Fibromyalgia Guide: Symptoms, Diagnosis, Physiology, and Treatments
This article on fibromyalgia is a deep dive into what fibromyalgia is, how to know if you have it, and what treatments are available. After reading this article, you'll have a complete physiological understanding of why fibromyalgia produces pain, fatigue, sleep disturbances, and more. In addition, we want you to be well-equipped with the latest research on evidence-based fibromyalgia treatment options. Finally, we'll outline what you can start doing at home to be on your way to recovery and pain relief.
Table of Contents
Overview (1) (2) (3)
Fibromyalgia is a chronic pain disorder of the nervous system involving widespread body pain. If you have fibromyalgia, likely, you may also be experiencing sleep issues, fatigue, brain fog, anxiety, depression, and the list goes on.
As we'll discuss in detail in this article, fibromyalgia is a complicated and multifaceted syndrome with no single exact known cause. However, we’re starting to understand much more about what’s going on under the hood of the condition. So stay tuned, and we’ll dive deeper into the in’s, out’s, and all the potential underpinnings of fibromyalgia.
How many people have fibromyalgia?
So how common is fibromyalgia? For starters, fibromyalgia is much more common in women than in men (>90%).
According to a recent systematic review, it's estimated that around 2.4%-6.8% of women are currently suffering from symptoms of fibromyalgia. It’s more common than you may think - if you have fibromyalgia, you’re certainly not alone!
Do doctors believe you?
Have you ever been told fibromyalgia doesn’t exist or that your pain is only imaginary?
The more we look at the science surrounding chronic pain, the more silly this statement is. Research shows that the prevailing myth of "fibromyalgia not existing" is simply an old wives tale that needs to be flushed away from medical practice.
According to the World Health Organization, fibromyalgia fits under the classification and meets the criteria of a health disorder, and for a good reason, as you’ll see.
What are the Signs and Symptoms of Fibromyalgia?
... I Think I Have it? (4)
Because fibromyalgia is a condition of our nervous system not playing nice, the symptoms can go far beyond pain.
Common signs and symptoms of fibromyalgia include, but are not limited to:
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Pain - duh
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Sleep disturbances and insomnia
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Fatigue
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Anxiety and depression
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Brain fog
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General sensitivity to stimulation, such as light or chemicals
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Joint and muscle stiffness
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Inability to carry out normal daily activity
Let’s get you warmed up for what doctors are thinking when they toss out a diagnosis of fibromyalgia.
As of 2016, per the American College of Rheumatology (ACR), you must meet all 4 of the following criteria to have fibromyalgia:
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1) Generalized pain, defined as pain in at least 4 of 5 regions, is present
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2) Symptoms have been present at a similar level for at least 3 months
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3) Widespread pain index (WPI) ≥ 7 and symptom severity scale (SSS) score ≥ 5 OR WPI of 4–6 and SSS score ≥ 9.
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4) A diagnosis of fibromyalgia is valid irrespective of other diagnoses. A diagnosis of fibromyalgia does not exclude the presence of other clinically important illnesses.
Plain English, please? Let’s make a little bit more sense of these criteria.
First of all, what are these 5 regions? You must have pain in 4 of these 5 areas:
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Left upper body
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Right upper body
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Left lower body
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Right lower body
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"Axial region” - Your neck / spine / torso.
Next, what is the Widespread Pain Index? It is a body chart where you place a little check at any of these 19 locations across your body that you experience pain.
How about the symptom severity score, or SSS? This scale looks at 3 domains: fatigue, waking unrefreshed, and cognitive symptoms. Each of these is rated on a scale of 1-3. The SSS then adds in more points if you experience headaches, pain, or depression.
Finally, we actually really like the last criteria. Many people assume fibromyalgia is just a diagnosis of exclusion or a placeholder until another underlying cause is found. This is entirely untrue! It turns out that an altered pain system, the basis of fibromyalgia is a condition in itself. Therefore you can have fibromyalgia alone or alongside other conditions. Now, with these definitions better defined, check out the list one more time!
Fibromyalgia is a pain processing disorder that can make you feel heightened pain (hyperalgesia) as well as pain from sensations, such as temperature or light touch, that normally wouldn’t cause pain (allodynia).
As anyone with fibromyalgia will tell you, pain is not the only symptom. Because fibromyalgia appears to be the result of a sensitized nervous system, sufferers also experience all types of other symptoms, such as insomnia, fatigue, and brain fog.
To understand how fibromyalgia works, we need to establish one thing out the gate that may surprise you: pain and tissue damage are not the same thing. Pain is a sensation produced by the nervous system when the brain determines the body is under physical threat.
When you have a well-functioning pain system, the nervous system is able to more accurately determine threats and produce pain accordingly. However, with fibromyalgia, one’s pain system becomes quite overactive resulting in chronic pain, even without any apparent injury. This is likely due to what scientists call central sensitization. We’ll talk more about that soon!
So how do you actually “get” fibromyalgia? This happens to be the million-dollar question that scientists haven’t quite solved just yet. Although the picture is still a little mucky, we have learned quite a bit to give us a basic understanding.
Fibromyalgia appears to be preceded by 3 ingredients:
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1) Genetic predisposition
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2) The right “environment” of risk factors
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3) An autoimmunity-type triggering event
We’ll cover genetic contributions to fibromyalgia soon, but let’s talk about some risk factors. The most commonly cited risk factors for fibromyalgia include:
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Childhood difficulties and/or trauma
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Female sex ~ 90% of all fibromyalgia cases
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Older/middle age
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Smoking
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High body mass index
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Pre-existing medical conditions, such as those with sleep disorders, headaches, depression, and other pain conditions
Fibromyalgia appears to be triggered similar to other autoimmune conditions with events such as viral infections, trauma, infection, or even a dysregulated gut microbiome.
Understanding the physiological drivers of fibromyalgia will give you a more clear sense of how fibromyalgia works and what you can do to treat it. We outline several key physiological factors of fibromyalgia below
Neural Factors and Central Sensitization (7)
Fibromyalgia and Your Brain Chemistry
Let’s start with the number one most important fact about pain - It is produced by the nervous system, specifically in the brain. Always. Every time. No exceptions.
You can think of chronic pain like heart disease. You may have all types of causes and symptoms, but ultimately, it stems from your cardiovascular system not working well. If you can’t get your cardiovascular system working better, it’s unlikely you’ll make too much progress on your heart disease. Well, chronic pain, such as fibromyalgia, and the nervous system work very much the same way.
Your nervous system is composed of billions of nerve cells known as neurons and is supported by little glial cells. In order for these neurons to talk to each other and carry out their nervous system duties, they rely on well-functioning cell machinery, energy availability, the right ions floating around, neurotransmitter concentrations (i.e. brain chemicals such as dopamine, serotonin...), and receptor density (the docking houses for these chemicals to bind to).
Why is this important? It turns out that fibromyalgia appears to be highly driven by brain chemical regulation related to pain processing more so than it is to “tissue damage”, weakness, or having a low pain tolerance, which is what we used to think. Maybe even what some doctors continue to think.
In fact, almost all fibromyalgia medications are related to this and the research on non-medication interventions overwhelmingly supports their ability to improve brain chemistry regulation, resulting in pain relief.
Excitatory vs. inhibitory neurotransmitters and receptors
So what are these brain chemicals? Neurotransmitters, what we will refer to as brain chemicals, are the molecules responsible for causing certain types of neurons to excite and fire or to inhibit and calm down.
When it comes to the nervous system, it isn’t always about nerves getting excitable and “firing”. In fact, “inhibition” or not allowing a neuron to fire is incredibly important as well. In certain areas of the pain pathway in the brain and spinal cord, when we have too much excitation and not enough inhibition, we can start to run into some problems. This is precisely what we see with chronic pain conditions, such as fibromyalgia.
The first brain chemical we’ll touch on is the excitable glutamate. Glutamate is a wildly abundant neurotransmitter throughout the central nervous system and it is responsible for excitation, especially when it comes to pain processing.
GABA is the opposing neurotransmitter responsible for inhibiting and quieting the nervous system. Think of glutamate and GABA as the gas and brake pedal. Interestingly enough, one can convert into the other and vice versa. It is a tightly regulated system, but things can go awry.
With fibromyalgia, we tend to see the nervous system upregulated to support glutamate as well as NMDA and AMPA receptors that glutamate interacts with.
Endogenous opioids and endocannabinoids
Pain processing doesn’t just involve glutamate and GABA. Many other brain chemicals play a role. Have you ever heard of opioids or cannabinoids? Chances are you have. However, did you know that your body can make its own?
The term, “endo” refers to “within.” Endocannabinoids and endogenous opioids are brain chemicals that have the ability to cause “analgesia,” otherwise known as pain relief! When we produce these chemicals it allows our brain to regulate our pain, no matter the injury or condition. However, in some situations, perhaps in fibromyalgia, we may lack the ability to produce and utilize these brain chemicals at a high level.
Mood stabilizing chemicals
A few other chemicals we’d be remiss to not mention are the mood-stabilizing chemicals of serotonin, dopamine, and adrenaline (epinephrine and norepinephrine).
These neurotransmitters, especially adrenaline, are related to stress and pleasure and help regulate the emotional centers in your brain. They also play a pivotal role in pain processing. It is then little surprise that anxiety and mood disorders have a major crossover with pain disorders such as fibromyalgia.
These chemicals are also an important reason why engaging in meaningful and pleasurable activity can result in better days than gloomy stressful ones.
Alterations in brain chemistry in people with fibromyalgia
Glutamate, GABA, endogenous opioids, endocannabinoids, serotonin, dopamine, adrenaline... What's that got to do with my fibromyalgia? It turns out quite a bit! How well we produce these chemicals, uptake them in their receptors, and break them down play a massive role in how you, me, or anyone else processes pain.
It has been shown that the dysregulation of these brain chemicals may influence fibromyalgia through a mechanism known as central sensitization. Keep reading to learn more!
What exactly is central sensitization? Central refers to your central nervous system: Your brain and spinal cord. Sensitization indicates increased responsiveness, specifically with pain. For example, let's say someone touches your skin or puts pressure on your body in an area that hasn't had an actual injury. Yet, it really hurts! Central sensitization is the science behind this.
Put together, you have a central nervous system with a highly responsive pain pathway. A more scientific definition would describe central sensitization as "An amplification of neural signaling within the central nervous system that elicits pain hypersensitivity". In fact, fibromyalgia could even be defined as a disorder rooted in central sensitization.
Central sensitization is a highly complex phenomenon, but we'll break it down into 3 main components hallmark of the process.
1) Bodily (Peripheral) Sensitization - Too much nociception (danger signals) coming from tissues within the body. Said another way, you have issues in your body that can't seem to calm down, often resulting in and from persistent inflammation. As a result, your central nervous system starts to get the message that it needs to change its operation to ensure your safety - I.e., more pain.
2) Loss of Brain-Based (Descending) Inhibition - Too little nociceptive blocking ability coming from the brain and spinal cord. Basically, the brain loses the ability to calm signals coming from the body. This is often the result of an imbalance and dysregulation of your brain chemistry.
3) Unhelpful Neuroplasticity (Learning) - Brain regions responsible for pain processing stay far too active and get way too good at their job. Put another way, your brain gets really good at learning how to produce pain.
The result of this combination? Pain amplification and a poor functioning pain system! With central sensitization, the nervous system may respond to all types of stimuli such as light touch, pressure, light, sound, temperature, and chemicals with an inappropriate and highly painful response. Sound familiar with fibromyalgia?
As much as fibromyalgia reflects your nervous system function, it is also heavily influenced by your immune system and inflammation. But, of course, these two systems are heavily tied together!
The Influence of your Immune System on Pain
Your immune system serves an essential duty to protect your body from foreign invaders. The immune system produces inflammation to help your body respond to and bounce back from potential tissue damage or foreign agents that could cause an infection.
When your immune system is activated with an inflammatory response, your body produces and mobilizes a variety of immune cells. Each of these cells has a specialized purpose to help your body stay safe and heal.
These inflammatory cells, such as cytokines, chemokines, and prostaglandins, can "sensitize" your nervous system, allowing your body to produce pain at a high level. This is especially obvious when you look at the way inflammation sensitizes your little sensory nerves.
Do you remember how your shin felt the last time you bumped it into a coffee table? Sore, right? That right there is the result of a local inflammatory response.
But how about if you got the flu, received a COVID-19 vaccine, or even contracted COVID-19? You may have felt your entire body feel quite achy. This is the result of a "systemic" inflammatory response.
So why would your immune system want to make you hurt in response to something dangerous, such as an injury or infection? If you think about it, pain's ability to discourage you from doing too much may provide an optimal environment for healing.
This makes sense for the short term, but it can be pretty detrimental in the long run. More and more research is linking long-term systemic inflammation as a highly influential factor in fibromyalgia.
Neuroinflammation
It turns out chronic inflammation of the nervous system, otherwise known as neuroinflammation, plays a significant role in creating, maintaining, and worsening chronic pain.
Neuroinflammation occurs in the central nervous system (the brain and spinal cord) when pro-inflammatory cytokines dysregulate nerve and neurotransmitter function associated with pain. A high amount of circulating pro-inflammatory cytokines also affects the blood-brain-barrier (BBB), resulting in even more neuroinflammation.
Neuroinflammation also plays a role in the peripheral nervous system, including your spinal nerves, their cell bodies (dorsal root ganglion - DRG), and the little danger sensing nociceptors you have throughout your body. Chronic inflammation can result in some really unpleasant changes to your DRG, which greatly contributes to your pain experience. Specifically, neuroinflammation can change the "expression" of various ion channels within a nerve that allows them to fire easier. This sounds good until you realize that the nerves that are getting upgraded happen to be the ones contributing to pain.
In both your central and peripheral nervous system, neuroinflammation activates tiny "helper cells" in the nervous system known as your "glial cells." In a state of neuroinflammation, your glial cells can cause significant contributions to the production of pain. These glial cells are also sensitive to increased excitatory brain chemicals, such as glutamate, resulting in even more neuroinflammation. Starting to see the connection?
Pro-inflammatory Immune Cells and Fibromyalgia
So what evidence do we have of neuroinflammation and fibromyalgia? Several studies have shown enhanced circulating pro-inflammatory immune molecules in patients with fibromyalgia compared to those without.
One example includes a study where patients with fibromyalgia had enhanced circulating immune cells, such as interleukin-8 in their cerebrospinal fluid compared to healthy controls.
Other studies have demonstrated increased pro-inflammatory immune cells, such as Interleukin (IL)-6, IL-8, IL-1B, and Tumor Necrosis Factor (TNF)-Alpha in individuals with fibromyalgia.
Autoimmunity and Fibromyalgia
Autoimmunity is the phenomenon when your immune system amounts an immune response against your own healthy and normal cells and tissues. Basically, an oopsie of the immune system resulting in inflammation and some adverse consequences. However, just because genes or even markers of autoimmunity exist doesn't necessarily mean that auto-immunity is actively occurring and/or the culprit. I.e., the correlation and causation conundrum.
Many in the research world have discussed the concept of fibromyalgia as an autoimmune condition, though more research is needed.
Whether fibromyalgia is an autoimmune condition or not, it does appear that those with fibromyalgia often suffer from other co-occurring autoimmune conditions, such as Hashimoto's hypothyroidism.
Common antibodies seen in people with fibromyalgia include antipolymer, anti-serotonin, anti-ganglioside, and antiphospholipid antibodies. In addition, some research has demonstrated an increase in thyroid auto-antibodies.
In one study, patients with fibromyalgia who also had ANA-positive antibodies demonstrated increased pain compared to those who did not
What would a good physiology read be without a discussion of stress and hormones? So let's see how stress affects the pathophysiology of fibromyalgia.
The HPA-Axis and Pain
Ever heard of the HPA-axis? This is short for the hypothalamic-pituitary-adrenal axis and is one of the main pathways in the body that regulates our stress response. The HPA-axis influences and is influenced by both the nervous and immune systems. This system is also tightly connected with the locus coeruleus-norepinephrine autonomic system. Or what most of us think of as the "fight or flight" branch of the autonomic nervous system.
The HPA-axis runs on a tight feedback loop to maintain homeostasis (i.e., all-is-good) through the endocrine system in the body. When a potential threat or stressor exists, the HPA-axis provides the hormonal and chemical machinery, such as cortisol, to help your body deal with the threat. When the stress resolves, the organs in this axis try to restore balance within your body.
Challenging the HPA-axis works well in the short term, but what if you strain the HPA-axis too long?
It turns out that chronic stress can lead to tremendous pressure on your HPA-axis, a dysfunctional immune system, and a sensitized nervous system. As you can imagine, this does not lead to optimal physiological function.
Neuroendocrine Dysregulation in Fibromyalgia
Stress stimulates the secretion of the steroidal hormone cortisol via the HPA-axis. Regulation of this stress hormone is hypothesized to play a significant role in fibromyalgia. Various studies have struggled to establish whether cortisol is typically increased or decreased in patients with fibromyalgia. Instead, most studies agree that cortisol is actually dysregulated with fibromyalgia.
For example, a recent study on neuroendocrine dysregulation found that the liver's ability to clear cortisol was relatively lower in patients with fibromyalgia compared to matched controls.
Other hormones related to chronic stress, the HPA axis, and fibromyalgia continue to be researched, such as thyroid hormone and IGF-1. The question remains whether hormonal dysregulation contributes to fibromyalgia or is the result of it. Or maybe both? More research needs to be done!
If your body was a video game and your cells had a health or energy bar, what would yours look like? Unfortunately, with fibromyalgia, like many pathological conditions, the bar tends to look more red than green due to the health and well-being of your mitochondria and cells.
What is Oxidative Stress?
Do you still happen to remember any facts about cells in your biology class from high school or college? Does the word mitochondria ring a bell somewhere?
It bears repeating from class that your mitochondria play a vital role in health and disease. Your mitochondria are organelles (small machinery within cells) that produce ATP - energy!
However, you might not have learned in a 101 course what happens after your mitochondria have created ATP.
During normal mitochondrial metabolism, a highly reactive chemical known as reactive oxidative species (ROS) is formed from oxygen when you generate ATP. To keep your cells healthy, detoxifying chemicals known as antioxidants help maintain ROS levels in check. However, excessive ROS results in a high level of free radicals that happen to be quite toxic and harmful to your cells.
The concept of oxidative stress refers to the balance between reactive oxidative species buildup and your body's ability to engage in sufficient detoxification. Sufficiently managing oxidative stress keeps your cells and your body both energized and healthy.
When your body is intensely physically, psychologically, or environmentally stressed, there is increased metabolic demand, and ROS production increases in turn.
To maintain healthy cells, having a well-functioning antioxidant and detoxification system is critical. Oxidative stress is influential in a vast amount of health-related disorders, including fibromyalgia.
The Role of Oxidative Stress in Fibromyalgia
From various studies, patients with fibromyalgia appear to have a more challenging time than others with regulating their oxidative stress. In one study, patients with fibromyalgia generated higher levels of harmful free radicals than those without and had a decreased antioxidant ability, further contributing to oxidative stress.
In another academic source on oxidative stress and fibromyalgia, the authors proposed that the progression of fibromyalgia may be heavily associated with ROS production. Therefore, treatment with antioxidants (the colorful polyphenols in plants) and antioxidant production is critical in treating fibromyalgia. Another reason to eat your veggies!
Is it possible to be predisposed to fibromyalgia? Is it predestined? Do we have any control? Time to talk about your genes and fibromyalgia.
What are genes? A gene refers to a portion of your DNA that provides your cells the instructions for making new proteins (i.e. structures). Proteins, in turn, serve as the building blocks of all of your cells, tissues, and well...everything in your body. Therefore, we all have our own unique DNA and instructions for what types of proteins we can make.
But just because you have the recipe for a tasty (or untasty) dish doesn't mean you'll make it.
This is where gene expression comes into play. Just having a gene isn't enough to make something happen; instead, it is the expression of the gene that results in protein production. So what causes genes to express?
Our bodies have remarkable systems in place to respond to stressors. Stressors can come in all forms, including internal stressors, such as too much of a hormone or chemical, psychological stressors, such as an upcoming interview, or environmental stressors, such as environmental toxins.
In an effort to adapt, our body turns on or off various genes resulting in gene expression.
However, suppose we happen to have various genes associated with a health condition, such as fibromyalgia. In that case, this may predispose us to the condition in the presence of the right environment.
It has been theorized that genetic predisposition for genes that regulate the pain system has a significant correlation to fibromyalgia, as shown in many studies.
However, despite this correlation, we have yet to discover a directly causal gene. Instead, a collection of genes that correlate with fibromyalgia is demonstrated. With that said, let's look at the genes that may be involved in fibromyalgia and why.
What Genes May Be Involved in Fibromyalgia?
The genes that appear to really matter with fibromyalgia and correlate to those experiencing symptoms include ones that control:
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GABA-ergic and Glutamatergic (Inhibitory and excitatory) neurotransmission
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Danger-signal (nociceptive) receptor channels
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Mu-opioid and cannabinoid receptors
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COMT activity (regulates catecholamines/adrenaline)
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Serotonin and dopamine availability
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Pro-inflammatory immune cell regulation
After reading all of the other physiological causes above... None of these genes should be a surprise! The regulation of brain chemistry and your pain system physiology is foundational in developing and maintaining chronic pain.
Psychosocial Factors and Sleep
Excitatory neurotransmitters, stress hormones, inflammatory cytokines, free radicals, and more...
This onslaught of brain and body chemical soup seems a bit overwhelming and out of your control. But, do you have any control? It turns out your behaviors, thoughts, and emotions have a tremendous impact on all of these physiological factors.
The term “mind-body” medicine has become a popular buzzword in recent years, but for a good reason. No, it does not refer to fibromyalgia being an imaginary disorder. Instead, there is overwhelming evidence that our brain and body interact in every imaginable way. What happens to our body impacts our brain, and what goes on in our brain affects the body.
The 2-way Relationship Between Pain and Psychosocial factors
There appears to be a two-way relationship between pain and what we refer to as psychosocial factors. For example, when we encounter distressing psychosocial conditions, our internal sense of stress and threat also become impacted.
Pain is, in its very definition, an unpleasant sensory and emotional experience to a real or perceived threat to the body. Therefore, when threat is high, especially threat to our bodies, the opportunity for chronic pain increases.
Psychosocial Pressures Affecting the Nervous System, Endocrine, and Immune System
Not only is there a mental state of threat in difficult psychosocial conditions, but our physiology also responds to threat.
When under distress, such as in a state of fear, anxiety, or depression, our body kicks on its excitatory fight or flight system, HPA-axis, and ramps up its immune response. We have just detailed, physiologically, the impact that these systems have upon fibromyalgia and pain. So, suppose we are suffering psychologically or socially. In that case, it will have a genuine impact on our brain chemistry and bodily regulation.
In turn, when we’re in pain, fatigued, or feeling ill, it affects our psychosocial state - It’s a terrible cycle!
Trauma, Anxiety, and Mood Disorders
As you can imagine, trauma, anxiety, and mood disorders are heavily correlated with the occurrence of fibromyalgia. Do they cause fibromyalgia, or are they the result of fibromyalgia? Or maybe just passers-by? It’s hard to tell, and the research is still out. However, it is crystal clear that the psychological and physiological pathways with these types of disorders and fibromyalgia share significant overlap. Worsening in one condition is likely to worsen the other. On the other hand, getting your mind and body back in gear may result in improvement in all conditions.
Living with any pain, mood, or anxiety condition is likely to maintain high levels of stress within the body, impacting gene expression, immune regulation, and brain chemistry.
This all relates back to the idea that fibromyalgia is not a disease state related to one particular pathological tissue or chemical. Rather, fibromyalgia and chronic pain constitute a functional disorder related to a dysfunctional pain system.
Pain, Neuroplasticity, and Learning
Even after we’re kids, our brains continue to learn and change, going all the way into old age! This concept is known as neuroplasticity.
Neuroplasticity plays a critical role in any chronic pain condition. Why so? Well, pain is part of our protection system, which keeps our body safe. One would hope that the nervous system would learn about new threats and adapt over time. The more threatening our brain believes something to be for our body, the more it will look to protect and viola - more pain.
Do this for a long time, and you’re becoming highly fluent in the pain language. Learning will occur.
With this concept in mind, your perception of potential harm, whether that be from something scary-looking on an x-ray, a physician telling you that you’ll suffer forever, or your mom telling you that you’re destined to have back pain can massively contribute to your pain system ramping up or down.
A football player getting a bone-crushing tackle in-game after getting a crucial first down? That guy is hopping right back up and pounding his chest. But, imagine someone with their brain chemistry a bit out of whack from recent stress and holding some genetic predisposition. Then, this person suddenly finds out they have a diagnosis of what they perceive is an incurable pain disorder. Which individual is likely to have a more ramped-up pain system?
Did you know that 90% of patients with fibromyalgia have difficulty with sleeping?
Poor sleep and fibromyalgia are indeed 2 peas in a pod. In fact, we haven’t met someone with fibromyalgia that didn’t have trouble sleeping.
There appears to be a 2-way relationship between sleep and pain. The worse sleep you have..., the more you hurt. On the other hand, if you have pain, it’s hard to sleep!
In addition, because anxiety, mood, stress, and trauma conditions are quite prevalent among those with fibromyalgia, it stands to reason that these may also contribute to poor sleep.
Poor sleep has an impact on the pain system and has been shown to reduce decreased pain thresholds, cognition, and pain sensitivity, among many other areas. Crummy sleep may worsen these symptoms through many mechanisms, such as increasing inflammation and stress hormones.
Put simply, if you can’t get your sleep even somewhat together, it may be hard to truly shake out of a chronic pain episode.
Fibromyalgia Treatment - I Need help! (1)
With so many factors potentially influencing the physiology of fibromyalgia, what in the world can you do to treat it? This section will go through the science and research behind various pharmaceutical and non-pharmaceutical treatments available for fibromyalgia.
Overview of Treatments for Fibromyalgia
The current body of scientific literature suggests a multidisciplinary treatment approach beginning with non-pharmaceutical (non-drug) approaches. However, under the recommendation and supervision of a physician, there are several classes of medication that have the potential to improve the symptoms of fibromyalgia. It is important to note that none of these medications appear to come without the potential for side effects. Additionally, none should be utilized as a sole treatment in itself.
Just as there is a range of physiological factors for fibromyalgia, there is a broad range of potential treatments. All guidelines suggest starting with conservative interventions.
When investigating various treatments, you’ll notice that they all appear to target one or more of the factors in the physiology section, such as neural sensitization, inflammation, the HPA axis, oxidation, sleep, or psychosocial factors. In particular, you’ll notice that medications for fibromyalgia tend to affect particular neurotransmitters related to the pain system - i.e., attempting to help regulate your brain chemicals.
Is There a Fibromyalgia Cure?
Although there is emerging evidence for the efficacy of multiple treatments listed below, there are no quick fixes, no panaceas, and certainly no “cures” for fibromyalgia. Why could this be? Well, as you may have realized so far, fibromyalgia isn’t a single thing to be cut out of your body or a single dysregulated hormone. We also have so much to learn in research!
Fibromyalgia is a functional and processing disorder of the pain system. This means there are heavy influences from the nervous, endocrine, and immune systems with genetic, environmental, and psychosocial contributions.
The plus side? Improvement is very possible in fibromyalgia, and some have even noted remission of symptoms. However, the research would suggest that you must dedicate your medical management to improving your pain system rather than playing “whack-a-mole” with symptoms or diagnosis-seeking if you truly want to make a major impact on your condition.
Unfortunately, no one treatment appears to be the single most effective for everyone. Therefore, you’ll have to work with your healthcare team to find what will work best for you while weighing goals, lifestyle, risks, and side effects.
Pharmacological Treatment for Fibromyalgia
Pharmacological treatment (i.e., using pharmaceutical drugs, medicine...) to treat chronic pain has been relatively well studied over recent years. Most, if not all, of the pharmaceuticals used in fibromyalgia act upon the “brain chemicals” and their receptors involved in sensitization of the nervous system and pain processing. These neurotransmitters include GABA, glutamate, endogenous opioids, serotonin, dopamine, and norepinephrine.
The endocannabinoid system is an aspect of the nervous system that helps regulate pain, immune function, inflammation, and a host of other bodily functions. This system may be altered in individuals with fibromyalgia, resulting in a decreased self-ability to control pain. Several substances look to activate the endocannabinoid system at what is known as the CB1 and CB2 receptor sites.
How Cannabinoids Work
The substances that are most heavily studied for fibromyalgia include:
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Medicinal cannabis (∆9-THC) - Medical marijuana
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Endogenous cannabinoids, such as Anandamide (AEA) and 2-arachidonoylglycerol (2-AG). These are cannabinoids your own body makes. They play on similar mechanisms as acetaminophen on “arachidonic acid.” Basically, your body’s own Tylenol! In the non-medicine section of treatment, we’ll talk more about how to generate your own.
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Synthetic cannabinoids - These are scientist-made pharmaceuticals that mimic endogenous cannabinoids. Nabilone is one common name here.
Cannabinoids of all types act on the CB1 receptor, providing an analgesic effect. This is what promotes the feel-good sensation many cannabis users hail. In addition, CB1 activation appears to decrease nociception. Essentially, decreasing the “danger signal” coming from the body that your brain uses to process pain.
In addition, the CB2 receptor appears to play a positive role in inflammation and immune function, which also plays a critical role in persistent pain.
Evidence and Risks
A 2021 systematic review on safety using 10 studies of 1136 patients found that cannabis was safe and well-tolerated in patients with fibromyalgia. The main adverse effects came with the feeling of being “high” though no serious adverse effects were demonstrated.
In another study on effectiveness, cannabis demonstrated ability in reducing pain, stiffness, relaxation, and feeling of well-being in some patients, but not all.
When it comes to synthetic cannabinoids, one randomized, double-blind placebo-controlled trial of 40 patients with fibromyalgia showed some promise. After 4 weeks, there were small but significant differences in pain (2 points on the 10 point scale) and anxiety in the synthetic cannabinoid group compared to the control group. Though the treatment group did suffer more side effects than the placebo group. Overall, it appears to be well-tolerated and may provide some pain relieving capacity.
What is the most prevalent neurotransmitter (chemical) in the brain? Is it the glorious dopamine? How about the famed serotonin? Okay, it has to be adrenaline, right?
It turns out the most prevalent chemical messenger in your brain is the lesser-known glutamate. As mentioned before, glutamate is an excitatory neurotransmitter and functions in the glutamine-glutamate-GABA cycle to balance neuronal excitation with inhibition.
Too much excitation and we can experience brain fog, mental health disorders, seizures, neuronal cell death, and, most importantly, fibromyalgia and chronic pain disorders - nervous system sensitization.
Now glutamate is the most common neurotransmitter in the brain for a reason. It’s what makes many of your nerves fire! Without it, your brain would be a mush of nothingness. It’s just you need to balance it out, recycle it, and counteract it with the proper receptor density, enzymes, and its counterpart - the inhibitory GABA.
When glutamate interacts with an NMDA receptor on a nerve cell, it allows an influx of calcium into the cell, which causes the “firing” and excitation. It has been theorized in the research that excessive transmission of this pathway is critical to the development and maintenance of central sensitization and chronic pain.
How Gabapentinoids Work
Gabapentinoids were initially developed to treat seizures and are classified as anti-convulsants. This is because seizures are essentially a massive surge of excitation and electrical activity in the brain.
However, as glutamate and neuronal excitation plays a central role in chronic pain and central sensitization, gabapentinoids have become a commonly prescribed medication.
Despite the name, gabapentinoids are not GABA, do not work with GABA receptors, do not convert to GABA, or interact with GABA.
Gabapentinoids work by interacting and binding with a particular spot on calcium channels at the end of a neuron. Blocking this channel prevents the neuron from releasing glutamate, thereby preventing the next neuron in line from firing.
Said another way, gabapentinoids stop a nerve from firing and produce inhibition within the nervous system. Thus, it works similarly to GABA, but it is not GABA.
There is even some evidence that gabapentinoids may also stimulate the GAD enzyme, which helps transform glutamate into GABA.
Some common names for gabapentinoids include:
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Pregabalin
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Lyrica
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Gabapentin
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Neurontin
Evidence and Risks
The latest Cochrane Review on Gabapentin looked at 37 studies including 5914 patients with chronic neuropathic pain. This review did not look at fibromyalgia in particular but did look at gabapentin for nervous-system-related disorders. In treating postherpetic neuralgia, 32% had a substantial benefit in their pain levels compared to 17% taking a placebo. Furthermore, 46% showed moderate benefit compared to 25% with placebo. These numbers were similar in patients with diabetic neuropathy.
For all conditions, adverse events were higher with gabapentin at 11% compared to placebo at 8%. However, serious adverse events were no more likely in gabapentin compared to placebo at around 3%. Common side effects included dizziness (19%), sleepiness (14%), swelling in the limbs (7%), and altered walking patterns (14%).
In a Cochrane review specific to fibromyalgia, a minority of people with moderate to severe pain due to fibromyalgia treated with a daily dose of 300 to 600 mg of pregabalin had a reduction of pain intensity over a follow-up period of 12 to 26 weeks, with tolerable adverse effects.
Looking specifically at fibromyalgia, one study demonstrated pregabalin's ability to reduce excitability in the brain associated with pain, resulting in reduced pain.
Overall, gabapentinoids appear to be relatively safe and have the potential for some benefit for pain reduction to a small subset of patients with fibromyalgia. However, there do appear to be side effects for many using these medications.
Opioids are a hot topic in the pain world, and for a good reason. A rise in overdose cases during the 2000s led opioids into the national spotlight as a potentially overused pain medication.
Due to the way they interact with opioid receptors, long-term use can induce “tolerance” to the medication, meaning it takes more and more to get the same effect. In turn, when use is taken away, there is a high potential for significant withdrawal symptoms. In addition, opioids have the potential for fatal overdose from respiratory depression (failure).
In light of the risks associated with opioid medication, much news and legislation have been passed down in recent years to more tightly control this substance. This has caused many with pain to feel undertreated and abandoned due to the significant withdrawal symptoms and lack of adequate follow-up treatment.
How Opioids Work
There are various opiates and opioid medications in circulation, both legally and illicitly, with various levels of risk and effectiveness. It is imperative that any opioid medication is prescribed and tightly followed by a supervising and referring physician.
In addition to exogenous opioids (i.e., medication), our body naturally produces safe endogenous opioids (i.e., our own brain chemicals). Several studies and thinkers in the pain-sphere have theorized that individuals with chronic pain have a dysregulated ability to produce their own opioids and, in addition, struggle to properly utilize opioid medication.
Opioids, whether exogenous or endogenous, are molecules that act upon opioid receptors throughout the nervous and GI system resulting in pain-relieving effects.
Evidence and Risks
From a guideline standpoint, the extended use of opioids has been discouraged by healthcare provider guidelines.
Tramadol is a synthetic opioid receptor agonist, working similar to an SNRI, is widely prescribed. Tramadol has been studied in fibromyalgia and has shown some potential benefits. However, tramadol has the potential for serious and significant side effects, such as dizziness, headache, constipation, addiction, withdrawal, nausea, serotonin syndrome, somnolence, pruritus seizures, drug-drug interactions with antimigraine, and antidepressants medications.
Codeine, a weaker opioid than many prescribed, was compared vs. tramadol in the treatment of pain. The overall results suggested that tramadol-acetaminophen tablets (37.5 mg/325 mg) were as effective as codeine-acetaminophen capsules (30 mg/300 mg) in the treatment of chronic pain
Naltrexone is a medication that is actually used to help people decrease opioid dependence. In some studies, it appears to have some evidence in reducing self-reported symptoms of fibromyalgia, and low-dose prescription has been shown to be potentially beneficial for fibromyalgia and seems to be safe and well-tolerated. However, in other studies, naltrexone had no significant effects on pressure pain threshold, deep tissue pain, temporal summation, or conditioned pain modulation in patients with fibromyalgia.
With all things considered and evidence from all types of studies, there are significant adverse effects of using opioids for fibromyalgia compared to other therapies and no clear, distinct advantage vs. other medication. Therefore, they are certainly not recommended as first-line therapy.
SNRIs are an FDA-approved and commonly prescribed class of medication for fibromyalgia. SNRIs are a type of medication that aims to increase the amount of serotonin and norepinephrine available to the neurons in your brain and is a class of antidepressants. To understand how SNRIs affect pain, it’s essential to understand how they work.
How SNRIs Work
A reuptake inhibitor acts by increasing the number of available neurotransmitters (in this case serotonin and norepinephrine) for neurons to use. When any neurotransmitter is present between neurons, some of the neurotransmitters become utilized and others are broken down or reuptake by other cells. The fewer neurotransmitters that are cleared out, the more available they are for potential use, therefore their effect may be more potent.
Serotonin and norepinephrine are involved in many human body processes, including pain, sleep, emotion, and mood regulation. It just so happens that the pain system appears to improve for some individuals when more of these particular brain chemicals available for use.
Some have theorized that serotonin and norepinephrine function in the pain system by regulating the descending inhibition mechanism that decrease the amount of nociception (i.e. danger signals) coming from an area. When we have less descending inhibition... we typically feel worse!
Other theories and small studies have looked at the ability of antidepressants, such as SNRIs, to reduce inflammatory markers, such as IL-1β and IL-6, and the blocking of sodium ion channels that are involved with pain transmission.
Evidence and Risks
Research has shown that many individuals with fibromyalgia also have a lower concentration of available serotonin than individuals without fibromyalgia. This finding may provide evidence as to why some with fibromyalgia find SNRIs effective for pain relief.
A 2018 Cochrane review of 18 studies and 7903 participants with fibromyalgia revealed that SNRIs had a 31% chance to decrease pain scores in half compared to a 21% chance from placebo. SNRIs provided a clinically relevant benefit for users to be “Much” or “Very Much” improved 52% of the time compared to 29% of the time with placebo.
Unfortunately, in this review, SNRIs did not appear to have too much of an effect at large for sleep, fatigue, or health-related quality of life.
19% of the subjects in the studies dropped out from SNRIs due to side effects compared to 10% of the placebo group; however, there was no difference in severe side effects in the SNRI group compared to placebo.
Based on this review and the current body of evidence, we can estimate that SNRIs may provide a meaningful benefit to around 1/3rd of those with fibromyalgia.
We have talked about glutamate, GABA, and NMDA receptors quite a bit so far. And rightly so, because these brain chemicals and receptors tightly regulate sensitivity and pain. These receptors also play a significant role in learning, which matters when it comes to chronic pain.
In the section on gabapentinoids, we discussed how these medications prevent too much neural excitation. It turns out there are more ways than this to put the brake on this system as well.
How NMDA Receptor Antagonists Work
As the name implies, NMDA receptor antagonists block excitatory neurotransmitters, such as glutamate, from activating NMDA receptors, thus preventing too much excitation, sensitization, and pain.
Two medications, ketamine and memantine, are increasing in popularity. However, these medications are pretty powerful and can be poorly tolerated with dangerous side effects.
Evidence and Risks
In one recent review that looked at 3 studies using ketamine for patients with fibromyalgia, over half (57%) had a pain reduction of 50% or greater.
Memantine functions as another NMDA antagonist and can reduce neurotoxicity with high levels of glutamate. A 2014 double-blind, randomized controlled trial showed that memantine significantly reduced pain for those with fibromyalgia at 6-month follow-up.
NMDA receptor antagonists, such as ketamine and memantine, are tightly controlled substances for illicit recreational use and for a good reason. Some of their side-effects include dependence, sexual impulse, and violence.
Remember, NMDA receptors are involved with a massive amount of your body’s functions beyond pain. Altering the function of these neurotransmitters with medication comes with significant risk without the assistance and recommendation of a qualified healthcare provider. Furthermore, like other potent medications, these NMDA receptor antagonists are not guaranteed to work, and the risks and harms can often outweigh the benefits.
“My pain isn’t from my depression... Why are you recommending antidepressants? I really hurt!”
Has this ever happened to you before? As was the case with SNRIs, antidepressants act on other symptoms than just depression. This is because many of the same brain chemicals involved with depression overlap with your pain system.
Tricyclic antidepressants (TCA) often end in “ine” such as the commonly prescribed amitriptyline. These medications have been a mainstay prescription for fibromyalgia for many years.
How TCAs Work
The exact way TCAs affect the pain system are still somewhat unclear. Some research and theory have investigated their ability to help regulate the body’s opioid receptors, which are critical to the pain system.
Similar to SNRIs, TCAs also act on amines, such as serotonin and norepinephrine. TCAs may also act on dopamine to a small extent.
Evidence and Risks
TCAs have been widely recommended by most clinical practice guidelines for fibromyalgia throughout the years.
According to the 2017 Eular Recommendations for the Management of Fibromyalgia, 13 trials of 919 subjects demonstrated that patients with fibromyalgia taking TCAs were more likely than controls to experience 30% pain reduction. In these studies, TCAs had a small positive effect on sleep as well.
In total, the research shows that medical management under the supervision and recommendation of a qualified healthcare provider has a place in the treatment of fibromyalgia.
Unfortunately, no single or combination of medications appears to be highly effective in truly eliminating all symptoms. Though, several classes appear to have some efficacy while remaining reasonably safe. However, even the more conservative medications, such as gabapentinoids, do not come without their side effects.
In addition, all research guidelines that we have read discuss the utilization of medication only in the context of a comprehensive plan of care that includes non-pharmacological treatments as we detailed above. In fact, guidelines call for these non-pharmacological treatments, such as movement, nutrition, stress reduction, and sleep regulation, to be the proper first-line therapy before attempting any medication.
Finally, several medications, such as NMDA-antagonists and opioids, come with severe risks associated with dependency and withdrawal. All medications in this deep dive are federally controlled, prescription-only, and require consultation with your doctor.
Conservative Fibromyalgia Treatments (6)
Before considering pharmacological treatments, many healthcare providers recommend non-pharmacological (conservative) treatments first, and for a good reason!
Alone, medications are rarely a fully effective treatment for fibromyalgia. Instead, the ability of non-medication treatments to treat fibromyalgia offers significant promise for several reasons that include, but are not limited to:
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Conservative treatments affect multiple factors at the same time related to fibromyalgia.
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Individual conservative treatments can be combined with pharmacological treatments without issue.
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Conservative treatments are safe.
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There is a growing body of evidence for the effectiveness of conservative treatments for fibromyalgia.
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Conservative treatments offer a sense of control and provide means for self-management
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Many conservative treatments can affect the source of what may be driving pain, such as stress or chronic inflammation, for example.
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Certain conservative treatments, such as exercise or meditation, may provide compounding benefits.
Let’s go through several of the more common and effective conservative treatments.
As humans, we need to move. It’s just the way we’re built. We don’t think we need to put any citations down to tell you that an active lifestyle has tremendous benefits over a sedentary one. But what about exercise and pain? It is a slightly complicated and nuanced activity to get into. Of course, later in this article and with the NewFrame Program, we provide all kinds of tips to make exercise effective and more enjoyable with fibromyalgia.
Exercise can involve various types of physical activity, including resistance training (e.g., strengthening or lifting), flexibility (e.g., mobility or stretching), aerobic (e.g., walking, running, swimming, biking), or general physical activity (e.g., gardening or playing with the kids).
Many people engage in exercise on their own or take to activities they've done their whole life. However, others have difficulty getting started or knowing how to safely exercise with pain. In this situation, many people are supervised by physical or occupational therapy to get started.
How Exercise Works for Fibromyalgia
Exercise can improve a wide range of physiological factors, many of which can improve the pain and symptoms of fibromyalgia.
When we get moving with exercise, especially with prolonged aerobic exercise, our bodies increase the production of several feel-good chemicals, including endogenous opioids, dopamine, and cannabinoids. This is what accounts for the runners high, but it’s also responsible for those times you’ve found yourself lost in an activity or on a hike. Even better, the more frequently we engage in exercise, the better we can engage the systems that bring us pain relief from physical activity.
One important concept to understand with exercise and health is the concept of adaptation to progressive physical stressors. When we expose our body to slightly increased physical stressors, such as a resistance training bout, our body will attempt to adapt to the stressor. Our body does this by turning on machinery to improve its ability to meet a similar demand next time. This is how exercise training makes you bigger, faster, and stronger!
This type of adaptation can happen in your bones, cartilage, muscles, tendons, and all kinds of bodily soft tissues, even if you’re currently experiencing pain.
The stronger, more mobile, and more resilient your bodily tissues are, the less nociception (danger signals) you're likely to produce, and ultimately the less pain you may have.
In addition to better feel-good chemicals and improving the physical makeup of your body, exercise can improve many other aspects of general health. Exercise-mediated effects include weight loss, endocrine regulation, immune function, mental well-being, and much more.
We do understand that exercise and pain is an ultimate catch-22. For many, it hurts to exercise, but if you can’t engage in regular exercise, it may make the hurt worse in the long term. It is critical to start at a point you can tolerate. You must take into account pacing and individual comfort and have an individualized plan. It may be comforting to know that, at large, exercise has generally been demonstrated as safe and well-tolerated for fibromyalgia. Let’s take a look at some of the evidence on exercise effectiveness for pain.
Evidence
According to the latest Cochrane Review on exercise and chronic pain, exercise has demonstrated favorable effects in reducing pain and improving physical function with a small-to-moderate effect. It also showed potential to improve psychological function and quality of life. Of note, this review found exercise to be safe with few adverse events.
One randomized controlled trial looked at 130 women with fibromyalgia performing individualized resistance training to their comfort level (e.g., Using bands, lifting weights, machines...). The study found significant improvements for knee strength, arm strength, health status, pain disability, and pain acceptance compared to those that didn’t.
In another study, a program involving low-intensity physical exercise was administered to 16 women with fibromyalgia, and 16 women served as controls without exercise. At the end of the study, the exercising women improved in pain catastrophizing, anxiety, depression, stress, pain acceptance, pain pressure threshold, quality of life, self-perceived functional capacity, endurance and functional capacity, and movement performance measures. The women in the control group? No improvement in any of these measures.
A 2017 systematic review and meta-analysis found strong evidence for physical exercise, such as aerobic and resistance training, to reduce pain, well-being, and symptoms of depression in those with fibromyalgia. The study also found the capacity for exercise to improve health-related quality of life.
Ahh, a good massage. For many of us, there is no better feeling afterward... And how about getting a well-timed joint mobilization or an "adjustment" of the back? These manual therapies can feel pretty good, but why so? What is actually happening with the laying of hands?
How Manual Therapies Affect Fibromyalgia
Over the years, and in clinical practice, there have been countless rationale behind what is actually happening during manual therapy (e.g., massage, mobilizations, manipulations/adjustments).
It turns out, most of these theories, such as re-aligning the spine, breaking up scar tissue, and altering fascia haven’t really held up to research.
Does that mean they don’t work? Not at all! But what’s really going on?
In short - We don’t have one perfect answer. Sorry reader! The long answer? Well, to begin, let’s look at it this way: the tissue in our body is incredibly strong, tough, and resilient.
Because of this, it’s not so easy to mash on skin/fat and have a lasting structural effect on the deeper tissues, such as breaking up scar tissues/adhesions/fascia or relocating bones. Furthermore, your spine is insanely strong and held in place with robust ligaments and connective tissue. It turns out our spines, vertebrae, and discs do not easily slip in or out of alignment. If it did, we’d be in a lot of trouble of potential paralysis!
What do we think is actually happening? Well, for one, yes, you can undoubtedly get some movement of superficial tissue like skin, muscle, as well as fluids, moving. But, more importantly, as it relates to pain - pressure, and stretch from manual therapy can activate and inhibit various brain regions. In doing this, manual therapy releases and regulates many of our feel-good brain chemicals - especially when the force from the hands comes from someone else!
During a manual therapy session, areas involved with pain can undergo distinct transient changes, such as the anterior cingulate cortex, the amygdala, and the insular cortex.
In a nutshell - Manual therapy appears to alter the way the brain processes pain. You may experience feelings of being back in alignment, relaxation, and pain relief by doing so.
Evidence
Let’s take a look at the evidence of how well manual therapy works with fibromyalgia.
A systematic review and meta-analysis of 9 studies and 404 patients found a small but statistically significant change in improved pain, anxiety, and depression in those undergoing massage therapy for fibromyalgia.
In a recent small randomized controlled trial out of Spain looking at the application of manual therapy, a group of women with fibromyalgia were able to experience decreased pain, muscular fatigue, and anxiety compared to controls.
Of all eastern medicine interventions, acupuncture has been the most widely adopted in our western world. It also happens to be reasonably evidence-based.
How Acupuncture Affects Fibromyalgia
Unfortunately, the mechanisms behind how acupuncture works are still a bit of a mystery. The current thinking in the research world is that it is not due to altered chi or energy pathways.
Instead, some studies have shown how acupuncture may help regulate the body’s own opioid system, serotonin, and substance-P levels. All of these are important to the pain system!
Evidence
A recent systematic review and meta-analysis comparing studies of acupuncture versus placebo control.
The results of these studies demonstrated a small but meaningful difference in pain levels in the short term. There was even preliminary evidence for long-term effects as well.
Most importantly? No adverse side effects. Why not give it a try?
Electric stimulation, often referred to as TENS (Transcutaneous electric nerve stimulation), is a common treatment for pain, including fibromyalgia. TENS refers to the little electricity patches that go on your skin and can make your skin tingle. If turned high enough, you can even make your muscles contract!
How TENS Affects Fibromyalgia
TENS acts by turning on various sensory nerves, such as “A-beta fibers,” which can affect the pain system in various ways. The most commonly cited way TENS affects the pain system is through the gate control theory.
In this theory, there is a location in the back part of your spinal cord analogous to a gate. Think of this area as a grand central station for signals coming back and forth between your body and brain.
Signals of “danger” coming from an injury or sensitized area may flood the gate and eventually result in a high amount of pain. When the gate is wide open, you'll feel the full effect of these signals in the form of pain.
However, various other signals, such as light touch, pressure, heat, cold, and signals coming from the brain can all close the gate. The more closed the gate is, the better you feel!
TENS, through various mechanisms, acts to help close the gate and improve your pain while it is active.
Evidence
According to a recent study, TENS appears to work quite well for pain when used alongside movement. After 4 weeks, subjects who used TENS while moving or exercising improved their pain and fatigue levels compared to those that did not.
In another study, TENS was shown to improve pain modulation and pain pressure threshold, meaning it took more of a noxious stimulus to bring on a pain response.
Diet, nutrition, and supplementation is a widely practiced treatment in fibromyalgia. Despite its popularity, there seems to be little guidance among healthcare practitioners and a lack of research.
Although there isn't nearly as much research in nutrition for fibromyalgia as for drugs, there are clear mechanisms for pain relief emerging in the nutritional literature. We'll talk through a few of these!
How Nutrition Affects Fibromyalgia
Have you ever heard the old term, "You are what you eat"? In a way, that's quite true! The molecules from broken-down food eventually make their way into the gut and influence our entire physiology. This enormity and complexity is part of the reason it's so challenging to design proper trials around diet. However, a few clear nutrition-regulated themes are presented in the nutritional research: excitotoxicity (nervous system sensitivity), oxidative stress, and inflammation. Did you notice that these 3 areas also happen to be 3 of the critical drivers of fibromyalgia, as we discussed earlier?
Excitotoxins and Diet
Dietary excitotoxins include foods that are high in glutamate or aspartame. These are your umami foods, such as soy sauce, mushrooms, broth, and many fillers / artificial sweeteners. This may also come in the form of monosodium glutamate (MSG) as a common additive.
Typically, dietary glutamate is safe and should remain separate from the brain due to what's known as the blood-brain barrier. However, there is evidence of compromise in this barrier in individuals with fibromyalgia and those with a history of brain injury. If this is the case, free glutamate from the diet may actually begin to affect pain and the central nervous system through what is known as excitotoxicity.
Several studies have explored diets low in excitotoxins and symptoms of fibromyalgia. In a few of these studies, a small number of patients with fibromyalgia have experienced drastic relief in symptoms. However, these studies are low in quality, and more needs to be done!
Oxidative Stress and Diet
As we learned earlier, excessive oxidative stress can be pretty harmful to our cellular energy powerhouses, known as our mitochondria. In the form of reactive oxidative species and free radicals, oxidative stress is naturally opposed by antioxidants.
It turns out that there are a wealth of antioxidants within vegetables, fruit, coffee, and wine. That's not such a bad list, right? How much these foods are actually able to make a difference in oxidative stress is still under investigation.
In addition, the evidence is not there for antioxidants in supplemental form to make a significant difference.
However, eating whole foods may be a better bet than processed foods lacking any potential for antioxidative properties. To some degree, diets high in vegetables have been shown to improve fibromyalgia symptoms, such as the Vegan and Mediterranean diets.
Inflammation and Diet
Inflammation may come directly from your diet and indirectly from the results of a poor diet (i.e., obesity and diabetes).
As it comes to inflammation, crappy diets high in processed sugar appear to lead to an increased inflammatory state in the body. Furthermore, excessive adipose (i.e. bodyfat), can also lead to a higher level of pro-inflammatory cytokines.
Put together, eating McDonald's doesn't just make you big. It makes you hurt.
Irritable Bowel Syndrome (IBS) and the Gut Microbiome
Taking care of your gut is essential too. After all, billions of tiny bacteria interact with your "nervous system in the gut" otherwise known as your enteric nervous system.
We're still in our infancy of understanding the gut microbiome, but we see that it affects health.
Choosing a diet that agrees with your gut also appears to make a difference in fibromyalgia symptoms. Irritable bowel syndrome is widespread among those that suffer from fibromyalgia. It turns out that there is some evidence that treating bowel distress with diets such as the FODMAP diet or a gluten-free diet has been shown to not only reduce symptoms of IBS but also pain! Now, of course, these diets are not for everyone and likely only affect those sensitive to high FODMAP or gluten foods, for example.
Supplements and Fibromyalgia
You may be asking yourself, "Okay, so diet is important, but what supplements are evidence-based?" Well, we were hoping you might ask!
Micronutrients are important to human health. You should aim to get them from your diet, but several are being studied specifically for fibromyalgia.
Far and away, magnesium is the most studied. Magnesium acts on the NMDA receptor (it keeps coming up!) to help with slowing down neuronal excitability. Theoretically, this should help decrease sensitization as well. Several studies have shown that those with fibromyalgia often have decreased intracellular magnesium levels. Insult to injury!
Several small studies have investigated magnesium supplementation on pain in fibromyalgia and have shown some early promising results.
Outside of magnesium, many other supplements have been studied, but none have amazing evidence or effect at large; however, some do show some promise in select individuals. Those with some promise include CoQ10, L-carnitine, zinc, and probiotics.
Finally, several vitamin and mineral levels have been shown to occasionally be low in patients with fibromyalgia. Those with low levels could benefit from supplementation, such as those deficient in vitamin D, iron, vitamin B12, and folate.
Remember, adding a supplement to your regimen is affecting your physiology. You should talk with your treating team about how these supplements may impact any medication you're on, as well as safe levels to try. For example, over-supplementation of any supplement, especially vitamin D, iron, and B vitamins, could hold the potential to cause some adverse effects.
Stress and mental health are fundamental and central areas to improve to overcome pain. What does staying in a persistently stressful state do to someone? Entire books are covering this, and far too much evidence and content are available for this write-up to cover. However, when it comes to fibromyalgia, psychological stress affects inflammation, pain learning (i.e., neuroplasticity), and the status of your brain chemicals. All of these can, in turn, influence a state of pain sensitization.
Mindfulness and meditation include a wide range of practices. However, central to all include bringing the self and your attention to the present moment. Many practices also include bringing attention and awareness to the breath.
How Mindfulness and Meditation Affect Fibromyalgia
Breath and present moment awareness allow us to step out of a sympathetic nervous system dominant state (i.e., fight or flight) and into a more relaxed and restful state.
Mindfulness and meditation also influence and amplify our cognitive flexibility. Meaning they allow the practitioner to better regulate their emotional reaction to unpleasant states, such as pain with less reactivity.
For example, patients with fibromyalgia have been shown to have increased activation of various brain regions, such as the insula, cingulate cortex, and somatosensory cortex. These regions contribute to a more reactive state when it comes to unpleasant physical and emotional states.
It turns out that a state of increased cognitive flexibility allows for better "learning" in these brain regions as it comes to pain in that we can down train and desensitize the nervous system.
Evidence
In a study looking at 8 weeks of mindfulness-based stress reduction, the mindfulness practitioners activated various brain regions vital to calming the pain system, as seen on EEG. In addition, the training appeared to help promote a less pro-inflammatory state.
A review looked at the effect of mindfulness on pain in 13 trials of over 1200 patients. Mindfulness was able to create a small, but meaningful change in pain state compared to controls.
In the same review, 6 studies looked at 559 patients performing meditative movements, such as yoga or tai-chi. Positive changes were seen in sleep and fatigue.
Summary of Conservative Management
In summary, there is a wide range of safe, available, and evidence-based interventions to improve fibromyalgia. Alone, no intervention appears to be vastly superior; however, regular exercise is strongly recommended by many guidelines.
Many of these treatments have not been studied in combination, and there may be promise in performing multiple simultaneously. It is heavily recommended in the evidence to implement these types of interventions into your daily routine if you struggle with fibromyalgia. Of course, we'll detail what that may look like further down the page. And, if you really want the best education on successfully adding these types of behaviors into your daily life, NewFrame will provide you with the foundation you need.
Fibromyalgia Treatment Team
Before you run off trying to tackle everything on your own, we’d recommend you first surround yourself with a qualified medical treatment team if you haven’t already. Although everything in this article is simply education and not meant as personal medical advice, the application can take quite a bit of expertise, nuance, and professional opinion. Again, we do not make medical recommendations here, but we certainly do not recommend self-biohacking with pharmaceuticals and supplements.
We recommend you seek out a team that includes a primary care provider, such as a family medicine physician, physician assistant, or nurse practitioner. Many breeze over the idea that their situation is too complicated for a primary care provider. We’d urge you to stay away from that line of thinking. It is essential to have a central provider that can spend time with you, make intelligent referrals, and be able to perform proper medical screening.
If you have a diagnosis of fibromyalgia, it’s likely you already have, or will be referred to, a rheumatologist. These specialists deal with inflammatory and auto-immune type disorders, which fibromyalgia tends to fall into. You may also be referred to a pain specialist or a psychiatrist who specializes in administering pain medication.
Most importantly, we’d argue, having a rock-solid therapy team is crucial to recovery. We recommend having a physical therapist, psychologist/counselor, and nutritionist available for all pain conditions. Movement, sleep, cognitive strategies, nutrition, and social adjustment with fibromyalgia are critical to overcoming pain and living a better life. Do not skimp on building rapport with a good rehab team and trying to tackle all of this solo.
What Can I Do To Feel Better with Fibromyalgia?
How to Relieve Fibromyalgia Symptoms
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You’ve learned a novel’s worth of information in this post, and that is exactly what it is - information. There is still so much we don't know in medicine about fibromyalgia. Far more research needs to be done to identify the most effective interventions for the right people. Based on what we know in pain research, taking action through habit and behavioral change is the first way to make progress on fibromyalgia treatment.
Of course, we recommend checking with your doctor before doing any of these activities that we’re about to talk about. But, still, these are the actionable steps that the current research recommends for fibromyalgia.
Home Fibromyalgia Treatments
Sleep and Fibromyalgia (18)
As we mentioned earlier, up to 90% of everyone with fibromyalgia suffers from poor sleep! We also know that the relationship between sleep and pain goes both ways. Meaning, if you sleep worse, you feel worse, and if you hurt, you can’t sleep.
Sleep hygiene is the practice of implementing small habits surrounding your sleep to put your brain and body in the right condition to fall asleep, even if you’re hurting! Now, these habits can take weeks, months, or even years to hit their full potential, but they must be done consistently. There is no better time to start than now.
Your circadian rhythm also heavily determines your ability to sleep. If you have too much blue light in the evening and too little in the daytime, your poor brain has no idea when it’s time to rest. Getting this in order is critical to sleeping soundly.
In the NewFrame program we offer more education on getting better sleep if you’re having pain.
If exercise were a pill, it would be flying off the pharmacy shelves. That’s how powerful the benefits of regular exercise are to your body. Unfortunately, especially with fibromyalgia, many things can get in the way of this.
Pain, fatigue, not knowing where to begin, not knowing what to do, and having a hard time staying consistent are common barriers many people encounter.
This is where a physical therapist can really come in handy. They may be able to help you find exercises that work with your pain. This is a much better approach than fearing the pain or a “no-pain-no-gain” strategy. Simply working in a way that your body agrees with is crucial to sustainable progress.
The research does not hold one form of exercise as superior over another for fibromyalgia, though as we mentioned above, it does recommend a combination of aerobic exercise, resistance (strength) training, and flexibility (stretching).
You can get creative with activities. Walking somewhere enjoyable counts for aerobic activity. Some with fibromyalgia find aquatic therapy to hit all 3 of those and feel better while doing it! Others prefer yoga to get the benefits of relaxation while still getting a workout.
Simply put, exercise is the most commonly recommended intervention for fibromyalgia, and any recovery plan without it may be falling short of its potential.
Fibromyalgia Diet (20)
Vegan, keto, gluten-free, Mediterranean, fasting, supplements? What in the world should I eat?
As you can see from the research on fibromyalgia and nutrition above, we are truly in our infancy to understand the best fibromyalgia diet. Unfortunately, there doesn’t appear to be one diet that stands out among the rest. However, there is some minor evidence for low-glutamate, low-FODMAP, Mediterranean, caloric restrictive, and vegan diets to benefit select people with fibromyalgia.
However, even though one diet does not stand out among the rest, we know that diet plays an integral role in the physiology of fibromyalgia and pain.
Based on the current evidence, it seems best to stick to the basic fundamentals of good nutrition, and it appears the literature recommends several core principles:
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Eat natural foods - Feast in a diet high in vegetables and fruits that offers potential antioxidative properties.
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Cut out the crap - Reduce sugar and caloric intake to reduce excessive body fat and avoid a pro-inflammatory state.
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Work with your gut - Pay attention to your individual food sensitivities that may affect your gut and symptoms, such as gluten intolerance, FODMAP foods, and foods high in free-glutamate
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Avoid nutrient deficiencies - Talk with your doctor to ensure you are not deficient in essential micronutrients, such as Vitamin D, Vitamin B12, folate, or iron, for example. The research has some preliminary evidence on magnesium, zinc, and multivitamin supplementation that has been shown to have a small effect on some individuals with fibromyalgia. But you should talk to your doctor or nutritionist first in this area.
Improving your fibromyalgia means improving the way your brain processes threat. With a highly sensitized nervous system, any potential physical threats to the body, such as sitting or standing too long, walking too far, or even temperature, can result in significant pain.
Pain isn’t only about physical threats though, even cognitive and emotional threats play a role in amping up your pain system, resulting in, well... More pain!
Cognitive-based interventions and skills, such as mindfulness and meditation, have demonstrated the ability to calm threats, which may lead to decreased pain, anxiety and improved overall well-being.
Engaging in these behaviors changes the mind’s relationship to these potential threats from overactive to tempered.
Working with a mental health professional specializing in cognitive and behavioral strategies is a wonderful way to learn these techniques. They may utilize various methods, including CBT and ACT, which have been shown to improve pain. There are even countless applications and videos that can teach you online too.
NewFrame provides many cognitive techniques, such as mindfulness practices and breathing techniques, designed specifically for pain conditions, such as fibromyalgia.
Lifestyle and Fibromyalgia
When you have fibromyalgia, it can really begin to consume your life if you aren’t careful. It’s important not to spend all of your time, energy, and attention fighting pain and neglecting what you value in life. That’s easy to say, of course, but harder to do in practice.
Spending your time doing things you find valuable and meaningful while working towards goals is critical. However, goals should not be just, “feel less pain.” Goals that incorporate your life values are fundamental to living a better life with fibromyalgia. And we don’t just say that as a way to manage the condition. To experience proper recovery, one needs to begin living a fulfilling and meaningful life with positive experiences and healthy social relationships.
How can your lifestyle and doing enjoyable activities impact fibromyalgia? Doing things that bring pleasure also improves your brain chemistry with feel-good neurotransmitters and hormones, such as serotonin and dopamine.
In NewFrame, we offer strategies to get your life back on track and find ways to feel better again. Don’t wait to feel better to start living. Instead, look for any little opportunity to take part in activities you enjoy.
Conclusion and Recovery Program for Fibromyalgia
Fibromyalgia is a complex pain condition affecting millions across the world. Despite not knowing the exact cause or holding a cure, the research holds promise for various emerging treatments.
Based on our evidence, connecting with a medical treatment team and establishing a foundation of improving your movement, sleep, nutrition, cognitive skills, and lifestyle are first-line treatment options.
This guide skims only the basics of these avenues of pain relief. By using NewFrame in your clinic, patients will learn actionable ways to take control of their pain to put them on the right track to recovery.