Multidimensional Therapy for the Fibromyalgia Syndrome

Personality traits, mood, emotional labiality, ingrained fears, sense [locus] of control, and psychiatric pathology can influence the responses of individuals to almost any clinical illness. That is not necessarily to say that the psychological dysfunction is the cause of the medical illness. On the other hand, these psychological factors are widely perceived to be more prevalent or have a greater influence upon a series of controversial medical conditions that are viewed as functional disorders. An admittedly incomplete listing of such disorders could include: fibromyalgia syndrome [FMS], chronic fatigue syndrome, myofascial pain syndrome [MPS], irritable bowel syndrome [IBS], tension headache, chronic pelvic pain, non-cardiac chest pain, irritable bladder syndrome, multiple chemical sensitivity, and temporomandibular disorder. In fact, there seems to be such a condition affecting nearly every organ system of the human body and, thus, represented in nearly every distinct subspecialty of medicine. The term “functional disorder,” in this context, has an interesting medical history beyond the scope of this review. Briefly, it began as a term to denote a disorder in which the function of a specific organ system was compromised, but with time and with the interpretations of a variety of prominent clinicians, the meaning has become reversed. The contemporary perception of a functional disorder is of “a condition in which the function is impaired but evidence for an objective disease is lacking.” The inference is that emotional factors are in some way responsible for [i.e., causative of] the symptoms. The American Psychiatric Association's DSM-IV manual adds a proviso to the rather similar definition of somatoform disorders by saying that “In contrast to factitious disorders and malingering, the physical symptoms [of somatoform disorders] are not under voluntary control.”

With this background we introduce the lead article in this issue of the Journal of Musculoskeletal Pain [JMP]. Coming from São Paulo, Brazil ([1]), this paper describes a randomized, controlled clinical trial of cognitive behavioral therapy [CBT] for the management of the FMS. A total of 60 treatment naïve patients with FMS, presenting to the academic physician authors, were randomly allocated to two groups that were comparable with respect to their demographic variables at baseline. Both groups were treated, using amitriptyline or cyclobenzaprine coupled with weekly clinical visits. In addition, the active intervention group received CBT for 10 weeks. Compliance was high, with only about 15% loss to follow-up. Outcome measures included a standard instrument measuring physical function, a depression instrument, and a patient global assessment of change that occurred while being in the program. Both groups improved significantly in most respects, but the CBT group did significantly better than the control group in the domains of the psychological measures. In their summary, the authors expressed no surprise with this finding “since CBT is a psychological intervention.”

When the intervention for FMS has been a physical-exercise-based program, it has been shown that physical function and pain both improve ([2]). To use the analogy of the CBT investigators, the exercise therapy study authors could have concluded that the results were understandable because the intervention had involved a physical/function focus.

These two examples of therapeutic success in managing aspects of the FMS suggest that the physical and the psychological components of the FMS may be on different tracks. That concept was supported by the characterization of a clinical cohort of FMS patients recruited for a clinical trial ([3]). Expanding upon the visual analogy of railroad tracks, which seem to converge in the distance until they become an apparent unity, one can anticipate that future improvements in our understanding of these disparate components of the FMS will allow them to become one.

An implication of these observations is that multimodal therapy is needed for the FMS. Administration of medications that have shown beneficial in monotherapy trials can now be coupled with exercise therapy and CBT, with the hope of achieving for FMS patients multidimensional improvement at a level not possible with therapy that has a unidimensional focus. This is, of course, not a new idea but rather a concept that emerging data has again reinforced.

Readers of JMP will be pleased to learn of another high quality epidemiology study of the FMS. This report comes from Diyarbakir, Turkey ([4]). The authors found a higher prevalence of FMS in Turkey than was found for most other countries, with the exception of southern Norway. Notice, by comparison, the JMP report of the substantially lower prevalence of FMS in China. Intriguing also is the Turkish investigators* finding of a difference in the prevalence of FMS in urban dwellers compared with rural dwellers.

In the same vein, an author from Gyeongju, Korea ([5]), reports conducting an epidemiological study designed to determine the prevalence of both chronic widespread pain [CWP] and CFS in the same cohort of Korean university freshman. The prevalence of CWP was found to be quite low, consistent with the young age and anticipated good health of university students. As expected, the prevalence of CFS was substantially lower than that of CWP.

From Cincinnati, Ohio, comes a report in collaboration with authors from several other U.S. locations ([6]). Their objective was to assess the health care utilization costs families of children with chronic pain incur. The results documented very substantial direct medical costs compounded by a considerable burden resulting from necessary time commitment of family members to health care visits. Fortunately, a multidisciplinary program was able to reduce the level of health care utilization and the commitment burden on family members.

The next paper comes from Chapel Hill, North Carolina, with a contributing author from Rochester, Minnesota ([7]). The investigators were dentists but the muscle chosen for study was the trapezius. They evaluated activation of the local twitch response [LTR] related to manipulation of trigger points in patients with MPS involving that muscle compared with the contralateral control trapezius muscle. Surface electromyographic recordings were obtained. Both palpation and needling activated the LTR in some patients along with induction of referred pain, but the patients perceived the LTR more frequently than did the operator. With local injection therapy, the severity of the perceived pain on the affected side was reduced.

The final full paper in this issue comes from Moscow, Russia, with contributing authors in several locations in Poland and in Germany ([8]). Their objective was to assess the efficacy of clostridium botulinum type A toxin-hemagglutinin complex in the treatment of adult adductor muscle spasticity due to multiple sclerosis. The study was randomized, placebo controlled. The primary outcome variable selected prospectively was improvement of at least one grade in the patient-selected functional outcome measure at week 4 after injection. The therapy achieved improvement in leg pain, but the primary outcome measure did not meet significance criteria.

The reader is encouraged to peruse several interesting Case Reports, a fascinating Research Ideas contribution, three Literature Columns with summaries of the important new developments in soft tissue pain published in other medical journals since the last issue of JMP, and several Book Reviews.

As always, readers of JMP are invited to submit original manuscripts for blinded peer review, case reports of general interest, research ideas to promote further investigation, and letters to keep us all informed. The JMP editorial office frequently receives relevant books to be evaluated by and for the benefit of our readers. Book reviewers are allowed keep the featured book after the evaluation report is completed. If you would be interested in being a book reviewer for the JMP, please communicate that to the Editor.

The International MYOPAIN Society [IMS] Meeting in August 19–23, 2007, in Washington, DC, was considered a success. A review of the meeting entitled “View from the Mountain Top” was written by Devin Starlanyl and published in the winter issue of Fibromyalgia Frontiers newsletter ([9]). Manuscripts from the invited speakers were published in JMP, volume 16, number 1/2 as a combined special symposium issue. Those who were unable to attend the MYOPAIN meeting and those who wish to jog a memory regarding some aspects of presentations will want to see that issue. The IMS staff members are already working on the big picture for the 2010 meeting to be held in Toledo, Spain. The IMS website www.myopain.com will offer details as they become available.