Current literature is trending towards exploring the impact of complementary and alternative treatments for fibromyalgia and an overall focus on multidisciplinary care.
In the second part of our Year in Review series, Rheumatology Network interviewed Andrea Chadwick, MD, to discuss the top highlights of fibromyalgia in the year 2022. She noted that recent research has focused on more complementary and alternative therapies, highlighting the potential importance of utilizing a multidisciplinary approach when managing patients, including cognitive behavioral therapy and acceptance and commitment therapy. Both physical and emotional functioning are becoming a more mainstream approach to treatment, instead of solely attempting to alleviate painful symptoms. Chadwick is Medical Director of Swing Care and Associate Professor in the Department of Anesthesiology, Pain, and Perioperative Medicine at the University of Kansas School of Medicine in Kansas City, Kansas.
Rheumatology Network: Were there any studies or new data related to fibromyalgia that stands out to you when looking back on 2022?
Andrea Chadwick, MD: There hasn’t been much in the way of drug development in 2022. However, I think the literature is becoming more and more aware of the impact that more complementary and alternative treatments can have for fibromyalgia and the importance of cognitive behavioral therapy, acceptance and commitment therapy, and an overall focus on multidisciplinary care.
Things have been very heavily interventional, focusing on what we can do to treat peripheral problems. Where I've seen the literature go is looking at that overall view of the patient, and making sure that we're coming up with not only care in the physical sense (making sure that patients are being active and trying to meet their goals for movement), but also taking into account some of the more novel therapies for fibromyalgia.
The seminal work for things like low-dose naltrexone came out probably about a decade ago, but we're finding more and more the utility of that drug, not only in fibromyalgia but any central sensitization syndrome and even in some autoimmune disorders.
I haven't seen much in the way of new drugs that have come out, but I have seen some reviews on low-dose naltrexone and case reports for low-dose naltrexone this year that have been worthy of reading.
In the review articles, I've seen a focus on multidisciplinary care, including that behavioral component, and getting to the point where the patient can accept that the real end goal of treatment and fibromyalgia is more of an acceptance of values and goals in their lives and how to marry that with their pain as opposed to complete elimination of pain.
RN: One of the reasons why I love covering fibromyalgia is because there's such an emphasis on taking integrative approach to treatment. It's interesting to be able to combine all these tools to help manage and treat patients.
AC: Absolutely. And even thinking outside of the box and looking at things that may not fit the norm. As medical doctors, we're traditionally educated on medications and certain types of therapies. But I recently finished a study looking at heat therapy in fibromyalgia patients based on patients telling me that heat made them feel better. And so, I received an internal grant at the University of Kansas to look at how hot water immersion multiple times a week might improve pain and physical functioning.
I partnered with a basic scientist who does work in essentially heat shock proteins. She runs a lab where she looks at the effect of heat on glycemic control and metabolic function in rodent models. We looked at heat shock protein levels and inflammation levels in humans. What we found, and we're getting ready to hopefully publish soon, is that the heat therapy over a course of 4-week treatment was very helpful for reducing pain and significantly improving physical functioning. Interestingly, the blood markers for heat shock protein and heat shock protein levels and inflammation appeared to show that the heat was helping to reverse some of the proinflammatory states of these patients. Who would have thought hot tub therapy would potentially be a treatment option for patients? But you know, I think the lived experience of patients, using the stories they tell us, and coupling it with science can come up with some really neat and novel information and innovation.
RN: Have you noticed any overarching trends in fibromyalgia management and treatment over the past year?
AC: I think the focus really has been on medications in the years past. When I was in training, you had your 3 FDA approved agents, and you could try off label usage of some medications. But a lot of times, at least in the training I had, there wasn't a whole lot that could be used to help patients and the importance of movement and physical activity, especially the behavioral care.
There are 3 silos of treatment options for fibromyalgia patients: physical modalities, pharmacologic modalities, and behavioral modalities. The behavioral component has really been shaping up to be one of the most important and more significant roles in fibromyalgia treatment, at least in my own practice. In the last half decade, many comprehensive pain programs, or even just health systems in general, are employing people who have expertise in things like cognitive behavioral therapy, as well as acceptance and commitment therapy. And I think that the patients themselves really have found value in those types of therapies.
So often we focus on symptom reduction as our ultimate goal as physicians. But what's interesting about the dogma that I've been witnessing over the last few years is this notion that the overall functioning of that person is more important, and that that includes physical functioning, yes, but emotional functioning, and improvements in fatigue and sleep. Focusing more on the whole person as opposed to just painful symptoms is really where I think fibromyalgia care is headed.
RN: What are some of their most pressing issues in fibromyalgia that you hope to see addressed or receive a greater focus on in 2023?
AC: I think that's a great question. There's still so much to know about how fibromyalgia develops in some individuals. And I think, in 2023, we're kind of in this post-COVID era. I'd like to see some research develop and treatment strategies be addressed for patients who did not have fibromyalgia-like symptoms or other co-occurring pain syndromes prior to their COVID infection and to understand those patients. How did they develop that fibromyalgia phenotype when they did not have it before their COVID infection? In my own practice, I've noticed that COVID infections for patients who already have fibromyalgia can lead to either a significant prolonged post-COVID course or in others they recover quite quickly from it.
I think it's rather timely too, as we're kind of coming out of the significant pandemic portion of the Coronavirus, that we're starting to understand how it's impacting patients with newly developed fibromyalgia as a result of their prior COVID infection or what the natural courses for those patients or for patients who developed COVID while they already had fibromyalgia.
But outside of the Coronavirus impact in the fibromyalgia world, I think focusing on research on novel treatments, whether they be pharmacologic or non-pharmacologic, are of desperate need. Because providers oftentimes feel that their armamentarium for helping address symptoms for fibromyalgia patients can be quite limited with the currently available number of FDA approved drugs. Ultimately, the amount of side effects we see with FDA approved and non-FDA approved drugs can oftentimes limit or preclude their use in patients with fibromyalgia.
RN: Is there anything else that we haven't addressed that you would like our audience to know?
AC: The readers should continue to look for good treatment options for their patients that involve improving access to care for patients with fibromyalgia. Fibromyalgia still, generally speaking, lacks a medical home. And so, I would encourage researchers or clinicians who are reading this feature to continue to focus on making sure that these patients are heard, seen, and validated and are being given the best care possible and being referred for fibromyalgia-specific care as much as possible.