As a medical doctor working in the field of rehabilitation medicine, I have for the last 10 years seen fibromyalgia patients almost on a daily basis. I have seen first hand how the pain, fatigue, sleep problems and other symptoms of fibromyalgia reduce function and quality of life. In this article you will learn what lifestyle treatments to focus on to reduce pain, fatigue and other symptoms of fibromyalgia.
What is fibromyalgia?
Two to four percent of the adult population suffer from fibromyalgia. The condition is usually invisible to others, but so limiting and troublesome for the person who suffers from it.
The most common feature of fibromyalgia is chronic widespread pain. For some, even light touch is uncomfortable and painful.
In addition to pain, other common symptoms include
- Fatigue
- Reduced sleep or sleep quality
- Mild cognitive dysfunction
- Abdominal symptoms / irritable bowel syndrome
- Depression and/or anxiety
The pain in fibromyalgia
The pain in fibromyalgia is mainly caused by changes in pain processing in the central nervous system, called central sensitization. Due to processes and mechanisms that we do not yet fully understand there is increased processing of pain stimuli from to the brain, while there is less physiological suppression of pain stimuli. In other words, a stronger «gas pedal» and weaker «brakes».
This may cause people to have hyperalgesia, that is increased pain response, or allodynia that is pain just from light touch.
The pain in fibromyalgia may be worsened by both internal and external factors, including stress and weather changes. When the weather is changing from high barometric pressure or sunny weather to low barometric pressure or rainy weather the fibromyalgia pain can worsen.
Treatment of fibromyalgia
Fibromyalgia is best treated with a broad approach where lifestyle and other non-drug therapies play an important role. Most people with fibromyalgia prefer non-drug therapies because the medications have limited effect and often unwanted side effects. For this reason it is important to know how to apply lifestyle treatment and other non-drug therapies effectively. For the rest of the presentation we will therefore explore what these treatments consist of and how to make the best use of them. Much can be done to improve fibromyalgia and a broad or multi modal approach often gives the best result.
Treatment goals
The general treatment goals of fibromyalgia are
- Reduce pain
- Improve sleep
- Reduce and cope with stress
- Improve and maintain functional ability and for as many as possible also improve work ability
This is often best achieved in a rehabilitation program extending over several weeks, where experienced doctors, physical therapists, psychologists and other allied health professionals work together for you reaching these goals.
Physical activity – general effects relevant to fibromyalgia
Physical activity is the only treatment that has a strong recommendation, which is based on the strong evidence that regular physical activity can reduce symptoms of fibromyalgia.
Physical activity has effect on many aspects of health and should be of particular interest to people with fibromyalgia
- Increased energy and quality of life
- Increased optimism and courage
- Increased impulse control
- Improved mental health (depression, anxiety)
- Improved cognitive function
- Improve sleep
- Reduced symptoms of stress
- May reduce symptoms of irritable bowel syndrome
Thus, regular physical activity improves all of the common symptoms or aspects of fibromyalgia, including pain, fatigue sleep problems, stress, cognitive function and mental health issues, as well as abdominal symptoms. However it is important not to overdo physical activity as it may increase symptoms.
Physical activity for fibromyalgia
As mentioned, physical activity is the only treatment with a “strong recommendation” and will over weeks and a few months reduce pain, stiffness and fatigue in many.
However, pain may often increase in the beginning of an exercise program. Typically will fibromyalgia patients at the rehabilitation where I work have increased pain in the first week or weeks of their stay.
One of the signs to be aware of is fatigue. If exercise increases your fatigue, particularly for several days after exercising it is recommended to reduce the amount of physical activity.
You may want to start with short, low intensity exercise (walking) and gradually over weeks and months increase the frequency of training, length of each training session and in the end also increase the intensity of your physical activity.
There is most evidence for endurance training, but resistance training has also shown positive effect on fibromyalgia symptoms. Swimming in a warm water pool is one of the best exercises for fibromyalgia.
On the other hand, being completely inactive tends to increase pain and stiffness.
Pacing and cognitive behavioral therapy
In my 10 years of experience treating fibromyalgia, one of the biggest challenges a person with fibromyalgia related fatigue has, is to accept and take into account the fatigue.
The person will often try to just pull themselves together and hope that things will go well. However this strategy tends to worsen the fatigue and other symptoms after a while. This is why pacing or activity management is so important part of managing fibromyalgia. In my experience, people with very heavy symptoms, particularly fatigue, do not balance activity and rest satisfactory, or they may have ongoing exacerbating factors. More on this later.
How we think about our health challenges may also influence fibromyalgia symptoms. Cognitive behavioral therapy has sown to reduce pain, improve mood and also quality of life among people with fibromyalgia.
Exacerbating factors
People with fibromyalgia often suffer from exacerbating factors including mental health issues, such as anxiety or depression. In addition many experiences a great amount of stress and sleep problems. Addressing these exacerbating issues may help reduce pain and fatigue.
In addition there may be additional causes of fatigue among people with fibromyalgia related fatigue. Detecting and addressing possible deficiencies such as vitamin B12, vitamin d and iron deficiencies, or common fatigue related conditions such as endocrine diseases may improve fatigue.
Fibromyalgia and stress
Long lasting stress, be it mental, physical or soscial stress, is often one of the factors that causes development of fibromyalgia.
Fibromyalgia is further a condition where stress may aggravate symptoms to a larger extent than other medical conditions. Of the common pain conditions stress increases pain much more among people with fibromyalgia than for example people with rheumatoid arthritis.
People react and tolerate stress differently. Hans Selye wrote that “Stress is not only about what happens to the individual, but also how the individual reacts to stress“. Some people have love toleranse to stress while other people have less bodily reaction to stress. To some extent people can increase resilience to stress.
There are many types of stress, including
- Social stressors: Loneliness, challenging relationships, abuse
- Emotional stress: Fear, bitterness, frustration, sadness, anger
- Job related stress: Time pressure, scarcity of resources, efficiency requirements, downsizing, unclear management, frequent changes.
- Physical stress: Noise, physical overload
It is essential that we are aware of the stressors so that we may address stress effectively.
Effects of stress
We are probably all familiar with how stress may influence us.
- Physical effects: Muscle tension and abdominal symptoms as well as increased heart rate and blood pressure.
- Mental effects: Increase in mental symptoms including anxiety and depression, and even post traumatic stress syndrome if the stress has been severe enough.
- Cognitive effects: Memory and attention are reduced, in addition to reduced learning ability
- Behavioral effects: Most visible to other people are behavioral effects of stress. We tend to be more easily irritated, frustrated, angry and impulsive, and also tend to adapt to a less healthy lifestyle under stress.
Reducing and managing stress
How do we best manage stress? As far as possible try to address the cause of stress as far as possible. There are many techniques that may reduce stress, but they may not always address the underlying reason for us being stressed.
- Pacing is probably the most important stress reducing tool if we constantly do more than what the body tolerates.
- If we tend to react with anger in traffic situations it may be a good strategy to work on impulsivity and thought habits.
- Forgiveness is an effective treatment for stress due to bitterness.
- Social stressors, such as challenging family relationships may be best dealt with through improving communication or setting limits.
- Financial stress does not go away with deep breathing or yoga. Seek professional help, create a budget and try to address the root cause of financial stress.
Reducing stress and increasing resilience
In addition to addressing the cause of tress as much as possible, there are other things we can do to reduce stress symptoms and increase stress resilience, such as
- Regular physical activity, preferably outdoors where we are exposed to daylight and nature.
- Be more in the present, not living with worries for tomorrow and remorse for yesterday. Watch children and pets, they are experts at being in the present
- Remember to relax, rest and get enough sleep. Like the jews and adventists try to take a whole day off, not just from work, but from everything that stresses you and focus on the most important and foundational aspects of life to get grounded before next week begin.
- Good social connections is vital for good mental health,
- Good nutrition
- Peace of mind, with a good conscience, and an outward focus is a stress releiver.
- Also try to include laughter, joy and a bit of humor into life. Laughter has shown to reduce stress within minutes.
Fibromyalgia and sleep
Reduced sleep is a common problem in fibromyalgia. Sleep is important for physical and mental health as well as for optimal cognitive function.
Studies have shown that people with fibromyalgia have
- Reduced sleep quality
- Unrefreshed sleep
- More frequent awakenings during night
- Spend more time awake in bed
- Less deep sleep
Lifestyle factors that affect deep sleep
Deep sleep is vital particularly for physical restoration and for feeling refreshed when waking up in the morning. There are several lifestyle factors that affects deep sleep. Watch this short video for more information about what factors improve or reduce deep sleep.
Improving sleep
As it goes for stress, so also for sleep issues. Try to address the cause of the sleep problem as far as possible. One of the most common cause of insomnia is mental health issues such as depression, anxiety or stress. In addition, pain is often a factor that prevents people with fibromyalgia to have poor sleep.
The most effective general sleep therapy is cognitive behavioral therapy for insomnia, where one of the core components is sleep restriction therapy.
It is a demanding but effective treatment and the strategy aims to increase sleep pressure.
If you sleep 5 hours a night you will start the treatment by going to bed 5 hours before the time you get out of bed in the morning. For example, you go to bed at 2 AM if you plan to get out of bed at 7 AM. When you sleep about 80-85% of the time you stay in bed, for a whole week, you go to bed 15-20 minutes earlier the next week. Slowly your body adapts and sleep more efficiently. As the weeks go by and the sleep improves you go earlier to bed.
This particular therapy has shown effects also in fibromyalgia with increased sleep quality, less pain, anxiety and depression.
Maintaining a good sleep hygiene
In addition to the other sleep measures mentioned earlier, it is always important to take care of the circadian rhythm by getting up and going to bed at approximately the same time every day. Get some exposure to daylight, preferably early in the day and avoid sleeping during the day.
Towards bed time reduce activating activities such as
- Avoid coffee and caffeine
- Do not use alcohol and tobacco close to bedtime
- Avoid large meals before bed
- Avoid strenous physical exercise the last hours before bedtime
- Avoid exposure to blue light (screen) the last hours before bedtime
- Keep the bedroom dark and quiet
Fibromyalgia and nutrition
When it comes to nutrition and fibromyalgia there is not yet enough evidence to make strong recommendations about specific foods or diet.
The best evidence is for using a low FODMAP diet for treating irritable bowel syndrome, a common condition among people with fibromyalgia. The diet is not a diet per se, but consists of excluding certain foods that have carbohydrates that tend to more easily cause fermentation in the digestive system.
For other foods, nutrients and diets there is mixed, weak or limited evidence.
After following the science and research on lifestyle and fibromyalgia for a while, there seems to be some evidence that vitamin D deficiency may aggravate fibromyalgia symptoms and that vitamin D supplemenation may improve symptoms. There is also some evidence that a plant based diet and diets for weight loss may reduce fibromyalgia symptoms.
Conclusion – lifestyle treatment of fibromyalgia
In conclusion, fibromyalgia is a condition with altered pain processing, with additional symptoms, commonly fatigue, reduced sleep, brain fog, mental health challenges and abdominal symptoms.
The most effective lifestyle treatment include
- Physical activity: Regular physical activity, preferably gradual increase over time.
- Activity management: If you suffer from fatigue, find a good balance between activity and rest. Doing more than the body tolerate will over time increase symptoms and make the condition worse.
- Manage and treat sleep difficulties, stress and mental health issues may cause people with fibromyalgia to have less pain and fatigue.
- Nutrition: Aim for a balanced, generally healthy diet. Avoid deficiencies.
In addition to lifestyle and other non-drug treatments there are several medications that may help to reduce pain, sleep problems and other symptoms of fibromyalgia.
Talk to your doctor if you do not experience satisfactory effect of the lifestyle and non-drug strategies presented here.
References
- Maleki, Behzad Hajizadeh, et al. “Low-to-moderate intensity aerobic exercise training modulates irritable bowel syndrome through antioxidative and inflammatory mechanisms in women: results of a randomized controlled trial.” Cytokine 102 (2018): 18-25. https://www.eular.org/myUploadData/files/2016_Mgt_Fibromyalgia_lay_summary.pdf
- https://www.eular.org/myUploadData/files/2016_Mgt_Fibromyalgia_lay_summary.pdf
- Katz, Robert S. “The Types of Stress That Appear to Aggravate the Symptoms of Fibromyalgia.” ARTHRITIS & RHEUMATOLOGY . Vol. 69. 111 RIVER ST, HOBOKEN 07030-5774, NJ USA: WILEY, 2017.
- Sandi, Carmen, and József Haller. “Stress and the social brain: behavioral effects and neurobiological mechanisms.” Nature Reviews Neuroscience 16.5 (2015): 290-304.
- https://www.mentalhelp.net/stress/emotional-impact/
- https://www.sleepassociation.org/about-sleep/stages-of-sleep/deep-sleep/
- https://www.sleep.com/sleep-health/too-hot-to-sleep
- Climent-Sanz , Carolina, et al. ” Cognitive behavioral therapy for insomnia ( CBT-i ) in patients with fibromyalgia : a systematic review and meta-analysis .” Disability and Rehabilitation (2021): 1-14.
- Silva, Ana Rita, et al. “Dietary interventions in fibromyalgia: a systematic review.” Annals of medicine 51.sup1 (2019): 2-14.
- Tomaino , Laura, et al. “Fibromyalgia and nutrition: An updated review.” Journal of the American College of Nutrition 40.7 (2021): 665-678.
- Qu, Kang, et al. “The efficacy of vitamin D in the treatment of fibromyalgia: a meta-analysis of randomized controlled studies and systematic review.” Expert Review of Clinical Pharmacology just-accepted (2022).
