In these presentations from the recent American College of Rheumatology meeting, new studies explore the neurology and psychology of pain in fibromyalgia (FM), patient knowledge, and evidence-based practice. The 2012 Canadian Fibromyalgia Guidelines recommend care by primary practitioners, not specialists. (Click on the abstract numbers to see the full abstract of a presentation.)
• A randomized crossover trial of milnacipran for FM used functional MRI (fMRI) and functional connectivity MRI (fcMRI) to image brain circuits involved in pain. Patients were given a moderately painful stimulus (pressure to the thumbnail), before and after milnacipran, and the activity and connectivity of pain-related areas were compared. First, on fMRI, patients displayed a significant reduction in activity in the insula, and the left inferior parietal lobule, after milnacipran. Then, on fcMRI, milnacipran increased connectivity between cortical regions and brain stem areas involved with descending analgesia – the cingulated cortex, the pons, the periaqueductal gray regions, and the insula. Milnacipran decreased connectivity between the anterior cingulated cortex and the inferior parietal lobule and mid cingulate cortex. These changes were associated with decreases in clinical pain and evoked pain. (Abstracts #802 and #805)
• A study examined common misperceptions among FM patients about the nature of their condition. In an office-based questionnaire of 21 patients, about half thought FM is related to stress, or previous trauma, or an unknown cause. One-quarter thought it was an autoimmune disease. Others thought it was caused by environmental toxins, food products, or allergies. (Abstract #1564)
• FM patients reported symptoms of hypervigilance, an exaggerated sense of threat in the surroundings, which is associated with post-traumatic stress disorder, and could also be associated with the general sensitization of pain, dysthenias, and insomnias of FM. Subjects with hypervigilance are more aware of social and environmental stressors, and have trouble sleeping. They are easily startled by mild stimuli and feel anxious in public. The results of the study are drawn from questionnaires administered to 100 patients with FM and 28 patients with rheumatoid arthritis in an office setting, as well as responses to an Internet survey from 763 self-identified female FM patients and 115 female controls. FM patients were about twice as likely to report waking up more than once in the night, feeling uncomfortable in crowded places, feeling uncomfortable if people are standing behind them, and being easily startled. The Internet survey was administered by AFFTER, a volunteer community FM organization. (Abstract #1858)
• Canadian evidence-based guidelines recommend the primary care setting for managing FM. The Canadian Fibromyalgia Guidelines Committee presented the new 2012 Canadian Fibromyalgia Guidelines, which set out to answer 18 key clinical questions, and made 60 recommendations. The ideal setting for most patients is the primary care practice, they say. The diagnosis of FM is clinical, not one of exclusion (although an examination is required to exclude other painful conditions). Tender point examination is not required. Specialist confirmation is not needed. Excessive testing is “strongly discouraged.” Treatment should actively involve patients, include non-pharmaceutical strategies, and use drugs at lower doses, in combinations, to facilitate adherence. (Abstract #1862)
