LETTER TO THE EDITOR

Sustained Improvement of
Fibromyalgia Syndrome After
Electroconvulsive Therapy for
Intractable Depression
To the Editor:
ibromyalgia syndrome (FMS) is a chronic
pain disorder characterized by diffuse
musculoskeletal pain, tiredness, sleep disorder, headaches, and cognitive dysfunction,
among other clinical manifestations.13
Fibromyalgia syndrome is often accompanied by depression.36 Both disorders
share common pathophysiologic mechanisms including low cerebrospinal fluid
levels of serotonin, norepinephrine, and dopamine.2,7,8 Thus, FMS patients are usually
treated with medications used for depression.911 Furthermore, treatments used for
refractory depression may also be considered for FMS. One of these options is electroconvulsive therapy (ECT), which is
an effective therapeutic alternative for the
treatment of medicine-resistant depression
and other psychiatric conditions.12 Some
reports suggest that ECT may reduce the
severe pain and symptoms associated with
FMS.13,14 Here, we present a 57-year-old
woman with refractory depression and FMS
who had a remarkable and sustained clinical response to ECT.
A 57-year-old woman received a diagnosis of FMS in October 2000 when she
presented with an 8-year history of severe
tiredness, diffuse musculoskeletal pain,
prolonged morning stiffness, insomnia, depression, anxiety, memory and concentration impairment, headaches, paresthesias,
vertigo, irritable bowel syndrome, and irritable bladder. Physical examination was
remarkable only for the presence of 18 of
18 tender points per the American College
of Rheumatology criteria for the classification of FMS.1 Complete blood cell count,
serum chemistries, liver function tests, creatine phosphokinase, uric acid, erythrocyte
sedimentation rate, and thyroid function
tests were within reference ranges. Antinuclear antibodies and rheumatoid factor
were negative.
She was treated with acetaminophen,
nonsteroidal anti-inflammatory drugs, several antidepressive agents (paroxetine, fluoxetine, sertraline, nefazodone, amitriptyline,
estacitalopram oxalate, duloxetine, and
aripiprazole), quetiapine fumarate, tramadol,
gabapentin, pregabalin, cyclobenzaprine,
zolpidem, clonazepam, and trigger point

injections. All these treatments were marginally effective to relieve her symptoms. Even
duloxetine treatment, which was started in
April 2005, was not helpful. From September
to December 2009, she received 11 courses
of ECT for severe and intractable depression. Afterward, she experienced a remarkable alleviation of her FMS. Symptoms
started to improve after the first session of
ECT. Musculoskeletal pain and headaches
resolved. The severity of other FMS symptoms such as tiredness, insomnia, paresthesias, and cognitive impairment decreased
to tolerable levels. Fibromyalgia syndrome
tender points decreased rapidly after ECT
and have remained absent afterward. Although she persisted with depression and
anxiety, these were well controlled with
duloxetine. Before ECT, she required pregabalin and tramadol on a daily basis, but
afterward she did not need these medications. Five years after ECT, she has remained
free of musculoskeletal pain symptoms, and
only mild nonmusculoskeletal symptoms
of FMS persisted.
Patients with FMS are characterized
by possessing a lower pain threshold that
is mostly attributed to abnormal processing of painful stimuli by the central nervous
system leading to central sensitization.2,14
Increasing evidence regarding the underlying pathophysiology of chronic pain
syndromes, including FMS, has further
elucidated the pathways involved in pain
processing.2,1417 In FMS, the transmission of nociceptive stimuli occurs more
avidly than antinociceptive signals.2 This
phenomenon is further enhanced by the
presence of low concentrations of several
neurotransmitters that have antinociceptive properties such as norepinephrine, serotonin, and dopamine.7,8
Because the main problem of FMS
lies on how pain is processed, perceived,
and imprinted on selected brain regions of
the central nervous system, then it would
not be unpractical to consider noninvasive
brain stimulation modalities as an alternative therapeutic approach. These modalities
including ECT, repetitive transcranial magnetic stimulation, and direct cranial stimulation are able to cause a resetting in several
brain regions that are essential in how nociceptive stimuli are processed.13 However,
evidence using these modalities for the treatment of chronic pain syndromes including
FMS, chronic regional pain syndrome, and
neuropathic pain is mostly derived from case
reports and small studies.1521
In a small prospective nonrandomized
study conducted in FMS patients who had

no evidence of depression, Usui et al14

evaluated how pain was affected by ECT
and which brain regions were involved.
These patients were previously treated with
antidepressants for the management of pain
but had no significant clinical response.
Before ECT several areas of the diencephalon including the thalamus had very poor
cerebral perfusion. After ECT, the blood
flow around the thalamus increased, and at
the same time, a significant decline in pain
was observed as evidenced by decrease in
the number of tender points to less than half
from baseline. However, reports on the use
of ECT in FMS are limited, and the results
are inconsistent. Huuhka et al22 showed
that ECT was safe and effective in treating
medicine-resistant depression but had no
effect on modulating pain and the physical
symptoms of FMS. On the other hand, in
a randomized controlled trial, FMS patients treated with repetitive transcranial
magnetic stimulation had significant improvement of musculoskeletal pain and
other related symptoms.23 This modality
appears to be safer than ECT and can be administered in an ambulatory setting.
It is not surprising that ECT may result effective for FMS. Electroconvulsive
therapy increases the concentration of several neurotransmitters that are deficient in
FMS such as serotonin, norepinephrine,
and dopamine.13,18 These neurotransmitters have been shown to have antinociceptive properties by enhancing the signaling
of peripheral stimuli to be transmitted more
efficiently through the descending pathways for processing in the central nervous
system.2,18 This effect is translated, in theory, to higher pain threshold and less hyperresponsiveness to peripheral stimuli.
Although ECT is proven to be effective in the treatment of mood disorders
as well as neuropathic pain, it has a negative stigma because of the technique itself
and possible cognitive adverse effects it
may entail. However, adverse events of
ECT are often self-limited and transitory.12,24
These events include headaches, nausea,
and vomiting, which are attributed to the
anesthesia being used. These effects have
been reduced by the use of newer anesthetics. The most worrisome adverse
effect is cognitive deficit, which include
short-term memory amnesia, but this is
usually transient.24,25
In summary, this case together with
other reports suggests that ECT may represent an effective and safe alternative
for the treatment of severe FMS refractory
to conventional therapy. Electroconvulsive

JCR: Journal of Clinical Rheumatology Volume 22, Number 5, August 2016

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JCR: Journal of Clinical Rheumatology Volume 22, Number 5, August 2016

Letter to the Editor

therapy appears to exert its analgesic effect by enhancing serotonergic, noradrenergic, and dopaminergic neurotransmission.18
Nonetheless, large randomized clinical trials are needed to clearly assess the benefit
of ECT for FMS.
Irma L. Vzquez-Sanabria, MD
Luis M. Vil, MD
Division of Rheumatology
Department of Medicine
University of Puerto Rico
Medical Sciences Campus
San Juan, Puerto Rico
luis.vila2@upr.edu

The authors declare no conflict of

interest.
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2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.