Fibromyalgia and the disability dilemma. A new era in understanding a complex, multidimensional pain syndrome

The concomitant diagnosis of fibromyalgia and connective tissue disorders: A systematic review

BACKGROUND

Anecdotally, fibromyalgia syndrome (FMS) and connective tissue disorders (hypermobile Ehlers-Danlos Syndrome (hEDS), Hypermobility Spectrum disorders (HSD) and Generalized Joint Hypermobility (GJH)) manifest overlap in their diagnostic approach and symptomatic features. Understanding this overlap is important for accurate diagnosis and the success of subsequent management. This study therefore aimed to identify the prevalence of concomitant diagnosis of FMS and hEDS/HSD/GJH in adults and their shared symptomatic manifestations using a systematic review.

METHODS

MEDLINE (via EBSCO host) was systematically searched. Observational research (case-control or single group) studies were considered for inclusion, where adults screened for hEDS/HSD/GJH and FMS were compared in terms of diagnostic prevalence, and musculoskeletal and non-musculoskeletal manifestations. Studies on pediatric populations were excluded. The quality of the included studies was assessed using the National Institute of Health Quality Assessment of Case-Control Studies and Jonna Briggs Critical Appraisal checklist for prevalence studies. The review was registered prospectively in PROSPERO (CRD42020216283).

FINDINGS

The review included eleven studies: nine case-control studies and two single group studies. The prevalence of concomitant diagnosis of hEDS/HSD and FMS ranged from 68%-88.9% and from 8.0 to 64.2% for GJH and FMS. The prevalence and severity of a range of objective and patient-reported features were similar between hEDS/HSD and FMS, including joint pain (duration, persistence, SF-36-pain component score); joint swelling; muscle weakness; neurological problems; multidimensional pain inventory-activity; dysautonomia and total autonomic symptoms burden (including orthostatic intolerance, reflex syncope, vasomotor, gastrointestinal, diarrhea, constipation and pupillomotor domains); function; and quality of life. Shared symptomatic features between GJH and FMS were mean pain level, tender points count, total myalgia score and psychological impact.

INTERPRETATION

There may be overlapping symptomatology and diagnostic prevalence of FMS and hEDS/HSD/GJH. Clinicians should consider both diagnoses to ensure appropriate diagnosis and management.

Real-Life Response to Erenumab in a Therapy-Resistant Case Series of Migraine Patients From the Province of Québec, Eastern Canada

BACKGROUND AND OBJECTIVE

Erenumab is the first migraine-specific preventive therapy approved by Health Canada since the approval of onabotulinumtoxinA 10 years ago. It is one of four calcitonin gene-related peptide antagonist monoclonal antibodies that have been commercialized worldwide for use in the headache pipeline. The objective of our study was to determine real-life efficacy of monthly erenumab for the prevention of migraine in a small case series of difficult-to-treat patients followed at a tertiary headache clinic from the Canadian province of Québec.

METHODS

We performed a retrospective chart audit of patients having failed four or more conventional migraine oral preventive therapies and who were treated with monthly self-administered subcutaneous erenumab (70 or 140 mg/mL dose) over a 1-year period. We assessed the patients' baseline characteristics, response to treatment, and tolerability.

RESULTS

A total of 18 patients with a diagnosis of high-frequency episodic migraines or chronic migraine met criteria (83.3% female; mean age: 48.7 years; mean duration of migraine condition: 32.9 years). Patients self-administered erenumab using a prefilled disposable autoinjector on a monthly basis; 16 patients received a 140 mg/mL dosage, two patients received a 70 mg/mL dosage. At 1 year follow-up, 50% of patients reported ≥ 50% reduction in migraine frequency and were deemed responders. Patients attempted six doses of erenumab therapy prior to discontinuation for non-response, except for two patients with other concomitant chronic pain conditions, who required ten doses to reach a 50% response. For the overall cohort, there was a decrease of 5.2 monthly migraine days; 9 days for responders and 1.3 days for non-responders (t-test (df = 16) = - 2.77, p = 0.014). There was an additional decrease of 7 monthly non-migraine days amongst patients with unremitting daily headaches; 8 days for responders and 5 days for non-responders (p > 0.05). There was a decrease of 5.4 monthly days using acute analgesics; 8.9 days for responders and 2 days for non-responders (T(16) = - 2.33, p = 0.033). The overall mean reduction in disability using the Headache Impact Test (HIT-6) score was 5.6 points; only responders showed a reduction in HIT-6 severity category (p > 0.05). The most commonly reported adverse event was constipation (16.7%), which did not lead to treatment discontinuation and was successfully managed in all patients with early counselling and intervention.

CONCLUSION

This study supports the efficacy of erenumab in a case series of therapy-resistant migraine patients from the region of Québec. A high rate of previously failed preventive oral agents and medication overuse did not predict response in our patient cohort. In the presence of real-world complexity factors, such as psychological distress, regular opioid consumption and concomitant chronic pain conditions, a longer therapy trial may be warranted in obtaining optimal response.

Self-reported disability in women with fibromyalgia from a tertiary care center

Background

The World Health Organization Disability Assessment Schedule (WHODAS) 2.0 is a generic instrument to assess disability. Pain and psychological factors seem to play a pronounced disabling role in fibromyalgia (FM). There are few studies that investigate the factors associated with disability in patients with fibromyalgia from the patient’s perspective. Information about FM disability using self-reported questionnaires is limited. This study aimed to assess the relationship between the ordinal response variable (degree of disability), and four explanatory variables: pain intensity, depression, anxiety, and alexithymia.

Methods

One hundred fifteen women with FM were enrolled in the cross-sectional study. For the assessment of disability the WHODAS 2.0 (36-item version) was used. Univariate and multivariate (ordinal logistic regression) analyses were performed to assess the relationship between pain (Visual Analogue Scale), depression and anxiety (Hospital Anxiety and Depression Scale), alexithymia (Modified Toronto Alexithymia Scale) and disability.

Results

Disability was detected by global WHODAS score in 114 patients (99%), with the corresponding percentages for mild, moderate and severe disability being 11.3, 46.96 and 40.87%, respectively. Global WHODAS score was more severe among subjects with depression (50 vs 36.4, p < 0.001, effect size = 0.33) and alexithymia (50 vs 33.6, p < 0.001, effect size = 0.38). Pain intensity mean scores for mild, moderate and severe disability were 5.0, 6.1 and 7.3, respectively (p < 0.001, omega-squared = 0.12). Pain intensity explained the global disability degree and its domains except for the cognitive one. Whereas, depression explained cognitive and personal relation domains. On the other hand, alexithymia explained global disability degree and all domains of WHODAS 2.0 questionnaire.

Conclusions

Most of the patients with fibromyalgia perceived themselves with moderate to severe disability. The main explanatory variables of the perceived disability were the pain intensity and psychological factors (alexithymia and depression).

Does self-perceived health correlate with physician-assessed functional limitations in medical work disability assessments?

OBJECTIVE

Our purpose was to obtain information about the correlation between workers' self-perceived health and physician-assessed functional limitations. We also studied whether this correlation differed between workers with subjective health complaints that cannot (SHC) and those that can be explained (non-SHC) by a well-defined medical disease.

METHODS

Baseline data of 2040 participants from a prospective cohort study were used for this study. These participants answered a questionnaire on their self-perceived health and received a medical work disability assessment during which physicians reported functional limitations. Pearson correlation analyses were used to calculate correlations between 4 functional limitation factors and 11 self-perceived health factors. For correlations with coefficients ≥0.30, linear regression analyses were performed to assess possible differences between participants with SHC (n = 363) and those with non-SHC (n = 1677).

RESULTS

We found correlations ≥0.30 between two functional limitation factors and six self-perceived health factors for all participants. SHC participants showed lower correlations than the non-SHC participants between the physical functional limitation and the SF-36 self-perceived physical health factors (-0.49, 95% CI -0.56 to -0.41 vs. -0.60, 95% CI -0.62 to -0.57) and between the mental functional limitation and the SF-36 self-perceived mental health factors (-0.30, 95% CI -0.39 to -0.20 vs. -0.40, 95% CI -0.44 to -0.36).

CONCLUSION

Self-perceived health showed overall low to moderate correlations with physician-assessed functional limitations. Some of these correlations were lower for workers with SHC than for those with non-SHC. This may indicate that physicians rely slightly more on well-defined medical complaints within medical work disability assessments.

[Drug therapy of fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles]

BACKGROUND

The regular update of the guidelines on fibromyalgia syndrome, AWMF number 145/004, was scheduled for April 2017.

METHODS

The guidelines were developed by 13 scientific societies and 2 patient self-help organizations coordinated by the German Pain Society. Working groups (n =8) with a total of 42 members were formed balanced with respect to gender, medical expertise, position in the medical or scientific hierarchy and potential conflicts of interest. A literature search for systematic reviews of randomized controlled drug trials from December 2010 to May 2016 was performed in the Cochrane library, MEDLINE, PsycINFO and Scopus databases. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine version 2009. The strength of recommendations was achieved by multiple step formalized procedures to reach a consensus. Efficacy, risks, patient preferences and applicability of available therapies were weighed up against each other. The guidelines were reviewed and approved by the board of directors of the societies engaged in the development of the guidelines.

RESULTS AND CONCLUSION

Amitriptyline and duloxetine are recommended in the case of comorbid depressive disorders or generalized anxiety disorder and pregabalin in the case of generalized anxiety disorder. Off-label use of duloxetine and pregabalin can be considered if there are no comorbid mental disorders or no generalized anxiety disorder. Strong opioids are not recommended.

Functional resonance magnetic imaging (fMRI) in adolescents with idiopathic musculoskeletal pain: a paradigm of experimental pain

BACKGROUND

Studies on functional magnetic resonance imaging (fMRI) have shown that adults with musculoskeletal pain syndromes tolerate smaller amount of pressure (pain) as well as differences in brain activation patterns in areas related to pain.The objective of this study was to evaluate, through fMRI, the brain activation in adolescents with idiopathic musculoskeletal pain (IMP) while performing an experimental paradigm of pain.

METHODS

The study included 10 consecutive adolescents with idiopathic musculoskeletal pain (average age 16.3±1.0) and 10 healthy adolescents age-matched. fMRI exams were performed in a 3 T scanner (Magnetom Trio, Siemens) using an event-related design paradigm. Pressure stimuli were performed in the nondominant hand thumb, divided into two stages, fixed pain and variable pain. The two local Research Ethics Committees (Ethics Committee from Universidade Federal de São Paulo- Brazil, process number 0688/11, on July 1st, 2011 and Ethics Committee from Hospital Israelita Albert Einsten - Brazil, process number 1673, on October 19th, 2011) approved the study.

RESULTS

The idiopathic musculoskeletal pain (IMP) group showed a reduced threshold for pain (3.7 kg/cm² versus 4.45 kg/cm², p = 0.005). Control group presented increased bain activation when compared to IMP group in the following areas: thalamus (p = 0.00001), precentral gyrus (p = 0.0004) and middle frontal gyrus (p = 0.03). In intragroup analysis, IMP group showed greater brain activation during the unpredictable stimuli of the variable pain stage, especially in the lingual gyrus (p = 0.0001), frontal lobe (p = 0.0001), temporal gyrus (p = 0.0001) and precentral gyrus (p = 0.03), when compared to predictable stimulus of fixed pain. The same intragroup analysis with the control group showed greater activation during the unpredictable stimuli in regions of the precentral gyrus (p = 0.0001), subcallosal area (p = 0.0001), right and left occipital fusiform gyrus (p = 0.0001; (p = 0.0007), middle gyrus (p = 0.01) and precuneus p = (0.02).

CONCLUSION

Adolescents with idiopathic musculoskeletal pain (IMP) tend to request higher brain function in cognitive-emotional areas when interpreting unpredictable sensory-perceptual situations. Therefore, it is assumed that this difference in pain processing in adolescents with IMP make the subjective experience of pain something more intense and unpleasant.

Decrease of Serum IGF-1 Level is Not Associated With Obstructive Sleep Apnea in Fibromyalgia Patients

Objectives

This study aims to investigate the relationship of serum insulin-like growth factor 1 (IGF-1) level with obstructive sleep apnea, the Pittsburgh sleep quality index (PSQI), age, body mass index, and fibromyalgia impact questionnaire (FIQ) in fibromyalgia syndrome (FMS) patients.

Patients and methods

A total of 105 female patients (mean age 41.8±9.0 years; range 26 to 55 years) with fibromyalgia (FMS group) who were diagnosed according to 2010 American College of Rheumatology criteria, and 51 female patients (mean age 39.9±10.8 years; range 24 to 54 years) with mechanical low back pain (MLBP) (control group) were included in the study. Age, smoking, educational status, tender point number, body mass index, duration of disease, FIQ, PSQI, and polysomnographic assessment of both FMS and control groups were recorded.

Results

Sleep disorder was detected in 88 patients in FMS group and 15 patients in control group (p<0.05). The PSQI score was higher in the FMS group compared to the control group (9.9±4.6 vs. 5.7±3.5). The FIQ score was higher in the FMS group compared to the control group (53.4±17.4 vs. 26.4±13.9; p<0.05). The serum IGF-1 level of FMS group was significantly lower than that of the control group (140.6±49.5 ng/mL vs. 177.2±58.5 ng/mL; p<0.05). In the FMS group, an examination of the correlation between serum IGF-1 level with the age, body mass index, obstructive sleep apnea syndrome, FIQ, and PSQI revealed a negative correlation between serum IGF-1 with the age and PSQI. The obstructive sleep apnea syndrome ratios of study groups were comparable with regard to the frequencies of mild, moderate, and severe obstructive sleep apnea syndrome.

Conclusion

In FMS patients, serum IGF-1 levels may decrease due to age and PSQI; however, this may not be related to the severity of obstructive sleep apnea.

Pain mystery score beliefs: a comparison of fibromyalgia and rheumatoid arthritis

Objectives. To compare the mysteriousness scores of the Pain Beliefs and Perceptions Inventory in fibromyalgia. Methods. Two cohorts of patients, one with fibromyalgia (FM) and one with rheumatoid arthritis (RA), completed the Mystery Scale component of the Pain Beliefs and Perceptions Inventory to determine whether subjects in the two diagnostic groups had significantly different scores on the Mystery Scale. Results. A total of 126 subjects (64 FM, 62 RA) completed all questionnaires. The FM group had a greater percentage of female subjects, more severe pain, more severe anxiety, more severe depression, and a higher perceived injustice score. When the RA and FM group scores for the Mystery Scale were adjusted for age, sex, pain severity, HADS scores, and perceived injustice scores, the FM group still had a higher Mystery Scale score. Discussion. Fibromyalgia is associated with a higher level of perception of mysteriousness in the Pain Beliefs and Perceptions Inventory than is seen with rheumatoid arthritis. This difference appears to be independent of levels of pain, depression, anxiety, and perceived injustice. This sense of mysteriousness may reflect a lack of understanding of pain in fibromyalgia as previously reported and may be an area to be addressed in therapy.

Fatigue-enhanced hyperalgesia in response to muscle insult: induction and development occur in a sex-dependent manner

Chronic muscle pain affects 20-50% of the population, is more common in women than men, and is associated with increased pain during physical activity and exercise. Muscle fatigue is common in people with chronic muscle pain, occurs in response to exercise, and is associated with release of fatigue metabolites. Fatigue metabolites can sensitize muscle nociceptors, which could enhance pain with exercise. Using a mouse model we tested whether fatigue of a single muscle, induced by electrical stimulation, resulted in enhanced muscle hyperalgesia and if the enhanced hyperalgesia was more pronounced in female mice. Muscle fatigue was induced in combination with a sub-threshold muscle insult (2 injections of pH 5.0 saline) in male and female mice. We show that male and female mice, fatigued immediately prior to muscle insult in the same muscle, develop similar muscle hyperalgesia 24 hours later. However, female mice also develop hyperalgesia when muscle fatigue and muscle insult occur in different muscles, and when muscle insult is administered 24 hours after fatigue in the same muscle. Further, hyperalgesia lasts significantly longer in females. Finally, muscle insult with or without muscle fatigue results in minimal inflammatory changes in the muscle itself, and sex differences are not related to estradiol (ovariectomy) or changes in brainstem activity (pNR1). Thus, the current model mimics muscle fatigue-induced enhancement of pain observed in chronic muscle pain conditions in the human population. Interactions between fatigue and muscle insult may underlie the development of chronic widespread pain with an associated female predominance observed in human subjects.

Efficacy of duloxetine in patients with fibromyalgia: pooled analysis of 4 placebo-controlled clinical trials

OBJECTIVE

To investigate the efficacy of duloxetine in the treatment of pain and improvement in functional impairment and quality of life in patients with fibromyalgia from a pooled analysis of 4 placebo-controlled, double-blind, randomized trials.

METHOD

Patients were eligible for inclusion in the studies if they were at least 18 years of age, met criteria for fibromyalgia as defined by the American College of Rheumatology, and had specified minimum pain severity scores. Across all studies, 797 patients received duloxetine 60-120 mg/d and 535 patients received placebo. Pain was assessed by the Brief Pain Inventory (BPI) 24-hour average pain severity score; other efficacy measures included the Clinical Global Impressions-Severity of Illness scale (CGI-S), Patient Global Impressions-Improvement scale (PGI-I), 17-item Hamilton Depression Rating Scale (HDRS-17), Fibromyalgia Impact Questionnaire (FIQ) total score, BPI pain interference items, Sheehan Disability Scale (SDS), and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) mental and physical components. Changes from baseline to endpoint (last observation carried forward) for most of the above efficacy measures were analyzed using an analysis-of-covariance model.

RESULTS

After 12 weeks of treatment, pain was significantly reduced in patients treated with duloxetine (P < .001) compared with placebo. In addition, duloxetine was superior to placebo in improving CGI-S (P < .001); PGI-I (P < .001); FIQ total (P < .001); HDRS-17 total (P = .003); SDS global functioning (P < .001), work/school (P = .018), and family life (P < .001); SF-36 mental (P < .001) and physical (P = .026) component; and BPI pain interference (P < .001) scores. Treatment-by-subgroup interactions were not significant for sex (P = .320), age (P = .362), or race (P = .180).

CONCLUSIONS

This pooled analysis provides evidence that 12 weeks of treatment with duloxetine 60-120 mg/d effectively improves fibromyalgia symptoms and may offer benefits beyond pain relief.

Is there a predisposition for the development of autoimmune diseases in patients with fibromyalgia? Retrospective analysis with long term follow-up

The objectives of the study were to evaluate the prevalence of antinuclear antibodies (ANA) in patients with fibromyalgia (FM) and the probability of the development of clinically overt connective tissue diseases. Four hundred and fifty FM patients were compared to 129 healthy matched blood donors. ANA testing was performed by immunofluorescence on rat tissue sections; in case of highly positive results, ANA were specified further by ELISA and immunodiffusion. All ANA positive FM patients were invited for a control examination. The ANA negative patients received a questionnaire, which was designed to identify those patients with possible connective tissue diseases (CTD). There was no significant difference in the frequency of ANA or thyroid antibodies between patients and controls (11.6% vs. 7%). Two patients had developed SLE: one was already ANA/anti-dsDNA positive at time of first diagnosis of FM; in the other, specific antibodies and SLE-related symptoms developed after 4.5 years. The probability for FM patients to develop CTD (SLE) within one year is 0.0027%, which is comparable to the incidence of SLE in the general population (0.005%). The risk of CTD is not increased in FM. The detection of ANA does not predict the development of CTD. However, in individual cases, FM may be an early sign of an autoimmune disease.

Benefits of physical training in fibromyalgia and related syndromes

OBJECTIVE

To review the published information on physical training for fibromyalgia (FM) and related syndromes.

METHODS

A search of Medline literature (via Ovid and PubMed) with the following keywords: FM, chronic fatigue syndrome, therapy, rehabilitation, aerobic, exercise, and cognitive behavioral therapy. The reference lists of articles were examined for additional related articles.

RESULTS

Several studies investigated the benefits of graded exercise therapy for patients with FM or related syndromes. Although some systematic reviews have not established an unequivocal benefit of physical training, most authors report a benefit for patients with chronic pain or fatigue. Ideally, such a therapy should be a part of multidisciplinary program. Muscular rehabilitation is reserved for preventing the deconditioning syndrome often reported in patients and the vicious cycle of pain, avoidance and inactivity behaviors, or even kinesiophobia, deconditioning, incapacity and psychological distress.

CONCLUSION

This review emphasizes the relevance of graded physical training for treating FM and related syndromes. The development of rehabilitation centers, with experts able to propose a relevant therapy to patients with chronic pain or fatigue, should help alleviate this public health problem.

Growth Hormone Perturbations in Fibromyalgia: A Review

OBJECTIVE

Fibromyalgia (FM) is a syndrome characterized by chronic widespread pain, fatigue, disrupted sleep, depression, and physical deconditioning. In this article, we review the literature on the normal activity of the hypothalamic-pituitary-growth hormone-insulin-like growth factor-1 (HP-GH-IGF-1) axis and its perturbations in FM subjects.

METHODS

Studies included in this review were accessed through an English language search of Cochrane Collaboration Reviews. Keyword MeSH terms included "fibromyalgia," "growth hormone" (GH), or "insulin-like growth factor-1" (IGF-1).

RESULTS

Twenty-six studies enrolling 2006 subjects were reviewed. Overall, low levels of IGF-1 were found in a subgroup of subjects. Growth hormone stimulation tests often revealed a suboptimal response, which did not always correlate with IGF-1 levels. No consistent defects in pituitary function were found. Of the 3 randomized placebo controlled studies, only 9 months of daily injectable recombinant GH reduced FM symptoms and normalized IGF-1.

CONCLUSIONS

These studies suggest that pituitary function is normal in FM and that reported changes in the HP-GH-IGF-1 axis are most likely hypothalamic in origin. The therapeutic efficacy of supplemental GH therapy in FM requires further study before any solid recommendations can be made.

Long-term follow up of a physical therapy programme for patients with fibromyalgia syndrome

The purpose of this study was to evaluate, in a long-term perspective, the impact of a physical therapy-based educational programme on patients with fibromyalgia syndrome (FMS). The programme includes information about the syndrome, information about pain and muscle physiology, training in warm water, stretching, body awareness therapy and relaxation in groups of 15 patients twice weekly, 2 hours during 10 weeks. A total of 240 patients with FMS participated in the study before and immediately after the programme and at a follow up with a mean of 35 months after the programme. Health status as measured with the Fibromyalgia Impact Questionnaire was answered by the patients at all three measurement points. Questionnaires concerning self-care, self-motivation and sense of coherence (SOC) were distributed at the follow up. The results showed a significant improvement on several symptoms when comparing before and after the programme, and at the time of follow up the patients' rated well-being was still improved. The results also showed that the patients' pretreatment perception of symptoms, well-being and SOC are predictors to the perception of general health at the follow up of a physical therapy programme. The conclusion is that a physical therapy programme for patients with FMS may have a positive impact on patients' general well-being but not on other symptoms.

Are patients with systemic lupus erythematosus at increased risk for Fibromyalgia?

Widespread chronic pain, fatigue, and distress do not represent risk factors for future systemic lupus erythematosus (SLE) or other autoimmune syndromes. On the other hand, SLE seems to be a significant risk factor for fibromyalgia (FM). Up to 47% of SLE patients fulfill FM criteria. SLE patients with concomitant FM are often highly symptomatic and dysfunctional. The presence of FM symptoms in SLE patients, however, does not predict more extensive organ involvement or lupus activity. The high concordance of SLE with FM suggests common mechanisms related to pain and distress in both patient groups. Recent research suggests involvement of N-methyl-D-aspartate (NMDA) and neurokinin receptor systems. Thus, autoimmune activity against these receptor systems in SLE patients could result in pain, cognitive defects, and chronic pain states including FM. Conversely, treatment of SLE-FM patients with inhibitors of NMDA or neurokinin receptors may prevent or alleviate cognitive abnormalities and chronic pain, as well as FM.

NO-mediated alterations in skeletal muscle nutritive blood flow and lactate metabolism in fibromyalgia

The purpose of these investigations was to determine if differences exist in skeletal muscle nutritive blood flow and lactate metabolism in women with fibromyalgia (FM) compared to healthy women (HC); furthermore, to determine if differences in nitric oxide-mediated systems account for any detected alterations in blood flow and lactate metabolism and contribute to exertional fatigue in FM. FM (n = 8) and HC (n = 8) underwent a cycle ergometry test of aerobic capacity, a muscle biopsy for determination of nitric oxide synthase (eNOS, nNOS, iNOS) content, and microdialysis for investigation of muscle nutritive blood flow and lactate metabolism. During prolonged (3h) resting conditions, the ethanol outflow/inflow ratio (inversely related to blood flow) increased in FM over time compared to HC (P < 0.05). FM also exhibited a reduced nutritive blood flow response to aerobic exercise (P < 0.05). There was an increase in dialysate lactate in response to acetylcholine in FM, and to sodium nitroprusside in both groups, with a greater rise in dialysate lactate in FM (P < 0.05). The iNOS protein content was higher in FM and was negatively correlated with total exercise time (r(2) = 0.462, P < 0.05).

IN CONCLUSION

(1) There is reduced nutritive flow response to aerobic exercise and reduced maximal exercise time in FM that might relate to higher iNOS protein content and contribute to exertional fatigue in FM; (2) The increased dialysate lactate in FM in response to stimulation of NOS or a nitric oxide donor suggest that FM may be more sensitive than HC to the suppressive effect of nitric oxide on oxidative phosphorylation.

Integrative Therapy for Fibromyalgia: Possible Strategies for an Individualized Treatment Program

One of the most complex patient treatment situations encountered by the clinician is the patient who presents with the cluster of signs and symptoms that lead to the diagnosis of fibromyalgia syndrome. While physicians focus primarily on pharmacologic treatment, a number of nonpharmacologic modalities have been shown to benefit patients as well. No one therapy is uniformly effective in every patient; treatment programs consisting of a combination of pharmacologic and nonpharmacologic therapies must be individualized to the patient, and the clinician may have to try several different modalities before reaching an optimal improvement in the patient's symptoms.

Myofascial pain, fibromyalgia or fibrositis?

The terms myofascial pain, fibromyalgia and fibrositis are critically examined. They constitute diagnostic labels for non-specific musculoskeletal aches and pains. Analysis of the evidence shows that none of these labels is substantiated by hard physical signs or by laboratory evidence of consistent pathological or biochemical abnormality. What is the objective evidence for disorder(s) of muscle, fascia or fibrous tissues, so clearly indicated by these diagnostic names? Alternative terms such as 'regional pain syndrome' or 'chronic pain syndrome' merely redefine the clinical problem without providing a mechanism or basis for diagnosis. Despite different diagnostic criteria, these conditions, along with chronic fatigue syndrome, have many demographic and clinical similarities, most notably tender trigger points. Indeed, the terms are often used interchangeably. There are few differences in the symptoms, physical findings, laboratory tests, functional status, psychosocial features and psychiatric disorders. This paper seeks not to deny the existence of aches and pains, but to critically examine the utility of these terms. The only claimed physical sign is the presence of tender trigger points over muscles or muscle attachments. Research suggests that tender points are a measure of general distress related to pain complaints but separately associated with fatigue and depression. They are present in some normal subjects and are variable in occurrence in time in the same individual. They reflect no demonstrable pathology. It is therefore argued that none of these commonly used diagnoses represent distinct disease entities. A possible but unproven alternative hypothesis is that such symptoms relate to neural pain with both peripheral and central components, and in some instances psychological or wilful embellishment.

Use Less Cosmetics—Suffer Less from Fibromyalgia?

BACKGROUND

Widespread muscular pain, tenderness, unrefreshing sleep, and fatigue all constitute the fibromyalgia syndrome (FMS), which is often seen in both general and rheumatology practice, primarily in women. The etiology is unknown. The FMS patient usually looks normal. The cardinal finding is the presence of focal areas of hyperalgesia, that is, tender points. My clinical impression was that FMS patients often complained of dry skin. My hypothesis was that overambitious cleaning, resulting in dry skin, and regular use of cosmetics as moisturizers could contribute to their symptoms.

METHODS

A prospective, randomized, controlled trial of 48 women with FMS (some of whom had a rheumatic condition) who were regular users of cosmetics was carried out to investigate if a reduced use of cosmetics would reduce the symptoms. The intervention group received special instructions on skin care, with reinforcement when needed.

RESULTS

After 2 years, there was significant improvement in pain (p < 0.02), sleep (p < 0.01), and stiffness (p < 0.02), together with better physical function (p < 0.01) and improved wellbeing (p < 0.01) in the experimental group, as measured by the Fibromyalgia Impact Questionnaire (FIQ).

CONCLUSIONS

The results should motivate further studies on the possible adverse effects of cosmetic use in FMS and perhaps other conditions.

What can rehabilitation interventions achieve in patients with primary fibromyalgia?

Symptoms of primary fibromyalgia (FM) persist for years, independent of applied therapy. That is the sad reality we have to deal with. But is that really true? The following review is a scan of literature from September 1, 2001 to August 31, 2002, concerning rehabilitation interventions for patients with FM, to find progress in this field and to ascertain state-of-the-art treatment strategies for the disease. The main problem when treating patients with FM successfully is the heterogeneity of the patients' group. Several investigators determined subgroups within FM patients diagnosed by the 1990 American College of Rheumatology classification criteria of FM. Therefore, uniform recommendations for treatment cannot be given. Current treatment recommendations for FM include reassurance and explanation of the nature of the illness, evaluation and eradication of mechanical stressors as far as possible, symptomatic analgesic drug treatment, moderate individually adapted physical exercises, and adjuvant psychotherapeutic support in an interdisciplinary setting. Individually adapted measures are highly emphasized to differentially treat FM subgroups, as far as identified. This review will focus on these points on the one hand, and provide an overview about the current symptomatically-oriented therapy on the other hand. This all occurs against the background of an unknown etiology of the disease so far. Experimental approaches will be noted as well. The demonstration of a long-term effective intervention for managing the symptoms associated with FM is needed.

Person-centered approach to care, teaching, and research in fibromyalgia syndrome: justification from biopsychosocial perspectives in populations

OBJECTIVES

To describe complex interactions of multiple factors believed to contribute to fibromyalgia syndrome (FMS) at a person-centered level to enhance approaches to care, teaching, and research. The main factors addressed were central nervous system sensory sensitization, autonomic nervous system (ANS) activation, neurohumoral perturbations, and psychosocial and environmental stressors. A person-centered approach is defined as attention to major biopsychosocial issues of affected individuals.

METHODS

Literature on classification, mechanistic pathways, course and outcomes, and management of FMS was reviewed to assess applications of person-centered approaches to care, teaching, and research. Various biopsychosocial influences were considered in relation to the heterogeneous subjective manifestations of this illness, including central hyperalgesia, ANS and other neurohumoral perturbations, functional hyperexcitability, nonrestorative sleep, and psychologic distress.

RESULTS

A person-centered approach to FMS can expand on and strengthen traditional biomedical concepts. Adding such a focus can help to untangle current controversies in the course, outcomes, and treatment of FMS. A person-centered approach can also help in the subgrouping of affected patients for greater specificity in care programs and in improved clinical investigations. In the biomedical model, diverse symptoms of FMS are often addressed separately and apart from their interconnectedness and linkages to the patient's individualized biopsychosocial factors. However, the causes of FMS symptomatology are not likely to be caused by uniform biologic abnormalities across populations. Rather, the syndrome likely results from personal reactivities to varied multifactorial biopsychosocial influences. Common denominators among individuals may include varying degrees of ANS activation (or personal susceptibility to ANS activation), nonrestorative sleep, negative affectivity, and other central pain sensitization mechanisms, among the pathways reviewed.

CONCLUSIONS

Innovative analytical methodologies will need to be developed to more effectively investigate complex interacting biopsychosocial dynamics at a person-centered level, including qualitative research, and multifactorial and multilevel techniques. Adding person-centered approaches to biopsychosocial concepts of FMS promises to show new physiopathogenetic insights and more effective treatment than current biomedical models alone. Person-centered approaches enhance patient-physician relationships and help prioritize patients' goals in mutually derived treatment plans.

Men living with fibromyalgia-type pain: experiences as patients in the Swedish health care system

BACKGROUND

Individuals with fibromyalgia (FM) frequently use health care services and experience only short-term improvements. They often feel that health care staff do not take them seriously. This increases the burden of living with the illness.

AIM

To describe how men living with fibromyalgia-type pain experienced being patients in the Swedish health care system.

METHOD

Narrative interviews with 14 men who fulfilled the American College of Rheumatology criteria for classification of fibromyalgia. Content analysis was used when analysing the data.

RESULTS

The results are described using five themes. Theme I 'Feeling afraid of being looked upon as being a whiner' highlights how the men endured a lot of pain before they sought health care, and how difficult it was to find a receptive listener. Theme 2 'Feeling like a guinea pig' shows that the men's feelings were twofold; they wanted examinations, even if these made them feel that they were being exposed to numerous treatments without any cure. Theme 3 'Feeling hopeful' describes the hope for a cure after having been referred to a specialist clinic. Theme 4 'Feeling neglected' illustrates being looked upon as an uninteresting patient and theme 5 'Feeling no recovery' illustrates the pain relief they gained, but not the actual cure.

CONCLUSION

Men with FM type pain experienced a long wait before treatment at a specialist clinic as well as no continuity and follow-ups in primary care and general hospitals. Encounters with engaged and skilful staff promoted the men's well-being despite the fact that no cure was available. Not being respected led to a feeling of being neglected despite the care received. Thus, the men had to accept the fact that they would never recover.

Efficacy and adverse effects of intravenous lignocaine therapy in fibromyalgia syndrome

BACKGROUND

To investigate the effects of intravenous lignocaine infusions (IV lignocaine) in fibromyalgia.

METHODS

Prospective study of the adverse effects of IV lignocaine in 106 patients with fibromyalgia; retrospective questionnaire study of the efficacy of IV lignocaine in 50 patients with fibromyalgia.

RESULTS

Prospective study: Two major (pulmonary oedema and supraventricular tachycardia) and 42 minor side-effects were reported. None had long-term sequelae. The commonest was hypotension (17 cases). Retrospective study: Pain and a range of psychosocial measures (on single 11-point scales) improved significantly after treatment. There was no effect of the treatment on work status. The average duration of pain relief after the 6-day course of treatment was 11.5 +/- 6.5 weeks.

CONCLUSIONS

Intravenous lignocaine appears to be both safe and of benefit in improving pain and quality of life for patients with fibromyalgia. This needs to be confirmed in prospective randomised controlled trials.

[Study of quality of life of patients with fibromyalgia: impact of a health education programme]

OBJECTIVE

To assess the impact of a programme of health education on the quality of life and frequency of attendance of persons with fibromyalgia.

DESIGN

Community clinical trial with randomised allocation.

SETTING

Sant Joan Despí urban Health District (Barcelona), with a population of 13 282 inhabitants.

PARTICIPANTS AND METHODS

67 women who attended our centre for consultation and were diagnosed with fibromyalgia by the Area Rheumatologist using the criteria of the American College of Rheumatology (1990). They were distributed at random into control and intervention groups.

MAIN MEASUREMENTS

Social and demographic variables (age, marital status, educational background, job situation), health variables (physical exercise taken, current treatment, symptoms evolution time) and frequency of attendance were gathered. The Nottingham Health Profile (NHP) for measuring quality of life was administered. The presence of psychological malaise was determined through the Mini International Neuropsychiatric Interview. After the intervention, which consisted of four health education sessions, the NHP was administered again and frequency of attendance was measured again.

RESULTS

The most important dimension on the NHP prior to intervention was pain (78.6 points), which was not modified either by physical exercise or the disease s time of evolution. Prevalence of psychological malaise was 64.6%. After the intervention there was a significant improvement in the pain dimension (P=.003).

CONCLUSIONS

Health education for people with fibromyalgia modifies their perception of quality of life and reduces their pain. In addition, this kind of activity increases understanding of illness and reduces dependence on the health services.

Quality-of-life, legal-financial, and disability issues in fibromyalgia

Patients with fibromyalgia have an altered quality of life that is hard to quantitate using existing indices. The principal legal issues associated with the syndrome are: Does fibromyalgia exist? Can it be caused by or flared by stress or trauma? Does disability apply to fibromyalgia and if so, how? These issues are critically reviewed.

Fibromyalgia following trauma: psychology or biology?

The concept that fibromyalgia may follow trauma is currently an area of intense debate within the medical field and is driven to a large extent by social and legal issues. This article questions whether the current literature supports the notion that trauma may cause fibromyalgia and explores the relative contribution of biology and psychology in the development of and sense of disability from fibromyalgia.

Environmental immunogens and T-cell-mediated responses in fibromyalgia: evidence for immune dysregulation and determinants of granuloma formation

Thirty-nine patients with fibromyalgia syndrome (FMS) according to American College of Rheumatology criteria were studied for cell-mediated sensitivity to environmental chemicals. Lymphocytes were tested by standard [(3)H]thymidine incorporation in vitro for T cell memory to 11 chemical substances. Concanavalin A (Con A) was used to demonstrate T cell proliferation. Controls were 25 contemporaneous healthy adults and 252 other concurrent standard controls without any aspect of FMS. Significantly higher (P < 0.01) stimulation indexes (SI) were found in FMS for aluminum, lead, and platinum; borderline higher (0.05 > P > 0.02) SI were found for cadmium and silicon. FMS patients showed sporadic responses to the specific substances tested, with no high-frequency result (>50%) and no obvious pattern. Mitogenic responses to Con A indicated some suppression of T cell functionality in FMS. Possible links between mitogenicity and immunogenic T cell proliferation, certain electrochemical specifics of granuloma formation, maintenance of connective tissue, and the fundamental nature of FMS are considered.

Pain in patients with fibromyalgia syndrome

Chronic diffuse pain and hyperalgesia are two cardinal features of pain in fibromyalgia syndrome (FMS). Advancement in understanding the pathophysiology and treatment efficacy often depends on pain that is defined and measured. Pain is a subjective phenomenon that we can measure only by indirect methods. In this article, we provide methodological guidelines for pain assessment and review recent developments in understanding pain mechanisms and evaluating treatments in FMS. Finally, we demonstrate the heterogeneity of the FMS population and suggest the need for matching treatments to patient characteristics in order to improve clinical outcomes.

Pain and allodynia/hyperalgesia induced by intramuscular injection of serotonin in patients with fibromyalgia and healthy individuals

The aim of this study was to investigate the effect of injection of serotonin (5-HT) into the masseter muscle on pain and allodynia/hyperalgesia. Twelve female patients with fibromyalgia (FM) and 12 age-matched female healthy individuals (HI) participated in the study. The current pain intensity (CPI) and the pressure pain threshold (PPT) of the superficial masseter muscles were assessed bilaterally. 5-HT in one of three randomized concentrations (10(-3), 10(-5), 10(-7) M) or isotonic saline was then injected into either of the two masseter muscles in a double-blind manner. After the injections the CPI and PPT were recorded ten times during 30 min. The injections were repeated twice with the other concentrations of 5-HT after 1 and 2 weeks, respectively. In the FM-group there was a non-significant increase of CPI after injection that lasted during the entire 30-min period irrespective of whether 5-HT or saline was injected. Neither did the PPT change significantly. In the HI-group pain developed significantly after injection irrespective of whether 5-HT or saline was injected, but significantly more so after 5-HT at 10(-3) M than saline injection. CPI decreased quickly and then remained on a very low level for most of the experiment. 5-HT at both 10(-5) M and 10(-3) M caused a significantly greater decrease of PPT than saline. In conclusion, our results show that 5-HT injected into the masseter muscle of healthy female subjects elicits pain and allodynia/hyperalgesia, while no such responses occur in patients with fibromyalgia.

Trauma and fibromyalgia: is there an association and what does it mean?

OBJECTIVES

The primary objective is to review current research with respect to the role of trauma in fibromyalgia (FM). A secondary objective is to hypothesize which steps need to be taken, first to determine whether such an association truly exists, and second to clarify what such an association might mean.

METHODS

An extensive literature review was undertaken, including Medline from 1979 to the present.

RESULTS

The strongest evidence supporting an association between trauma and FM is a recently published Israeli study in which adults with neck injuries had greater than a 10-fold increased risk of developing FM within 1 year of their injury, compared with adults with lower extremity fractures (P= .001). Several other studies provide a hypothetical construct for such an association. These include studies on (1) postinjury sleep abnormalities; (2) local injury sites as a source of chronic distant regional pain; and (3) the concept of neuroplasticity. There are, however, several primary arguments against such an association: (1) FM may not be a distinct clinical entity; (2) FM may be a psychological, rather than physical, disease; (3) the evidence supporting any association is limited and not definitive; (4) the Israeli study, itself, has some methodological limitations; and (5) other factors may be more important than the injurious event in determining chronic symptoms after an acute injury.

CONCLUSIONS

Although there is some evidence supporting an association between trauma and FM, the evidence is not definitive. Further prospective studies are needed to confirm this association and to identify whether trauma has a causal role.

Chronic widespread pain as a medico-legal issue

A systematic approach to the determination of disability in persons with chronic widespread pain is based on a careful history, examination for tender points, and special investigations to establish a firm diagnosis. Further assessment requires determination of subjective and objective measures of impairment. The causes of fibromyalgia are multifactorial and understanding them requires an appreciation of the role of physical or psychological trauma, and associated medical and psychosocial factors. Despite the presence of disability risk factors, most patients with fibromyalgia maintain a good range of normal daily activities and continue working.

Joint hypermobility in patients with fibromyalgia syndrome

OBJECTIVE

To test the hypothesis that joint hyperlaxity can play some role in the pathogenesis of pain in primary fibromyalgia.

METHODS

A total of 66 women with fibromyalgia (according to the 1990 American College of Rheumatology criteria) and 70 women with other rheumatic diseases were examined for joint laxity based on 5 criteria (The Non-Dominant Spanish modification). Individuals meeting 4 or 5 criteria were considered to be hyperlax.

RESULTS

Joint hyperlaxity was detected in 18 (27.3%) of the patients with fibromyalgia and 8 (11.4%) of those with another rheumatic disorder. The statistical analysis revealed significant differences (P < 0.05) between both groups.

CONCLUSION

The results of this study suggest that joint hypermobility and fibromyalgia are associated. Joint hyperlaxity may play a prominent role in the pathogenesis of pain in fibromyalgia.

Fibromyalgia, chronic fatigue, and other iatrogenic diagnostic algorithms. Do some labels escalate illness in vulnerable patients?

Contemporary medicine has the sophistication to identify the clinical settings in which the hunt for a diagnosis can be harmful to a patient's health. Which patients are best served by a prolonged search for a cause? Why has the disease-illness paradigm backfired for so many patients? Dr Hadler challenges readers to look at the difficult questions linked with diagnostic labels that might teach patients to stay sick.