I didn’t intend to get into a theme this week, but this paper arrived in my inbox this morning, and given both the prevalence of fibromyalgia, and the often ‘fuzzy’ management that can be provided, I thought it might be worthwhile taking a look at it. The paper itself is a pre-print, but has been revised earlier this year and is probably the final version.
The outline of the paper covers diagnostic criteria, and briefly discusses the place of neuroimaging (if only we could get that done readily here!), but notes that many other conditions overlap or mimic FM such as hypothyroidism, tendonitis, ankylosing spondylitis, as well as chronic fatigue, suggesting some sort of common pathway in either the peripheral or central nervous system, raising the possibility of some common treatment approach. So far though, it’s not clear – and it’s important to rule out these other conditions that all have their own management approach before deciding that FM is what the problem is.
The next section of the paper reviews the current state of knowledge around pathophysiology as a basis for treatment and rehabilitation. Both peripheral and central sensitisation seem implicated in FM, leading to amplification of sensory impulses that alter pain perception. Increased excitation of various peripheral structures can in turn lead to neuroplastic changes in the central nervous system – winding up the whole experience for the person in the middle of it!
Imamura, Cassius & Freni, the authors of this paper, briefly review some of the factors thought to play a role in the reduced threshold for neuronal firing, including elevated levels of substance P, calcitonin gene-related peptide, bradykinin, and so on. Included in their review are CNS factors such as the altered non-REM sleep of people with FM – and that this is associated with the severity of symptoms; the association between depression and FM; and neuroimaging studies showing a change in regional cerebral blood flow to pain-related structures in people with FM.
If these aspects of FM can be explained to people with the pain problem it could make a significant difference to their own attitude toward their pain. For many people, it can take several years before a diagnosis of FM is made: during this time the beliefs and approaches of many practitioners can influence their understanding of their pain – and sadly, some practitioners are not empathic and can take a somewhat pejorative approach to people with the disorder. Knowledge can lead to understanding – and understanding can lead to a sense of empowerment.
Moving through the paper, the authors indicate that treatment needs to be based on the proposed model of fibromyalgia. That is, it needs to address central mechanisms rather than peripheral ones (so, no more NSAIDs, opioids or corticosteroids!), and the overall approach needs to be ‘rehabilitative’ – I’d suggest biopsychosocial as the model! The shift is from curing the problem to improving health status and health -related quality of life.
There are two arms of management for fibromyalgia:
(1) pain relief through medication and ‘physical’ strategies to reduce peripheral and central sensitisation
(2) cognitive behavioural approaches to manage sleep, fatigue, mood, cognitive problems, headache, migraine and other problems associated with FM.
Although the authors suggest ‘education’ as a cornerstone – I’d rather suggest helping the person to reconceptualise their problem as one of pain processing. Education can be seen as simply providing information – reconceptualising is about helping the person see themselves and their pain problem as something they can manage, something only they can do – and something they can do.
The remainder of the paper looks at pharmacological approaches and the rationale for using tricyclic antidepressants and/or serotonin/norepinephrine-reuptake inhibitors, and tramadol because of their effect on reducing afferent transmission at the dorsal horn or increasing the activity of the descending inhibitory pain systems.
It should be noted that even these drugs don’t always reduce the pain and all have their own array of side-effects – so they need to combined with self management.
Nonpharmacological approaches are then reviewed. This is where the interdisciplinary team can take the lead because these approaches are both effective – and once learned, don’t consume health resources in quite the same way as medications can.
Exercise gets the nod – remembering that exercise can include enjoyable daily activities such as walking, gardening, dancing and playing with the dog, not just going to a gym!
Electrical stimulation – this is suggested, although as far as I know, it’s not readily available – Imamura et al. indicate transcranial direct current stimulation as an effective approach, but I haven’t heard much of this as a strategy available in New Zealand. (If anyone has, let me know). I’m also not entirely comfortable with this as a self management strategy – it sounds pretty invasive and requires health care input, at least initially.
Acupuncture – this is less well-documented, and results are, as these authors say, ‘controversial’. They suggest that ‘clinical benefits seem to be of small magnitude and of short duration’ – my main concern would be that unless the person can ‘do it themselves’, it will involve more appointments, so I’d not be comfortable with it as a self management approach. I hold a similar view of injections – Imamura et al suggest that ‘concomitant myofascial pain, along with instruction in relaxation techniques, may benefit some patients with an associated mysfascial pain component.’
The final area reviews, very, very briefly, cognitive behavioural therapy. The authors indicate its use for ‘associated psychological and psychiatric comorbidity’, but I’d be inclined to challenge this. The perception of pain involves thoughts and beliefs about the meaning of pain – and the effect of reconceptualising fibromyalgia as not being a ‘life sentence’ or a ‘constant struggle’, and understanding what some of the mechanism are, will bring about changed perception. Distress reduction, increased sense of self efficacy and more effective approaches to activity, relaxation, cognitions, as well as effective communication skills and working on relationships – these are all integral to living a good life despite pain.
Overall – this is a nice, brief review especially of some of the pathophysiology of fibromyalgia and the rationale for the treatment approaches suggested. There are plenty of good references, and while it’s not an ‘easy’ read, it’s quite brief and contains the essentials.
From Imamura, M., Cassius, D., & Fregni, F. (2009). Fibromyalgia: From treatment to rehabilitation European Journal of Pain Supplements DOI: 10.1016/j.eujps.2009.08.011