Central Sensitivity Syndrome Associated with Fibromyalgia and Chronic Pain Conditions
Medical literature repeats the same thing over and over—fibromyalgia is characterized by widespread pain, tenderness, and a number of other symptoms. Technically it’s accurate, but it boils so much misery, so many missed days at work, and so many lost moments of life into a such tidy little package that it doesn’t do justice to the people living daily with fibromyalgia.
The chronic pain of fibromyalgia leads to central sensitivity, which in turn makes patients more vulnerable to developing one or more of the other conditions that are part of central sensitivity syndrome. Patients can learn to manage their symptoms and take steps to avoid comorbidities when pharmacists take the time to counsel about these connected health issues.
Central Sensitivity Syndrome and Fibromyalgia
In the United States, fibromyalgia affects 6.4 percent of adults, although prevalence ranges from nearly 8 percent in women to 5 percent in men.1 That’s a significant number of people facing life-long, chronic and widespread pain and fatigue. These patients fall into one of three functional subsets—adaptive copers, interpersonally distressed, and dysfunctional. On average, their pain leads to 10 outpatient visits yearly and one hospitalization every three years. But that’s not the worst of it.
Chronic pain from fibromyalgia—or any disease—causes permanent changes in the spinal cord and brain, which in turn lead to allodynia and hyperalgesia. This type of central sensitization means that pain is amplified because ordinary sensations that shouldn’t hurt become extremely painful. Researchers have documented that multiple disorders belong on the spectrum of central sensitization syndrome (CSS) because they all have central pain and other overlapping symptoms. A partial list of CSS conditions includes:2
- Irritable bowel syndrome
- Chronic fatigue syndrome
- Interstitial cystitis/painful bladder syndrome
- Temporomandibular joint disorder
- Regional pain syndromes such as myofascial pain syndrome
The CSS conditions share similar pathophysiological processes resulting in five physical and psychological symptoms dubbed the SPADE pentad: sleep disturbance, pain, anxiety, depression and low energy or fatigue.3 As a result, the differential diagnosis can sometimes be a challenge.
Early Identification is Crucial But Difficult
Getting an early diagnosis for fibromyalgia puts patients on the road to pain management and hopefully preventing central sensitization. Yet, an early diagnosis is hard to come by for a variety of reasons. Since symptoms come and go, and everyone has a different tolerance for pain, patients may not consult a doctor until they’ve had fibromyalgia awhile. Then once they get to the doctor, the medical assessment moves at a slow pace because every other potential condition must be ruled out.
The diagnostic criteria for fibromyalgia established by the American College of Rheumatology require doctors to complete a widespread pain index and a symptom severity scale. Patients also complete questionnaires that quantify their pain, severity of problems like fatigue, nonrestorative sleep and cognitive dysfunction, and the presence of abdominal cramps, depression or headache. Collecting information from the patient’s perspective balances the tendency of physicians to underestimate symptom severity. Fibromyalgia can be diagnosed when three criteria are met:
- The widespread pain index and symptom severity scale must reach minimally required scores.
- The symptoms have been present at a similar level for at least three months.
- All other disorders have been ruled out.
While an assessment for CSS is not required to diagnose fibromyalgia, considering the syndrome at the time of the fibromyalgia evaluation may reduce unnecessary testing and help form a more accurate diagnosis.4 Teaching the patients about CSS also goes a long way toward helping them understand their diagnosis and it motivates compliance with the treatment regimen.
Rundown on Treatment Options
Pharmacists may encounter patients after they have a diagnosis when they fill a prescription. It’s more likely you’ll have the opportunity to interact with them long before they visit the doctor. Most have been regular customers as they search for over-the-counter products to relieve pain. They may even purchase supplements to help them sleep or products touted to boost energy. Whenever you talk with them, keep this one important guideline in mind: Pharmacologic agents should always be used in combination with non-pharmacologic therapy.
Psychological therapy – Pharmacologic interventions provide limited benefit if psychosocial and behavioral factors aren’t managed. Anxiety, stress and depression commonly occur in fibromyalgia—depression should be aggressively treated. Cognitive behavioral therapy is effective for psychological concerns and it also improves pain in up to half of all patients.
Exercise – It’s so essential for fibromyalgia patients to stay active that exercise is an integral part of therapy. Patients should start gently and progress gradually to avoid over-exertion that makes fatigue worse. Patients who exercise also report better pain relief.
Sleep – Virtually everyone with fibromyalgia suffers from poor sleep and lack of sleep worsens symptoms. Patients should learn proper sleep hygiene and take basic steps, like avoiding large meals, caffeine and alcohol close to bedtime. Medications should be considered only when diet and behavioral changes have failed.
- Pregabalin, duloxetine, and milnacipran are FDA-approved to treat pain in patients with fibromyalgia.
- Antidepressants – Tricyclic antidepressants are proven to relieve pain and improve sleep. Selective serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors are also effective.
- Skeletal muscle relaxants – Cyclobenzaprine is the only muscle relaxant that provides long-term pain control and improves sleep, so it’s often taken as a single nighttime dose.
- Anticonvulsants – In addition to pregabalin, gabapentin is effective for pain, depression and anxiety.
- Antianxiety agents – Clonazepam, buspirone and benzodiazepines are just a few of the options used for anxiety. They also work as sleep aides.
- Analgesics – Tramadol is generally recommended. NSAIDs and acetaminophen aren’t very effective for fibromyalgia pain, but may help when coexisting inflammatory disorders are present.
Pharmacist Outreach Improves Health Outcomes
It’s crucial to keep central sensitization syndrome in the conversation when you counsel patients with fibromyalgia for one vital reason: Patients with fibromyalgia have a significantly higher risk of developing another condition on the spectrum. The more you can teach them about the role chronic pain plays in CSS and how it connects multiple conditions, the better their chances become for avoiding comorbid health problems.
Pharmaceutica North America provides agents often prescribed for patients with fibromyalgia, including cyclobenzaprine, gabapentin and amitriptyline. Contact us today to talk about how our prescription drug products, bulk active pharmaceutical ingredients and OTC supplements can meet the health care needs of your patients.
- “Fibromyalgia,” July 2016, http://emedicine.medscape.com/article/329838-overview ↩
- “The Prevalence of Fibromyalgia in Other Chronic Pain Conditions,” November 2011, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3236313/ ↩
- “Fibromyalgia and Coexisting Chronic Pain Syndromes,” September 2016, http://www.practicalpainmanagement.com/pain/other/co-morbidities/fibromyalgia-coexisting-chronic-pain-syndromes ↩
- “Central Sensitization Syndrome and the Initial Evaluation of a Patient with Fibromyalgia: A Review,” April 2015, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4422459/ ↩