Advertisement

Unravelling Fibromyalgia—Steps Toward Individualized Management

Published:September 21, 2017DOI:https://doi.org/10.1016/j.jpain.2017.08.009

      Highlights

      • Fibromyalgia is a heterogenous condition.
      • There is a need for individualized treatments, because the average effects of any treatments are modest.
      • Individualized treatment of fibromyalgia can be on the basis of subgrouping of patients according to associated medical conditions and on disease severity.
      • Categorizing fibromyalgia as mild, moderate, or severe can be on the basis of clinical criteria or on questionnaires.
      • Shared decision-making on treatment options can be on the basis of patient preferences and comorbidities.

      Abstract

      The heterogeneity of the clinical presentation and the pathophysiologic mechanisms associated with fibromyalgia (FM), and the modest results on average for any therapy, call for a more individualized management strategy. Individualized treatment can be on the basis of subgrouping of patients according to associated conditions (mental health problems, chronic overlapping pain conditions, other somatic diseases) or on disease severity. Categorizing FM as mild, moderate, or severe can be on the basis of clinical assessment (eg, degree of daily functioning) or on questionnaires. Shared decision-making regarding treatment options can be directed according to patient preferences, comorbidities, and availability in various health care settings. The European League Against Rheumatism guidelines recommend a tailored approach directed by FM key symptoms (pain, sleep disorders, fatigue, depression, disability), whereas the German guidelines recommend management tailored to disease severity, with mild disease not requiring any specific treatment, and more severe disease requiring multicomponent therapy (combination of drug treatment with aerobic exercise and psychological treatments). When indicated, treatments should follow a stepwise approach beginning with easily available therapies such as aerobic exercise and amitriptyline. Successful application of a tailored treatment approach that is informed by individual patient characteristics should improve outcome of FM.

      Perspective

      This article presents suggestions for an individualized treatment strategy for FM patients on the basis of subgroups and disease severity. Categorizing FM as mild, moderate, or severe can be on the basis of clinical assessment (eg, degree of daily functioning) or questionnaires. Subgroups can be defined according to mental health and somatic comorbidities.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ablin J.N.
        • Amital H.
        • Ehrenfeld M.
        • Aloush V.
        • Elkayam O.
        • Langevitz P.
        • Mevorach D.
        • Mader R.
        • Sachar T.
        • Amital D.
        • Buskila D.
        • Israeli Rheumatology Association
        Guidelines for the diagnosis and treatment of the fibromyalgia syndrome [in Hebrew].
        Harefuah. 2013; 152 (751, 750): 742-747
        • Alciati A.
        • Sgiarovello P.
        • Atzeni F.
        • Sarzi-Puttini P.
        Psychiatric problems in fibromyalgia: Clinical and neurobiological links between mood disorders and fibromyalgia.
        Reumatismo. 2012; 64: 268-274
        • Arnold L.M.
        • Choy E.
        • Clauw D.J.
        • Goldenberg D.L.
        • Harris R.E.
        • Helfenstein Jr, M.
        • Jensen T.S.
        • Noguchi K.
        • Silverman S.L.
        • Ushida T.
        • Wang G.
        Fibromyalgia and chronic pain syndromes: A white paper detailing current challenges in the field.
        Clin J Pain. 2016; 32: 737-744
        • Arnold L.M.
        • Hudson J.I.
        • Wang F.
        • Wohlreich M.M.
        • Prakash A.
        • Kajdasz D.K.
        • Chappell A.S.
        Comparisons of the efficacy and safety of duloxetine for the treatment of fibromyalgia in patients with versus without major depressive disorder.
        Clin J Pain. 2009; 25: 461-468
        • Arnold L.M.
        • Sarzi-Puttini P.
        • Arsenault P.
        • Khan T.
        • Bhadra Brown P.
        • Clair A.
        • Scavone J.M.
        • Driscoll J.
        • Landen J.
        • Pauer L.
        Efficacy and safety of pregabalin in patients with fibromyalgia and comorbid depression taking concurrent antidepressant medication: A randomized, placebo-controlled study.
        J Rheumatol. 2015; 42: 1237-1244
        • Barnett K.
        • Mercer S.W.
        • Norbury M.
        • Watt G.
        • Wyke S.
        • Guthrie B.
        Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study.
        Lancet. 2012; 380: 37-43
        • Bennett R.
        The Fibromyalgia Impact Questionnaire (FIQ): A review of its development, current version, operating characteristics and uses.
        Clin Exp Rheumatol. 2005; 23: S154-S162
        • Benor D.
        • Rossiter-Thornton J.
        • Toussaint L.
        A Randomized, controlled trial of wholistic hybrid derived from eye movement desensitization and reprocessing and emotional freedom technique (WHEE) for self-treatment of pain, depression, and anxiety in chronic pain patients.
        J Evid Based Complementary Altern Med. 2017; (Epub ahead of print])
        • Bernardy K.
        • Klose P.
        • Welsch P.
        • Häuser W.
        Efficacy, acceptability and safety of cognitive behavioural therapies in fibromyalgia syndrome – A systematic review and meta-analysis of randomized controlled trials.
        Eur J Pain. 2017; (Epub ahead of print)
        • Boomershine C.S.
        • Emir B.
        • Wang Y.
        • Zlateva G.
        Simplifying fibromyalgia assessment: The VASFIQ brief symptom scale.
        Ther Adv Musculoskelet Dis. 2011; 3: 215-226
        • Chronic Pain Research Alliance
        Impact of chronic overlapping pain conditions on public health and urgent need for safe and effective treatments.
        (Available at:)
        • Clauw D.J.
        Fibromyalgia: A clinical review.
        JAMA. 2014; 311: 1547-1555
        • Derry S.
        • Cording M.
        • Wiffen P.J.
        • Law S.
        • Phillips T.
        • Moore R.A.
        Pregabalin for pain in fibromyalgia in adults.
        Cochrane Database Syst Rev. 2016; (CD011790)
        • Docampo E.
        • Collado A.
        • Escaramís G.
        • Carbonell J.
        • Rivera J.
        • Vidal J.
        • Alegre J.
        • Rabionet R.
        • Estivill X.
        Cluster analysis of clinical data identifies fibromyalgia subgroups.
        PloS One. 2013; 8: e74873
        • Eich W.
        • Bär K.J.
        • Bernateck M.
        • Burgmer M.
        • Dexl C.
        • Petzke F.
        • Sommer C.
        • Winkelmann A.
        • Häuser W.
        Definition, classification, clinical diagnosis and prognosis of fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles.
        Schmerz. 2017; (Epub ahead of print)
        • Fairburn C.G.
        • Patel V.
        The global dissemination of psychological treatments: A road map for research and practice.
        Am J Psychiatry. 2014; 171: 495-498
        • Fitzcharles M.A.
        • Ste-Marie P.A.
        • Goldenberg D.L.
        • Pereira J.X.
        • Abbey S.
        • Choinière M.
        Canadian guidelines for the diagnosis and management of fibromyalgia syndrome: Executive summary.
        Pain Res Manag. 2013; 18: 119-126
        • Forte M.L.
        • Butler M.
        • Andrade K.E.
        • Vincent A.
        • Schousboe J.T.
        • Kane R.L.
        Treatments for Fibromyalgia in Adult Subgroups.
        (Available at)
        http://www.ncbi.nlm.nih.gov/books/NBK274474/
        Date accessed: November 30, 2016
        • Glombiewski J.A.
        • Bernardy K.
        • Häuser W.
        Efficacy of EMG- and EEG-biofeedback in fibromyalgia syndrome: A meta-analysis and a systematic review of randomized controlled trials.
        Evid Based Complement Alternat Med. 2013; 2013: 962741
        • Häuser W.
        • Ablin J.
        • Fitzcharles M.A.
        • Littlejohn G.
        • Luciano J.V.
        • Usui C.
        • Walitt B.
        Fibromyalgia.
        Nat Rev Dis Primers. 2015; 1: 15022
        • Häuser W.
        • Galek A.
        • Erbslöh-Möller B.
        • Köllner V.
        • Kühn-Becker H.
        • Langhorst J.
        • Winkelmann A.
        Posttraumatic stress disorder in fibromyalgia syndrome: Prevalence, temporal relationship between posttraumatic stress and fibromyalgia symptoms, and impact on clinical outcome.
        Pain. 2013; 154: 1216-1223
        • Häuser W.
        • Schmutzer G.
        • Brähler E.
        • Wolfe F.
        Patient health questionnaire 15 as a generic measure of severity in fibromyalgia syndrome: Surveys with patients of three different settings.
        J Psychosom Res. 2014; 76: 307-331
        • Häuser W.
        • Urrútia G.
        • Tort S.
        • Uçeyler N.
        • Walitt B.
        Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia syndrome.
        Cochrane Database Syst Rev. 2013; (CD010292)
        • Henningsen P.
        • Zipfel S.
        • Herzog W.
        Management of functional somatic syndromes.
        Lancet. 2007; 369: 946-955
        • Jessup M.
        • Marwick T.H.
        • Ponikowski P.
        • Voors A.A.
        • Yancy C.W.
        2016 ESC and ACC/AHA/HFSA heart failure guideline update—what is new and why is it important?.
        Nat Rev Cardiol. 2016; 13: 623-628
        • Jiao J.
        • Davis Iii J.M.
        • Cha S.S.
        • Luedtke C.A.
        • Vincent A.
        • Oh T.H.
        Association of rheumatic diseases with symptom severity, quality of life, and treatment outcome in patients with fibromyalgia.
        Scand J Rheumatol. 2015; 1: 1-8
        • Jiao J.
        • Vincent A.
        • Cha S.S.
        • Luedtke C.A.
        • Oh T.H.
        Association of abuse history with symptom severity and quality of life in patients with fibromyalgia.
        Rheumatol Int. 2015; 35: 547-553
        • Jones K.D.
        • Adams D.
        • Winters-Stone K.
        • Burckhardt C.S.
        A comprehensive review of 46 exercise treatment studies in fibromyalgia (1988–2005).
        Health Qual Life Outcomes. 2006; 4: 67
        • Lage-Hansen P.R.
        • Chrysidis S.
        • Lage-Hansen M.
        • Hougaard A.
        • Ejstrup L.
        • Amris K.
        Concomitant fibromyalgia in rheumatoid arthritis is associated with the more frequent use of biological therapy: A cross-sectional study.
        Scand J Rheumatolm. 2015; 1: 1-4
        • Lange M.
        • Petermann F.
        Influence of depression on fibromyalgia: A systematic review.
        Schmerz. 2010; 24: 326-333
        • Lipkovich I.A.
        • Choy E.H.
        • Van Wambeke P.
        • Deberdt W.
        • Sagman D.
        Typology of patients with fibromyalgia: Cluster analysis of duloxetine study patients. BMC Musculoskelet Disord.
        (15; 450)2014
        • Lubrano E.
        • Iovino P.
        • Tremolaterra F.
        • Parsons W.J.
        • Ciacci C.
        • Mazzacca G.
        Fibromyalgia in patients with irritable bowel syndrome. An association with the severity of the intestinal disorder.
        Int J Colorectal Dis. 2001; 16: 211-215
        • Lumley M.A.
        • Schubiner H.
        • Lockhart N.A.
        • Kidwell K.M.
        • Harte S.E.
        • Clauw D.J.
        • Williams D.A.
        Emotional awareness and expression therapy, cognitive behavioral therapy, and education for fibromyalgia: a cluster-randomized controlled trial.
        Pain. 2017; (Epub ahead of print)
        • Macfarlane G.J.
        • Kronisch C.
        • Dean L.E.
        • Atzeni F.
        • Häuser W.
        • Fluß E.
        • Choy E.
        • Kosek E.
        • Amris K.
        • Branco J.
        • Dincer F.
        • Leino-Arjas P.
        • Longley K.
        • McCarthy G.M.
        • Makri S.
        • Perrot S.
        • Sarzi-Puttini P.
        • Taylor A.
        • Jones G.T.
        EULAR revised recommendations for the management of fibromyalgia.
        Ann Rheum Dis. 2017; 76: 318-328
        • Mansfield K.E.
        • Sim J.
        • Croft P.
        • Jordan K.P.
        Identifying patients with chronic widespread pain in primary care.
        Pain. 2017; 158: 110-119
        • Martínez-Martínez L.A.
        • Mora T.
        • Vargas A.
        • Fuentes-Iniestra M.
        • Martínez-Lavín M.
        Sympathetic nervous system dysfunction in fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and interstitial cystitis: A review of case-control studies.
        J Clin Rheumatol. 2014; 20: 146-150
        • Murakami M.
        • Osada K.
        • Mizuno H.
        • Ochiai T.
        • Alev L.
        • Nishioka K.
        A randomized, double-blind, placebo-controlled phase III trial of duloxetine in Japanese fibromyalgia patients.
        Arthritis Res Ther. 2015; 17: 224
        • Naeem F.
        • Phiri P.
        • Munshi T.
        • Rathod S.
        • Ayub M.
        • Gobbi M.
        • Kingdon D.
        Using cognitive behaviour therapy with South Asian Muslims: Findings from the culturally sensitive CBT project.
        Int Rev Psychiatry. 2015; 27: 233-246
        • Pauer L.
        • Winkelmann A.
        • Arsenault P.
        • Jespersen A.
        • Whelan L.
        • Atkinson G.
        • Leon T
        • Zeiher B.
        • A0081100 Investigators
        An international, randomized, double-blind, placebo controlled, phase III trial of pregabalin monotherapy in treatment of patients with fibromyalgia.
        J Rheumatol. 2011; 38: 2643-2652
        • Perrot S.
        • Russell I.J.
        More ubiquitous effects from non-pharmacologic than from pharmacologic treatments for fibromyalgia syndrome: A meta-analysis examining six core symptoms.
        Eur J Pain. 2014; 18: 1067-1080
        • Perrot S.
        • Schaefer C.
        • Knight T.
        • Hufstader M.
        • Chandran A.B.
        • Zlateva G.
        Societal and individual burden of illness among fibromyalgia patients in France: Association between disease severity and OMERACT core domains.
        BMC Musculoskelet Disord. 2012; 13: 22
        • Petzke F.
        • Brückle W.
        • Eidmann U.
        • Heldmann P.
        • Köllner V.
        • Kühn T.
        • Kühn-Becker H.
        • Strunk-Richter M.
        • Schiltenwolf M.
        • Settan M.
        • von Wachter M.
        • Weigl M.
        • Häuser W.
        General treatment principles, coordination of care and patient education in fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles [in German].
        Schmerz. 2017; 31: 246-254
        • Przekop P.
        • Haviland M.G.
        • Zhao Y.
        • Oda K.
        • Morton K.R.
        • Fraser G.E.
        Self-reported physical health, mental health, and comorbid diseases among women with irritable bowel syndrome, fibromyalgia, or both compared with healthy control respondents.
        J Am Osteopath Assoc. 2012; 112: 726-735
        • Ranzolin A.
        • Brenol J.C.
        • Bredemeier M.
        • Guarienti J.
        • Rizzatti M.
        • Feldman D.
        • Xavier R.M.
        Association of concomitant fibromyalgia with worse disease activity score in 28 joints, health assessment questionnaire, and short form 36 scores in patients with rheumatoid arthritis.
        Arthritis Rheum. 2009; 61: 794-800
        • Rehm S.E.
        • Koroschetz J.
        • Gockel U.
        • Brosz M.
        • Freynhagen R.
        • Tölle T.R.
        • Baron R.
        A cross-sectional survey of 3035 patients with fibromyalgia: Subgroups of patients with typical comorbidities and sensory symptom profiles.
        Rheumatology (Oxford). 2010; 49: 1146-1152
        • Rivera J.
        • Vallejo M.A.
        • Offenbächer M.
        Classifying fibromyalgia patients according to severity: The combined index of severity in fibromyalgia.
        Rheumatol Int. 2014; 34: 1683-1689
        • Schaefer C.
        • Chandran A.
        • Hufstader M.
        • Baik R.
        • McNett M.
        • Goldenberg D.
        • Gerwin R.
        • Zlateva G.
        The comparative burden of mild, moderate and severe fibromyalgia: Results from a cross-sectional survey in the United States.
        Health Qual Life Outcomes. 2011; 9: 71
        • Thieme K.
        • Mathys M.
        • Turk D.C.
        Evidenced-based guidelines on the treatment of fibromyalgia patients: Are they consistent and if not, why not? Have effective psychological treatments been overlooked?.
        J Pain. 2017; 18: 747-756
        • Thieme K.
        • Turk D.C.
        • Gracely R.H.
        • Maixner W.
        • Flor H.
        The relationship among psychological and psychophysiological characteristics of fibromyalgia patients.
        J Pain. 2015; 16: 186-196
        • Torres X.
        • Bailles E.
        • Valdes M.
        • Gutierrez F.
        • Peri J.M.
        • Arias A.
        • Gomez E.
        • Collado A.
        Personality does not distinguish people with fibromyalgia but identifies subgroups of patients.
        Gen Hosp Psychiatry. 2013; 35: 640-648
        • Toussaint L.L.
        • Whipple M.O.
        • Vincent A.
        Post-traumatic stress disorder symptoms may explain poor mental health in patients with fibromyalgia.
        J Health Psychol. 2017; 22: 697-706
        • Turk D.C.
        • Okifuji A.
        • Sinclair J.D.
        • Starz T.W.
        Differential responses by psychosocial subgroups of fibromyalgia syndrome patients to an interdisciplinary treatment.
        Arthritis Care Res. 1998; 11: 397-404
        • Üçeyler N.
        • Burgmer M.
        • Friedel E.
        • Greiner W.
        • Petzke F.
        • Sarholz M.
        • Schiltenwolf M.
        • Winkelmann A.
        • Sommer C.
        • Häuser W.
        Etiology and pathophysiology of fibromyalgia syndrome : Updated guidelines 2017, overview of systematic review articles and overview of studies on small fiber neuropathy in FMS subgroups [in German].
        Schmerz. 2017; 31: 239-245
        • Üçeyler N.
        • Häuser W.
        • Sommer C.
        Systematic review with meta-analysis: Cytokines in fibromyalgia syndrome.
        BMC Musculoskelet Disord. 2011; 12: 245
        • Üçeyler N.
        • Sommer C.
        • Walitt B.
        • Häuser W.
        Anticonvulsants for fibromyalgia.
        Cochrane Database Syst Rev. 2013; (CD10782)
        • van Koulil S.
        • van Lankveld W.
        • Kraaimaat F.W.
        • van Helmond T.
        • Vedder A.
        • van Hoorn H.
        • Donders R.
        • de Jong A.J.
        • Haverman J.F.
        • Korff K.J.
        • van Riel P.L.
        • Cats H.A.
        • Evers A.W.
        Tailored cognitive-behavioral therapy and exercise training for high-risk patients with fibromyalgia.
        Arthritis Care Res (Hoboken). 2010; 62: 1377-1385
        • Vincent A.
        • Hoskin T.L.
        • Whipple M.O.
        • Clauw D.J.
        • Barton D.L.
        • Benzo R.P.
        • Williams D.A.
        OMERACT-based fibromyalgia symptom subgroups: An exploratory cluster analysis.
        Arthritis Res Ther. 2014; 16: 463
        • Vitiello M.V.
        • McCurry S.M.
        • Shortreed S.M.
        • Baker L.D.
        • Rybarczyk B.D.
        • Keefe F.J.
        • Von Korff M.
        Short-term improvement in insomnia symptoms predicts long-term improvements in sleep, pain, and fatigue in older adults with comorbid osteoarthritis and insomnia.
        Pain. 2014; 155: 1547-1554
        • Wilson H.D.
        • Robinson J.P.
        • Turk D.C.
        Toward the identification of symptom patterns in people with fibromyalgia.
        Arthritis Rheum. 2009; 61: 527-534
        • Wolfe F.
        • Clauw D.J.
        • Fitzcharles M.A.
        • Goldenberg D.L.
        • Häuser W.
        • Katz R.L.
        • Mease P.J.
        • Russell A.S.
        • Russell I.J.
        • Walitt B.
        2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria.
        Semin Arthritis Rheum. 2016; 46: 319-329
        • Wolfe F.
        • Clauw D.J.
        • Fitzcharles M.A.
        • Goldenberg D.L.
        • Häuser W.
        • Katz R.S.
        • Mease P.
        • Russell A.S.
        • Russell I.J.
        • Winfield J.B.
        Fibromyalgia criteria and severity scales for clinical and epidemiological studies: A modification of the ACR preliminary diagnostic criteria for fibromyalgia.
        J Rheumatol. 2011; 38: 1113-1122
        • Wolfe F.
        • Clauw D.J.
        • Fitzcharles M.A.
        • Goldenberg D.L.
        • Katz R.S.
        • Mease P.
        • Russell A.S.
        • Russell I.J.
        • Winfield J.B.
        • Yunus M.B.
        The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity.
        Arthritis Care Res (Hoboken). 2010; 62: 600-610
        • Wolfe F.
        • Fitzcharles M.A.
        • Goldenberg D.L.
        • Häuser W.
        • Katz R.L.
        • Mease P.J.
        • Russell A.S.
        • Jon Russell I.
        • Walitt B
        Comparison of physician-based and patient-based criteria for the diagnosis of fibromyalgia.
        Arthritis Care Res (Hoboken). 2016; 68: 652-659
        • Wolfe F.
        • Smythe H.A.
        • Yunus M.B.
        • Bennett R.M.
        • Bombardier C.
        • Goldenberg D.L.
        The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee.
        Arthritis Rheum. 1990; 33: 160-172
        • Wolfe F.
        • Walitt B.T.
        • Rasker J.J.
        • Katz R.S.
        • Häuser W.
        The use of polysymptomatic distress categories in the evaluation of fibromyalgia (FM) and FM severity.
        J Rheumatol. 2015; 42: 1494-1501
        • Yunus M.B.
        The prevalence of fibromyalgia in other chronic pain conditions.
        Pain Res Treat. 2012; 2012: 584573
        • Zech N.
        • Bernardy K.
        • Hansen E.
        • Häuser W.
        Efficacy, tolerability and safety of guided imagery/hypnosis in fibromyalgia.
        Eur J Pain. 2017; 21: 217-227