46. Acupuncture and Fibromyalgia

News Letter, Vol. 4 (10), October, 2012, © Copyright

 

Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.

Robert Blizzard III, DPT

www.drxuacupuncture.co

Rehabilitation Medicine and Acupuncture Center

1171 East Putnam Avenue, Building 1, 2^nd Floor

Greenwich, CT 06878

Tel: (203) 637-7720

Fax: (203)637-2693

Fibromyalgia

Helen is a 46 years old female, who complains of pain all over the body for about one year. Her husband lost his job about one year ago and has tried his best to find one.  However, he has had no such luck. Helen started to worry about her family financial situation and very often could not sleep well. She always feels sluggish as sleep is not replenishing her energy. She wake up feeling very stressed out and moody and worrying about everything.  She gradually developed pain all over the body, feeling tenderness at symmetric points, such as neck, upper back, shoulders, elbows, middle back, low back, hip, knee and calf. The pain is getting worse, now even moderate touch could make her feel pain. She was forced to move out of her house because she was unable to pay her mortgage and moved in an apartment recently. This made her symptom worse,  she went to her primary care physician, who checked her blood work, chest x-ray and EKG, all were normal, and  prescribed Ambien and pain medication, such as Oxycodone, she felt temporarily  relief, however, she had constipation, headache, sometimes diarrhea, felt very tired when waking up. Because the symptoms were getting worse, therefore, she came to me for evaluation  and treatment.

Upon examination, she looked very tired and fatigue, spoke with a low tone, she was found to have many tender points along the spine, chest ribs, shoulders, elbows, hips and knees, when she was touched by my fingers.

This patient might have fibromyalgia, a common syndrome, most often occurring in middle age women.  Symptoms are long-term, body-wide aches, pains and tenderness.  Typically symmetric in the joints, muscles, tendons, and other soft tissues, very often with accompanying fatigue, depression, insomnia, and anxiety.

Causes

The cause is unknown. Possible causes or triggers of fibromyalgia include:

1. Genetics: the mode of inheritance is currently unknown, but it is common to see patients in one family, especially mother and daughter.
2. Stress: an important precipitating factor, Fibromyalgia is frequently found with stress-related disorders, such as chronic fatigue syndrome, posttraumatic stress syndrome, irritable bowel syndrome, and depression.
3. Physical or emotional trauma
4. Poor sleep.

Among the above possible causes, the most important are stress and poor sleep,   stress and poor sleep make a noxious cycle: Stress causes poor sleep, poor sleep enhances stress, both stress and poor sleep make muscles unable to relax, for a long time period, the muscles nerve get chance to relax, then it twists together and forms the tender points and bends, which are symmetric and long term.

Fibromyalgia is most common among women aged 20 to 50.

Symptoms-Pain

Widespread pain, fatigue, and severe pan in response to light pressure, numbness and tingling sensation, muscle spasm and weakness in all 4 extremities, nerve pain, muscle taut band, twitching, chronic sleep disturbances, and irritable bowel syndrome.

Fibromyalgia patients tend to wake up with body aches and stiffness, pain improves during the day and gets worse at night. Some patients have pain all day long. Pain may get worse with activity, cold or damp weather, anxiety, and stress.

Fatigue, depressed mood, and sleep problems are seen in almost all patients with fibromyalgia. Many say that they can’t get to sleep or stay asleep, and they feel tired and stiffness when they wake up.

Many patients experience impaired concentration, poor memory, inability to multi-task, poor attention span, anxiety and depression.

The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia New Diagnostic Criteria and measurement of symptom severity.

Arthritis Care Res (Hoboken). 2010 May;62(5):600-10.

The new criteria keep the requirements that other causes be ruled out and that symptoms have to have persisted for at least 3 months.  They also includes 2 new methods of assessment, the widespread pain index (WPI) and the symptom severity (SS) scale score.

The WPI lists 19 areas of the body and you say where you’ve had pain in the last week.  You get 1 point for each area, so the score is 0-19.

                                                                         http://www.home-health-care-physical-therapy.com/Fibromyalgia-Tender-Points.html

For the SS scale score, the patient ranks specific symptoms on a scale of 0-3.  These symptoms include:

• Fatigue
• Waking unrefreshed
• Cognitive symptoms
• Somatic (physical) symptoms in general (such as headache, weakness, bowel problems, nausea, dizziness, numbness/tingling, hair loss)

The numbers assigned to each are added up, for a total of 0-12.

This next part is really interesting to me.  Instead of looking for a hard score on each, there’s some flexibility built in, which recognizes the fact that fibromyalgia impacts us all differently, and that symptoms can fluctuate.

For a diagnosis you need EITHER:

1. WPI of at least 7 and SS scale score of at least 5, OR
2. WPI of 3-6 and SS scale score of at least 9.

Treatment

The goal of treatment is to improve impaired function, help a person mentally and physically cope with the symptoms, and to help relieve pain and other symptoms,

The first type of treatment may involve:

• Physical therapy
• Exercise and fitness program
• Stress-relief methods, including light massage and relaxation techniques

Physical Therapy is aimed at treating the disease consequences of fibromyalgia including pain, fatigue, deconditioning, muscle weakness and sleep disturbances among others.

Modalities such as ultrasound and TENS machines will help reduce localized and generalized musculoskeletal pain in fibromyalgia patients.

Massage is great to reduce muscle tension and spasms which prevent efficient muscle motion.  Techniques such a joint mobilizations and deep tissue massage prescribed with other therapeutic interventions such as stretching will help your muscles more effectively.

Physical Therapy consult is very beneficial to address sleeping disturbances affecting about 80% of all patients.  Positioning while sleeping and relaxation techniques prior to sleeping can help correct this serious problem.

Fitness machines such as exercise bikes or elliptical machines will improve important measures of cardiovascular fitness, subjective and objective measures of pain.  Also improving is subjective energy levels, work capacity along with physical and social activities.

Focusing on core stability will reduce overloading of the muscle system by supporting the muscles of your spine.  There is a great impact on conditioning weak muscles for improving postural fatigue and positioning.  With a strong core, your body will have a stable, center point.

There is great evidence based research for Whole Body Vibration use on patients with fibromyalgia.  A 6-week study published in 2008, in The Journal of Alternative and Complementary Medicine, by Alentorn-Geli et al reports that WBV safely reduces pain and fatigue while also improving physical function in patients with fibromyalgia.  Here at Rehab Medicine & Acupuncture Center, we have been using this evidence based device in successfully treating symptoms of fibromyalgia.

Another study looking at the benefits of WBV with fibromyalgia performed by Sanudo et al in 2010 was published in Clinical and Experimental Rheumatology. This study examined women with fibromyalgia performing exercise training 2 times a week along with WBV three days a week compared with an exercise only group over a 6-week period with a focus on strength and quality of life.  Significant improvements in all outcomes measured were found from baseline in both groups though additional health benefits were observed with the supplementary WBV.

The second line of treatment is medications, such as antidepressant or muscle relaxant in order to improve sleep and pain tolerance, Duloxetine (Cymbalta), Pregabalin (Lyrica) and Milnacipran (Savella) are very often prescribed.

However, many other drugs are also used to treat the condition, including:

• Anti-seizure drugs
• Other antidepressants
• Muscle relaxants
• Pain relievers
• Sleeping aids

Cognitive-behavioral therapy is an important part of treatment. This therapy helps you learn how to:

• Deal with negative thoughts
• Keep a diary of pain and symptoms
• Recognize what makes your symptoms worse
• Seek out enjoyable activities
• Set limits

Acupuncture treatment for Fibromyalgia

Acupuncture points mainly are selected from meridians of Tai Yang and Sao Yang, plus cupping.

UB9 Yuzhen, UB16 Dushu, UB18 Ganshu, UB23 Shenshu, Ren6 Qihai, Du20 Baihui, GB13 Bensheng, GB21Jianjin, GB34 Yanglingquan, LI15 Jianyu, ST 36 Zusanli, Sp8 Diji, Ki8 Jiaoxin, UB59 Fuyang, Arshi, etc.

 

Helen’s Treatment:

Helen underwent our treatment about 3 months. I first helped her improve her sleep. According to Chinese Medicine, the key factor was sleep, if the patient can have better sleep, her noxious cycle will be broken, and along with her improvement of sleep, her muscles was gradually relaxed and her pain was gradually reduced. She also was encouraged to have physical therapy to improve her functional abilities and join the entertainment activities,  she had difficulty playing tennis at beginning, after a few treatments, her performance of tennis was getting better, and after all the treatment for three months,  her pain is almost gone and quality of life is much better.

Tips for patients:

1. Keep a peaceful mood, and you have to realize that your worrying does not take away your stress, but adds stress to you.
2. Try to get a good sleep nightly, take hot shower before go to bed and avoid TV in order to have a nice sleep routine.
3. Massage sleep points 5 mins before you go to bed.
4. Force yourself  to attend the entertainment activities

Tips for Acupuncturists:

1. Try to help patients to have good sleep by selecting Baihui, An Mian, etc.
2. Try to help patients to have stress reduction by selecting Shen Men, Shen Shu, etc.
3. Encourage patients attend all the activities.
4. Cupping along UB meridian is very helpful.