Beyond pain in fibromyalgia: insights into the symptom of fatigue

Abstract

Fatigue is a disabling, multifaceted symptom that is highly prevalent and stubbornly persistent. Although fatigue is a frequent complaint among patients with fibromyalgia, it has not received the same attention as pain. Reasons for this include lack of standardized nomenclature to communicate about fatigue, lack of evidence-based guidelines for fatigue assessment, and a deficiency in effective treatment strategies. Fatigue does not occur in isolation; rather, it is present concurrently in varying severity with other fibromyalgia symptoms such as chronic widespread pain, unrefreshing sleep, anxiety, depression, cognitive difficulties, and so on. Survey-based and preliminary mechanistic studies indicate that multiple symptoms feed into fatigue and it may be associated with a variety of physiological mechanisms. Therefore, fatigue assessment in clinical and research settings must consider this multi-dimensionality. While no clinical trial to date has specifically targeted fatigue, randomized controlled trials, systematic reviews, and meta-analyses indicate that treatment modalities studied in the context of other fibromyalgia symptoms could also improve fatigue. The Outcome Measures in Rheumatology (OMERACT) Fibromyalgia Working Group and the Patient Reported Outcomes Measurement Information System (PROMIS) have been instrumental in propelling the study of fatigue in fibromyalgia to the forefront. The ongoing efforts by PROMIS to develop a brief fibromyalgia-specific fatigue measure for use in clinical and research settings will help define fatigue, allow for better assessment, and advance our understanding of fatigue.

(506) The complex relationship between pain intensity and physical functioning in fibromyalgia: the mediating role of depression

“…It bears mention that several other factors may play a role in explaining the relationship between pain intensity and physical functioning; previous research in other chronic pain populations has indicated that catastrophizing, fear of reinjury, and pain-related anxiety may impact this relationship as well (Denison, Asenlof, & Lindberg, 2004;Peters et al, 2004;Scott, Kroenke, Wu & Yu, 2016); and there is evidence that these factors contribute to the experience of depression as well (Sturgeon & Zautra, 2013). Another plausible relationship worth exploring is the role of fatigue/decreased energy; fatigue is a hallmark symptom of fibromyalgia, with some estimates suggesting prevalence rates as high as 76% in FM patients (Vincent, Benzo, Whipple, McAllister, Erwin, & Saligan, 2013). It stands to reason that fatigue may also play a role in the relationship between depression/negative affect and physical functioning/disability as it is correlated with both (Vincent et al, 2013).…”

“…Another plausible relationship worth exploring is the role of fatigue/decreased energy; fatigue is a hallmark symptom of fibromyalgia, with some estimates suggesting prevalence rates as high as 76% in FM patients (Vincent, Benzo, Whipple, McAllister, Erwin, & Saligan, 2013). It stands to reason that fatigue may also play a role in the relationship between depression/negative affect and physical functioning/disability as it is correlated with both (Vincent et al, 2013). Although we were unable to examine these factors in the present study, future research should attempt to further illustrate the complex relationships between psychological constructs, pain, fatigue, and functioning with FM patients; this work may involve looking for subgroups within the populations that exhibit various patterns of these other factors; this work would be especially important given the only partial mediation of our depression mediator.…”

Fatigue in rheumatic diseases

“…Evidence from clinical trials with TNF-α inhibitors suggests that improvement in disease activity is associated with improvement in fatigue (110)(111)(112). Serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, or tricyclic antidepressants could improve the symptoms of fatigue (97). Hypovitaminosis D-associated fatigue should be managed with vitamin D supplements (113).…”

“…This approach should be continued until symptom improvement is achieved. The management includes non-pharmacological and pharmacological modalities (97). Non-pharmacological modalities always begin with patient education.…”

“…Patient education can include pacing, energy conservation, increasing physical activity, getting regular exercise, rest-activity balance, balanced diet, lifestyle moderation, stress management, time management, and sleep hygiene (97). Cognitive behavioral therapy deals with links between thoughts and feelings that may drive behaviors and uses cognitive restructuring to help patients make behavioral changes (100).…”