RESEARCH FINDINGS USING GUIDED IMAGERY FOR
Fibromyalgia

August, 2006

Prevalence and Costs
Fibromyalgia syndrome (FMS) affects between 2%-6% of the population, with 80%-90% of those affected being women (“Fibromyalgia,” 2005. Estimates of direct and indirect healthcare and economic costs range up to 20 billion dollars annually (Wolfe, Anderson et al, 1997b). Many FMS patients are unable to work or to carry out the activities of daily living, and suffer depression and other related conditions. Fibromyalgia, along with back pain and arthritis, have been identified as the chronic pain syndromes that contribute the greatest clinical and economic burden to society (“Fibroymyalgia;” Wolfe, Anderson et al, 1997a.)


What is Fibromyalgia?
The American College of Rheumatology (ACR) criteria for a diagnosis of fibromyalgia includes having pain in more than three locations in the body for more than three months, accompanied by specific anatomical tender points. There are 18 of these points, 9 on each side of the body. For an adult to be diagnosed with fibromyalgia, he or she must have severe discomfort when pressure is applied to 11 out of 18 of these tender points (Romano, 2000; Smith, 2001; Wolfe, 1990), although there these guidelines are not universally accepted (“Fibromyalgia,” 2005).

In addition to fibromyalgia’s characteristic muscle pain and fatigue, symptoms can include sleep difficulties, depression, inability to concentrate (so-called “fibro-fog”), headaches, morning stiffness, abdominal pain, bloating, alternating constipation and diarrhea, infertility, and parasthesias (Fibromyalgia, 2005).

The causes of fibromyalgia remain unclear, but some of the suspected factors include physical trauma, chronic pain, muscle abnormalities, viral or bacterial infection, immune system dysfunction, emotional trauma, and hormonal changes (“Fibromyalgia,” 2005). Some experts believe that cases of fibromyalgia caused by trauma or serious infectious illness tend to be more severe and have a worse prognosis (Romano, 2000).


Medical Treatment
Since the cause is unknown, medical treatment of fibromyalgia is largely symptomatic. Medications for pain management including anti-inflammatories, narcotics, and acetaminophen. Other medications include antidepressants, cyclobenzaprine for muscle spasm, anti-anxiety drugs, antispasmodics for bowel symptoms, and sleep medications. Because each patient presents with different symptomatology, treatment, including complementary and alternative approaches, must be individualized (Goldenberg, Burckhardt, et al, 2005; Morris, Bowen, et al, 2005).


Mind/Body Treatments Often More Effective
FMS patients with chronic pain symptoms can clearly benefit from relaxation techniques, biofeedback, hypnosis, cognitive-behavioral therapy and meditation skills (Berman & Swyers, 1997; Berman & Swyers, 1999; Beckelew, Conway, et al, 1998; Edinger, Wohlgemuth, et al, 2005; “Fibromyalgia,” 2005; Haanen, Hoenderdos, et al, 1991; Hadhazy, Ezzo, et al, 2000; Jackson, O’Malley & Kroenke, 2006; Kaplan, Goldenberg, et al, 1993; Leao & da Silva, 2004; Singh, Berman et al, 1998). Interestingly, patients fared better when hypnosis was combined with analgesic suggestions than when hypnosis was combined with relaxation suggestions (Castel, Perez, et al, 2006).

Results in juvenile fibromyalgia patients using CBT have also been impressive, with one study’s authors’ reporting significant reductions (p=.006) in patient pain, anxiety, fatigue, somatic symptoms and quality of sleep (Degotardi, Klass, et al, 2005; Kashikar-Zuck, Swain, et al, 2005). A recent review concluded that CBT was effective, especially when used as part of a comprehensive program; it was particularly effective with juvenile fibromyalgia (Bennett & Nelson, 2006).

In one 2006 study, subjects who received cognitive-behavioral treatment for FMS reported significant reductions in pain, and improvements in cognitive and affective variables; the operant-behavior treatment group had significant improvements in physical functioning and behavioral variables; both groups maintained their improvements at 6- and 12-month follow up; subjects in the attention-placebo group actually deteriorated (Thieme, Herta & Dennis, 2006). Authors of a 2006 review concluded that for the 11 painful syndromes reviewed (including FMS), CBT was “the most consistently demonstrated to be effective” (Jackson, O’Malley & Kroenke, 2006).

Patients self-using audiotaped guided imagery reported improved self-efficacy and improvement in non-pain FM symptoms (Menzies, Taylor, et al, 2006).

There is strong evidence that these mind-body therapies plus exercise are more effective than standard medical treatment and can lead to patients needing fewer office visits and less medication (Bernard, Prince, et al, 2000; Buckelew, Conway, et al, 1998; Hadhazy, Ezzo, et al, 2000; Rossy, Buckelew, et al, 1999; Wolfe, Anderson, et al, 1997b).

Research suggests that mind-body therapies are particularly effective when used as part of a multidisciplinary approach to treatment (Berman & Swyers, 1999; Bernhard, Price & Edsall, 2000; Romano, 2000) Patients taking an active role in their treatment can be a vital factor in coping successfully with FMS (Buckelew, Huyser, et al, 1996; Drum, 1999); patients with high positive expectancy also have improved outcomes (Goossens, Vlaeyen et al, 2005)—mind body approaches such as guided imagery and hypnosis can help build positive expectancy.


Conclusion
Used as a complementary treatment, guided imagery can help patients cope with fibromyalgia syndrome, save medical care resources, and reduce patient economic burdens and suffering.


References
Bennett R, Nelson D. Cognitive behavioral therapy for fibromyalgia. Nat Clin Pract Rheumatol. 2006 Aug;2(8):416-24.

Berman BM, Swyers JP. Establishing a Research Agenda for Investigating Alternative Medical Interventions for Chronic Pain. Primary Care. 1997 Dec;24(4):743-58.

Berman BM, Swyers JP. Complementary Medicine Treatments for Fibromyalgia Syndrome. Baillieres Best Pract Res Clin Rheumatol. 1999 Sep;13(3):487-92.

Bernard AL, Prince A, Edsall P. Quality of Life Issues for Fibromyalgia Patients. Arthritis Care Res. 2000 Feb;13(1) :42-50.

Buckelew SP, Conway R, Parker J, Deuser WE, Read J, Witty TE, Hewett JE, Minor M, Johnson JC, Van Male L, McIntosh MJ, Nigh M, Kay DR. Biofeedback/ Relaxation Training and Exercise Interventions for Fibromyalgia: A Prospective Trial. Arthritis Care Res. 1998 Jun;11(3): 196-209.

Buckelew SP, Huyser B, Hewett JE, Parker JC, Johnson JC, Conway R, Kay DR. Self-efficacy Predicting Outcome Among Fibromyalgia Subjects. Arthritis Care Res. 1996 Apr;9(2): 97-104.

Castel A, Perez M, Sala J, Padrol A, Rull M. Effect of hypnotic suggestion on fibromyalgic pain: Comparison between hypnosis and relaxation. Eur J Pain. 2006 Aug 2; [Epub ahead of print]

Degotardi PJ, Klass ES, Rosenberg BS, Fox DG, Gallelli KA, Gottlieb BS. Development and Evaluation of a Cognitive-Behavioral Intervention for Juvenile Fibromyalgia. J Pediatr Psychol. 2005 Aug 24. [Epub ahead of print].

Drum D. (1999) The Chronic Pain Management Sourcebook. New York: McGraw-Hill/Contemporary Books.

Edinger JD, Wohlgemuth WK, Krystal AD, Rice JR. Behavioral insomnia therapy for fibromyalgia patients: a randomized clinical trial. Arch Intern Med. 2005 Nov 28;165(21):2527-35.

[no authors listed] Fibromyalgia. Mayo Foundation for Medical Education and Research (MFMER). Jan. 27, 2005. http://www.mayoclinic.com/health/fibromyalgia/DS00079 Accessed July, 2006.

Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17;292(19):2388-95.

Goossens ME, Vlaeyen JW, Hidding A, Kole-Snijders A, Evers SM. Treatment expectancy affects the outcome of cognitive-behavioral interventions in chronic pain. Clin J Pain. 2005 Jan-Feb;21(1):18-26; discussion 69-72.

Haanen HC, Hoenderdos HT, van Romunde LK, Hop WC, Mallee C, Terwiel JP, Hekster GB. Controlled Trial of Hypnotherapy in the Treatment of Refractory Fibromyalgia. J Rheumatol. 1991 Jan;18(1): 72-5.

Hadhazy VA, Ezzo J, Creamer P, Berman BM. Mind-body Therapies for the Treatment of Fibromyalgia: A Systematic Review. J Rheumatol. 2000 Dec;27(12):2922-8.

Jackson JL, O'Malley PG, Kroenke K. Antidepressants and cognitive-behavioral therapy for symptom syndromes. CNS Spectr. 2006 Mar;11(3):212-22.

Kaplan KH, Goldenberg DL, Galvin-Nadeau M. The Impact of a Meditation-based Stress Reduction Program on Fibromyalgia. Gen Hosp Psychiatry. 1993 Sep;15(5):284-9.

Kashikar-Zuck S, Swain NF, Jones BA, Graham TB. Efficacy of cognitive-behavioral intervention for juvenile primary fibromyalgia syndrome. J Rheumatol. 2005 Aug;32(8):1594-602.

Leao ER, da Silva MJ. [Music and chronic muscular-skeletal pain: the evocative potential of mental images] [Article in Portuguese] Rev Lat Am Enfermagem. 2004 Mar-Apr;12(2):235-41. Epub 2004 May 19.

Menzies V, Taylor AG, Bourguignon C. Effects of guided imagery on outcomes of pain, functional status, and self-efficacy in persons diagnosed with fibromyalgia. Journal of Alternative and Complementary Medicine. 2006 Jan-Feb; 12 (1): pg 23-30.

Morris CR, Bowen L, Morris AJ. Integrative therapy for fibromyalgia: possible strategies for an individualized treatment program. South Med J. 2005 Feb;98(2):177-84.

Romano T. Fibromyalgia Update (1999-2000). The Pain Practitioner Newsletter of the American Academy of Pain Management. Vol 10, 2, 2000. Pg. 9.

Rossy LA, Buckelew SP, Dorr N, Hagglund KJ, Thayer JF, McIntosh MJ, Hewett JE, Johnson JC. A Meta-analysis of Fibromyalgia Treatment Interventions. Ann Behav Med. 1999 Spring;21(2):180.

Singh BB, Berman BM, Hadhazy VA, Creamer P. A Pilot Study of Cognitive Behavioral Therapy in Fibromyalgia. Altern Ther Health Med. 1998 Mar;4(2): 67-70.

Smith IK. Hurting All Over. Time. 2001 Feb 19: 84.

Smith WA. Fibromyalgia Syndrome. Nurs Clin North Am. 1998 Dec;33(4): 653-69.

Thieme K, Herta F, Dennis TC. Psychological Pain Treatment in Fibromyalgia Syndrome: Efficacy of Operant-Behavioral and Cognitive-Behavioral Treatments (ISRCTN83953414). Arthritis Res Ther. 2006 Jul 19;8(4):R121 [Epub ahead of print]

Wolfe F, Anderson J, Harkness D, Bennett RM, Caro XJ, Goldenberg DL, Russell IJ, Yunus MB. Health Status and Disease Severity in FMS: Results of a Six-Center Longitudinal Study. Arthritis Rheum. 1997a Sep;40(9):1571-9.

Wolfe F, Anderson J, Harkness D, Bennett RM, Caro XJ, Goldenberg DL, Russell IJ, Yunus MB. Prospective, Longitudinal Study of Service Utilization and Costs in FMS. Arthritis & Rheum. Sept. 1997b.

Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P, et al. The American College of Rheumatology 1990. Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis and Rheumatism. 1990 33(2).160-172.