SANTA MONICA, CALIF. – Exercise and cognitive-behavioral therapy complement rather than replace pharmacology in the management of fibromyalgia, according to Dr. Philip J. Mease.
Findings from several studies have shown that such nonpharmacologic treatments may lessen the primary symptoms of fibromyalgia while helping to correct some maladaptive behaviors, mood disturbance, and deconditioning.
Philip J. Mease
Not all nonpharmacologic therapies are equally effective. The literature suggests that aerobic exercise, cognitive-behavioral therapy, and patient education all lessen pain and improve function. The same benefits are not reported with strength training, acupuncture, biofeedback, balneotherapy, and hypnotherapy, Dr. Mease said at the meeting, sponsored by Skin Disease Education Foundation (SDEF) and the University of Louisville.
This year the American College of Rheumatology published diagnostic criteria for fibromyalgia that shifted the emphasis from tender point examination and focused instead on the other symptoms that cause misery in these patients, such as sleep disturbance and fatigue (Arthritis Care Res. 2010;62:600-10).
Specifically, the diagnostic criteria are composed of two parts: a widespread pain index (WPI) that establishes the absence or presence of pain in up to 19 body areas but does not require the physician to press on those areas, and the symptom severity (SS) scale, that grades the patient’s fatigue, sleep, and cognition and the patient’s overall symptom burden.
Patients who have an overall symptom burden of 7 or more on the WPI and an SS score of 5 or more or a WPI score of 3-6 and an SS score of 9 or more fell within the fibromyalgia domain, and the scores correlated well with the tender point score on the American College of Rheumatology 1990 classification criteria.
These criteria, although already published, are considered preliminary and are being tested in clinical settings to confirm their reliability.
Data from recent, unpublished research out of the National Data Bank of Rheumatic Diseases show that 20% of patients with rheumatoid arthritis have scores that indicate concomitant fibromyalgia and 10% of patients with osteoarthritis have scores consistent with fibromyalgia, according to Dr. Mease. He noted that these findings confirm the observation that fibromyalgia often coexists with other chronic pain conditions.
In addition to the recognized role for nonpharmacologic therapies, there has been a sea change in pharmacologic management of fibromyalgia. "I am intrigued by the emergence of a better understanding of the neurobiologic basis of central pain, central fatigue, and central dyscognition as they relate to fibromyalgia, irritable bowel syndrome, and even some of our rheumatoid and lupus patients," Dr. Mease said.
In parallel with the increased appreciation for the role of neurobiology in the pathogenesis of fibromyalgia, there have been data from clinical trials of agents targeting some of the neurobiologic pathways that are proving to be better than placebo in lessening some of the symptoms of fibromyalgia, said Dr. Mease, a rheumatologist at the University of Washington, Seattle, as well as director of the division of rheumatology research at the Swedish Medical Center there.
Many rheumatologists might roll their eyes when the discussion turns to fibromyalgia, but recent findings are confirming quantitatively that these patients feel pain with unusual intensity. Findings from functional MRI studies have shown that, even at rest, the brain of patients with fibromyalgia has increased connectivity within multiple brain networks that may explain both the patients’ experience of spontaneous pain and fluctuations in pain that are unrelated to activity. In addition, the increased connectivity may have implications for cognition (Arthritis Rheum. 2010;62:2545-55).
Dr. Mease reported that?he presented data from a study of 363 patients with fibromyalgia who were treated with either pregabalin alone or in combination with milnacipran at the annual meeting of the European League Against Rheumatism earlier this year. Those treated with the combination therapy (pregabalin at 150-225 mg twice daily plus 50 mg of milnacipran) for 11 weeks showed a 20-point improvement on the visual analog scale (VAS) for pain assessment. In addition, 51% considered themselves "very much improved" on the Patient Global Impression of Change (PGIC) scale.
In contrast, patients on monotherapy showed a 5-point improvement on the VAS, and 24% considered themselves very much improved on the PGIC. About one-third of the patients did not finish the trial.
SDEF and this news organization are owned by Elsevier. Dr. Mease disclosed that he has financial relationships with Cypress Bioscience, Forest, Lilly, Pfizer, and UCB.