Non-Pharmacological Treatment Options for Patients with Fibromyalgia

Fibromyalgia is a generalized chronic pain syndrome characterized by widespread pain and tenderness to palpation at multiple anatomically defined soft tissues and associated with depression, anxiety, insomnia, cognitive dysfunction, chronic fatigue, and autonomic dysfunction. In 2010, American College of Rheumatology modified classification criteria defined in 1990. This is one of the most common musculoskeletal complaints in physician’s chambers. For lack of specific pharmacological treatment options, non-pharmacological treatment modalities are found to have some immediate efficacy and a variable efficacy in the long term. We searched literatures and reviewed randomized controlled trials for possible predictors of outcome in fibromyalgia. The effects of non-pharmacological interventions are limited and positive outcomes largely disappear in the long term. However, within the various populations with fibromyalgia, treatment outcomes showed considerable individual variations. Subgroups of patients with high levels of psychological distress may benefit from non-pharmacological interventions. Some of the relevant published articles demonstrated the beneficial effects of non-pharmacological treatment options, specially exercise, cognitive behavioral therapy and alternative and complementary medicine, in the context of non-availability of specific pharmacotherapy.


Introduction
According to American College of Rheumatology (ACR) 1990 criteria, fibromyalgia (FM) is a chronic musculoskeletal pain syndrome characterized by widespread pain and tenderness in at least 11 of the 18 so-called tender points. 1 The publication of American College of Rheumatology (ACR) preliminary diagnostic criteria for fibromyalgia (FM) in 2010 (ACR 2010) eliminated the tender point examination, thus making it possible to study FM in survey and clinical research.The diagnostic criteria for FM are satisfied if the following 3 conditions are met: 1) The Widespread Pain Index (WPI) ≥7 and the Symptom Severity Score (SS) ≥5, or the WPI is 3-6 and the SS ≥9; 2) Symptoms have been present at a similar level for at least 3 months; and 3) The patient does not have a disorder that would otherwise explain the pain. 2 Fibromyalgia lies at the end of a continuum of polysymptomatic distress rather than being a discrete disorder.Advanced neuroimaging techniques showed dysfunctioning of hippocampus and other cerebral abnormalities in fibromyalgia patients as well as greater gray matter loss than in healthy controls. 3he prevalence of FM in western countries varies between 2% and 10% and the majority of the patients are female. 4,5Most patients report a high degree of impairment in their daily functioning.−8 Over the past few decades, a wide range of potential treatments has been applied and evaluated.Medication mainly focuses on short-term relief of symptoms, whereas non-pharmacological interventions aim to address the long-term consequences of the disease, such as disability, psychological distress, muscular deconditioning and weakness.Interventions mainly consist of elements of cognitive-behavioral therapy (CBT), exercise training, or a combination of the two.Overall, reviews have shown non-pharmacological approaches to be more effective than pharmacological treatments. 9,10

Non-pharmacological treatments
At present, pharmacological treatments for fibromyalgia have a rather discouraging cost/benefit ratio in terms of poor symptom control and high incidence of side effects.The interdisciplinary treatment programs have been shown to improve subjective pain with greater success than monotherapy with drugs.Physical therapies, rehabilitation and alternative therapies are generally perceived to be more "natural", having fewer adverse effects, and in some way, to be more effective. 11Exercise and cognitive-behavioral treatments which exist in the multimodal approach and encompass largely selfmanaged strategy, demonstrate the beneficial effects of both different types of exercise and cognitivebehavioral treatment. 12on-pharmacological treatments, particularly exercise and CBT, have yielded effect sizes and cost-benefit ratios comparable to medications. 13

Cognitive-behavioral therapy
CBT is one of the most prevalent treatments for patients with FM.A distinction can be made between singlemethod interventions such as education and relaxation programs, and multi-method.Educational programs provide information about active self-management of pain, coping, relaxation techniques, the importance of physical activity and social support, and individual strategies for behavioral change.Few studies investigated the effect of education as a single-method intervention 14−16 and found the educational programs to yield some benefits for the patients' self-efficacy and pain-coping skills. 15However; the programs were not effective in diminishing pain and disability or in improving mood.Other single-method CBTs are relaxation techniques, for example, progressive relaxation, biofeedback and autogenic training which are used in patients with FM to diminish muscular tension and interrupt the pain-tension cycle.−19 Multi-method CBT typically consists of a combination of various therapeutic elements, such as cognitive restructuring, pain-coping skills, problem-solving techniques, goal setting, increasing activity levels, activity pacing, stress management and adjustment of pain-related medication, and frequently also comprises educational and relaxation components.−23 Two studies found no effects on pain, disability and mood 10,15 while two other studies reported varying effects 24,25 .

Exercise-training
Exercise training programs include aerobic exercise, strength training, flexibility exercises and hydrotherapy.Aerobic exercise is the most widely used exercise intervention and comprises of various types of exercises such as cycling, walking and aerobic dancing.Aerobic exercises increase cardiovascular fitness and reduce pain and other fibromyalgia symptoms.
Many studies investigated the effect of aerobic exercise 16,21,[24][25][26][27][28][29][30][31] and some of these found improvements on disability 21,28,31 .Only three studies conducted follow-up assessments 16,21,30 of which one showed limited long-term improvements in pain and disability. 30Strength training has been investigated three times in randomized controlled trials 32−34 and positively affected disability in two of the three studies.Finally, five studies evaluated aerobic exercise in combination with muscle-strength training and obtained mixed results.Three studies demonstrated a decrease in pain and disability 35−37 and these effects were maintained during follow-up.Treatments that incorporate improved physical function and relaxation, such as yoga and Tai Chi may also be helpful. 38

Combination of education and exercise training
−42 Two other studies reported positive effects for disability, such as an enhanced physical condition. 43,44Of the three studies that included follow-up assessments, 16,40,42 two studies found long-term effects on pain and disability 40,42 and one also on mood. 40Relaxation combined with exercise training appeared to be effective in diminishing pain and disability in daily life, and the effects were maintained at the 1-year follow-up. 14ing and coworkers 45 showed that socio-demographic and psychosocial variables were relevant in predicting the success of treatment, but the explained variance was relatively small.

Alternative and complementary medicine
In recent years, alternative and complementary medicines have been requested by the population, especially by individuals with fibromyalgia, for whom the isolated conventional therapy has shown limited benefits, requiring multidisciplinary treatment.From February to July 2003, Wahner-Roedler et al 46 carried out a study to assess the use of alternative and complementary medicine in a tertiary center for treatment of fibromyalgia.Of the 289 participants (263 women and 26 men), 98% reported the use of some type of alternative and complementary therapy, and the most frequently reported were: exercises (48%); treatment through prayers (45%); therapeutic massages (44%); chiropraxis (37%); use of vitamin C (35%) and vitamin E (31%), magnesium (29%), complex B (25%), and green tea (24%); and weight loss programs (20%).Moreover, 51% of the patients reported using one or more medicinal herbs or dietary supplements, and 8% of patients of all ages, mainly those between 18 and 64 years, reported the use of ginseng. 46Literature has shown low level of evidence for the above-described alternative and complementary treatments for fibromyalgia, except for acupuncture, some phytotherapic agents, nutritional supplements, and massages. 47,48challenge in the treatment of fibromyalgia is the inclusion of an alternative and complementary therapy in the daily routine of rheumatologists, when the previously indicated therapy fails, in the presence of side effects, or when the patient refuses to undergo the conventional treatment.In fact, little is known about the efficacy of alternative and complementary therapies in fibromyalgia and their tolerance.Studies of scientific quality are scarce, and they are always questioned due to the reduced size of their samples, and the lack of both adequate control groups and adequate follow-up. 49In alternative medicine, the best results have been obtained by use of acupuncture whose benefits for patients with fibromyalgia have been mostly reported in studies which are inadequately controlled and non-double-blind. 50

Conclusion
Advanced neuroimaging techniques indicate that central factors are important in the processing of pain in people with fibromyalgia and suggest that they have a narrow range of pain tolerance and perhaps other sensory stimuli before it becomes noxious.Pharmacological treatment has limited value, but comprehensive treatment care including nonpharmacological modalities can make a difference.Patients with fibromyalgia with a relatively high level of psychological distress and impact of the disease on daily living are likely to benefit most from non-pharmacological interventions.Associated contributing factors of fibromyalgia should be addressed with relevant pharmacological options in adjunct to physical approach.Future research and the clinical practice should respect the heterogeneity and individual variability in patients with fibromyalgia and should aim at developing non-pharmacological interventions that best match the needs of the individual patient.The target should focus on health related quality of life.Taken as a whole although some patients improve, the data tend to suggest minimal improvement in most cases despite treatment.