Fibromyalgia syndrome: practical strategies for improving diagnosis and patient outcomes

Recent advances in the understanding of the etiology, epidemiology, diagnosis, and treatment of fibromyalgia must be applied in clinical practice to achieve optimal patient outcomes. Current evidence indicates that fibromyalgia is a hyperalgesic state, resulting from a generalized problem with augmented pain processing that likely results from the way the spinal cord and the brain process pain and other sensory information. The descending pain pathway involving serotonin, norepinephrine, and dopamine, as opposed to the descending opioid pain pathway, appears to be selectively attenuated. Newer treatment options targeted at the pain mechanisms include the alpha(2)-delta pregabalin, which binds to the alpha(2)-delta subunit of voltage-gated calcium channels in neurons, and the serotonin-norepinephrine dual reuptake inhibitors duloxetine and milnacipran. The US Food and Drug Administration (FDA) has approved pregabalin, duloxetine, and milnacipran for the management of fibromyalgia. In addition to pharmacologic therapy, patient education, cognitive behavioral therapy, aerobic exercise, and strength and flexibility training are important components of care. An individualized treatment plan should be developed with consideration of each patient's unique combination of fibromyalgia symptoms, functional level, and the presence of the comorbid psychiatric and medical conditions that are common in patients with fibromyalgia. This educational activity provides clinicians with the tools necessary to differentiate fibromyalgia syndrome from other chronic pain conditions through a review of recent clinical data and an application of an advanced understanding of pain pathways. Strategies to manage patients with comorbid conditions are explored, with an emphasis on the importance of a multidisciplinary approach to patient care. Online Access: http://www.cmeaccess.com/cme/ajm_fibro_program/