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The Journal of Rheumatology Volume 75, No. Is Fibromyalgia a Neuropathic Pain Syndrome? The Journal of Rheumatology Volume 75, no. Is fibromyalgia a neuropathic pain syndrome? Michael C Rowbotham J Rheumatol 2005;75;38-40 http://www.jrheum.org/content/75/38 1. Sign up for TOCs and other alerts http://www.jrheum.org/alerts 2. Information on Subscriptions http://jrheum.com/faq 3. Information on permissions/orders of reprints http://jrheum.com/reprints_permissions The Journal of Rheumatology is a monthly international serial edited by Earl D. Silverman featuring research articles on clinical subjects from scientists working in rheumatology and related fields. Downloaded from www.jrheum.org on September 24, 2021 - Published by The Journal of Rheumatology Is Fibromyalgia a Neuropathic Pain Syndrome? MICHAEL C. ROWBOTHAM ABSTRACT. The fibromyalgia syndrome (FM) seems an unlikely candidate for classification as a neuropathic pain. The disorder is diagnosed based on a compatible history and the presence of multiple areas of musculoskeletal tenderness. A consistent pathology in either the peripheral or central nervous system (CNS) has not been demonstrated in patients with FM, and they are not at higher risk for diseases of the CNS such as multiple sclerosis or of the peripheral nervous system such as peripheral neuropathy. A large proportion of FM suf- ferers have accompanying symptoms and signs of uncertain etiology, such as chronic fatigue, sleep distur- bance, and bowel/bladder irritability. With the exception of migraine headaches and possibly irritable bowel syndrome, the accompanying disorders are clearly not neurological in origin. The impetus to classify the FM as a neuropathic pain comes from multiple lines of research suggesting widespread pain and tenderness are associated with chronic sensitization of the CNS. An examination of how the term neuropathic pain is defined reveals a conceptual split into 2 partially overlapping groups of disorders: those with demonstrable pathology in the nervous system and those characterized primarily by enduring dysfunction in the nervous system. Requiring demonstrable pathology in the nervous system in the definition of neuropathic pain is the traditional approach. The expansion of the definition to require only enduring nervous system dysfunction is less palatable because it opens the classification to many disorders of uncertain etiology, including com- plex regional pain syndrome. As it is uncertain which of the many different chronic pain syndromes include an enduring component of central sensitization, restricting the term “neuropathic pain” to those disorders with a primary etiology clearly related to the peripheral or CNS is prudent and consistent with clinical prac- tice. (J Rheumatol 2005;32 Suppl 75:38-40) Key Indexing Terms: FIBROMYALGIA NERVOUS SYSTEM PATHOLOGIC PROCESSES INTRODUCTION of abnormal findings reported to date, there is no con- Fibromyalgia (FM) is a chronic pain syndrome consisting sensus3. Although a number of studies have demonstrat- of widespread musculoskeletal pain and tenderness. Can ed altered thresholds for pain and abnormal windup to FM be considered a neuropathic pain syndrome? It seems repetitive noxious stimuli, pathological changes in the central a conceptual leap is needed to bridge the gap between or peripheral nervous system have not been identified. Other pain accompanying a disorder diagnosed using the crite- lines of investigation have focused on abnormalities of the ria of musculoskeletal tenderness on the Manual Tender hypothalamic-pituitary-adrenal axis and endocrine dysfunc- Point Survey1 and pains accompanying disorders defined tion, including growth hormone deficiency and abnormal in terms of pathologically verifiable damage to the nerv- thyroid function, all of which can affect function of the nerv- ous system. FM is not a new disorder; Gowers wrote ous system or, in theory, result from pathology in the brain. about “lumbago” 100 years ago2. In the intervening Before considering whether FM should be classified as a years, fibrositis and muscular rheumatism were used to neuropathic pain, a review of the current taxonomy of neu- distinguish the disorder we now call fibromyalgia from ropathic pain and related terms is in order. Not all neuro- inflammatory conditions with objective findings in joints, pathic pain syndromes are alike, and clinicians vary widely in such as osteoarthritis and rheumatoid arthritis. their willingness to describe various chronic pains in neuro- A large body of work on the etiology of FM has left pathic terms. the question of nervous system function aside and focused on whether the structure and function of muscle HOW IS NEUROPATHIC PAIN DEFINED? and connective tissue is abnormal. Despite a wide variety A convenient starting point is the International Association for the Study of Pain (IASP) taxonomy4 (also available from: http://www.iasp-pain.org/terms-p.html#Neuropathic%20pain). From the University of California San Francisco (UCSF) Pain Clinical Neuropathic pain is defined as “pain initiated or caused by a pri- Research Center, San Francisco, California, USA. mary lesion or dysfunction in the nervous system.”Neuropathic Dr. Rowbotham has received research grants, consulting fees, lecture hono- pain is then broken down into 2 major divisions based on lesion raria, owns stock in, or has received support in the past year from Biogen, location. Peripheral neuropathic pain occurs “when the lesion or Elan, Fujisawa, Hind Health Care, Lilly, NeuroMolecular, NeuroMedTech, dysfunction affects the peripheral nervous system.”Central pain Pfizer, Theravance, UCB Pharma, Wyeth-Ayerst, and Xenoport. is defined in a manner consistent with the peripheral neuro- M.C. Rowbotham, MD. pathic pain definition as “pain initiated or caused by a primary lesion or dysfunction in the central nervous system” (CNS). Address reprint requests to Dr. M.C. Rowbotham, UCSF Pain Clinical Further, “central pain may be retained as the term when the Research Center, 1701 Divisadero Street, Suite 480, San Francisco, CA 94115. E-mail: [email protected] lesion or dysfunction affects the central nervous system.” Personal non-commercial use only. The Journal of Rheumatology Copyright © 2005. All rights reserved. 38 The Journal of Rheumatology 2005, Volume 32 Supplement 75 Downloaded from www.jrheum.org on September 24, 2021 - Published by The Journal of Rheumatology NEUROGENIC PAIN CAUSED BY A TRANSITORY have such severe allodynia that examining for a more ele- PERTURBATION IN THE NERVOUS SYSTEM mental underlying sensory dysfunction (touch threshold, Neurogenic pain, defined as “pain initiated or caused by thermal threshold, pin prick perception) becomes difficult a primary lesion, dysfunction, or transitory perturbation if not impossible. Although uncommon, some patients in the peripheral or central nervous system,” also appears with post-stroke pain have few or no non-sensory findings in the IASP taxonomy. This term is easily confused with on neurological examination to help locate lesions by clin- neuropathic pain, and should probably not be perpetuat- ical examination. In these patients, an MRI study con- ed. It is here that terminology begins to blur between firming a lesion in sensory pathways in the CNS is crucial. “normal” pain, as might occur after simple trauma or However, there is one accepted example of neuropathic surgery, and pathological pain. Depending on how pain with prominent touch-evoked pain, no underlying broadly a “transitory perturbation in the nervous sys- sensory deficit, and diagnostic imaging studies that are tem” is interpreted, this category may include any somat- usually normal: trigeminal neuralgia. The neuropathic ori- ic pain in which an area of transient secondary hyperal- gin of the pain can be confirmed at surgery because the gesia surrounds an area of intense primary afferent stim- majority of patients are found to have a vascular abnor- ulation. More than a century ago, Henry Head meticu- mality affecting the trigeminal ganglion. lously documented patterns of cutaneous sensory dys- Progression of a regional myofascial pain syndrome to function (Head’s zones) accompanying visceral disorders widespread pain, thereby meeting criteria for FM, is a of the heart, ureters, and prostate5, as did Fields6. Studies widely appreciated phenomenon. Similarly, development by Dahl and others have mapped and quantitated the of widespread musculoskeletal pain and other FM symp- time course of secondary hyperalgesia after surgery7. toms is observed in some patients with nervous system Therefore, some aspects of postoperative pain, or for that pathology and a clearly defined regional neuropathic pain matter, any pain associated with prolonged activation of syndrome [including complex regional pain syndrome primary afferent nociceptors and either central or periph- (CRPS II)]. Eventually, the patient appears to have FM, eral sensitization, would fall into this category, and the although the initial regional neuropathic pain should still term is meant more for short-term pain problems rather be evident. How involvement of the nervous system in than disorders notable for their unremitting and chronic these cases of “secondary” FM differs from typical cases nature, like FM. However, given Head’s observations, the of neuropathic pain remains uncertain. widespread pain of FM and frequent co-occurrence of Clinical neurologists tend to think in terms of a primary irritable bowel syndrome (IBS) and FM is noteworthy. lesion in the nervous system in patients with chronic pain and symptoms that appear referable to the nervous
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