ESTES PARK, COLO. – Nonpharmacologic therapy is as important as medications in successful management of fibromyalgia, yet the nondrug interventions are greatly underutilized, Dr. Sterling G. West asserted at a conference on internal medicine sponsored by the University of Colorado.
"Nonpharmacologic therapy has to be used. If you don’t, you won’t get near the success rate you will by combining it with pharmacotherapy," said Dr. West, professor of medicine and a rheumatologist at the University of Colorado, Aurora.
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Experts say that nonpharmacologic therapy, which includes exercise, psychological support and stress management, is crucial in managing fibromyalgia but is often underutilized. Warm water exercise is highly recommended by the Arthritis Foundation.
The core elements of nonpharmacologic therapy for this challenging disorder are education, exercise, sleep hygiene, psychological support, and stress management.
Two educational websites he recommends for his fibromyalgia patients are www.fmaware.org and www.knowfibro.com.
"You’ll find they get 20% better just knowing what they’re dealing with," according to Dr. West.
He particularly likes www.knowfibro.com. "It basically tells patients that it’s up to them to get better. They can’t just lay back and say, ‘Give me disability.’ They have to participate and actively try to improve," the rheumatologist explained.
The emphasis with regard to exercise needs to be on aerobic activity. Patients must understand the importance of exercising on their bad as well as good days, and that their pain may initially get worse as they become more active.
Fibromyalgia patients are exquisitely sensitive to medications and their side effects. The same is true for exercise. As with drug prescriptions, the exercise prescription has to start low and build up gradually. A good rule of thumb is to begin with 15 minutes of physical activity per day, increasing it by 5 minutes per day each week until reaching 30 minutes per day. The intensity is gradually boosted to the moderate range, or 75% of maximum heart rate. For patients who find land-based exercise too painful at first, warm water exercise is a good alternative. The Arthritis Foundation sponsors pool-based warm water exercise programs in every state that are available to fibromyalgia patients.
Sleep apnea is quite common in patients with fibromyalgia, many of whom aren’t particularly overweight. It needs to be addressed as part of the comprehensive treatment of this pain disorder, Dr. West continued.
The need to involve a skilled psychologist often becomes apparent at a physician’s initial encounter with a fibromyalgia patient. Two questions Dr. West always asks as part of his history taking are, "What do you do to cope with your pain?" and "Do you think your pain will ever get better?"
"If a patient answers no to that second question, you know you’re in big trouble because the patient is catastrophizing. That means you need to elicit the help of a psychologist with expertise in pain to help you deal with this. Your patient is going to need their help in addition to the things you’re going to do," he explained.
Another situation where a psychologist’s help is essential is in the fibromyalgia patient with early-life trauma in the form of sexual and/or physical abuse. Often patients with the most severe fibromyalgia have such a history.
"The patient may have never previously been asked about early-life trauma. If you’re going to unroof that scab, you’d better have someone in the background who can help you," Dr. West advised.
Strong evidence supports the utility of cognitive-behavioral therapy in improving pain, fatigue, physical function, and mood.
An estimated 6 million American adults have fibromyalgia, making this disorder more common than gout.
The current view of fibromyalgia is that it’s an afferent processing disorder leading to central and peripheral amplification of pain pathways and additional somatic complaints. It features increased excitation at the level of the dorsal horn nuclei and inhibition of descending pathways responsible for diffuse noxious inhibitory control. Insight into the neurotransmitters involved has led to more rational use of medications.
Nonetheless, the clinical trial data for drug therapy point to effect sizes that are "modest at best" for all drug classes, he observed, adding that "30% to 40% of patients get 40% to 50% relief of their pain; that’s what you can tell patients they can expect. But those are averages. You’ll have patients who respond well to their medicine and others who won’t respond at all. You can’t tell which ones are going to respond well and which aren’t until you try them. You try a drug, and, if it doesn’t work, you try something different, and you keep on until you find what works best," Dr. West said.