Fibromyalgia Syndrome: Science or Somatic?
Steven P. Cohen, MD*

This issue of Johns Hopkins Advanced Studies in Medicine highlights the proceedings of a national symposium series on the management of patients with fibromyalgia syndrome (FMS).

The clinical and scientific content of the symposia, which were held in Chicago, Baltimore, and San Francisco in October and November 2009, was specifically developed to provide primary care physicians and advanced practice nurses with information about FMS that is both current and relevant to day-to-day practice. The same overall objective was also in mind when choosing the distinguished faculty of experts in pain management.

The majority of patients with FMS seek treatment from their primary care physicians.¹ This is understandable because most patients feel that their primary care providers know them best, are familiar with a broad range of illnesses, and will know when, and to whom, to refer. Indeed, this level of confidence and trust between a provider and a patient gives the provider an unparalleled opportunity to build on the relationship, conduct a thorough evaluation, establish the diagnosis, and initiate appropriate treatment.

Although many primary care physicians are able to provide appropriate care for their patients with FMS, others feel that they need to learn more about FMS so that they can do more for their patients. Ergo, the symposium series, this publication, and numerous other educational activities focusing on FMS.

Sadly, however, there are also clinicians who do not recognize FMS as a “real” illness, but as a somatic (or psychosomatic) syndrome. More often than not, they tell patients that their pain “is all in your head,” and then dismiss these patients as “chronic complainers.” Convincing these providers that FMS is a real disorder of central and peripheral pain processing, as supported by an accumulating body of scientific evidence, is a major challenge to the medical profession as a whole.

The impetus for FMS research was the publication of diagnostic criteria by the American College of Rheumatology (ACR) nearly 2 decades ago.² By providing a standardized case definition of FMS, the criteria led to numerous clinical, epidemiologic, genetic, and neuroimaging studies suggesting that FMS is primarily a neural disease in which central factors play a critical role, as well as a polygenic disorder. In fact, nearly all of the scientific data supporting FMS as a central pain processing disorder have been reported since 1990.

The articles in this issue of Johns Hopkins Advanced Studies in Medicine address several different aspects of FMS, including the mechanisms believed to play a role in its pathophysiology, the barriers that need to be overcome to ensure more effective treatment, and the rationale for targeting neurotransmitters to modulate the pain response. In addition, each article includes a case study illustrating the complexities and challenges of managing patients with FMS.

In the first article, Howard Smith, MD, reviews the epidemiology of FMS and its significant negative impact on daily functioning and quality of life, the ACR diagnostic criteria, and the clinical evaluation of patients with generalized pain. He examines several mechanisms thought to be involved in the pathophysiology and pain processing abnormalities of FMS, and presents findings from neuroimaging studies that suggest central sensitization as the underlying cause. He also describes several of the pathways involved in pain modulation.

In the second article, I address some of the barriers to appropriate treatment of FMS that physicians routinely encounter in clinical practice. These include difficulty in establishing a diagnosis, the often frustrating task of dealing with “difficult” patients, the high prevalence of comorbid conditions that also need to be treated, the time- and labor-intensive efforts involved in helping patients apply for disability benefits, and inadequate or nonexistent healthcare coverage. In addition, I review strategies for treating difficult patients and for overcoming the major barriers to appropriate care of patients with FMS.

Daniel Clauw, MD, follows with a review of the paradigm shift that has changed the way we think of chronic pain, emphasizing that the mechanisms underlying chronic pain and acute pain are markedly different from each other and therefore respond to different treatments. He also addresses the role of genes in setting the “volume control” that determines how the brain and spinal cord process pain and other sensory information, and explains the rationale for modulating the augmented pain response in FMS and other chronic central pain states by targeting the neurotransmitters involved in increasing and decreasing the volume control setting. He concludes with a discussion of the pharmacologic and nonpharmacologic modalities used to treat FMS, and presents his own recommendations for treatment.

Undoubtedly, this is a dynamic era in the management of FMS and other central pain disorders, with recently approved and emerging therapies that specifically target the neurotransmitters involved in pain augmentation and inhibition providing novel mechanism-based approaches to treatment. We are confident that you will find the information presented in this publication to be useful and relevant to your clinical practice.

REFERENCES

1. Adler GK, Geneen R. Hypothalmic-pituitary-adrenal and autonomic nervous system functioning in fibromyalgia. Rheum Dis Clin North Am. 2005;31:187-202, xi.

2. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33:169-172.

*Associate Professor of Anesthesiology, Director of Medical Education for Pain Management Division, Johns Hopkins University School of Medicine, Baltimore, Maryland; Director of Chronic Pain Research, Walter Reed Army Medical Center, Washington, DC.

Address correspondence to: Steven P. Cohen, MD, Associate Professor of Anesthesiology, Director of Medical Education for Pain Management Division, The Johns Hopkins Pain Management Division, 550 North Broadway, Suite 301, Baltimore, MD 21205. E-mail: scohen40@jhmi.edu.

The content in this monograph was developed with the assistance of a medical writer. The authors made substantial contributions to the intellectual content of the articles by conceiving and designing the original presentations, researching references and studies, drafting the manuscripts, reviewing and revising the manuscripts, and/or providing supervision.