Carol Ross (Fibromyalgia Wales) - Managing the Condition
The management of fibromyalgia has 4 main components:-
- Patient education
- Physical therapy
- Psychological therapy/support
- Drug treatment
People with fibromyalgia often require a tailored approach to treatment, largely depending on their symptoms and their required outcome. All patients should receive a clear diagnosis and education about their condition. Patient information leaflets are widely available (see the reference and resource section), however they are an addition to face-to-face explanation. They need to be made aware of the chronic nature of their condition, that interventions, at best, provide partial symptomatic relief and that they are likely to have a condition that waxes and wanes. They should also be helped to realise that they are part of the treatment and that adherence to treatment regimes is an important factor in success.
Stress reduction, sleep-hygiene and weight reduction (if overweight) should all be encouraged. The patient should be encouraged to remain in work if possible, as this provides focus, increases self-esteem and in a way “normalises” day-to-day life. There may be simple adaptations that can be made to the workplace and the patient should be encouraged to speak to their employer or HR department. Occasionally a “fit note” may be required to support a patient in work place adaptations (e.g. ergonomics of work station, standing or lifting, length and timing of shifts or absenteeism due to fibromyalgic flares)
A graduated exercise regime confers benefit. The patient should be warned to start slowly and build up, as an immediate escalation of exercise may exacerbate symptoms. The efficacy of exercise is evidence based. The techniques employed in the “Motivate 2 Move” site may be useful, encourage incidental and “accidental” exercise.
There is little or no evidence for massage or physiotherapy, however all forms of exercise are suitable and exercise in heated pools may lessen the pain, perceived by some, after even gentle exercise. The adherence to exercise regimes is poor, with fatigue and exacerbation of pain being the main inhibiting factors and motivation and mood also contributing to dropping out. There is some evidence that directed or group exercise has greater adherence rates particularly when starting an exercise regimen.
Psychological therapy and support may include CBT where available. It is not suitable for everyone and the resources simply do not exist to treat all patients with fibromyalgia. The availability of on-line CBT may prove helpful, in particular Living Life To The Full and the Mood GYM. The patient should be encouraged to try to stay positive, not to focus on the pain and try to live with the pain as opposed to searching for causes or in the worst case scenario catastrophising (having a severe negative perception of the pain) or even stopping moving for fear that even simple movements will exacerbate the pain – these are poor prognostic indicators.
Drug treatment should be tailored to the patient and the choice of medication should take in to account the additional symptoms affecting the patient. A meta analysis published in 2011 estimated treatment differences vs. placebo, separately, for duloxetine, fluoxetine, gabapentin, milnacipran, pramipexole, pregabalin, either of two tricyclic antidepressants, and tramadol plus paracetamol.
The analysis examined pain response and did not report on other symptoms. The response was measured as a 30% reduction and a 50% reduction in reported pain from baseline.
The results revealed that “when compared with placebo, statistically significant pain responses (improvement of 30% and 50%) were observed for patients treated with duloxetine, milnacipran 200 mg/day, pregabalin 300 or 450 mg/day, and tramadol plus paracetamol. Treatment with fluoxetine, gabapentin, or milnacipran 100 mg/day resulted in significant findings for the 30% improvement in pain response.”
The authors concluded “all eight active treatments displayed evidence suggesting improvement over placebo in the treatment of pain in patients suffering from fibromyalgia. Indirect comparison of active treatments found no strong differences.” They also found that seven of the eight regimens had increased discontinuation due to side effects when compared to placebo (the exception being fluoxetine). Severe adverse effects were statically significant for milnacipran (a serotonin–norepinephrine reuptake inhibitor (SNRI) licensed specifically for fibromyalgia but currently only available in the US and Russia) and pregabalin.
DARE comments on this review:- “This review's inclusion criteria were clear. Relevant databases were searched. Efforts were made to find published studies, but not unpublished studies which increased potential for publication bias. It was unclear whether any language restriction was applied in the search, which made it difficult to assess the risk of language bias. Steps were undertaken to minimise biases and errors in the study selection process, but it was unclear whether quality assessment and data extraction were also performed in duplicate. Appropriate criteria were used to assess study quality. Statistical heterogeneity was assessed and appropriate methods were used to pool the results. However, in view of the risk of publication bias and the small number of included studies for each comparison, the authors' conclusions should be interpreted with caution.”
In particular the use of pain relief and NSAIDs is fraught with difficulty. Patients presenting with chronic pain syndromes have typically tried OTC medications (including Paracetamol, Ibuprofen, weak opioids and combinations of the three). They may have been prescribed stronger opioids and some will be using this medication on a regular basis with minimal or no symptom relief. A long term evaluation of opioid use in fibromyalgia demonstrated that opioid use was at the best a neutral act and possibly adversely affected the outcome. There is no evidence for NSAID use in fibromyalgia and Paracetamol alone has not been studied. It is unlikely that analgesic use would modulate the pain augmentation seen in fibromyalgia --- however fibromyalgia often co-exists with other conditions (notably osteoarthritis) and the use of these medications would be indicated to treat these conditions. Tramadol needs careful consideration, as, whilst there is evidence for its efficacy, there are concerns over dependence, mood altering properties and suicidal tendencies.
Medscape report:- The US Food and Drug Administration (FDA) announced that it has added a warning of suicide risk to the labels of tramadol hydrochloride. The revised labels instruct clinicians not to prescribe tramadol to patients who are suicidal or addiction-prone, and to exercise caution in prescribing the medications to patients who use alcohol excessively, suffer from emotional disturbance or depression, or take tranquilizers or antidepressants.
"Tramadol-related deaths have occurred in patients with previous histories of emotional disturbances or suicidal ideation or attempts as well as histories of misuse of tranquilizers, alcohol, or other [central nervous system–active] drugs."
A pragmatic approach may be to use this treatment algorithm (you can download a copy here).