Deconstructing Chronic Low Back Pain in the Older Adult – Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part III: Fibromyalgia Syndrome
SOURCE: Pain Medicine 2015 (Sep); 16 (9): 1709-1719 ~ FULL TEXT
Gita Fatemi, Meika A. Fang, Paula Breuer, Paul E. Cherniak,
Angela Gentili, Joseph T. Hanlon, Jordan F. Karp,
Natalia E. Morone, Eric Rodriguez, Michelle I. Rossi,
Kenneth Schmader, Debra K. Weiner
VA Greater Los Angeles Healthcare System,
Los Angeles, California
OBJECTIVE: To present the third in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributors to pain and disability in older adults with CLBP. This article focuses on fibromyalgia syndrome (FMS).
METHODS: A modified Delphi approach was used to create the evaluation and treatment algorithm, the table discussing the rationale behind each of the algorithm components, and the stepped-care drug recommendations. The team involved in the creation of these materials consisted of a principal investigator, a 5-member content expert panel, and a 9-member primary care panel. The evaluation and treatment recommendations were based on availability of medications and other resources within the Veterans Health Administration (VHA) facilities. However, non-VHA panelists were also involved in the development of these materials, which can be applied to both VA and civilian settings. The illustrative clinical case was taken from the clinical practice of the principal investigator.
RESULTS: Following expert consultations and a review of the literature, we developed an evaluation and treatment algorithm with supporting materials to aid in the care of older adults with CLBP who have concomitant FMS. A case is presented that demonstrates the complexity of pain evaluation and management in older patients with CLBP and concomitant FMS.
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CONCLUSIONS: Recognition of FMS as a common contributor to CLBP in older adults and initiating treatment targeting both fibromyalgia syndrome (FMS) and chronic low back pain (CLBP) may lead to improved outcomes in pain and disability.
KEYWORDS: Back Pain; Chronic Pain; Elderly; Fibromyalgia; Low Back Pain
From the FULL TEXT Article:
Fibromyalgia syndrome (FMS) is a challenging diagnosis for many health care providers given the breadth of symptoms patients have on presentation and the paucity of specific objective findings. Twenty-five years ago, FMS was initially described as a syndrome characterized by widespread musculoskeletal pain that could not be explained by another diagnosis.  FMS has been increasingly recognized to encompass additional features such as fatigue and nonrestorative sleep, and these other symptoms are included in the updated 2010 American College of Rheumatology (ACR) criteria.  The prevalence of FMS increases with age, has a female preponderance, peaks in the seventh decade, and varies from <1% to 5%. 
Prior reports have shown a relationship between chronic low back pain (CLBP) and widespread pain among patients in a variety of settings. A cross-sectional postal questionnaire study of musculoskeletal symptoms in the community reported that 893 of the 2,893 respondents (31%) experienced low back pain in the previous week with 222 (24%) of these individuals having localized low back pain and 281 (31%) reporting widespread pain in at least four other areas.  Recently, a large cross-sectional comparative analysis of 647 patients who were seen for CLBP in a primary care setting revealed that approximately 25% of these individuals also experienced chronic widespread pain as defined by the 2010 ACR criteria for fibromyalgia.  Those patients with CLBP and chronic widespread pain were more likely to be female and have more somatic symptoms and comorbidities than patients with only CLBP. Over 40% of patients with a primary spine diagnosis who presented to an academic outpatient pain clinic met survey criteria for FMS.  In our clinical experience, one in five older adults with CLBP has evidence of FMS, a prevalence that has also been suggested by other investigators.