 5km to 10km a day min for walks) I do yoga, pilates, swim and agility work.
I mediate daily as I've dun for the past 20 odd years but it has gotten harder to do with the spinal pain that creaps up on me when I'm in any one position long enough (more then a few minutes).
I wasn't over weight when first told I was at a 20% body fat and good bmi (not the case now 3 years later unfortunately) I don't understand what's going on and neither does my medical team. I fit the profile for fibro I'll give them that but a lot of what is happening doesn't feel related since I've lost 90% of my muscle tone/mass and struggle to even lift a 2L bottle or a 5kg bag of potatoes. Yet I do my weight n strength training changing it up weekly but instead of maintaining muscle strength I've lost it (even my old fitness coach doesn't understand how I could louse it with what I was doing vs struggle to even do now).
I push through the pain, I don't take anything for it unless it has me in tears and even then I'll push with heat, cold, massage, etc before agreeing to even take the extra strength advil.
I'm just so frustrated with everything I'm as positive as I can be I'm not looking at things being worse and I forget that I can't do things so often that it is frustrating because I forget that I don't have the strength or mobility to do something yet I go to do it because I've always been able to do so until the past couplease of years n it's still not sunk in!

Aug 29, 2018 10:16 PM

I so relate. Very well said.

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