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Multidisciplinary approach to fibromyalgia: What is the teaching?

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Fibromyalgia (FM) is a rheumatic disease that is characterised by chronic musculoskeletal pain, stiffness, fatigue, sleep and mood disorder. FM patients demonstrate dysregulation of pain neurotransmitter function and experience a neurohormone-mediated association with sleep irregularities. There are currently no instrumental tests or specific diagnostic markers for FM, and many of the existing indicators are only significant for research purposes. Anti-depressants, non-steroidal anti-inflammatory drugs (NSAIDS), opioids, sedatives, muscle relaxants and antiepileptics have all been used to treat FM with varying results. It has been shown that interdisciplinary treatment programmes lead to greater improvements in subjective pain and function than monotherapies. Physical exercise and multimodal cognitive behavioural therapy are the most widely accepted and beneficial forms of non-pharmacological therapy.

Introduction

Fibromyalgia (FM) is a generalised chronic pain condition that is often accompanied by fatigue, sleep disturbance, and psychological and cognitive alterations [1], [2]. It is the prototypical form of a central sensitisation syndrome [1] and prevalence studies show that it affects 2–4% of the population (approximately half a million Italians). It is more common among adult women, but may also affect men and children.

There are currently no instrumental tests or specific diagnostic markers, and the characteristic symptoms of the disease overlap those of many other conditions [3]. However, it is becoming more manageable as a result of the use of more rational evidence-based pharmacological therapy and a growing awareness that therapy needs to go beyond pain. Many studies have found that patients with FM are less physically fit than control groups of the same age, gender and occupation [4], *[5]. The functional limitations reported by patients include reduced exercise tolerance, fatigue, and pain exacerbations caused by the activities of daily living (ADL) [6], which means that non-pharmacological therapeutic strategies aimed at improving aerobic fitness, muscular strength and endurance may be important in reducing disease-related disabilities [7], [8]. The effective management of FM is complex and requires a multidisciplinary approach, and it has been shown that integrated treatment, including appropriate patient education, aerobic exercise and cognitive-behavioural therapy, is effective in alleviating symptoms.

Section snippets

Diagnosis

FM is usually diagnosed in clinical and observational research studies on the basis of the American College of Rheumatology (ACR) criteria [9]: pain must have been present for at least three months in all four quadrants of the body, and there must be >11/18 positive tender points (TPs) revealed by applying pressure (4 kg/cm2) at pre-defined body sites. However, these criteria do not take into account the wide range of symptoms commonly associated with FM, and reflected by the term ’syndrome’,

Inter-disciplinary treatment

The aim of treating FM is to decrease pain and increase function by means of a multimodal therapeutic strategy which, in most cases, includes pharmacological and non-pharmacologic interventions [12] and has the main goal of symptom management [13]. As FM patients typically present complex symptoms and comorbidities, they cannot realistically be managed by primary care physicians alone, but require the assistance of multidisciplinary teams with expertise in a variety of physical, cognitive,

Education and psychological domains

A number of the techniques used in the management of FM are based on patient education, and are intended to reduce anxiety, increase treatment compliance, improve coping behaviours and self-efficacy, and draw attention away from symptoms and towards improved function and a better quality of life. It has long been recognised that patients have an essential right to education, and the findings of this review suggest that they should be offered exercises and education (including information and

Pharmacologic treatments

Once a diagnosis of FM is made, patients are usually started on pharmacological treatment. Boomershine and Crofford [23] suggest that the three drugs currently approved by the American Food and Drugs Administration (FDA) should now be used as ‘anchor drugs’ and, although still important, could later be complemented by older approaches. Unfortunately, no direct comparative studies have yet been published, and there is still no consensus as to where to start.

FM patients experience amplified

Analgesic treatment

Tramadol has been found to be beneficial in FM patients [33], [34]. It is an atypical pain reliever that has a different action on the CNS (the re-uptake of serotonin and norepinephrine) from that of other narcotics. Its most common side effects are drowsiness, dizziness, constipation and nausea, and it should not be given in combination with tricyclic antidepressants (TCAs). Alone or in combination with acetaminophen, it is commonly prescribed at a dose of 200–300 mg/day to relieve FM-related

Treating fatigue, sleep and mood disorders

Fatigue and sleep disturbances are major complaints among FM patients [2]. Appropriate treatment of sleep disturbances and physical rehabilitation are the best means of managing fatigue in the long term. The medications commonly used in narcolepsy have been used to treat fatigue in FM patients [43]. Modafinil has been approved by the FDA for the treatment of excessive somnolence associated with narcolepsy, shift workers and sleep apnea, and can be useful if fatigue prevents patients from

Non-pharmacological treatments

Most FM patients complain of severe functional limitations in activities of daily living [55] and, not surprisingly, are physically deconditioned [5]. Active and passive mobilisation have both been tried, but recent reviews do not clearly show their efficacy. Active aerobic and anaerobic physical exercises are pivotal treatments in FM, but patients often find it difficult to start and maintain exercise programmes [56], [57]. The internet can provide access to many types of physical training and

Combination therapy

In general, about half of all treated patients with medication seem to experience a 30% reduction of symptoms, suggesting that many patients with FM will require additional therapies [69]. The number of randomized controlled trials of exercise or behavioral interventions in the FM literature has increased dramatically in the past decade [70], [71]. Progressive walking, simple strength training movements, stretching activities, aerobic exercise improve functional status, and self-efficacy in

Conclusions

It is clear that, as in the case of other disorders, the most efficacious treatment of FM needs to combine the main elements of pharmacotherapy, exercise, physical therapy and CBT. A number of medical treatments have been used to treat the various symptoms of FM (pain, sleep disturbances, anxiety and depression) with the final aim of improving the patients’ quality of life. Psychological and physical therapy may sometimes be more effective than pharmacological treatment. A number of studies

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