Jacob N. Ablin MD
Tel Aviv Sourasky Medical Center, Israel
Fibromyalgia remains a project under construction. While decades of research as well as clinical experience have added greatly to our current understanding and appreciation of fibromyalgia, the true nature of the disorder and the scope of the problem remain elusive. Diagnostic criteria continue to evolve, reshaping both the clinical spectrum as well as the epidemiology and cultural understanding of fibromyalgia as a nosological entity. At the same time, cutting-edge research technologies continue to be developed, constantly opening new windows and new perspectives into the pathogenesis of fibromyalgia and chronic pain in general. Functional neuroimaging, next generation sequencing and epigenetics, as well as novel tools for inducing neuroplasticity, all may reshape fibromyalgia as we know it over the coming years.
Fibromyalgia continues to hold an unusual place among rheumatological disorders. While the major clinical symptoms of fibromyalgia, i.e. widespread musculoskeletal pain, fall squarely into the field of rheumatology, probably encompassing many of the very patients who would have been described in past generations as suffering from “rheumatism” of one kind or another, it has become ever more obvious that the underlying pathogenic mechanisms involved in initiating and perpetuating the fibromyalgia syndrome are connected more closely to dysfunctional processing within the central nervous system then to “rheumatological” tissues such as synovium and cartilage. Thus, fibromyalgia should better currently be addressed in similar strategies as are being applied to other complex CNS disorders, including depression. In this aspect it is noteworthy to pay attention to the inspirational “Research Domain Criteria” (acronym RDoC) which is being developed and implemented by the National Institute of Mental Health .
This ambitious project is striving to integrate emerging findings from hitherto diverse fields of research such as genetics, physiology, network analysis and psychology in order to create a new matrix for classifying and diagnosing patients suffering from mental disorders. This approach, which conceptually may eventually replace the criteria – based taxonomies such as the DSM, aims at eventually reaching true individualized precision medicine. It is appealing to vision, that other complex conditions involving the CNS such as fibromyalgia, will eventually similarly be addressed. In such a system an individual patient would actually not necessarily need to be given an ICD – based label such as fibromyalgia, but would rather undergo extensive genetic (and epigenetic) profiling, including pharmacogenetic evaluation, as well as functional neuroimaging aimed at identifying abnormal patterns of connectivity; physiologic pain processing could also be incorporated such as assessment of conditioned pain modulation (CPM) and other patterns of pain processing. Psychological and cognitive assessment would also be incorporated as well as psycho-social evaluation. Ultimately, this process would culminate in a very personalized plan of treatment, combining optimal pharmacological agents together with non-pharmacological tools all aimed at alleviating pain, minimizing disability and restoring function.
This description may yet sound somewhat utopian at the current point in time. Currently, fibromyalgia patients are diagnosed based on criteria which change at a rather alarmingly rapid pace and often the diagnosis appears to be made by physicians not very well acquainted with the diagnostic criteria to begin with. Both over – diagnosis and under diagnosis are abundant and many misconceptions remain among both laymen as well as in the medical community, regarding what fibromyalgia is and what it is not. Patients are all to often frustrated to encounter lack of knowledge as well as disrespect and disbelief, all of which naturally impede clinical rapport and reduce any prospect for significant improvement. These predicaments can only gradually be overcome through better education and increased awareness.
It is in this perspective that one must regard the establishment of ongoing academic frameworks for dissemination of up-to-date scientific and clinical information regarding the fibromyalgia syndrome. While fibromyalgia has hitherto mainly been discussed and debated on the sidelines of major scientific venues centered on either rheumatology or pain, it has often been relegated to somewhat back scene setting within theses forums. Establishing an ongoing tradition of scientific conferences focusing on fibromyalgia, which will showcase recent advances in this complex field and highlight areas of ongoing debate, is sure to attract broad attendance by both clinicians and researchers; moreover involving fibromyalgia patients within this endeavor is a highly productive stratagem which may help in increase patient engagement and decreasing the sense of alienation felt by many patients as well as in encouraging collaboration between patients and researchers for reaching optimal results. In the aftermath the first international congress on controversies in fibromyalgia, held in Vienna, Austria in March 2019, the organizers hope to initiate an ongoing tradition of similar events to be held in additional locations helping to sketch at least the initial outlines of a roadmap for achieving the ambitious project that lays ahead, in order to bring relief to the immense number of individuals currently suffering from the fibromyalgia syndrome.
Insel TR: The NIMH research domain criteria (RDoC) project: precision medicine for psychiatry. American Journal of Psychiatry 2014, 171(4):395-397.