Is fibromyalgia a real disease?

Fibromyalgia is a Real Disease with Established Pathophysiology and Treatment Guidelines

Fibromyalgia should be recognized as a complex and heterogeneous condition where there is abnormal pain processing and other secondary features, as supported by established clinical guidelines. 1, 2

Pathophysiological Basis

Fibromyalgia is characterized by:

• Central sensitization with altered pain processing 1, 3
• Peripheral sensitization with changes in nociceptor signaling 3
• Inflammatory and immune mechanisms 3
• Neurotransmitter and neuroendocrine disturbances including:
  • Reduced levels of biogenic amines
  • Increased concentrations of excitatory neurotransmitters
  • Dysregulation of the hypothalamic-pituitary-adrenal axis 4

Diagnostic Recognition

The condition is recognized by major medical organizations including:

• European League Against Rheumatism (EULAR) 1, 2
• American College of Rheumatology 5
• World Health Organization (WHO) 6

Fibromyalgia affects approximately 2% of the general population and is more common in women than men 3, 5.

Clinical Presentation

Key symptoms include:

• Chronic widespread musculoskeletal pain (defining feature)
• Fatigue
• Non-refreshed sleep
• Cognitive impairment ("fibro fog")
• Mood disturbances 1, 3, 5

Evidence-Based Management

EULAR guidelines recommend a graduated approach to treatment:

1. First-line: Non-pharmacological approaches

   • Exercise therapy (strongest evidence, "strong for" recommendation) 1, 2
   • Patient education 1, 2
   • Heated pool treatment/hydrotherapy 1, 2
   • Cognitive behavioral therapy 1, 2

2. Second-line: Pharmacological interventions

   • Amitriptyline (10-25mg at bedtime) for pain and sleep disturbance 1, 2
   • Duloxetine (60-120mg/day) and milnacipran (100-200mg/day) for pain and depression 1, 2
   • Pregabalin (150-450mg/day) for pain 1, 2
   • Tramadol for pain management 1, 2

3. Not recommended

   • Strong opioids (lack of proven benefit, risk of dependence) 1, 2
   • Corticosteroids 1, 2

Treatment Outcomes

• Treatment typically provides modest benefits rather than complete symptom resolution 2
• Pain reduction of 30-50% is considered a successful outcome 2
• The primary goal is improving quality of life and function 2

Common Pitfalls in Management

1. Diagnostic delay: Diagnosis often takes >2 years with multiple physician consultations 1
2. Overreliance on medications: Non-pharmacological approaches, particularly exercise, have the strongest evidence base 1, 2
3. Inappropriate use of opioids: Strong opioids are not recommended and may worsen outcomes 1, 2
4. Failure to address psychological aspects: Cognitive behavioral therapy is an important component of management 1, 2
5. Unrealistic expectations: Setting realistic goals is essential as treatments typically provide modest benefits 2

The medical community's understanding of fibromyalgia has evolved significantly, with substantial evidence supporting its existence as a distinct clinical entity with neurobiological underpinnings. While the exact pathophysiology continues to be refined, the condition is recognized by major medical organizations and has established diagnostic criteria and treatment guidelines.