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Ali Weekley

Professor Hellmers

English 1201

7 August 2021

What is the best treatment to manage fibromyalgia?

Roughly 2-8% of the population worldwide is affected by fibromyalgia and one-third of

that population is disabled from the disease (Sarzi-Puttini). Nikki Marshall, a 52-year-old

mother, is a part of this statistic. She describes her struggle with fibromyalgia as, “Much of the

time it[fibromyalgia] feels as though everything is uphill; as though my flesh hurts just being on

my bones. It’s grinding and relentless and exhausting. I can think of just two days this year that

were pain-free. They were golden” (Marshall). Nikki Marshall deserves to be more than just a

statistic. Fibromyalgia is a chronic widespread pain disorder that causes physical and

psychological symptoms. This disease is known to drastically influence a person’s quality of life

both physically and mentally. Currently, there is no cure or traditional method of treatment. To

improve the quality of life for people suffering with fibromyalgia, it is necessary to utilize a

multidisciplinary approach that encompasses pharmaceuticals, physical exercise, and

psychological treatments.

Fibromyalgia is not a new disease, but the understanding and relevance of the disease has

grown the past decade. Dr. Erin Lawson and Dr. Mark S. Wallace, who are both apart of the

Department of Anesthesiology and Center for Pain Medicine at University of California San

Diego, wrote the book Fibromyalgia: Clinical Guidelines and Treatments to provide the most

updated information of the disease as of 2015. Dr. Lawson and Dr. Wallace explain that to

diagnosis fibromyalgia, a person must experience chronic widespread pain for over 3 months,
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have tenderness in their trigger points, and eliminate other possible diagnoses. The patient may

also present with other symptoms like fatigue, insomnia, stiffness, irritable bowel syndrome,

anxiety, or emotional distress (Lawson and Wallace 29). There are 18 trigger points located on

the body and these areas are where the most pain and tenderness occurs for patients (see Fig. 1).

The pain does not have a distinct description but can be a burning, aching, or sharp pain. Women

are more likely to develop fibromyalgia than men. The main reason this disease is hard to treat is

from the lack of understanding the epidemiology and large variety of symptoms that are present

with the disease (Carter). Fibromyalgia presents with symptoms that are physical and

psychological. This makes it is evident that a multidisciplinary approach is necessary to address

all aspects and symptoms of the disease to improve a person’s quality of life.
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The first approach is to use pharmaceuticals to treat the physical aspects of the disease.

Pain associated with fibromyalgia is contributed to central sensitization which is “the process of

plastic change in the CNS[central nervous system] that establishes a perpetual pain

hypersensitivity state” (Lawson and Wallace 38). Therefore, by using pharmaceuticals that

address this central sensitization problem in the central nervous system the patient will

theoretically have less pain. The major classes of medication for fibromyalgia consist of

antidepressants, serotonin norepinephrine reuptake inhibitors, antiepileptic medication, muscle

relaxants, and nonsteroidal anti-inflammatory drugs. Current FDA approved medications for

fibromyalgia alone are pregabalin, duloxetine, and milnacipran (Lawson and Wallace 103).

These medications can help target the widespread pain caused by central sensitization.

Decreasing physical pain with pharmaceuticals can improve a patient’s quality of life.

However, Dr. Piercarlo Sarzi-Puttini indicates in her academic journal “Diagnostic and

therapeutic care pathway for fibromyalgia” that many patients withdrawal from the use of their

medications due to the side effects. It is challenging to propose a solution like pharmaceuticals

when it could do more harm than good. Dr. Piercarlo Sarzi-Puttini states, “results obtained with

pharmacological treatment alone are often unsatisfactory, and drug treatment should be part of a

multidisciplinary therapeutic approach, which also includes nonpharmacological strategies.”

Indicating that some pharmaceutical options do prove effective, but it is vital to incorporate

nonpharmacological treatments to allow the patient to have the best quality of life.

A common nonpharmacological treatment is exercise. Exercise is used to address both

physical and psychological symptoms. There are numerous forms of exercise like stretching,

physical therapy, weightlifting, and aerobic exercise. Dr. Alexandro Andrade, part of the

UDESC Department of Human Movement and Science, performed a study that consisted of 12
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weeks preferred exercise that she detailed in her academic journal “Preferred Exercise and

Mental Health of the Patients with Fibromyalgia Syndrome.” Preferred exercise was classified

by the patient choosing their own exercises. The research “found that 12 weeks of preferred

exercise (resistance training, walking, or stretching) reduced the impact of FMS on quality of

life, decreased depression, and improved the mood states of patients with FMS” (Andrade). This

indicates that exercise can ease both physical and psychological symptoms that are associated

with fibromyalgia. Dr. Alexandro Andrade believes that the patients’ moods improved because

they were able to pick their exercises which gave them a sense of determination and gratification

when completing the exercise. By performing exercises of choice, patients can get both a

physical and psychological benefit from this nonpharmacological method. Similar conclusions

are drawn by Dr. Lawson and Dr. Wallace stating, ”Low-intensity, low-impact aerobic exercise

programs with the ability to tailor the exercise prescription to the needs of the individual show

the strongest evidence for clinical improvement in symptoms” (72). Exercise at an appropriate

level tailored to the patient is proven to be helpful in improving the quality of life for patients.

Furthermore, the way the patient approaches exercise is important to ensure that they are

not doing any harm and can maximize the benefits. Dr. Piercarlo Sarzi-Puttini found that

exercise should be performed regularly and consists of periods of rest and recovery. No patient

will have the same regimen as not everyone’s bodies are the same. Dr. Lawson and Dr. Wallace

found that many fibromyalgia patients complain that after exercise they feel more tired or more

pain (73). This has led to patients not complying with their exercise protocol even though there is

strong research evidence that supports the benefits of exercise. A daily exercise regimen is

important for helping pain but needs to be carefully assessed to ensure that it is not doing harm.

That is why it is best to exercise “at levels high enough to exert an analgesic and anxiolytic effect
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but low enough to avoid exacerbation of pain symptoms” (Lawson and Wallace 97). The

analgesic and anxiolytic effect is what makes people feel good after exercising. For fibromyalgia

patients who deal with constant pain, it is necessary to make use of this natural pain killer effect

from exercise. Exercise can be done in many different forms and picking the one that suits the

patient’s needs can help ease physical and psychological symptoms of fibromyalgia.

For example, Nikki Marshall explains in her article that her exercise approach took over a

year to perfect. Marshall walks 7,500 steps a day as that is the most beneficial for her, at the age

of 52. On top of physical exercise, she incorporates yoga into her routine almost every day and

finds, “Its lessons about how to meet challenge with grace help hugely – as do the endorphins

and the half hour of deep relaxation I dive into after every class” (Marshall). While not every

patient is like Marshall it is evident that experimenting with different routines can help determine

what types of exercise is the best for the patient.

An additional approach is to eliminate stress in the patient’s life. Dr. Teemu Zetterman

works in the Department of Anesthesiology, Intensive Care and Pain Medicine and has found

that “FM patients often report an inability to relax” and “repeated cognitive stress increases pain

intensity in FM patients.” From his research, Dr. Zetterman believes that targeting stress and

anxiety could help alleviate pain. Dr. Lawson and Dr. Wallace also recognized this claim and

state, “There is a clear connection between anxiety and physical tension and therefore anxiety

becomes all the more provocative to the myofascial-type pain associated with fibromyalgia”

(95). It is indicated that a patient’s pain can become worse due to the physical and psychological

stresses that the patient experiences. Therefore, finding treatments that approach dealing with

stress and any prevalent psychological disorders can help improve the patient’s quality of life.
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A technique to combat stress is muscle relaxation and guided imagery. Muscle relaxation

consists of the patient tensing a group of muscles as they breathe in and then untensing their

muscles as they breathe out (“Stress Management”). University of Michigan Health states,

“When your body is physically relaxed, you cannot feel anxious. Practicing progressive muscle

relaxation for a few weeks will help you get better at this skill, and in time you will be able to

use this method to relieve stress.” This research demonstrates muscle relaxation as a tool to

combat the physical symptoms that stress puts on the body. In addition to muscle relaxation,

patients can also utilize guided imagery. Carter states, “When used in conjunction with

progressive muscle relaxation, guided imagery has proved beneficial in assisting fibromyalgia

patients in managing symptoms of pain through cognitive distraction.” The cognitive distraction

that is used in guided imagery is engaging the five senses to create a pleasant place and thought

of mind (Carter). These techniques of muscle relaxation and guided imagery concentrate on

using the patient’s mind and thoughts to distract their body from identifying the pain. These

techniques can help improve the quality of life of patients while also utilizing other techniques.

There are other ways to approach the psychological factors associated with fibromyalgia.

“Integrating Counseling and Brain-Based Treatments for Fibromyalgia” is an article that brings

attention to the importance of addressing the psychological effects of the disease. Carter, the

author, states, “the rate of patients suffering from fibromyalgia and reporting one or more mood

disorders is approximately 74%. This renders traditional pharmacological interventions

inadequate as a singular approach to the treatment of fibromyalgia.” Since fibromyalgia has

strong psychological correlations then it is beneficial to utilize methods that address these

psychological symptoms and disorders. The psychological methods that have produced positive

results are cognitive behavioral therapy, meditation, guided imagery, counseling, and methods of
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cognitive distraction (Carter). Not all these methods need to be performed but implementing one

or two as a resource for a patient can benefit their quality of life.

Cognitive behavioral therapy (CBT) is one method of treatment that is highly

recommended to patients. In his academic journal, Dr. Bennett explains that “the pain component

of fibromyalgia is caused by an abnormal processing of sensory impulses, usually referred to as

central sensitization.” Central sensitization has been discovered as a source of pain so treatments

that try to improve this abnormal processing are thought to relieve symptoms of fibromyalgia.

Dr. Bennett states, “The main therapeutic techniques employed in CBT are twofold: first, the

identification and modification of dysfunctional thought patterns that are interfering with

therapeutic progress; and second, the engagement of the patient in behavioral interventions

aimed at breaking the vicious circle between symptoms and patterns of dysfunctional

performance.” CBT consists of multiple techniques that work together to help improve the

patient’s quality of life. Dr. Bennett’s research consisted of CBT “focusing on strategies for self-

management of pain and stress, relaxation training, and recognition of maladaptive thought

patterns with appropriate substitutions and problem solving.” From this research, “Significant

improvements were obtained for pain severity, life interference, sense of control, affective

distress, depression, perceived physical impairment, fatigue, and anxiety” (Bennett). By

implementing proper techniques of how patients think about pain and cope with disease, the

patient can begin to gain a sense of control and rebuild their neural pathways to decrease their

symptoms. The symptoms relieved by CBT where not just psychological but also physical pain.

When a person has a clearer mind they not only think better, but they feel better. There is strong

support for patients with fibromyalgia to use CBT in combination with medications and exercise
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(Bennett). CBT is a great technique that should be utilized with other modalities of treatments to

ensure the best quality of life.

While CBT targets the neural pathways psychologically, acupuncture is a method to

target the neurol pathways physically. Acupuncture consists of needles being safely placed into

muscles that are filled with inflammation. For patients with fibromyalgia, the needles are usually

stuck into their inflamed trigger points to break up inflammation and relieve pain. Dr. Lawson

and Dr. Wallace have found with repeated treatments, “acupuncture can lead to neuroplasticity

and long-term depression of pain pathways”(114). This signifies that acupuncture is correlated

with a decrease in pain overtime due to redeveloping the physical pain pathways that have

changed from having fibromyalgia. From the Department of Physiotherapy and Rehabilitation,

Dr. Karatay researched what physical pathways/neurotransmitters are affected by acupuncture in

his academic journal. Patients with fibromyalgia are known to have low levels of serotonin,

which controls pain, emotion, mood, cognition, and various motor functions, and higher levels of

SP in their cerebrospinal fluid, which is a “mediator in pain transmission and sensation”

(Karatay). Dr. Karatay found that after acupuncture was performed over an interval of time the

serotonin levels increased back to normal and the SP levels decreased back to normal. This

would explain why patients feel certain benefits from acupuncture because their body and pain

receptors are returning to a state of normalcy. Acupuncture is one of many treatments that can

help alleviate pain, but it is insufficient as the only treatment to be utilized.

The pharmaceutical, physical, and psychological treatments available are not limited to

the ones discussed in this paper. There are numerous other alternative medicines that some

patients do find helpful. Other options might be yoga, massage, biofeedback, nerve stimulation,

hypnotherapy, vitamins, herbs, and marijuana (Lawson and Wallace 117-124). However, there is
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not a strong understanding as to how they help and many of them are costly. There needs to be

more research performed to justify implementing these treatments into the patient’s regimen.

Again, not everyone is the same and testing different treatments out for an extended period might

be what it takes to find the right combination of treatments that produce the best quality of life

for a patient.

Conversely, health fads are leading many people to believe that a change in diet will lead

to a healthier pain free life. Diet is one thing that many people change when they want a healthier

lifestyle. Dr. Lawson and Dr. Wallace found “in an Internet survey of 2596 fibromyalgia

patients, 40% believed their pain, stiffness, and fatigue were exacerbated after exposure to

certain foods and 68% used nutritional supplements to control their symptoms” (75). Many

patients think that diets can help their pain, so it would be thought that patients with fibromyalgia

should follow a certain anti-inflammatory diet. However, there are no current dietary studies that

identify specific foods and additives that increase fibromyalgia symptoms. If a patient does not

have any allergies or already determined stomach issues, then there is no need to try an

extremely restrictive diet. These diets are hard to follow long term and ultimately might only

alleviate a little pain. That is why it is advised by Dr. Lawson and Dr. Wallace to focus on

making healthy lifestyle changes (76) like the ones already discussed: exercise, reducing stress,

psychological treatments.

Lastly, fibromyalgia is unfortunately a common disease that causes physical and

psychological distress on the patient. Patients experience the symptoms on varying levels, but

their quality of life is typically filled with pain that can eventually become disabling. People with

fibromyalgia are still people and deserve to have a better quality of life. Patient and peer

education is important so that everyone can understand the disease and support can be properly
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given where needed. Carter discusses that, “Many myths and misconceptions about fibromyalgia

can cause additional difficulties for those experiencing this condition.” Patients should gather

information from their doctors who can provide proper education on this crippling disease. The

easiest treatment of them all is to be educated and understand the disease.

In brief, fibromyalgia is a disease that has no cookie cutter solution. Patients must take a

proactive approach of trial and error to find the best treatments to improve their quality of life.

The best types of treatment options that have shown effective through medical research are drugs

that target the abnormal pain receptors, exercise, acupuncture, CBT, guided imagery, muscle

relaxation, and disease education. Every patient is different and requires a unique combination of

treatments to address their psychological and physical symptoms. A multidisciplinary approach

provides the best chance for patients with fibromyalgia to take back control of their lives.
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Works Cited

Andrade, Alexandro, et al. “Preferred Exercise and Mental Health of the Patients with

Fibromyalgia Syndrome.” Complementary Therapies in Clinical Practice, vol. 40, no.

April 2019, Elsevier Ltd, 2020, p. 101195, doi:10.1016/j.ctcp.2020.101195. Accessed 18

July 2021.

Bennett, Robert, and David Nelson. “Cognitive Behavioral Therapy for Fibromyalgia.” Nature

Clinical Practice Rheumatology, vol. 2, no. 8, 2006, pp. 416–24,

doi:10.1038/ncprheum0245. Accessed 27 July 2021.

Carter, Hannah, et al. “Integrating Counseling and Brain-Based Treatments for

Fibromyalgia.” Counseling Today, vol. 63, no. 11, May 2021, pp. 12–14. EBSCOhost,

search.ebscohost.com/login.aspx?direct=true&db=vsh&AN=150243718&site=eds-live.

Accessed 18 July 2021.

Karatay, Saliha, et al. “Effects of Acupuncture Treatment on Fibromyalgia Symptoms,

Serotonin, and Substance P Levels: A Randomized Sham and Placebo-Controlled

Clinical Trial.” Pain Medicine (United States), vol. 19, no. 3, 2018, pp. 615–28,

doi:10.1093/pm/pnx263. Accessed 27 July 2021.

Lawson, Erin, and Mark S. Wallace. Fibromyalgia: Clinical Guidelines and Treatments.

Springer International Publishing Switzerland, 2015.

Leyasw. “Symptoms and signs fibromyalgia tender points vector image.” VectorStock, www.vect

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31164736. Accessed 27 July 2021.

Marshall, Nikki. “Fibromyalgia flattens me. Here’s what helps me cope with constant pain.” The

Guardian, 30 June 2021, www.theguardian.com/australia-news/commentisfree/2021/jun/

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30/fibromyalgia-flattens-me-heres-what-helps-me-cope-with-constant-pain. Accessed 18

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Sarzi-Puttini, Piercarlo, et al. “Diagnostic and Therapeutic Care Pathway for

Fibromyalgia.” Clinical and Experimental Rheumatology, vol. 39 Suppl 130, no. 3, May

2021, pp. 120–127, www.clinexprheumatol.org/article.asp?a=17132.pdf. Accessed 18

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Stress Management: Doing Progressive Muscle Relaxation.” University of Health Michigan

Medicine, University of Michigan, 31 Aug. 2021, www.uofmhealth.org/health-

library/uz2225. Accessed 27 July 2021.

Zetterman, Teemu, et al. “Muscle Activity and Acute Stress in Fibromyalgia.” BMC

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