Fibromyalgia is a complex and disabling condition with no precise etiology or definitive medical treatment. Research suggests that the condition is related to central nervous system dysfunctions, neuropeptide action, and hypothalamic-pituitary-adrenal axis abnormalities. It is a common condition affecting 1% to 2% of the population with a majority (80%) of female patients. An estimated 25% of patients in some rheumatology practices suffer from fibromyalgia. Many patients are unable to work and estimates suggest that private insurers in Canada pay more than $200 million per year in disability claims for fibromyalgia.

The American College of Rheumatology’s criteria for the diagnosis of fibromyalgia are a history of widespread musculoskeletal pain for at least 3 months and pain in 11 or more of 18 specific tender point sites.[1] Patients are also known to have numerous and varied complaints, including chronic fatigue, sleep difficulties, cognitive impairment, irritable bowel syndrome, premenstrual symptoms, irritable bladder, parasthesias, and psychological distress.[2] Some patients have significant fatigue and their diagnoses overlap with chronic fatigue syndrome. Surveys suggest that 66% to 99% of patients with fibromyalgia are using at least one complementary therapy such as acupuncture or massage because pharmacologic therapies provide insufficient relief of symptoms and are not curative.[3,4] There is a limited amount of high-quality evidence on the effectiveness of acupuncture in the treatment of fibromyalgia.[5] One randomized controlled trial[6] demonstrated that fibromyalgia patients receiving real acupuncture fared significantly better than patients receiving sham acupuncture.

Combining acupuncture and counseling

After training in acupuncture with the Acupuncture Foundation of Canada Institute (AFCI), I used the institute’s acupuncture protocol for fibromyalgia on 24 fibromyalgia patients in my practice. The protocol was developed by AFCI director of education Dr Sona Tahan and is based on research in Shanghai on acupuncture and fibromyalgia. The points were selected according to Chinese medicine theory. The 24 fibromyalgia patients in my treatment group were diagnosed by their rheumatologist or family physician and referred to me for treatment with acupuncture because of patient interest in acupuncture, and often as a last resort after failure to improve with medical treatments. As acupuncture is not covered by BC’s Medical Services Plan, patients either paid privately or used their extended health benefits to pay for treatment.

Patients received 12 weeks of acupuncture treatment at identical acupuncture points in the same sequence.[7] Four sets of points were used in a 4-week cycle:

• GV 14, UB 23 
• GV 4, UB 20
• CV 6, SP 10 
• UB 13, UB 17

Patients were seen for 30-minute sessions and treated twice weekly with each set of points. Each 4-week cycle was repeated three times, with a 1-week to 2-week interval between cycles. Acupuncture needles were inserted for 15 minutes and moxibustion was used to warm the needles for 10 minutes. Moxibustion involves holding a stick of gently smoldering moxa (a herbal agent) 1 cm to 2 cm from the acupuncture needle in order to transmit heat along the shaft. In Chinese practice, moxibustion is used to help patients who are exhausted improve their energy and sense of well-being. Needles warmed by moxa increase the stimulation of the acupuncture point and the bioelectrical circulation along the acupuncture meridians. All the fibromyalgia patients tolerated the moxa well in spite of some odor sensitivities.

During the 30-minute acupuncture sessions patients were also provided with a concurrent counseling program that covered the following areas: nutrition, lifestyle, sleep, stress management, pacing, breathing and relaxation exercises, mind-body strategies for pain management, and cognitive therapy. All patients were counseled to stop smoking, to stop drinking coffee and alcohol, and to gradually increase exercise levels. Outdoor walking was highly recommended, starting at their tolerance level and increasing to 45 minutes a day.

Patients receiving pharmacologic treatments continued with their medications.

Results

All patients filled out the same medical symptom questionnaire before and after the 12-week program. The average age of the patients was 46 years and all were female. The average disease duration was 9 years. One patient stopped the program after 1 month because she felt worse, and three patients went into remission after 1 month and did not complete the program. The remaining 20 patients completed the full program. Of these 20 patients, three reported slight improvement (10% to 20% improvement in their medical symptom scores), 10 reported moderate improvement (21% to 50% improvement), and seven reported significant improvement (greater than 50% improvement). The highest level of improvement was seen in a patient with a score that was 78% better. Patients with greater than 50% improvement in scores also reported verbally that they felt recovered or had achieved almost complete remission. The average improvement for the 20 patients was 43% over the 12-week period, with most of the patients (85%) reporting moderate to large improvement in symptoms. Age of the patients did not appear to affect the success of the treatment program, however, patients with longer disease duration seemed to make less progress. It is unknown whether patients with long disease duration needed longer treatment to reach a higher level of recovery.

Discussion

Acupuncture is believed to correct neuroendocrine dysfunctions by stimulating endorphins in the midbrain.[8-11] Endorphins have multiple homeostatic effects on the neuroendocrine system and are known to reduce pain, improve mood, and increase the patient’s sense of well-being. In this small study, some patients appeared to respond very quickly to acupuncture. About half reported sleeping better and noticed an improvement in symptoms within the first month of treatment. As they were treated for 12 weeks, many experienced the typical waxing and waning of symptoms related to physical and emotional stresses in their lives. The counseling helped improve their coping skills, improve pacing, and avoid relapses. Many of the patients were perfectionists and high achievers who experienced frustration with the limitations of fibromyalgia. Cognitive therapy helped them to re-evaluate their standards and values and, thereby, change their behaviors from those that continually result in relapses to those that support recovery.

In my clinical experience, negative perceptions and pessimism also seem to be symptoms of fibromyalgia. Perhaps this is related to a mild neurotransmitter imbalance. Research suggests that cognitive therapy can help patients overcome negativity and pessimism and can thus be effective in the management of fibromyalgia.[2,3] Some patients who do not respond to counseling or are not interested in making lifestyle or behavioral changes may respond well to 12 weeks of acupuncture, but from my observations they seem to relapse several weeks or months later. Some patients with more significant psychological disorders such as obsessive-compulsive disorder or anxiety disorder related to abuse in childhood may require more extensive counseling from a psychologist.

From my observations, most fibromyalgia patients make the fastest recovery with concurrent acupuncture and counseling. For those patients not able to afford acupuncture treatments, an education, counseling, and mind-body relaxation program without acupuncture can be useful. Those who are motivated to learn and are open to change can make good progress without acupuncture. Many have a transformational experience that gives them insight into their diagnosis and a new way to approach their challenges.

Perhaps the most cost-effective approach to fibromyalgia would be early diagnosis and referral to a facilitated, structured, mind-body relaxation training program offered in a community support group. Patients who continue to have debilitating symptoms might then benefit from an acupuncture treatment program of 12 weeks’ duration combined with ongoing counseling and cognitve therapy to encourage self-empowerment and self-care. (Indefinite acupuncture treatments should be avoided as some chronic pain patients become dependent on passive modalities.) Relapses might be treated with a 2-week to 4-week course of acupuncture with counseling to explore the reasons for the relapse and ways to avoid future relapses. Perhaps family physicians without acupuncture training could provide counseling and follow-up for their fibromyalgia patients while another health care professional, such as a physiotherapist, could provide acupuncture treatments.

Conclusion

I believe that acupuncture combined with education, lifestyle counseling, relaxation training, and some cognitive therapy can effectively treat fibromyalgia. There is a limited amount of high-quality research on the effectiveness of acupuncture for treating fibromyalgia,[12] so larger randomized controlled trials are needed to provide more data and to determine which patients are most likely to respond well to this approach. Long-term follow-up studies are also needed to determine if the patients who respond to acupuncture will have a sustained recovery. Further studies on groups of patients receiving acupuncture alone or counseling alone would also determine if there is greater effectiveness because of synergy when combining a treatment modality (acupuncture) that directly stimulates midbrain neurotransmitters with a treatment modality (counseling and education) that stimulates higher brain functions to make the necessary lifestyle and cognitive changes that will promote a sustained recovery.

Because fibromyalgia is a complex, multifactorial condition with no curative medical treatment, further research into comprehensive treatment programs is needed to reduce the significant impairment in quality-of-life and economic productivity that is presently caused by the condition.

Competing interests
None declared.

Teresa Clarke, MD

Dr Clarke practised as a family physician in Surrey, BC for 10 years and is now chief of medical staff at the Centre for Integrated Healing, a nonprofit society that provides complementary cancer care services. She also facilitates group sessions on recovery from fibromyalgia and chronic fatigue using a mind-body approach. See www.fmrecovery.com [18] for further information.