Exercise and antidepressants improve fibromyalgia

Journal of Family Practice, April, 2004 by Anna Quisel, James Gill, Dene Walters

Muscle relaxants (primarily cyclobenzaprine) and nonsteroidal anti-inflammatories have been studied, with no evidence of a positive effect. (51) Thus, the best evidence currently supports the use of aerobic exercise and antidepressants, particularly tricyclics, for the treatment of fibromyalgia.

* INSTRUCTIONS TO PATIENTS, MANAGEMENT FOLLOW-UP

Persons with fibromyalgia should know that although specific symptoms, particularly pain, may be not be dramatically reduced with treatment, aerobic exercise and tricyclic antidepressants alleviate some symptoms with minimal adverse effects (SOR: A). Emphasize that these treatments have been shown to improve one's ability to cope with fibromyalgia symptoms. The best-studied antidepressant for treating fibromyalgia is amitriptyline, usually given at 25 to 50 mg, nightly.

Exercise. Prescribe aerobic exercise, at least twice per week for 20 to 60 minutes, targeting a heart rate of 55% to 90% of the predicted maximum (180 beats per minute-age) (SOR: A). One caveat: aerobic exercise in the literature was usually supervised, so the ideal exercise regimen might be a fibromyalgia-specific program.

Medication. Consider a trial of amitriptyline, 25 to 50 mg every night, for up to 6 weeks (SOR A). A caveat: tricyclic antidepressants may also have significant side effects, which could outweigh moderate benefits. Moreover, treatment effectiveness beyond 2 months has not been proven. Therefore, longitudinal measurement of outcomes should be part of ongoing care.

Follow-up. Studies have not determined which measures are best to follow (see "Assessing treatment efficacy"), but they might include the following (SOR: C):

1. Pain (eg, visual analogue scale, pain drawings)

2. Number of tender points, and tenderness

3. Physical function (eg, cardiorespiratory fitness, self-reported physical function measured by the physical-impairment subscale of the FIQ, (56) strength)

4. Global well-being or perceived improvement (eg, physician-rated change, FIQ total score)

5. Self-efficacy (eg, Arthritis Self-efficacy Questionnaire)

6. Fatigue and sleep (eg, FIQ fatigsubscale, sleep visual analogue scale)

7. Psychological function (eg, FIQ subscales for depression and anxiety)

8. Ability to work

9. Health care consumption and costs. (47,50)

Education or psychological coping strategies may also contribute positively to overall patient and family well-being. Consider education/ psychological counseling (SOR: C) and acupuncture (SOR: B).