Peter A. Ste-Marie

2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary.

BACKGROUND Recent neurophysiological evidence attests to the validity of fibromyalgia (FM), a chronic pain condition that affects >2% of the population. OBJECTIVES To present the evidence-based guidelines for the diagnosis, management and patient trajectory of individuals with FM. METHODS A needs assessment following consultation with diverse health care professionals identified questions pertinent to various aspects of FM. A literature search identified the evidence available to address these questions; evidence was graded according to the standards of the Oxford Centre for Evidence-Based Medicine. Drafted recommendations were appraised by an advisory panel to reflect meaningful clinical practice. RESULTS The present recommendations incorporate the new clinical concepts of FM as a clinical construct without any defining physical abnormality or biological marker, characterized by fluctuating, diffuse body pain and the frequent symptoms of sleep disturbance, fatigue, mood and cognitive changes. In the absence of a defining cause or cure, treatment objectives should be patient-tailored and symptom-based, aimed at reducing global complaints and enhancing function. Healthy lifestyle practices with active patient participation in health care forms the cornerstone of care. Multimodal management may include nonpharmacological and pharmacological strategies, although it must be acknowledged that pharmacological treatments provide only modest benefit. Maintenance of function and retention in the workforce is encouraged. CONCLUSIONS The new Canadian guidelines for the treatment of FM should provide health professionals with confidence in the complete care of these patients and improve clinical outcomes.

Opioid Use in Fibromyalgia Is Associated with Negative Health Related Measures in a Prospective Cohort Study

As pain is the cardinal symptom of fibromyalgia (FM), strategies directed towards pain relief are an integral component of treatment. Opioid medications comprise a category of pharmacologic treatments which have impact on pain in various conditions with best evidence for acute pain relief. Although opioid therapy other than tramadol has never been formally tested for treatment of pain in FM, these agents are commonly used by patients. We have examined the effect of opioid treatments in patients diagnosed with FM and followed longitudinally in a multidisciplinary pain center over a period of 2 years. In this first study reporting on health related measures and opioid use in FM, opioid users had poorer symptoms and functional and occupational status compared to nonusers. Although opioid users may originally have had more severe symptoms at the onset of disease, we have no evidence that these agents improved status beyond standard care and may even have contributed to a less favourable outcome. Only a formal study of opioid use in FM will clarify this issue, but until then physicians must be vigilant regarding the multiple adverse consequences of opioid therapy.

Canadian Pain Society and Canadian Rheumatology Association Recommendations for Rational Care of Persons with Fibromyalgia. A Summary Report

Objective. To summarize the development of evidence-based guidelines for the clinical care of persons with fibromyalgia (FM), taking into account advances in understanding of the pathogenesis of FM, new diagnostic criteria, and new treatment options. Methods. Recommendations for diagnosis, treatment, and patient followup were drafted according to the classification system of the Oxford Centre for Evidence-Based Medicine, and following review were endorsed by the Canadian Rheumatology Association and the Canadian Pain Society. Results. FM is a polysymptomatic syndrome presenting a spectrum of severity, with a pivotal symptom of body pain. FM is a positive clinical diagnosis, not a diagnosis of exclusion, and not requiring specialist confirmation. There are no confirmatory laboratory tests, although some investigation may be indicated to exclude other conditions. Ideal care is in the primary care setting, incorporating nonpharmacologic and pharmacologic strategies in a multimodal approach with active patient participation. The treatment objective should be reduction of symptoms, but also improved function using a patient-tailored treatment approach that is symptom-based. Self-management strategies combining good lifestyle habits and fostering a strong locus of control are imperative. Medications afford only modest relief, with doses often lower than suggested, and drug combinations used according to clinical judgment. There is a need for continued reassessment of the risk-benefit ratio for any drug treatment. Outcome should be aimed toward functioning within a normal life pattern and any culture of disablement should be discouraged. Conclusion. These guidelines should provide the health community with reassurance for the global care of patients with FM with the aim of improving patient outcome by reducing symptoms and maintaining function.

Fibromyalgia: evolving concepts over the past 2 decades

From being a condition of suspect validity 2 decades ago, fibromyalgia is now much more widely accepted as a true syndrome, with pathogenesis centred in the nervous system and abnormalities shown in pain-regulating mechanisms at various levels of the central and peripheral nervous systems.[1][1]–[

The Dilemma of Medical Marijuana use by Rheumatology Patients

“Severe pain” is the most common reason for medicinal herbal cannabis use, with arthritis and musculoskeletal pain cited as the most prevalent specific medical condition (1,2). Eighty percent of marijuana users in a US pain clinic report use for myofascial pain, whereas up to one-third of persons in population studies in the UK and Australia reported use for treatment of arthritis pain (1–3). Similarly, “severe arthritis” is the diagnosis for 65% of Canadians authorized to possess cannabis for medicinal purposes as of June 2013 (4). Medical marijuana has, however, never been recommended by any rheumatology group worldwide for symptom relief in rheumatic conditions. As the health care professionals best placed to advise on issues of rheumatic diseases, rheumatologists must have a voice in the current debate concerning medical marijuana, hereafter identified as herbal cannabis. Advocacy for access to cannabinoid treatments has led to a societal groundswell, with regulatory bodies around the globe considering the legalization of herbal cannabis for medicinal use. Currently, herbal cannabis is legalized for medicinal use in 20 states in the US as well as in the District of Columbia. Physicians will therefore be caring for patients who may be self-medicating with herbal cannabis or may request medical advice about cannabis. In order to responsibly advise patients on any medical issue, and in particular herbal cannabis, it is essential that the health care professional has a competent knowledge of the subject based on sound scientific study. In this review, we examined the current evidence for dosing and administration, efficacy, and risks of herbal cannabis in rheumatic pain management, and thereby addressed practical issues confronting rheumatologists whose patients request advice. We confined our comments to herbal cannabis as it pertains to rheumatic conditions, acknowledging that evidence and information may differ for other conditions. We did not enter into the debate addressing the legalization of recreational herbal cannabis.

Association of herbal cannabis use with negative psychosocial parameters in patients with fibromyalgia

Patients with chronic pain, including fibromyalgia (FM), may seek treatments outside of mainstream medicine. Medicinal cannabinoids are popularly advocated for pain relief but with limited evidence for efficacy in FM. The extent of use of cannabinoids in FM is unknown.

Efficacy, Tolerability, and Safety of Cannabinoid Treatments in the Rheumatic Diseases: A Systematic Review of Randomized Controlled Trials.

To assess the efficacy, tolerability, and safety of cannabinoids (phyto‐ and syntheto‐) in the management of rheumatic diseases.

A Medicolegal Analysis of Worker Appeals for Fibromyalgia as a Compensable Condition Following Workplace Soft-tissue Injury

Objective. Workplace injuries may be implicated in the causation of fibromyalgia (FM), hence linking FM to compensation. We examined the appeals by workers directed to an appeals tribunal for causation of FM following soft-tissue injury sustained in the workplace. Methods. One hundred fifty tribunal decisions relevant to FM were examined using a predetermined protocol. New-onset FM was appealed in 123, and aggravation of preexisting FM in 15. Results. All injuries were of a soft-tissue type, without persistent physical findings to explain continued symptoms. The tribunal accepted 67% of appeals for aggravation of FM, and 59% for new-onset FM. Time from injury to FM diagnosis was 4.3 ± 4.1 years, with 6.3 ± 2.8 physicians cited for each worker, and with previous health status not reported for 26%. Injuries were a single event in 68%, with location in low back for 44%, and shoulder/upper limb in 40%. The FM diagnosis was based on a rheumatologist report in 74%. Conclusion. Over half of appeals for aggravation or causation of FM following a work-related soft-tissue injury were accepted by the tribunal, with importance ascribed to a rheumatologist diagnosis. Concerns are raised regarding lengthy duration from injury to diagnosis, claimants’ high healthcare use, and neglect of mention of previous health status. The attribution of causation of FM to a soft-tissue workplace traumatic event is contentious and requires further examination.

Real-life assessment of the validity of patient global impression of change in fibromyalgia

Objectives Patient Global Rating of Change (GRC) scales are commonly used in routine clinical care given their ease of use, availability and short completion time. This analysis aimed at assessing the validity of Patient Global Impression of Change (PGIC), a GRC scale commonly used in fibromyalgia, in a Canadian real-life setting. Methods 167 fibromyalgia patients with available PGIC data were recruited in 2005–2013 from a Canadian tertiary-care multidisciplinary clinic. In addition to PGIC, disease severity was assessed with: pain visual analogue scale (VAS); Patient Global Assessment (PGA); Fibromyalgia Impact Questionnaire (FIQ); Health Assessment Questionnaire (HAQ); McGill Pain Questionnaire; body map. Multivariate linear regression assessed the PGIC relationship with disease parameter improvement while adjusting for follow-up duration and baseline parameter levels. The Spearmans rank coefficient assessed parameter correlation. Results Higher PGIC scores were significantly (p<0.001) associated with greater improvement in pain, PGA, FIQ, HAQ and the body map. A statistically significant moderate positive correlation was observed between PGIC and FIQ improvement (r=0.423; p<0.001); correlation with all remaining disease severity measures was weak. Regression analysis confirmed a significant (p<0.001) positive association between improvement in all disease severity measures and PGIC. Baseline disease severity and follow-up duration were identified as significant independent predictors of PGIC rating. Conclusions Despite that only a weak correlation was identified between PGIC and standard fibromyalgia outcomes improvement, in the absence of objective outcomes, PGIC remains a clinically relevant tool to assess perceived impact of disease management. However, our analysis suggests that outcome measures data should not be considered in isolation but, within the global clinical context.

Disability in Fibromyalgia Associates with Symptom Severity and Occupation Characteristics

Objective. It is intuitive that disability caused by illness should be reflected in illness severity. Because disability rates for fibromyalgia (FM) are high in the developed world, we have examined disease and work characteristics for patients with FM who were working, unemployed, or receiving disability payments for disability as a result of FM. Methods. Of the 248 participants in a tertiary care cohort study of patients with FM, 90 were employed, 81 were not employed and not receiving disability payments, and 77 were not working and currently receiving disability payments awarded for disability caused by FM. Demographic, occupation, and disease characteristics were compared among the groups. Results. The prevalence of disability caused by FM was 30.8%. There were no demographic differences among the working, unemployed, or disabled patients. With the exception of measures for anxiety and depression, all measurements for disease severity differed significantly among the groups, with greater severity reported for the disabled group, which used more medications and participated less in physical activity. Disabled patients were more likely previously employed in manual professions or the service industry, whereas employed patients were more commonly working in non-manual jobs that included clerical, managerial, or professional occupations (p = 0.005). Conclusion. The one-third rate of disability for this Canadian cohort of patients with FM is in line with other reports from the western world. Associations of disability compensation were observed for subjective report of symptom severity, increased use of medications, and previous employment in more physically demanding jobs.