2. Education and goal setting

The diagnosis of FM has positive influences on the management of this disease and leads to decrease in primary care visit, diagnostic tests and prescriptions. The nest stage is the training of patients. When the patient is convinced that the disease is not life-threatening, the anxiety will decrease [11]. The training and detailed goal setting are extremely important. Training on the treatment must be provided to the patient and his/her family as well. Acknowledging of the pain and the effects of this pain in his/her life is important. The patient must also be told to be active in his/her rehabilitation period, and it must be emphasized that she/he is not alone in this process. In this step, concrete goals must be set during the treatment period [12]. Mentioning the positive expectations from the treatment period and the prognosis and the participation of the patient are, again, extremely important. It is also useful to tell patients that there will be good days and bad days and that the treatment will decrease the effects of the symptoms but not completely eliminate the disease. It is extremely important that the patients are careful about the sleep hygiene, exercise schedule and some other nonpharmacologic modalities [11].

Strong evidence shows that patient training is effective in the FM management. In a randomized-controlled study, untreated controls were compared with trained FM patients and positive outcomes were reported [13]. The training was generally provided in groups like lectures with printed materials, discussions with groups and demonstrations. The duration of the trainings lasted between 6 and 17 sessions. The positive outcomes of the trainings included improvement in pain, sleep quality, fatigue, self-efficacy, and quality of life. Positive outcomes lasted between 3 and 12 months. In a study in which 100 patients were included, a multidisciplinary training program was applied for 1–1/2 days, and important positive improvements were reported it terms of Fibromyalgia Impact Questionnaire (FIQ) total score, pain scores, fatigue, morning tiredness, stiffness, anxiety, and depression in the 1-month follow-up [13, 14].

According to some clinicians, labeling FM in itself would deteriorate the symptoms, but a prospective study showed that the labeling, i.e., the diagnosis, did not have any adverse effects, on the contrary, it improved function over 18 months [15].

There are several studies in which well-controlled trials were reported as well as some other studies that reported that they could not find statistically significant superiority over other intervention methods when compared with the trained control group [16]. Burckhardt et al. [17] provided training to FM patients in one group, physical training condition and training to another group, and included delayed treatment waitlist controls in another third group [17]. They reported improved measurements in terms of physical activity in the active treatment groups [18].

If the patients are prone to be trained on self-management of the FM, a training and multiprofessional or multimodal program is the most important first-step action to involve the patients in the planned therapeutic activities. If such a program is not possible, an informed physician can provide patient education, and for detailed nonpharmacologic treatments, a specialist may also be consulted [18, 19].

### 3. Exercises

In this chapter, nonpharmacological treatment options will be explained in light of the last

The diagnosis of FM has positive influences on the management of this disease and leads to decrease in primary care visit, diagnostic tests and prescriptions. The nest stage is the training of patients. When the patient is convinced that the disease is not life-threatening, the anxiety will decrease [11]. The training and detailed goal setting are extremely important. Training on the treatment must be provided to the patient and his/her family as well. Acknowledging of the pain and the effects of this pain in his/her life is important. The patient must also be told to be active in his/her rehabilitation period, and it must be emphasized that she/he is not alone in this process. In this step, concrete goals must be set during the treatment period [12]. Mentioning the positive expectations from the treatment period and the prognosis and the participation of the patient are, again, extremely important. It is also useful to tell patients that there will be good days and bad days and that the treatment will decrease the effects of the symptoms but not completely eliminate the disease. It is extremely important that the patients are careful about the sleep hygiene, exercise schedule and some other nonpharmacologic modalities [11]. Strong evidence shows that patient training is effective in the FM management. In a randomized-controlled study, untreated controls were compared with trained FM patients and positive outcomes were reported [13]. The training was generally provided in groups like lectures with printed materials, discussions with groups and demonstrations. The duration of the trainings lasted between 6 and 17 sessions. The positive outcomes of the trainings included improvement in pain, sleep quality, fatigue, self-efficacy, and quality of life. Positive outcomes lasted between 3 and 12 months. In a study in which 100 patients were included, a multidisciplinary training program was applied for 1–1/2 days, and important positive improvements were reported it terms of Fibromyalgia Impact Questionnaire (FIQ) total score, pain scores, fatigue, morning tiredness, stiffness, anxiety, and depression in the 1-month follow-up [13, 14]. According to some clinicians, labeling FM in itself would deteriorate the symptoms, but a prospective study showed that the labeling, i.e., the diagnosis, did not have any adverse

effects, on the contrary, it improved function over 18 months [15].

There are several studies in which well-controlled trials were reported as well as some other studies that reported that they could not find statistically significant superiority over other intervention methods when compared with the trained control group [16]. Burckhardt et al. [17] provided training to FM patients in one group, physical training condition and training to another group, and included delayed treatment waitlist controls in another third group [17]. They reported improved measurements in terms of physical activity in the active treatment

If the patients are prone to be trained on self-management of the FM, a training and multiprofessional or multimodal program is the most important first-step action to involve the patients in the planned therapeutic activities. If such a program is not possible, an informed physician

published guidelines.

groups [18].

2. Education and goal setting

36 Discussions of Unusual Topics in Fibromyalgia

McLoughlin et al. [20] reported that many female patients with FM are active at a less level when compared with healthy women whose ages match [20]. They have low perceived functional ability. They also demonstrate impaired physical performance [21]. There are many reports that described positive effects of various types or combined exercises on patients with FM [22]. Pain in FM patients may be associated with the central nervous system (CNS) painprocessing abnormalities including central sensitization and insufficient pain inhibition, peripheral tissues, as well as muscles, which might contribute to chronic pain via initiating and/or maintaining central sensitization [23]. In this way, exercise is expected to contribute to pain via muscle microtrauma process, repair and adaptation, which are associated with normal-acute exercise and exercise training. It has been reported in previous studies that there are metabolic outcomes in muscle tissues, which is consistent with deconditioning [24]. Some of these findings might be normalized by aerobic and strength training-induced metabolic adaptations, which contribute to improvements in pain [25]. In addressing conditions experienced by FM patients, exercise training was reported to be used successfully [8].

Although there are studies mentioning the efficiency of short-term aerobic exercises, the level of evidence for these studies is low. Effects on pain and tender points were determined to be at an insignificant level in statistical terms. In terms of the secondary outcomes such as depression, fatigue and sleep, the evidence is not clear on the effects of aerobic exercise on depression (in this respect, two studies reported medium/large effects [26]). There is no evidence that aerobic exercise prescribed at American College of Sports Medicine levels had effects on fatigue in FM patients [27]. Despite the fact that a meta-analysis shows that aerobic exercise has a positive effect on well-being and physical function, several factors moderated our appraisal. It has been demonstrated that aerobic and strength training improves depression in individuals that have depression at clinical level [28]. Moderate exercise can be beneficial for sleep in people with sleep complaints. It is also visible in training-related improvements in cardiorespiratory fitness. This situation suggests that fatigue may also be improved because as the maximal aerobic capacity of a person improves, that person will perform daily life activities at lower absolute percentages of maximal capacity [22]. Kurt et al. conducted a randomized study and reported that the FIQ score, sleep quality, total myalgic score, and depression scores of the group that received only aerobic exercise treatment improved after 15 sessions; however, in the third month follow-up, it was observed that the measurements regressed to the values that were present before the treatment. In recent studies, it has been reported that especially combined exercises or the combinations of exercise and other treatment options are more efficient [29].

According to a Cochrane compilation conducted on the efficiency of resistance exercises in FM patients, it has been reported that moderate- and moderate- to high-intensity resistance training improves pain, tenderness, muscle strength, and multidimensional function in FM patients, and it is obvious that the level of evidence for these studies is low. In addition, it has also been reported that resistance exercises are superior to flexibility exercises in terms of wellness, FM symptoms, and physical fitness; however, aerobic exercises are more successful than resistance exercises [8]. In an 8-week exercise program in which aerobic exercises and muscle strengthening exercises were compared, it was reported that fitness, depression, pain, sleep, fatigue, tender point count, and quality of life were improved in FM patients in both exercise groups, and no differences at statistically significant level were observed between the two exercise types [30].

In recent years, Pilates has become a popular exercise form for healthy people and for people who need rehabilitation. Pilates exercises focus on core strengthening, posture, and coordination of breathing with movement and combines Asian and Western techniques. In 2009, Altan et al. [40] conducted a study and examined the effects of Pilates in 49 female FM patients. They showed improvements in pain scores and FIQ results compared to the control group (home relaxation and stretching exercises); but after an extra 12-week follow-up, no differences were detected between the groups [40]. In a recent randomized controlled study, the Visual Analogue Scale, algometry, Anxiety Inventory, FIQ, and Quality of life score were showed to

Nonpharmacologic Treatment for Fibromyalgia http://dx.doi.org/10.5772/intechopen.70515 39

In a study in which moderate-to-high intensity aerobic exercise by means of Nordic walking and low-intensity walking exercises applied twice a week (in 15 weeks) was compared, the former was found to be a feasible mode of exercise and resulted in improved functional capacity and a decreased level of activity limitations [42]. Mannerkorpi et al. [43] conducted a randomized-controlled study and reported similar results [43]. In a meta-analysis in which the effect of Qigong, which is a Chinese medical exercise combining static/dynamic physical exercises, breathing exercises, and meditation on FM was investigated, it was reported that there were little number of patients and studies on the topic, and although there was a lowquality evidence, Qigong might be a useful approach for FM patients in terms of pain, life

In a Cochrane compilation in which the aquatic exercise studies were compiled, it was reported in studies that compared study groups and control groups that improvements could be achieved in aquatic exercise group in terms of pain, involvement, and physical functions. When aquatic exercises were compared with land exercises, it was reported that there were no differences at a statistically significant level between the groups, and when aquatic exercises were compared with the Ai-Chi exercises, it was reported that Ai Chi was superior to aquatic exercises for stiffness [45]. Recently, a randomized-controlled study, which includes both aquatic therapy and land-based therapy (warm-up, proprioceptive exercises, stretching, and relaxation periods), was reported. In a program of the study being applied for 3 days a week for 3 months, improvements were determined in both groups in terms of pain and balance, but no significant differences were detected between the groups [46]. Andrade et al. [47] reported that aquatic physical training with standardized intensities did not cause significant changes in body composition but was effective in promoting increased VO2 at peak cardiopulmonary exercise test in women with FM [47]. The purposes of physical activity and exercise training include improving physical fitness and function together with the symptoms of fibromyalgia, and optimizing health, because a sedentary lifestyle and deconditioning are associated with the symptoms of fibromyalgia [20]. Moreover, a lower percentage of maximum capacity may be achieved in daily activities with more efficiency and the symptoms are less likely to increase [48]. Furthermore, targets depend on baseline body functions and the severity of the symptoms together with individual preferences and motivations [49]. In contrast, in a study, it was reported that nearly 2% of the competitive sport players had FM, which shows that people with FM may be extremely active. Although regular exercises (i.e., aerobic, strength, flexibility) are among the most important elements in the FM management, it is also important that the intensity, duration, incidence, and type of any adverse effects and frequency must be

improve in patients with FM [41].

quality, and sleep improvements [44].

There are exercise recommendations given in the past years such as American Pain Society (APS: 2005), (2) Association of the Scientific Medical Societies in Germany (AWMF: 2012), (3) Canadian Pain Society (CPS: 2013; also used in the United Kingdom), and (4) European League Against Rheumatism (EULAR: 2016) guidelines related to FM. APS, CPS, and AWMF assigned the highest ranking of recommendation for aerobic exercises [31]. In EULAR 2016 FM management guide, the proof levels of aerobic and stretching exercises are given as A in Ia Proof Level. However, according to the previous studies, it has also been reported that none of the two exercises was superior to the other one [10].

Besides these, especially in the last decade, extensive research was conducted on low-impact aerobics, flexibility, stretching, strength training exercise technique spectra, and some traditional exercise techniques such as Tai Chi, chi gong, yoga, and Nordic walk. In a more recent cohort study, it has been reported that Tai-Chi exercises could be an efficient rehabilitation method for FM in case it was done with the supervision of an expert [32]. It has been reported that Ai-Chi exercises, which are a form of Tai-Chi movements in water, led to reduced pain and improved life quality as well as physical-mental health in FM patients in a 10-week aquatic therapy program [33].

In two randomized-controlled studies, it was reported that Tai Chi had a potential as a useful method in the multidimensional treatment of FM [34]. Furthermore, studies showed improvement at a statistically significant level in static and dynamic balance, and timed get-up-and-go. According to these results, it was shown that functional mobility decreased the falling risk with Tai Chi in functional measurements and minimized difficulties in performing essential daily physical activities [35]. The German Pain Society 2017 guideline in "Complementary and alternative procedures for fibromyalgia syndrome" strongly recommends Qigong, Tai Chi, and yoga for the FM treatment [36].

Fischer-White et al. [37] conducted a compilation study and reported that there was a need for comprehensive yoga instructions, and they stated that the use of yoga in FM was investigated by a limited number of researchers, although there were no adequate proofs [37]. The yoga programs included traditional yoga postures, breathing exercises and meditation. In a study in which 22 FM women patients were included in an 8-week yoga program, improvements were observed in fibromyalgia symptoms and functional deficit [38]. In a controlled study conducted by Ide et al. [39] pranayama (a breathing technique in yoga) was utilized in combination with a range of motion and relaxation exercises in aquatic medium for female FM patients (sessions lasted for 1 h, four times a week, and 4 weeks). Important improvements were shown on several SF-36 and FIQ components together with global pain and dyspnea scores [39].

In recent years, Pilates has become a popular exercise form for healthy people and for people who need rehabilitation. Pilates exercises focus on core strengthening, posture, and coordination of breathing with movement and combines Asian and Western techniques. In 2009, Altan et al. [40] conducted a study and examined the effects of Pilates in 49 female FM patients. They showed improvements in pain scores and FIQ results compared to the control group (home relaxation and stretching exercises); but after an extra 12-week follow-up, no differences were detected between the groups [40]. In a recent randomized controlled study, the Visual Analogue Scale, algometry, Anxiety Inventory, FIQ, and Quality of life score were showed to improve in patients with FM [41].

it is obvious that the level of evidence for these studies is low. In addition, it has also been reported that resistance exercises are superior to flexibility exercises in terms of wellness, FM symptoms, and physical fitness; however, aerobic exercises are more successful than resistance exercises [8]. In an 8-week exercise program in which aerobic exercises and muscle strengthening exercises were compared, it was reported that fitness, depression, pain, sleep, fatigue, tender point count, and quality of life were improved in FM patients in both exercise groups, and no differences at statistically significant level were observed between the two exercise types [30].

There are exercise recommendations given in the past years such as American Pain Society (APS: 2005), (2) Association of the Scientific Medical Societies in Germany (AWMF: 2012), (3) Canadian Pain Society (CPS: 2013; also used in the United Kingdom), and (4) European League Against Rheumatism (EULAR: 2016) guidelines related to FM. APS, CPS, and AWMF assigned the highest ranking of recommendation for aerobic exercises [31]. In EULAR 2016 FM management guide, the proof levels of aerobic and stretching exercises are given as A in Ia Proof Level. However, according to the previous studies, it has also been reported that none of

Besides these, especially in the last decade, extensive research was conducted on low-impact aerobics, flexibility, stretching, strength training exercise technique spectra, and some traditional exercise techniques such as Tai Chi, chi gong, yoga, and Nordic walk. In a more recent cohort study, it has been reported that Tai-Chi exercises could be an efficient rehabilitation method for FM in case it was done with the supervision of an expert [32]. It has been reported that Ai-Chi exercises, which are a form of Tai-Chi movements in water, led to reduced pain and improved life quality as well as physical-mental health in FM patients in a 10-week aquatic

In two randomized-controlled studies, it was reported that Tai Chi had a potential as a useful method in the multidimensional treatment of FM [34]. Furthermore, studies showed improvement at a statistically significant level in static and dynamic balance, and timed get-up-and-go. According to these results, it was shown that functional mobility decreased the falling risk with Tai Chi in functional measurements and minimized difficulties in performing essential daily physical activities [35]. The German Pain Society 2017 guideline in "Complementary and alternative procedures for fibromyalgia syndrome" strongly recommends Qigong, Tai Chi,

Fischer-White et al. [37] conducted a compilation study and reported that there was a need for comprehensive yoga instructions, and they stated that the use of yoga in FM was investigated by a limited number of researchers, although there were no adequate proofs [37]. The yoga programs included traditional yoga postures, breathing exercises and meditation. In a study in which 22 FM women patients were included in an 8-week yoga program, improvements were observed in fibromyalgia symptoms and functional deficit [38]. In a controlled study conducted by Ide et al. [39] pranayama (a breathing technique in yoga) was utilized in combination with a range of motion and relaxation exercises in aquatic medium for female FM patients (sessions lasted for 1 h, four times a week, and 4 weeks). Important improvements were shown on several SF-36 and FIQ components together with global pain and dyspnea

the two exercises was superior to the other one [10].

38 Discussions of Unusual Topics in Fibromyalgia

therapy program [33].

scores [39].

and yoga for the FM treatment [36].

In a study in which moderate-to-high intensity aerobic exercise by means of Nordic walking and low-intensity walking exercises applied twice a week (in 15 weeks) was compared, the former was found to be a feasible mode of exercise and resulted in improved functional capacity and a decreased level of activity limitations [42]. Mannerkorpi et al. [43] conducted a randomized-controlled study and reported similar results [43]. In a meta-analysis in which the effect of Qigong, which is a Chinese medical exercise combining static/dynamic physical exercises, breathing exercises, and meditation on FM was investigated, it was reported that there were little number of patients and studies on the topic, and although there was a lowquality evidence, Qigong might be a useful approach for FM patients in terms of pain, life quality, and sleep improvements [44].

In a Cochrane compilation in which the aquatic exercise studies were compiled, it was reported in studies that compared study groups and control groups that improvements could be achieved in aquatic exercise group in terms of pain, involvement, and physical functions. When aquatic exercises were compared with land exercises, it was reported that there were no differences at a statistically significant level between the groups, and when aquatic exercises were compared with the Ai-Chi exercises, it was reported that Ai Chi was superior to aquatic exercises for stiffness [45]. Recently, a randomized-controlled study, which includes both aquatic therapy and land-based therapy (warm-up, proprioceptive exercises, stretching, and relaxation periods), was reported. In a program of the study being applied for 3 days a week for 3 months, improvements were determined in both groups in terms of pain and balance, but no significant differences were detected between the groups [46]. Andrade et al. [47] reported that aquatic physical training with standardized intensities did not cause significant changes in body composition but was effective in promoting increased VO2 at peak cardiopulmonary exercise test in women with FM [47]. The purposes of physical activity and exercise training include improving physical fitness and function together with the symptoms of fibromyalgia, and optimizing health, because a sedentary lifestyle and deconditioning are associated with the symptoms of fibromyalgia [20]. Moreover, a lower percentage of maximum capacity may be achieved in daily activities with more efficiency and the symptoms are less likely to increase [48]. Furthermore, targets depend on baseline body functions and the severity of the symptoms together with individual preferences and motivations [49]. In contrast, in a study, it was reported that nearly 2% of the competitive sport players had FM, which shows that people with FM may be extremely active. Although regular exercises (i.e., aerobic, strength, flexibility) are among the most important elements in the FM management, it is also important that the intensity, duration, incidence, and type of any adverse effects and frequency must be prescribed [50]. Prescribing exercises for FM patients requires extreme care. After a detailed assessment that includes cardiovascular system, a personal exercise program for the target is designed [48]. Although the most prominent exercises are aerobics and stretching exercises in many studies, there is no such thing as "the most proper treatment." Different exercises may be combined in the same séance or in different séances. However, the evidence level on flexibility exercises is low, and they are generally combined with stretching exercises [51].

Superficial heat and deep infrared heat, ultrasound application and the local thermal effect induced by stroking massages were reported to be useful for FM patients [58, 59]. The real

Nonpharmacologic Treatment for Fibromyalgia http://dx.doi.org/10.5772/intechopen.70515 41

The exact mechanisms of immersion of the body in mineral/thermal water or applying mud, which alleviates FM symptoms, are not understood adequately. It is considered that this effect

To discriminate between nonspecific mechanisms of simple bathe in hot water (hydrotherapeutic, in a broader sense), specific mechanisms (hydromineral and crenotherapeutic) depending on chemical and physical properties of the water are used. Buoyancy, resistance, immersion, and temperature together play important roles in this mechanism. Hot stimuli increase the threshold of pain and produce analgesia on nerve endings. A relief in muscle spasms is achieved via gamma fibers in muscle spindles and the descending pain inhibitory system is activated. The "Gate Theory" claims that relief in pain may stem from the temperature and hydrostatic pressure of water on the skin [61]. The absorption of minerals dissolved in thermal waters may be influential

Some previous studies reported that sulfur baths had anti-inflammatory effects. Spa water that includes sulfur is thought to inhibit the production of cytokines especially IL-2 and interferon gamma. It has been claimed by some authors that memory T-cells are the principal targets of waters that are rich in sulfur because they are mainly produced by CD4 lymphocytes. Sulfurcontaining water reduces the capacity of memory T-cells to proliferate and therefore the

The exact mechanism of balneotherapy on fibromyalgia is not clear yet. Ardiç et al. [64] showed decreased levels of anti-inflammatory markers interleukin 1 (IL-1), prostaglandin E2, and leukotriene B4 after 15 sessions of balneotherapy in 44 FM patients [64]. Furthermore, heat and mineral contents of water have useful effects on body (especially in musculoskeletal, endocrinologic system, and in pain pathways). They also contain increased plasma endorphin and cortisol levels, and are responsible for the activation of diencephalic-pituitary-adrenal axis and decreased plasma levels of several inflammatory mediators (IL-1, IL-6, prostaglandin E2, leukotriene B4, tumor necrosis factor alpha) [29, 61]. Balneotherapy is recommended strongly by AWMF, APS and EULAR for the FM treatment [31]. In EULAR recommendations, it has been stated that without balneotherapy and exercise, hydrotherapy would not have any superiority and both were recommended with weak recommendation level [10]. In a recent comprehensive meta-analysis that investigated the efficiency of balneotherapy in FM patients, it was reported that there was weak evidence on the efficiency of balneotherapy; however, it could be applied as a supplementary treatment together with the basic treatment. It has been observed that the frequency and duration of treatment were taken in different terms in many

In a 2-week study in which Bağdatlı et al. [66] compared the efficiency of balneotherapy and mud-pack, it was reported that Balneotherapy was a more efficient treatment in terms of

efficacy of both superficial and deep heat is still a topic for further studies [56].

stems from a combination of mechanical, thermal and chemical factors [60].

4.2. Balneotherapy, mud-pack/bath, hydrotherapy

in the mechanism of balneotherapy [61, 62].

cytokine production, which alters immune response [63].

different studies. There is no standardization on this [65].

It has been reported by many authors that the frequency of exercises must be increased gradually starting from low intensity (by using the "start-low & go-slow" technique) to achieve at least moderate intensity [52]. Strengthening exercises must be started at lower resistance level of the normal values according to the age. If pain, fatigue and other FM symptoms increase, the duration of exercise session must be decreased. Also, the intensity of the exercises should be increased by 10% within 2 weeks of exercise (without exacerbating the symptoms) [48]. In recent studies, a formula that was computed with heartbeat according to the age in FM patients was developed. In terms of the target heartbeat zones for aerobic training within the anaerobic threshold, a training intensity range was shown to improve cardiorespiratory fitness. In previous studies, authors reported that maximum heartbeat could be predicted by using either (208 (0.7 age)) or (220 age). They also suggested sedentary individuals with FM to train within the anaerobic threshold at 52–60% of the heartbeat reserve or at 75–85% of the predicted maximum heartbeat [53].
