Integrative therapy for fibromyalgia: possible strategies for an individualized treatment program.

Abstract: One of the most complex patient treatment situations encountered by the clinician is the patient who presents with the cluster of signs and symptoms that lead to the diagnosis of fibromyalgia syndrome. While physicians focus primarily on pharmacologic treatment, a number of nonpharmacologic modalities have been shown to benefit patients as well. No one therapy is uniformly effective in every patient; treatment programs consisting of a combination of pharmacologic and nonpharmacologic therapies must be individualized to the patient, and the clinician may have to try several different modalities before reaching an optimal improvement in the patient's symptoms.

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Few if any clinical diagnoses evoke more diverse responses and opinions than that of fibromyalgia (FMS). Physician opinions vary greatly; some see it as an illness that is difficult to manage and can have a significant effect on every facet of the lives of those afflicted. Others admit uncertainty in the diagnosis but believe it is a disorder better managed by someone in another specialty. (1) Finally, there are those who discount the diagnosis entirely. (2) Patients' perceptions, likewise, vary from those who strive to live a normal life despite their symptoms to those who are unable to cope with the disorder. Quite often they are also frustrated with the medical community's inability to understand, empathize with, and manage their complaints.

The incidence of FMS in the United States is estimated to be approximately 2% (3); the vast majority are female. Common to these patients are complaints of fatigue, diffuse myalgias and arthralgias, sleep disturbance, and tenderness at discreet points on their body. (4) Patients also may report irritable bowel syndrome, paresthesias, Raynaud symptoms, and recurrent headaches. (4,5) Wolfe et al (6) described 18 such tender points that are used for clinical studies of FMS, which many clinicians use to make the diagnosis. While the criteria can be helpful in making the diagnosis, care must be taken to avoid overreliance on this research tool; some patients who generally fit the diagnosis could have fewer than the requisite 11, and many patients have tenderness at other sites as well. While some practitioners consider FMS a "diagnosis of exclusion," reserved for those without any other discernible disease, the fact that many patients diagnosed with rheumatologic disorders have findings of FMS as well (7) demonstrates that this is not an appropriate diagnostic approach.

Does FMS Exist? The Great Debate

Much debate has appeared in the rheumatologic literature regarding the validity of the diagnosis of FMS. Some authors suggest that it is a disorder more appropriate for the behavioral medicine fields rather than being a "real" rheumatologic diagnosis. Ironically, such opinions are aired at a time when research has uncovered neuroendocrine, biochemical, and genetic factors involved in the development and treatment response of numerous psychiatric disorders, including anxiety and depression, both of which have been frequently identified in FMS patients. While some argue that such findings are in significantly different clinical settings and have not been shown to be a factor in FMS, (2) an alternative interpretation of such data is that perhaps theses factors manifest dramatically different clinical disorders in different patients.

Finally, some within rheumatologic circles have implied that physicians could better utilize their time by limiting that directed toward treating FMS patients. (8) Such an opinion may be driven in part by the recognition that the needs of patients with FMS are often time-consuming; the patients often come with numerous complaints and concerns unable to be resolved in the span of an office visit. In addition, practitioners who try to deal with FMS patients become frustrated by the fact that no single therapeutic approach is effective in all patients; it seems that any treatment modality will only help a fraction of patients, often providing partial relief at best. Yunus et al (9) recently suggested that there is identifiable heterogeneity between FMS patient types; perhaps this is a major reason for the varied response rates to treatments.

It is our belief that irrespective of what the academic experts opine, the population of patients with the cluster of signs and symptoms now identified with the diagnosis of FMS are in need of help with their problems, without regard to the validity of the diagnosis or cause of the disorder. The chronic nature of their symptoms and variable response rate to treatments should prompt the clinician to combine a wide range of pharmacologic and nonpharmacologic strategies, in the hopes that by individualizing the treatment program, a maximal benefit can be achieved.

Rather than continuing any further debate regarding the validity of the diagnosis of FMS, we wish to discuss possible strategies that may be beneficial in patients who present with the constellation of signs and symptoms identified as being part of the disorder known as FMS.

Pharmacotherapeutic Options

A variety of medications may be beneficial to the FMS patient; medication classes and options should be chosen on the basis of the patient's primary complaints. Identification of significant sleep disturbance, presence of feelings of stress, anxiety, or depression, and complaints of extreme pain help direct the clinician toward certain medication classes.

Sleep disturbance

The most commonly used class of medications is the tricyclic antidepressants (TCAs). Amitriptyline, nortriptyline, and imipramine have shown benefit in selected patients. (10) Generally, the choice is left to the practitioner, and personal experience suggests that a patient may respond better to one than another. Dosing should be based on effectiveness of sleep without excessive morning "hangover." The wide range of dosages available in these medications permits easy titration in most patients.

Cyclobenzaprine, a commonly used muscle relaxant, has also shown efficacy in improving sleep in many patients. (11) Recent release of a 5 mg dose permits the use of a lower dose for those complaining of excessive sedation with half of a standard 10 mg tablet. The tetracyclic antidepressant trazodone may also prove beneficial to some patients who have complained of inadequate sedation with the tricyclic medications or cyclobenzaprine; effective doses vary by patient, ranging from 25 to 150 mg.

In each case, the dose must be individualized to provide adequate sedation while minimizing morning "hangover"; patients seem to be more amenable to titrating upward than downward, so starting with a lower dose may be preferable. In some cases, morning hangover may be minimized by having the patient take the medication 1 hour before bedtime rather than at bedtime.

Two other medications that may be beneficial in select patients are zolpidem and zaleplon. Both of these medications have relatively short half-lives, which may make their use favorable in those patients with morning hangover despite use of minimal doses of the TCAs. Both are nonbenzodiazepine hypnotics. Unlike benzodiazepines, studies suggest no evidence of rebound or habituation with prolonged use of either medication. (12-14)

Anxiety and depression symptoms

Selective serotonin-reuptake inhibitors (SSRIs) are increasingly used in patients with chronic pain syndromes, including FMS. Goldenberg et al (15) demonstrated the combination of fluoxetine and amitriptyline to be efficacious in FMS patients; clinical experience suggests that other SSRIs may also be effective. Again, no one SSRI is uniformly effective in all FMS patients; individual patients may require trial of several before identifying the one that is best for that specific patient.

In general, benzodiazepines have been reserved for patients who have failed the aforementioned medications. Alprazolam has been shown effective in some patients, (16) but concerns regarding habituation with this class has led most practitioners to try other medications first.

Analgesics 

The use of certain analgesics in FMS patients remains controversial; in general, it is thought that opioids are not appropriate therapy for most FMS patients, and certainly are not as initial agents. The chronic nature of the patient's symptoms coupled with concerns regarding habituation and addiction should prompt extreme caution in using narcotic analgesics. Acetaminophen, tramadol, and nonsteroidal anti-inflammatory drugs have been beneficial in FMS patients. (17,18)

Other agents

Based on data suggesting GABA-ergic effects in patients with various mood disorders, (19) medications such as gabapentin have been used by some practitioners; unfortunately, no large-scale studies using this medication have been presented. Other agents in this class have also shown potential in preliminary studies, (20) further supporting possible utility of these medications.

One of the most popular therapies suggested on Internet sites is expectorant guaifenesin; this medication was the subject of a popular book, in which it was touted as a "cure" for FMS. Despite the author's lengthy rationale for the use of guaifenesin, and despite some data suggesting mild analgesic effects by other agents in the same chemical class, (21) no patient studies have been published to date showing any effectiveness in FMS. In one study, no difference between those receiving the agent and placebo could be identified; furthermore, none of the pathways suggested by the author as causes of FMS could be shown to be affected by guaifenesin. (22) In the absence of any clinical data, therefore, guaifenesin cannot be advocated; fortunately, this is probably a fairly benign treatment, affecting primarily the patient's wallet.

Nonpharmacologic modalities

In most patients, the focus of treatment of fibromyalgia is medication-related; unfortunately, this approach has, as noted previously, very limited success in providing significant improvement in most patients. Given the complex nature of the patients' complaints and underlying problems, the addition of nonpharmacologic measures that complement the effects of the medications may further enhance the patients' well-being and improve their general well-being. Again, each patient's treatment plan should be individualized to their capability; however, certain modalities should be a part of every FMS patient's therapy.

Behavior modification: Sleep hygiene 

Behavior modification is essentially a self-management program that combines direction by a therapist with other patient education modalities.

One important area of behavior modification is sleep hygiene. While good sleep hygiene may not be sufficient to resolve problems of insomnia, poor sleep hygiene may be a significant contributor to insomnia. (23) Many of the symptoms of poor sleep--fatigue, lack of concentration, irritability, and diffuse pain--coincide with symptoms of FMS. While much effort is directed toward prescription medications or improving sleep through herbal remedies, there is insufficient focus on changes the patient can make that can have an effect on controlling their symptoms.

A sleep assessment should be made in every FMS patient, to attempt to ascertain the type of sleep problem that the patient is experiencing. First, signs of underlying medical conditions, such as sleep apnea syndrome or thyroid disease, should be identified. Next, the practitioner should review the patient's bedtime routine. Finally, recognition of other confounding factors should be made. Examples of this include whether the significant other works swing shift or snores, or whether the patient is a parent or a caregiver who awakens easily while listening for their charges.

Once these factors are addressed, a dialogue on sleep hygiene can begin. Table 1 contains a list of some suggestions to improve sleep hygiene in the insomniac patient.

One area often discussed with FMS patients is that of the daytime nap. While a short nap may help, prolonged daytime sleeping should be discouraged. Sleep pressure is thought to have an important influence on the amount of delta/deep sleep during the initial portion of sleep, (32) and insomniac patients have a decreased sleep pressure resulting in increased difficulty falling asleep if they have taken a nap. If a nap is necessary, it should be limited to 30 minutes and completed at least 8 hours before bedtime.

Exercise

Exercise is well known to be beneficial to the general overall health and well-being of any individual, regardless of their FMS status. (24) As with pharmacologic therapy, the exercise program in the FMS patient must be tailored to the individual. Goals in FMS patients should include developing general physical fitness, improving emotional well-being and functional status, and providing a sense of control. (25)

Jones and Clark (26) outlined 5 principles that should be included in an FMS patient's exercise prescription:

1. Minimize muscle microtrauma. Because muscle microtrauma causes localized pain and can lead to aggravation of generalized pain, low-intensity exercise is preferable in early stages of the exercise program.

2. Minimize central sensitization. Patients should avoid exertional activities that aggravate their symptoms, which could, in turn, lead to reluctance to exercise.

3. Emphasize low-intensity exercise. A graduated exercise program should be designed to slowly lessen the level of deconditioning.

4. Recognize the need to individualize exercise. One should promote activities that are enjoyable to the patient to maximize compliance with the program.

5. Maximize self-efficacy. By doing this, the patient develops a greater sense of control, which is beneficial to both physical and psychologic health.

Physical therapy/occupational therapy: Is it beneficial?

Physical or occupation therapy evaluation is a commonly used first-line nonpharmacologic modality and can set the groundwork for subsequent exercise programs. Through their initial assessment of the patient's exercise capabilities and levels of conditioning, physical and occupational therapists can be integral in devising an individualized exercise program appropriate for the FMS patient. Exercise recommendations and choices can be tailored to the patient's tastes and abilities and to resources available in their respective communities. At the same time, educational modalities should be incorporated in the plan in order for the patient to achieve maximal benefit from the exercise program. (27) A good rehabilitation program should address the physical fitness of the fibromyalgia patient as well as promoting functional lifestyles designed to improve physical and emotional flexibility, balance in life, and wellness. (28)

In this era of healthcare rationing by payors, costs and duration of such programs is controversial. One study demonstrated that a prolonged, structured physiotherapy program may not be necessary if a home program acceptable to the motivated patient can be developed. (29) Therapy centers, therefore, may be able to develop a home program that requires only periodic follow-up to monitor progress and make appropriate adjustments to the exercise regimen.

Traditional types of exercise

Aqua therapy. Aqua therapy is considered by many practitioners to be an ideal exercise for the fibromyalgia patient. The warm water is soothing to tired, sore, and tense muscles. The patient's natural buoyancy decreases gravitational stresses, and the water provides a measure of controlled resistance. While most studies examine the direct benefits of water-based aerobic exercise for FMS patients, (30) a recent study compared the effects of pool- and land-based dynamic muscle training on muscle strength, physical function, pain, and general well-being in FMS patients. Both programs improved functionality, but the pool-based patients also demonstrated overall improvement in psychologic well-being as well. In addition, dropout data suggested patients tolerated warm water exercise better than the gym-based programs (31)

Walking. Many clinicians prescribe a walking program for their FMS patients. However, certain pitfalls that may undermine potential benefits must be recognized. Poor strength, improper body mechanics, tight muscles, and balance difficulties can aggravate symptoms rather than benefit an already painful condition. Strict limitations in the early stages of an exercise program may actually benefit in the long run. Rooks et al (32) noted that after an initial 4-week period of a controlled level of exercise, women can begin to progress, decrease, or maintain their level of intensity to achieve physiologic change for symptom improvement and cardiovascular fitness.

As with any exercise program, the lack of compliance is a major factor in unsustained symptom management. Repeated encouragement by the provider will help provide the positive reinforcement to maintain exercise levels. Barriers to continuing the program should be addressed if possible. Most communities have areas that are accessible for walkers year round. For example, many shopping malls open their public corridors early for walkers, removing the obstacle of inclement weather.

Strength training. Strength training is another integral part of the complete picture to improving the quality of life for the fibromyalgia patient. As with other exercise programs, a graduated strengthening program that focuses on the functional strength and muscle toning rather than body building will offer the most benefit. (32) Strength training should be performed no more than 3 times per week, with a rest period of 48 to 72 hours between sessions. Building muscle is important, but not to the point of sacrificing flexibility and endurance.

Exercise programs must be tailored to meet the individual patient's specific needs. These are just a few of the basic exercises that are available to patients. It is important to encourage patients to be active in some type of exercise daily. Stretching before and after an activity will aid in the release of often tight muscle bands and is essential to achieving the balance needed to progress in an exercise program and improve quality of life.

Nontraditional exercise modalities

Yoga. Yoga is an ancient system of mental, physical, and spiritual training, which, according to advocates, is designed to "bring body mind and spirit into harmony." (33) Several different types of yoga exist; the most common form in the United States is Hatha Yoga.

Yoga programs incorporate a combination of gentle stretches, balancing poses, and breathing techniques. Practitioners of yoga cite multiple health benefits of improved strength, endurance, and flexibility, (34) and advocates claim that this particular type of exercise encourages the participant to listen to the body and enhances the mind-body connection.

Although there are no studies on benefits in FMS patients, proponents claim it can provide effects similar to meditation and deep relaxation, resulting in reduced stress levels. It is also reputed to promote a feeling of well-being that can have a positive effect on chronic pain and depression levels seen in many patients. (33)

Tai Chi. Tai Chi is another Eastern exercise modality gaining popularity in the West. Chinese philosophy describes it as improving the flow of "qi," the vital life energy that sustains health and calms the mind. (33)

Considered in China as a form of "moving meditation," Tai Chi is often prescribed as therapy. Through flowing postures, the patient proceeds with gentle range of motion exercises, with additional emphasis on controlled breathing. Because its movements are slower, it may actually be a more suitable exercise regimen for middle-aged, older, and debilitated patients who have been sedentary. (35) A study on osteoarthritic women demonstrated that it was a regimen that could easily be performed and resulted in improvement in arthritic symptoms, balance, and physical conditioning. (36) Studies in FMS have not been reported; however, this modality may be appropriate for the extremely deconditioned patient.

Qi Gong. Similar to Tai Chi, this Chinese exercise program incorporates breathing exercises, meditation, and movement intended to strengthen and direct the flow of "qi" through the body to promote health and self-healing. (33) Qi Gong differs from Tai Chi in that it has fewer movements, and postures are held for several seconds. Given the very low impact levels, patients can do this regardless of fitness level. Reports of data from an uncontrolled study of Qi Gong and meditation in FMS patients demonstrated improvement in depression levels, coping skills, pain threshold, and function, with effects being seen 6 months after completing the initial study. (33) Unfortunately, other unpublished data has shown it to be no better than an active education and support program. Similarly, suggestions of improvement with Qi Gong were seen in elderly patients with chronic physical illness, although statistical significance was not reached. (37)

Patients using one of these modalities should avail themselves of an experienced instructor to develop a solid grasp of the fundamentals and to modify the program to meet their specific needs. Because of this requirement, the choice of which modality to use may be limited by availability of a qualified instructor and classes in one's community.

Cognitive behavioral therapy 

Cognitive behavioral therapy (CBT) is a mind-body approach based on the theory that thought and behavior can affect a person's symptoms and be an obstacle to recovery.

The therapist focuses on decreasing "unhealthy thinking" while helping the patient to develop the ability to cope, not only with illness, but also life events and relationships in general.

CBT is an approach that may be a particularly well-suited modality in those patients in whom significant levels of anxiety and distress can be identified. (38) While more prolonged therapeutic processes have been the standard, (39) a recent study described a more intense but brief program incorporating pharmacologic and exercise therapy with cognitive behavioral therapy. Those receiving CBT were twice as likely to achieve meaningful improvement compared with control subjects receiving only the first two modalities. (40)

A major barrier to utilization of this therapy is the perceived stigma that many patients will attach to the use of CBT. To many patients, suggestion of this intervention is that the clinician thinks the symptoms are "all in my head." One solution to overcome this barrier is to use CBT as part of a more comprehensive adjunctive therapy program, explaining that it is just one of several techniques designed to improve the patient's general well-being. (41)

Other nontraditional modalities

Because of the limited effectiveness of standard therapies, many practitioners have used a variety of nontraditional therapeutic modalities in the treatment of patients with FMS. While the advocates of these modalities can readily provide testimonials and anecdotal evidence, controlled trials are often either lacking, flawed, or contradictory.

Massage therapy 

Several forms of massage therapy exist, varying in technique, approach, and focus. Asian-style massage therapists focus their activities on "balancing the flow of vital energy," whereas the more traditional Swedish massage techniques are designed to improve function through muscle manipulation. (33) In a small study by Swedish researchers, a gradual improvement in pain relief, depression, and quality of life was noted over a 10-week course of massage therapy, but patient pain was at 90% baseline 6 months after treatment. (42) Although the findings in this study do not definitively exclude the use of massage therapy as a component of the fibromyalgia treatment regimen, further studies are needed to determine whether massage therapy has sustained value when used in conjunction with other treatment modalities.

Acupuncture

This Eastern therapeutic modality is based on the theory that an energy called chi or "qi" is flowing through the body along energy pathways called meridians. If the flow of this chi is blocked or unbalanced at any point on a pathway, illness may ensue. Traditional Chinese practitioners believe acupuncture can unblock and balance the flow of chi, thus restoring one's health. Western medicine practitioners who have studied acupuncture theorize that acupuncture reduces pain through biological mechanisms, perhaps involving opioid peptides and stimulation of the hypothalamus and pituitary gland or changes in neurotransmitters, hormones, or the immune function. (33)

Several conflicting studies have been performed on the effectiveness of acupuncture in chronic disease, including fibromyalgia. While a Brazilian study reported that FMS patients receiving the acupuncture had significant improvement in outcome measures, the patients in this study were also taking amitriptyline and encouraged to follow a basic exercise program. (43) A recently reported study showed that both sham acupuncture and traditional acupuncture were equally effective in reducing many domains of symptoms, suggesting a strong placebo effect. (44)

Chiropractic

Chiropractic therapy is based on the theory that a person's health is generally determined by the condition of the nervous system and its relation to the spine and the muscles. (33) Chiropractic care combines spinal manipulation with ultrasound, heat, massage, electrical stimulation and stretching. Some within the chiropractic community advocate chiropractic care as a cure-all for many if not all disease processes. One study in a small group of FMS patients demonstrated that chiropractic treatment improved range of motion at cervical and lumbar spine and in straight leg raises, (44,45) suggesting that some patients can benefit from this modality. Unfortunately, because of concerns with potential neurologic injury with neck manipulation, (46,47) this modality should not be given a blanket approval. (48)

Biofeedback 

Biofeedback is a method of consciously controlling a body function that is normally regulated automatically by the body, such as skin temperature, muscle tension, heart rate, or blood pressure. Through sensors attached to the patient's body, a monitoring device provides instant feedback on a specific body function related to relaxation levels. The therapist trains the patient in mental exercises to control certain body functions.

There are several types of biofeedback monitoring systems, including electromyography, peripheral/hand temperature, and electroencephalograph-driven stimulation. Electromyography-type biofeedback, or neurofeedback, uses a device that measures muscle tension while the person practices a relaxation technique, such as meditation, progressive muscle relaxation, or visualization. Electroencephalograph-driven stimulation utilizes brain activity toward a similar end. Peripheral temperature or hand temperature biofeedback measures the skin temperature of the hands while the person tries to increase it through visualization or guided imagery. By the therapist's directing the patient's thoughts, an increase in blood flow to the hands results in increased hand temperature.

In each of these modalities, the hope is that by training the patient to control certain activity levels within their own body they may, in turn, develop an improved sense of control over their physical and emotional reactions.

While the premise of improving patient control is a rational treatment goal, the data have not been conclusive or consistent. While some studies have shown clear benefits, (49) a more recent study showed no benefit when compared with fitness training. (50) One factor in this variable efficacy may be related to patient selection; Drexler et al (51) suggest that patients with increased underlying psychologic problems may not respond as well to biofeedback alone.

Further studies will need to be done to identify the appropriate patient for biofeedback, as well as which other therapies should be used conjunctively.

Hypnosis

One modality that has been shown effective in some patients refractory to other therapies is hypnotherapy. In a controlled study involving 40 patients considered to have "refractory fibromyalgia," a 12-week therapy program resulted in significant improvement; moreover, the improvement was seen at 24 weeks as well. (52) In some patients who have failed other behavioral therapies, this may be an option.

Dietary modification

The influence of dietary considerations in FMS patients is another area that has drawn much attention in the lay literature. Claims regarding certain food groups or additives as causing or exacerbating symptoms can be found in numerous books and Internet web sites. Unfortunately, far less information appears in the medical literature regarding this issue.

In one series of four patients, elimination of monosodium glutamate (MSG) and MSG plus aspartame from their diet resulted in complete resolution of their symptoms. The researchers postulated that there may be a subset of FMS patients whose symptoms may be a manifestation of "excitotoxin syndrome" and that a trial of "excitotoxin elimination" could benefit some patients. (53) The suggestion to avoid excitotoxins such as MSG or aspartame is likely a benign intervention, but there is a lack of further evidence to support this observation.

Strict dietary regimens have also been advocated. The use of a vegetarian diet has been suggested by some authors (54); it should be noted that most of the patients were overweight, raising the question of whether the weight loss, with its improved general health status, could have contributed to the favorable response. One group advocates a far more spartan vegan diet consisting largely of uncooked vegetables. (55) As a result of favorable response by 19 of the 30 women, the authors concluded that this dietary intervention may improve fibromyalgia symptoms. As with other alternative therapies, conflicting data is present in the medical literature. (56) At this time, there is insufficient evidence to recommend any dietary intervention other than what would be considered a healthy, nutritionally balanced diet in FMS patients.

Vitamins, minerals, herbals, and supplements

The lay literature and the Internet is rife with advertisements and "articles" expounding the benefits of dietary supplements. While the casual observer can readily see the numerous claims made about their products, most of the public overlooks the disclaimer "These statements have not been reviewed by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any illness," found in small print at the bottom of the page.

One popular class is the broad-spectrum pills with multiple vitamins and minerals, as well as extracts of various herbs. While anecdotal, testimonial evidence is provided, no controlled trials demonstrate their efficacy. A double-blinded, placebo-controlled study investigated one supplement promoted as a treatment for fibromyalgia. This supplement contains 36 ingredients, including vitamins, minerals, amino acids, and antioxidants. The researchers reported that after 6 months, patients taking the supplement did not demonstrate a significant difference from the placebo group. (57)

Because supplements are sold as dietary supplements, there is less scrutiny by government agencies, and one cannot be certain that the ingredients listed on the container are actually present. For example, an examination of Echinacea products currently available in stores showed a wide variety of quantities of the substance itself; in fact, 10% had no detectable Echinacea at all. (58) With such a range seen in products containing a single substance, one must question the contents of products reputed to contain dozens of substances.

Many of these products can be found in stores that specialize in "natural" or "complementary" therapies. As with the veracity of the products, those selling the products may make claims or suggestions that cannot be supported by any scientific evidence and may even lead to a worsening of the patient's health and well-being. (59)

Finally, the patient perception that something that is "natural" must be better and safer is pervasive today. Unfortunately, most of the public fails to learn of the large number of adverse effects resulting from use of dietary supplements. (60)

In short, while clinicians and patients use dietary supplements extensively for a variety of conditions, including fibromyalgia, there is no certainty that what they are taking will actually help or that the pill or capsule actually contains the advertised product. In most cases, the worst effect is on the patient's finances; in some cases, they can also adversely affect their health.

Conclusion

Many experts and clinicians argue over what the disorder known as fibromyalgia actually is; many practitioners become frustrated with the unsuccessful resolution of symptoms in their patients. All too often, much effort is focused on the pharmacologic treatment of FMS without including nonpharmacologic modalities.

An integrative approach, using exercise programs, good sleep hygiene techniques, and other interventions as needed may result in a better outcome in FMS patients. The approach must be individualized to each patient's clinical presentation, taking into account the patient's health status, anxiety/depression levels, home stress levels, and home situation. Modalities that include direct control by the patient may also prove beneficial in improving the outcome of an otherwise difficult and frustrating clinical condition.

Table 1. Suggestions and tips to improve sleep hygiene

 (1) The room should be free of distractions: No pets and no television.
     It should be enforced that the bedroom is not a study or family
     room.
 (2) The room should have a comfortable sleeping temperature and noise
     level. A "white noise machine" may help elicit a relaxation
     response and lessen external noise effects.
 (3) An established bedtime and awakening time must be maintained. This
     is based on the minimum amount of sleep the patient requires to
     function.
 (4) A "wind-down time" should begin 60 to 90 minutes before the
     designated bedtime. This is a time to begin to relax and "let go"
     of the day's events.
 (5) If the patient wishes to watch television before bedtime,
     stimulating programming and the news should be avoided. Reading
     choice should be light, avoiding books that are difficult to put
     down.
 (6) Some experts suggest writing down the cares or worries of the day
     in a journal 45 to 60 minutes before bedtime. Entries should be
     brief to avoid detracting from the relaxation time.
 (7) Preparation for the next day should either be done before the
     "wind-down time" or put off until the next day.
 (8) Deep breathing exercises can be done at bedtime: by focusing on
     breathing, the patient can draw attention away from distractions,
     allowing the muscles and mind to relax.
 (9) Avoid caffeine, nicotine, and alcohol. The latter may cause
     drowsiness but will disrupt the sleep cycle.
(10) Physical exertion or exercise should be completed several hours
     before bedtime.
(11) Daytime naps should be discouraged.
(12) No food ingestion within several hours of sleeping. Eating causes
     blood flow to be diverted to digestive activities rather than
     relaxation.
(13) Avoid clock watching. A patient unable to fall asleep within 15 to
     20 minutes of going to bed should get up and engage in relaxation,
     returning only when feeling sleepy. The goal of this is to avoid
     the association of tossing and turning, rather than sleeping, with
     the bedroom.
(14) The patient's mattress may be an issue. A soft surface is
     recommended to support the body comfortably.
(15) Some sleep centers advocate at least 40 minutes of strong light
     exposure after arising.

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Christopher R. Morris, MD, FACR, Laraine Bowen, PA-C, and Alton J. Morris, MD, FACP 

From Arthritis Associates, Kingsport, TN.

Reprint requests to Dr. Christopher Morris, 3 Sheridan Square. Kingsport, TN 37660. Email: [e-mail]