Sore points

Guidelines for managing fibromyalgia syndrome in a primary care setting

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By  Healthcare Middle East Published  October 25, 2006

Sore points|~|hand2.jpg|~|“As with other pain syndromes, FMS symptoms are largely subjective and lack unique pathophysiological characteristics, so diagnosis can be complex.”|~|At any one time, 10% to 20% of the population reports chronic generalised muscoskeletal pain that cannot be explained by a specific structural or inflammatory condition. This idiopathic, widespread pain will often fit the diagnostic criteria for fibromyalgia syndrome (FMS). FMS is second only to osteoarthritis as the condition most frequently diagnosed by rheumatologists, and it is far more common in women than men. It is characterised by a history of chronic musculoskeletal pain and tenderness at specific points on the body. Aching often starts around the neck and shoulders and grows to encompass the back, chest, hips, arms, and legs. FMS is frequently accompanied by fatigue and sleep problems, and often by depression, leading some clinicians to question whether fibromyalgia is simply chronic fatigue syndrome under another name. Certainly, FMS sufferers feel the weariness characteristic of chronic fatigue syndrome, and patients with chronic fatigue syndrome may report tenderness in muscle-tendon sites. While no discrete boundary separates the two syndromes, patients with fibromyalgia generally report more pain, whereas patients with chronic fatigue syndrome are more likely to present with sore throats, swollen lymph glands, and low-grade fevers. Other FMS comorbidities include chronic muscular headaches, irritable bowel syndrome, irritable bladder, and chronic fatigue syndrome. Each of these illnesses is comorbid with mood disturbances. Fibromyalgia can be disabling and a source of enormous frustration. Because its cause is unknown, prevention is impossible. As with other pain syndromes, FMS symptoms are largely subjective and lack unique pathophysiological characteristics, so diagnosis can be complex. Indeed, physicians are divided on whether diagnosis is beneficial at all. Some clinicians argue that an FMS diagnosis has an adverse effect on patient outcome, making patients feel more disabled than they are. However, one study does suggest that establishing a diagnosis, alongside patient education, is a beneficial component of FMS management. The study, designed to monitor the health status of patients post-diagnosis, showed that previously non-labelled FMS patients reported less symptoms and a significant improvement in health satisfaction three years after diagnosis. No significant increase in the percentage of diagnosed patients claiming disability was reported.||**||Causes of FMS|~|hand2.jpg|~|“The strongest evidence for medication efficacy in FMS is for tricyclic antidepressants, notably amitriptyline and desipramine.” |~|We know that fibromyalgia is not a muscle disease, as was once thought. The frequent comorbidity of FMS, irritable bowel syndrome and chronic fatigue syndrome with mood disorders suggests neuroendocrine and stress-response abnormalities may be a shared cause. Many studies have shown that patients with fibromyalgia demonstrate abnormal pain processing. Patients have lower-than-average levels of cortisol, which in turn reduces serotonin and norepinephrine levels, increasing sensitivity to pain and possibly depression. Physiological evidence of altered pain processing in FMS is also demonstrated by a two- to three-fold higher concentration of cerebrospinal fluid substanceP compared with that in healthy controls. In 2002, an imaging study published in the journal Arthritis and Rheumatism showed for the first time that the brains of FMS patients experience pain at a relatively low level of pressure stimulation. Researchers have also found low levels of growth hormone (GH) in fibromyalgia sufferers. This may be due to the GH’s diurnal secretion pattern, which is inhibited by the sleep problems common in FMS. A shortage of GH can impede muscle maintenance and repair, contributing to weakness and fatigue. In combination, these factors produce a self-perpetuating cycle of pain, fatigue, and poor sleep. What instigates this cycle is still unknown, and could differ from patient to patient. However, many patients report a viral disease or an emotional or physical trauma immediately before developing fibromyalgia. Psychosocial factors also contribute greatly to the clinical expression of FMS. ||**||Diagnosing fibromyalgia|~|hand2.jpg|~|"Before making a diagnosis, it is advisable to perform tests to exclude other diseases."|~|The American College of Rheumatology’s criteria for diagnosis include persistent widespread musculoskeletal pain and excess tenderness in at least 11 of 18 specific muscle-tendon sites (see ‘At a glance’). Before making a diagnosis, it is advisable to perform tests to exclude other diseases, such as rheumatoid arthritis, osteoarthritis, and lupus. While fibromyalgia can be debilitating, it doesn’t produce the kind of muscle, bone, and joint damage associated with these diseases. ||**||Treating FMS|~|hand2.jpg|~|"Central nervous system agents have proved the most effective pharmacotherapy for FMS."|~|Despite improved recognition and understanding of FMS, researchers have yet to identify a single, universally effective treatment. It is thought the most effective approach combines multidisciplinary therapies such as medication, stress reduction, exercise, and cognitive behavioral therapy. However, very few trials have combined medication and nonpharmacological treatments so evaluation of this treatment is limited. A cardinal rule is to encourage patients to learn as much as possible about the condition to help reduce distress and increase their sense of control. - Medications Central nervous system agents have proved the most effective pharmacotherapy for FMS (see ‘At a glance’). Despite the variety in their labels, these antidepressants, muscle relaxants and anticonvulsant all target various neurochemicals in the brain and spinal cord that can affect pain sensation and tolerance. While none of the drugs are currently approved by the FDA for the treatment of FMS, their varying efficacy has been demonstrated in randomised clinical trials. The strongest evidence for medication efficacy in FMS is for tricyclic antidepressants; notably amitriptyline and desipramine. Several trials have shown these agents improve sleep, fatigue, pain and sense of wellbeing in FMS sufferers. However, they offer little improvement in tender-point pain. Cyclobenzaprine, usually marketed as muscle relaxant but structurally a tricyclic compound, has demonstrated similar benefits. Selective serotonin reuptake inhibitors (SSRI) have also proved moderately effective. One crossover trial found fluoxetine (20mg/d) as well as amitriptyline (25mg/d) was better than placebo in a number of outcome measures in FMS patients, improving pain, fatigue and depression. Again, pain in tender points was not significantly improved. To date, serotonin-norepinephrine reuptake inhibitors have not been widely tested in FMS, and available study results are conflicting. While a trial of 90 FMS patients found that Venlafaxine (75mg/d) was not significantly different from placebo, two small open-label studies using higher doses reported limited efficacy. Tramadol, with or without acetaminophen, has been shown to provide pain relief to FMS patients. No studies have demonstrated that nonsteroidal anti-inflammatory drugs are effective when used alone, although they may be useful when combined with other medications. Lastly, gabepentin, an anticonvulsant medication, is currently under study but no results have been reported. However, pregabalin, a second-generation anticonvulsant, was shown in one study to significantly improve pain in FMS patients. Pregabalin (450 mg/d) reduced the average severity of pain compared with placebo, with a significant number of patients reporting a more than 50% improvement in pain. Improvements in sleep, fatigue and overall wellbeing were also reported. - The importance of exercise Cardiovascular exercise can provide huge benefits to fibromyalgia patients. Clinical trials have shown that regular strength and aerobic training over a period of months can increase strength and endurance, reduce pain and stiffness, improve coping skills, and generally improve wellbeing. Physical activity also helps relieve depression, anxiety, and fatigue. Moderate-intensity aerobic exercise twice a week, for example, has proved effective in improving tender-point pain pressure thresholds and reducing overall pain. Several studies have shown pool exercise to be well tolerated and particularly helpful for FMS patients. The exercise is low-impact and the warm water may reduce stiffness and pain. It may be useful to refer patients to a physical therapist or exercise physiologist to ensure the type and intensity of their programme is suited to their particular situation. Working out too hard may increase pain and fatigue and reduce compliance. Patients should start at a level that feels comfortable, and take time to rest as needed. They can then gradually increase the duration and intensity of the exercise, taking care not to escalate until they’re ready. For low-impact aerobic exercise, such as biking, walking, and swimming, patients should start with 20 minutes a day, two to three times a week, gradually increasing to 30 minute sessions. - Mind-body strategies There is strong evidence that psychological and behaviour therapy, particularly cognitive behaviour therapy (CBT), is effective in FMS. Unrelenting pain and other symptoms can understandably lead to discouraging thoughts, which can spiral into depression, anxiety, and anger, exacerbating FMS symptoms. CBT teaches patients that their thoughts influence how they feel and behave. Its goal is to help them learn how to turn unproductive thought patterns into helpful ones. This may include, for example, learning how to shift focus from what they can’t do anymore to activities they can still enjoy, or adjusting expectations to minimise disappointment. During CBT, fibromyalgia sufferers also learn how to adapt daily activities to prevent flareups caused by doing too much, or lethargy caused by doing too little. This may help them maintain routines, which can improve mood and reduce isolation. Randomised controlled trials of CBT found it decreased pain severity and improved function, fatigue and mood in FMS sufferers. Reducing stress can also help ease pain, improve sleep and concentration, and alleviate depression and anxiety from fibromyalgia. Harvard Medical School’s Dr Herbert Benson, who coined the term “relaxation response”, recommends meditation and other relaxation techniques for relieving stress. Meditation is aimed at quieting the autonomic nervous system, which regulates heart, breathing, and metabolic rates. The goal is a calm mental state brought on by focused breathing, repetition of a word or phrase, and an effort to empty the mind of random thoughts. Another mind-body strategy, progressive muscle relaxation, involves tensing and relaxing muscles, one at a time. Some patients may prefer guided imagery, in which they learn how to travel in their minds to a comforting place, in response to pain.||**||Ongoing management|~||~||~|Like any chronic pain syndrome, FMS is complex to diagnose and treat. However, there is strong evidence to suggest a multidisciplinary approach that targets both the physical and psychological factors of FMS offers the best chance of relieving the greatest number of symptoms. Clinical trials have shown that low-dose tricyclic medications, as well as cardiovascular exercise, CBT and patient education are all effective tools in treating FMS. Finding the right balance of these therapies for optimal FMS management is best achieved when patients and healthcare professionals work as a team. ||**||At a glance: The American College of Rheumatology criteria |~||~||~|History of widespread pain has been present for at least three months Definition: Pain is considered widespread when all of the following are present: - Pain in both sides of the body - Pain above and below the waist In addition, axial skeletal pain (cervical spine, anterior chest, thoracic spine or low back pain) must be present. Low back pain is considered lower segment pain. Pain in 11 of 18 tender point sites on digital palpation Definition: Pain, on digital palpation, must be present in at least 11 of the following 18 tender point sites: - Occiput (2) - at the suboccipital muscle insertions - Low cervical (2) - at the anterior aspects of the intertransverse spaces at C5-C7 - Trapezius (2) - at the midpoint of the upper border - Supraspinatus (2) - at origins, above the scapula spine near the medial border - Second rib (2) - upper lateral to the second costochondral junction - Lateral epicondyle (2) - 2 cm distal to the epicondyles - Gluteal (2) - in upper outer quadrants of buttocks in anterior fold of muscle - Greater trochanter (2) - posterior to the trochanteric prominence - Knee (2) - at the medial fat pad proximal to the joint line. Digital palpation should be performed with an approximate force of 4 kg. A tender point has to be painful at palpation, not just ‘tender’.||**||At a glance: FMS medications|~||~||~| - Tricyclic antidepressants Amitriptyline (Elavil), desipramine (Norpramin), others. Can help relieve pain and depression. Side effects include anxiety, drowsiness, dizziness, dry mouth, and constipation. - Selective serotonin reuptake inhibitors Fluoxetine (Prozac), others. Can help relieve pain and depression. Fewer side effects than tricyclic antidepressants. - Serotonin-norepinephrine reuptake inhibitors Venlafaxine (Effexor). May help relieve pain and depression. Not extensively tested in fibromyalgia. - Muscle relaxants Cyclobenzaprine (Flexeril), carisoprodol (Soma), others. Can help relieve pain and restore normal sleep patterns. - Analgesics / nonsteroidal anti-inflammatory drugs Tramadol (Ultram), acetaminophen. Tramadol provides pain relief but may be habit-forming. Acetaminophen and NSAIDs may be useful in combination with analgesics or tricyclic medications. - Anticonvulsants Gabapentin (Neurontin), pregabalin. Currently under study for relieving pain and improving sleep in fibromyalgia. ||**||

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