LAUSR

To the Editor: We have read with much interest the paper by Eiad A. Ramzy recently published in Pain Practice. In this paper the author outline the importance of emotional and psychological components of fibromyalgia (FM). The combined use of the antidepressant paroxetine and pregabalin is associatedwith reduced somatic and depressive symptoms after 10 weeks of treatment. Accordingly the challenge in treating this disease is linked to its complexity. Pain physicians frequently run into patients with FM diagnosis. However, this diagnosis is complicated for the lack of universally agreed criteria and a differential diagnosis is frequently not performed. The presence of physical and mental symptoms in addition to myofascial pain outlines the complexity of the disease that can be considered as amodel of chronic pain. It has been suggested that behind the FM symptoms there is the onset of pathogenic mechanisms into peripheral tissues, a reduction of descending pain control pathways and spinal hypersensitivity. Moreover, pain perception and processing are significantly altered. Consequently, if we consider only the transduction, conduction and transmission of painwe limit our knowledge of FM and the patient care. A recent IASP a task force for pain classification included the FM into the “widespread chronic primary pain” category. This pain spreading could be related to an increased sympathetic activity of central neurons, to an extensive state of hypersensitivity of the somatosensory system and to an impairment of descending inhibitory systems. Moreover, an amplified perceptual-emotional component of pain is characteristic element of FM. The question could be if FM should be considered only within the more general widespread chronic pain condition or it represents a subcategory. We can therefore consider FM as a chronic pain syndrome or we need to add the term “chronic pain disease”? The persistence of pain in FM can act both on the cognitivebehavioral, affective-motivational, and discriminative systems that can lead to a multilevel patient change and to a modification of peripheral pathogenic mechanisms. In other words, it establishes a new “disease” that is different from the initial appearance. How can we treat the FM as chronic pain disease? Interventional and drug pain therapies are ineffective in modulating the mechanisms underlying this complex framework of supraspinal and spinal systems alterations. Therefore, the biopsychosocial model which provides the integrated implementation of medical therapy, occupational therapy, physiotherapy, psychotherapy and cognitive behavioral therapy (Fig. 1) could be the only effective model to treat FM symptoms. How the pain physician can adopt the biopsychosocial model? Pain therapy practice demonstrates the importance of multidisciplinary skills for the pain physician that should be able to integrate medical and interventional procedures with cognitive and psychological approach for the reintegration of the patient into the social framework through a biopsychosocial rehabilitation path.