Journal Club
January 2013
Brought to you by the AOCPMR Student Council
Article title:
MANAGEMENT OF FIBROMYALGIA SYNDROME
Authors:
Don L. Goldenberg, M.D., Crol Burckhardt, Ph.D., Leslie Crofford, M.D.
Journal/Source:
Journal of American Medical Association 2004; 292(19):2388-2395
Discussion:
Fibromyalgia Syndrome (FMS) is a chronic and pervasive disorder. There is a 2% prevalence of FMS in
the US affecting women at a 4:1 ratio. FMS can be compared to other chronic pain disorders such as back
pain and headache in scope of clinical, physiological, and psychosocial characteristics. When this article
was written (in 2004), there were no drugs approved by the FDA for the management of FMS. This
clinical review develops a management plan based on an expertly analyzed literature review. Outcomes
for treatment were based on parameters specific to FMS diagnosis, comorbid dysfunction, and associated
factors.
FMS is characterized by chronic, idiopathic, widespread pain that radiates from joints or tissue. FMS is
diagnosed by history of pain lasting for more than 3 months or generation of pain with applied pressure
in 11 of 18 areas (arms, buttocks, chest, knees, lower back, neck, rib cage, shoulders, and thighs). FMS is
comorbid with depression, insomnia, irritable bowel syndrome, chronic fatigue syndrome, mood
disorder, rheumatic disease, and cognitive dysfunction.
FMS patients feel pain more acutely and with fewer stimuli. Recent research has found important
physiological findings: a 3 fold increase in substance P concentration in CSF, altered pain processing on
brain imaging, and altered temporal summation of pain stimuli. Psychosocial factors in FMS might be
relative to an altered baseline to stress tolerance and may be genetic. Potential genetic predisposing
factors for FMS are indicated in serotonin transporter genes and the catechol-O-methyltransferase
enzyme (COMT).
This review presents a stepwise approach to management of Fibromyalgia, initially indicating patient
education, cardiovascular exercise, and treatment of comorbid illness such as sleep disturbance and
mood disorder. A combined approach to treatment with low dose tricyclic antidepressants (amitriptyline
and cyclobenzaprine), cardiovascular exercise, cognitive behavioral therapy, and patient education is
considered most beneficial to patients who do not resolve with initial treatment. At the writing of this
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article, RCTs for SNRIs were underway and results for these trials are anticipated. Currently, the SNRIs
duloxetine and milnacipran, along with the anticonvulsant, pregabalin, are FDA approved medications for
FMS.
The stepwise plan is based on treatment efficacies as found by literature review. Outcomes of treatment
across studies were accumulated mainly by self-assessment using tools such as the FIQ (Fibromyalgia
Impact Questionnaire, which measures physical functioning, work status, depression, anxiety, sleep, pain,
stiffness, fatigue, and well-being); clinical assessment using manual tenderpoint assessment, dolorimetry
(measures threshold and tolerance), and exercise fitness was also utilized.
The functionality of FMS patients correlates with their ability to self-manage pain. Some successful
treatments, such as CBT and education, address functionality directly and it is interesting to note their
impact reported on pain. Pharmacological treatment seemed to have greater effect on peripheral
symptomology and it is ironic that in FMS using non-medicinal therapy to reduce pain and drug therapy
to treat comorbid symptoms is indicted.
Here is a summary of significant effects of the recommended and FDA approved treatments: Patient
education improved pain, sleep, fatigue, self-efficacy, quality of life, and 6-minute walk. Cardiovascular
exercise was significant for terderpoint pain pressure threshold and general pain. Cognitive behavioral
therapy improved pain, function, fatigue, and mood. Combined therapy (CBT, cardiovascular exercise,
and education) improved pain severity, physician rating of disease severity, and FIQ. TCAs improved
most clinical outcomes, especially sleep quality. SNRIs improved general FIQ scores. Pregabalin lowered
pain severity and was effective at improving general pain in a large percent of patients.
A drawback to the research presented as highlighted by the authors is the lack of long term study for this
chronic illness. Most pharmacological studies were of 6-12 week duration. Findings for tricyclic
antidepressants were based on evidence from short term studies and were shown to lose their effect in
one long term study. Another shortcoming is a lack of data from patients comorbid with rheumatic
disease, which has a 25-65% comorbidity with FMS (the CDC classifies FMS as a type of arthritis). Future
research should examine longer term data, individualized patient prognosis and treatment, and operate
within a more stringent definition of what comprises Fibromyalgia.
Questions:
1. What would be on a differential diagnosis for an FMS patient?
2. How might psychosocial factors contribute to FMS?
3. What is the difference between amitriptyline and cyclobenzaprine?
4. Why might some FMS patients have better outcomes from certain therapies?
5. What is the argument for a physician who believes sharing an FMS diagnosis with a patient will
inhibit treatment?
6. Compare findings for cardiovascular, strength training, and stretching exercises.
7. What is the difference between a clinical review and a literature review?
8. What is the difference between coaggregation and comorbidity?
Reviewer:
Michael Flamm, OMS-II, NYCOM PM&R Journal Club Chair
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