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11 Articles in this Series
Introduction
A PAINWeek 2019 preview with EVP Debra Weiner
Comparing Marijuana and Hemp
Fibromyalgia: What’s New in Diagnosis and Pain Management
Life Hacks to Teach Patients with Chronic Pain
Managing Pain (and Function) in Osteoarthritis: Are Patients and Physicians on the Same Page?
Marijuana: How to Proceed When Controlled Substances are Involved
Menopause Comes with More than Mood Swings - It Deserves its Place Among Chronic Pain Conditions
More APPs Are Coming to the Forefront of Pain Care
Motivational Interviewing and Its Extension into Pain Management
Revisiting Documentation
Side Chat: Modern Analgesic Trials

Fibromyalgia: What’s New in Diagnosis and Pain Management

with Gary W. Jay, MD

 

Fibromyalgia, or chronic widespread pain, is now known in the medical community as a central hypersensitivity disorder. Affecting 10 to 30% of the population, this condition is not like a pneumonia with specific bacteria involved, but rather, presents in patients on a continuum, explained Gary W. Jay, MD, FAAPM, a clinical professor of neurology at University of North Carolina Chapel Hill and an Editorial Board Advisor to PPM. It is no longer a specifically defined “disorder.” A patient may have fibromyalgia symptoms today, but not tomorrow, and then again on the next day. This type of central sensitization comes with allodynia and hyperalgesia, and the pain may be a common contributor to inflammation and neuropathy. Most importantly, in fibromyalgia, pain may be amplified, secondary to changes in central pain perception.

“It’s useful to consider these patients as having multifocal pain as well as other somatic symptoms,” said Dr. Jay. In addition to pain, patients often experience fatigue, stiffness, sleep and mood disturbances, and sexual dysfunction.

Traditional concepts around pain processing involve nociceptive pain that goes to the spine and then signals the brain. With fibromyalgia, said Dr. Jay, this is flipped a bit. This type of central pain is not related to structural damage in the brain or spinal cord but rather to dysfunction in key areas. “Nociception may not exist in just one spot but also may be peripheral and central,” he said. The pain may be post-stroke related or trauma-related (eg, a car accident), among other factors, and it comes with cognitive and mood impacts.

Diagnostics and Updated Criteria

Assessment for fibromyalgia has also changed. In the past, 11 out of 18 positive tender points needed to be affected. New criteria (released in 2010) do not require a “clinical diagnosis,” as the description for fibromyalgia has somewhat exploded—a physical exam may come across as negative except for possible tender points. In addition, the expanded, more sensitive, criteria capture far more men with the condition (before 2010, prevalence was about 10 women to 1 man). A two-page patient questionnaire may be used to assess 19 possible areas of pain and 41 possible symptoms.

A typical patient with fibromyalgia may experience headache, memory challenges, dry eye or mouth, affective disorders, TMJ symptoms, vestibular complaints, chemical sensitivity, esophageal symptoms, neutrally mediated hypotension, noncardiac chest pain, pelvic or bladder pain, low back pain, IBS, and nondermatomal paresthesias. A patient may also go back and forth between medications that work. (Image: 123RF)

“As a continuum with somatic symptoms, the condition is quite complicated,” said Dr. Jay. A typical patient, he shared, may have headache, memory challenges, dry eye or mouth, affective disorders, TMJ symptoms, vestibular complaints, chemical sensitivity, esophageal symptoms, neutrally mediated hypotension, noncardiac chest pain, pelvic or bladder pain, low back pain, IBS, and nondermatomal paresthesias. A patient may also go back and forth between medications that work.

In terms of diagnostic tests, Dr. Jay said that x-rays and autoimmune tests are generally not helpful. There are some differential diagnoses to consider, ranging from a virus to Lupus, from rheumatoid or osteo-arthritis to neuropathies and multiple sclerosis, from hepatitis to spinal stenosis. What’s key for clinicians to understand, noted Dr. Jay, is that the presence of these other disorders does not exclude fibromyalgia—there could be a secondary diagnosis. “Fibromyalgia is no longer an all-or-nothing diagnosis. With pain not solely due to inflammation or peripheral tissue—there is no specific label for the type of pain the patient is feeling,” he said.

Current Treatment Options for Fibromyalgia

FDA has approved three medications for fibromyalgia: pregabalin, duloxetine, and milnacipran—all were approved just before 2010. While not indicated for fibromyalgia, tricyclic antidepressants (TCAs) may actually be the most helpful, said Dr. Jay, particularly amitriptyline (25 to 50 mg/day) and cyclobenzaprine (10 to 40 mg/day). The TCAs help with pain and somatic symptoms.

Dr. Jay pointed to the work of Moldofsky’s in the 1970s, which essentially showed amitriptyline to be the best drug for fixing sleep architecture while also improving musculoskeletal stiffness, mood, and other symptoms that fibromyalgia patients commonly face. Other studies have showed the significance of amitriptyline in benefitting fibromyalgia compared to naproxen (Goldenberg, Arthritis Rheum, 1986) and fluoxetine.

In safety and efficacy trials looking at duloxetine, compared to placebo, research has shown it leads to a higher reduction in average pain scores. A milnacipran versus placebo study demonstrated markedly improved patient global scores as well. What’s interesting about fibromyalgia patient studies overall, shared Dr. Jay, is that it’s the only pain population to have two six-month studies (not just 12 weeks) under its belt.

Turning to pregabalin and gabapentin, anticonvulsants that reduce calcium influx at the nerve terminals to inhibit pain neurotransmitters, Dr. Jay said the most positive pain relief results in the literature have been associated with a 450 mg/day pregabalin dose. At 300 mg/day, pregabalin has been shown to improve sleep quality, fatigue, and global measure of change, but not pain.

“So here’s the trick,” said Dr. Jay, sharing his own clinical experience with fibromyalgia patients. “If patients cannot afford 600 mg of pregabalin a day, I typically will go up to, when necessary 1800 mg/day of gabapentin (above that reduces bioavailability) and if that doesn’t fix the problem as well as I had hoped, I will add in 25 mg BID-TID pregabalin. With this dosing, 8 out of 10 patients find relief. You may think, well, these are both gabapentinoids, but remember that pregabalin has different side chains.”

Clinicians may also consider naltrexone. Dr. Jay noted that there are no good studies on this drug yet for fibromyalgia, but “anecdotally, it may work as a back-pocket option.”

As for what does not work with fibromyalgia management, Dr. Jay reminded the PAINWeek audience that NSAIDs are not effective even though they may have a synergistic effect when combined with centrally acting medications. There is no evidence that the disease is inflammatory. There is also “no evidence whatsoever that opioids work in fibromyalgia—zero percent—and in many cases, opioids make fibromyalgia worse,” he said.

What about Nonpharmacological Options?

Exercise is a treatment of choice, said Dr. Jay, specifically highlighting cardiovascular exercise (not weight training); water-based therapy, and Tai-Chi. Cognitive Behavioral Therapy (CBT) is great if your patient can access it.  Acupuncture has demonstrated mixed results; massage treatment of at least 5 weeks may improve pain, anxiety, and depression. Trigger point injections may help if performed correctly, and TENS may provide a patient with short-term relief. There is not much support in the literature for Qi Gong, chiropractic, or nutritional supplements, however.

Key Takeaways

After his talk, Dr. Jay shared with PPM a few points to remember:

  • Fibromyalgia remains a diagnosis which encompasses a number of physical and psychological symptoms, including pain (that is amplified secondary to changes in CNS pain perception) as well as other central hypersensitivity diagnoses, including IBS, multiple chemical hypersensitivities, interstitial cystitis and more, with cognitive symptoms, fatigue, headache and other associated problems.
  • More than 60% of fibromyalgia patients may have a myofascial pain syndrome, which providers can help clinically.
  • Fibromyalgia patients churn through their medications—they are constantly changing them.
  • Finally, NSAIDs and opioids, per various published studies, are not helpful in treating the disorder.
Next summary: Life Hacks to Teach Patients with Chronic Pain
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