Chronic widespread pain

  • Winfried Häuser

    Adjunct Professor, Department Psychosomatic Medicine and Psychotherapy, Technical University Munich, Germany Senior Physician, Department Internal Medicine, Germany
  • Claudia Sommer

    Professor, Neurology and Pain Research, University of Würzburg, Germany
  • Serge Perrot

    Head of the Pain Centre, Cochin Hospital, Professor of Clinical Pharmacology, Paris University, France
  • Mary-Ann Fitzcharles

    Clinician, Teacher and Clinical Researcher at McGill University, Canada

Chair: Winfried Häuser, Germany
Chronic primary pain, nociplastic pain, functional pain; where do we stand?
Claudia Sommer, Germany
Anybody who has been on a nomenclature committee know how difficult it is to find appropriate words for experiences, states of mind, feelings, and for diseases and disorders related to them. The definition of pain has been a struggle, and the new IASP definition of pain “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” has been the subject of vivid discussion. If there is a clear cause of any pain, like a bone fracture in acute pain, or, for example, hip arthrosis in chronic pain, it is relatively easy to explain and to communicate this. Pain that is felt (experienced) by a person, but for which no specific cause has been found, is difficult to understand, to communicate, and to explain. Different ways to talk about this kind of pain have been used in the past. The new classification of diseases, ICD11, has introduced the category of “chronic primary pain”. This is defined as; “chronic pain in one or more anatomical regions that is characterised by significant emotional distress (anxiety, anger/frustration or depressed mood) or functional disability (interference in daily life activities and reduced participation in social roles). Chronic primary pain is multifactorial: biological, psychological and social factors contribute to the pain syndrome. The diagnosis is appropriate independently of identified biological or psychological contributors unless another diagnosis would better account for the presenting symptoms.” Nociplastic pain is a term introducd by the IASP Terminology Task Force in 2017. It is defined as “pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain.” The term was intended for clinical usage and not supposed to be a diagnosis or a synonym for “central sensitization”. The term “functional pain” is misleading. It is used as a synonym to “primary pain” by some, but not by all authors. These terms will be discussed using clinical examples.
Chronic widespread pain; assessment and differential diagnosis
Serge Perrot, France
Fibromyalgia: state of the art management
Mary Ann Fitzcharles, Canada
Effective management of fibromyalgia (FM) remains a challenge for numerous reasons. There is no” gold standard” of treatment, symptom presentation is heterogeneous, and contrary to patient expectations, drugs provide only a modest effect. Recent FM guidelines from Europe, Germany, Canada, and Israel have emphasized several overarching principles for care. The diagnosis of FM should be prompt, and management should be patient tailored with active patient participation. Unnecessary investigations and excessive healthcare encounters should be avoided.

Beginning with non-pharmacologic strategies, treatment should follow a stepwise approach with the aim to maintain function and reduce symptoms. It should be emphasized that any drug treatment should be balanced regarding benefits and risks, and drug treatment should not be viewed as a lifelong necessity. Healthcare professionals can expect to care for individual patients with FM over many years and will require patience and empathy.

Using an approach of patient tailored personalized management, address specific symptoms with focus on the weight of individual symptoms experienced by the patient and according to the severity of the condition. Symptoms that are prominent for patients with FM include pain, sleep and mood disturbance, fatigue and impaired function. Identify realistic outcome goals with a focus towards treat-to-target. Ideally we should aim for a 30%, or better still a 50% reduction in symptoms, as well as improvement in function. When using a drug, if possible, choose one that could impact more than one symptom.

Non-pharmacologic treatments have the strongest evidence for effect, including exercise, multicomponent treatment, cognitive and behavioral therapies (CBT), and meditative movement. There is limited evidence for treatments such as acupuncture, massage, chiropractic treatment amongst others, mainly due to the poor quality of studies. Drugs are unfortunately not great, with only a modest effect for most, associated with a high rate of side effects, although a few patients may have an appreciable effect. Drugs in the categories of antidepressants and gabapentinoids have the best evidence for effect, and use of opioids is strongly discouraged. Need for continued drug treatment should be evaluated at every clinic encounter, with emphasis to demedicalize and deprescribe whenever possible.
Pharmacotherapy for fibromyalgia?
Winfried Häuser, Germany


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