Fibromyalgia Management: Integrating Acupuncture and Mindfulness Practice
Abstract
Fibromyalgia is a complex chronic pain condition that is difficult to treat and affects nearly 2% of the United States population. Although most guidelines encourage non-pharmacological modalities as initial treatment approaches, there is no adequate standard of care. Most patients require gentle multimodal integrative approaches to pain management. This paper includes scientific research to support acupuncture and mindfulness practices as useful methods for managing fibromyalgia pain. Clinical experiences with the use of acupuncture and mindfulness practice suggest when used together, pain symptoms improve with lasting results by targeting both mind and body approaches. In addition to a display of evidence supporting these claims, this paper also reviews techniques that may be implemented by acupuncture practitioners and other medical professionals in a clinical setting.
Fibromyalgia Management: Integrating Acupuncture and Mindfulness Practice
Fibromyalgia is a complex disease that affects nearly 2% of the United States' adult population, according to the Centers for Disease Control (2020), totaling approximately 4 million adults and climbing. Given the number of patients with fibromyalgia, it is a condition that deserves more funding for research in integrative care since the pathogenesis and etiology are still not understood in the scientific community.
Fibromyalgia is also known as "pain syndrome." The article Fibromyalgia syndrome: etiology, pathogenesis, diagnosis, and treatment (Bellato et al., 2012) states that fibromyalgia is a condition that can be characterized by "chronic widespread pain at multiple tender points, joint stiffness, and systemic symptoms (e.g., mood disorders, fatigue, cognitive dysfunction, and insomnia) without a well-defined underlying organic disease."
There is currently no adequate standard of care, though most guidelines encourage non-pharmacological methods as initial approaches to treatment.
Mechanisms of Fibromyalgia
The mechanism of fibromyalgia and most other idiopathic pain remains a mystery to the scientific community. There is, however, enough evidence to support that, at minimum, idiopathic pain can be attributed to a neuropathic imbalance with increased nociceptive input. In a healthy patient, when he or she experiences pain, the proprioceptive nerves tell the body where it is experiencing pain and sends strong signals to the midbrain to release enkephalins, the body’s natural opioids. These enkephalins then block pain receptors that lie along the spine, reducing the signals from nociceptive nerves, which tell our body to experience pain.
In fibromyalgia and other chronic pain cases, the proprioceptive nerves' signal strength becomes weakened, resulting in an inability to reach the midbrain to release enkephalins leading to a persistent input of nociceptive signals. This persistent nociception can result in increased inflammatory cytokines and changes to the brain and spinal cord, ultimately leading to chronic pain conditions such as fibromyalgia.
An article titled Effects of Cognitive-Behavioral Therapy on Brain Connectivity Supporting Catastrophizing in Fibromyalgia (Lazaridou et al., 2017) suggests catastrophizing proliferates pain symptoms and causes fibromyalgia. With magnetic resonance imaging, this study identified more activity in the brain's pain areas while patients were ruminating on their pain symptoms, and less activity when they were engaged in mindfulness practices.
Description of Research
There have been many studies confirming the effectiveness of mindfulness practices and acupuncture in combatting symptoms of fibromyalgia. As the condition is still not fully understood, there is no standard of care in western medicine that works for each patient. Most patients require gentle multimodal integrative approaches to pain management. Acupuncture targets the proprioceptive nervous system, while the practice of mindfulness targets catastrophizing. These modalities can be used in tandem to provide a holistic approach to the two major factors contributing to increased nociceptive input and fibromyalgia pain.
Acupuncture
A study titled Acupuncture therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials (Zhang et al., 2019) supports acupuncture as a safe and effective method of managing fibromyalgia. This study used twelve randomized control trials, all of which compared acupuncture to sham acupuncture or pharmaceuticals. These twelve studies supported acupuncture as being the most effective modality in achieving quality of life in the long term with no adverse side effects.
The Mechanisms of acupuncture-electroacupuncture on persistent pain (Zhang et al., 2014) uses animal studies to identify how acupuncture works within the body to reduce chronic pain. It shows that the acupuncture needle draws blood to the area of insertion, encouraging circulation. An analgesic effect is promoted by placing needles both locally and distally in the retinaculum, which is thick with fascia and abundant with proprioceptive nerves. Stimulating these nerves locally and distally increases proprioceptive signal strength, tells the midbrain to release opioids that will block pain receptors, and desensitize nociceptive input.
Mindfulness
A study by Adler-Neal and Zeidan (2017) mentions that fibromyalgia patients experience psychological distress, leading to increased pain sensitivity by releasing pro-inflammatory cytokines. This inflammation heightens nociceptive input by releasing the neuropeptide substance P. This persistent nociceptive stimulation leads to a desensitizing of proprioception and chronic pain. Improving stress management in patients suffering from fibromyalgia will decrease inflammatory processes that lead to chronic pain.
This study mentions several trials supporting mindfulness practices in fibromyalgia management, but more are needed to identify which interventions work the most effectively. There are many approaches to practicing mindfulness, including breathing meditations, walking and eating meditations, yoga, and even mindfulness homework.
Several studies, including Meditation awareness training for the treatment of fibromyalgia syndrome: A randomized controlled trial (Van Gordon et al., 2016), support mindfulness approaches that focus on social engagement, non-attachment, and acceptance as the most effective interventions when managing pain. This study observed 74 patients using mindful meditation to manage fibromyalgia and 74 patients receiving the control, cognitive behavioral therapy. Patients in the mindfulness meditation group showed more significant immediate and sustained relief from fibromyalgia symptoms than their counterparts in the control group.
Description of Own Experience using Mindfulness and Acupuncture
Each patient is unique and may require different approaches to managing fibromyalgia. The integration of acupuncture and mindfulness practices will often help a patient restore neuropathic homeostasis that the body needs to live pain-free.
Because of acupuncture's immediate activation of the nervous system, it is not uncommon for patients to experience relief after one session of gentle needle technique. Studies show chronic pain will likely return with catastrophizing and rumination, so it is essential to implement guided meditation to moderate stress and help patients detach from painful experiences.
Anecdotal evidence gathered in a clinical setting suggests meditation should begin before the acupuncture treatment begins. In this meditation, patients are first prompted to notice the rise and fall of their belly and chest, an exercise called guided breathing. The practitioner then asks the patient to observe that their body feels lighter and more expansive with each inhale, and then smaller and heavier with each exhale. The patient is then asked to notice a sensation of melting into the table with each exhale.
During the acupuncture treatment, practitioners use guided imagery such as a body scan, gratitude meditation, sound meditation, or picturing each detail of a place in nature that generates peace. One effective technique is to have the patient focus on their heart, visualizing a small bright light radiating from their chest. The patient is encouraged to let the bright light serve as a reflection of their happiest, healthiest, and safest self. The patient is guided to let the light grow bigger with each breath until it encompasses their entire body as if submerged in bathwater. During this meditation, the practitioner follows an appropriate acupuncture protocol to address pain symptoms, providing physical relief that reinforces the positive experience of the meditation.
These simple guided meditations have helped patients control their thoughts and identify when they are ruminating on pain or catastrophizing. The patient can then build enough control of their mind to shift their focus from pain to a peaceful and pain-free space. Experience suggests patients have better outcomes when they are encouraged to take mindful practices home and work on them every day.
Through the tangible effects from acupuncture treatments integrated with mindful practices, neuropathic homeostasis in the body can be achieved with the lasting results of a symptom-free patient.
Conclusion and Recommendation
Evidence exists to support acupuncture and mindfulness practices as beneficial and effective in treating patients suffering from fibromyalgia. Where acupuncture works to improve the physical, neurological imbalances in the body that induce pain, mindfulness helps strengthen the psychological distress that causes pain and inflammation. By integrating this mind-body approach to healing, fibromyalgia is managed effectively from each angle. While each modality may be useful on its own, together, they produce lasting results.
Clinical experience suggests acupuncture practitioners who apply mindfulness meditations in their own office by guiding patients through breathing techniques, body awareness, or imagery contributes to a reduction of symptoms in their fibromyalgia patients. In addition to meditation during treatment, practitioners should encourage patients to download guided meditation apps, practice gentle yoga, or visit a mindfulness meditation specialist. To ensure patients receive proper support of the mind and body in dealing with fibromyalgia, guided meditation experts should also refer patients or students to acupuncture practitioners for collaborative care. By integrating these two effective techniques, fibromyalgia patients may improve significantly.
References
Center for Disease Control and Prevention. (January 6, 2020) Fibromyalgia.
https://www.cdc.gov/arthritis/basics/fibromyalgia.htm
Bellato, E., Marini, E., Castoldi, F., Barbasetti, N., Mattei, L., Bonasia, D. E., & Blonna,
D. (2012). Fibromyalgia syndrome: etiology, pathogenesis, diagnosis, and treatment. Pain research and treatment, 2012, 426130. https://doi.org/10.1155/2012/426130
Lazaridou, A., Kim, J., Cahalan, C. M., Loggia, M. L., Franceschelli, O., Berna, C.,
Schur,P., Napadow, V., & Edwards, R. R. (2017). Effects of Cognitive-Behavioral Therapy (CBT) on Brain Connectivity Supporting Catastrophizing in Fibromyalgia. The Clinical journal of pain, 33(3), 215–221. https://doi.org/10.1097/AJP.0000000000000422
Zhang, X. C., Chen, H., Xu, W. T., Song, Y. Y., Gu, Y. H., & Ni, G. X. (2019).
Acupuncture therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. Journal of pain research, 12, 527–542. https://doi.org/10.2147/JPR.S186227
Zhang, R., Lao, L., Ren, K., & Berman, B. M. (2014). Mechanisms of acupuncture
electroacupuncture on persistent pain. Anesthesiology, 120(2), 482–503. https://doi.org/10.1097/ALN.0000000000000101
Adler-Neal, A. L., & Zeidan, F. (2017). Mindfulness Meditation for Fibromyalgia:
Mechanistic and Clinical Considerations. Current rheumatology reports, 19(9), 59. https://doi.org/10.1007/s11926-017-0686-0
Van Gordon, W., Shonin, E., Dunn, T. J., Garcia-Campayo, J., & Griffiths, M. D. (2017).
Meditation awareness training for the treatment of fibromyalgia syndrome: A randomized controlled trial. British journal of health psychology, 22(1), 186–206. https://doi.org/10.1111/bjhp.12224
Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., Newberry, S., Colaiaco, B.,
Maher, A. R., Shanman, R. M., Sorbero, M. E., & Maglione, M. A. (2017). Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, 51(2), 199–213. https://doi.org/10.1007/s12160-016-9844-2
Arnold, L. M., Clauw, D. J., Dunegan, L. J., Turk, D. C., & FibroCollaborative (2012). A
framework for fibromyalgia management for primary care providers. Mayo Clinic proceedings, 87(5), 488–496. https://doi.org/10.1016/j.mayocp.2012.02.010