Pain management in fibromyalgia

Fibromyalgia is a multidimensional syndrome that is hard to define exactly. Therefore, it poses a great challenge to health care providers to diagnosis it and initiate the treatment. 

As fibromyalgia involves a set of diverse symptoms including pain, tenderness, fatigue, non-refreshing sleep, stiffness, cognitive dysfunction, environmental sensitivity, mood disorders, poor balance, muscle weakness, functional impairments, and disability; that makes it a multidimensional syndrome.

Against this backdrop, it is of little surprise that clinical studies involving medications failed to deliver encouraging results. The problem of multidimensionality in fibromyalgia is well summed up in a review by Dr Turk’s review as, “despite similarities in symptoms, patients with fibromyalgia are unique, and require individualized treatment based on their symptoms and experiences. Providers must avoid adopting the ‘patient-uniformity myth’, assuming that all patients with the same diagnosis are identical and thereby require the same treatment regimen.”

For beneficial doctor- patient relationship, educating patients is a key factor. It is important for fibromyalgia patients to realize the fact that there is currently no cure for fibromyalgia; looking for what medically doesn’t exist may distract them focusing on engagement and self-management. 

Dr Turk rightly says, ““a blind focus on illness per se ignores the real ability of individuals with fibromyalgia to make meaningful gains, and further keeps them from enjoying life that they have before them despite symptoms.” Cognitive – behavioral therapy is thought to be most effective approach that focuses on thoughts, feelings and behaviors, and is thus ideally suited for treating fibromyalgia. Important components of cognitive-behavioral therapy as follows;

·        Education reassurance; 

·        Focus on functional gains rather than fibromyalgia as a disease; 

·        Realistic goal setting; 

·        Lifelong self-management; 

·        Pacing and increasing activities; 

·        Managing sleep; 

·        Addressing cognitive dysfunction – use of daily planners, to do lists, attention        techniques; 

·        Recognizing the role of stress in symptom development; 

·        Counteracting maladaptive thinking; 

·        Relapse and maintenance;

·        Improved communication with others;

·        Assertiveness training; and 

·        Use of medications. 

  

Fatigue is major symptom that most of patients complain about. The research on neurophysiology of fatigue is still in its infancy. Fatigue and sleep disturbance are multidimensional and partly related to hypersensitivity to unpleasant sensory stimuli. The management of fatigue needs to involve regular exercise and improved sleep hygiene. However, many patients find exercise aggravates their fatigue and pain, and they quit exercise before any benefits are realized. Patients need to focus on physical activity but it doesn’t mean going to gym. As a fibromyalgia patient you should consult your care provider about how to successfully increase your level of activity. The emphasis here should be to develop a self-management skill that requires paradigm shift from passive patient role to an active role.

Fibromyalgia patients are particularly concerned about dietary interventions. Loads of dietary recommendations can be found on internet that usually focus on foods that benefit fibromyalgia and foods that aggravate fibromyalgia. Majority of such recommendations are anecdotal. However some scientific evidence supports the recommendations of avoiding glutamate and aspartate. Recent research shows that glutamate is the major excitatory neurotransmitter in the brain and that fibromyalgia patients have higher levels of glutamate in the cerebrospinal fluid. Aspartate activates NMDA receptors that leads to central sensitization.  

Central sanitization is linked with peripheral pain generators. The myofascial trigger points play an important role in the development of central sanitization.

Several studies over time have indicated that sleep dysfunction may lead to the development fibromyalgia in healthy individuals. Among currently available treatments amitriptyline and pregabalin can improve sleep quality. Interestingly, there is one study that finds daytime napping is associated with increased severity.

Many contributors of scientific studies have noted “fibromyalgia continues to be a very difficult condition to successfully treat. Fibromyalgia is by nature a multi-symptom, possibly multi-mechanistic disorder; thus any single modality that does not cover relevant areas of fibromyalgia would likely fail. The importance of considering individual variations in developing a personalized approach cannot be overstated.”

Owing to multi-symptom nature of fibromyalgia, medical experts stress using psychological – behavioral approaches in the management of fibromyalgia. Equally important is to encourage patients’ active engagement in all therapies, until a patient becomes fully committed, the chances of success are considerably reduced.

Even at that point of time the medications and therapies remain an exercise of trial and error. A recent review in Expert Opinion in Pharmacotherapy notes available evidence supports  pregabalin, duloxetine and milnacipran as the drugs of choice for the treatment of this disease, followed by amitriptyline and cyclobenzaprine. 

Opioids are widely used as pain relieving substances, however there is no evidence  that pure opioids, such as morphine or oxycodone have any benefit in fibromyalgia. Tramadol has moderate evidence for efficacy, but adverse events and drug cross-reactions limit its use. Low-dose naltrexone targets activated glial cells and has some evidence of benefits.