Advances in the treatment of fibromyalgia: current status and future directions

Hypnotic treatment synergizes the psychological treatment of fibromyalgia: a pilot study

In this pilot study, we compare the efficacy for fibromyalgia of multimodal cognitive behavioral treatments, with and without hypnosis, with that of a purely pharmacological approach, with a multiple baseline N = 1 design. We randomly assigned six hospital patients to the three experimental conditions. The results suggest that psychological treatment produces greater symptom benefits than the conventional medical treatment only, especially when hypnosis is added. We conclude that hypnosis may be a useful tool to help people with fibromyalgia manage their symptomatology.

Fibromyalgia: a randomised, controlled trial of a treatment programme based on self management

OBJECTIVE

To evaluate the efficacy of a treatment programme for patients with fibromyalgia (FM) based on self management, using pool exercises and education.

METHODS

Randomised controlled trial with a 6 month follow up to evaluate an outpatient multidisciplinary programme; 164 patients with FM were allocated to an immediate 6 week programme (n = 84) or to a waiting list control group (n = 80). The main outcomes were changes in quality of life, functional consequences, patient satisfaction and pain, using a combination of patient questionnaires and clinical examinations. The questionnaires included the Fibromyalgia Impact Questionnaire (FIQ), Psychological General Well-Being (PGWB) index, regional pain score diagrams, and patient satisfaction measures.

RESULTS

61 participants in the treatment group and 68 controls completed the programme and 6 month follow up examinations. Six months after programme completion, significant improvements in quality of life and functional consequences of FM were seen in the treatment group as compared with the controls and as measured by scores on both the FIQ (total score p = 0.025; fatigue p = 0.003; depression p = 0.031) and PGWB (total score p = 0.032; anxiety p = 0.011; vitality p = 0.013,). All four major areas of patient satisfaction showed greater improvement in the treatment than the control groups; between-group differences were statistically significant for "control of symptoms", "psychosocial factors", and "physical therapy" No change in pain was seen.

CONCLUSION

A 6 week self management based programme of pool exercises and education can improve the quality of life of patients with FM and their satisfaction with treatment. These improvements are sustained for at least 6 months after programme completion.

[Coping and appraisal in rheumatoid arthritis and fibromyalgia patients]

OBJECTIVES AND METHODS

In a cognitive framework appraisal and coping are seen as major factors in the adaptation of chronic pain patients. This study evaluates the differences between rheumatoid arthritis (N = 70) and fibromyalgia (N = 74) outpatients in regard to coping and appraisal, and the relationship between appraisal, coping and adaptation in general.

RESULTS

In rheumatoid arthritis patients acceptance of illness and cognitive-reappraising coping prevails. In fibromyalgia patients, however, passive, emotion-focused coping and the judgement of illness as a "threat" or "punishment" (Lipowsky) was pronounced. A connection between individual appraisal of the illness and means of coping was observed. There was also a strong relationship between coping and adaptation, with one third of the variance of the mood variables explained by appraisal and coping. The presence of a psychic disorders played only a minor role.

CONCLUSIONS

A detailed understanding of the relationship between appraisal, coping, and adaptation may contribute to improved treatment concepts in pain patients. One aim of psychotherapy in chronic pain patients should be to reduce passive, emotion-focused coping and to change maladaptative concepts of illness.

Person-centered approach to care, teaching, and research in fibromyalgia syndrome: justification from biopsychosocial perspectives in populations

OBJECTIVES

To describe complex interactions of multiple factors believed to contribute to fibromyalgia syndrome (FMS) at a person-centered level to enhance approaches to care, teaching, and research. The main factors addressed were central nervous system sensory sensitization, autonomic nervous system (ANS) activation, neurohumoral perturbations, and psychosocial and environmental stressors. A person-centered approach is defined as attention to major biopsychosocial issues of affected individuals.

METHODS

Literature on classification, mechanistic pathways, course and outcomes, and management of FMS was reviewed to assess applications of person-centered approaches to care, teaching, and research. Various biopsychosocial influences were considered in relation to the heterogeneous subjective manifestations of this illness, including central hyperalgesia, ANS and other neurohumoral perturbations, functional hyperexcitability, nonrestorative sleep, and psychologic distress.

RESULTS

A person-centered approach to FMS can expand on and strengthen traditional biomedical concepts. Adding such a focus can help to untangle current controversies in the course, outcomes, and treatment of FMS. A person-centered approach can also help in the subgrouping of affected patients for greater specificity in care programs and in improved clinical investigations. In the biomedical model, diverse symptoms of FMS are often addressed separately and apart from their interconnectedness and linkages to the patient's individualized biopsychosocial factors. However, the causes of FMS symptomatology are not likely to be caused by uniform biologic abnormalities across populations. Rather, the syndrome likely results from personal reactivities to varied multifactorial biopsychosocial influences. Common denominators among individuals may include varying degrees of ANS activation (or personal susceptibility to ANS activation), nonrestorative sleep, negative affectivity, and other central pain sensitization mechanisms, among the pathways reviewed.

CONCLUSIONS

Innovative analytical methodologies will need to be developed to more effectively investigate complex interacting biopsychosocial dynamics at a person-centered level, including qualitative research, and multifactorial and multilevel techniques. Adding person-centered approaches to biopsychosocial concepts of FMS promises to show new physiopathogenetic insights and more effective treatment than current biomedical models alone. Person-centered approaches enhance patient-physician relationships and help prioritize patients' goals in mutually derived treatment plans.

Rational and targeted pharmacologic treatment of fibromyalgia

Despite disappointing results when subjected to randomized clinical trials, pharmacologic agents remain an important component of FM management. Addressing the main symptoms of pain, disturbed sleep, mood disturbances, fatigue, and associated conditions is essential to improve patient functioning and enhanced quality of life. However, much work remains to design clinical trials which address the complexity of FM, while satisfying evidence based medicine paradigms.

[Study of quality of life of patients with fibromyalgia: impact of a health education programme]

OBJECTIVE

To assess the impact of a programme of health education on the quality of life and frequency of attendance of persons with fibromyalgia.

DESIGN

Community clinical trial with randomised allocation.

SETTING

Sant Joan Despí urban Health District (Barcelona), with a population of 13 282 inhabitants.

PARTICIPANTS AND METHODS

67 women who attended our centre for consultation and were diagnosed with fibromyalgia by the Area Rheumatologist using the criteria of the American College of Rheumatology (1990). They were distributed at random into control and intervention groups.

MAIN MEASUREMENTS

Social and demographic variables (age, marital status, educational background, job situation), health variables (physical exercise taken, current treatment, symptoms evolution time) and frequency of attendance were gathered. The Nottingham Health Profile (NHP) for measuring quality of life was administered. The presence of psychological malaise was determined through the Mini International Neuropsychiatric Interview. After the intervention, which consisted of four health education sessions, the NHP was administered again and frequency of attendance was measured again.

RESULTS

The most important dimension on the NHP prior to intervention was pain (78.6 points), which was not modified either by physical exercise or the disease s time of evolution. Prevalence of psychological malaise was 64.6%. After the intervention there was a significant improvement in the pain dimension (P=.003).

CONCLUSIONS

Health education for people with fibromyalgia modifies their perception of quality of life and reduces their pain. In addition, this kind of activity increases understanding of illness and reduces dependence on the health services.

Neuroendocrine mechanisms in fibromyalgia-chronic fatigue

Fibromyalgia and chronic fatigue syndrome are poorly understood disorders that share similar demographic and clinical characteristics. Because of the clinical similarities between both disorders it was suggested that they share a common pathophysiological mechanism, namely, central nervous system dysfunction. This chapter presents data demonstrating neurohormonal abnormalities, abnormal pain processing and autonomic nervous system dysfunction in fibromyalgia and chronic fatigue syndrome. The possible contribution of the central nervous system dysfunction to the development and symptomatology of these conditions is discussed. The chapter concludes by reviewing the effect of current treatments and emerging therapeutic modalities in fibromyalgia and chronic fatigue syndrome.

Chiari I malformation as a cause of orthostatic intolerance symptoms: a media myth?

There is much interest in a putative relationship between Chiari I malformation and symptoms of orthostatic intolerance. It has been reported at scientific meetings that a number of patients with chronic fatigue syndrome or fibromyalgia have Chiari I malformation, or hindbrain compression in the absence of Chiari, and that they experience improvement after decompression surgery. Many of these patients have symptoms of orthostatic intolerance. A connection between Chiari I malformation and these conditions has been discussed in newspaper articles and on national television programs. Patients have also had access to much information on this topic via the Internet. Unfortunately, the Chiari I malformation and orthostatic intolerance connection is almost entirely unsupported by peer-reviewed literature. The purpose of this article is to provide an objective review of the available information.

Fibromyalgia syndrome improved using a mostly raw vegetarian diet: an observational study

BACKGROUND

Fibromyalgia engulfs patients in a downward, reinforcing cycle of unrestorative sleep, chronic pain, fatigue, inactivity, and depression. In this study we tested whether a mostly raw vegetarian diet would significantly improve fibromyalgia symptoms.

METHODS

Thirty people participated in a dietary intervention using a mostly raw, pure vegetarian diet. The diet consisted of raw fruits, salads, carrot juice, tubers, grain products, nuts, seeds, and a dehydrated barley grass juice product. Outcomes measured were dietary intake, the fibromyalgia impact questionnaire (FIQ), SF-36 health survey, a quality of life survey (QOLS), and physical performance measurements.

RESULTS

Twenty-six subjects returned dietary surveys at 2 months; 20 subjects returned surveys at the beginning, end, and at either 2 or 4 months of intervention; 3 subjects were lost to follow-up. The mean FIQ score (n = 20) was reduced 46% from 51 to 28. Seven of the 8 SF-36 subscales, bodily pain being the exception, showed significant improvement (n = 20, all P for trend < 0.01). The QOLS, scaled from 0 to 7, rose from 3.9 initially to 4.9 at 7 months (n = 20, P for trend 0.000001). Significant improvements (n = 18, P < 0.03, paired t-test) were seen in shoulder pain at rest and after motion, abduction range of motion of shoulder, flexibility, chair test, and 6-minute walk. 19 of 30 subjects were classified as responders, with significant improvement on all measured outcomes, compared to no improvement among non-responders. At 7 months responders' SF-36 scores for all scales except bodily pain were no longer statistically different from norms for women ages 45-54.

CONCLUSION

This dietary intervention shows that many fibromyalgia subjects can be helped by a mostly raw vegetarian diet.

Pharmacologic treatment of fibromyalgia

Fibromyalgia is a chronic syndrome characterized by widespread pain, unrefreshed sleep, disturbed mood, and fatigue. Until such time as we have a clearer understanding of the trigger and/or pathophysiologic mechanisms producing these symptoms, pharmacologic treatment should be aimed at individual symptoms. Such treatment should ideally be offered as part of a multidisciplinary treatment program using both pharmacologic and nonpharmacologic treatment modalities. Critical components of any successful fibromyalgia treatment program include addressing physical fitness, work and other functional activities, and mental health, in addition to symptom-specific therapies. The main symptoms that should be addressed include pain, sleep disturbances including restless leg syndrome, mood disturbances, and fatigue. Pharmacologic therapy should also be considered for syndromes commonly associated with fibromyalgia including irritable bowel syndrome, interstitial cystitis, migraine headaches, temporomandibular joint dysfunction, dysequilibrium including neurally mediated hypotension, sicca syndrome, and growth hormone deficiency. This article provides general guidelines in initiating a successful pharmacologic treatment program for fibromyalgia.

Static magnetic fields for treatment of fibromyalgia: a randomized controlled trial

OBJECTIVE

To test effectiveness of static magnetic fields of two different configurations, produced by magnetic sleep pads, as adjunctive therapies in decreasing patient pain perception and improving functional status in individuals with fibromyalgia.

DESIGN

Randomized, placebo-controlled, 6-month trial conducted from November 1997 through December 1998.

SETTING AND SUBJECTS

Adults who met the 1990 American College of Rheumatology criteria for fibromyalgia were recruited through clinical referral and media announcements and evaluated at a university-based clinic.

INTERVENTIONS

Subjects in Functional Pad A group used a pad for 6 months that provided whole-body exposure to a low, uniform static magnetic field of negative polarity. Subjects in the Functional Pad B group used a pad for 6 months that exposed them to a low static magnetic field that varied spatially and in polarity. Subjects in two Sham groups used pads that were identical in appearance and texture to the functional pads but contained inactive magnets; these groups were combined for analysis. Subjects in the Usual Care group continued with their established treatment regimens.

OUTCOME MEASURES

Primary outcomes were the change scores at 6 months in the following measures: functional status (Fibromyalgia Impact Questionnaire), pain intensity ratings, tender point count, and a tender point pain intensity score.

RESULTS

There was a significant difference among groups in pain intensity ratings (p = 0.03), with Functional Pad A group showing the greatest reduction from baseline at 6 months. All four groups showed a decline in number of tender points, but differences among the groups were not significant (p = 0.72). The functional pad groups showed the largest decline in total tender point pain intensity, but overall differences were not significant (p = 0.25). Improvement in functional status was greatest in the functional pad groups, but differences among groups were not significant (p = 0.23).

CONCLUSIONS

Although the functional pad groups showed improvements in functional status, pain intensity level, tender point count, and tender point intensity after 6 months of treatment, with the exception of pain intensity level these improvements did not differ significantly from changes in the Sham group or in the Usual Care group.

Antidepressant treatment of fibromyalgia. A meta-analysis and review

Fibromyalgia is a common musculoskeletal pain disorder associated with mood disorders. Antidepressants, particularly tricyclics, are commonly recommended treatments. Randomized, controlled trials of antidepressants for treatment of fibromyalgia were reviewed by methodology, results, and potential predictors of response. Twenty-one controlled trials, 16 involving tricyclic agents, were identified; 9 of these 16 studies were suitable for meta-analysis. Effect sizes were calculated for measurements of physician and patient overall assessment, pain, stiffness, tenderness, fatigue, and sleep quality. Compared with placebo, tricyclic agents were associated with effect sizes that were substantially larger than zero for all measurements. The largest improvement was associated with measures of sleep quality; the most modest improvement was found in measures of stiffness and tenderness. Further studies are needed utilizing randomized, double-blind, placebo-controlled, parallel designs with antidepressants administered at therapeutic dose ranges, using standardized criteria for fibromyalgia and systematically assessed for co-occurring psychiatric illness.

Primary care and specialist management options

Fibromyalgia syndrome varies from being a mild intermittent disorder to one that is severe and protracted. Much of the management of the more common milder type is best done at the primary care level with the expectancy of improvement in key symptoms and a generally good prognosis. Careful appraisal of the dimensions of fibromyalgia is needed with an individualized management strategy. Critical to good outcome is the need for an understandable explanation of the mechanism of fibromyalgia and introduction to self-management skills that include exercise and techniques that minimize aberrant responses to psychosocial stressors. The primary care practitioner is well placed to identify risk factors that associate with fibromyalgia in order to minimize emotional distress accompanying illness or psychosocial predicaments. Little formal research has been done on these important areas. In contrast, there is much information on management of fibromyalgia when it presents to specialist practice. More complex and expensive approaches result in variable changes in the outcome of fibromyalgia.

Drug therapy

Because of the lack of understanding of the basis of fibromyalgia, therapy remains empiric. This article reviews the different drug elements used in fibromyalgia, including psychotropic agents (antidepressants, sedatives and hypnotics), anti-inflammatories, analgesics and other pharmacological compounds. The strength of evidence for the therapeutic effect of each medicinal modality is presented, with the emphasis on results of randomized controlled trials. The importance of the expected effects of the current drug modalities, and whether these drugs have short- or long-term effects, are also discussed. Future directions, including testing of newer antidepressants, analgesics and non-steroidal anti-inflammatory drugs (Cox-2 selective inhibitors), as well as the need for long-term comparative trials of both drug efficacy and toxicity, are discussed.

Psychological and behavioral approaches to pain management for patients with rheumatic disease

This article reviews the efficacy of the psychological and behavioral pain management interventions that have been evaluated among adult patients with rheumatoid arthritis (RA), osteoarthritis (OA), and fibromyalgia (FM). Using published criteria for empirically validated interventions, it is concluded that cognitive-behavioral therapies and the Arthritis Self-Management Program represent well-established treatments for pain among patients with RA and OA. These interventions involve education, training in relaxation and other coping skills, and rehearsal of these skills in patients' home and work environments. There currently are no psychological or behavioral interventions for pain among FM patients that can be considered as well-established treatments. Future intervention research should use clinically meaningful change measures in addition to conventional tests of statistical significance, attend to the pain management needs of children, and assess whether outcomes produced in university-based treatment centers generalize to those in local treatment settings.