Spine Pain + Fibromyalgia Flag Resistance to Standard Therapy

CHICAGO – More than 40% of patients who presented to a tertiary pain center with axial spine pain met the criteria for fibromyalgia. These patients may represent a subset of the spine pain population who will be unresponsive to standard interventions.

The presence of fibromyalgia may undermine the effectiveness of opioids, according to the investigators.

"Our group is very interested in the concept of centralized pain and in trying to better differentiate patients based on phenotype at the point of care. Many patients seek care for axial spine pain, and the outcomes are mixed," Dr. Chad M. Brummett noted at the annual meeting of the American Society of Anesthesiologists.

"Fibromyalgia-positive patients were different in all phenotypic measures of pain, mood, and function assessed."

"We are interested in applying what has been learned about fibromyalgia to the spine community. The field has been writing about personalized care for 20 years, but we still tend to give all patients the same drugs. Our aim is to provide physicians with information that will guide therapy," said Dr. Brummett, director of adult pain research at the University of Michigan Back and Pain Center in Ann Arbor.

He noted that failure rates for facet interventions for the treatment of axial spine pain have ranged from 39% to 47%, and persistent pain is common. There is a growing appreciation in the pain community of a subset of patients with altered central pain processing leading to widespread body pain, such as fibromyalgia, who may require a different treatment approach, he said.

The observational cohort study included 256 new patients categorized as having axial spine pain; of the 244 who completed the American College of Rheumatology fibromyalgia survey, 101 patients (41.4%) met the ACR fibromyalgia criteria.

"We saw profound phenotypic differences between the two groups," Dr. Brummett noted, although he acknowledged that as a tertiary care facility his group is "bound to see a more failed population."

"Some would argue whether this means they have fibromyalgia or not, and that is not clear, but certainly this is a different group," he emphasized.

Dr. Brummett and colleagues observed significant differences in pain, function, mood, and anxiety in the fibromyalgia-positive pain population, compared with patients who did not meet the ACR criteria for fibromyalgia. For example, among the 101 patients with fibromyalgia, the mean pain intensity score on the Brief Pain Inventory was 7.05, while it was 6.10 in those without fibromyalgia. Scores for both depression and anxiety were higher for those with fibromyalgia than those without (mean depression and anxiety scores on the Hospital Anxiety and Depression Scale were 11.33 and 11.38, respectively, for those with fibromyalgia and 7.47 and 6.81, respectively, for those without). Likewise, the mean Patient Reported Outcomes Measurement Information System score for physical function was 27.96 for those with fibromyalgia and 32.24 for those without.

"Fibromyalgia-positive patients were different in all phenotypic measures of pain, mood, and function assessed," reported Dr. Brummett, who along with his colleagues was awarded for having the "Best Clinical Abstract" at the meeting.

The investigators also asked the patients questions about the efficacy of previous interventions. Current use of opioid medications was reported by 60.4% of fibromyalgia-positive patients and 43.4% of fibromyalgia-negative patients (P = .012). Although not significant, fibromyalgia-positive patients taking opioids reported lower efficacy. Epidural interventions were common in both groups, at 37.6% and 43.8%, respectively, but fibromyalgia-positive patients rated the epidurals as being less effective (P = .036).

"We are not saying that patients meeting fibromyalgia criteria, if they have clear-cut radiculopathy, should not have steroid injections. But there may be a difference in response to these interventions," he explained.

"I don’t think our ability to predict response to treatment is very good, even with diagnostic algorithms laid out to us," he added. "Our data should help us better define the most appropriate treatments for these patients."

There were significantly more women in the fibromyalgia-positive group than there were in the fibromyalgia-negative group (64% vs. 50%). This was the only demographic characteristic that was significantly different between the two groups.

Fibromyalgia patients are known to have alterations of central pain processing and may respond differently to interventions and medications. "If patients understand that they may have only a 50/50 chance of responding to a standard intervention for spine pain, they may rethink it," he suggested.

He maintained that future studies of pain medications and interventions should include a measure of central sensitization, such as the fibromyalgia survey. "It is our belief that these are different patients, but we don’t yet have enough objective data to guide treatment. We have to understand our patient population better," Dr. Brummett concluded.

Dr. John Dombrowski, director of the Washington (D.C.) Pain Center and head of the American Society of Anesthesiologists communications committee, commented that the percentage of concurrent fibromyalgia in the study seems high, "but since this is a tertiary setting they are probably seeing the worst of the worse patients."

"While this may be a selected population, the results are still interesting," he said. "Obviously, this subset of patients has issues. They have a predilection for more central pain, and many will need multimodal therapy. Pain patients are challenging, and fibromyalgia makes them even more challenging. This study underlines the fact that we cannot rely on interventional treatments alone."

Dr. Brummett said that he had no relevant disclosures.

CHICAGO – More than 40% of patients who presented to a tertiary pain center with axial spine pain met the criteria for fibromyalgia. These patients may represent a subset of the spine pain population who will be unresponsive to standard interventions.

The presence of fibromyalgia may undermine the effectiveness of opioids, according to the investigators.

"Our group is very interested in the concept of centralized pain and in trying to better differentiate patients based on phenotype at the point of care. Many patients seek care for axial spine pain, and the outcomes are mixed," Dr. Chad M. Brummett noted at the annual meeting of the American Society of Anesthesiologists.

"Fibromyalgia-positive patients were different in all phenotypic measures of pain, mood, and function assessed."

"We are interested in applying what has been learned about fibromyalgia to the spine community. The field has been writing about personalized care for 20 years, but we still tend to give all patients the same drugs. Our aim is to provide physicians with information that will guide therapy," said Dr. Brummett, director of adult pain research at the University of Michigan Back and Pain Center in Ann Arbor.

He noted that failure rates for facet interventions for the treatment of axial spine pain have ranged from 39% to 47%, and persistent pain is common. There is a growing appreciation in the pain community of a subset of patients with altered central pain processing leading to widespread body pain, such as fibromyalgia, who may require a different treatment approach, he said.

The observational cohort study included 256 new patients categorized as having axial spine pain; of the 244 who completed the American College of Rheumatology fibromyalgia survey, 101 patients (41.4%) met the ACR fibromyalgia criteria.

"We saw profound phenotypic differences between the two groups," Dr. Brummett noted, although he acknowledged that as a tertiary care facility his group is "bound to see a more failed population."

"Some would argue whether this means they have fibromyalgia or not, and that is not clear, but certainly this is a different group," he emphasized.

Dr. Brummett and colleagues observed significant differences in pain, function, mood, and anxiety in the fibromyalgia-positive pain population, compared with patients who did not meet the ACR criteria for fibromyalgia. For example, among the 101 patients with fibromyalgia, the mean pain intensity score on the Brief Pain Inventory was 7.05, while it was 6.10 in those without fibromyalgia. Scores for both depression and anxiety were higher for those with fibromyalgia than those without (mean depression and anxiety scores on the Hospital Anxiety and Depression Scale were 11.33 and 11.38, respectively, for those with fibromyalgia and 7.47 and 6.81, respectively, for those without). Likewise, the mean Patient Reported Outcomes Measurement Information System score for physical function was 27.96 for those with fibromyalgia and 32.24 for those without.

"Fibromyalgia-positive patients were different in all phenotypic measures of pain, mood, and function assessed," reported Dr. Brummett, who along with his colleagues was awarded for having the "Best Clinical Abstract" at the meeting.

The investigators also asked the patients questions about the efficacy of previous interventions. Current use of opioid medications was reported by 60.4% of fibromyalgia-positive patients and 43.4% of fibromyalgia-negative patients (P = .012). Although not significant, fibromyalgia-positive patients taking opioids reported lower efficacy. Epidural interventions were common in both groups, at 37.6% and 43.8%, respectively, but fibromyalgia-positive patients rated the epidurals as being less effective (P = .036).

"We are not saying that patients meeting fibromyalgia criteria, if they have clear-cut radiculopathy, should not have steroid injections. But there may be a difference in response to these interventions," he explained.

"I don’t think our ability to predict response to treatment is very good, even with diagnostic algorithms laid out to us," he added. "Our data should help us better define the most appropriate treatments for these patients."

There were significantly more women in the fibromyalgia-positive group than there were in the fibromyalgia-negative group (64% vs. 50%). This was the only demographic characteristic that was significantly different between the two groups.

Fibromyalgia patients are known to have alterations of central pain processing and may respond differently to interventions and medications. "If patients understand that they may have only a 50/50 chance of responding to a standard intervention for spine pain, they may rethink it," he suggested.

He maintained that future studies of pain medications and interventions should include a measure of central sensitization, such as the fibromyalgia survey. "It is our belief that these are different patients, but we don’t yet have enough objective data to guide treatment. We have to understand our patient population better," Dr. Brummett concluded.

Dr. John Dombrowski, director of the Washington (D.C.) Pain Center and head of the American Society of Anesthesiologists communications committee, commented that the percentage of concurrent fibromyalgia in the study seems high, "but since this is a tertiary setting they are probably seeing the worst of the worse patients."

"While this may be a selected population, the results are still interesting," he said. "Obviously, this subset of patients has issues. They have a predilection for more central pain, and many will need multimodal therapy. Pain patients are challenging, and fibromyalgia makes them even more challenging. This study underlines the fact that we cannot rely on interventional treatments alone."

Dr. Brummett said that he had no relevant disclosures.

CHICAGO – More than 40% of patients who presented to a tertiary pain center with axial spine pain met the criteria for fibromyalgia. These patients may represent a subset of the spine pain population who will be unresponsive to standard interventions.

The presence of fibromyalgia may undermine the effectiveness of opioids, according to the investigators.

"Our group is very interested in the concept of centralized pain and in trying to better differentiate patients based on phenotype at the point of care. Many patients seek care for axial spine pain, and the outcomes are mixed," Dr. Chad M. Brummett noted at the annual meeting of the American Society of Anesthesiologists.

"Fibromyalgia-positive patients were different in all phenotypic measures of pain, mood, and function assessed."

"We are interested in applying what has been learned about fibromyalgia to the spine community. The field has been writing about personalized care for 20 years, but we still tend to give all patients the same drugs. Our aim is to provide physicians with information that will guide therapy," said Dr. Brummett, director of adult pain research at the University of Michigan Back and Pain Center in Ann Arbor.

He noted that failure rates for facet interventions for the treatment of axial spine pain have ranged from 39% to 47%, and persistent pain is common. There is a growing appreciation in the pain community of a subset of patients with altered central pain processing leading to widespread body pain, such as fibromyalgia, who may require a different treatment approach, he said.

The observational cohort study included 256 new patients categorized as having axial spine pain; of the 244 who completed the American College of Rheumatology fibromyalgia survey, 101 patients (41.4%) met the ACR fibromyalgia criteria.

"We saw profound phenotypic differences between the two groups," Dr. Brummett noted, although he acknowledged that as a tertiary care facility his group is "bound to see a more failed population."

"Some would argue whether this means they have fibromyalgia or not, and that is not clear, but certainly this is a different group," he emphasized.

Dr. Brummett and colleagues observed significant differences in pain, function, mood, and anxiety in the fibromyalgia-positive pain population, compared with patients who did not meet the ACR criteria for fibromyalgia. For example, among the 101 patients with fibromyalgia, the mean pain intensity score on the Brief Pain Inventory was 7.05, while it was 6.10 in those without fibromyalgia. Scores for both depression and anxiety were higher for those with fibromyalgia than those without (mean depression and anxiety scores on the Hospital Anxiety and Depression Scale were 11.33 and 11.38, respectively, for those with fibromyalgia and 7.47 and 6.81, respectively, for those without). Likewise, the mean Patient Reported Outcomes Measurement Information System score for physical function was 27.96 for those with fibromyalgia and 32.24 for those without.

"Fibromyalgia-positive patients were different in all phenotypic measures of pain, mood, and function assessed," reported Dr. Brummett, who along with his colleagues was awarded for having the "Best Clinical Abstract" at the meeting.

The investigators also asked the patients questions about the efficacy of previous interventions. Current use of opioid medications was reported by 60.4% of fibromyalgia-positive patients and 43.4% of fibromyalgia-negative patients (P = .012). Although not significant, fibromyalgia-positive patients taking opioids reported lower efficacy. Epidural interventions were common in both groups, at 37.6% and 43.8%, respectively, but fibromyalgia-positive patients rated the epidurals as being less effective (P = .036).

"We are not saying that patients meeting fibromyalgia criteria, if they have clear-cut radiculopathy, should not have steroid injections. But there may be a difference in response to these interventions," he explained.

"I don’t think our ability to predict response to treatment is very good, even with diagnostic algorithms laid out to us," he added. "Our data should help us better define the most appropriate treatments for these patients."

There were significantly more women in the fibromyalgia-positive group than there were in the fibromyalgia-negative group (64% vs. 50%). This was the only demographic characteristic that was significantly different between the two groups.

Fibromyalgia patients are known to have alterations of central pain processing and may respond differently to interventions and medications. "If patients understand that they may have only a 50/50 chance of responding to a standard intervention for spine pain, they may rethink it," he suggested.

He maintained that future studies of pain medications and interventions should include a measure of central sensitization, such as the fibromyalgia survey. "It is our belief that these are different patients, but we don’t yet have enough objective data to guide treatment. We have to understand our patient population better," Dr. Brummett concluded.

Dr. John Dombrowski, director of the Washington (D.C.) Pain Center and head of the American Society of Anesthesiologists communications committee, commented that the percentage of concurrent fibromyalgia in the study seems high, "but since this is a tertiary setting they are probably seeing the worst of the worse patients."

"While this may be a selected population, the results are still interesting," he said. "Obviously, this subset of patients has issues. They have a predilection for more central pain, and many will need multimodal therapy. Pain patients are challenging, and fibromyalgia makes them even more challenging. This study underlines the fact that we cannot rely on interventional treatments alone."

Dr. Brummett said that he had no relevant disclosures.