Fibromyalgia (FM) is a rheumatologic disease that causes chronic, diffuse musculoskeletal pain. It can be associated with numerous other symptoms with generalized features such as fatigue, sleep disturbance, and psychological features such as depression and mood disorders. The pathophysiology of fibromyalgia is not completely understood, however current evidence indicates either an alteration in the processing of stimulus in the central nervous system or dysfunctional central pain modulation.
Currently, pharmacologic therapy is the main modality used to treat chronic pain. Numerous drugs and treatment regimens are in use albeit with a low response in patients. Pharmacological drugs prescribed commonly are opioids, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, painkillers, and antidepressants.
Therefore, the focus has shifted from current therapeutic options to exploring and developing new biological compounds from natural products and related products to treat fibromyalgia.
Alternative treatment options
Use of Medical Plants and Related Natural Products in the treatment of fibromyalgia
A systematic review of randomized controlled trials (RCTs) was conducted to compare the use of herbal preparations as opposed to standard treatment or placebo . The medicinal compounds used in the treatments were capsaicin, nabilone, the compound O24, Modified Meta050, and coenzymeQ10. All the patients in these trials were included based on the diagnostic criteria of fibromyalgia established in 1990 by the American College of Rheumatology and actualized for Wolfe et al. (2010).
Two studies were reviewed that investigated the effects of capsaicin (a compound obtained from chili peppers). The first RCT was conducted on 108 patients testing locally applied capsaicin (0.075%) in fibromyalgia patients. Its efficacy was then compared with that of the standard treatments received by the control group. The patients were then assessed according to pain and other factors such as body mass index (BMI) several physical symptoms, myalgia score, pressure pain threshold, pain, fatigue, anxiety, and depression. At the end of the therapy, both groups showed an overall improvement resulting in a decrease in pain, improvement in physical function, and sleep, and fatigue. Six weeks after concluding the trial, those who applied topical capsaicin still showed significant improvement in several clinical outcomes when compared to the controls.
The other double-blinded RCT investigated the effects of 0.025% topical capsaicin in the treatment of fibromyalgia, comparing the results against the group treated with a placebo cream. Out of the randomly assigned forty-five patients, half were treated with topical capsaicin while the other half were given placebo cream. Following four weeks of double-blinded treatment, the patients were assessed for pain, stiffness, and sleep disruption. Patients treated with capsaicin reported significant improvement of sensitivity and pain but did not record any improvement in the quality of sleep.
An RCT that investigated the effects of oral nabilone, a synthetic cannabinoid, was also reviewed. The trial was randomized, double-blinded, and placebo-controlled and aimed at determining the benefit of nabilone in pain management and life quality improvement in patients with fibromyalgia. Forty patients were randomized and received nabilone or an equivalent placebo, and reassessed after four weeks for pain and number of tender points. In 4 weeks there were no significant improvements in the placebo group, however, there were significant decreases in pain and anxiety in the nabilone-treated group. Based on the RCT, it can be concluded that Nabilone is a beneficial and well-tolerated treatment option for fibromyalgia patients.
The O24 Pain Neutralizer is a natural pain relief solution that contains camphor oil (white), eucalyptus oil, Aloe vera oil, peppermint oil, rosemary oil, lemon oil, and orange oil. This was investigated by a double-blinded placebo-controlled trial study with 153 subjects. The patients were randomized and trained in the application of O24 oil or placebo oils, (peppermint oil identical in smell and appearance) every four hours as needed for pain. After four weeks, patients were assessed for pain, tender point, and strength. Improvements were noted in the visual analog scale night pain rating with topical O24.
Meta050 is a proprietary standardized combination of reduced iso-alpha acids from hops, rosemary extract, and oleanolic acid. This was investigated for its possible effects on pain in patients with fibromyalgia. Fifty-four patients received 440mg of Meta050 three times a day for four weeks, which was increased to 880mg twice a day for the following four weeks in the majority of patients. Pain and specific symptoms were recorded utilizing the Abridged Arthritis Impact Measurement Scale (AIMS2) and the Fibromyalgia Impact Questionnaire (FIQ). Fibromyalgia patients demonstrated some improvement in pain; however, the decrease in pain did not reach significance until after eight weeks on the supplement.
The subjective effects of coenzyme Q10 combined with a Ginkgo biloba extract were investigated with an open clinical trial. For this 23 subjects received oral doses of 200mg coenzyme Q10 combined with 200mg Ginkgo biloba extract. The patients were then assessed for quality of life after twelve weeks of treatment. Out of those who completed the trial, 68% mentioned that they would like to continue with the treatment. The overall subjective views of the patients, regardless of the quality of life scores, were that the majority (64%) felt the treatment was beneficial.
In the randomized clinical trial, 230 adults with fibromyalgia received one of three treatments in small groups of patients, each of which was provided for eight weekly sessions. The tested therapy which was known as Emotional Awareness and Expression Therapy (EAET), helped the subjects recognize that changeable neural pathways associated with emotions affected pain and other symptoms. EAET assisted patients to process emotional experiences, learn how to adaptively express important feelings, and empowered people to be straightforward in relationships. Patients who underwent EAET showed positive results with reduced pain, physical impairment, along with reduced attention and concentration problems, anxiety, and depression, than patients who received the education intervention.
Electronic databases (up to June 2013) were searched to identify relevant studies for a systematic review to evaluate the evidence of the benefits of massage therapy for patients with fibromyalgia. Nine randomized controlled trials involving 404 patients met the inclusion criteria for the review. From the meta-analyses, it could be concluded that massage therapy, with a duration of ≥ 5 weeks, could significantly improve pain.
A systematic review with 16 quantitative studies was conducted to investigate the effect of sleep on fibromyalgia. It was identified from the results of the review that chronic and increased pain was associated with reduced sleep quality, efficiency, and duration as well as increased sleep disturbance and total time awake. It also showed an association between depressive symptoms and both pain and sleep in patients with fibromyalgia. Therefore, it can be concluded that improving sleep quality should be a part of the management strategy for fibromyalgia.
Aerobic exercise training
Randomized controlled trials (RCTs) were chosen that compared aerobic training interventions (a dynamic physical activity that increases breathing and heart rate to submaximal levels for a prolonged period) to either no exercise or another intervention of adult patients with fibromyalgia. Out of the 13 RCTs assessed with a total of 839 people, it could be concluded that aerobic exercise may slightly decrease pain intensity and slightly improve physical function, and is well tolerated.