Major Advances in FibromyalgiaMichael R. Clark, MD, MPH, MBA

Hi. I am Dr. Michael Clark, Director of the Chronic Pain Treatment Programs in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins Medical Institutions in Baltimore, Maryland. I am here in Chicago at the annual meeting of the American College of Rheumatology to talk to you about some of the recent discoveries and updates in the treatment of fibromyalgia.

I want to cover a few topics that range from what we know about the pathophysiology of fibromyalgia to thinking about its comorbidities, and ultimately, its treatment. This is a difficult condition, as you know, and it has been a bit of a mystery in our field, as to exactly why patients suffer from the symptoms that they experience on a daily basis.

We now have some new insights from functional imaging studies showing that these patients suffer from a form of central sensitization, what we commonly see in other neuropathic pain conditions, and what we are now discovering to be the end result of some of the nociceptive conditions. For example, when we image these patients, we see a hyperactivity in various centers in the brain. As we start to engage patients in treatment trials, we have been able to show that you can dial back that amplification with different types of treatment, specifically, pharmacologic treatments such as pregabalin, and also nonpharmacologic treatments such as yoga exercises.

This is now beginning to help us connect the dots. We have clinical trials showing patients improving with treatment. We know what the treatments do, for the most part, at a pharmacologic or physiologic level, and then, when we have the opportunity to see that happen in real time with functional imaging, we are able to put together a nice understanding of how these conditions affect patients.

Another aspect of fibromyalgia is recognizing that we are still not making the diagnosis very commonly. We are still missing patients who could benefit from our treatments. For example, as we look at populations of patients with more chronic inflammatory conditions, such as osteoarthritis or rheumatoid arthritis, we have now been able to discover that these patients have many of the symptoms of fibromyalgia and many meet the criteria for fibromyalgia. So we want to be thinking about how this condition may also be the result or comorbidity of other chronic pain conditions.

Fibromyalgia does not exist in isolation, but affects patients who are vulnerable to pain syndromes, and ultimately, the mechanisms of central sensitization. These patients will also benefit from treatment, and we should be looking for the opportunity to treat them.

The last point that I want to mention is the recognition of depression in these patients. There has been a long-standing controversy as to whether patients with fibromyalgia (because we couldn't find a specific cause or etiology of their condition) were in some ways simply depressed or had some other psychiatric condition. That has not served our patients well. In fact, it has made us stigmatize them in ways that we are trying to move away from.

It is important to recognize that patients with any chronic pain syndrome -- fibromyalgia included -- are vulnerable to depression or mood disorders. Some of the same mechanisms apply when we think about how depression is generated in the brain and how neuropathic pain occurs. So as you are taking care of patients and seeing other patients with chronic pain, think about whether depression is present, and don't deprive those patients of treatment specific to their affective disorder. Those medications and types of psychotherapy will help them, not only to put their depression into remission, but will remove one of the logs from a raging fire that is fueling their pain, their disability, and their poor quality of life.

I hope you take away from this short update some of the benefits that we have seen occur over the past year of work and take that into your practice to help make these patients better, and experience the satisfaction of doing so.

Thanks very much.

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  • The last two paragraphs are very enlightening, tho' to most of us fibro sufferers they may appear to be stating the obvious.

    For years, successive GPs have said to me :"You're depressed!" to which I have replied that I am not depressed per se, but the amount of pain that I suffer doesn't exactly encourage me to be happy!

    There is a difference between clinical depression and the misery caused by chronic pain, though I do accept that there may be a correlation.

    I feel that the use of antidepressant medication in the treatment of fibromyalgia is valid only if the depression persists after thorough efforts to find and treat the cause of the pain, which as we all know may vary.

    I am distressed that many GPs will treat a suspected fibro patient using antidepressant medication as the 'first line of defence' without establishing a proper diagnosis or considering the effects of co-morbidity such as lupus, rheumatoid disease or osteo arthritis.

    Thanks Lacey for forwarding this interesting article.

    Regards ... Moffy

  • Yes yes and yes.. see other article .. Electrostimulation Device Shown to Improve Fibromyalgia... and other article... Vagus Nerve Stimulation Shows Early Promise in Fibromyalgia ..will post others as and when I can ... xxx

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