- Indian Rheumatology association
B G Dharmanand MD, DM
Senior Consultant Rheumatologist, Manipal Vikram Hospital, Bengaluru, India
How do you approach the diagnosis of fibromyalgia in clinical practice?
In contrast to the 2% prevalence of Fibromyalgia (FM) in the general population, around 1 in 10 patients with autoimmune rheumatic diseases have coexisting FM. It may contribute to pain and the patient may complain of fatigue. FM components may also influence the pain VAS and patient Global assessment. If not recognised and addressed, patients may be considered as having refractory disease and will result in unnecessary escalation on immunomodulation and expose patients also to incremental risk for side effects.
What is your approach to managing fibromyalgia symptoms?
First step is to recognise the FM by also assessing the pain, fatigue, sleep disturbance and affective symptoms apart from classical symptoms of AIRD. Management involves non-pharmacological measures before considering medications. Patient education, and explaining the link between inadequate sleep and stress on pain threshold and the relatively non serious nature of the pain and also reassuring that the FM pain does not reflect his or her AIRD worsening, all could be the initial approach to FM component.
How do you decide on pharmacological and non-pharmacological treatments?
Non-Pharmacological measures are the cornerstone of managing FM and are as effective as medications. Patients with milder symptoms may require only non-pharmacological interventions. If not better or if there is a strong element of pain and distress is present, medications are introduced. Most commonly utilised non-pharmacological measures are
Which medications do you find most effective?
Choice of medications depends upon the dominant domain of clinical symptoms ie., pain, insomnia, fatigue, IBS.
If pain is the major presentation, tricyclic antidepressants like Amitriptyline, SNRIs like Duloxetine or Pregabalin or Gabapentin may be used. It is better to start with a small dose and gradually escalate the dose. (For example; pregabalin 25 mg HS and increase over 5-10 days to 50 and then to 75 till you reach 300 mg or the best tolerated dose. Can keep a larger dose at night to avoid day time drowsiness). Explain that the medicine effect may take a few weeks to work.
If insomnia is the main symptom, it is better to rule out primary sleep disorders like OSA and RLS. Tricyclics and pregabalin can help sleep. Some may need benzodiazepines or zolpidem may be used for a short period.
What role does physical therapy and exercise play in your treatment strategy for fibromyalgia?
Exercises make a difference to fibromyalgia symptoms. All types of exercises like conditioning exercise, stretching exercises and later strengthening exercises are useful.
Due to severe pain and more importantly fatigue, FM patients resist exercises and comply poorly with exercise advice. Starting slow and progress slow is the mantra for FM patients. Patients also value a written exercise prescription more than oral advice. Following is a sample exercise prescription,
Ms. XXXXX, 28/Female
Walking for 5 minutes for 1 week
10 minutes for 1 week
15 minutes for 1 week
20 minutes for 1 week
5-10 minutes of warm up/Stretching exercises
Review in 4 weeks and report response
Most physiotherapists are not aware of FM and are ill equipped to address exercise therapy for FM patients. It is better to identify a Physiotherapist and train him/her about FM and the results would improve. Gentle Fascial stretch helps FP patients.
Do you collaborate with other specialists in managing fibromyalgia?
Yes, I collaborate regularly with a physiotherapist who has special interest in FM management. Clinical psychologists help to address chronic pain, sleep and affect. CBT and other methods are well studied and are effective in making the patient cope with FM better. In patients with severe depression, anxiety or OCD will require cooperation with psychiatrists.
How do you integrate psychological interventions?
Basic patient education is provided by me in the clinic. Reassurance, explaining pain mechanisms like the difference between nociceptive pain and nociplastic pain, connection between stress and pain, lack of sleep and pain are the few issues addressed. Addressing the patient’s fear and concerns is important. Basic sleep hygiene and exercise prescription is given during the education session. Pacing is an important concept which if implemented will help patients manage their life more efficiently.
Many patients are reluctant to visit a mental health professional unless we give an impression that the problem is genuine and real and only that they are producing faulty neural circuits. Clinical psychologists also need to be introduced to the concept of FM and not all are trained in pain management. CBT is the most commonly applied psychological intervention. Pain reprocessing therapy and hypnosis are also employed by the psychologists.
Treating FM can be frustrating, time consuming and tests our abilities. Need to have extra time for the patients, to develop a team of physical therapists and a psychologist. In the end, it is a gratifying experience providing comfort to often neglected patients.
