Fibromyalgia - is it all in their head?

Jose da Silva delivered a presentation entitled "Fibromyalgia - Where the body meets the brain?" that suggests the pain from FM may be affected by changes in the circuitry of the brain. He reviewed several studies that are shedding some new light on FM.

One study evaluated temporal summation of pain in the brain in 35 patients with pain and depression associated with FM. In the resting state, patients with FM had less connectivity in certain important areas of the brain compared to healthy controls. The temporal summation of pain in patients with FM was also altered, suggesting that FM patients have a tonic level of somatosensory processing due to chronic clinical pain. This leads to reduced somatosensory connectivity between different subregions in the brain. In other words, patients with FM have an altered pain sensation resulting from connectivity of regions in the brain that is not found in healthy controls.

Another study evaluated anatomical changes of the brain in 43 patients with FM who had pain and depression compared to healthy controls. There was a reduction in frontal lobe connections in FM patients compared with healthy controls. The study also provides support for the role of the cerebellum as a pain processing area in FM.

A study on cognitive appraisal aimed to evaluate how negative affect and cognitions in FM are associated with greater pain sensitivity. Functional MR imaging was collected from 31 patients with FM during painful stimuli of the lower limb. There was an association between pain catastrophizing and pain sensitivity, which was mediated by low activity in the lateral prefrontal cortex during pain anticipation. The lateral prefrontal cortex controls the descending pain modulatory system. Therefore, reduced activation during pain anticipation may be an important mechanism for the pain sensitizing effect of negative cognitive and emotional processes. However, the lack of controls in this study limits the interpretability of the results.

In a study of 46 patients with FM and 16 controls, some patients with FM (35-41%) had significantly reduced intra-epidermal nerve fibres. This finding was not clearly related to clinical symptoms and causality could not be inferred. It is possible that a subset of patients with other autoimmune diseases may have small fibre neuropathy but this remains to be confirmed.

A medical record review looking at the number of medical and psychiatric conditions as well as the number and type of medications used in patients with FM showed that more than 50% of FM patients had more than 7 medical, psychiatric or sleep-related comorbidities. More than 50% of the patients were prescribed more than 3 medications for FM and a large number of these patients were taking opioids and benzodiazepines.

Is there anything new that we can apply to our FM patients? We know that non-pharmacological treatments are effective but they are difficult to prescribe and patient adherence to these treatments is low. The current pharmacological treatments are ineffective, poorly tolerated and may have adverse effects and addictive properties. The development of new medications for FM has been frustratingly slow. Some novel devices that have been proposed include spinal cord stimulation or repetitive transcranial magnetic stimulation/transcranial direct current stimulation.

As a clinician, what I took from this session is that educating patients and providing cognitive-behavioural strategies may be helpful. A negative outlook seems to correlate with pain. So stay positive! Focus on and reinforce the positive. 

Here's some food for thought: Maybe people with FM should come to Rome for a day to enjoy the sunshine and hustle of this beautiful city. 

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