Fibromyalgia: Meet the Professor Session

Lesley M. Arnold, MD, professor of Psychiatry and director, Women's Health Research Program, University of Cincinnati College of Medicine, Cincinnati, OH

After a brief meet-and-great-in which it was learned that of 18 people in the room, Syria, France, Germany, Greece, Brazil, Puerto Rico, and of course the US were represented-Dr. Arnold reviewed her objectives for participants in the session:

• Discuss the most recent thoughts regarding the pathophysiology of fibromyalgia (FM) and related disorders
• Prescribe a treatment program for the typical FM patient and serve as a consultant to that patient and the primary care provider
• Describe the principles of a comprehensive treatment program for the more challenging FM patient

With much discussion between the presenter and participants, Arnold presented various study results and experiences. First, she reviewed the American College of Rheumatology 1990 FM criteria, which she said are still the core research standard. She explained the criteria state that a FM diagnosis is based on a history of widespread pain for 3 or more months that is on both the left and right sides of the body, both above and below the waist, and consists of axial skeleton pain; additionally, the pain should exist in 11 of 18 tender point sites on digital palpation.

The presenter then focused on the characteristic clinical features of FM, which she listed as:

• Widespread body aches, pain, and tenderness
• Fatigue
• Cognitive problems Trouble concentratingForgetfulnessDisorganized thinking
• Sleep disturbances
• Stiffness
• Depressive and anxiety symptoms
• Impaired social and occupational functioning

Discussion moved to prevalence of comorbidities among patients with FM. Arnold reviewed study results that showed a painful neuropathy prevalence of 22.8% in patients with FM, compared with 2.8% for patients without FM. Circulatory disorders, depression, diabetes, and sleep disorders had a prevalence of 22% and 12.1%, 12.3% and 2.8%, 5.9% and 3.9%, and 5.7% and 1% in patients with and without FM, respectively.

The speaker later reviewed the risk factors for FM, noting that the disorder is strongly familial with an odds ratio of 8.5 for first-degree relatives. She also explained that FM coaggregates with major mood disorder in families and with mood disorders, anxiety disorders, eating disorders, irritable bowel disorder, and migraine, taken collectively. Additionally, she stated, FM may share a common physiologic abnormality with some psychiatric and medical disorders.

Also associated with FM, as well as chronic widespread pain, are several stressors. Arnold listed them as early life stressors, peripheral pain syndromes (eg, rheumatoid arthritis, osteoarthritis), physical trauma or stress, certain catastrophic events (war but not natural disasters), infections, and psychological stress/distress.

Arnold next reviewed the role played by neurotransmitters in FM. She explained that Substance P and glutamate (along with other excitatory amino acids) may play a role in central pain sensitization, with Substance P seen at elevated levels in cerebrospinal fluid of patients with FM compared with controls, and glutamate seen at elevated levels in the cerebrospinal fluid of patients with FM compared with controls. Also, there is evidence of dysfunction in serotonin, norepinephrine, and dopamine in FM.

Moving on to the overall management strategy in FM, the presenter explained that reduction of clinical pain is key. Specifically, this is optimized when ALL pain sources are addressed, with treatment individualized depending on pain symptoms. Management should also consist of treatment of other symptom domains and improvement in function and global health status. 

After discussion of various drugs, including alpha-2-delta ligands and serotonin/norepinephrine reuptake inhibitors, focus switched to treatment with exercise and cognitive behavioral therapy to close out the session. The rationale for exercise to treat the chronic pain associated with FM is as follows, according to Arnold:

• Patients become sedentary because of pain and other symptoms
• Deconditioning from lack of exercise can make pain and other symptoms worse
• Exercising can reverse effects of deconditioning

Although the exact mechanism by which exercise improves chronic pain is unknown, stated the presenter, improvement in symptoms can occur without changes in cardiovascular fitness levels. Further, Arnold explained that aerobic training at moderate intensity likely improves overall wellbeing and physical function, and strength and flexibility training may decrease pain, tender points, and depression, and may improve overall wellbeing, according to results from a pair of studies.

When considering cognitive behavioral therapy (CBT) for FM, Arnold said the program should be designed to teach patients techniques to reduce their symptoms, increase coping strategies, and identify and eliminate maladaptive illness behaviors. She noted that CBT has be shown to be effective for nearly any chronic medial illness, although the effectiveness of CBT is based on the content, therapist, and program.

Arnold closed the discussion by explaining that treatment of FM should address all sources of pain and comorbid symptoms and disorders, and the FM may share common physiologic abnormalities with some psychiatric and medical disorders.