Dr. Antonio Collado

Doctor of Medicine, specialist in Rheumatology and co-author of ‘Fibromyalgia. Essential advice and treatments’

Dr. Antonio Collado, a rheumatologist and expert in fibromyalgia, talks to us about the latest advances in the treatment of this disease that causes chronic musculoskeletal pain and offers advice to alleviate its symptoms.

 

“In fibromyalgia, physical exercise produces benefits at a biological level, not only improvements in health status, but also in the brain mechanisms of pain control, but it must be adapted to the patient”

Chronic musculoskeletal pain is the main characteristic of fibromyalgia, which was recognised as a disease by the World Health Organisation 26 years ago and for which there is still no cure, although there have been significant advances in its treatment, says Antonio Collado, Doctor of Medicine and Specialist in Rheumatology, president and founding member of the Spanish Society of Fibromyalgia and Chronic Fatigue Syndrome and co-author of Fibromyalgia. Essential Advice and Treatments (Amat editorial). On the occasion of World Fibromyalgia Day, this specialist talks to us about the most effective therapies to control its symptoms and advice to improve the quality of life of those affected, and takes the opportunity to thank the exceptional work of patient associations that offer unconditional support to all those affected.

Fibromyalgia is said to be the most common cause of chronic generalised musculoskeletal pain and is suffered by approximately 2.45% of the adult population in Spain. What exactly does this disease consist of?

Indeed, fibromyalgia is the most common cause of widespread or extensive chronic pain. This type of pain affects 10% of the general population and fibromyalgia accounts for approximately one third of this prevalence. It is the first disease classified within what the World Health Organization (WHO) recognizes as primary extensive chronic pain – those pains that are not secondary exclusively to an illness or injury. The prevalence of 2.45% in the Spanish population found by the EPISER study is probably higher because when other criteria are applied it is reaching between 3 and 5% in almost all of Europe.

It mainly affects women, although men can also suffer from it, and is characterized by an alteration in the nociceptive system – an alarm system made up of nerves that travel through the body structures – both morphological and functional, which causes it to change in such a way that it begins to produce spontaneous pain in practically the entire musculoskeletal system. This alteration occurs in the pain fibers and in their organization within the spinal cord and the brain for reasons that are unknown.

Are there physiological or environmental characteristics that may predispose a person to developing fibromyalgia?

We know some risk factors, such as family history – family predisposition –, we know that it is more frequent in women, and there are certain characteristics at an individual level, such as suffering from migraine or pelvic pain, which can be signs of the future appearance of fibromyalgia, although this is not always the case.

The disease usually appears progressively, with symptoms that are intermittent at first and then become continuous, and when this occurs in most cases it begins to functionally affect daily life activities, because this pain is often accompanied by a feeling of fatigue, sleep disturbances…, and at that time the disease is already very expressed and that is when the patient goes to the doctor.

Is there anything possible to do to prevent its occurrence?

If it is detected in time, it can be improved and stabilized and prevent the development of a more serious disease, because in many people it begins with moderate symptoms. In patients between 45 and 55 years of age, which is one of the stages of life with the greatest burden –at a work, social or family level–, it is a critical moment to intervene if fibromyalgia manifests itself in a more moderate or mild form, because it can worsen when they are subjected to situations of physical load or to social-work stressors or family stressors that are not resolved and can worsen the nociceptive system and aggravate the sensitivity to pain. That is the right moment to be able to initiate prevention strategies.

The problem is the delay in diagnosis of fibromyalgia, which in Spain is between six and seven years. This is due to different variables; the patient usually has symptoms that are moderate, intermittent, recurrent, which they attribute to load or stress factors. When they go to the doctor, sometimes they do an X-ray and find no alterations. There are many factors that influence the delay in diagnosis and when the disease has progressed its impact is already worrying and may be irreversible.

Fibromyalgia is the first disease classified within what the World Health Organization (WHO) recognizes as primary extensive chronic pain.

It is important to take into account the risk factors mentioned above in order to identify people who are more likely to develop the disease. Although we do not have a biological marker, as is the case with diabetes, for example, we can be alert to the factors that can trigger or aggravate fibromyalgia, especially the fact of having recurrent pain.

If there are no specific tests, how is fibromyalgia diagnosed?

There are two situations; one is the identification of possible fibromyalgia, people who have symptoms and do not meet the full criteria, which is the ideal situation for treatment. And the other situation is that in which the diagnosis is made by applying the clinical criteria that we have today and that when they are met the disease is already quite advanced and, in many cases, there is already severe affectation. Therefore, the ideal is to identify the patient who has signs compatible with fibromyalgia, but not complete criteria.

In both cases the patient can be treated, although in the first case preventive treatments can be used – such as cognitive-behavioral treatments, which are very important, and also pharmacological ones – while in the second the therapeutic efforts are much greater, and in severely affected patients the results are less.

 

How to manage fibromyalgia: the three pillars of treatment

 

What is the recommended treatment for fibromyalgia? Have there been any advances in recent years?

There have been advances in the last 25 years because before we had nothing, although they are insufficient because more research is needed to identify molecules or treatment pathways that are much more specific to the disease from a biological point of view.

In these years we have identified a therapeutic pattern that has allowed long-term control of the disease and is based fundamentally on three aspects: a pharmacological treatment directed by a doctor, a treatment that we call functional adaptation that is based on changes in the management of the activity being carried out, which is approached from a cognitive-behavioral point of view and has to be directed by a professional specialized in psychology and pain management and by occupational therapists who know how to work with ergonomics and load situations. And the third pillar of treatment, which is physical exercise.

 

A family history of fibromyalgia or suffering from migraines or pelvic pain may be signs of the future onset of the disease.

Physical exercise produces benefits at a biological level, not only improvements in health status, but also in the brain's mechanisms for controlling pain. But this physical activity must be adapted to the patient; you cannot tell them: "go and do physical exercise" because it would be like telling a diabetic "eat better"; that is not useful because it must be an exercise specifically adapted to people with fibromyalgia.

The same thing happens with behavioural changes; it is not about giving advice such as "reduce stress, or work less", just as you cannot tell a diabetic "eat less", but you have to give them a diet, some indications about eating habits... In the case of fibromyalgia it would be the same. In summary: pharmacology, functional adaptation or cognitive-behavioral and occupational treatments and physical exercise.

 

What are the most recommended exercises for these patients?

Each case must be individualized because a patient with moderate fibromyalgia and an acceptable physical and health condition that allows them to perform cardiovascular exercise that is progressively increased is not the same as a patient with severe impairment, or even chronic fatigue syndrome that causes intolerance to the effort that exercise entails.

But to give general advice, generally aerobic exercises tend to give better results whenever it is possible to do them, some strength exercises, and stretching exercises are also useful, especially at the beginning. Some techniques such as tai chi or yoga are usually advisable.

 

Are there alternative therapies that have been shown to be effective in relieving fibromyalgia symptoms?

Currently, what is being talked about is complementary therapies, and in the case of fibromyalgia, since there is no drug that cures the disease, all of them are considered complementary because it is necessary to use therapies that are synergistic. Outside of pharmacology, cognitive-behavioral interventions and physical exercise, there are some things that can be done to improve the situation.

For example, nutrition is very important, that the diet is appropriate for the patient. And we know that obesity is a risk factor and a cause of worsening. In addition, the disease itself has the ability to cause obesity due to the patient's reduced mobility, due to inadequate intakes associated with the physical and emotional state, and probably related to hormonal mechanisms that make people with fibromyalgia tend to gain weight easily.

 

When patients with fibromyalgia are subjected to situations of physical stress or social, work or family stressors that are not resolved, pain sensitivity can be aggravated.

Therefore, treatment should include an appropriate diet, which should be based on what we call anti-inflammatory food, which includes omega 3 fatty acids, nuts, oily fish, vegetables, little meat, and is rich in vitamins and antioxidants, because this disease, like chronic pain, also leads to important oxidation mechanisms that affect health. Food supplements, however, have not clearly demonstrated benefits.

Techniques such as transcutaneous stimulation are also used to relieve localized pain. Sleep hygiene is essential. Sleep disorders are a risk factor, but also a sign that helps detect the disease, because when a person with recurrent pain begins to have sleep disturbances, this is also an early indicator. To improve sleep quality, it is important not to use exclusively sedative drugs because they worsen sleep quality in the long term and have other adverse effects, such as dependence.

 

 

Myths about fibromyalgia that need to be debunked

One chapter of the book is dedicated to myths about fibromyalgia. Which are the main ones that should be disproved?

There is still a general perception, even among professionals, that fibromyalgia is a disease derived from psychological factors and stress. This is not true. Stress is a physiological situation that prepares us to face problems and address their solution. The fact that a person suffers acute stress, even if it is strong, does not necessarily determine the type of disease; in fact, it has not been seen that the disease occurs more frequently after major stressors.

When stressors cause a continued emotional situation and a solution is not found, this constitutes an important load factor for the nociceptive system, the brain and the body in general and can cause the worsening of a disease that is already present, but that does not mean that suffering from stress is a cause of fibromyalgia.

 

Pain has no mercy. When it sets in and becomes chronic, there is no way to resolve it with resistance; you always lose that battle.

It is also common to downplay pain, because it is something that everyone experiences at some point. This is a myth that must be dispelled because fibromyalgia is a serious disease with serious consequences and although pain is difficult to objectify from the outside, it causes a lot of damage. We must not forget that chronic pain is classified as a disease; it is no longer just a symptom. And it is merciless. When it becomes established and chronic, there is no way to resolve it with resistance; you always lose that battle.

And, at a social level, what strategies should be incorporated to improve the lives of these patients?

There is still a long way to go at the health and social level. In our country we have inadequate practices in the treatment of pain. In Spain there is no national plan to address chronic pain. This situation generates tremendous socioeconomic burdens. Fibromyalgia disables more than 40% of those affected and that means between 8,000 and 11,000 euros per patient per year, between direct and indirect costs, including health care and the development of disability that is not treated.

Another deficit is the lack of professionals dedicated to chronic pain from different specialties. Not only in the field of anesthesiology, which is the classic specialty that has addressed acute pain, but in others such as rheumatology, rehabilitation, psychology, neurology..., which have a lot to do with chronic pain and in which there are no professionals encouraged to be able to train in its management.

Fibromyalgia is a little helpless because after the diagnosis there are no specialists dedicated to it; Some rheumatologists do it, but very few. Some units have been created in some areas of the country, and for this reason the pain units run by anesthesiologists would have to become chronic pain units that can also treat patients with fibromyalgia and with a multidisciplinary character, which is the most important thing.

From a sociological point of view, the challenges are also very important because we are talking about 40% of disabled people with great difficulties in attending to their usual tasks and the recognition of some degree of disability in them does not reach 20%, so there is a lack of recognition of the difficulties. In addition, there are no occupational health plans within companies or mutual insurance companies aimed at preventing disability in people with fibromyalgia, or recognizing it once it has been established.