Editorial - Strategies for managing fibromyalgia

Written by Philip M. Hanno, MD Thursday, 18 March 2010 BERKELEY, CA (Reprinted with permission from UroToday.com)

What Can We Learn From Other Chronic Pain Syndromes?

Now that “interstitial cystitis” has been recognized as primarily a chronic pain syndrome, with the nomenclature revised accordingly (“bladder pain syndrome”), it seems there should be synergies and economies of scale in studying associated chronic pain syndromes. An interesting review on strategies for managing fibromyalgia by Leslie Arnold from Cincinnati, Ohio caught my attention, and is worthwhile reading material for those with an interest in BPS.

The review begins with the statement, “The presentation of fibromyalgia is heterogeneous, and the treatment approach should be individualized for each patient based on the severity of the patient’s pain, the presence of other symptoms or comorbidities, and the degree of functional impairment.” Certainly this could apply to BPS just as well. It goes on, “The management of fibromyalgia involves the treatment of not only pain, but also the other symptoms or disorders that commonly occur in patients with fibromyalgia, such as fatigue, sleep disturbances, cognitive impairment, stiffness, and mood or anxiety disorders.”

Both pregabalin and gabapentin have been employed to treat fibromyalgia, and the results have been similar. Pregabalin studies resulted in an FDA indication for the disorder. Randomized trials showed improvement vs. placebo in treating the pain of fibromyalgia of 28.9% to 13.2% (significant), 42% to 35% (insignificant), and 48% to 30% (significant). Success in the latter two studies was a 30% reduction in pain diary score. Generic gabapentin showed a 51% response compared to 31% response to placebo. Both drugs appeared modestly effective, but further data on gabapentin is unlikely to materialize given that it is available in generic form. Randomized clinical trials of these drugs for bladder pain syndrome have not been reported.

The author notes a lack of data supporting the use of opiates in fibromyalgia and the fact that use of opiates continues to be controversial. This is not only because of the lack of supportive efficacy data in fibromyalgia, but also because of the abuse potential of opiates and the emerging evidence of opioid-induced hyperalgesia. Recent preclinical studies suggest that chronic use of opioids induces neuroadaptive changes that are mediated, in part, through the neurkinin-1 receptor and result in enhancement of nociceptive input. The potential development of opioid-induced hyperalgesia might limit the usefulness of opioids in controlling chronic pain over the long term.

The pain and fatigue of fibromyalgia provide the rationale for using exercise as a treatment modality. For many patients, a gradual increase in exercise, as tolerated, to reach a goal of 30 to 60 minutes of low to moderate intensity land-based aerobic exercise 2-3 times weekly appears to be associated with positive short-term benefits.

Cognitive behavioral therapy (change the way we think to feel / act better even if the situation does not change) , operant behavioral therapy (changing observed pain behaviors using video feedback of pain expressions, contingent positive reinforcement of pain-incompatible behaviors, and punishment of pain behaviors), and attention control (general therapist guided discussions) may all have a place in treatment, but it is important to match treatments to patient characteristics in order to improve outcomes.

A review of acupuncture concluded that there is no evidence from rigorous clinical trials that it is effective for fibromyalgia. Mindfulness meditation and Qigong movement therapy also failed to show benefit in a controlled clinical trial setting.

Finally, education is considered to be an important therapeutic option that can be combined with other treatment. The author concludes that exercise, education, and perhaps other nonpharmacologic therapies accompany pharmacologic treatments to optimize results. It appears that we have much to learn by studying treatment trials of other chronic pain disorders and adding the evolving techniques to our own treatment of bladder pain syndrome, not instead of, but in addition to our bladder specific therapeutic interventions.

Am J Med. 2009 Dec;122(12 Suppl):S31-43 10.1016/j.amjmed.2009.09.009