Fibromyalgia Treatment|Fibromyalgia Pain Treatment
 

Fibromyalgia

What is fibromyalgia syndrome?

Fibromyalgia syndrome (FMS) is a common widespread pain condition. It occurs in about 3.4% of women and 0.5% of men. Wolfe, F., & Cathey, W. (1983). Prevalence of primary and secondary fibrositis. Journal of Rheumatology, 10, 965-968. It has a typical set of symptoms:  

  • Widespread pain

  • Heightened perceptual sensitivities to pain and touch

  • Excessive fatigue

  • Sleep disturbance

  • Morning stiffness

  • Limited cognitive deficits

  • Anxiety

While not considered part of FMS per se, patients commonly also report irritable bowel symptoms, Reynaud’s symptoms, dysmenorrhea, urinary urgency, and depression.  

 

fibromyalgia

 

FMS has long been considered a diagnosis of exclusion, meaning all other conditions, such as rheumatoid arthritis or osteoarthritis, must first be ruled out. For this reason, FMS is sometime referred to pejoratively as ‘a wastebasket’ diagnosis.

 

However, there is increasing consensus among healthcare providers that FMS is an actual condition and that it is a disorder of central sensitization. Martinez-Lavin, M. (2007). Biology and therapy of fibromyalgia: Stress, stress response, and fibromyalgia. Arthritis Research and Therapy, 9, 216. Clauw, D. J. (2009). Fibromyalgia: An overview. Pain, 122(12), S3-S13. Meeus M., & Nijs, J. (2007). Central sensitization: A biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Journal of Rheumatology, 26, 465-473. Central sensitization is a condition of the nervous system. The nervous system becomes stuck in a state of high reactivity. Central sensitivity involves multiple changes to the nervous system, including the brain, and leads to all of the above-mentioned symptoms.  

 

There is no definitively known cause of FMS. Likely, there are multiple types of causes across different individuals with FMS as well as multiple factors leading to the condition within any one individual. FMS has some known risk factors that may be involved in bringing on FMS: traumatic injury, surgery, illness; interpersonal trauma and anxiety; sleep disturbance; and perfectionistic personality traits. There may also be some genetic predisposition that must be in place before the other factors can lead to the condition.

 

The course of FMS can vary across different individuals. While it can get worse, it is not inevitable that it worsens. Additionally, with treatment, it can get better.  

 

Is there a cure for fibromyalgia syndrome?

FMS has no cure.  It is a chronic pain disorder. Chronic conditions are health conditions that have no cure and which tend to last indefinitely. Healthcare for chronic conditions focuses on the following: 

  • Reducing symptoms

  • Reducing the impact that the condition has on the patient’s life

The goal is to live well despite having the condition.  

 

Therapies & procedures for fibromyalgia syndrome

Common treatments for FMS are anti-inflammatory medications, antidepressant medications, anticonvulsant medications, opioid medications, physical therapy, trigger point injections, cognitive behavioral therapy, and chronic pain rehabilitation programs.  

 

These therapies are not equally effective. In fact, their relative effectiveness varies quite a bit. Additionally, conventional agreement suggests that no one therapy, even when it is in fact helpful, is not sufficient by itself for patients to dramatically improve. As such, most clinicians agree that effective treatment for FMS requires a multidisciplinary approach.

 

Anti-inflammatory medications

Non-steroidal, anti-inflammatory medications are either over-the-counter or prescribed pain medications. FMS patients commonly take them.  In preparation for developing treatment guidelines for the American Pain Society, Goldenberg Goldenberg, D. L., Burckhardt, C., & Crofford, L. (2004). Management of fibromyalgia syndrome. Journal of the American Medical Association, 292, 2388-2395. doi:  10.1001/jama.292.19.2388 reviewed the research literature on all common treatments for FMS, including the use of non-steroidal, anti-inflammatory medications. They found no evidence to support the use of these medications for FMS.  

 

Antidepressants medications

Because some antidepressants are heavily advertised for use in FMS, patients are frequently familiar with them. When considering their use, it is important to understand the different types of antidepressants and their relative effectiveness.  

 

Roughly, there are three types of antidepressant medications. Serotonin norepinephrine reuptake inhibitors (SNRI’s) are the newest types of antidepressant medications. SNRI’s are typically the ones that are advertised for use in FMS. Selective serotonin reuptake inhibitors (SSRI’s) are the second type and are a little older. They were originally developed for use in depression. They are now sometimes also used for FMS. Tricyclic antidepressants are the third type. They are the oldest type of antidepressants. They too were originally developed for use in depression. However, they also have a long history of use for FMS, chronic pain in general, and sleep disturbances.  

 

Surprisingly, the newest type of antidepressant medications, the SNRI’s, are not the most effective, despite having been specifically developed for use in FMS. Hauser, W., Wolfe, F., Tolle, T., Uceyler, N. & Sommer, C. (2012). The role of antidepressants in the management of fibromyalgia: A systematic review and meta-analysis. CNS Drugs, 26, 297-307. The most effective type of antidepressant are the tricyclics. These are the oldest type.  They are moderately effective in reducing pain and sleep disturbance. They are also mildly effective in reducing fatigue.  

 

The SNRI’s, the newest type of antidepressants, are at most mildly effective in reducing pain. Neusch, et al., Neusch, E., Hauser, W., Bernardy, K., Barth, J. & Juni, P. (2013). Comparative efficacy of pharmacological and non-pharmacological interventions in fibromyalgia syndrome: Network meta-analysis. Annals of the Rheumatic Diseases, 72, 955-962. in their meta-analysis, found that the effectiveness of SNRI's is statistically significant, when compared to a placebo, but the improvement is so small that it is questionable whether it is clinically relevant. Their effect on reducing sleep disturbance, fatigue, and depression are not substantial. 6  

 

The SSRI’s are also mildly effective for reducing pain and depression. Their effect on sleep disturbance was not substantial. 6  

 

All antidepressants tend to have high rates of discontinued use because of intolerable side effects.

 

Anticonvulsants medications

Anticonvulsant medications are also commonly prescribed for FMS. Patients might know of at least some of these medications as they are also frequently advertised. Meta-analyses 7 Hauser, W., Bernardy, K., Uceyler, N., & Sommer, C. (2009). Treatment of fibromyalgia syndrome with gabapentin and pregabalin – A meta-analysis of randomized controlled trials. Pain, 145, 169-181. Straube, S., Derry, S., Moore, R. A., & McQuay, H. J. (2010). Pregabalin in fibromyalgia:  Meta-analysis of efficacy and safety from company clinical trial reports. Rheumatology, 49, 706-715. doi: 10.1093/rheumatology/kep432 Tzellos, T. G., Toulis, K. A., Goulis, D. G., Papazisis, G., Zampellis, Z. A., Vakfari, A., & Kouvelas, D. (2010). Gabapentin and pregabalin in the treatment of fibromyalgia: A systematic review and meta-analysis. Journal of Clinical Pharmacy and Therapeutics, 35, 639-656. doi: 10.1111/j.1365-2710.2009.01144.x show that they are statistically better than placebo, but likely only mildly effective.

 

Hauser, et al., 8 in their meta-analysis, reported effect sizes with use of gabapentin and pregabalin in the mildly effective range. Straube, et al., 9 and Tzellos, et al., 10 did not cite standard effect sizes, but rather a different statistic called, number needed to treat (NNT). This statistic represents how many people on average need to be treated before one of them achieves at least a 50% reduction in their symptoms. Both studies show that the NNT for anticonvulsant medications is 7 to 8. That is to say, on average, seven to eight FMS patients will have to be treated with anticonvulsants before one of them will have a 50% or greater reduction in pain. Both of the latter studies cite high rates of discontinuing the medications because of intolerable side effects.

 

Opioid medications

Opioid medications are narcotic pain medications. Their use is controversial for FMS, or for any type of noncancer, chronic pain. In their review of the research literature, Goldenberg, et al., 5 found no studies that found opioid medications to be effective for FMS.

 

Physical therapy

Physical therapy is generally considered a necessary therapy for FMS. It is consistently shown to be moderately effective in reducing pain and depression, and in increasing functioning. Specifically, low impact aerobic exercise is typically considered the gold standard. 5 7 Busch, A. J., Barber, K. A., Overend, T. J., Peloso, P. M., & Schachter, C. L. (Updated August 17, 2007). Exercise for treating fibromyalgia. In Cochrane Database Reviews, 2007, (4). Retrieved May 16, 2011, from The Cochrane Library, Wiley Interscience. However, Hooten, et al., Hooten, W. M., Qu, W., Townsend, C. O., & Judd, J. W. (2012). Effects of strength vs aerobic exercise on pain severity in adults with fibromyalgia: A randomized equivalence trial. Pain, 153, 915-923. found that strengthening exercises were similarly effective as low impact aerobic exercise.

 

Trigger point injections

In their review of the research, Goldenberg, et al., 5 found no evidence to suggest that trigger point injections are effective in the management of FMS.

 

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a common type of treatment that emphasizes self-management. Self-management is a catchall phrase for a number of health behaviors and ways of coping which, when done by the patient, can have positive effects on FMS.  The positive effects are the following:

  • Reducing symptoms of FMS (by reducing the reactivity of the nervous system)

  • Getting better at coping with the symptoms that remain so that they are less distressing and impairing

A health psychologist who specializes in chronic pain rehabilitation usually provides CBT.  

 

A meta-analysis of clinical trials of CBT for FMS shows that CBT is mildly to moderately effective in reducing pain, fatigue, sleep disturbances, and disability. Glombiewski, J. A., Sawyer, A. T., Guterman, J., Koenig, K., Reif, W., & Hofmann, S. G. (2010). Psychological treatments for fibromyalgia: A meta-analysis. Pain, 151, 280-295. Moreover, unlike any other treatment for FMS, these effects are long-lasting. A later meta-analysis also found CBT effective for FMS. 7

 

Multidisciplinary chronic pain rehabilitation

Multidisciplinary chronic pain rehabilitation consists of cognitive behavioral therapy, mild aerobic exercise and other types of physical therapy as needed, and non-narcotic pain medication management. The latter usually consists of the use of antidepressant medications or anticonvulsant medications.  

 

In their meta-analysis, Hauser, et al., Hauser, W., Bernardy, K., Arnold, B., Offenbacher, M., & Schiltenwolf, M. (2009). Efficacy of mulicomponent treatment in fibromyalgia syndrome: A meta-analysis of randomized controlled clinical trials. Arthritis & Rheumatism, 61, 216-224. found that multidisciplinary care as described above was moderately effective in reducing pain, and very effective in reducing fatigue and depression, and very effective in increasing quality of life.

 

Numerous investigators conclude that multidisciplinary chronic pain rehabilitation is the gold standard for treatment of FMS. 5 7 Rossy, L. A., Buckelew, S. P., Dorr, N., Hagglund, K. J., Thayer, J. F., McIntosh, M. J., Hewett, J. E., & Johnson, J. C. (1999). A meta-analysis of fibromyalgia treatment interventions. Annals of Behavioral Medicine, 21, 180-191. Sarzi-Pattuni, P., Buskila, D., Carrabba, M., Doria, A., & Atzeni, F. (2008). Treatment strategy in fibromyalgia syndrome: Where are we now? Seminars in Arthritis and Rheumatism, 37, 353-365.

 

Author

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain. The Institute for Chronic Pain is an educational and public policy think tank. Its purpose is to bring together thought leaders from around the world in the field of chronic pain rehabilitation and provide academic-quality information that is also approachable to all the stakeholders in the field: patients, their families, generalist healthcare providers, third party payers, and public policy analysts. Its aim is to change the culture of how chronic pain is managed through education and consultation efforts that advocate for the use of empirically supported conceptualizations and treatments of chronic pain. Dr. McAllister is also on staff of the chronic pain rehabilitation services for Courage Kenny Rehabilitation Institute, Minneapolis, MN, USA. He also blogs at the Institute for Chronic Pain Blog.

 

References

Last Updated on Friday, 14 November 2014 23:55

Published on Friday, 27 April 2012 13:37

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