Exercise, TENS, medications may offer mild relief, no ‘magic bullet’ for fibromyalgia
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Patient education in combination with a variety of pharmacologic and non-pharmacologic therapies are necessary to adequately manage fibromyalgia, noted a speaker at the 2021 Rheumatology Nurses Society annual conference.
Susan Chrostowski, DNP, APRN, ANP-C, coordinator of the Adult Gerontology Nurse Practitioner Program at Texas Woman’s University, raised an important question for RNS attendees managing patients with fibromyalgia: “How can we help?” she said. “That basically falls into two categories. We have medicines and we have other things besides medicines.”
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As far as the FDA is concerned, there are three medications approved for fibromyalgia. They are pregabalin (Lyrica, Pfizer), duloxetine, milnacipran (Savella, Abbvie). “In the last decade, we have not had any new medications come out for an indication for the treatment of fibromyalgia,” she said.
Chrostowski noted that these drugs yield only 25% to 40% in pain reduction of any kind. She added that “meaningful” relief occurs in only around 40% to 60% of patients, while just 10% to 25% find that their pain is reduced by half. “What this tells us is that we don’t have a magic bullet,” she said. “We don’t have a pill that is just going to make everything wonderful for them.”
Regarding opioids like hydrocodone and oxycodone, Chrostowski offered the simple message that they should be avoided due to risk of addiction and lack of efficacy. “They are not getting enough benefit to outweigh the risks associated,” she said.
That said, while acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) are not considered effective for fibromyalgia, they may have utility in comorbid conditions like osteoarthritis.
To the point that many fibromyalgia patients use cannabis and cannabinoid products for pain relief, sleep improvement or reduction in anxiety, Chrostowski repeated the refrain used by many in the rheumatology community. “Research is still lacking in this area,” she said.
Psychotherapy and cognitive behavioral therapy (CBT) are the non-pharmacotherapeutic approaches that have undergone the most rigorous investigation in fibromyalgia, according to Chrostowski. “Cognitive behavioral therapy helps coping strategies and managing stress,” she said. “It can help reduce the use of sleep medications.”
Exercise is another non-pharmacologic therapy that has shown efficacy. “Low impact exercise, overall, is perceived as beneficial,” she said. “Aquatic exercise may have a slight benefit over land-based exercises.”
Resistance training can help reduce depression and anxiety, according to Chrostowski. In addition, “meditative movement therapies” such as tai chi, qigong and yoga can be efficacious.
Patients have also benefitted from spa-based treatments such as balneotherapy, mud packs and hydrotherapy. “Hot thermal baths may help with pain and quality of life,” Chrostowski said.
Similarly, modest benefit can be gained from acupuncture. “There have been lots of studies of this over the years, some of better quality than others,” Chrostowski said. “There can be low to moderate improvement in pain and stiffness.”
Looking deeper into the non-pharmacologic category, some patients have tried transcranial and transcutaneous electric stimulation (TENS) for pain relief or general improvements in function associated with fibromyalgia. “Some studies have shown benefit with pain relief and general fibromyalgia-related function.”
Vibroacoustic and rhythmic sensory stimulation are other methods, but studies have shown mixed results with these approaches.
Chrostowski pointed out that most of the management strategies discussed are more effective in combination with patient education. “We have to explain the condition and that there is no cure,” she said. “Assure them this is a real disease. It is kind of incredible that there are still providers out there that consider this a trashcan diagnosis. Just because we don’t have an answer for it yet does not mean there is not an underlying organic cause.”
In terms of applying any of these strategies in the clinic, Chrostowski stressed the idea of setting reasonable goals and expectations. Tailoring therapy to the individual patient is essential to optimizing outcomes, as is validation and encouragement through the treatment process.
The final point Chrostowski wanted to drive home is that all of the strategies mentioned require patient buy-in and commitment. “Empower your patients to take control and learn what they need to know about this,” she said. “Just keep trying different things until they find what works best.”
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Chrostowski S. Demystifying Fibromyalgia for the Nurse and Advanced Practice Provider (APP). Presented at: Rheumatology Nurses Society annual conference; August 4-7, 2021 (virtual meeting).
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