The Complete Guide to Fibromyalgia by Sharon Ostalecki

Fibromyalgia: Dr. Joseph Meerschaertt, M.D., Dr. Peter Ianni, Ph.D.

Regardless of gender, fibromyalgia may be mild, moderate, or severe. ¹⁴

• Mild fibromyalgia is characterized by mild muscle pain - that is, a pain level of 1, 2, or 3 on a 10-point scale. It is little or no hindrance in everyday functioning. Treatment is often by a primary care practitioner (PCP), who may prescribe a tricyclic antidepressant (Elavil, Sinequan, etc.). Symptoms respond to education, instruction in sleep hygiene, self-directed exercise, and over-the-counter medications.

• Moderate fibromyalgia is characterized by moderate muscle pain - that is, a pain level of 4, 5, or 6 out of 10. It somewhat hinders everyday functioning. Some PCPs with pain management experience can manage moderate fibromyalgia, whereas others refer patients to physical medicine and rehabilitation (PM&R) specialists, also known as physiatrists. Patients with moderate fibromyalgia usually need supervised exercise, usually with a physical therapist. They often need a combination of medicines, including anti-inflammatories, muscle relaxants, anticonvulsants, and selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs). Patients with moderately severe fibromyalgia often need prescription analgesics.

• Severe fibromyalgia is characterized by severe muscle pain - that is, a pain level of 7, 8, or 10 out of 10. It greatly hinders everyday functioning. Patients are either unable to work or must frequently call in sick. Some have access to an in-patient multidisciplinary program, but usually a physiatrist or other pain management specialist puts together an individualized program that involves several health care providers specializing in the treatment of severe fibromyalgia. They titrate their treatments to maximize pain relief and functioning while minimizing pain flares. The American Pain Society's medication guidelines for managing fibromyalgia should be followed to maximize pain relief while minimizing side effects.¹⁵ If you need opioid analgesics (codeine, morphine, etc.) most practitioners refer you to a pain psychologist to assess your addiction risk. They also require you to sign a participation agreement. We have found behavioral pain management prudent, as well, because it reduces the need for excessive opioid dosage escalation.

A physiatrist is a specialist in the diagnosis and nonsurgical treatment of pain. A physiatrist usually employs a team approach to restoring a patient's abilities (rehabilitation) through various means, such as medications, physical/occupational therapies, injections, behavioral interventions, and so forth. Therefore, health care providers in other disciplines are often part of the team. Your team members might include a physical therapist, an orthotist, a sleep physician, a nutritionist, a psychologist, and a yoga therapist, for example.

Our primary goals in treating pain are twofold:
• To increase your functional capacity (i.e., how much you can do)
• To minimize the level of pain and suffering

The Treatment Team

As I mentioned previously, a primary care physician can manage mild fibromyalgia. Some patients with moderately severe fibromyalgia, and all patients with severe fibromyalgia, need multidisciplinary or transdisciplinary pain control.

The difference between multidisciplinary and transdisciplinary treatment is in the level of cooperation among team members. In the multidisciplinary approach, each health care provider (e.g., your physical therapist, your orthotist, your sleep physician, and so forth) treats you independently but communicates with other team members. Over time, each team member learns what the others are doing. Eventually, the team's treatments become oriented as a whole.

The team is now a transdisciplinary one in which the health care providers' interventions overlap to fill in and reinforce the goals that characterize the team's treatment orientation. For example, initially, a multidisciplinary team member might tell a patient with severe fibromyalgia to push through the pain, assuming that the pain is mild and the patient just deconditioned. However, once team members begin to identify which patients do poorly when told to push through the pain (i.e., those with moderate-to-severe pain), they make other recommendations like pacing, slowing down, conserving endurance, and resetting priorities. The transdisciplinary approach ensures consistency. You can imagine how confusing it would be for the patient if his or her health care providers gave conflicting instructions because they have no uniform treatment orientation.

Your physiatrist forms several hypotheses about the abnormalities that need to be corrected or addressed. Note that the mere presence of an abnormality doesn't mean that it must be corrected. Even if it does, delaying the treatment of a particular abnormality is often best. The timing of corrective intervention is important to avoid triggering a flare-up of your pain symptoms. A pain flare can discourage the patient, who has come to the specialist seeking relief of pain.

Knowing which corrections to order, which interventions to order, and when to order them is the fruit of the physiatrist's experience with fibromyalgia. Your input is important. Questions are welcome. Learning about the rehabilitation process shapes your understanding of how to get better.

There are many impediments to getting better, because what worked for your mild pain in the past no longer works for the more severe pain you have now. Your physiatrist taps into her or his experience with fibromyalgia patients. In fact, doctors always try to tap into their understanding of what has resulted in recovery versus what has impeded recovery in former patients. Physiatry addresses your pain problems via many different treatments. Although some seem to contribute little to your improvement, the additive effect of several small improvements can be substantial over time.

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