Your muscles are tight and achy. You may even feel ropy bands with firm knots in the mid-section of the muscle. These are myofascial trigger points, and their location often overlaps with the 18 tender points used for diagnosing fibromyalgia. Just pressing on them can send your pain through the roof. But can muscle relaxants ease the tension in your muscles and help untie (or at least loosen) your painful knots?
The question of whether muscle relaxants can relieve your pain is complicated by the fact that this class of medications is very diverse, meaning that many drugs in this class vary substantially from the others. So some muscle relaxants might do the job better than others. Two fibromyalgia specialists offer advice on this topic based on their clinical experience, including which medications in this class they prefer and the doses they prescribe. See table below for more details.
Robert Katz, M.D., of Rush University Medical Center in Chicago, IL, says:
“Muscle relaxants do help reduce tenderness and may relax patients or ease their anxiety. I tend to prescribe Zanaflex and low dose Flexeril and use them quite often in the treatment of fibromyalgia. I tell patients I don’t want them sedated, but I also do not want their muscles so tender; I want their muscles relaxed.
“I start with very low doses, sometimes half a tablet, and I see how the patient does on it. I try to give these medications during the daytime when patients have their greatest amount of pain and muscle tenderness. Muscle relaxants have a transient effect. This means that patients cannot take them at bedtime to reduce morning stiffness eight hours later. They must be on board when the patient has the most amount of pain.
“I suspect that this class of medications somehow relaxes the central nervous system a bit and they also have a relaxing effect on the peripheral system (i.e., the muscles). It is somewhat like getting a massage. However, I have never been able to document how much these agents reduce muscle tenderness.”
Richard Podell, M.D., of the UMDNJ-Robert Wood Johnson Medical School, with practices in Springfield and Somerset, NJ, offers the following advice:
“Some patients find valium-type medications (i.e., benzodiazepines, including Klonopin and Xanax), Flexeril or Skelaxin useful for reducing muscle pain, stiffness, twitching, and spasms. Two muscle relaxants used in multiple sclerosis to treat muscle spasms, Zanaflex and Lioresal, are sometimes helpful in fibromyalgia, too. The major drawback for daytime use of these medications is sedation, with the exception of Skelaxin, because it does not effect the central nervous system.
“With regards to dosing, I typically begin with 25 to 50 percent of the usual standard starting dose. Fibromyalgia patients as a group are very sensitive to medication side effects, necessitating that one start low and build up slowly. Otherwise, the initial drug effects are likely to bowl a patient over.
“As to why these medications work, we know so little about drug mechanisms, I’ve learned to be quite humble. Some treatments should help in theory but they don’t and vice versa. More impressively, various drugs act one way in one person and the opposite in others, and it is not just people with fibromyalgia. It is well-known that benzodiazepine/valium-type relaxants cause sedation and relieve anxiety in most people, but produce activation and increased anxiety in a small yet significant subset.”
Lowest Possible Doses
In order to minimize daytime sedation and other side effects, Katz and Podell begin patients on the lowest possible dose. Here’s the rundown, with the generic name in parentheses:
- Flexeril (cyclobenzaprine): 5 mg (10 mg tablet cut in half)
- Lioresal (baclofen): 5 mg (10 mg tablet cut in half)
- Klonopin (clonazepam): 0.25 mg (0.5 mg tablet cut in half)
- Valium (diazepam): 1 mg (2 mg tablet cut in half)
- Xanax (alprazolam): 0.125 mg (0.25 mg tablet cut in half)
- Skelaxin (metaxalone): 200 mg (400 mg tablet cut in half)
- Zanaflex (tizanidine) : 1 mg (4 mg tablet is scored two ways)
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Though classified as a disorder of the musculoskeletal system, the condition is now seen as a central nervous system problem. Symptoms include increased sensitivity to pain, achy and stiff joints, fatigue, and specific tender points on the back, chest, arms, and legs. Migraines, sleep disorders, and irritable bowel syndrome are also common complaints. Up to 3 percent of the population may suffer from fibromyalgia, but with no clear cause, the condition is difficult to diagnose.
Western Medicine Approach:
A formal diagnosis for fibromyalgia didn’t exist until 1990, but now there are three FDA-approved meds to combat the pain. Still, says Nancy Klimas, MD, director of the Allergy and Immunology Clinic at the University of Miami, “there is much more to treatment than a pill.” Strategies are needed to improve sleep, stretch and restore symmetry to muscles that have been shortened by spasm, and raise overall conditioning through exercise.
Practitioners believe the root of fibromyalgia is a disturbance in nerves that blocks energy. The disturbance, says Devi S. Nambudripad, MD, PhD, and a licensed acupuncturist, is caused by sensitivities to substances ranging from pollen to vaccines to chemical agents in fabrics. Anxiety and depression may also play a part. Practitioners use acupuncture to release energy and allergy testing to identify problem substances.
Fibromyalgia is a systemwide breakdown, says Jacob Teitelbaum, MD, medical director of the nationwide Fibromyalgia & Fatigue Centers. After suffering from the disease in the 1970s, he developed his own protocol; in studies, patients improved by as much as 91 percent. He recommends supplements to help sufferers sleep, balance hormones, boost immunity, and improve nutrition. He also prescribes regular exercise.
“The pain of fibromyalgia is not caused by depression,” says Leonard Jason, PhD, professor of psychology at DePaul University, “but depression can deepen a patient’s experience of pain.” Mental health professionals may play a complementary role in treatment, but it’s a vital one. Cognitive behavioral therapy can relieve depression and help patients identify sources of stress that magnify their symptoms.
People with fibromyalgia face a unique challenge because they must combat not only the condition’s disabling symptoms, but they face the stress of having an illness that is hard to diagnose, slow to respond to treatment and frequently not taken seriously by others because they look normal. This combination of factors often leaves those with fibromyalgia feeling helpless and hopeless.
Feelings of anxiety and depression are common among people with fibromyalgia, with an average of 18 percent of fibromyalgia patients suffering major depression at any point in time (1).
The pain of fibromyalgia is not simply a physical entity; pain always has an emotional component, which varies from person to person.
To focus only on the cause and treatment of physical pain, ignores the profound impact of pain on your emotions. Everyone has their own perspective of pain. The same amount of pain that causes manageable discomfort in one person can be emotionally devastating to another.
The changes in your life that accompany fibromyalgia make pain even more difficult to handle. Most individuals find family support, the stability of a regular job, and the refreshment of physical activity help bolster them in overcoming life’s emotional hurdles. But chronic pain and sleep deprivation can erode a person’s normally dependable sources of stability, alienating friends and family. The resulting imbalance can make the original symptoms of pain, sleep loss, or social withdrawal even more distressful.
Some fibromyalgia sufferers find that seeing a psychiatrist or psychologist helps them to better manage the physical and emotional aspects of living with fibromyalgia. Seeking psychiatric assistance to cope with fibromyalgia, is not an admission that “it is all in your head.” Instead, you are accepting that having such an illness is difficult to manage. For instance, patients with rheumatoid arthritis often benefit from psychological counseling even though their condition has obvious physical changes.
As a fibromyalgia sufferer, you may seek simple, short-term counseling sessions or intensive therapy. Whatever the case, your treatment will ultimately depend on your individual needs.
Because Western medicine was slow to accept fibromyalgia, it is behind in its work; this is an area where patients will want to take a serious look at alternative approaches. Energy-based medicine could offer some important advances in treatment over the next decade, but since it has yet to be tested by independent research, it’s premature to base your therapy solely on this approach. I’m more impressed by Teitelbaum’s supplement regimen as he has tested his theories. I would add counseling, as it should always be a part of fibromyalgia treatment. If after a couple of months you don’t see improvement, talk to your doctor about drug therapy. You may also want to read this >>
(1) ”The relationship between fibromyalgia and major depressive disorder,” by J.I. Hudson and H.G. Pope, Rheumatic Disease Clinics of North America, Controversies in Fibromyalgia and Related Conditions, Vol. 22, No. 2, May 1996, pages 285-303.
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