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Treating the Complexities of Fibromyalgia Improves Pain Management

February 15, 2018
Early recognition of the many common comorbidities that often present in patients with fibromyalgia may assure more targeted and effective symptom management.

With Irwin Jon Russell, MD

While widespread musculoskeletal pain and joint tenderness is the hallmark of fibromyalgia, mood and cognitive changes are often present as well. However, there are other common comorbidities that typically arise with fibromyalgia (FM) that deserve equal attention.

One notable finding from this review of prior research was a higher prevalence of fibromyalgia in men when revised diagnostic criteria were applied.1

A recent review of studies exploring the relationship between fibromyalgia syndrome and the prevalence of psychiatric and organic comorbidities provided strong evidence for a higher rate of these co-existing conditions than in the general population.1 Howard Amital, MD, MHA, at Sheba Medical Center and his colleagues reported that the common occurrence of  “such comorbidities may blur the classical clinical presentations and erroneously lead to misinterpretation of disease activity,” as published in Current Opinion in Rheumatology.

Fibromyalgia may present with or be confused by common co-morbid conditions.Assessing for likely co-morbidities that appears as or with fibromyalgia will assure the best treatment.

The authors made a strong case for the need to first consider the array of possible overlapping somatic disorders, such as post-traumatic stress disorder, ankylosing spondylitis, even cardiovascular disease, any of which may lead to a misdiagnosis of fibromyalgia in patients who may not have the syndrome but would face therapies or unnecessary medications along with avoidable side effects.1

Fibromyalgia Requires a Comprehensive Differential Diagnosis of All Symptoms 

Irwin Jon Russell, MD, medical director at Fibromyalgia Research and Consulting, told Practical Pain Management that “distinguishing symptoms that confirm fibromyalgia is as important as understanding the reasons for the symptoms. And, while systemic lupus erythematosus may be a comorbidity of fibromyalgia, proper treated requires medications that may not be as effective in managing symptoms of fibromyalgia.

Just as important, the study authors emphasized concerns that because fibromyalgia has vast comorbidities many of these patients may go undiagnosed.1

According to Dr. Russell, physicians who commonly diagnose the comorbidities often experienced by patients with fibromyalgia such as irritable bowel syndrome or sleep disturbances might have patients suspected of having FM complete a fibromyalgia-specific assessment, especially among those who present with widespread musculoskeletal pain. “If you’re treating a fibromyalgia comorbidity, think of fibromyalgia especially if they say they hurt all over,” he said.

The authors highlighted the most common psychiatric and somatic conditions as a roadmap for pain practitioners to keep in mind when patients present with a diagnosis of fibromyalgia or symptoms that may raise the specter of such a diagnosis.1

Psychiatric Conditions Are Only One Common Pain Co-Conspirator

Reports of a higher prevalence of psychiatric disorders among patients with fibromyalgia than the general population have been fairly consistent. In particular, conditions such as post-traumatic stress disorder (PTSD), bipolar disorder, depression, and anxiety, were the most common psychiatric-based conditions reported.1

In a study of eight medical centers in Germany, 45.3% of patients with fibromyalgia met the criteria for PTSD compared to 3.0% of controls.2In this same patient population, 65.7% of the patients met the criteria for a depressive disorder, and 67.9% were diagnosed with an anxiety disorder.2

Among female patients with comorbid depression and fibromyalgia, complaints of higher pain intensity, fatigue, and poor sleep quality were consistently reported compared to their counterparts who had minimal signs of depression.3

“Sleep disturbances, in particular, have had a prevalence rate of about 90% among the fibromyalgia patients in my practice,” said Dr. Russell.

Given the overwhelming evidence for anxiety and depression appearing at twice the rate in the presence of FM as in healthy controls, mental health support should be provided or a referral made for these patients.1

  • Rheumatologic Comorbidities

The review1also sheds light on the link between FM and various rheumatologic comorbidities. The prevalence for rheumatic diseases in patients previously diagnosed with fibromyalgia, at least in one study, was estimated at 23% of patients More telling, the mean visual analog scale scores for pain, fatigue and function were almost twice as high as in those patients with rheumatology-related conditions but with no features of FM.4

  • Cardiovascular comorbidities

In a large, well designed 12-year study, “FM to be an independent risk for coronary heart disease, with an increased risk of 47%.” In addition, traditional risk factors, such as high blood pressure, hyperlipidemia, and diabetes were more common in patients with fibromyalgia as compared to the general population.5

  • Diabetes

Some evidence suggests a higher rate of diabetes in patients with fibromyalgia with a prevalence ranging from 9 to 23%.6,7 The research illuminates that fact that patients with FM and diabetes present with more tender points and complaints of widespread pain than patients with FM but no diabetes.8

Another confounding factor in patients with diabetes is diabetic neuropathy, which arises in nearly 62% of individuals with comorbid fibromyalgia and diabetes versus 2.5% in patients with diabetes but no fibromyalgia.9

  • Gastrointestinal complications

The connection between FM and gastrointestinal disorders, particularly irritable bowel syndrome, (IBS) has been well documented; the prevalence of coexisting fibromyalgia and IBS ranges from 12.9 to 81%.6,7 

Given the popularity of the gluten-free diet, pain practitioners might heed the prevalence data that support a heightened risk for gluten sensitivity in patients with FM.8 Yet, screening for celiac is discouraged, possibly due to the lack of a celiac correlation but still a common hypersensitivity to wheat-based foods. 

Interestingly, select medications such as tramadol appeared to reduce the risk of patients diagnosed with fibromyalgia, developing IBS.9 Reports of comorbidity of FM with other common gastrointestinal conditions: inflammatory bowel disease, ulcerative colitis, and Crohn’s disease, show little if any correlation with FM.

Clinical Strategies to Account for Common Fibromyalgia-Related Comorbidities

In treating any patient who presents with symptoms suggestive of fibromyalgia, there are some steps that pain practitioners may take to more effectively address the myriad concomitant conditions, Dr. Russell told Practical Pain Management

Here are Dr. Russell’s suggested strategies:

  • Emphasize physical movement: Russell notes that several studies have highlighted the benefit to pain management from certain types of physical activity in patients with fibromyalgia. He points to water-based, walking-in-place exercises, and qi gong that “could be best described as graceful motion,” is similar to tai-chi but more gentle and less demanding.
  • Explore treatments to Ease Pain.  In addition to studies backing the benefits of exercise on FMS patients, Russell notes studies have also shed light on the effectiveness of medications like Cymbalta and Savella. A program that seeks to combine the pain management benefits of both therapeutic and pharmaceutical treatments may have lasting positive effects on FMS patients.
  • Educate Patients: Beyond the usual effort of offering patients a solid understanding of FM, patients should also be reassured that when they stick to their treatment plan, symptoms will be better managed, and while flares will occur, they won’t last. Giving them encouragement from the beginning will go a long way in having them adhere to their treatment plan when they experience a symptom flare.

Even more than recognizing the complexity of diagnosing fibromyalgia, pain practitioners will serve their patients better with a sound “understanding of the pathogenesis of fibromyalgia,” Dr. Russell said, “There is a wealth of evidence for the different potential causes of FM, ranging from trauma to abnormalities in how the brain processes pain. But further research that improves our understanding of the causes of FM will guide practitioners in managing the condition as well as its vast comorbidities.”

No authors indicated a conflict of interest with regard to this publication.

Last updated on: September 26, 2019
Continue Reading:
An Osteopathic Approach to Fibromyalgia

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