Rheumatologists must step in at the beginning of diagnosis when necessary. “Many primary care physicians are uncomfortable dealing with the musculoskeletal exam,” she says. “We should …assist our primary care colleagues with differential diagnoses.”
She reviewed clinical criteria for fibromyalgia syndrome (FMS). “We’re talking about pain processing abnormality,” she says. “We need a unified understanding and treatment of these syndromes.” She outlined the etiology of FMS and trace genetic vulnerability to the syndrome before discussing treatment implications for the concept of central pain.
“Treatments used for nocioceptive musculoskeletal pain do not work well in most FMS patients,” notes Dr. Crofford. Treatments must address the problems of altered pain processing in the spinal cord and altered descending inhibition of pain signals. When it comes to regarding FMS symptoms as either a psychiatric or medical issue, she believes this debate is harmful and unproductive. Regardless of what you believe the underlying cause of the symptoms is, treatment should be dually focused, with pharmacologic and non-pharmacologic therapies.
“You need a holistic approach,” she says. “Prescribing a pill isn’t going to cut it.” FMS patients’ symptoms are real to them and very disabling.
Rheumatologists should make patients active participants in their own treatment, educating them on the meaning of a chronic illness and explaining clearly what they can do to alleviate symptoms—for example, following specific exercise regimens.
As for medication, Dr. Crofford urges rheumatologists to individualize treatment according to pain symptoms. This includes treating visceral pain (e.g., irritable bowel syndrome and migraine); treating peripheral pain generators (e.g., normal musculoskeletal pain) with non-narcotic analgesics and non-steroidal anti-inflammatory drugs; and treating FMS or central pain with norepinephrine/serotonin reuptake inhibitors or alpha-2-delta ligands, for example.
“Start with agents that treat the central pain syndrome,” she says. “Reduction of clinical pain is optimized when all pain sources are addressed.”
Dr. Crofford ended her presentation with a review of recent treatment research that may lead to better symptom management, including studies of gabapentin and pregabalin.
Jane Jerrard is a journalist based in Chicago.
