Individuals with fibromyalgia (FM) and/or complex regional pain syndrome (CRPS) reported more pain triggers and intensifiers, pain-related diagnoses, depression, anxiety, somatic symptoms, and bodily changes than both patients with other pain conditions and pain-free controls, in a new survey.¹

Investigators at the University of Bath in the United Kingdom conducted an online survey of 452 people diagnosed with FM patients, 390 with CRPS patients, 88 patients with both diagnoses, 311 with other pain conditions, and 441 without pain. Gender makeup reflected the demographics of the conditions, with females making up the vast majority of respondents.

In general:

• Those with FM reported more changes in vision and hearing, urinary and intestinal function, and eating and drinking (eg, more sensitive stomachs, weight gain or loss, etc) than both patients with other forms of pain and the pain-free control group.
• People with CRPS reported experiencing more changes in hair, skin, and nails, and with infection and healing (ie, greater susceptibility to illness, slower rates of wound and bruise healing).
• Those with FM, CRPS, or both conditions reported more changes in movement (eg, more difficulty walking, balance issues, tremors) than the other groups.
• People with either FM or FM/CRPS were also more likely to report other pain conditions, including:

– back pain, affecting 52% of FM/CRPS patients and 41% of FM patients
– migraine, affecting 30% of FM/CRPS patients and 32% of FM patients
– osteoarthritis, affecting 32% of FM/CRPS patients and 28% of FM patients.
– almost half of the respondents with FM, and one-third of those with FM/CRPS had irritable bowel disease.

Researchers were surprised to discover that symptoms were not more common in patients with other pain conditions compared to those without chronic pain. (Image: iStock)

Unexpected Findings for FM and CRPS

As the UK investigators suspected, bodily changes and sensory sensitivity were more common in patients with CRPS and/or FM. However, researchers were surprised to discover that these symptoms were not more common in patients with other pain conditions compared to those without chronic pain, noted lead co-author Dr. Antonia ten Brink of the University of Bath’s Department of Psychology and Centre for Pain Research.

Also unexpected was that, “People with fibromyalgia in particular were more likely to report discomfort when exposed to triggers such as bright lights and loud sounds, but there were fewer differences between groups regarding the pain or distress triggered by the same environmental cues,” according to Dr. ten Brink.

“Our findings show that none of the bodily changes or sensory sensitivities were unique to CRPS or fibromyalgia… and not every person with CRPS or fibromyalgia reported bodily changes and enhanced sensory sensitivity,” added Dr. Janet Bultitude, a senior author or the research and a senior lecturer at the University of Bath’s Department of Psychology and Centre for Pain Research.

Nevertheless, noted Dr. Bultitude, “Clinicians should bear in mind that if someone has been diagnosed with CRPS or fibromyalgia, they have a higher likelihood of also being bothered by these symptoms.”

Clinical Considerations for Patients with Dual Diagnoses: Fibromyalgia and CRPS

Interestingly, subjects with both chronic conditions (CRPS and FM) did not report any more suffering in terms of pain intensity, depression, or anxiety than those with only one of those conditions. Noted Dr. Bultitude, “So, although people with both conditions might have more complex clinical needs, our results give no reason to think that there are at a greater risk of mental health problems.”

However, these individuals may have more microbiome issues, notes Gordon Ko, MD, FRCPC, PhD. A PPM editorial advisor, Dr. Ko serves as medical director of the Fibromyalgia Integrative Medicine Clinics at the Sunnybrook Health Sciences Centre and the Canadian Centre for Integrative Medicine. He pointed out that, “In these conditions, a common underlying pathophysiology is neurogenic inflammation, of which the root cause – from a functional medicine perspective – may include gut dysbiosis.”^2-4

To explain, “Gut dysbiosis often manifests with skin symptoms,” which could be related to skin changes reported by CRPS patients, he said.⁵ Furthermore, “Remember that 75% of our immune system is housed in the gut; perhaps this is a factor in the higher rates of infection and healing issues in CRPS patients,” who have also been reported to be more prone to immune system dysfunction.⁶

See also, the microbiome and opioid dependence.

How to Approach Treatment for FM and CRPS

For family physicians, CRPS and FM treatment typically starts with neuropathic pain medications, Dr. Ko shared. Pregabalin, duloxetine, and milnacipran are all FDA-approved for fibromyalgia syndrome and neuropathic pain; gabapentin and/or amitriptyline may also be prescribed.^7-11

While “high-dose long term opioids are discouraged for use in those with fibromyalgia, the analgesics (with opioid and SNRI actions) tramadol and tapentadol may be a safer, more effective option. Muscle relaxants such as cyclobenzaprine, baclofen,and tizanidineare are also often used,” Dr. Ko noted.^12-15  Off-label use of the pharmaceutical cannabinoids nabilone, dronabinol, and nabiximols have also been studied for pain relief,^16-18 however, noted Dr. Ko, “The difficulty with long-term use of all such drugs is the development of tolerance (typically after about 2 years), and possible aggravation of the underlying gut dysbiosis.”

Interventional pain physicians may add IV lidocaine-ketamine infusions, guided nerve blocks, and radiofrequency denervation to the above medications. Some clinicians, including Dr. Ko, have found benefit with Botox injections for FM and nerve pain.^19-24

Finally, lifestyle issues are important to properly manage both fibromyalgia and CRPS – including the bodily and sensory symptoms studied in the survey herein. These interventions may include:

• Dietary changes (eliminating potential irritants such as gluten and food allergens; intermittent fasting, and reducing the intake of sugar, oils, animal and processed foods, and salt). Food changes should be made on an individual, trial-and-error basis as evidence for them in managing FM is low. ^25-27
• Exercise, including physiotherapy-directed training, and mirror therapy for CRPS patients, and cardio, aquatic, and core exercises for those with FM. Movement therapies (ie, Feldenkrais, yoga, Pilates) can help; a portable neuromodulation stimulator device may enhance balance if that is a struggle.^28-31
• Nutritional supplements (especially vitamin D and probiotics) and hormone replacement therapy based on epigenetics and personalized functional medicine.^32-34
• Stress management techniques and psychotherapies such as mindfulness, cognitive behavioral therapy, biofeedback, and neuro-EEG feedback.^35-39