Dear Dr. <Name>,
I would like to kindly ask your attention to the information leaflet enclosed developed to give Fibromyalgia (FM) patients the latest information on how to cope with their condition. The current guidelines to managing and treating FM clearly recommend that patients (and their relatives) should learn as much as possible about it, as this is likely to help reduce any fear and anxiety it might generate (e.g., Arthritis Care, 2013; Arthritis Research, 2011). In this sense, this leaflet explains what Fibromyalgia is, what its main physical and psychological symptoms are and what treatment alternatives are currently available.
As you know, FM is a syndrome characterised by chronic widespread pain in muscles, tendons and ligaments, without a distinct underlying organic disorder; in addition, these patients also suffer from excessive fatigue and sleep disturbances (Bellato et al., 2012; Albin et al., 2012). Furthermore, some patients also report a range of other physical – e.g. headaches, irritable bowels, urge to urinate, restless leg syndrome, poor circulation or temporomandibular joint disorder – and psychological comorbid symptoms – e.g. anxiety, depression, irritability or poor concentration (Thieme K., Flor F., & Turk C.T., 2006; Arthritis Care, 2013). Incidence rate is estimated to be between 0.5% and 5.8% (Häuser, Bernardy, Arnold and Offenbacher, 2009), with a female to male ratio of 10:1 (Karlsson, Burell, Anderberg and Svärdsudd, 2015).
The precise etiology and the biological mechanisms of the condition are still relatively unclear, but current research suggests that FM integrates a wider continuum of conditions characterised by central sensitisation (Albin et al., 2012). According to this view the central nervous system (CNS) overreacts to pain, but while central sensitisation is part of the explanation, other factors such as hormones, immune system and external stressors are likely to play a role (Bellato et al, 2012).
Several drugs – including Tricyclic antidepressants (TCA; e.g. amitriptyline), selective serotonin reuptake inhibitors (SSRIs; e.g. fluoxetine), anti-convulsion drugs (e.g. pregablin) and mild doses of non-steroid anti-inflammatory drugs (NSAIDS; e.g. ibuprofen) – have been identified to treat FM’s central pain and associated comorbid symptoms (Häuser, Walitt, Fitzcharles, Sommer, 2014). However, research shows that the benefits are limited and that the benefit-risk balance advises caution at the moment of prescribing these drugs (Häuser et al., 2014); in fact, the average patient only experiences a 30% improvement with medication (Jones, Mist, Casselberry, Ather and Christopher, 2015). Moreover, studies indicate that the benefits disappear if treatment is discontinued, which often happens due to intolerance to side effects (Glombiewski et al., 2010). In the same direction, treatment outcome is frequently undermined by patients’ low self-efficacy and negative social responses to patients’ emotions of pain. (Karlsson et al., 2015).
Current evidence suggests that framing FM within the biopsychosocial framework and promoting a multidisciplinary approach to treatment will produce the best outcomes (Glombiewski et al., 2010; Karlsson et al. 2015). With this in mind, I will now expand on some of the typical psychological symptoms of FM and the most common and effective non-pharmacologic treatments.
As you might be aware, in 2010 the American College of Rheumatology (ACR) replaced the “tender points” diagnostic criteria with the new diagnostic methodology. Alongside with a widespread pain index (WPI) for measuring pain extent, the new methodology introduced a symptom severity (SS) scale to evaluate the patients’ condition in three distinct “non-pain” criteria – fatigue, waking unrefreshed and cognitive symptoms – and in a fourth criteria grouping all other somatic symptoms (American College of Rheumatology, 2010). Clearly, this change recognises the fundamental role played by “non-pain” symptoms, in particular psychological symptoms, in characterising FM.
Central to this discussion is the question: are the observed “non-pain” symptoms a consequence of the physical pain endured by patients or are (some of) these symptoms the trigger for the physical pain? For instance, experiments have shown that people that are repeatedly awakened during deep sleep suffer the typical pain symptoms of FM and, effectively, EEG studies show that FM patients have deep sleep (restorative sleep) constantly interrupted by lighter REM sleep. However, several factors, including musculoskeletal pain, can result in sleep problems (Arthritis Foundation, 2011). In this first example, is bad sleep causing pain or pain causing bad sleep? The same logic could also be applied for the cognitive symptoms of anxiety and depression: Melzack and Wall’s Gate-control theory provides a good explanation to why these factors amplify the experience of pain (Hasset and Gevirtz, 2009), but, on the other hand, it is also evident that the experience of pain, and in particular chronic pain, is likely to generate anxiety and depression (Eccleston, Morley and Williams, 2013). It seems clear that, independently of triggers, FM is characterised by a vicious circle where mind and brain interplay to create or amplify its symptoms.
One widely accepted model describes stress as a major culprit (Albin et al., 2012, Karlsson et al., 2015). In this model, stressful events such as psychological and physical trauma, catastrophic events, depression, viral infections and other overlapping pain syndromes, including rheumatoid arthritis, act as triggers to initiate the condition (Arthritis Care, 2013; Bellato, 2012). Effectively, many FM patients have endured psychosocial and/or physical stressful events – including childhood trauma – while others display a history of maladaptive behaviours and thought processes leading to physical and mental over-burden (Albin et al., 2012), all factors conducive of stress and anxiety.
At this stage, it is important to note that these factors not only might have triggered the development of FM, but also could now represent an obstacle to the implementation of an effective medication plan (Albin et al., 2012).
Glombiewski, Sawyer, Gutermann, Koenig and Hofmann (2010) conducted a meta-analysis of 23 studies, involving 1396 fibromyalgia patients. The included studies described a varied number of treatment options and combinations including educational approaches, exercise, mindfulness/relaxation techniques, and cognitive and behavioural therapies. Glombiewski et al. (2010) reported a small, but significant effect size for short-term pain reduction and a small to medium size effect for long-term pain reduction. The researchers also reported these treatments to be effective in reducing sleep problems, depression, physical and emotional functional status, and catastrophizing. Overall, although the size effects were small, the results were found robust and stable at follow-up.
Educational approaches and Exercise
Educational approaches aim at increasing patients’ understanding on the complex nature of FM, and their use is largely consensual (Hassett et al., 2009). Burckhardt, Mannerkorpi and Bjelle A. (1994), for instance, conducted a randomised controlled trial (RCT) to evaluate the effectiveness of self-management education and self-management education combined with physical training in reducing FM symptoms. The researchers concluded that both treatment conditions significantly improved quality of life and self-efficacy measures, and pain in tender points.
Bellato et al. (2012) report on evidence that aerobic exercises that focus on stretching and gradually evolve to strengthening are the most effective. In particular, Bellato et al. (2012) highlight the benefits of Tai chi in improving physical functioning, quality of sleep, self-efficacy and functional mobility. Moreover, the authors reference the positive outcomes of aquatic exercises.
Mindfulness-Based Stress reduction (MBSR) techniques have been reported to be useful in treating some of the symptoms of FM. In a large study involving 4986 people from 30 different countries, Jones et al. (2015) concluded that the severity and impact of FM is related to poorer mindfulness in four of five subscales of the Five Facet Mindfulness Questionnaire (FFMQ), suggesting that FM patients experience symptoms that might be alleviated by mindfulness techniques.
Cognitive Behavioural Therapy (CBT)
Cognitive Behavioural Therapy makes use of techniques from both behavioural and cognitive therapies and it emphasizes the idea that changing maladaptive thought processes results in changes in behaviour and emotions (Hassett et al, 2009).
Glombiewski et al. (2010) reported that CBT was significantly better than other treatments in reducing the intensity of short-term pain and CBT combined with relaxation/biofeedback was significantly better in reducing sleep problems. One important conclusion out of this study is that greater effect sizes on pain reduction and depression can be achieved with higher treatment doses of CBT.
On a RCT conducted by Alda et al (2011), CBT also showed higher efficacy than recommended pharmacological treatments and treatment as usual (TAU) in function and quality of life, and in significant mediators, such as pain catastrophizing.
Operant Behavioural Therapy (OBT)
Contrary to CBT, Operant Behavioural Therapy focuses on the alteration of observable random habits conducive of pain and on changing pain behaviours, without paying explicit attention to any underlying thought processes (Thieme et al., 2006). Thieme et al. (2006) compared the use of OBT and CBT for the treatment of FM, concluding that both therapies have significant positive outcomes in pain reduction and physical and behavioural variables. Furthermore, the researchers highlighted that OBT (but not CBT) achieved a significant reduction in subsequent visits to physician compared to a placebo group, having obvious positive implications in healthcare costs.
In concluding this section, I would like to note that even though the treatment options discussed here have been described as standalone alternatives, there is strong support for the short-term efficacy of a multicomponent approach (Häuser et al., 2009).
In summary, current research suggests that clinicians could explain fibromyalgia to patients as a non-life-threatening genetic condition that has been triggered and is reinforced by stressful events. While this explanation brings a sense of “normality” to FM, it also opens the door for a multipurpose and multidisciplinary treatment, where general practitioners, specialists and the patients have an active role. Pharmaceutical and psychological treatments have proven to be effective in reducing a number of physical and mental symptoms, but the chances of success are only as high as the patients’ understanding and commitment to treatment, and their willingness to adapt their lifestyle and change maladaptive habits.
I hope you will find the enclosed leaflet informative and you will be able to use it in your practice. If you would have any questions please do not hesitate to contact me.
Albin N.A., Buskila D., Van Houdenhove B., Luyten P., Atzeni F., Sarzi-Putini P. (2012). Is fibromyalgia a discrete entity? Autoimmune Reviews. 11, 585-588. doi:10.1016/j.autrev.2011.10.018
Alda, M., Luciano, J. V., Andrés, E., Serrano-Blanco, A., Rodero, B., del Hoyo, Y. L., … García-Campayo, J. (2011). Effectiveness of cognitive behaviour therapy for the treatment of catastrophisation in patients with fibromyalgia: a randomised controlled trial. Arthritis Research & Therapy, 13(5), R173. doi:10.1186/ar3496
American College of Rheumathology (2010). 2010 Fibromyalgia Diagnostic Criteria – Excerpt. Retrieved from https://www.rheumatology.org/practice/clinical/classification/fibromyalgia/fibro_2010.asp
Arthritis Care (2013). Fibromyalgia Factsheet [PDF File]. Retrieved from http://www.arthritiscare.org.uk/PublicationsandResources/Listedbytype/Factsheets/main_content/FibromyalgiafactsheetOct2013.pdf
Arthritis Foundation (2011). Fibromyalgia [PDF File]. Retrieved from http://www.arthritis.org.za/.cm4all/iproc.php/Pamphlets/Fibromyalgia.pdf
Arthritis Research (2011). Fibromyalgia [PDF File]. Retrieved from http://www.arthritisresearchuk.org/~/media/Files/Arthritis-information/Conditions/2013-Fibromyalgia.ashx
Bellato E., Marini E., Castoldi F., Barbasetti N., Mattei L., Bonasia D.E., & Blonna D. (2012). Fibromyalgia Syndrome: Etilology, Pathogenisis, Diagnosis, and Treatment. Pain Research and Treatment. 12, 246130. doi:10.1155/2012/426130
Burckhardt C.S., Mannerkorpi K., Hedenberg L., & Bjelle A. (1994). A randomized, controlled clinical trial of education and physical training for women with fibromyalgia. Journal of Rheumatology. 21(4), 714-720
Ecclestone, Morley and Williams (2013). Psychological approaches to pain management: evidence and challenges. British Journal of Anaesthesia. 111(1), 59-63. doi:10.1093/bja/aet207
Glombiewski J.A., Sawyer A.T., Gutermann J., Koenig K., Rief W., & Hofmann S.G. (2010). Psychological treatments for Fibromyalgia: A meta-analysis. Pain. 151, 280-295
Grossman P., Tiefenthaler-Gilmer U., Raysz A., & Kesper U. (2007). Mindfulness training as an intervention for fibromyalgia: evidence of postintervention and 3-year follow-up benefits in well-being. Psychotherapy and psychosomatics. 76(4), 226:233
Hassett, A. L., & Gevirtz, R. N. (2009). Nonpharmacologic Treatment for Fibromyalgia: Patient Education, Cognitive-Behavioral Therapy, Relaxation Techniques, and Complementary and Alternative Medicine. Rheumatic Diseases Clinics of North America, 35(2), 393–407. doi:10.1016/j.rdc.2009.05.003
Häuser W., Bernardy K., Arnold B., Offenbächer M., & Schiltenwolf M. (2009). Efficacy of a Multicomponent Treatment in Fibromyalgia Syndrome: A Meta-Analysis of Randomised Controlled Clinical Trials. Arthritis and Rheumatism, 61(2), 216-224. doi:10.1002/art.24276
Häuser W., Walitt B., Fitzcharles M., Sommer C. (2014). Review of pharmacological therapies in fibromyalgia syndrome. Arthritis Research and Therapy. Arthritis Research & Therapy, 16, 201.
Jones K.D., Mist S.D., Casselberry M. A., Ather A., & Christopher M.S. (2015). Fybromyalgia Impact and Mindfulness Characteristics in 4986 people with Fybromialgia. Explore. 11, 304-309
Karlsson, B., Burell G., Anderberg U., & Svärdsudd K. (2015). Cognitive behaviour therapy in women with fibromyalgia: A randomized clinical trial. Scandinavian Journal of Pain. 9 , 11 – 21. doi:10.1016/j.sjpain.2015.04.027
Thieme K., Flor F., & Turk C.T. (2006). Psychological pain treatment in fibromyalgia syndrome: efficacy of operant behavioural and cognitive behavioural treatments. Arthritis Research and Therapy. 8, R121. doi:10.1186/r2010
Arthritis Care website: http://www.arthritiscare.org.uk/AboutArthritis/Conditions/Fibromyalgia
American Chronic Pain Association website: http://www.theacpa.org/condition/Fibromyalgia
Arthritis Foundation website: http://www.arthritis.org/about-arthritis/types/fibromyalgia/
Arthritis Research website: http://www.arthritisresearchuk.org/arthritis-information/conditions/fibromyalgia.aspx
Fibromyalgia UK: http://www.fmauk.org
National Health Service website: http://www.nhs.uk/Conditions/Fibromyalgia/Pages/Introduction.aspx