Fibromyalgia Treatment in the Primary Care Setting

Fibromyalgia impact

By: David Lechnyr, LCSW

This article discusses some of the different approaches in the treatment of Fibromyalgia Syndrome (FMS) in the primary care setting. However, this approach can be adapted towards multiple clinical treatment settings, such as behavioral/mental health.

Let’s examine a hypothetical case history with a 42-year-old female with continuous pain following an automobile collision 18 months ago. She presents with the following:

  • Seen multiple doctors
  • Has tried acupuncture and chiropractic
  • She is disabled and irritable
  • You review her hand carried records showing an extensive work up including X-rays and MRI of C and LS spine
  • Multiple failed drug trials; only Vicodin helps a little
  • Her presenting complaint is, “No one is doing anything to help me.”

Presenting Symtoms

First, we need to consolidate her issues by gathering a list of her current symptoms.  She reports the following:

  • Sleep disturbances
  • “Pain all over”
  • Fatigue
  • Dry, itchy eyes
  • Muscle tenderness
  • Joint pain
  • Current Symptoms
  • Persistent diarrhea
  • Tension headaches
  • Morning stiffness
  • Depression and irritability

The Clinical Interview

Next, we conduct an interview. It’s important to include both the physical, mental, and behavioral health components of her case.  We find that this reveals the following:

  • Almost any activity makes her pain worse; now inactive (physical)
  • Does not sleep well, does not feel rested upon awakening (physical)
  • Gained 22 lbs since accident (physical)
  • Feels frustrated with herself for not coping better (psychological)
  • Appears depressed (psychological)
  • Doses of opioids have been escalating with numerous side effects (physical)
  • She wants to be “fixed” (behavioral)

Clinical Observations

During the course of the interview, we need to keep in mind our clinical observation of the patient’s pain behaviors.  We note the following:

  • Walks in a stiff posture with limited movement of neck
  • Rubs neck frequently
  • Walks in a guarded fashion
  • Sighs
  • Facial grimacing when gets in and out of chair
  • Husband rolls his eyes when he observes her “pain behaviors”

What Do You Tell the Patient?

Historically, this tends to fall into one of three categories. Population studies have showed that providing the fibromyalgia syndrome (FMS) label does not increase illness behavior, disability, or office visits.

  1. That she has fibromyalgia, a disease that has no cure; suggest a handout, book, or website
  2. That she has generalized pain syndrome of unclear etiology and will have to learn to live with it; refer to pain sensation score and have her come back at your next routine check-up (3 mo)
  3. That she has fibromyalgia syndrome (FMS); suggest further investigation and symptom management

What Do You Consider?

  • Peripheral pain generators
  • Central sensitization
  • Chronic distress
  • Disability

Is FMS Primarily a Psychiatric Disease?

This depends on your orientation.  Its pathophysiology is similar to the anxiety-depression spectrum of disorders.  However, FMS is like other diseases that are made worse by or lead to stress-depression. Additionally, FMS is in the group of affective spectrum disorders. So, the answers currently are “yes”, “no”, and “maybe”.

Is FMS Primarily a Psychiatric Disease?

Reference: Goldenberg DL. Arthritis Foundation Bulletin Rheum Dis. 2004;53 [Evidence Level C]

  • FMS non-patients did not have a greater incidence of psychiatric disease
  • 20% of FMS patients who seek any care have psychiatric disease
  • 90% of tertiary referral patients have a past or present history of psychiatric disease

Is FMS Primarily an Affective Spectrum Disorder?

  • Depression
  • Attention deficit disorder
  • Bulimia nervosa
  • Migraine
  • Irritable bowel syndrome
  • FMS (Fibromyalgia Syndrome)
  • Generalized anxiety
  • Panic disorder
  • Posttraumatic stress disorder
  • Social phobia
  • Premenstrual syndrome
  • Irritable bladder
  • Temporomandibular joint dysfunction
  • Chronic headaches

Which Drug Has Multiple Randomized Trials Showing Benefit?

Which Treatments Show the Strongest Benefit in APS Guidelines?

Reference:  Guideline for the Management of Fibromyalgia Syndrome Pain in Adults and Children; APS Clinical Practice Guidelines Series, No. 4, 2005. [Evidence Level C]

  • Strongest:  cardiovascular exercise, CBT, patient education, multidisciplinary therapy, amitriptyline, cyclobenzaprine
  • Moderate:  strength training, hypnotherapy, biofeedback, massage, balneotherapy, tramadol, SSRIs, SNRIs, anticonvulsants
  • Weak:  chiropractic, tender point injections, SAMe, growth hormone, malic acid
  • No evidence:  flexibility exercises, nutritional, herbs, other complementary and alternative medicines (CAM), benzo, melatonin, guaifenesin, DHEA (dehydroepiandosterone)

Other Names associated with Fibromyalgia Syndrome

  • Fibrositis
  • Neurasthenia
  • Psychogenic Rheumatism
  • Myofascial Pain Syndrome
  • FMS

American College of Rheumatology Disease Criteria

Wolfe F, et al. Arthritis Rheum. 1990;33:160–172 [Evidence Level C] suggests:

  • Widespread pain
    • Above and below the waist
    • Right and left side of the body
    • Axial skeleton
  • Present for 3 months or more
  • 11 or more tender points

Tenderness in the General Population

Pain and other somatic symptoms occur as a continuum rather than as “yes” or “no”. All of the defining features of 10 somatic syndromes such as FM, IBS, etc. occur as a continuum. However, while tenderness is important, tender points are misleading. Tenderness is highly correlated with psychological factors, especially distress. It gives an inappropriate impression about the nature of the problem in fibromyalgia (i.e., in the muscle). It accounts for over-representation of distressed, unfit, females. Finally, eleven is a totally arbitrary number.

Fibromyalgia isn’t just fibromyalgia

  • Tension/migraine headache
  • Affective disorders
  • Temporomandibular joint syndrome
  • Constitutional Weight fluctuations
  • Cognitive difficulties
  • ENT complaints (sicca sx., vasomotor rhinits, accommodation problems)
  • Vestibular complaints
  • Multiple chemical sensitivity, “allergic” symptoms
  • Esophageal dysmotility
  • Night sweats
  • Weakness
  • Sleep disturbances
  • Esophageal dysmotility
  • Neurally mediated hypotension, mitral valve prolapse
  • Non-cardiac chest pain, dyspnea due to respiratory mm. dysfunction
  • Interstitial cystitis, female urethral syndrome, vulvar vestibulitis, vulvodynia
  • Irritable bowel syndrome
  • Nondermatomal paresthesias

Event at Onset of Symptoms

  • 60% of patients will identify:
    • Physical trauma – 40%
    • Psychological trauma – 30%
    • Infection – 15%
    • Surgery – 10%

Etiology

  • Viral
  • Genetic
  • Oxygen
  • Chiari type 1
  • Sleep
  • HPA (hypothalamopituitary) axis
  • Phosphate deposition
  • Central sensitization

Genetics and Theories of Fibromyalgia

  • Strong familial predisposition (Arnold et al. Arthritis Rheum. 2004;50:944-952)
  • Phosphate Deposition (R. Paul St. Amand, MD)
    • Hard to detect phosphate crystals deposit in muscle tissue
    • Symptoms similar to untreated gout
  • Chiari Type I Malformation (Michael Rosner, MD)
    • Herniation of cerebellar tonsils
    • Surgery needed to correct
  • Sleep Theory (Harvey Moldofsky, MD)
    • Alpha-delta sleep anomaly
    • Reproduced in normal volunteers
  • Disorders of Chronic Stress
    • Increase in corticotropin releasing factor
    • Reduction in CRF-1 receptors
    • Reduction in ACTH
    • Blunted cortisol response
    • Increase somatostatin
    • Reduction in growth hormone
  • Central Processing (Clauw DJ, et al. Spine. 1999;24;2035–2041. [Evidence Level B])
    • fMRI (functional magnetic resonance imaging) abnormalities
    • Pain threshold lowered
    • Pain inhibitory pathways less effective
  • Sensory Processing: “volume control”
    • Normal detection threshold, but an lowered noxious threshold
    • This is not just to pressure, but also other stimuli, e.g. heat, noise, electrical stimulation

Paradigm Shift in Fibromyalgia

  • Discrete illness
  • Pain, focal areas of tenderness
  • Part of a larger continuum
  • Many somatic symptoms, diffuse tenderness
  • Psychological and behavioral factors nearly always present
  • Psychological behavioral factors play roles in some

Treatment Options for FMS

There are few proven treatments for Fibromyalgia Syndrome in randomized controlled trials:

Despite this, the most prescribed solution tend to involve anti-inflammatories, with a patient preference for opioids.

Emerging Treatment Options for FMS

  • Duloxetine
  • Milnacipram
  • Xyrem (sodium oxybate) – approved for Excessive Daytime Sleepiness, Cataplexy in Narcolepsy
  • Patient education
  • Biofeedback
  • Pacing
  • Cognitive restructuring
  • Group support
  • Treating underlying mood disturbances

Steps to Help Patients With Chronic Pain

The bottom line is that Fibromyalgia Syndrome (FMS) needs to be managed as chronic pain along with all existing treatment options.  It’s important to remember the gold standards for working with chronic pain:

  • Accept pain as real
  • Protect from excessive invasive testing
  • Set realistic goals
  • Expect to treat, but not to cure
  • Evaluate in terms of what they do, not what they say
  • Prescribe medication on time-contingent, not “as-needed” (PRN) basis
  • Prescribe gradual increase in physical exercise
  • Clarify difference between hurt and harm
  • Educate family to encourage patient’s increased activity
  • Focus on patient’s activities not pain
  • Help patient to get involved in pleasurable activities

Photo credit: Pixabay/MissCaraReads