Fibromyalgia syndrome (FMS) is a chronic, painful, and sometimes disabling condition commonly encountered by primary care physicians. Recent research has provided information about the pathophysiology of FMS that has implications for treatment. For example, it now seems most likely that the major pathophysiologic mechanisms of FMS involve central sensitization in the CNS, although a peripheral source of nociception may initiate and/or perpetuate this sensitization. Thus, drugs that act through the CNS (such as tricyclic agents, selective serotonin reuptake inhibitors [SSRIs], and tramadol) are more likely to be effective than those that act primarily at a peripheral level-for example, NSAIDs. The same CNS mechanism may also explain why hypnotherapy or meditation may be beneficial in FMS.
Understanding pathophysiologic mechanisms, as discussed in our article in the September 1, 2003, issue,1 is important for treating disease. Although the mechanisms in FMS are incompletely understood at this time, the relevant factors for treatment purposes include central sensitization (amplified or perpetuated by poor sleep); psychological distress; peripheral pain generators (eg, overuse of body parts, repetitive trauma, and arthritis); deconditioning; and other aggravating factors (eg, weather, noise, and comorbid conditions).
The management of FMS has been reviewed in detail.2Key components of treatment are shown in Table 1. We will describe each of these below.
POSITIVE AND EMPATHETIC ATTITUDE OF THE PHYSICIAN
The management of FMS begins with the very first contact with the patient. Many patients with aches and pains have had an unhelpful or even unpleasant experience with their previous health care providers, or heard of such experiences from their friends. Greeting a patient in a friendly and positive manner goes a long way to assure that you are a kind and interested physician. Maintain such an attitude of caring throughout the period of consultation and subsequent follow-ups.
MAKING A FIRM DIAGNOSIS
As we emphasized in our previous article,1 FMS should be diagnosed by its own characteristic features of widespread pain and multiple tender points, and not by "ruling out" other conditions, as stated in the American College of Rheumatology (ACR) criteria.1 Ordering one more test to exclude such and such disease may cause anxiety, since such an approach is not only unnecessary, it may also indicate uncertainty on the part of the physician, and thus erode a patient's confidence in him or her.
PATIENT EDUCATION, REASSURANCE, AND INDIVIDUALIZATION OF TREATMENT
After the diagnosis is made, patient education is a most important step. Provide information to patients with FMS, in a simple, understandable way regarding the diagnosis and probable cause, aggravating factors (Table 2), and prognosis, and then use Table 1 to discuss various elements of management. Emphasize that a patient's pain and other symptoms are "real" and based on a "chemical imbalance," such as excessive substance P and decreased serotonin. However, reassure your patient that FMS is not life-threatening (despite much pain), and that it does not cause tissue damage. (We avoid using the term "benign" because patients who are suffering may resent it.) Advise on general healthy behavior, including weight loss, smoking cessation, good sleep habits, and regular exercise. Also emphasize the need for both nonpharmacologic and pharmacologic therapy. A recent study has found an association between overweight and several important FMS features, such as fatigue, decreased physical function, and increased number of tender points.3Smoking is positively associated with pain, global severity, and functional difficulties.4
Tailor your management according to each patient's symptom profile. For example, some patients may have significant psychological distress, while others have a predominant sleep problem, and yet others have specific aggravating factors, such as poor sleep, repetitive trauma (vocational and recreational), and mental stress. Some patients cope with their symptoms fairly well, while others do not. Although FMS is a chronic painful condition, emphasize that most patients find relief with appropriate treatment for a period of time, and that during this time they can be meaningfully functional.
ADDRESSING AGGRAVATING FACTORS
Aggravating factors that should be addressed are listed in Table 2. The importance of physical fitness (in the context of deconditioning) will be described in detail under "Nonpharmacologic Intervention."Other important factors will be discussed here. Note that treatment of concomitant hypothyroidism does not eliminate FMS symptoms, but it may help relieve fatigue and low energy.
Psychological factors. Psychological distress is correlated with pain, including pain in FMS.5 Thus, psychological factors, such as anxiety, stress, depression, and poor coping, should always be addressed. Stress is an important factor in both triggering and perpetuating FMS symptoms. Besides counseling for psychological difficulties, anxiolytics and antidepressants in appropriate doses may be required. SSRIs are as effective as tricyclic agents for depression and have fewer side effects. If necessary, refer patients to a psychologist for stress reduction or to a psychiatrist for refractory anxiety and depression.
Improving sleep quality. Nonrestorative sleep exacerbates pain and fatigue. Poor sleep at night predicts pain the next day.6 Take a good sleep history and offer suggestions for improved sleep quality (Table 3). Morning fatigue is a sensitive indicator of nonrestorative sleep. Restless legs syndrome and/or periodic limb movement disorder is an important cause of sleep disturbance and is treatable with medications (see "Pharmacologic Management").
Environmental factors. Depending on individual sensitivity to specific weather factors, advise your patients to avoid unnecessary outside trips in the winter and to stay in comfortable temperature in an air-conditioned room in the summer as much as possible. Many patients are also sensitive to noise, smell, and light. Hyperresponsiveness to many of these environmental stimuli, as well as to many medications, is thought to be attributable to central sensitization.1
Occupational factors. Prolonged sitting or standing at work, adverse ergonomic factors that cause muscle or other soft tissue strain, repetitive motion, and job stress and dissatisfaction may all contribute to FMS symptoms. Based on current knowledge of pain physiology, repetitive motions are likely to cause central sensitization1 and subsequent amplification and intensification of pain. Because an important goal of treatment of FMS is to keep the patient employed, both for psychological and economic reasons, these work-related aggravating factors should be discussed with the employer, along with appropriate recommendations, such as change of duties and improvement of adverse ergonomic conditions.
Comorbid conditions. Although this theory has not been directly proved in patients with FMS, current knowledge of central sensitization operative in FMS suggests that any continued source of peripheral nociception enhances this sensitization and worsens pain. Thus, arthritis of any kind, neuropathy, or headaches should be treated. Restless legs syndrome disturbs sleep (Table 2).
Family and social factors. Adverse family circumstances, such as a stressful marriage, demanding children, and a lack of empathy and understanding by family members, can add significant distress. This, in turn, may aggravate pain, fatigue, and other associated symptoms, such as headaches and migraine. However, excessive attention from a solicitous spouse may also adversely affect a patient's pain.7 Refer your patient to a psychologist for assistance with coping skills, if needed. Encourage patients to have a hobby and a network of support.
1. Arslan S, Yunus MB. Fibromyalgia: making a firm diagnosis, understanding its pathophysiology. Consultant. 2003;43:1233-1244a.
2. Inanici F, Yunus MB. Management of fibromyalgia syndrome. In Rachlin ES, Rachlin IS, eds. Myofascial Pain and Fibromyalgia: Trigger Point Management. Philadelphia: Mosby; 2000:33-55.
3. Yunus MB, Arslan S. Relationship between body mass index and fibromyalgia features. Scan J Rheumatol. 2002;31:27-31.
4. Yunus MB, Arslan S. Relationship between fibromyalgia features and smoking. Scand J Rheumatol. 2002;31:301-305.
5. Dailey PA, Bishop GD, Russell IJ, Fletcher EM. Psychological stress and the fibrositis/fibromyalgia syndrome. J Rheumatol. 1990;17:1380-1385.
6. Affleck G, Urrows S, Tennen H, et al. Sequential daily relations of sleep, pain intensity, and attention to pain among women with fibromyalgia. Pain. 1996; 68:363-368.
7. Romano JM, Turner JA, Friedman IS, et al. Sequential analysis of chronic pain behaviors and spouse responses. J Consult Pain Clin Psychol. 1992; 60:777-782.
8. Leventhal LJ. Management of fibromyalgia. Ann Intern Med. 1999;131:850-858.
9. McCain GA, Bell DA, Mai FM, Halliday PD. A controlled study of the effects of a supervised cardiovascular fitness training program on the manifestations of primary fibromyalgia. Arthritis Rheum. 1988;31:1135-1141.
10. DeLuze C, Bosila L, Zirbs A, et al. Electroacu- puncture in fibromyalgia: results of a controlled trial. BMJ. 1992;305:1249-1252.
11. Williams DA, Cary MA, Groner KH, et al. Improving physical functional status in patients with fibromyalgia: a brief cognitive behavioral intervention. J Rheumatol. 2002;29:1280-1286.
12. Vlaeyen JW, Teeken-Gruben NJ, Goossens ME, et al. Cognitive-educational treatment of fibromyalgia: a randomized clinical trial, I: clinical effects. J Rheumatol. 1996;23:1237-1245.
13. Nicassio PM, Radojevic V, Weisman MH, et al. A comparison of behavioral and educational interventions for fibromyalgia. J Rheumatol. 1997;24: 2000-2007.
14. Haanen HC, Hoenderdos HT, van Romunde LK, et al. Controlled trial of hypnotherapy in the treatment of refractory fibromyalgia. J Rheumatol. 1991;18:72-75.
15. Kaplan KH, Goldenberg DL, Galvin-Nadeau M. The impact of a meditation-based stress reduction program on fibromyalgia. Gen Hosp Psychiatry. 1993; 15:284-289.
16. Goldenberg DL, Felson DT, Dinerman H. A randomized, controlled trial of amitriptyline and naproxen in the treatment of patients with fibromyalgia. Arthritis Rheum. 1986;29:1371-1377.
17. Bennett RM, Gatter RA, Campbell SM, et al. A comparison of cyclobenzaprine and placebo in the management of fibrositis. A double-blind controlled study. Arthritis Rheum. 1988;31:1535-1542.
18. Arnold LM, Hess EV, Hudson JI, et al. A randomized, placebo-controlled, double-blind, flexible-dose study of fluoxetine in the treatment of women with fibromyalgia. Am J Med. 2002;112:191-197.
19. Goldenberg D, Mayskiy M, Mossey C, et al. A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia. Arthritis Rheum. 1996;39:1852-1859.
20. Russell IJ, Kamin M, Bennett RM, et al. Efficacy of tramadol in treatment of pain in fibromyalgia. J Clin Rheumatol. 2002;6:250-257.
21. Silber MH, Restless legs syndrome. Mayo Clin Proc. 1997;72:261-264.
22. Reddy SS, Yunus MB, Inanici F, Aldag JC. Tender point injections are beneficial in fibromyalgia syndrome: a descriptive, open study. J Musculoskel Pain. 2000;8:7-18.
23. Baldry P. Superficial dry needling at myofas- cial trigger point sites. J Musculoskel Pain. 1995;3: 117-126.
24. Roth SH, Fleischmann RM, Burch FX, et al. Around-the-clock, controlled-release oxycodone therapy for osteoarthritis-related pain: placebo-con-trolled trial and long-term evaluation. Arch Intern Med. 2000;160:853-860.
25. Mao J. Opioid-induced abnormal pain sensitivity: implications in clinical opioid therapy. Pain. 2002; 100:213-217.
26. Crofford LJ, Appleton BE. Complementary and alternate therapies for fibromyalgia. Curr Rheumatol Rep. 2001;3:147-156.
27. Jacobsen S, Danneskiold-Samsoe B, Andersen RB. Oral S-adenosylmethionine in primary fibromyalgia. Double-blind clinical evaluation. Scan J Rheumatol. 1991;20:294-302.
28. Alfano AP, Taylor AG, Forseman PA, et al. Static magnetic fields for treatment of fibromyalgia: a randomized controlled trial. J Altern Complement Med. 2001;7:53-64.
29. Yunus MB. Fibromyalgia syndrome: is there any effective therapy? Consultant. 1996;36:1279-1285.