Technical Information: Guidelines for the Diagnosis and Treatment of Fibromyalgia.
Edited By: Gregory C. Gardner, M.D.
Last updated Friday, January 07, 2005
Management and treatmentTreatment Treatment consists of three parts; understanding sources of stress
that cause the patient distress, address sleep disturbance, and address
stretching and reactivation.
There are currently only theories on what causes FMS but most now
focus on a central causes such as neuroendocrine abnormalities. Whether
biological or psychological or some combination of both, our role as
health care providers is to give our patients the best care available
to maximize health and quality of life. In a few years it is hoped that
these guidelines will be updated to reflect important breakthroughs in
the understanding and treatment of FMS. Stress and distress It is important to know the patient and how they deal with stress and
what sources of stress are present in their lives. Patients may benefit
from the care of a pain psychologist or counselor to help sort these
issues out. Patients with mood disorders should of course be treated,
as few patients with active depression/anxiety will get better without
therapy.Sleep disturbance Try to understand why the patient feels they don’t sleep well. It
may be related to anxiety or depression and if so treatment for these
may make a difference. If sleep apnea is possible it should be
addressed with a sleep study. Sleep hygiene includes taking time to
relax before trying to sleep and avoid vigorous exercise within several
hours of initiating sleep. Medication for sleep should be given if the
above issues are not identified. Medications are selected for the
ability to induce sleep and not disturb stage four sleep. Medication
for sleep can include the following:
For mild cases suggest melatonin or low dose diphenylhydramine
(Benadryl). Tylenol PM is an easy dosing form for diphenylhydramine.
- Cyclopenzaprine, a muscle relaxant; begin with 5-10 mg/night and may increase as needed to maximum of 40-50 mg/night.
- Low dose tricyclic antidepressant i.e. amytriptyline 10-75 mg/night, nortriptyline 10-75 mg/night, trazadone 25-100 mg/night.
- Effexor has been used for sleep and for chronic pain.
- Ambien is an expensive medication but can be used if all else fails. Doses of 5-20 mg can be used.
- Neurontin can help with sleep and has been used for chronic pain as well. Dose of 300 to 1200 mg may be reasonable.
Stretching and reactivation This is one of the most important aspects of treatment. Aerobic
conditioning improves pain control by raising pain thresholds, improves
physical stamina, and can even lower anxiety and depression scores. If
done progressively, it also helps to restore confidence in the ability
to be active. It is useful to send the patient to physical therapy for
initiation of the AM stretching program and to help them develop a
slowly progressive aerobic program. Occasionally more intense physical
therapy program may be helpful to initiate exercise or to treat a
flare. Generally though, weeks of physical therapy are not useful
treatment should be directed to make patients independent of the
medical system. Occasional massage therapy may be useful for some
patients. Cognitive behavioral therapy has emerged as a potentially
useful form of therapy to address somatic illness. It entails
stretching, reactivation, stress management, and non-pharmacological
pain management techniques.Other issues Opiates should be avoided. Rarely a small bank account of low potency
narcotics can be provided i.e. 10 Tylenol #3 with the understanding
that these will be refilled only once a month. Tramadol or Ultram can
also be used as an alternative. We rarely recommend more than 3 per
day. NSAIDs rarely work in FMS and most patients have previously tried
them. Patients who feel they need continuous narcotics should be
referred to a pain clinic for multidisciplinary care including
psychological evaluation. In general, patients with FMS and other
somatic pain syndromes feel under-treated with narcotics no matter the
dose.When to refer Referral to a pain specialist or multidisciplinary pain clinic
should be done only after the primary care provider has exhausted
efforts on behalf of the patient. Keeping people with FMS in the
primary care setting may lessen sense of disability. It is important
for the primary care provider to give the person with FMS the majority
stake in their own improvement. Stretching, exercising, staying
involved in life without overscheduling, and seeking counseling for
personal or family issues are to be done by the patient as part of the
overall therapy. Goals should be modest i.e. 50-75% improvement but a
motivated patient may achieve more than this. DO NOT consider success a
return to pre-FMS pain and fatigue levels. If the patient is unable to
assume these responsibilities, then a referral to a pain specialist may
be warranted to give the patient greater assistance.
Final thought: Sir William Osler taught us that “It is more
important to know what sort of patient has a disease than what sort of
disease a patient has.” This patient centered focus is very important
when trying to help our patients with fibromyalgia.
Surgery for arthritis at the University of Washington If you are interested in making an appointment to discuss this procedure, you can request an appointment using our online referrals website. To request a referral online, please click here. You can also call 206-598-4288 (outside the Seattle area: 800-440-3280) to make an appointment.Disclaimer
This resource has been provided by the University of Washington Department of Orthopaedics and Sports Medicine as general information only. This information may not apply to a specific patient. Additional information may be found at http://www.orthop.washington.edu or by contacting the UW Department of Orthopaedics and Sports Medicine.
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