Chapter 2-Three Things We Know About Fibromyalgia

There is a lot of good content in this chapter, so bear with me as I share it.  Let me know what you think!  The information in this chapter discussion are not meant to diagnose or treat fibromyalgia.  Always, check with your doctor before beginning any treatment.

Despite being the second most prevalent rheumatologic disease, there has been relatively little research undertaken to understand Fibromyalgia.

1. Fibromyalgia is Associated with Disordered Pain Processing

The evidence in the medical literature is strongly supportive of abnormal processing of pain information in the central nervous system to physically induced pain such as pressure, heat, cold, or electrical stimulation resulting from generalized lowered pain thresholds in fibromyalgia.  The evidence is strongly supportive of an abnormality in the central nervous system pain processing known as central nervous system sensitization or central sensitization for short.  People with fibromyalgia feel pain more readily and with a much higher sensitivity, than those without fibromyalgia.  There is clear evidence for increased sensitivity to external painful stimuli in patients with fibromyalgia.

There are, also, neurotransmitter abnormalities which can be associated with serotonin level issues.  Not source or cause of pain has been identified in all of the studies.  Studies have not identified the sources or cause of the seemingly spontaneous pain reported in fibromyalgia.

2.  The Treatment of Fibromyalgia is Profoundly Disappointing.

Patients are being told they have a chronic painful disease that may impair their ability to function with no known cause, cure, or highly effective treatment and that they must learn to live with it.

Medications do not seem to help much.  Nonsteroidal anti-inflammatory drugs (NSAIDS) are frequently prescribed despite the evidence indicating that they are no better than the placebo.  Prednisone has not been show to be of benefit, either.  Analgesics are also frequently used in managing fibromyalgia symptoms despite little data regards their effectiveness.  Acetaminophen has shown less benefit.  Tramadol (Ultram) is a weak opioid medication.  There is some benefit using it alone or in combination with acetaminophen.  Antidepressant and other psychoactive medications are used frequently to manage the symptoms of fibromyalgia.  The most used and studied is Elavil and the muscle relaxant Flexeril.  In low doses (10-50 mg daily) Elavil has shown improved pain.  Flexeril in studies (given 10-40 mg daily) have reported improvement in pain, sleep, global well-being, and fatigue.  Long term use of either Elavil or Flexeril is unknown.  Selective serotonin reuptake inhibitors (SSRIs) (like Prozac, Celexa, and Zoloft) are a class of drugs that have been highly successful in treating psychiatric conditions such as depression, anxiety, and phobias.  When given to treat fibromyalgia in studies, they are not consistently showing improvement in pain.  But one study using Prozac and Elavil showed they were more effective in reducing pain and symptoms than either drug alone.  When studies were conducted using Effexor the results were mixed and inconsistent.  Cymbalta (used in studies) showed some improvement in some but not all pain measures, reduction in tender point counts, and some improved quality of life measures in women with fibromyalgia, but not in men.  S-adenosyl-L-methionine (SAMe) is a compound that has antidepressant, anti-inflammatory, and analgesic properties.  One trial showed improved mood and tender points, another showed improvement in mood, pain, overall disease activity and fatigue, and a third study showed no benefit.  Studies using Neurontin and/or Lyrica demonstrated improvements in pain, sleep, fatigue, and global symptom severity in higher doses. A placebo controlled trial to assess the benefit of Lyrica in patients with fibromyalgia showed that 63% of patients achieved significant reduction of pain initially, and after 26 weeks of treatment, 32% of those patients lost the therapeutic response achieved at onset but significantly more patients sustained a defined improvement compared to placebo treatment.  The expectorant guaifenesin has been used to treat fibromyalgia on the assumed, but unproved, theory that there is an excess accumulation of phosphate in the muscles and that this can be excreted by the action of guaifenesin.   A one year double blind controlled trial failed to demonstrate any improvement in global functioning or tender point counts.

The medication trial data do show that Flexeril and Elavil appear to be the most helpful drugs in managing fibromyalgia for reasons to be yet determined.

Study programs providing exercise about 1-3 times weekly for a range of about 6 weeks to 6 months and involved either walking, bicycling, dancing, or swimming with or without accompanying education, showed improvement in pain, pain threshold, tender point counts, fatigue, quality of life, and psychological distress.  But improvement is not uniformly noted.  Maximal exercise has been shown to increase pain sensitivity in patients with fibromyalgia.  The degree of improvement is not dramatic.  Tender point pain threshold improves by 28% and pain is reduced by 11%.  Some patients receive nominal benefit from aerobic cardiovascular fitness training while others cannot tolerate such programs.

Cognitive behavioral therapy (CBT) programs include education, coping skills training, cognitive and behavioral training, and relapse prevention.  All programs are centered around fibromyalgia.  Additional components may include relaxation training, stress management, biofeedback, meditation, exercise, physical therapy, or occupational therapy.  Studies are showing benefits from CBT.  There is improvement in pain, tender point counts, stiffness, stress when stress management is incorporated, distress, functional ability, sleep mood including depression and anxiety, and general healthy assessment.  And it sustained up to 30 months following completion of the program.

It is virtually impossible to perform blinded studies with regard to the patient and the treatment provider for non-medication interventions.  Hands-on type treatments are subjective in their application and difficult to standardize.  Some of those treatments are Electromyography (EMG) biofeedback, hypnosis and relaxation training, meditation, neck support, acupuncture, nutritional interventions and dietary supplements, whirlpool baths with valerian, dietary modifications, static magnet therapy, chiropractic intervention, massage therapy.  As with all the other treatments reviewed, the treatment trial data clearly tell us that fibromyalgia is not a homogeneous disease or process and that we have no clue as to what to target any treatment against nor how to measure its benefit.

3.  Patients with Fibromyalgia Do Not Do Well In the Long-Term

Patients with fibromyalgia in general do not do well in the long term, although those with milder symptoms may do better because inherently they have less severe symptoms and involvement.

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