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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Fibromyalgia Syndrome: Science or Somatic?


Goal
To provide primary care physicians and advanced practice nurses with up-to-date information on the treatment and management of patients with fibromyalgia syndrome.

Target Audience
This activity is designed for primary care physicians and advanced practice nurses. No prerequisites required.

Learning Objectives
Upon the conclusion of this activity, the participant should be able to:

  • Explain dysregulation of neurotransmitters in patients with fibromyalgia syndrome (FMS) and how it relates to pain response.
  • Evaluate current diagnostic criteria and neuroimaging diagnostics supporting the evidence of central sensitization, as well as genetic polymorphisms.
  • Identify clinician barriers encountered when treating patients with FMS and develop strategies to increase quality of patient care.
  • Compare and contrast the efficacy and safety of targeted neurotransmitter therapies and nonmedicinal therapies used to treat FMS.
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

Accreditation Statement
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity: 2 hours.

After reading this monograph, participants may receive credit by completing the CME test, evaluation, and receiving a score of 70% or higher.

Release date: December 15, 2009. Expiration date: December 15, 2011.

Disclaimer Statement
The opinions and recommendations expressed by faculty and other experts whose input is included in this activity are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This activity is supported by an educational grant from Lilly USA, LLC and Pfizer Inc.

Johns Hopkins Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, d/b/a Advanced Studies in Medicine, an HMG Company, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2009 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The Johns Hopkins University School of Medicine to require the disclosure of the existence of any relevant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Course Director and Participating Faculty reported the following:

COURSE DIRECTOR

Steven P. Cohen, MD
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
Dr Cohen reports having no relationships with commercial interests related to this activity.

 

PARTICIPATING FACULTY

Daniel Clauw, MD
Professor of Anesthesiology and Medicine
Division of Rheumatology
University of Michigan Medical Center
Ann Arbor, Michigan
Dr Clauw reports serving as the principal investigator on grants from Forest Laboratories and Pfizer Inc; and serving as a consultant for AstraZeneca, Eli Lilly and Company, Pierre Fabre, and UCB, Inc.

Howard Smith, MD
Associate Professor of Anesthesiology,
Internal Medicine, and Physical
Rehabilitation and Medicine
Academic Director of Pain Management
Albany Medical College
Albany, New York
Dr Smith reports serving on the speakers’ bureau for Cypress Pharmaceutical, Inc and Forest Laboratories.

 

Off-Label Product Discussion: The audience is advised that an article in this CME activity contains reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Clauw—g-hydroxybutyrate, selective serotonin reuptake inhibitors, and tricyclic antidepressants.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Note: Grants to investigators at The Johns Hopkins University are negotiated and administered by the institution which receives the grants, typically through the Office of Research Administration. Individual investigators who participate in the sponsored project(s) are not directly compensated by the sponsor, but may receive salary or other support from the institution to support their effort on the project(s).

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.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.