Everybody Get Up: Treating Fibromyalgia

Two weeks ago we covered the diagnostic criteria and some of the pathobiology of fibromyalgia. All of that isn’t so helpful without strategies for treating fibromyalgia or widespread pain in general. This week and next week will focus on evidence for treating fibromyalgia.

Oh, and what happened to last week’s Physio Weekly? We have been on vacation, but to make up for it, here is a free tool to help with diagnosing fibromyalgia based on Wolfe et al.’s 2016 criteria. Even if you aren’t in the position to medically diagnose, it’s helpful to know when patients meet the criteria.

Just Work That Body, Work That Body

In the clinic, I have heard patients offer a wide variety of knowledge of how to manage fibromyalgia; some mention that only gabapentin has helped, and others have noticed that certain types of exercise is helpful, and some are surprised to hear that anything can help at all. What does the evidence say?

There are many interventions that are unimpressive for fibromyalgia. Based on Cochrane reviews, whole body vibration and acupuncture offer no benefit beyond sham interventions, and the evidence is insufficient to support or refute transcutaneous electrical nerve stimulation (TENS). The evidence for myofascial release therapy is not sufficient to support its use for chronic musculoskeletal pain in general.

Recent practice guidelines offer conflicting advice. Still, the non-pharmacologic interventions with the greatest evidence are exercise and cognitive-behavioral therapy. Exercise takes many forms, and it’s challenging to determine whether one form of exercise offers more pain relief or improved function compared to other forms.

Aquatic exercise, land-based aerobic exercise, and resistance exercise all seem to offer meaningful improvements in pain and function.

In the clinic, though, it’s sometimes hard to sell exercise when it hurts. One reason that exercise might hurt more, like we discussed last issue, is that pain modulation is sub-optimal with fibromyalgia.

This means that you might find more success with low-intensity exercise, at least to start, when working with those with fibromyalgia. Even walking short distances can be a place to start, and using a graded walking program is one way to blend exercise with cognitive-behavioral strategies. In fact, one trial found positive effects with just brisk walking for 20-30 minutes per day.

As for resistance exercise, even body weight resistance, if sessions are at least twice per week and for 40-60 minutes, appears effective for reducing pain and improving function.

Here’s Your Chance, Do Your Dance

There are other ways to exercise, too, of course. Tai chi is one example. I love tai chi, though I usually only offer it when patients mention that they’ve heard about it.

This Youtube video is one that I share, because it’s easy, relaxing, and not as corny as other exercise videos. Tai chi postures are difficult to put onto a handout because of the “flowing” nature of postures, rather than the “start here and end there” movements of resistance exercise.

Yoga, on the other hand, is more accessible than tai chi. (My three-year-old son says that I look like a bug when I do tai chi, but he says that I look I’m exercising when I do yoga.) In fact, this randomized trial found that yoga postures were more effective for treating low back pain than traditional physiotherapy exercises. Yoga with Adriene is an easy starting point for beginners.

We’re Gonna Take It Into Overtime

Exercise is the bread and butter of physiotherapy. But is it good enough on its own for fibromyalgia?

I don’t think so. What happens when patients simply don’t want to exercise? What if patients are so afraid of movement that they don’t even want to shop at the big stores? What if patients are so stressed about their pain that they’re having trouble sleeping? What if there is evidence for central sensitization?

Next week will highlight some of the components of cognitive behavioral therapy, which adds significant value to the treatment of fibromyalgia and other persistent pain syndromes.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

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