Clinical Correlate 7: Fibromyalgia
Study Questions:
1. What is the physiological difference between myofascial pain syndrome and FMS? What diagnostic elements can help you distinguish between the two? Would trigger point injections (injections of local anesthetic into the muscle at the area of soreness) be more effective in treating FMS or myofascial pain syndrome?
2. Many times, sedatives and hypnotics disrupt the natural sleep cycle, stopping the natural progression of types of sleep. Considering FMS patients never reach Stage 3 or 4 of sleep, would you suggest sedatives or hypnotics in treatment of FMS?
3. If FMS is due to a disruption of the neuroendocrine response to stress, would a patient with FMS be hyperreactive or hyporeactive to stress? What data supports your answer?
A. Goldenberg DL, Burckhardt C, Crofford L. Management of Fibromyalgia Syndrome. JAMA. 2004;292:2388-2395.
In the previous clinical correlate, we discussed chronic fatigue syndrome and the difficulty in its treatment and diagnosis. Fibromyalgia syndrome (FMS) is similar to CFS in its unclear pathophysiology as well as that it is difficult to treat and diagnose ; in fact, it lies within the same spectrum as CFS. Currently, the diagnosis of FMS is made on the basis of a history of widespread pain (bilateral on both the upper and lower body) and excessive tenderness in at least 11 of 18 specific muscle-tendon sites. Additionally, patients with FMS are more likely to have lowered pain thresholds and altered pain perception and processing than unaffected persons. Since the symptoms are global, and because FMS is often comorbid with CFS and irritable bowel syndrome, it is thought that the cause is related to the neuroendocrine system, specifically the response to stress. Studies have shown that patients with FMS have altered neuroendocrine patterns both basally and in response to stimulus. Therefore, it is reasonable to believe that treatment involving the nervous and endocrine system may be beneficial.
This article reviewed over 500 published human trials on the topic of FMS to determine what treatment, if any, consistently ameliorated patients’ lives. Most of the studies measured change in pain and fatigue and used the Fibromyalgia Impact Questionnaire (FIQ), which measures both physical and psychological aspects of FMS.
Both pharmacologic and nonpharmacologic treatments were examined. Since FMS involves the nervous system, antidepressants, muscle relaxants, and anticonvulsants (which all affect neurochemicals) have all proven to be effective. Tricyclic antidepressants, specifically amitriptyline and cyclobenzaprine, have consistently shown to be effective, while other antidepressants, such as SSRIs and SNRIs, have not been as consistently effective. Tramadol, an analgesic, as well as pregabalin, an anticonvulsant, have been shown to be moderately effective in the RCTs published (there are currently RCTs underway to examine these drugs more). There is very little evidence to support the use of growth hormone, serotonin, and S-adenosyl-methionine. There is no evidence to support use of NSAIDs, opiods, hypnotics, corticosteroids, melatonin, calcitonin, thyroid hormone, DHEA, or magnesium.
For nonpharmacologic treatments, patient education, cardiovascular exercise, cognitive-behavior therapy (CBT), and multi-disciplinary therapy have all consistently been shown to be effective. Patient education was shown to be effective in relieving FMS, even though the various education programs varied in length and format. High-intensity, aerobic, muscle strengthening, and pool exercise have all been shown to improve FMS. CBT techniques, including meditation, relaxation, and stress management, have consistently shown improvement. Additionally, these techniques, when combined, significantly improve FMS. Strength training, acupuncture, hypnotherapy, biofeedback, and balneotherapy have all been effective, but not strongly and consistently. There is little evidence to suggest electrotherapy, chiropracty, or manipulation, and none to suggest trigger point injections or just flexibility exercise are effective treatments. Trigger point injection is clinically common, but there has not been an RCT to prove its effectiveness.
Based on these results, physicians should initiate a low dose of a tricyclic antidepressant in combination with cardiovascular exercise and CBT as soon as they have diagnosed as patient with FMS and evaluated and addressed the common comorbidities. If this treatment plan does not work, referring to a specialist or initiating another medication (SSRIs SNRIs, tramadol, or anticonvulsants) would be appropriate.
While there have been over 500 RCTs on the treatment of FMS, there is still much to explore. First of all, these trials have shown that FMS can be quite heterogeneous in its expression and treatment. Additionally, when comorbidities such are rheumatoid arthritis or lupus are present, the treatment strategy may change. Also, few RCTs combined both pharmacologic and nonpharmacologic treatments. Future RCTs should address both these aspects to determine their effectiveness when combined.
Millea PJ, Holloway RL. Treating Fibromyalgia. Am Fam Physician 2000;62:1575-82,1587
Fibromyalgia is an extremely common chronic condition that can be challenging to manage. Although the etiology remains unclear, characteristic alterations in the pattern of sleep and changes in neuroendocrine transmitters such as serotonin, substance P, growth hormone and cortisol suggest that dysregulation of the autonomic and neuroendocrine system appears to be the basis of the syndrome. The diagnosis is clinical and is characterized by widespread pain, tender points and, commonly, comorbid conditions such as chronic fatigue, insomnia and depression. Treatment is largely empiric, although experience and small clinical studies have proved the efficacy of low-dose antidepressant therapy and exercise. Other less well-studied measures, such as acupuncture, also appear to be helpful. Management relies heavily on the physician's supportive counseling skills and willingness to try novel strategies in refractory cases.