4. Physical treatment modalities

The definition of physical therapies involves all treatments in which a physical activity or technique is used to have therapeutic effects. Such techniques are mostly used in the context of rehabilitation and are used on the basis of their ascertained mechanisms of action (i.e., the activation of the spinal gate, release of endogenous opiates, local metabolic action, etc.) Physical therapies have several types such as thermal (hot and cold), mechanical, light, electrical, and magnetic stimulation. Each of these has its own mechanism of action; however, peerreviewed evidence of their effectiveness in FM is missing. Recent reviews have reported nonhomogeneous results, while some reviews are cautious in stating efficacy based only on few randomized-controlled trials. It is strongly suggested to conduct more studies to show a long-term, effective intervention for managing the FM symptoms [54]. Other reviews that have anecdotal evidence or small-scale observational physiotherapy studies report that physical therapies can be effective for various symptoms [55, 56].

#### 4.1. Heat and cold

Although local cold therapy application with ice cubes or cooling sprays is useful in other muscle pains, they do not have any influence in FM. Cold sprays are applied with stretchspray techniques. On the other hand, whole body cryotherapy at 67C seems to have some short-term effect on some active trigger points and on the intensity of the pain. There are no data available about the long-term efficacy [56, 57].

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

#### 4.2. Balneotherapy, mud-pack/bath, hydrotherapy

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

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 definition of physical therapies involves all treatments in which a physical activity or technique is used to have therapeutic effects. Such techniques are mostly used in the context of rehabilitation and are used on the basis of their ascertained mechanisms of action (i.e., the activation of the spinal gate, release of endogenous opiates, local metabolic action, etc.) Physical therapies have several types such as thermal (hot and cold), mechanical, light, electrical, and magnetic stimulation. Each of these has its own mechanism of action; however, peerreviewed evidence of their effectiveness in FM is missing. Recent reviews have reported nonhomogeneous results, while some reviews are cautious in stating efficacy based only on few randomized-controlled trials. It is strongly suggested to conduct more studies to show a long-term, effective intervention for managing the FM symptoms [54]. Other reviews that have anecdotal evidence or small-scale observational physiotherapy studies report that physical

Although local cold therapy application with ice cubes or cooling sprays is useful in other muscle pains, they do not have any influence in FM. Cold sprays are applied with stretchspray techniques. On the other hand, whole body cryotherapy at 67C seems to have some short-term effect on some active trigger points and on the intensity of the pain. There are no

exercises is low, and they are generally combined with stretching exercises [51].

the predicted maximum heartbeat [53].

40 Discussions of Unusual Topics in Fibromyalgia

4. Physical treatment modalities

therapies can be effective for various symptoms [55, 56].

data available about the long-term efficacy [56, 57].

4.1. Heat and cold

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

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 in the mechanism of balneotherapy [61, 62].

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 cytokine production, which alters immune response [63].

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

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 nonrefreshed awaking, pain intensity, FIQ score, fatigue, stiffness, anxiety, and depression subscales of FIQ in the follow-up measurements 1 month after the treatment [66]. The efficiency of balneotherapy and mud-bath was compared in another randomized-controlled study, and it was reported that both the treatments were influential on FM symptoms; however, the effect of mud-bath lasted more [67]. In a study conducted by Neumann et al., it was reported that balneotherapy had useful effects on FM symptoms and on the life quality of the patients [68].

meta-analysis about the effectiveness of tDCS in FM, it is more likely to control pain and

Nonpharmacologic Treatment for Fibromyalgia http://dx.doi.org/10.5772/intechopen.70515 43

The data on using laser in FM are few and conflicting; however, there are some rare studies reporting efficacy. In some studies, it has been reported that there were no effects [75, 76] while in some others, it has been reported that there is a statistically significant reduction in both spontaneous and mechanical pain [77]. It is difficult to compare various treatment protocols because of the varying lengths of emission wave and power across different and nonstandard-

There are numerous studies in the literature on biofeedback approaches. Buckelew et al. [78] conducted a study and compared electromyogram (EMG) biofeedback, exercise training, combination treatment (biofeedback and exercise) and an educational/attention control group [78]. Compared to the control group, they reported that patients in the treatment groups showed improvements in some functional and clinical scores. Another controlled trial was conducted in which patients were assigned to either a fitness program or surface EMG, and the authors could not show significant improvement compared to the control group [79]. Although there are contrary results, the findings that are mostly positive suggest that EMG biofeedback may

In the revised recommendations of EULAR for managing FM, there were two reviews that were conducted about biofeedback. Glombiewski et al. [80] reviewed 7 studies with 321 participants. Treatment sessions varied from 6 to 22. The control therapy consisted of sham biofeedback, attention control, medication and treatment as usual. Biofeedback was influential in reducing the intensity of the pain, although all trials showed poor quality. EULAR has weak

Cognitive behavioral therapies (CBTs) are a combination of cognitive + behavioristic therapies. In cognitive part, such a therapy will ensure that there will occur changes in emotions and behaviors [18]. In this way, several drawbacks like overgeneralizing, magnifying negative aspects, minimizing positive ones and catastrophizing will be eliminated. Such drawbacks will be replaced with realistic and effective considerations, which will eventually decrease emotional stress and self-defeating behavior. Specifically, in FM, the consideration or the expectation of the worst possible outcome has been associated with the severity of the pain, decreased functioning and affective distress in FM [81, 82]. In cognitive therapy step, worries like "This is the worst pain, and I cannot do anything" are replaced with statements such as "Although my pain is worse, there are still things I can do to lessen it." Behavioral therapy, on the other hand, unlike the cognitive one, is based on the claim that thoughts and feelings are not as important as

improve general FM-related function in FM patients than sham tDCS [74].

be a preferred treatment option for some patients with FM [18].

opposition about biofeedback [10].

5. Cognitive behavioral therapies

4.5. Laser

ized protocols [56].

4.6. Biofeedback

After the treatment, Evcik et al. [69] reported important improvements in three parameters. It was reported in their study that there were low FIQ scores and some painful points at the sixth month follow-up assessments when they compared the baseline. However, Beck depression scores were increased to near-baseline level [69]. Dönmez et al. [70] also conducted a study and reported that balneotherapy was influential on FIQ scores, sleep disturbance, and on some painful points when compared to the baseline values in the sixth month [70]. In a randomizedcontrolled study in which combined treatment approaches were compared, it was reported that when balneotherapy and aerobic exercises were applied together with the existing treatment, the FIQ, depression scale, sleep quality, and total myalgic scores were better when compared to the exercise + balneotherapy group, and in addition, the effect duration could last as long as 3 months in terms of sleep quality in a combined therapy [29].

#### 4.3. Electrical stimulation: TENS

Electrical current is the most frequently used physical therapy technique in pain management. Transcutaneous electrical nerve stimulation (TENS) is an electrical current for pain relief applied by means of superficial electrodes applied on skin. Investigators have found positive results with fibromyalgia using TENS [71]. In one review article, it was reported that TENS was a useful methodology to control specific symptoms like localized musculoskeletal pain [55]. On the other hand, it is possible to claim that TENS and related techniques can be useful in treating specific, contingent and localized pains, but they do not have obvious effects on generalized pain syndromes like FM [56].

#### 4.4. Transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS)

The possibility of central mechanisms in the pathogenesis of FM has led to the idea that transcranial stimulation treatments can be performed. Thus, studies were conducted in FM patients. The tDCS procedure applies a weak current to the scalp, while TMS therapy uses electrical current to produce a magnetic field. Then this magnetic field penetrates to skull to generate an electrical field in the brain of the patient. Stimulation of the primary motor cortex produces antinociceptive effects, while stimulation of the dorsolateral prefrontal cortex has antidepressant effects.

In a review that examined the effectiveness of tDCS and TMS, decrease in pain scores was reported after these treatments, but different results were reported in the number of tender points, in functional assessments, and in depression scales [72]. In a guideline about therapeutic use of tDCS, level B evidence (probable efficacy) was found for FM [73]. In a more recent meta-analysis about the effectiveness of tDCS in FM, it is more likely to control pain and improve general FM-related function in FM patients than sham tDCS [74].

#### 4.5. Laser

nonrefreshed awaking, pain intensity, FIQ score, fatigue, stiffness, anxiety, and depression subscales of FIQ in the follow-up measurements 1 month after the treatment [66]. The efficiency of balneotherapy and mud-bath was compared in another randomized-controlled study, and it was reported that both the treatments were influential on FM symptoms; however, the effect of mud-bath lasted more [67]. In a study conducted by Neumann et al., it was reported that balneotherapy had useful effects on FM symptoms and on the life quality of the

After the treatment, Evcik et al. [69] reported important improvements in three parameters. It was reported in their study that there were low FIQ scores and some painful points at the sixth month follow-up assessments when they compared the baseline. However, Beck depression scores were increased to near-baseline level [69]. Dönmez et al. [70] also conducted a study and reported that balneotherapy was influential on FIQ scores, sleep disturbance, and on some painful points when compared to the baseline values in the sixth month [70]. In a randomizedcontrolled study in which combined treatment approaches were compared, it was reported that when balneotherapy and aerobic exercises were applied together with the existing treatment, the FIQ, depression scale, sleep quality, and total myalgic scores were better when compared to the exercise + balneotherapy group, and in addition, the effect duration could last

Electrical current is the most frequently used physical therapy technique in pain management. Transcutaneous electrical nerve stimulation (TENS) is an electrical current for pain relief applied by means of superficial electrodes applied on skin. Investigators have found positive results with fibromyalgia using TENS [71]. In one review article, it was reported that TENS was a useful methodology to control specific symptoms like localized musculoskeletal pain [55]. On the other hand, it is possible to claim that TENS and related techniques can be useful in treating specific, contingent and localized pains, but they do not have obvious effects

4.4. Transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation

The possibility of central mechanisms in the pathogenesis of FM has led to the idea that transcranial stimulation treatments can be performed. Thus, studies were conducted in FM patients. The tDCS procedure applies a weak current to the scalp, while TMS therapy uses electrical current to produce a magnetic field. Then this magnetic field penetrates to skull to generate an electrical field in the brain of the patient. Stimulation of the primary motor cortex produces antinociceptive effects, while stimulation of the dorsolateral prefrontal cortex has

In a review that examined the effectiveness of tDCS and TMS, decrease in pain scores was reported after these treatments, but different results were reported in the number of tender points, in functional assessments, and in depression scales [72]. In a guideline about therapeutic use of tDCS, level B evidence (probable efficacy) was found for FM [73]. In a more recent

as long as 3 months in terms of sleep quality in a combined therapy [29].

patients [68].

(TMS)

antidepressant effects.

4.3. Electrical stimulation: TENS

42 Discussions of Unusual Topics in Fibromyalgia

on generalized pain syndromes like FM [56].

The data on using laser in FM are few and conflicting; however, there are some rare studies reporting efficacy. In some studies, it has been reported that there were no effects [75, 76] while in some others, it has been reported that there is a statistically significant reduction in both spontaneous and mechanical pain [77]. It is difficult to compare various treatment protocols because of the varying lengths of emission wave and power across different and nonstandardized protocols [56].

#### 4.6. Biofeedback

There are numerous studies in the literature on biofeedback approaches. Buckelew et al. [78] conducted a study and compared electromyogram (EMG) biofeedback, exercise training, combination treatment (biofeedback and exercise) and an educational/attention control group [78]. Compared to the control group, they reported that patients in the treatment groups showed improvements in some functional and clinical scores. Another controlled trial was conducted in which patients were assigned to either a fitness program or surface EMG, and the authors could not show significant improvement compared to the control group [79]. Although there are contrary results, the findings that are mostly positive suggest that EMG biofeedback may be a preferred treatment option for some patients with FM [18].

In the revised recommendations of EULAR for managing FM, there were two reviews that were conducted about biofeedback. Glombiewski et al. [80] reviewed 7 studies with 321 participants. Treatment sessions varied from 6 to 22. The control therapy consisted of sham biofeedback, attention control, medication and treatment as usual. Biofeedback was influential in reducing the intensity of the pain, although all trials showed poor quality. EULAR has weak opposition about biofeedback [10].

## 5. Cognitive behavioral therapies

Cognitive behavioral therapies (CBTs) are a combination of cognitive + behavioristic therapies. In cognitive part, such a therapy will ensure that there will occur changes in emotions and behaviors [18]. In this way, several drawbacks like overgeneralizing, magnifying negative aspects, minimizing positive ones and catastrophizing will be eliminated. Such drawbacks will be replaced with realistic and effective considerations, which will eventually decrease emotional stress and self-defeating behavior. Specifically, in FM, the consideration or the expectation of the worst possible outcome has been associated with the severity of the pain, decreased functioning and affective distress in FM [81, 82]. In cognitive therapy step, worries like "This is the worst pain, and I cannot do anything" are replaced with statements such as "Although my pain is worse, there are still things I can do to lessen it." Behavioral therapy, on the other hand, unlike the cognitive one, is based on the claim that thoughts and feelings are not as important as 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 lowering stress (for example imagery, breathing, muscle relaxation, etc.) [18].

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

Nonpharmacologic Treatment for Fibromyalgia http://dx.doi.org/10.5772/intechopen.70515 45

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

Massage is commonly used in TCM therapy in FM patients. Based on the patient survey data,

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

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

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

"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

than 5 weeks gave significant improvement in pain, anxiety, and depression [89, 92].

the intervention has been reported with the highest satisfaction levels [18].

allocation. EULAR has a weak opposition about massage [10].

6.3. Meditative movement/mindfulness/mind-body therapy

chiropractic treatments [10].

consistent. EULAR proposes acupuncture as weak [10].

6.2. Manual therapy/massage/chiropractic

lubricates and hydrates the corrective tissues [91].

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

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