Fibromyalgia - Buskila

Question 1

What are the criteria for fibromyalgia?

Answer 1

1. Widespread pain index (WPI) >7 7 and symptom severity (SS) scale score > 5 or WPI 3–6 and SS scale score > 9.
    Fatigue
    Waking un-refreshed
    Cognitive symptoms
2. Symptoms have been present at a similar level for at least 3 months.
3. The patient does not have a disorder that would otherwise explain the pain.

Question 2

What are examples of pronociceptive and antinociceptive factors?

Answer 2

Pronociception:
NGF – nerve growth factor
SP – substance P
EAA – excitatory amino acids
PG – prostaglandins
Increased in fibromyalgia

Antinociception:
5HT – serotonin
NE – Norepinephrine
DA – dopamine
EO – endogenous opioids
Cortisol
Decreased in fibromyalgia

Question 3

What is the treatment for fibromyalgia?

What algorithm is used?

Answer 3

Step 1: Patient education (with family best)

2: Pharmacologic treatment (combination/step down with two different mechanism)
3: Nonpharmacologic treatment (exercise, CBT)
4: Additional modalities (usually chosen by the patient, hydrotherapy, spa treatment, tai chi)

Pharmacological:

Strong evidence:
Dual reuptake inhibitors such as
-tricyclic compounds (amitriptyline, cyclobenzaprine)
-SNRIs and NSRIs (venlafaxine, milnacipran, duloxetine)
-Anticonvulsants (e.g. gabapentin, pregabalin)
Modest evidence:
-Tramadol
-Selective serotonin reuptake inhibitors (SSRIs)
Weak evidence - Growth hormone, 5-hydroxytryptamine, tropisetron, S-adenosyl-L-methionine (SAMe)
No evidence - Opioids, corticosteroids, nonsteroidal anti-inflammatory drugs, benzodiazepine and nonbenzodiazepine hypnotics, guanifenesin

Nonpharmacological:

Strong evidence:
-Education
-Aerobic exercise (more than drugs)
-Cognitive behavior therapy
Modest evidence:
-Strength training
-Hypnotherapy, biofeedback, balneotherapy (spas)
Weak evidence - Acupuncture, chiropractic, manual and massage therapy, electrotherapy, ultrasound
No evidence: tender (trigger) point injections, flexibility exercise