The Physician’s Toolbox

“YOU HAVE FIBROMYALGIA, A CHRONIC AND PAINFUL CONDITION FOR WHICH THERE IS NO CURE.”

You may have heard these very words from the doctor who first diagnosed your condition, and perhaps you thought: “I’m stuck with this and nothing can be done?” As a physician who has fibromyalgia and specializes in this disorder, I know the hopelessness one may feel upon the initial diagnosis but you also need to know that, even though fibromyalgia cannot be cured (yet!), there are numerous treatment options available to help manage FM and improve your quality of life.

IF FIBROMYALGIA HAS DECONSTRUCTED YOUR LIFE, your physician can start the process to “rebuild” you by reaching into the physician’s toolbox and prescribing various “tools” to help. Let’s review what’s in the physician’s toolbox.

EDUCATION

I believe this to be the most important treatment tool available for making your FM more manageable. Education is the blueprint of your reconstruction. Your physician should explain your diagnosis and treatment goals. FM is not life-threatening, deforming, or paralyzing, and it doesn’t turn into one of these conditions. It is not easy having fibromyalgia, but it is a treatable disorder and it can improve or even go into “remission.”

Newly diagnosed patients should be provided with information and be empowered to take an active role in becoming informed. Resources such as the internet, journals, libraries, and support groups can help enhance patients’ knowledge and help them become self-responsible. You want to take control of FM and strive to cope successfully with this condition each and every day. Your doctor and medical team can give a lot of recommendations, and they want to point you in the right direction, but ultimately, you have to live your own life with FM.

PRESCRIBED MEDICATIONS

Certain drugs may help reduce pain, improve fatigue, improve sleep, and help overall fibromyalgia. Many studies have been published that show numerous prescribed medicines can benefit those with FM. Physicians are able to prescribe these medicines off-label for fibromyalgia because of evidence-based studies. Very recently, the FDA approved Lyrica for fibromyalgia. Basically there are three main categories of drugs prescribed in fibromyalgia for the three most common symptoms: pain, fatigue, and poor sleep. These categories include:

1. PAIN RELIEVERS (TRADITIONAL AND ADJUVANT)
2. FATIGUE MEDICINES
3. SLEEP MODIFIERS

The pain relievers category includes traditional pain medicines such as opioids, NSAIDs, muscle relaxers, tramadol, and migraine medicines. Examples of opioid medicines include hydrocodone, oxycodone, morphine, and fentanyl. NSAIDs include ibuprofen and naproxen, as well as Cox II inhibitors such as celecoxib. Muscle relaxers include cyclobenzaprine and methocarbamal.

The adjuvant analgesics include categories of medicines such as antidepressants, anticonvulsants, benzodiazepines, antispasticity medicines, and dopamine agonists.

Fatigue medicines can, as you might have guessed, help improve fatigue and mental alertness. Medicines in this category include antidepressant medicines; a good example is the dual acting serotonin and norepinephrine reuptake inhibitor duloxetine. Other antidepressant medicines and central nervous system stimulants such as modafinil can be prescribed as fatigue medicines.

Since poor sleep is a major problem in FM, sleep modifiers can be prescribed to improve the quality of sleep. When one sleeps better, the day usually starts off and goes better. Sleep medicines include benzodiazepines like temazepam and nonbenzodiazepines such as zolpidem tartrate and eszoplicone. Medicines in the tricyclic antidepressant family (such as amitriptyline), ben­zodiazepines (such as lorazepam or clonazepam), and dopamine agonists (such as pramipexole and ropinirole) are other types of medicines found to be helpful in improving sleep in FM patients.

Newer medicines have more selective action and fewer side effects compared to the older medicines, but a mixture of old and new medicines are often used in the treatment of FM. Numerous other medicines can be helpful, including guaifenesin, dextromethorphan, and lidocaine patches. There is no magic medicine that works for everyone, and everyone responds differently to medicines. Many people with FM do not tolerate medicines well. Ultimately, prescribed medicines are part of an over­all treatment plan, and your physician will try to find the most effective combination based on experience, and through trial and error.

More than one strategy may work for different people and different doctors. Some basic strategies that seem to work best for me include educating patients about realistic expectations for medicines, using the lowest effective dose of medicines, discontinuing any medicine that is not working, using controlled substances responsibly, being flexible, and keeping the medication plans as simple as possible.

THERAPEUTIC INJECTIONS

Therapeutic injections are a different way to administer medicine for pain management in fibromyalgia. One type of injection that can be effective is a trigger point injection, especially for particularly painful areas with muscle spasms. A combination of a local anesthetic and a corticosteroid is usually injected into one to six painful soft tissue areas. I find that the average trigger point injection lasts three to four weeks and can help other treatments to work more effectively. If injections are helpful, they can be done on a regular basis, depending on the patient’s needs and physician recommendations.

Other types of injections that can be tried include Botox injections for refractory trigger point areas or migraine headaches, joint injections, epidural injections, selective nerve root blocks, and facet injections. There are specific indications for each of these injections that can be part of the overall FM treatment. IV lidocaine infusions may also help in those who have a lot of central neuropathic-type FM pain. Your physician can recommend therapeutic injections that may work for you.

PHYSICAL MEDICINE TREATMENTS

A physical medicine program is an important part of the overall FM treatment program. It may also be called a physical therapy program or therapy program. It includes modalities such as heat, cold, electric stimulation, or water therapy. Also included are exercises such as stretching, strengthening, stabilization, conditioning, aerobics, and aquatics. Learning proper body mechanics is an important therapy goal also.

Manual therapy, a form of hands on treatment, can be very effective in FM. Massage therapy can decrease pain by relaxing muscles, improving circulation and oxygenation, removing waste build-up in the muscles, increasing muscle flexibility, and reeducating muscles.

Other manual therapy techniques that can be used in the treatment of FM include myofascial release, trigger point therapy, craniosacral therapy, strain/ counter strain techniques, and lymph drainage therapy. A manual therapist (physical therapist, massotherapies’, neuromuscular therapist, or other specialist) can perform specialized techniques to try to correct bone align­ment, reduce muscle spasms, and enhance the body’s normal neuromuscular pattern. My patients tell me that manual therapy is one of the most effective treatments.

I believe there are two main goals when prescribing therapy:

1. Find out what works to reduce the pain and improve physical activity and ability.
2. Teach the patient an individualized home program.

I find that moist heat, manual therapy (including myofascial release and massage), stretches, and a regular exercise program work the best for most people with FM, but there is no guaranteed recipe for success. As with medications, a physical medicine program needs to be a medically supervised “trial and error” approach.

ALTERNATIVE THERAPIES

Alternative, or complementary, medicine has been increasing in popularity over the years. People with FM are interested in alternative medicine approaches because conventional medicine often fails in the management of conditions causing chronic pain. Alternative medicine strategies emphasize the interaction between the body and the mind, and promote the body’s natural ability to maintain harmony and balance among its hormones, enzymes, muscles, and organs to prevent disease and to allow the body to heal itself. These treatments can be helpful as part of an overall treatment plan for FM.

Perhaps the most popular and well-known alternative therapy is chiropractic medicine. A holistic approach that includes manipulation and adjustments can help individuals achieve a higher state of well­being and, of course, decrease pain.

Acupuncture has been successful in pain relief, particularly as an alternative to conventional pain medicine. Acupuncture stimulates the body’s own natural painkiller, endorphin; improves the nerve function; and decreases pain impulses. Homeopathic therapy and naturopathic medicine are other alternative options that use specific diets, supplements, herbal medicines, and small doses of homeopathic medicine to try to reduce pain and spasms, and improve the body’s immune system and overall function.

Various forms of relaxation, including biofeedback, meditation, yoga, and Tai Chi, are considered alternative strategies. I think it’s important for a physician to prescribe relaxation as part of the treatment, just as he or she would prescribe exercise. The physician can refer you to various alternative specialists who will then become part of your treatment team.

NUTRITIONAL APPROACHES

People with FM usually have a number of nutritional deficiencies, imbalances, and metabolism changes that can be helped by dietary strategies and supplements. There is no nutritional cure for fibromyalgia at the present time, but we can increase our nutritional awareness as it pertains to fibromyalgia to try to improve nutrient absorption, boost the immune system, eliminate toxins from the body, create optimal biochemical pathways, minimize food sensitivity or adverse reactions, improve energy level, and achieve optimal body weight.

There are probably as many diets and supplements out there as there are patients with fibromyalgia! I believe the treating physician plays the most important role in guiding each patient to the best type of diet and supplement strategies based on each person’s unique needs.

I have found that a diet higher in protein and lower in carbs, and nutritional supplements including a magnesium and malic acid combination and colostrum, have been helpful. Our diets need to be balanced so proper vitamins, minerals and nutrients are obtained. I help patients find a diet plan that makes the most sense for them, but in the end, common sense needs to prevail to eat right and make wise food choices. It is reasonable to expect sound nutritional strategies to help reduce fatigue, anxiety, allergies, and irritable bowel symptoms, as well as control weight. Perhaps someday we’ll be able to eat away our fibromyalgia!

BEHAVIORAL THERAPY

FM affects your entire body. Physicians need to consider the mental pain the patients experience as well as the physical pain; one can’t heal without the other. Numerous stressors can occur as a result of chronic pain, which affects your emotions, your job, your finances, and your relationships. Many people with FM develop associated psychological problems, such as decreased self-esteem, depression, and anxiety. Sometimes behavioral and psychological treatments need to be prescribed as part of fibromyalgia treatment. These can include:

1. Psychotherapy. For FM, this treatment is designed to evaluate mental aspects of a chronic illness through re-education, reassurance, and support.
2. Counseling. This is professional “guidance” using information gathered from the patient’s history, interview, and various tests.
3. Cognitive retraining. This can include cognitive and behavioral therapies and EEG – biofeedback techniques to achieve relaxation, improve concentration, and obtain pain relief.

HOME PROGRAM

Various medical professionals can help you manage your FM, and I believe every­one should be able to find some treatment that works. At the end of the day, however, you can’t bring your physical therapist, massotherapist, chiropractor, or treating doctor home with you; it is your responsibility to develop a successful home program that works best for you.

Your physician can help guide you to a successful home program that is practical and helps you maintain a stable baseline. Each home program should include a consistent stretching program, exercises, proper body mechanics, modalities, and regular relaxation. Your physician can review over-the-counter medicines, supplements and diet strategies, and ongoing prescription medications as part of your regular program. A successful home pro­gram will give you confidence and em­power you to keep your FM under control as best you can.

SUMMARY

Being diagnosed with fibromyalgia is not the end for you. Your new diagnosis is actually the beginning. You have suffered with numerous symptoms, and have encountered uncertainty and fears of the unknown, but with your diagnosis comes a validation that you have a real and treatable condition. Now that you have your diagnosis, it’s time to get started in treatment. Living with FM isn’t easy, but it gets easier over time-once you realize that you have a lot of treatment options and strategies, and an excellent chance of establishing a program that will work for you.

Fibromyalgia has caused a lot of changes in our lives, but we need to remind each other that we are not alone, and that we can do better even if we hurt. Your physician is ideally suited to be your construction engineer. Whether you need a good hammer, a sturdy vise grip, a reliable screwdriver, or perhaps some glue and an extension cord, your physician is ready with the toolbox to help you build a better tomorrow.

Dr. Mark. Pellegrino has been in private practice since 1988 in Physical Medicine and Rehabilitation. In his Canton, Ohio, practice, he’s seen more than 20,000 patients with FM.

Dr. Pellegrino was diagnosed with FM during his residency at Ohio State University in 1986.