Fibromyalgia and Chronic Pain Syndromes: A White Paper Detailing Current Challenges in the Field

Abstract

This manuscript, developed by a group of chronic pain researchers and clinicians from around the world, aims to address the state of knowledge about fibromyalgia (FM) and identify ongoing challenges in the field of FM and other chronic pain syndromes that may be characterized by pain centralization/amplification/hypersensitivity. There have been many exciting developments in research studies of the pathophysiology and treatment of FM and related syndromes that have the potential to improve the recognition and management of patients with FM and other conditions with FM-like pain. However, much of the new information has not reached all clinicians, especially primary care clinicians, who have the greatest potential to use this new knowledge to positively impact their patients' lives. Furthermore, there are persistent misconceptions about FM and a lack of consensus regarding the diagnosis and treatment of FM. This paper presents a framework for future global efforts to improve the understanding and treatment of FM and other associated chronic pain syndromes, disseminate research findings, identify ways to enhance advocacy for these patients, and improve global efforts to collaborate and reach consensus about key issues related to FM and chronic pain in general.

FIGURE 1

The pain continuum. Fibromyalgia (FM) is part of a larger continuum that comprises a number of clinical syndromes, some examples of which are shown here. This continuum ranges from predominantly nociceptive (peripheral), to predominantly neuropathic, to predominantly centralized pain conditions. Many experts agree that FM rests at the end of the continuum of pain processing. IBS indicates irritable bowel syndrome; TMJD, temporomandibular joint disorder. Courtesy of Don L. Goldenberg, MD.

FIGURE 2

The prevalence of fibromyalgia (FM) in other chronic pain conditions. A number of chronic pain conditions can overlap or coexist with FM. It is useful to keep this in mind so that proper diagnosis and management can be undertaken. The percentages in this graphic are for illustrative purposes and are based upon the medical literature. CRPS indicates complex regional pain syndrome; IBS, irritable bowel syndrome; TMJD, temporomandibular joint disorder. Courtesy of Daniel J. Clauw, MD.

FIGURE 3

Objective evidence shows augmented pain sensitivity in individuals with fibromyalgia (FM) versus matched controls. A, The graph depicts mean pain ratings plotted against stimulus intensity. In FM patients, a low stimulus pressure (2.4 kg/cm²) produced a much higher pain level (mean±SD, 11.30±0.90) than in controls. However, in control subjects, a much higher stimulus pressure elicited a pain response similar to that in FM patients. B, The scan is a functional magnetic resonance image (fMRI) of the brain of a patient with FM from the same study. The imaging study demonstrated that, in patients with FM, pain processing areas of the brain are activated at a much lower level of stimulus than in control subjects. There is overlap (as indicated by the yellow area on the fMRI) between the areas activated with a low-intensity stimulus in FM patients (red area) and a high-intensity stimulus in control subjects (green area). In other words, the overlap between brain activation in FM patients receiving a low stimulus pressure and controls receiving almost twice as much pressure (ie, the amount required to cause the same amount of pain) suggests a mechanism involving central amplification of pain in the patients with FM. Because regions of brain activation in FM patients and healthy controls overlap, the pain experienced by both sets of subjects is real. Objective evidence such as this would be a valuable component of the educational framework proposed in this publication. Gracely et al. Reprinted with permission from John Wiley and Sons. Copyright [John Wiley and Sons, New York, NY]. All permission requests for this image should be made to the copyright holder.