Fibromyalgia is a common cause of chronic pain and disability that impinges on all areas of a person’s day-to-day living. This paper examines causality, symptoms and some of the available treatments. It also highlights how nurses can care for people with the condition by encouraging understanding, coping skills and appropriate treatments.
Helen Henderson, BSc (Hons), RN.
Chronic Pain Liaison Nurse, Pain Clinic, Belfast City Hospital
Fibromyalgia, despite its name, is not a primary muscular disorder but rather an idiopathic condition characterised by a variety of signs and symptoms. The most predominant symptom is diffuse musculoskeletal pain in four quadrants, with reproducible tenderness in at least 11 of 18 defined tender points.
Characteristically, clinical findings show discordance between symptoms and actual disability. There appears to be no neurological abnormality, weakness or synovitis, and blood chemistry findings are all within normal limits. However, Russell (1998) showed some discrete abnormalities of growth hormone, with neuropeptides present in some subjects. Despite these findings there is no evidence to suggest that a single event or trigger causes fibromyalgia. Rather, a multitude of factors appear to play a role in the development of the condition.
Assessment is pivotal to the successful management of pain, and it is widely acknowledged that the patient’s own description of pain intensity must be viewed as the gold standard (McCaffrey, 1980). However, this is a somewhat unidimensional approach and it is important to use a number of different strategies to assess the multifactoral aspects of chronic pain.
A clinical diagnosis of fibromyalgia is largely based on the patient’s history and validated using the established tender-point examination (Wolfe et al, 1990). An initial general musculoskeletal and neurological examination is performed to exclude other conditions and prevent unwarranted and expensive laboratory tests and procedures.
For patients with fibromyalgia, pain diaries are used to record pain, pain behaviour and associated events. Diaries enable patients to take a more active role in their care and are used to highlight the effectiveness (or otherwise) of medications and treatments. There are, however, some drawbacks to using diaries. First, the patient must be literate and, second, the process may, perhaps, actually encourage the sufferer to focus entirely on the pain.
There is no single cause of fibromyalgia, which makes it difficult to treat pharmacologically. As a result, management is mainly focused on treating symptoms, namely pain and fatigue. Anti-inflammatory, analgesic and antidepressant drugs are all used in treating the condition. Anti-inflammatory drugs, however, are not a particularly effective treatment as there is generally little evidence of tissue inflammation.
Antidepressants such amitriptyline may be used with some patients, although these drugs are not licensed for pain relief in the UK (Rowbotham, 2000); the dosage used is lower than that used specifically for clinical depression. Amitriptyline is believed to have a normalising effect on the sleep centre and the pain-gating mechanism in the spinal cord by potentiating the effects of serotonin on the central nervous system. However, the lack of uniform effectiveness and the large number of undesirable side-effects limit the use of this drug.
Analgesics are of little use in the long term, but provide relief during flare-ups. Other less common treatments include hormonal stimulation. The effects of using human growth hormone have been examined by Bennett et al (1998). Initial results showed encouraging signs of improvement in fibromyalgic symptoms; however, not only can the cost of daily injections be prohibitive but a follow-up of patients after the study showed a tendency to relapse. The role of human growth hormone is therefore not definitive and requires further investigation.
It is apparent that drug therapy is often insufficient for patients with fibromyalgia and it is necessary to use adjuvant non-medicinal, non-pharmacological treatments. As a result, there is a move from the medical model of managing this type of pain to a more psychosocial approach, whereby the multidisciplinary team co-ordinates its efforts through pain-management programmes.
Cognitive behavioural programmes
These are essential for decreasing pain perception through education of the patient about the condition, pacing, goal-setting, relaxation and changing lifestyle, together with an exercise regimen aimed at increasing activity and fitness (Arathuzik, 1994: Turk and Meichenbaum, 1994).
Behavioural therapy can be viewed as a means of encouraging healthy behaviours and discouraging those that maintain pain. The aim is to break the vicious cycle of dysfunction and disability. However, a Cochrane Review (Karjalainen et al, 1999) concluded that there was little empirical evidence for the efficacy of multidisciplinary rehabilitation for patients with fibromyalgia. Nevertheless, the review also suggested that behavioural treatments and stress management were important components of patient care. Together with education and exercise, these approaches have shown positive long-term effects.
Exercise and relaxation
Exercise is frequently advocated in an attempt to increase the strength of the lumbar muscles. Initially researchers such as Nachemson (1980) warned against lumbar exercises, believing that they would increase the load on the lumbar spine to unacceptable levels. However, McCain (1996) reported significant improvements in pain threshold measurements over fibromyalgia ‘tender points’ in patients who undertook a 12-week fitness training programme. Whatever the exercise regimen employed, it must be graduated, paced, realistic, encouraged, assessed, supervised and preferably carried out in a small group.
Relaxation techniques must be taught in conjunction with exercise programmes. These techniques include guided imagery, meditation, hypnosis, breathing techniques and progressive and autogenic relaxation. The aim is to reduce central nervous system activity, decrease muscle tension and break the pain/tension cycle, thereby regaining control of the pain. The techniques may be mastered by almost anyone but require patience and practice.
Heat will counteract stiffness and relax muscle spasm (Mobily et al, 1994). Although any beneficial effect is invariably short-lived, the treatment offers a simple, cost-effective and non-pharmacological intervention for symptomatic relief. It may be applied in a variety of ways, including hot-water bottles, hot baths and electrically heated packs. Many patients use such applications as a matter of course and, despite its short-lived effects, it is a valuable technique.
Transcutaneous electrical nerve stimulation
Transcutaneous electrical nerve stimulation (TENS) is another method of providing drug-free pain relief. Two electrodes are placed on the skin and low-frequency electrical currents are used to stimulate nerve fibres and subsequently inhibit the pain gate. This treatment has the advantages of being non-invasive, portable, cheap, non-addictive and user-friendly. The disadvantages are minimal and occur infrequently.
Complementary therapies: acupuncture
Acupuncture needles are applied to the most tender areas or trigger points. This stimulation of the painful area may reverse deep-muscle spasm, followed by relief of symptoms and improvement in mobility. Despite much anecdotal evidence on the benefits of acupuncture, few high-quality randomised trials have been carried out to assess its efficacy.
The mechanisms behind acupuncture are not fully understood and despite the need for specialist training it is a simple technique. However, a patient’s belief in the treatment may be an important factor in its effectiveness.
The role of the nurse
There is no specific treatment for this condition to provide a cure, yet much can be done to improve the quality of a patient’s life.
The nurse’s role cannot be underestimated in relation to the management and care of patients. The World Health Organization (1994) recognises the patient’s right to be fully informed about the disease and care, and acknowledges that many individuals welcome the opportunity to actively participate in decisions regarding treatment. The nurse’s role must, therefore, involve the following:
- Reassuring the patient not only that there is no serious underlying pathology, but also that you believe their condition and symptoms are genuine
- Providing a comprehensive explanation that is easily understood, and helping patients rationalise their symptoms and treatments
- Providing advice on coping strategies, pacing techniques and dealing with flare-ups
Explaining the value of exercise and relaxation
- Developing a realistic routine to improve sleep patterns, introducing exercise, relaxation and stress management programmes and preventing social isolation, in co-operation with the patient.
The multifaceted nature of fibromyalgia makes it difficult to treat using conventional therapies. As the Cochrane Review (Karjalainen, 1999) acknowledges, there is a need for a research strategy to evaluate current service provision and the efficacy of treatments, particularly with a view to assessing long-term outcomes.
There are several approaches to pain treatment, each with its own advantages and end-points. Analgesia, or the removal of pain, is not always possible in chronic conditions and thus treatments are aimed at the reduction of pain levels and pain management - the aim being that the patient learns to control the pain as opposed to the pain controlling the patient.
Treatments may be used in isolation or in combination, whichever regimen best suits the patient. Finally, as suggested by Hepworth (1989): ‘The underlying message must be that with motivation, knowledge and, above all, a flexible, multidisciplinary approach, anything is possible.’
- Fibromyalgia Support Northern Ireland, 18 Woodcot Avenue, Belfast BT5 5JA. Tel: 028-9065 4243.
- Fibromyalgia Association UK, PO Box 206, Stourbridge DY9 8YL. Tel: 01384-820052. website: www.ukfibromyalgia.com
- Arthritis Research Campaign, Copeman House, St Mary’s Court, Chesterfield, Derbyshire S41 7TD. Tel: 01246-825845.
Arathuzik, M.D. (1994)Effects of cognitive-behavioural strategies on pain in cancer patients. Cancer Nursing 17: 3, 207-214.
Bennett, R.M., Clark, S.C., Walczyk, J.A. (1998)A randomised double-blind placebo controlled study of growth hormone in the treatment of fibromyalgia. American Journal of Medicine 104: 227-300.
Hepworth, S. (1996)Chronic pain service. Nursing Standard 17: 10, 19-20.
Karjalainen, K., Malmivasra, A., van Tulder, M. et al. (1999)Multidisciplinary rehabilitation for fibromyalgia and musculoskeletal pain in working age adults (Cochrane Review). In: The Cochrane Library 4. Oxford: Update Software.
McCaffrey, M. (1980)Understanding your patient’s pain. Nursing 10: 9, 26-31.
McCain, A. (1996)A cost-effective approach to the diagnosis and treatment of fibromyalgia. Rheumatic Disease Clinics of North America 22: 2, 15-18.
Mobily, P., Herr, K., Nicholson, A. (1994)Validation of cutaneous stimulation interventions for pain management. International Journal of Nursing Studies 31: 6, 533-544.
Nachemson, M. (1980)A critical look at the conservative treatment for low back pain. In: Jayson, M. The Lumbar Spine and Back Pain. London: Pitman.
Rowbotham, D.J. (2000)Chronic Pain. London: Martin Dunitz.
Russell, I.J. (1998)Advances in fibromyalgia: possible role for central neurochemicals. American Journal of Medicine 315: 377.
Turk, D.C., Meichenbaum, D. (1994)A cognitive- behavioural approach to pain management. In, Wall, P.D., Melzack, R. Textbook of Pain. (3rd edn). Edinburgh: Churchill Livingstone.
Wolfe, F., Smyth, H.A., Yunus, M.B. (1990)Criteria for the classification of fibromyalgia: report of the Multicentre Criteria Committee (American College of Rheumatology, Atlanta). Arthritis and Rheumatism, 33: 160.
World Health Organization. (1994)A Declaration on the Promotion of Patients’ Rights in Europe. Copenhagen: WHO.