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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 NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 3 hours. Nurses may only claim

continuing nursing education credit commensurate with the credit awarded

for completion of this course activity.

Pharmacology content is credited for 1 hour (60 minutes).

Statement of Learning Need

Fibromyalgia is one of the most common chronic pain conditions. To

understand fibromyalgia as a syndrome nurses require knowledge of chronic

pain and how to recognize the clinical presentation and support patients to

experience improved outcomes.

Course Purpose

To provide nurses knowledge about chronic pain syndromes and medical and

alternative treatments as it relates to fibromyalgia.


Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD; William S. Cook, PhD; Douglas Lawrence, MA;

Susan DePasquale, CGRN, MSN, FPMHNP – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP.

Release Date: 1/1/2016 Termination Date: 5/28/2017

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.


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 NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment

of Knowledge Questions after reading the article, and providing

feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.


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:

Psycheducation.org is a helpful website focused on bipolar, anxiety and

related mood disorders written for the layperson to understand, which

includes a section on fibromyalgia. It includes tools that the nurse may

introduce to patients to help them trend their mood and, in particular, their

sleep. There are other helpful teaching aids and resources on hormones,

mood regulation and sleep in this website, including medication, light

therapy and lifestyle recommendations that have been raised in this course

with respect to fibromyalgia treatment. Fibromyalgia and ongoing studies on

how the condition affects mood can be reviewed through the site search

within Psycheducation.org: http://www.psycheducation.org/.

References Section

The reference section of in-text citations include published works intended as

helpful material for further reading. Unpublished works and personal

communications are not included in this section, although may appear within

the study text.

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http://www.psychiatrictimes.com/cognitive-disorders/fibromyalgia-syndrome-guide-perplexed/page/0/6

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http://www.psychiatrictimes.com/fibromyalgia/alternate-criteria-fibromyalgia-diagnosis-shown-better-easier

http://www.psychiatrictimes.com/fibromyalgia/alternate-criteria-fibromyalgia-diagnosis-shown-better-easier

http://www.ars.usda.gov/is/graphics/photos/oct00/K9093-1.htm

fibromyalgia: chronic pain - nursece4less.com · module training series for trauma patient...

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