Fibromyalgia as Viewed by Pain Medicine Specialists in Colombia
- Daniel GFernández-Ávila
https://doi.org/10.46856/grp.10.e002
Cite as:
Fernández-Ávila DG, Ronderos-Botero DM, Rincón-Riaño DN, Gutiérrez JM. Fibromyalgia as Viewed by Pain Medicine Specialists in Colombia [Internet]. Global Rheumatology. Vol. 1 / Jun - Dic [2020]. Available from: https://doi.org/10.46856/grp.10.e002
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Fibromyalgia as Viewed by Pain Medicine Specialists in Colombia
Introduction: The concepts and perceptions regarding the diagnosis and treatment of fibromyalgia among pain medicine specialists are not objectively known, which motivated us to carry out the present study.
Methods: Descriptive cross-sectional study. Through a focus group involving two rheumatologists, two pain medicine specialists, and an expert in qualitative research methods, a survey was designed to assess the perceptions and concepts that pain medicine specialists have regarding the diagnosis and treatment of fibromyalgia. The survey was self-administered and anonymous, distributed via an internet link sent to pain specialists who are members of the Colombian Association for the Study of Pain.
Results: The survey was completed by 81 pain medicine specialists. 71.6% (n=58) consider there is sufficient evidence to regard fibromyalgia as a disease; 90.1% (n=73) use the 1990 ACR criteria to diagnose fibromyalgia, and 60.5% (n=49) reported using the 2010 classification criteria. The most commonly prescribed medications for fibromyalgia management were antidepressants (96.3%), followed by anticonvulsants (88.9%) and analgesics (84%). 84% of the physicians refer these patients to psychiatry and 63% to a rheumatologist.
Conclusion: This study provides information about the perceptions regarding the diagnosis and treatment of fibromyalgia among a group of Colombian pain medicine specialists.
Fibromyalgia is a chronic disease whose main symptom is widespread musculoskeletal pain, usually associated with a wide range of symptoms that, along with the pain, negatively impact patients’ quality of life (1). It was recognized as a disease by the World Health Organization (WHO) in 1992, as a clinical syndrome of unknown etiology that causes chronic, diffuse, and disabling musculoskeletal pain, and is often accompanied by conditions such as fatigue, sleep disturbances, headaches, and irritable bowel syndrome, among others (2).
The prevalence of fibromyalgia ranges from 2% to 4% in the general population, with a higher incidence in women (female-to-male ratio of 9:1) (3,4). In Colombia, an estimated prevalence of 0.72% (95% CI: 0.47–1.11%) was determined in a study using the COPCORD (Community Oriented Program in the Rheumatic Diseases) screening methodology and questionnaire, which evaluated 6,693 individuals from six cities across the country (5).
The classification criteria for fibromyalgia were initially defined in 1990 by the American College of Rheumatology (ACR) (6). Over the next 20 years, various observations were made by different authors—including the lead author of the 1990 criteria—seeking a new way to classify these patients (7). In May 2010, new classification criteria were proposed (8), aiming to incorporate not only aspects related to pain but also the complex spectrum of symptoms affecting these patients.
Fibromyalgia represents a diagnostic and therapeutic challenge for physicians, regardless of their specialty, due to the complexity of a disease characterized by widespread pain as the main symptom, in combination with other clinical findings that are difficult to quantify, such as fatigue, sleep disorders, and cognitive dysfunction (9). Several of these symptoms may overlap with other musculoskeletal diseases, especially in early stages, which complicates the diagnostic process (10). Patients with fibromyalgia often consult multiple medical specialists, both at the onset of symptoms for diagnostic confirmation and throughout treatment and clinical follow-up (11).
The pain medicine specialist plays a key role in the approach and treatment of chronic pain without an apparent underlying cause, using a “neuropathic pain,” “non-nociceptive pain,” or “central sensitivity” framework, where hyperalgesia and allodynia are typical (12,13).
However, the concepts surrounding the diagnosis and treatment of fibromyalgia among pain medicine specialists in Colombia are not objectively known; to date, only informal and unpublished subjective information has been available. The aim of this study is to obtain objective data on the subject and to describe the concepts and perceptions regarding the diagnosis and treatment of fibromyalgia among Colombian pain medicine specialists.
Descriptive cross-sectional study. A survey was designed through a focus group composed of two rheumatologists, a pain medicine specialist, and an expert in qualitative research methods. The survey consisted of four domains. The first domain addressed general and identification aspects of the physician (age, gender, years of experience, and city of practice); the second domain inquired about diagnostic aspects of the disease; the third covered therapeutic options used (pharmacological, non-pharmacological, and alternative treatments); and the fourth domain explored opinions on the multidisciplinary management of fibromyalgia and referrals to other specialists. The response options were presented using a Likert scale. A pilot test was conducted with 10 pain medicine residents to assess the survey's duration and the clarity of the questions. The survey was self-administered and anonymous, distributed via an internet link sent to pain medicine specialists who are members of the Colombian Association for the Study of Pain. Data were collected in a database and analyzed using Microsoft Excel®. A descriptive analysis was performed, using frequencies and percentages for qualitative variables and measures of central tendency for quantitative variables.
The survey was completed by 81 pain medicine specialists. Of the respondents, 72.8% (n = 59) were male, and 49.4% (n = 40) were over 50 years of age. 71.6% (n = 58) of the specialists believe that there is sufficient evidence to consider fibromyalgia a disease. 48.1% (n = 39) consider the 1990 ACR criteria sufficient for diagnosing fibromyalgia, and more than 90% of these specialists use them in the diagnostic approach to patients with suspected fibromyalgia. However, up to 60.5% (n = 49) have also used the 2010 ACR classification criteria.
43.2% (n = 35) of the respondents believe that fibromyalgia patients feel rejected by their specialty, and 82.7% (n = 67) believe these patients are rejected by physicians from other specialties.
Regarding treatment approaches, the most commonly prescribed medications for fibromyalgia by pain medicine specialists are antidepressants, reported by 96.3% of respondents, followed by anticonvulsants (88.9%) and analgesics (84%). Among antidepressants, the most frequently used is amitriptyline (52.1%), followed by fluoxetine (48%) and duloxetine (39.1%).
Among anticonvulsants, the most used is pregabalin (87.1%), followed by gabapentin (79.3%) and carbamazepine (74.4%). The most frequently prescribed analgesic is acetaminophen plus tramadol (57.7%), followed by acetaminophen plus tizanidine (54.2%), with nonsteroidal anti-inflammatory drugs (NSAIDs) being rarely used (Figure 1).
In terms of non-pharmacological management, 58% (n = 47) of the specialists prescribe hydrotherapy as part of the treatment for fibromyalgia.
Regarding referral to other specialties for interdisciplinary care, 84% (n = 68) of the specialists refer patients to psychiatry, and 63% (n = 51) refer to rheumatology.
Finally, 48% of respondents believe that the management of fibromyalgia patients should be led by a physical medicine and rehabilitation specialist within a multidisciplinary team, while only 28% believe that leadership should fall to the pain medicine specialist (Figure 2).
Our study is the first to describe the concepts and perceptions of pain medicine specialists regarding their diagnostic and therapeutic approach to patients with fibromyalgia. The first key finding is that seven out of ten pain medicine specialists consider fibromyalgia a disease, in contrast to other specialties where the legitimacy of this condition is often questioned (14,15). Previous studies have reported challenges in diagnosing, approaching, and treating fibromyalgia in general medicine and other specialties such as psychiatry, physical medicine and rehabilitation, and rheumatology, indicating that training on fibromyalgia-related topics is often inadequate (16–18).
A common concern among various specialists is the frustration caused by delays in diagnosis, which often leads to dissatisfaction and a sense of helplessness when treating these patients. This stems from the uncertainty surrounding the etiology of fibromyalgia, which contributes to delays in initiating treatment and produces variable, often unsatisfactory, outcomes (19,20).
In terms of diagnostic criteria, nearly 90% of pain medicine specialists use the 1990 American College of Rheumatology (ACR) criteria for the diagnostic approach in fibromyalgia patients. These findings are similar to other specialties, such as in the study by Mu R. et al., where 83.7% of rheumatologists reported still using the 1990 ACR criteria (18). However, 61% of pain specialists in our study also reported using the 2010 ACR classification criteria, a figure notably higher than those reported in other studies (21). Another study comparing the use of the 1990 ACR criteria among Latin American and European rheumatologists found usage rates of 61.7% and 35.7%, respectively, results that align with our findings (22).
Regarding treatment, Colombian pain medicine specialists generally provide medical management aligned with international guidelines (1,23), primarily prescribing antidepressants such as amitriptyline, fluoxetine, and duloxetine, anticonvulsants such as pregabalin and gabapentin, and analgesics such as acetaminophen combined with a mild opioid or muscle relaxant—in preference to acetaminophen alone. Importantly, nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed infrequently, which is appropriate given that these drugs are not recommended for fibromyalgia management.
There is a clear emphasis on interdisciplinary management, with nearly 85% of patients referred to psychiatry and 64% to rheumatology, and more than 50% of respondents believe that the lead physician in the interdisciplinary team should be a physical medicine and rehabilitation specialist, rather than a pain medicine specialist.
Fibromyalgia patients must contend not only with chronic pain and other syndrome-related symptoms but also with a lack of acceptance from family members (24) and, at times, from healthcare providers involved in their care. It is essential to validate the pain experienced by fibromyalgia patients, as, despite ongoing questions from various medical fields, there is sufficient evidence supporting the existence of this condition, and further research is needed to advance our understanding of its pathophysiology, diagnosis, and treatment (25,26).
This study presents objective information on key aspects of fibromyalgia that had previously been based solely on informal, anecdotal data among specialists. These findings can serve as valuable feedback for pain medicine colleagues and provide a foundation for further studies, such as extending this survey to other specialties involved in fibromyalgia care, including psychiatry, internal medicine, and family medicine. Our research group is currently conducting similar surveys among other specialists in Colombia and across Latin America.
Objective information is presented regarding perceptions of fibromyalgia among a group of Colombian pain medicine specialists. This information may serve as valuable feedback for these professionals and as a foundation for further studies aimed at increasing both the quantity and quality of data to improve the management of this complex condition.
No external funding.
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