6. Traditional and complementary medicine

The requirement of traditional and complementary medicine (TCM) processes is very common in patients with chronic diseases for which conventional therapies have failed to obtain a cure all around the world. The rheumatologic disorders are one of the most common causes of admission to the TCM practitioners. The TCM usage rate of patients with FM reaches almost 100% [86, 87].

#### 6.1. Acupuncture

Acupuncture is a traditional Chinese medicine form. Needles are placed at various predefined points on the body. It has many effects including reducing pain. It is claimed to work by reducing the inflammation, causing endorphin release, and creating a calmer mind [88]. Many studies showed its use in reducing pain in FM and other pain types when compared to no treatment or sham acupuncture [89]. It has been shown that acupuncture decreases the number and intensity of painful spots. It also modifies neurohormonal parameters [56].

In a clinical study, 70 patients underwent electroacupuncture. It was reported that there was 70% improvement in some parameters in the intervention group against 4% in the sham acupuncture group [90].

In the revised recommendations of EULAR for managing FM, there were eight reviews about acupuncture. In one high-quality review, it was reported that acupuncture, when used together with the standard therapy, resulted in a 30% improvement in pain scores. Electric acupuncture was also associated with improvements in pain and fatigue. Some mild and transient adverse events were also reported. The active mechanism of acupuncture has not been clarified, and the evidence supporting the use of real vs. sham acupuncture is less consistent. EULAR proposes acupuncture as weak [10].

#### 6.2. Manual therapy/massage/chiropractic

operant behaviors, and tries to increase adaptive behavior via positive-negative reinforcement. Behavioral therapy also extinguishes maladaptive behaviors by punishing the patient in such cases. There are several behavioral techniques that might be applied in FM like behavioral activation (getting patients move again), graded exercises (initiating exercise and then activities increasing slowly), activity pacing (not overdoing it on the days when the patient feels well and remaining active on days when the patient feels bad), pain-reducing behaviors (not reinforcing behaviors related with secondary gain), sleep hygiene (identifying the behaviors that are known to disrupt sleep), and learning relaxation techniques for the purpose of lower-

In general, applying CBT for FM has three steps [83]. Step 1 consists of training in which the participation of the patient in pain management is focused on and the nature of the pain is dealt with. In step 2, there is skill training on pain reduction to improve functional status and sleep quality, etc. In Step 3, these skills are applied in real-life situations. CBT also involves homework assignments to learn and practice these skills. The "Booster Sessions" also aim the

In the revised recommendations of EULAR for managing FM there were 5 reviews that included 30 trials and at least 2031 participants about CBT. Although the quality of individual trials was reported as being weak in general, in one quality review, there were 23 trials comprising >2000 patients [85]. Cognitive behavioral therapies (CBTs) were effective in reducing pain and disability after the treatment when compared with the controls. The results lasted

The requirement of traditional and complementary medicine (TCM) processes is very common in patients with chronic diseases for which conventional therapies have failed to obtain a cure all around the world. The rheumatologic disorders are one of the most common causes of admission to the TCM practitioners. The TCM usage rate of patients with FM reaches almost 100% [86, 87].

Acupuncture is a traditional Chinese medicine form. Needles are placed at various predefined points on the body. It has many effects including reducing pain. It is claimed to work by reducing the inflammation, causing endorphin release, and creating a calmer mind [88]. Many studies showed its use in reducing pain in FM and other pain types when compared to no treatment or sham acupuncture [89]. It has been shown that acupuncture decreases the num-

In a clinical study, 70 patients underwent electroacupuncture. It was reported that there was 70% improvement in some parameters in the intervention group against 4% in the sham

In the revised recommendations of EULAR for managing FM, there were eight reviews about acupuncture. In one high-quality review, it was reported that acupuncture, when used

ber and intensity of painful spots. It also modifies neurohormonal parameters [56].

ing stress (for example imagery, breathing, muscle relaxation, etc.) [18].

44 Discussions of Unusual Topics in Fibromyalgia

same thing and help to sustain the effects for longer durations [84].

for longer durations. EULAR proposes behavioral therapies as weak [10].

6. Traditional and complementary medicine

6.1. Acupuncture

acupuncture group [90].

Manual treatments are hands-on therapies used to increase motion range and to decrease pain and swelling. Tissue and muscles relaxation along with stretching exercises is the commonly used manual treatments. Proprioceptive neuromuscular facilitation is used to increase range of motion and strength. Pain leads to immobilization, which further leads to soft tissue (fascia, tendons, ligaments etc.) restriction that can create abnormal strain pattern that can crowd or pull the osseous structures out of proper alignment resulting in compression of joints, which produces pain and/or dysfunction. Neural and vascular structures can also be compressed causing neurological or ischemic conditions. Shortening of the myofacial fasicle can limit its functional length, reducing its strength contractile potential or deceleration capacity facilitating positive changes in this system by therapeutic intervention like myofascial release. Mobilizing the restricted fissure can reverse the effects of immobilization provided that it does not last for an excessive period. Movement encourages the collagen fibers to align themselves along the lines of structural stress and improves the balance of glycosaminoglycans and lubricates and hydrates the corrective tissues [91].

Massage is commonly used in TCM therapy in FM patients. Based on the patient survey data, the intervention has been reported with the highest satisfaction levels [18].

A systematic review and meta-analysis examined fatigue, anxiety, depression, and sleep disturbance. They also included studies investigating traditional Chinese massage that was not extensively reviewed previously. Their main result was that massage therapy that lasted more than 5 weeks gave significant improvement in pain, anxiety, and depression [89, 92].

In the revised recommendations of EULAR for managing FM, there were 6 reviews reported including 1 meta-analysis in which there are 9 trials and 404 patients. Methodological problems were noted with all of the studies, only four were at low risk of bias in terms of random allocation. EULAR has a weak opposition about massage [10].

Chiropractic treatments, like massage therapy, have also become a popular modality in FM patients. Few randomized-controlled trials were reported in FM patients using chiropractic modalities [18, 56]. In the revised recommendations of EULAR for managing FM, there were three reviews about chiropractics. The most recent compilation summarized three studies [93]. The studies were of poor quality and lacked robust data. EULAR has strong opposition about chiropractic treatments [10].

#### 6.3. Meditative movement/mindfulness/mind-body therapy

"Mind and body therapy" is a heterogeneous term that means as "meditative movement therapy" or "complementary and alternative exercise." The goal is to improve the flow of qi (the life energy) through the body with purposeful hand and body movements. A review of studies demonstrated improvements after 6 months compared to baseline in patients with FM. However, the studies had significant methodological issues and variability [94]. Tai Chi is another mind-body technique with specific movements. A meta-analysis that included seven studies evaluated Tai Chi for FM that showed improvements in some symptoms [89, 95].

concentrate first on nonpharmacologic modalities. This is in view of accessibility, cost, safety and patient preference. It is considered that in addition to the existing standard treatment modality of the patient, the treatment may be more efficient and the burden of medication might be reduced with the selection of the best nonpharmacologic treatment option for the

Among these nonpharmocologic treatment methods, exercise therapy, balneotherapy, cognitive behavioral therapies, acupuncture, and meditative movement/mindfulness/mind-body therapies are more effective treatment methods according to the evidence-based medicine approach. These are summarized in Table 1. In case of severe disability, combination therapies

Aerobic exercise Pain [10, 29, 30], physical functions [10, 29], global well-being [30], emotional

Strengthening exercise Pain [8, 10, 30], physical functions [8, 10], global well-being [8, 30], emotional

Tai Chi exercises/Ai-chi exercises/yoga Pain [32, 39],decreased quality of life [32, 33, 39], loss of balance [35], physical

Balneotherapy Pain [10, 66–70], fatigue [66–68], stiffness [66], physical functions [66, 67, 69, 70],

Cognitive behavioral therapies Pain [10, 18], disability [10, 18], emotional distress/depression/anxiety/ maldaptive thoughts [18], fatigue [18] Acupuncture Pain [10, 56, 88, 89], fatigue [10, 88], stiffness [88, 89], global well-being [88], number of tender points [89]

pain [10, 89, 94, 95]

\*According to the evidence-based results of guidelines, systematic reviews and meta-analyses.

sleep disturbance [29, 30], decreased quality of life [30]

sleep disturbance [29, 30], decreased quality of life [30]

disturbances [67, 68], number of tender points [67, 69]

distress/depression [28–30], fatigue [22, 30], number of tender points [29, 30],

Nonpharmacologic Treatment for Fibromyalgia http://dx.doi.org/10.5772/intechopen.70515 47

distress/depression [28, 30], fatigue [22, 30], number of tender points [8, 29, 30],

Sleep disturbance [10, 89, 94, 95], fatigue [10, 94, 95], emotional distress [10, 94],

emotional distress/depression/anxiety [66, 68, 69], decreased quality of life [67, 68], sleep disturbance [67, 68, 70], headache/gastrointestinal

Nonpharmacologic therapies Which symptoms improved after treatment

functions [39]

patient.

should be performed.

Exercise therapy

Author details

Meditative movement/

mindfulness/mind-body therapies

Kırşehir, Turkey

Fatmanur Aybala Koçak and Emine Eda Kurt\*

\*Address all correspondence to: eedakurt@gmail.com

Table 1. Most effective\* nonpharmacological therapies for fibromiyalgia.

Medical Faculty, Department of Physical Medicine and Rehabilitation, Ahi Evran University,

In the revised recommendations of EULAR for managing FM, there were six reviews focusing on qigong, yoga, Tai Chi, or a combination of them. However, there was inadequate evidence for individual recommendations. EULAR proposes meditative movement as weak [10].

There were 6 reviews that included 13 trials and 1209 participants about mindfulness/mindbody therapy in the EULAR revised recommendations. One recent review provided evidence that mindfulness-based stress reduction resulted in improvements in pain compared with usual care. However, these effects were considered to be biased. EULAR proposes mindfulness/ mind-body therapy as weak [10].

#### 6.4. Guided imagery/hypnotherapy

Although hypnosis is one of the oldest therapies for pain, interest in hypnosis for controlling chronic pain rose only in the last decade. Hypnosis is defined as a state of consciousness involving focused attention and reduced peripheral awareness and is characterized by an enhanced capacity for response to suggestion [96]. Imagery is defined as a dynamic, psychophysiological process in which a person imagines and experiences an internal reality in the absence of external stimuli. These images can be initiated by the patient or guided by a therapist. In a systematic review conducted on evaluating the efficacy, acceptability and safety of guided imagery/hypnosis (GI/H) in FM, randomized-controlled trials comparing GI/H with controls were analyzed. The main outcomes were ≥50% pain relief, ≥20% improvement of health-related quality of life, psychological distress, disability, acceptability and safety at the end of therapy and a 3-month follow-up. There were 7randomized controlled trials (RCTs) with 387 subjects that were included into a comparison of GI/H vs. controls. There was a benefit from GI/H compared to the controls at the end of the therapy [97]. In the revised recommendations of EULAR for managing FM, hypnotherapy evaluation was considered weak [10].
