Non-pharmacological treatment for Fibromyalgia : Complementary/Alternative treatment may be your first choice…

Valerie Aloush M.D. 
Fibromyalgia Clinic, Department of Rheumatology, Tel Aviv Sourasky Medical Center, Israel

Fibromyalgia (FM) is a complex syndrome characterized by chronic widespread pain, sleep disturbances, fatigue and cognitive impairment, associated in some cases with anxiety and depression. FM affects quality of life in many aspects (personal, familial, social and professional) and remains a therapeutic challenge. Comprehensive treatment of this condition aims not only to alleviate pain but rather needs a holistic approach to address both physical and psychological symptoms; to treat pain and functional consequences of pain. In this regard, non-pharmacological interventions have been shown to be effective, most of them with low cost and high tolerability. 
Education is the first required step to ensure adherence and compliance to treatment program. Understanding fibromyalgia, its causes, natural history, and treatment options leads to better coping and improved outcomes. Validation of the diagnosis of FM also helps reducing health-related anxiety.

Low-intensity aerobic exercise training, starting gradually, has been shown to improve health-related quality of life (HRQOL), decrease pain intensity and improve physical function. Aquatic training is beneficial for improving wellness, symptoms, and fitness in adults with fibromyalgia. Exercise training (exercise performed against a progressive resistance) may improve function, pain, tenderness and muscle strength in women with FM. 

Meditative movement therapies (MMT) - involving core elements of specific movements, meditative instruction and breath regulation- are considered as a complex intervention integrating concepts of mind and body, with physical, emotional and spiritual aspects. In recent years, there is abundant literature reporting benefits of MMT in various chronic pain conditions, including fibromyalgia. 
Qi Gong and Tai Chi have shown significant improvement regarding pain, sleep disturbances, fatigue, depression and HRQOL. Better outcomes are obtained when MMT is practiced daily, which may be challenging for FM patients. One recent study has shown that Tai Chi improves cardiac autonomic function, sympatho-vagal balance, pain, fatigue, strength and flexibility in women with fibromyalgia. Another study shows that Yoga may modulate abnormal pain processing in fibromyalgia, demonstrated by improvements in heat pain tolerance and pressure pain threshold.
Balneotherapy (BT) (treatment based on thermal mineral water from natural springs) and hydrotherapy (HT) (normal water) are additional alternative interventions usually recommended in the management of FM. Studies of BT and HT in FM patients have shown improvement on pain and HRQOL, with no significant effects on depressive symptoms. How these therapies may improve FM symptoms is not fully understood, but effects on pain alleviation may be explained by hydrostatic pressure and effects of temperature on the nerve endings, as well as by muscle relaxation. 

Cognitive Behavioral Therapy (CBT) aims to reinforce self-efficacy in managing symptoms of FM and plays a central role in the non-pharmacological management of FM. CBT improves physical functioning and pain, and reduced catastrophizing, by improving pain-related brain responses, as demonstrated in functional MRI studies. Other complementary and alternatives therapies that have demonstrated clinical benefit on symptoms of FM include hypnosis/ guided imagery, biofeedback and acupuncture. Brain neuromodulation constitute promising therapeutic options for FM patients, although current use is still limited by low availability and high costs. Optimal management of FM patients requires an integrated multidisciplinary approach beyond pharmacologic therapy, including education, exercise, psychological and complementary interventions, that must be tailored according to symptoms, patient's preferences and financial resources in order to ensure adherence to the treatment program as well as for improving outcomes.