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Fibromyalgia and Pain Management
Though fibromyalgia is commonly seen in both primary care and subspecialty settings, there is ample evidence that healthcare professionals in general are uncomfortable and unfamiliar with the diagnosis and management of this condition.4 Family physicians should be prepared to distinguish fibromyalgia from other chronic pain conditions and use patient education, pharmacotherapy, and lifestyle changes to help their patients with this chronic condition.
Diagnosis and Evaluation of Chronic Pain
- Neuropathic pain is caused by injury or dysfunction of the somatosensory system and encompasses a broad range of conditions, including diabetic peripheral neuropathy, trigeminal neuralgia, and postherpetic neuralgia. Patients usually describe a burning, shooting, or stabbing sensation. Neuropathic pain often follows a nerve distribution, such as a dermatomal distribution for postherpetic neuralgia or median nerve distribution for carpal tunnel syndrome. Fibromyalgia is characterized by a variety of symptoms. Though its pathophysiology is unclear, fibromyalgia is generally considered to be a neuropathic pain syndrome.
- Myofascial or musculoskeletal pain is characterized by aching, stiffness, or soreness in muscle and soft tissue in different regions of the body. Chronic myofascial or musculoskeletal pain often follows soft tissue injury. Examples include pain resulting from muscle strains and tears.
- Inflammatory pain results from a range of conditions that involve release of inflammatory chemicals that stimulate afferent pain fibers. Examples include arthritis, postoperative pain, and pain resulting from infection.
- Mechanical or compressive pain is similar to myofascial or musculoskeletal pain in that it is characterized by aching, stiffness, or soreness. However, a key feature of mechanical or compressive pain is aggravation with activity and some relief with rest. This pain results from mechanical pressure that stimulates pain-sensitive neurons. Common examples include many types of neck and back pain, including that from compression fractures and disc herniations.
Diagnosis of Fibromyalgia
Most importantly, the 1990 ACR criteria did not consider important symptoms of fibromyalgia such as fatigue and sleep disruption. For these reasons, the ACR has developed a set of preliminary diagnostic criteria for fibromyalgia that do not rely on tender-point examination and that account for the effects and severity of the condition (Figure).14 These new criteria are not intended to replace the original 1990 criteria, which remain the gold standard. The new criteria were developed by extracting useful diagnostic variables in a multicenter study of 829 fibromyalgia patients and control subjects. Symptoms satisfy the new diagnostic criteria if three conditions are met:
- Widespread pain index and symptom severity score
- Widespread pain index (ie, the number of predefined anatomic areas in which pain has been experienced in the past week) of ≥7 and
- Symptom severity score that takes into consideration fatigue, sleep, cognitive, and somatic symptoms of ≥5 or
- Widespread pain index of 3 to 6 and symptom severity score ≥9
- Symptoms at a similar level of at least 3 months’ duration
- Pain that cannot be attributed to another etiology
Figure. Widespread Pain Index and Symptom Severity Score
|1. WPI: Note the number of areas in which the patient has had pain over the last week. In how many areas has the patient had pain? Score will be between 0 and 19.|
|__ Shoulder girdle, left||__ Hip (buttock, trochanter), left||__ Jaw, left||__ Upper back|
|__ Shoulder girdle, right||__ Hip (buttock, trochanter), right||__ Jaw, right||__ Lower back|
|__ Upper arm, left||__ Upper leg, left||__ Chest||__ Neck|
|__ Upper arm, right||__ Upper leg, right||__ Abdomen|
|__ Lower arm, left||__ Lower leg, left|
|__ Lower arm, right||__ Lower leg, right|
|2. SS scale score:|
|__ Waking unrefreshed|
|__ Cognitive symptoms|
|For the each of the 3 symptoms above, indicate the level of severity over the past week using the following scale:|
|0 = no symptoms|
|1 = slight or mild problems, generally mild or intermittent|
|2 = moderate, considerable problems, often present and/or at a moderate level|
|3 = severe: pervasive, continuous, life-disturbing problems|
|Considering somatic symptoms in general, indicate whether the patient has:*|
|0 = no symptoms|
|1 = few symptoms|
|2 = a moderate number of symptoms|
|3 = a great deal of symptoms|
|The SS scale score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the extent (severity) of somatic symptoms in general. The final score is between 0 and 12.|
*Somatic symptoms that might be considered: muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering problem, muscle weakness, headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud's phenomenon, hives/welts, ringing in ears, vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearing difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms.
General Principles of Chronic Pain Treatment
Key ICSI recommendations applicable in the primary care setting for managing chronic pain include incorporating exercise and assessing and managing mental health comorbidities, including depression. ICSI recommends that primary care physicians use these initial cognitive behavioral strategies:
- Educate patients about chronic pain, including its effects on sleep, mood, work, and relationships, as well as the importance of stress management, exercise, and relaxation therapy
- Reassure patients that the physician believes their pain is real
- Encourage patients to take an active role in management of their pain
- Explain to patients that pain should not be the determining factor in activity, when to take drugs, or when to schedule return appointments. Activity should occur on a regular, predictable schedule. For example, return appointments should take place on a regular schedule and should not be dictated by pain level.
- Encourage a step-wise approach for patients to return to work
- Engage family members and others in the care plan
Comprehensive Treatment of Fibromyalgia
Exercise and Balneotherapy. Many studies have shown the benefits of exercise for fibromyalgia.16 Many types of exercise have been shown to be effective, including aerobic conditioning, flexibility training, and strength training. Furthermore, heated pool treatment (ie, balneotherapy, or spa therapy) has been shown to be effective with or without exercise.17
Cognitive Behavioral Therapy and Operant Behavioral Therapy. Cognitive behavioral therapy (beyond the initial steps described heretofore and often including relaxation therapy) and operant behavioral therapy (which emphasizes increased activity, inclusion of significant others to reduce reinforcement of pain behaviors, and reduction of pain-contingent drugs) have been shown to be effective in reducing symptoms. These therapies can be offered to patients if available.
Alternative Therapies. Alternative therapies are frequently pursued for relief of fibromyalgia symptoms. German guidelines for alternative treatments recommend meditative movement therapies (eg, tai chi, yoga) and acupuncture.18 The ICSI also recommends acupuncture for fibromyalgia based on high-quality evidence.5 Herbs and supplements have been evaluated in small studies, but more evidence is needed before their use can be recommended.19
Guidelines and algorithms for pharmacologic management of fibromyalgia are available. These guidelines evaluate the strength of evidence underlying particular drugs at the time they were published rather than providing an algorithm for treatment. The algorithms emphasize only the three FDA-approved drugs as initial treatment.20,22
The choice of initial treatment depends on a number of factors including the type and severity of symptoms, comorbid psychosocial conditions, and tolerance of adverse effects. A reasonable, initial approach is to begin with low-dose (25 mg) amitriptyline or cyclobenzaprine (10 mg) as part of a comprehensive treatment plan. The dose can be increased gradually and modestly, depending on the response. Most therapeutic drug trials for fibromyalgia have lasted at least 6 to 12 weeks. If the response to initial therapy is unsatisfactory within that time, a different class of drug can be tried, either as an alternative or as an adjunct to initial therapy.
Table. Efficacy Level of Drugs Used to Manage Fibromyalgia
|Efficacy Level||Drug or Drug Class||Dosage|
|Strong||Amitriptyline||25-50 mg at bedtime|
|Cyclobenzaprine||10-30 mg at bedtime|
|Modest||Duloxetine (Cymbalta)||30-60 mg daily|
|Gabapentina||1200-2400 mg daily|
|Milnacipran (Savella)||100 mg daily|
|Pregabalin (Lyrica)||300-450 mg daily|
|SSRI||20-80 mg daily|
|Tramadol||200-300 mg daily|
|Weak or none||NSAID|
a Arnold LM, Goldenberg DL, Stanford SB. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. 2007;56:1336-44.
Opioids for Chronic Pain
The Federation of State Medical Boards (FSMB) has developed a model policy for the use of controlled substances to manage pain. The policy recommends thorough evaluation of the patient, use of a written treatment plan, periodic review of pain management, appropriate referral/consultation, maintenance of complete and accurate medical records, compliance with all controlled substance laws and regulations, and obtaining informed consent for treatment. Informed consent should specify how opioids and other controlled substances will be prescribed and their use will be monitored. This includes the number and frequency of prescription refills that will be provided, reasons why pharmacologic therapy can be discontinued (eg, violation of agreement specified in the consent), and drug screening to monitor for appropriate use and simultaneous use of drugs of abuse.23
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