THE OFFICIAL NEWS SOURCE OF ACR CONVERGENCE 2022 • NOVEMBER 10-14



Controversial fibromyalgia concepts continue to evolve

The diagnosis, classification, and treatment of fibromyalgia have been controversial, as three leading experts — each representing a unique perspective — will confirm during a Wednesday morning symposium. Two of the presenters of Evolving Concepts in Fibromyalgia at 9:00 am in Room 30 E will provide updates on diagnosing and treating, while the third will discuss whether to even attempt to treat the condition.

Classified by the ACR in 1990, fibromyalgia has long frustrated patients and their physicians. It is more common in women than men, by a 2:1 ratio. It affects about 3 percent of women and is characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood issues. It has been difficult to diagnose and treat because of a lack of a well-categorized tissue pathology, and its symptoms often overlap with other common chronic illnesses. Understanding the pathophysiology of fibromyalgia is the first step in facing the challenges common to the treatment of this condition.

Daniel J. Clauw, MD
Daniel J. Clauw, MD

The symposium’s first presenter, Daniel J. Clauw, MD, Professor of Anesthesiology, Rheumatology, and Psychiatry at the University of Michigan, Ann Arbor, and Director of the Chronic Pain and Fatigue Research Center, will focus on the condition when it presents with autoimmune diseases.

Physicians have gotten much wrong about fibromyalgia, he said.

“Fibromyalgia is more of an end of a continuum rather than a discrete disease,” he said. “Understanding where patients are on the continuum will enable the physicians to select more effective treatments.”

Many of the traditional approaches to pain management — drugs such as opioids — are ineffective for fibromyalgia, said Dr. Clauw. Emerging treatment options target co-morbid symptoms that are often associated with pain, such as sleep disturbance, mood, and fatigue.

Dr. Clauw acknowledged that the disease presented a challenge to rheumatologists whose approach to treating autoimmune disorders didn’t translate to fibromyalgia.

“If you don’t like the term fibromyalgia, use the term you want to use [for] centralized pain,” he said. “If you appreciate that, then you’ll use the right treatment.”

Ideally, a pain specialist or primary care physician coordinates fibromyalgia treatment with support from a range of healthcare providers, Dr. Clauw said.

Marina Lopez-Sola, PhD
Marina Lopez-Sola, PhD

Also presenting at the symposium will be Marina Lopez-Sola, PhD, Assistant Professor in the Department of Anesthesiology at University of Cincinnati, OH. Dr. Lopez-Sola approaches the issue from a cognitive scientist’s perspective. She recently published post-doctoral research in the journal Pain exploring breakthrough studies of brain signatures in fibromyalgia sufferers.

“Neuroimaging and other physical and psychological assessments have contributed to providing insight into our understanding of the disease,” she said. “My intention is to give a broad perspective on how neuroimaging, physical function, and psychology have informed our knowledge of fibromyalgia and related conditions with two main focuses — sensory and affective/cognitive dysfunction.

“I will discuss neuroimaging-based scientific knowledge from the past and the main limitations of these methodological approaches. Then I’ll focus on new ways to overcome such limitations and how the development of new neuroimaging measures that are being validated across studies and across the world may finally provide the medical community with objective neural tests to identify and characterize pathophysiology subtypes in different fibromyalgia patients and objectively assess and quantify treatment effects.”

Researchers have identified numerous subsets of fibromyalgia, Dr. Lopez-Sola said.

“For example, some patients may show central amplification of pain, others may show altered multi-sensory processing, whereas others may show both or none of those. Some may engage value-related circuits during sensory processing, whereas others may not.”

Dr. Lopez-Sola noted that exercise interventions, mindfulness-based cognitive therapy (MBCT), and certain medications may exert their effects via different neural mechanisms. Using the neural-markers approach enables physicians to quantify to which each treatment normalizes the expression of different neural markers that have been previously developed and validated to track fibromyalgia.

“For example, we may find that exercise-based interventions downregulate the pain-specific neural marker, whereas MBCT does not, or MBCT may downregulate emotional markers that we may find altered in FM,” she said. “Those are now only speculation, but eventually we will be able to measure and report the specific effects of the different available treatments on objective, reproducible markers of brain pathophysiology in fibromyalgia.”

Brian Walitt, MD, MPH
Brian Walitt, MD, MPH

Not all fibromyalgia experts agree that contemporary theories of pain perception derived from psychophysical and neuroimaging studies provide meaningful, causal insight into the problem of fibromyalgia. Presenting this perspective will be Brian Walitt, MD MPH, National Institute of Nursing Research at the National Institutes of Health. He will consider the current fibromyalgia paradigm and the sources of its support, review the evidence and lack of evidence regarding the efficacy of fibromyalgia treatments, and discuss alternative ways in which the treatment of fibromyalgia patients may be considered.[gap height=”20″]