Overview: Fibromyalgia

• Diagnostic criteria for fibromyalgia syndrome (FM) have been reconsidered by Wolfe et al.

• Chronic widespread pain of at least 3 months’ duration remains a hallmark of the disease.

• However, tender points are no longer relevant. Rather, the number of painful areas reported by the patient in the past week is documented (Widespread Pain Index), and the severity of associated symptoms of fatigue, waking unrefreshed, and cognitive difficulties is assessed and scored (Symptom Severity Scale Score).

• The previously noted increased prevalence in women may have been an artifact of using the tender point examination in the diagnostic criteria.

• When this criterion is eliminated, the difference in prevalence between women and men appears to be reduced.

• This finding is further supported by previous research show- ing no impact of the menstrual cycle on symptoms of FM.

• Increasing evidence supports the hypothesis that the pathophysiology of FM is the result of genetic and biologic factors, environmental triggers, and neurophysiologic abnormalities.

• Investigators generally agree that the increase in pain sensitivity that is typical of patients with FM is the result of central augmentation of sensory input and diminished central pain inhibitory function.

• Among first-degree relatives of patients with FM, those who do not complain about any pain problems demonstrate increased pain sensitivity com- pared with healthy controls.

• Careful history taking often reveals a stressful trigger event or period, such as an accident, a flulike illness, emotional stress, or overwork, preceding the onset of symptoms.

• Post-traumatic stress disorder often exists as a comorbidity.

• Thus, the role of environment in the pathophysiology of FM cannot be downplayed and may help guide a clinician in creating treatment plans for patients with FM.

Important Points to Consider

• Fibromyalgia research suggests that this is a disorder of central nervous system pain sensitization and augmentation associated with neuroendocrine and immune system abnormalities. Explaining this to patients may have some therapeutic benefit.

• Evidence suggests that Eastern movement practices such as tai chi, yoga, and qi gong, which contain strong meditative components, appear to be helpful for patients with fibromyalgia in reducing pain and improving function.

• Mainstays of a treatment plan for fibromyalgia
  include an exercise prescription, mind-body types of interventions, treatment of comorbid depression, and judicious trials of other complementary and alternative medicine modalities and allopathic pharmaceuticals. However, every treatment plan should be individualized and flexible.

Fibromyalgia Clinical Diagnostic Criteria

Prevention Prescription

No proven preventive strategy exists for FM, but the following may help to fortify a susceptible individual against the “slings and arrows of outrageous fortune”:

• Exercise and maintain a normal body weight. Combine aerobics, strength training, and stretching. Consider tai chi and yoga. Make exercise a time to play.

• Eat a healthy whole foods diet, rich in plant sources of antioxidants.

• Avoid trans fats and excess caffeine, alcohol, and sugars.

• Honor your temperament and sensitivity.

• Learn more about yourself and your unique needs and values in work and relationships.

• Journal to stay in touch with your inner feelings and to give voice to negative feelings and stressful events when they arise.

• Put yourself high on the list of things to take care of each day.

• Consider regular massage therapy or other bodywork to this end.

• Learn to meditate, and practice daily.We recommend a mindfulness-based stress reduction course.

• Allow yourself creative outlets such as art, or creative writing.

• Live for your own heart's desires, and allow yourself time and space to figure out what these are. If you get stuck in life, find a good psychotherapist.

Therapeutic Review

This summary provides the most helpful options for treating FM symptoms. FM has no documented “cure.”

Studies have reported an improvement in 5% to 53% of patients, although 47% to 100% of patients continue to meet criteria for FM 2 to 5 years after diagnosis.

Only a few patients experience complete resolution of symptoms. Despite these dismal statistics, we cannot emphasize enough the therapeutic benefit of generous listening and affirming the patient’s felt experience.

In our practices, approximately 75% of patients will report “some” relief of symptoms with treatment.

Better response to treatment is seen in younger patients and in those with continued employment, supportive families, and an absence of litigation or affective disorders.

Nutrition

• Encourage a whole foods anti-inflammatory diet with ample plant antioxidants, omega-3 fatty acids, and minerals.

• Counsel avoidance of trans fats and simple sugars.

Exercise

• Write an exercise prescription tailored to the patient’s individual preferences and fitness starting point.

• Encourage aerobic exercise, strength training, and stretching.

• Suggest warm-water exercise classes, tai chi, yoga, and qi-gong.

• Even 30 minutes of daily cumulative lifestyle activity is beneficial.

Mind-Body Therapy

• Encourage mindfulness meditation training and daily practice.

• Suggest reading The Mindbody Prescription and working through one of the available mind-body workbook programs.

• Suggest journaling about emotions and stressors to help increase affective self-awareness.

• Refer for cognitive-behavioral therapy if roles and relationships are problematic or if the patient feels “stuck.”

• Consider biofeedback and hypnotherapy as alternatives.

Acupuncture

• If the patient can afford treatments, encourage a five-session trial.

Bodywork

• Suggest regular massage therapy or other bodywork as a way of endorsing self-care.

Supplements

• Omega-3 fatty acids (fish oil): 2000 to 4000 mg daily

• Magnesium: 400 to 750 mg daily

• Vitamin D (cholecalciferol): to maintain 25-(OH) vitamin D levels higher than 40 ng/mL and lower than 100 ng/mL year-round

• S-adenosylmethionine: 800 mg twice daily

Botanicals

• Turmeric, ground root: 500 to 1000 mg two to three times daily

• Ginger, ground root: 1 g to 4 g total daily divided into two to three doses

• Boswellia: 250 to 500 mg three times daily

• St. John’s wort: 300 mg three times daily

Pharmaceuticals

• Amitriptyline: 5 to 50 mg nightly as tolerated

• Nortriptyline: 25 to 100 mg daily

• Fluoxetine: 10 to 20 mg daily

• Paroxetine: 10 to 30 mg daily

• Duloxetine: 30 mg for 1 week, increasing to 60 mg thereafter

• Milnacipran: 12.5 mg daily to start, increasing to 50 mg twice daily by the end of the first week; 100 mg twice daily may be needed

• Cyclobenzaprine: 2.5 mg daily, titrating to 40 mg daily in divided doses as needed

• Trazodone: 25 to 300 mg nightly as needed

• Gabapentin: 300 mg initially, increasing slowly to a maximum of 3600 mg daily as tolerated

• Pregabalin: 50 mg three times daily, increasing to a total of 600 mg per day over 7 days

• Tramadol: 50 to 400 mg daily in divided doses

  
  

Key Web Sources

• http://www.unlearnyourpain.com

• http://www.mindbodymedicine.com

• http://www.emofree.com

• http://www.emdr.com

• http://www.med.ufl.edu/rheum/FMSarticles/article25.htm

• http://naturaldatabase.therapeuticresearch.com