Fibromyalgia - a complex construct with a multidisciplinary approach
B. Fonseca Silva1, P. Felgueiras2, A. Oliveira1
1Unidade Local de Saúde Gaia e Espinho, Psychiatry, Vila Nova de Gaia, Portugal, 2Unidade Local de Saúde de Matosinhos, Psychiatry, Matosinhos, Portugal
Background: Fibromyalgia is a chronic pain disorder characterized by generalized musculoskeletal pain frequently associated with other symptoms, especially fatigue, sleep disturbances, cognitive dysfunction and mood disorders. It is a common disease, with a global average prevalence estimated at approximately 2.7%, and it is significantly more common in women than in men, in a ratio of 3:1.
The aetiology and pathophysiological mechanisms of FM remain unclear, though it is widely regarded as a pain regulation disorder, classified as a central sensitization syndrome. Despite the known impact in quality of life of the patients, its diagnosis and management remain a challenge for healthcare professionals (and themselves).
The aetiology and pathophysiological mechanisms of FM remain unclear, though it is widely regarded as a pain regulation disorder, classified as a central sensitization syndrome. Despite the known impact in quality of life of the patients, its diagnosis and management remain a challenge for healthcare professionals (and themselves).
Aims & Objectives: To summarize the evidence in relation to the pharmacological and non-pharmacological management of fibromyalgia.
Method: Non-systematic review of the literature, regarding the treatment approach of fibromyalgia.
Results: The heterogeneity of fibromyalgia requires a holistic, comprehensive, multidisciplinary, patient-centered approach. According to the most recent recommendations, treatment begins with patient education and involves the simultaneous application of pharmacological and nonpharmacological treatments.
Discussion & Conclusions: Optimal management requires prompt diagnosis and providing the patient with information about the condition. There should be a comprehensive assessment of pain, function and the psychosocial context.
It is recommended that nonpharmacological therapy should be first-line therapy. Patient education is recommended as the first step, and it is defined as a set of educational activities that aim to improve a patient`s health by restructuring a patient`s perception of a disease.
The latest EULAR recommendations favour aerobic (exercise) training as an important disease-modifying factor. It can be combined with other non-pharmacological therapies - hydrotherapy, acupuncture - although they are weakly recommended. Other non-pharmacological options which demonstrate promising results includes myofascial techniques, maitland spinal mobilization, cranial electrical stimulation and transcranial magnetic stimulation. In case of lack of effect of the above therapeutic approaches, there should be individualised treatment according to patient need.
Psychological therapies should be considered for those with mood disorder or unhelpful coping strategies. The most effective therapy, CBT, is an adjunctive treatment, particularly in regard to sleep, depression, anxiety, and chronic pain. Pharmacologic management of fibromyalgia may combined with the management discussed before. There are three drugs approved by FDA: pregabalin, duloxetine, and milnacipran. Duloxetine and milnacipran should be used in comorbid depression; Amitriptyline is recommended for sleep disturbances, while nortriptyline is better suited to treat fatigue. Antiepileptics (gabapentin, pregabalin) have been shown to modulate pain, promote physiological sleep, and act as an anxiolytic. Other pharmacologic options for treatment of pain include tramadol, low-dose naltrexone, and NMDA receptor antagonists. Armodafinil and methylphenidate improve fatigue and mood, and increase concentration; however, they require further clinical trials.
Interestingly, the administration of placebo has proven more effective than no treatment in many clinical settings. Despite significant progress in pharmacological research, a cure remains elusive. This arises some questions about whether there are characteristics of patients with fibromyalgia that predict response to specific therapies, or which specific non-pharmacological treatment plan take better clinical results. Nowadays, the combination of medication is encouraging with the multicomponent treatments which includes a variety of non-pharmacological options.
It is recommended that nonpharmacological therapy should be first-line therapy. Patient education is recommended as the first step, and it is defined as a set of educational activities that aim to improve a patient`s health by restructuring a patient`s perception of a disease.
The latest EULAR recommendations favour aerobic (exercise) training as an important disease-modifying factor. It can be combined with other non-pharmacological therapies - hydrotherapy, acupuncture - although they are weakly recommended. Other non-pharmacological options which demonstrate promising results includes myofascial techniques, maitland spinal mobilization, cranial electrical stimulation and transcranial magnetic stimulation. In case of lack of effect of the above therapeutic approaches, there should be individualised treatment according to patient need.
Psychological therapies should be considered for those with mood disorder or unhelpful coping strategies. The most effective therapy, CBT, is an adjunctive treatment, particularly in regard to sleep, depression, anxiety, and chronic pain. Pharmacologic management of fibromyalgia may combined with the management discussed before. There are three drugs approved by FDA: pregabalin, duloxetine, and milnacipran. Duloxetine and milnacipran should be used in comorbid depression; Amitriptyline is recommended for sleep disturbances, while nortriptyline is better suited to treat fatigue. Antiepileptics (gabapentin, pregabalin) have been shown to modulate pain, promote physiological sleep, and act as an anxiolytic. Other pharmacologic options for treatment of pain include tramadol, low-dose naltrexone, and NMDA receptor antagonists. Armodafinil and methylphenidate improve fatigue and mood, and increase concentration; however, they require further clinical trials.
Interestingly, the administration of placebo has proven more effective than no treatment in many clinical settings. Despite significant progress in pharmacological research, a cure remains elusive. This arises some questions about whether there are characteristics of patients with fibromyalgia that predict response to specific therapies, or which specific non-pharmacological treatment plan take better clinical results. Nowadays, the combination of medication is encouraging with the multicomponent treatments which includes a variety of non-pharmacological options.
In sessions