Interesting article

[Guest guest]

I kinda found this article interesting....If we could only find a doctor who

would play the " advocate " ....I'm almost willing to drive across the country

to find one single doctor who knows what they are doing with this disease and

how to keep it under control. As you can see its 4:00 a.m. and I have been up

for 2 hours...can't sleep, but I gurantee you when sunlight hits my windows I

won't be able to stay awake....whats up with this???

Principles of Treating Fibromyalgia

, MD

There is currently no cure for fibromyalgia and fibromyalgia patients may be

symptomatic for many years with a reduced quality of life and varying levels

of dysfunction. However engagement in a productive lifestyle and minimization

of dysfunction can usually be achieved by paying attention to 4 major areas :

pain, exercise, sleep and psyche.

Pain. The use of NSAIDs in fibromyalgia patients is usually disappointing; it

is unusual for fibromyalgia patients to experience more than a 20% relief of

their pain, but many consider this to be worthwhile. Narcotics (

propoxyphene, codeine, morphine,oxycodone, methadone) may provide a

worthwhile relief of pain in a small subgroup of severely afflicted

patients, but fibromyalgia patients seem especially sensitive to opioid side

effects (nausea, constipation, itching and mental blurring) and often decide

against the long term use of these drugs. The oft quoted problem with http://www.myalgia.com/addiction%20def.htm " >

addiction seldom occurs when narcotics are used to treat chronic pain..

Tramadol (Ultram), a recently introduced analgesic seems to provide partial,

but significant, pain attenuation in many fibromyalgia patients – it is

currently undergoing controlled trials. The severity of pain and the location

of " hot spots " typically varies from month to month, and the judicious use of

myofascial trigger point injections and spray and stretch is worthwhile in

selected patients, but should be viewed as an aid to active participation in

a regular stretching and aerobic exercise program.

Evaluation by an occupational and physical therapist often provides

worthwhile advice on improved ergonomics, biomechanical imbalance and the

formulation of a regular stretching program. Hands-on physical therapy

treatment with heat modalities is reserved for major flares of pain, as there

is no evidence that long term therapy alters the course of the disorder. The

same comments can be made for acupuncture, TENS units and various massage

techniques.

Exercise. A gentle program of stretching and aerobic exercise is essential to

counteract the tendency for deconditioning that leads to progressive

dysfunction in fibromyalgia patients. Prior to stretching, muscles should be

warmed either actively by gentle exercise or passively by a heating pad, warm

bath or hot tub. Stretching will aid in the release of the often tightened

muscle bands and when properly performed will provide pain relief. The amount

of the stretch is important. Stretching to point of resistance and then

holding the stretch will allow the Golgi tendon apparatus to signal the

muscle fibers to relax. Stretching to the point of increased pain will

precipitate a contraction of additional fibers and have a deleterious effect.

The stretch should be gentle and sustained for 60 seconds. Often patients

must work up to this amount of time and start with 10-15 seconds on and then

10-15 seconds off. There is good evidence that fibromyalgia patients benefit

from increased aerobic conditioning, but many are reluctant to exercise on

account of increased pain and fatigue. However, most patients, can be

motivated to increase their level of fitness if they are provided realistic

guidelines for exercise and have regular follow-up. Exercise prescription

should emphasize non-impact loading exercise such as use of walking,

stationary exercycles and water-therapy. The eventual aim is to exercise 3 to

4 times a week at 60 to 70% of the maximal heart rate for 20 to 30 minutes.

Most fibromyalgia patients cannot start out at this level but need to

establish a regular pattern of exercise. I have found that an acceptable

initiation for most patients is to start with two or three daily exercise

sessions of only 3-5 minutes each. The duration should then be increased

until they are doing three 10 minute sessions, then two 15 minute sessions

and finally one 20 to 30 minute session performed 3 times per week.

Sleep. All fibromyalgia patients complain of fragmented non-refreshing sleep.

A treatable cause for the sleep disturbance should always be sought. For

instance, a small number of patients have sleep apnea and benefit from

continuous positive airway pressure therapy. Other patients have nocturnal

myoclonus associated with a restless leg syndrome and may often be helped by

the prescription of clonazepam (Klonopin), 0.1 mg at bedtime or

carbidopa-levodopa (Sinemet), 10/100 at bedtime. In the majority of patients,

the sleep disturbance seems to be rooted in psychological distress or due to

pain itself. For instance, a regional myofascial pain syndrome consequent to

a whiplash injury may cause a persistent sleep disruption, which eventually

leads to the appearance of widespread musculoskeletal pain consistent with

the fibromyalgia syndrome; this transition from regional pain to widespread

pain typically occurs over a period of 6 to 18 months. In some patients,

trochanteric bursitis or subacromial bursitis/tendinitis causes a sleep

disruption every time the patient turns over onto that side, and appropriate

treatment of the bursitis (see previous section) may lead to a more

restorative sleep pattern. In many fibromyalgia patients, the sleep

disturbance may be helped by the judicious prescription of a low-dose

tricyclic antidepressant (TCA). The doses required to promote restorative

sleep in fibromyalgia are not in the range required to treat depression.

Currently there seems to be no logical way of knowing which TCA to prescribe.

The ideal medication would produce restorative sleep with a feeling of being

refreshed on awakening with no side effects. In reality, some patients are

excessively sensitive to TCAs and have a severe sense of " morning hangover " ;

this may be helped by switching from one of the more sedative agents to a

more stimulant TCA. Other patients find TCAs unacceptable owing to

anticholinergic side effects, such as tachycardia, dry mouth, and

constipation. Most TCAs cause some weight gain, but in certain patients this

may amount to 20% of their initial body weight and is thus unacceptable. The

author often initiates TCA therapy with a trial of four medications taken for

6 days each with a 1-day washout between. Patients can be advised to start

medication on a Friday evening to minimize the inconvenience of a possible

hangover the next morning. If the patient has not taken a TCA before, the

following drugs and dosages can typically be used: amitriptyline (Elavil,

Endep), 10 mg at bedtime; doxepin (Sinequan, Adapin), 10 mg at bedtime;

nortriptyline (Pamelor, Aventil), 10 mg at bedtime; trazadone (Desyrel), 25

mg at bedtime and cycobenzaprine (Flexeril) 10mg at bedtime – cycobenzaprine

has a TCA structure and is also a muscle relaxant. Unless the patient has a

concomitant major depressive illness, the author does not routinely advocate

selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac),

because they may exacerbate insomnia and causes agitation. When SSRIs are

used in patients with concomitant major depression, the author usually

prescribes a low-dose TCA, such as trazadone 50 mg at bedtime. Some

fibromyalgia patients are very intolerant of TCAs due to a persistent daytime

hangover effect. In such cases the author uses zolpidem (Ambien) 10mg at

bedtime, with instructions not to use it more than 3 times a week.

Psyche. Patients with chronic pain often develop secondary psychological

disturbances, such as depression, anger, fear, withdrawal and anxiety.

Sometimes these secondary reactions become the " major problem " , however it is

a common mistake to attribute all of the patients symptomatolgy to an

aberrant psyche. The prompt diagnosis and treatment of these secondary

features is essential to effective overall management of fibromyalgia

patients. Some patients develop a reduced functional ability and have

difficulty being competitively employed. In such cases the treating physician

needs to act as an advocate in sanctioning a reduced or modified load at work

and at home. The overall philosophy of treating fibromyalgia patients,

however, is to provide them with realistic expectations of what can be done

to help and de-emphasize the role of medications. Frequent visits to physical

therapists, masseurs, and chiropractors or a dependence on repeated

myofascial trigger point injections should be discouraged. Unless the patient

has an obvious psychiatric illness, referral to psychiatrists is usually

non-productive. Psychological counseling, particularly the use of techniques

such as cognitive restructuring and biofeedback, may benefit some patients

who are having difficulties coping with the realities of living with their

pain and associated problems.