Rehabilitation and Fibromyalgia: Practice Essentials, Overview, Multidisciplinary Rehabilitation

Fibromyalgia is recognized as one of many central pain-related syndromes that are common in the general population. Research advances have led to the conclusion that disturbances within the central nervous system (CNS) known as central sensitization represent the most likely source. ^{[1, 2]}

Rehabilitation

Some investigators believe that a successful fibromyalgia rehabilitation program involves not only a multidisciplinary team of professionals (eg, physician, medical psychologist, physical and massage therapists, exercise physiologist) with expertise in the treatment of soft-tissue disorders but also includes various modalities (eg, exercise, education, cognitive behavioral therapy) individualized for each patient. ^[3]

Traditional therapy or rehabilitation may worsen the patient's symptoms. Monitor the progress of the patient in rehabilitation. As goals are met and symptoms change, modify the rehabilitation prescription to meet the individual's current needs.

Analgesia modalities

Pain-reduction modalities include the following ^[4] :

• Electrotherapy

• Cryotherapy

• Therapeutic heat - A literature review by Honda et al indicated that in patients with fibromyalgia, thermal therapy reduces pain, the number of tender points, and the Fibromyalgia Impact Questionnaire (FIQ) score ^[5]

• Systemic administration of local anesthetics for neuropathic pain (eg, intravenous lidocaine): Use with caution; may be associated with cardiac and neurologic side effects

Aerobic and flexibility regimens

Daily aerobic and flexibility exercises may be an essential component of the fibromyalgia rehabilitation program. ^[6] The goal of these exercises is for the patient to exercise safely without increased pain.

An exercise regimen should include the following considerations:

• Always start at low levels of exercise and progress slowly: Begin with gentle warm-up, flexibility exercises; progress to stretching all of the major muscle groups

• Low-impact aerobic exercise at least 3 times weekly

• Target exercise regimen: 4-5 times a week for at least 20-30 minutes each time; may take months to achieve

For patients who may never achieve the level of the target exercise regimen, encourage them to exercise at the highest level possible without worsening their symptoms. ^[7]

Psychologic rehabilitation strategies

Psychologic intervention is a necessary component in a rehabilitation program for fibromyalgia. Treatment options include the following ^[8] :

• CBT

• Relaxation training

• Group therapy

• Biofeedback

• Stress management

See Fibromyalgia: Slideshow, a Critical Images slideshow, to identify strategies for accurately diagnosing and treating fibromyalgia.

Fibromyalgia is now recognized as one of many central pain-related syndromes that are common in the general population. Research advances have lead to the conclusion that disturbances within the central nervous system (CNS) known as central sensitization represent the most likely source. ^[1] In a study by Alonso-Blanco, a connection was found in women between the number of active myofascial trigger points (MTrPs) and the intensity of the spontaneous pain and widespread mechanical hypersensitivity; nociceptive inputs from these MTrPs may be linked to central sensitization. ^[9]

Some investigators believe that a successful fibromyalgia rehabilitation program involves a multidisciplinary team of professionals and various modalities individualized for each patient. ^[3] The team should include the physician, a medical psychologist, physical and massage therapists, and an exercise physiologist. These professionals should have expertise in the treatment of soft-tissue disorders.

Traditional therapy or rehabilitation may worsen the patient's symptoms. Monitor the progress of the patient in rehabilitation. As goals are met and symptoms change, modify the rehabilitation prescription to meet the individual's current needs.

Go to Fibromyalgia and Juvenile Primary Fibromyalgia Syndrome for complete information on these topics.

A number of randomized, controlled trials of multidisciplinary treatment and exercise, combined with education and/or cognitive behavioral therapy showed that patients with fibromyalgia had improvements on a 6-minute walk, with significant decreases in pain and beneficial efficacy.

One randomized, controlled trial of multidisciplinary rehabilitation showed improvement in health-related outcomes in a nonclinical, community-based setting at 15-month follow-up. ^[10]

A published study that evaluated the impact of a physical therapy–based educational program on patients with fibromyalgia found that the program had a positive impact on patients' well-being. ^[11] The study also concluded, however, that the program had no effect on the other symptoms of fibromyalgia.

Reviewing 9 studies, which included a total of 1,119 patients, Häuser et al found evidence that treatment combining at least 1 educational or psychological therapy with at least 1 exercise therapy can provide short-term reduction in pain, fatigue, and depressive symptoms. ^[12] The study results also indicated that physical fitness benefits from the treatment can be maintained over the long term.

Numerous modalities, including electrotherapy, cryotherapy, and therapeutic heat, can reduce pain. ^[4] Teach patients how and when to use therapeutic modalities as part of their maintenance program. One investigator has recommended muscle energy treatments, positional release methods, and massage as part of the rehabilitation program to decrease stiffness and pain.

It has been shown that inhibition of the pain pathway can be achieved by systemic administration of local anesthetics such as intravenous lidocaine in neuropathic pain states. On this basis, intravenous lidocaine has been used for the management of fibromyalgia pain. This treatment option is not a traditional pain management option, and it may be associated with cardiac and neurologic side effects.

A small study evaluating the effect of intravenous lidocaine combined with amitriptyline on pain relief and plasma serotonin, norepinephrine, and dopamine levels revealed no benefit in reducing pain or in changing plasma serotonin and norepinephrine levels. ^[13] Thirty patients were treated with amitriptyline 25 mg plus either intravenous saline or lidocaine in saline. Each patient had plasma serotonin, norepinephrine, and dopamine levels drawn at the beginning of the study and at 4 weeks. Patients rated their pain intensity on a numeral scale initially and weekly for 4 weeks. Since this study failed to show benefit in fibromyalgia pain and significant side effects are associated with intravenous lidocaine, caution is recommended if considering intravenous lidocaine with or without amitriptyline.

Ekici et al compared the efficacy of manual lymph drainage therapy (MLDT) with connective tissue massage (CTM) in the treatment of fibromyalgia. ^[14] In a randomized, controlled trial utilizing 50 women with primary fibromyalgia, 25 patients were treated with MLDT, with the rest receiving CTM therapy. Both techniques appeared to be useful in reducing pain and improving patients' health status and health-related quality of life. However, patient responses on the FIQ indicated that MLDT was better than CTM at reducing morning tiredness and anxiety.

Some investigators have found that daily aerobic and flexibility exercises are an essential component of the rehabilitation program. ^[6] Exercise was first recognized to have therapeutic benefits in the late 20^th century. At that time, patients were randomized to receive 20 weeks of high-intensity exercise or flexibility training. Improvements in fitness, global assessment ratings, and tender-point pain thresholds were greater in the high-intensity group than in the flexibility group. Subsequent clinical trials have confirmed the benefits of aerobic exercise and muscle strengthening on mood and physical functioning.

Patients should begin with gentle warm-up, flexibility exercises and progress to stretching all of the major muscle groups. Low-impact aerobic exercise is necessary at least 3 times weekly. Patients should always start at low levels of exercise and progress slowly. The goal is to exercise safely without increased pain. The patients' target exercise regimen is 4-5 times a week for at least 20-30 minutes each time; this may take the patient months to achieve.

Some patients with fibromyalgia may never be able to achieve this level of exercise; encourage them to exercise at the highest level possible without worsening their symptoms. ^[7]

Some investigators believe that aquatic exercise may be the safest and gentlest aerobic conditioning exercise available for this group. Aquatic therapy enables aerobic conditioning and also flexibility, strengthening, and stretching exercise. Aquatic exercise is well tolerated and is especially helpful for some patients. ^{[3, 15]}

A study by Chenchen Wang et al indicated that tai chi is a more effective treatment for fibromyalgia than aerobic exercise. In patients who participated in tai chi twice weekly for 24 weeks, the Revised FIQ score differed from that of patients who underwent the same schedule and duration of aerobic exercise by 16.2 points. ^[16]

A randomized, controlled trial by Larsson et al indicated that resistance exercise improves muscle strength (including isometric knee extension force and isometric elbow flexion force), raises health status (based on the FIQ score), and reduces current pain intensity, in women with fibromyalgia. The study involved 130 women with the condition and included a person-centered program of progressive resistance exercise. ^[17]

Similarly, a study by Glasgow et al indicated that resistance exercise training significantly reduces disease impact in women with fibromyalgia. After 8 weeks of training, the one-repetition maximum for chest press and leg extension in patients was significantly increased. However, resistance training did not eliminate autonomic dysfunction, with controls having, for example, a lower resting heart rate than the fibromyalgia patients. ^[18]

A literature review by Jyun-Jhe Wang et al indicated that the effects of resistance exercise on fibromyalgia are comparable to or better than those derived through absence of intervention, flexibility exercise, and aerobic exercise. Compared with no intervention, resistance exercise better decreased the total score on the FIQ and was superior in reducing pain scores, tender points, and depression as well as in improving physical function. The total FIQ score was also lower than that associated with flexibility exercise, while resistance exercise had a similar effect to aerobic exercise on pain control, tender point reduction, and physical function improvement. ^[19]

A literature review by Andrade et al indicated that in patients with fibromyalgia, strength training can reduce pain, fatigue, depression, anxiety, and the number of tender points, while improving functional capacity and quality of life. ^[20]

A literature review by Sanada et al indicated that following exercise, dietary, or multidisciplinary intervention, patients with fibromyalgia undergo a reduction in serum interleukin-8 (IL-8) and IL-6, suggesting that such interventions have an anti-inflammatory effect. ^[21]

A rehabilitation program for fibromyalgia is incomplete without psychological intervention.

Many patients with fibromyalgia have increased levels of stress and feelings of depression, anxiety, and frustration.

Several treatment options are available. According to Buckelew, cognitive behavioral therapy (CBT), relaxation training, group therapy, biofeedback, and stress management are some of the most useful options. ^[8]

Buckelew and colleagues found that patients receiving aerobic training plus biofeedback had significant improvements in tender-point pain, self-reported physical function, and self-efficacy for function, as compared with a control group. ^[8]

Farin et al developed the Fibromyalgia Participation Questionnaire to record impairments patients experience in their daily lives. The instrument has psychometric properties and is useful for evaluations and clinical trials. ^[22]

Cognitive behavioral therapy

CBT techniques emphasize changes in thought patterns and behaviors. ^[23] CBT can be performed in a 1-on-1 or group setting, with beneficial effects achievable in as few as 10 sessions. These techniques have been used in chronic pain treatment programs that manage patients with fibromyalgia.

A study that reviewed the results of 13 programs using CBT found that generally, CBT provided improvements in pain-related behaviors, coping strategies, and overall physical function. ^[24] However, providing CBT alone is not advantageous over group programs of exercise and/or education.

Genetic predisposition

Increasing evidence suggests that genetic and environmental factors play a role in the etiopathology of fibromyalgia. The most probable mode of inheritance is polygenic. According to Olson, early results of studies involving more than 140 families may confirm that the genes associated with serotonin play a role in fibromyalgia. ^[25]

Some evidence indicates that the etiology of fibromyalgia may involve polymorphisms of genes in the serotonergic, catecholaminergic, and dopaminergic systems. ^[26] Reeser reported in his study that the apolipoprotein E4 (Apo E4) genotype and selected environmental exposures (motor vehicle accidents) increases the risk of subsequent diagnosis of fibromyalgia. ^[27] One hundred fifty-one case subjects diagnosed with fibromyalgia and 300 control subjects participated in the study. Apo E4 genotype was determined by single nucleotide polymorphism analysis in both case subjects with fibromyalgia and in the control group. Although these data suggest that specific interaction between individuals with at least one copy of the Apo E4 allele and the involvement in a motor vehicle accident may increase the risk of being diagnosed with fibromyalgia, it does not appear to influence the degree of pain or degree of functioning among the cases diagnosed with fibromyalgia. Future genetic studies are needed in the fields of fibromyalgia and related conditions.