Classification, epidemiology, and natural history of fibromyalgia

The Efficiency of Kinesiotherapy versus Physical Modalities on Pain and Other Common Complaints in Fibromyalgia

Due to its variety of signs and symptoms, there have been numerous attempts to treat fibromyalgia (FM), but a cure has yet to be established. The aim of this study was to evaluate the effects of a complex kinetic therapy program and a combined physical modality program on pain and other common symptoms of FM. Patients and methods: A total of 78 female patients were included in this study; 39 subjects underwent a kinesiotherapy (KT) intervention (combining aerobic and Pilates exercises), and 39 participated in a physical modality (PM) program (including electrotherapy (TENS and low-laser therapy) and thermotherapy). Results: Regarding the parameter of pain assessment, kinesiotherapy demonstrated its superiority both during the treatment period and in the evaluation 3 months after therapy cessation. Both in terms of patient-reported pain (inter-group comparisons: p = 0.000 at T3) and the examination of tender points (inter-group comparisons: p = 0.000 at T3), as well as the algometric assessment, pain was alleviated by the two forms of applied kinetic therapy. The observed functional impairment was statistically significantly influenced (p = 0.001) at the end of the kinetic program application, while for the perceived functional impairment, neither therapy proved superiority over the other at any point of evaluation (inter-group comparisons: p = 0.715 at T3). Regarding the influence of the emotional consequences implied by fibromyalgia, neither the forms of kinesiotherapy nor the chosen physical modalities proved superiority at any point of evaluation (HAQ anxiety inter-group comparisons: p = 0.000 at T3). In conclusion, even though kinesiotherapy had superior influences on fibromyalgia pain in the studied group, the current research lends credence to the significance of non-pharmacological therapy in managing fibromyalgia. Participants demonstrated positive advancements in subjective and objective pain assessments, as well as improvements in functional and emotional well-being.

Pain catastrophizing and risk of progression to widespread pain among patients with chronic low back pain: A retrospective cohort study

BACKGROUND

Chronic low back pain often progresses to widespread pain. Although many factors are associated with progression, their roles in contributing to chronic widespread pain (CWP) are often unclear.

OBJECTIVE

To determine if pain catastrophizing is an independent risk factor for CWP.

DESIGN

Retrospective cohort study within a national pain research registry from April 2016 through August 2022.

METHODS

A total of 1111 participants with chronic low back pain, but without CWP, were included. Participants were followed at quarterly intervals for up to 48 months to measure CWP risk. Survival analyses involved Kaplan-Meier plots and the Cox proportional hazards model to measure CWP risk according to pain catastrophizing and subscale scores for rumination, magnification, and helplessness.

RESULTS

Crude CWP risks for moderate pain catastrophizing (HR, 2.13; 95% CI, 1.54-2.95; P < 0.001) and high pain catastrophizing (HR, 3.98; 95% CI, 2.95-5.35; P < 0.001) were each elevated in comparison with low pain catastrophizing. Adjusted CWP risks for moderate pain catastrophizing (HR, 1.80; 95% CI, 1.27-2.53; P < 0.001) and high pain catastrophizing (HR, 2.82; 95% CI, 1.98-4.02; P < 0.001) remained elevated in analyses that controlled for potential confounders. Corresponding results were observed in the survival analyses involving rumination, magnification, and helplessness.

CONCLUSIONS

Pain catastrophizing appears to be an independent risk factor for progression to CWP among patients with chronic low back pain. These findings provide a rationale for interventions aimed at reducing pain catastrophizing, including rumination, magnification, and helplessness, among patients with chronic low back pain.

Patient-journey of fibromyalgia patients: A scoping review

BACKGROUND

Fibromyalgia (FM) is a chronic disease characterized by widespread pain. Although much is known about this disease, research has focused on diagnosis and treatment, leaving aside factors related to patient's experience and the relationship with healthcare system.

OBJECTIVES

The aim was to analyze the available evidence on the experience of FM patients from the first symptoms to diagnosis, treatment, and follow-up.

METHODS

A scoping review was carried out. Medline and the Cochrane Library were searched for original studies or reviews dealing with FM and focusing on "patient journey". Results were organized using a deductive classification of themes.

RESULTS

Fifty-four articles were included in the qualitative synthesis. Five themes were identified: the patient journey, the challenge for the health systems, a complex doctor-patient relationship, the importance of the diagnosis, and the difficulty of standardizing the treatment.

CONCLUSIONS

This scoping review confirms the negative impact of FM on the patient, their social environment, and health systems. It is necessary to minimize the difficulties encountered throughout the diagnosis and follow-up of patients with FM.

Psoriasis and Fibromyalgia: A Systematic Review

Psoriasis is a chronic inflammatory cutaneous condition characterized by several comorbidities, including musculoskeletal disorders. While the association with psoriatic arthritis has been widely addressed in literature, the aim of the present systematic review was to identify all available evidence on the relationship between psoriasis and fibromyalgia, a musculoskeletal syndrome primarily characterized by chronic widespread pain. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and MedLine and Web of Science (WOS) databases were searched for literature up to March 2023. After the removal of duplicate records, a total of 11 articles were deemed eligible for inclusion in a qualitative synthesis. Our results suggested that psoriatic patients had a higher prevalence of fibromyalgia (8-30%), with a very high impact on symptoms of psoriasis. Moreover, fibromyalgic patients had a slightly increased prevalence of psoriasis (2.2-6.7%) compared to the control groups. Finally, several studies demonstrated the substantial impact of fibromyalgia on psoriatic outcome measures in patients with concomitant psoriatic arthritis. In conclusion, available data support a potential interplay between psoriasis and fibromyalgia, but further research is encouraged in this area.

The patient journey of fibromyalgia in Latin America

OBJECTIVES

To explore the patient journey of people with fibromyalgia (FM) in Latin American countries in order to identify problems in health care and other areas that may be resolvable.

METHODS

Qualitative study with phenomenological and content analysis approach through focus groups and patient journey (Ux; User Experience) methodology. Nine virtual focus groups were conducted with FM patients and healthcare professionals in Argentina, Mexico and Colombia recruited from key informants and social networks.

RESULTS

Forty-three people participated (33 were clinicians and 10 were patients). The agents interacting with the patient in their disease journey are found in three spheres: healthcare (multiple medical specialists and other professionals), support and work life (including patient associations) and socioeconomic context. The line of the journey presents two large sections, two loops and a thin dashed line. The two major sections represent the time from first symptoms to medical visit (characterized by self-medication and denial) and the time from diagnosis to follow-up (characterized by high expectations and multiple contacts to make life changes that are not realized). The two loop phases include (1) succession of misdiagnoses and mistreatments and referrals to specialists and (2) new symptoms every so often, visits to specialists, diagnostic doubts, and impatience. Very few patients manage to reach the final phase of autonomy.

CONCLUSION

The journey of a person with FM in Latin America is full of obstacles and loops. The desired goal is for all the agents involved to understand that self- management by the patient with FM is an essential part of success, and this can only be achieved with early access to resources and guidance from professionals.

Prevalence of Genetic Diamine Oxidase (DAO) Deficiency in Female Patients with Fibromyalgia in Spain

Diamine oxidase (DAO) is an enzyme that metabolizes intestinal histamine. Single nucleotide polymorphisms (SNPs) of the Amine Oxidase Copper Containing 1 (AOC1) gene can lead to low enzymatic activity or functionality in histamine metabolism. This study aimed to determine the prevalence of DAO deficiency for four variants of the AOC1 gene, p.Thr16Met (rs10156191), p.Ser332Phe (rs1049742), p.His664Asp (rs1049793), and c.691G > T (rs2052129), in 98 Spanish women with fibromyalgia between the ages of 33 and 60 years, and compare the distribution of allelic and genotypic frequencies with those of European population samples in Hardy–Weinberg equilibrium extracted from the Allele Frequency Aggregator (ALFA) database. The patients’ DNA was extracted, and analyzed using SNPE Multiplex (Single Nucleotide Primer Extension). The prevalence of genetic DAO deficiency was 74.5% based on the four variants of the AOC1 gene. SNP deficits were found at frequencies of 53.1% for p.Thr16Met, 49% for c.691G > T, 48% for p.His664Asp, and 19.4% for p.Ser332Phe. The allele and genotypic frequencies of the women with fibromyalgia did not differ from the European population. Variants of the AOC1 gene that are associated with genetic DAO deficiency could serve as a disruptive biomarker in patients with fibromyalgia. This study was registered in ClinicalTrials.gov Identifier: NCT05389761.

Survey of knowledge and attitude towards fibromyalgia among physicians in Karachi, Pakistan

Objectives

Our study aims to assess knowledge and understanding of FM among doctors employed at a tertiary care hospital in Karachi, Pakistan with a focus on its diagnostic criteria, treatment modalities, and general knowledge of symptoms.

Study Design

Cross-sectional Study.

Methods

Our cross-sectional study recruited participants through convenience sampling. A total of 104 participants responded, which included (a) House Officers, (b) Medical Officers, and (c) Residents. A structured questionnaire was used, and an electronic form was generated which was then emailed to the participants to acquire their responses.

Results

The majority (66.3%) of our respondents were female and the median age was 26 years. A majority (93.3%) accepted FM as a separate and distinct clinical identity, and 79.8% were confident in recognizing its general symptoms. Widespread pain (95.2%) and fatigue (80.8%) were correctly identified as most commonly observed symptoms. Moreover, 68.3% of respondents possessed no knowledge of both ACR 1990 and 2010 diagnostic criteria for FM. Of those aware, majority favored using the most recent ACR 2010 criteria (72.7%). Majority of our respondents (75%) preferred using pharmaceutical and non-pharmaceutical interventions simultaneously in the treatment.

Conclusions

Our study indicates that while physicians have satisfactory knowledge of the symptoms and treatment modalities of FM, a knowledge gap concerning its diagnostic criteria exists. Proper treatment can only be successful when physicians successfully diagnose FM, therefore, future training programs should use this fact as a stepping stone for advances in its healthcare.

Life among Chinese fibromyalgia patients: a cross-sectional study

OBJECTIVE

This study is to examine the impact of age on the clinical characteristics, fibromyalgia-related symptom severity and quality of life (QOL) among Chinese fibromyalgia patients.

METHODS

A packet of questionnaires on demographics, medical history, and severity of six major symptoms of fibromyalgia (i.e., pain, fatigue, sleep quality, depression, stress, and QOL) was completed by 124 Chinese patients. The patients were stratified into three groups by age (32 (25.8%) "young" patients, ≤ 39 years; 73 (58.9%) "middle-age" patients, 40-59 years; and 19 (15.3%) "older" patients, ≥ 60 years). Analysis of covariance was conducted and adjusted for body mass index and symptom fibromyalgia duration.

RESULTS

The majority of patients in this study were women (107, 86.3%), and the mean age was 49.4 years (SD 10.8 years). Pairwise comparisons among the three age groups found that the young and middle-aged patients were significantly more troubled than the older patients by their symptoms in several categories: morning tiredness (P ≤ 0.012), depression (P ≤ 0.002), anxiety (P ≤ 0.004), mental health index (P ≤ 0.002), and mental component summary score (P ≤ 0.017). The middle-aged patients reported more trouble than the older patients with regard to social functioning (P = 0.008), emotional roles (P = 0.012), depression (P = 0.012), and sleep quality (P = 0.017). The young patients exhibited the highest levels of current experienced stress (young vs. old, P = 0.013).

CONCLUSION

This study has identified that middle-aged Chinese fibromyalgia patients exhibited less compromise of their QOL than did their older peers. This discrepancy begs a logical explanation and deserves further study. Key Points • This is the first clinical study to show the potential effect of age on fibromyalgia patients in China. • Characteristics, symptom severity, and QOL differ in different age groups. • The younger patients are, the worse their quality of life.

Prevalence and Incidence of Patients With Fibromyalgia in Catalonia Between 2010 and 2017: A Descriptive Observational Study

OBJECTIVE

To measure the prevalence and cumulative incidence of individuals diagnosed with fibromyalgia (FM) in Catalonia between 2010 and 2017.

METHODS

A retrospective observational study of the population of Catalonia between 2010 and 2017, both included, was designed to describe the incidence, prevalence, and sociodemographic characteristics of individuals diagnosed with fibromyalgia. A total of 56 098 patients were included in the study. The scope of the study were the 283 Primary Care Teams (PCT), all managed by the Instituto Catalán de la Salud [Catalan Institute of Health] (ICS).

RESULTS

The diagnosis of FM is higher in females (95.4%) than males (4.55%), with a mean age of 53.0 [45.0-61.0] years. The prevalence of FM in the total population was 0.4% in 2010 and 1.4% in 2017. The highest prevalence was found in the 55 to 65 age group (1.05% in 2010, and 2.46% in 2017). A relationship was found between the prevalence of FM and the degree of socioeconomic deprivation in urban areas: the greater the deprivation, the greater the prevalence of FM. The cumulative incidence of FM in the population remained constant over time (0.11% in 2010 and 0.10% in 2017), being more prevalent in women than men (0.18% women, 0.01% men in 2017).

CONCLUSIONS

Our study confirms that FM is a prevalent disease in Catalonia, with an upward trend in recent years and it is more prevalent in women.

The Social Course of Fibromyalgia: Resisting Processes of Marginalisation

This sociological article reports an empirical study into the lived experience of fibromyalgia. It includes 28 participants (26 women, 2 men) with a formal diagnosis of fibromyalgia. Data collection consisted of the completion of an identity box project and subsequent interviews. Data analysis followed the principles of iterative, inductive, semantic thematic analysis, and led to the identification of four major themes: the role of the social in making sense of the experience, the process of redefining lifegoals, the refusal to accept fibromyalgia as a diagnosis, and the consideration of identifying as a patient. These themes in turn demonstrate four forms of resistance against processes of marginalisation amongst those who have been diagnosed with fibromyalgia: (1) the incorporation of societal expectations and norms into their life-stories; (2) the re-making the lifeworld at a cerebral level through redefining reality and creating a new, socially acceptable reality; (3) the active rejection of the fibromyalgia diagnosis; and (4) the employment of active and pro-active countermeasures to assuming the sick role.

Evaluation of fibromyalgia syndrome in patients with rosacea

Objectives

This study aims to investigate the frequency of fibromyalgia syndrome (FMS) in rosacea patients and the relationship between disease disability score of FMS and quality of life score of rosacea.

Patients and methods

This cross-sectional controlled clinical trial was performed between December 2017 and December 2018. One hundred female rosacea patients (mean age 43.2±10.1; range, 21 to 65 years) and 100 age- and sex-matched control subjects (mean age 41.2±11.1; range, 22 to 68 years) with no history of skin disease and systemic diseases including diabetes, cardiovascular, renal and hepatic diseases were recruited. Dermatology Life Quality Index (DLQI) scores were calculated using a 10-item self-administered questionnaire. The diagnosis of FMS was established according to 2010 American College of Rheumatology diagnostic criteria. Fibromyalgia Impact Questionnaire (FIQ) was used to determine the clinical severity and functional disability, while Visual Analog Scale (VAS) was used to determine pain severity in the patients with FMS.

Results

The frequency of FMS in patient group was significantly higher than control group (p=0.019). The mean duration of FMS in patient group was significantly higher than control group (p=0.001). There was no significant difference in terms of the age of onset of FMS, FIQ and VAS scores between groups (p=0.53, p=0.54, p=0.07, respectively). DLQI scores were significantly correlated with FIQ scores in the patient group (r=0.43, p=0.008).

Conclusion

The frequency of FMS in rosacea patients was significantly higher than control subjects without any skin disease and there was a correlation between disability score of FMS and quality of life score of rosacea. Investigating fibromyalgia symptoms in rosacea patients may be helpful for providing patient-based therapeutic approaches where neurologically based treatments may also be beneficial for rosacea.

Fibromyalgia in HIV-positive patients in Nigeria: A cross-sectional prospective study

BACKGROUND

Fibromyalgia is a chronic pain syndrome of unknown etiology characterized by chronic widespread musculoskeletal pain and tenderness. It affects the quality of life of patients and has been associated with the human immunodeficiency virus (HIV). The study aimed to determine the prevalence of fibromyalgia in HIV-positive patients and assess the effect of fibromyalgia on their functional status.

METHODOLOGY

This was a cross-sectional study comprising 160 treatment-naive HIV-positive patients and 160 age- and sex-matched HIV-negative controls. The diagnosis of fibromyalgia was based on the 2011 modification of the 2010 American College of Rheumatology diagnostic criteria by assessing the widespread pain index and symptom severity score. The severity of fibromyalgia was assessed with the revised fibromyalgia impact questionnaire.

RESULTS

The prevalence of fibromyalgia in HIV-positive individuals was found to be 10.6%, which was significantly higher compared with controls (3.1%; P = .008). There was no significant association between fibromyalgia and age, gender, or occupation. There was a significant relationship between CD4 count levels (P < .001), WHO clinical stage (P < .001), and fibromyalgia. A statistically significant higher score on the Revised FM Impact Questionnaire was found in HIV-positive individuals with fibromyalgia (P < .001).

CONCLUSION

The study found that HIV-positive patients had a significantly higher incidence of fibromyalgia than controls and this was related to active indices of HIV disease. Fibromyalgia had a greater clinical impact on HIV patients than in controls. As a result, fibromyalgia should be identified and treated in people living with HIV.

Effectiveness of Acceptance and Commitment Therapy in Central Pain Sensitization Syndromes: A Systematic Review

OBJECTIVES

Acceptance and commitment therapy (ACT) is considered by the American Psychological Association as an evidence-based treatment for a variety of disorders, including chronic pain. The main objective of the present systematic review was to determine the effectiveness of ACT in patients with central pain sensitization syndromes (CPSS).

METHODS

This systematic review was conducted according to the guidelines of the Cochrane Collaboration and PRISMA statements. The protocol was registered in advance in the Prospective Register of Systematic Reviews (PROSPERO) international database. The selected articles were evaluated using the Cochrane risk of bias (ROB) assessment tool. The PubMed, Scopus, and Web of Science databases were searched.

RESULTS

The literature search identified 21 studies (including investigations of fibromyalgia syndrome, irritable bowel syndrome, and migraine) eligible for the systematic review. There were no studies regarding the effectiveness of ACT for chronic tension-type headache (CTTH), interstitial cystitis (IC), or temporomandibular disorder (TMD). The evaluation of ROB showed that 12 of the selected studies were of low quality, 5 were of moderate quality, and 4 were high quality. ACT reduces some clinical symptoms, such as anxiety, depression, and pain. This positive effect of ACT might be mediated by pain acceptance, psychological flexibility, optimism, self-efficacy, or adherence to values. ACT showed better results in comparison to non-intervention (e.g., "waiting list") conditions, as well as pharmacological and psychoeducational interventions. It is not entirely clear whether extended ACT treatments are more advantageous than briefer interventions.

CONCLUSIONS

There are few studies about the effectiveness of ACT on CPSS. However, ACT seems to reduce subjective CPSS symptoms and improve the health-related quality of life of these patients. The absence of studies on the effectiveness of ACT in CTTH, IC, and TMD, indicate the pressing need for further ACT studies in these CPSS.

Fibromyalgia syndrome - a risk factor for poor outcomes following orthopaedic surgery: A systematic review

BACKGROUND

Fibromyalgia (FM) is a complex syndrome incorporating many features associated with poor outcome in orthopaedic surgery. Aim of the present review was to comprehensively characterize the available evidence on the consequences of pre-existent FM on the outcomes of orthopaedic surgery.

METHODS

We performed a systematic search in MedLine and Web of Science (WOS) to identify studies evaluating the effect of FM on patient-centred outcomes, opioids consumption and postoperative complications.

RESULTS

The search strategy identified 519 records in PubMed and 507 in WOS. A total of 27 articles were deemed eligible for inclusion in qualitative synthesis. Based on quality assessment, 10 studies were rated as good quality, 10 as fair quality and 7 as poor quality. Studies reporting the prevalence of FM in consecutive patients undergoing orthopaedic surgery (n = 19) were included in quantitative synthesis. The pooled prevalence of FM in patients undergoing orthopaedic surgery was 4.1% (95% CI: 2.4-6.8) in those receiving hip or knee surgery, 10.1% (95% CI: 5.7-17.2) in those receiving shoulder or elbow surgery and 21.0% (95% CI: 18.5-23.7) in those receiving spinal surgery. The results of our systematic review consistently report FM as a significant risk factor for less satisfaction, higher pain, worse functional outcome, increased risk for postoperative opioids prescription and higher rate of medical and surgical complications following orthopaedic surgery.

CONCLUSION

Identifying pre-existing FM in patients scheduled for elective orthopaedic surgery may help to better assess the benefit/risk ratio, improve patients' awareness and minimize any discrepancy between expectancy and results.

Neuroendocrine Modulation of Cognitive Performance in the Patients with Fibromyalgia

BACKGROUND

Fibromyalgia (FM) is a chronic widespread pain disorder associated with fatigue, tender points, sleep disturbances, and mood disorders. Symptoms associated with FM also include decreased cognitive function in which the neural basis is poorly understood. Neuroendocrine hormones may be correlated with cognitive performance under some ill conditions. However, we are unaware of current evidence on neuroendocrine hormones as factors influencing cognitive function in adults with FM.

OBJECTIVES

The aim of the study was to assess whether neuroendocrine hormones could affect cognition in the patients with FM.

STUDY DESIGN

This study used a case-control trial design.

SETTING

Study patients were recruited from the neurological outpatient clinics in the Second Affiliated Hospital and Affiliated Chaohu Hospital of Anhui Medical University and met the American College of Rheumatology criteria for FM.

METHODS

Forty-six patients with FM were compared with twenty-nine healthy controls (HCs). Several measures of cognitive performance and serum levels of neuroendocrine hormones were used to make these comparisons, and the patients were also asked to complete questionnaires on depression and sleep quality. Partial correlation analysis was performed to control the confounders and linear regression analysis was used to examine the effects of neuroendocrine hormones on cognitive measures.

RESULTS

The FM patients had worse performance in attention, short-term memory, orientation, object working memory and spatial reference memory, higher depression scores, and worse sleep quality than HCs. The raised level of cortisol and gonadotropin-releasing hormone (GnRH) can protect general cognition, whereas the raised level of cortisol and thyroid-stimulating hormone (TSH) will damage spatial memory.

LIMITATIONS

We did not study the sex hormones comprehensively.

CONCLUSIONS

The FM patients showed significant cognitive impairment in several domains. The altered levels of cortisol, thyrotrophin-releasing hormone (TRH), and GnRH may mediate cognitive changes in FM.

Temporomandibular Disorders and Fibromyalgia: A Narrative Review

Temporomandibular disorder (TMD) and fibromyalgia (FM) have some clinical characteristics in common, for instance the chronic evolution, the pathophysiology incompletely understood and a multifactorial genesis. The incidence and the relationship between TMD and FM patients are the aims of this review. A MEDLINE and Pubmed search was performed for the key words “temporomandibular disorder” AND “fibromyalgia” from 2000 to present. A total of 19 papers were included in our review, accounting for 5449 patients. Ten studies, reporting a total of 4945 patients with TMD, showed that only 16.5% of these patients had diagnosis of FM, whereas 12 studies, reporting a total of 504 patients with FM, demonstrated that 77.0% of these patients had diagnosis of TMD. A comorbid relationship exists between TMD and FM. The complexity of both diseases shows the importance of a multimodal and interdisciplinary.

Demographic Characteristics and Clinical Features of Fibromyalgia in China: A Cross-Sectional Study

Objective

The aim of this study is to characterize the demographics, fibromyalgia-related symptom severity and quality of life (QOL) among Chinese fibromyalgia patients.

Methods

A total of 124 patients who met the ACR 1990 criteria were recruited. Each subject completed a packet of questionnaires for collecting data on the demographics, medical history and severity of six major symptoms of fibromyalgia (i.e., pain, fatigue, sleep quality, depression, stress and QOL).

Results

The majority of the study subjects were women (86.3%), were married (78.2%) and had a mean age of 49.4 years and a median symptom duration of 24 months. Compared to their female counterparts, male patients were younger, were more likely to be employed, had a higher income and were more likely to be current smokers and alcohol drinkers (all p ≦ 0.027). Most patients experienced moderate to severe pain (69.4%), severe fatigue (70.2%) and moderate to severe depression (53.3%). A small percentage (19.4%) of the patients had very poor quality of sleep, and over one third (37.1%) suffered from moderate to severe stress. Less than one third (27.5%) patients’ health status was moderately or highly impacted by fibromyalgia. The mental health of men was affected significantly more than that of women, with lower SF-36 scores in the SF-36 mental component summary (p = 0.043) and role emotional (p = 0.006).

Conclusion

This study has revealed that Chinese fibromyalgia patients might share similar demographics but milder fibromyalgia-related symptoms and better mental QOL compared to patients of other races and ethnic groups. Some differences between male and female patients were found, too. Further cross-sectional studies with a larger sample size and nationwide study sites are needed to replicate those clinical findings.

Quality of rheumatology care for patients with fibromyalgia and chronic pain syndromes

Background

One-third of primary care providers (PCPs) refer patients with fibromyalgia or chronic pain (FM/CP) to specialist care, typically rheumatology. Yet, comprehensive data on the quality of rheumatology care for patients with FM/CP are currently lacking.

Methods

Records of patients referred for rheumatology consultation for FM/CP and seen at a single academic centre between 2017 and 2018 were extracted by retrospective chart review. Variables were diagnostic accuracy (at referral vs consultation), resource utilisation (investigations, medications, medical and allied health referral), direct costs (physician billing, staff salary, investigation fees) and access (consult wait time). Patient experience and referring PCP experience surveys were administered.

Results

79 charts were identified. Following consultation, 81% of patients (n=64) maintained the same diagnosis of FM/CP, 19% (n=15) were diagnosed with regional pain and 0% of patients (n=0) were diagnosed with an inflammatory arthritis or connective tissue disease. Investigations were ordered for 37% of patients (n=29), medication prescribed for 10% (n=8) and an allied health referral provided for 54% (n=43). Direct costs totalled $19 745 (average $250/consult; range $157–$968/consult). Consultation wait time averaged 184 days (range 62–228 days). Out of the seven (64%) responses to the patient experience survey, 86% of patients (n=6) were satisfied with provider communication but the consultation ‘definitely’ met the expectations of only 57% (n=4). The PCP survey returned an insufficient response rate.

Conclusions

This study found that no patient referred to rheumatology care for FM/CP was diagnosed with an inflammatory arthritis or connective tissue disease. Furthermore, patients with FM/CP experience lengthy wait times for rheumatology care which delay their management of chronic pain. Interdisciplinary and collaborative healthcare models can potentially provide higher quality care for patients with FM/CP.

Fibromyalgia and obesity: A comprehensive systematic review and meta-analysis

INTRODUCTION

Obesity has been associated with several complications, including musculoskeletal disorders. Aim of the present systematic review was to identify all available evidence on the relationship between fibromyalgia (FM) and obesity, including epidemiological association, impact of obesity on FM severity and effect of weight loss strategies on FM symptoms.

METHODS

MedLine, Cochrane Central Register of Controlled Trials and Web of Science databases were searched up to September 2020 to identify eligible articles. Data from studies reporting the prevalence of obesity in FM patients were pooled using a random-effects model.

RESULTS

After removal of duplicate records, 393 studies proceeded to review. A total of 41 articles were deemed eligible for inclusion in final synthesis. Quality assessment revealed that the overall risk of bias was high. The overall prevalence of obesity in FM was 35.7% (95% CI: 31.8 - 39.9%), with higher figures reported for USA. The majority of studies included demonstrated that obesity is associated with different domains of the disorder, including composite measures of activity, pain severity, tender point count, stiffness, fatigue, physical functioning/disability, sleep, cognitive dysfunction, and quality of life; the strength of correlation was weak on average. Inconsistent data were available regarding the correlation with depression and anxiety. Only few studies addressed the effect of therapeutic weight loss in FM, either by bariatric surgery, diet/exercise combination or behavioral weight loss, providing preliminary evidence for a potential benefit of weight loss in ameliorating FM symptoms.

CONCLUSIONS

Available data support a potential interplay between obesity and FM-related symptoms. Weight management should be encouraged in patients with FM.

Definition of fibromyalgia severity: findings from a cross-sectional survey of 2339 Italian patients

OBJECTIVE

To establish optimal cut-off values for the scores of the revised Fibromyalgia Impact Questionnaire (FIQR), the modified Fibromialgia Assessment Scale (FAS 2019mod), and the Polysymptomatic Distress Scale (PDS) in order to distinguish five levels of FM disease severity.

METHODS

Consecutive FM patients were evaluated with the three clinimetric indices, and each patient was required to answer the anchor question: 'In general, would you say your health is 1 = very good, 2 = good, 3 = fair, 4 = poor, or 5 = very poor?'-which represented the external criterion. Cut-off points were established through the interquartile reconciliation approach.

RESULTS

The study sample consisted of 2181 women (93.2%) and 158 men (6.8%), with a mean age of 51.9 (11.5) years, and mean disease duration was 7.3 (6.9) years. The overall median FIQR, FAS 2019 mod and PDS scores (25th-75th percentiles) were respectively 61.16 (41.16-77.00), 27.00 (19.00-32.00) and 19.0 (13.00-24.00). Reconciliation of the mean 75th and 25th percentiles of adjacent categories defined the severity states for FIQR: 0-23 for remission, 24-40 for mild disease, 41-63 for moderate disease, 64-82 for severe disease and >83 for very severe disease; FAS 2019 mod: 0-12 for remission, 13-20 for mild disease, 21-28 for moderate disease, 29-33 for severe disease and >33 for very severe disease; PDS: 0-5 for remission, 6-15 for mild disease, 16-20 for moderate disease, 21-25 for severe disease and >25 for very severe disease.

CONCLUSIONS

Disease severity cut-offs can represent an important improvement in interpreting FM.

Land- and pool-based intervention in female fibromyalgia patients: A randomized-controlled trial

OBJECTIVES

The aim of this study was to assess the effect of a standard physical rehabilitation intervention (SPRI) program, in pool-based (SPRI-P) and land-based (SPRI-L) environments, applied to female fibromyalgia (FM) patients with mild-to-moderate symptoms during a period of 20 weeks.

PATIENTS AND METHODS

Between September 2016 and September 2017, a total of 73 female FM patients (mean age 48.2±6.8 years; range, 30 to 59 years) who suffered from FM were included in this study on a voluntary basis. The SPRI program was applied to the patients for 20 weeks. The severity of FM was assessed using the Fibromyalgia Impact Questionnaire. The dependent variables including self- perceived pain, perceived fatigue, aerobic capacity, depressive symptoms, and the overall impact of FM were evaluated.

RESULTS

Self-perceived pain, perceived fatigue, overall impact of FM (p<0.05) and depressive symptoms (p<0.001) of the participants in the SPRI-P program decreased in the post-test values, compared to the pre-test values. Using the SPRI-L program, a significant improvement in the aerobic capacity (maximum consumption of relative oxygen and distance in meters), overall impact of FM (p<0.05), and depressive symptoms (p<0.01) was observed.

CONCLUSION

Our study results indicated that the SPRI-P program yielded improvements in patients with FM in self-perceived pain, perceived fatigue, depressive symptoms, and overall impact, as well as improving the aerobic capacity. In addition, in the SPRI-L program, the participants increased their capacities, self-perceived pain, and overall impact of FM.

Fibromyalgia diagnosis and biased assessment: Sex, prevalence and bias

Purpose

Multiple clinical and epidemiological studies have provided estimates of fibromyalgia prevalence and sex ratio, but different criteria sets and methodology, as well as bias, have led to widely varying (0.4%->11%) estimates of prevalence and female predominance (>90% to <61%). In general, studies have failed to distinguish Criteria based fibromyalgia (CritFM) from Clinical fibromyalgia (ClinFM). In the current study we compare CritFM with ClinFM to investigate gender and other biases in the diagnosis of fibromyalgia.

Methods

We used a rheumatic disease databank and 2016 fibromyalgia criteria to study prevalence and sex ratios in a selection biased sample of 1761 referred and diagnosed fibromyalgia patients and in an unbiased sample of 4342 patients with no diagnosis with respect to fibromyalgia. We compared diagnostic and clinical variables according to gender, and we reanalyzed a German population study (GPS) (n = 2435) using revised 2016 criteria for fibromyalgia.

Results

In the selection-biased sample of referred patients with fibromyalgia, more than 90% were women. However, when an unselected sample of rheumatoid arthritis (RA) patients was studied for the presence of fibromyalgia, women represented 58.7% of fibromyalgia cases. Women had slightly more symptoms than men, including generalized pain (36.8% vs. 32.4%), count of 37 symptoms (4.7 vs. 3.7) and mean polysymptomatic distress scores (10.2 vs. 8.2). We also found a linear relation between the probability of being females and fibromyalgia and fibromyalgia severity. Women in the GPS represented 59.2% of cases.

Discussion

The perception of fibromyalgia as almost exclusively (≥90%) a women’s disorder is not supported by data in unbiased studies. Using validated self-report criteria and unbiased selection, the female proportion of fibromyalgia cases was ≤60% in the unbiased studies, and the observed CritFM prevalence of fibromyalgia in the GPS was ~2%. ClinFM is the public face of fibromyalgia, but is severely affected by selection and confirmation bias in the clinic and publications, underestimating men with fibromyalgia and overestimating women. We recommend the use of 2016 fibromyalgia criteria for clinical diagnosis and epidemiology because of its updated scoring and generalized pain requirement. Fibromyalgia and generalized pain positivity, widespread pain (WPI), symptom severity scale (SSS) and polysymptomatic distress (PSD) scale should always be reported.

Low-level laser therapy and anesthetic infiltration for orofacial pain in patients with fibromyalgia: a randomized clinical trial

BACKGROUND

To compare the analgesic effect of anesthetic infiltration of lidocaine 2% and low-level laser therapy (LLLT) by GaAlAs into tender points of patients with orofacial pain and fibromyalgia (FM).

MATERIAL AND METHODS

A randomized clinical trial was performed with adults (N=66) that were allocated into two groups (1:1): Group A received LLLT irradiation by Diode Laser GaAlAs (780nm) with expositions twice a week during six weeks and Group B was treated with anesthetic infiltration of lidocaine 2% without vasoconstrictor once a week for four weeks. The pain assessment included the Visual Analogic Scale (VAS) and tenderness to palpation.

RESULTS

No dropout and adverse effect was observed during the study. The pain decreased significantly in each group after the treatment (p=0.0001, β=1.0), even though no statistical difference was found between both treatments (p=0.46, β= 0.82). The presence of tender points decreased after both treatments, with responsively in some types of masticatory muscles (p<0.05) except posterior temporalis muscle. The patients perception showed that both treatments were effective and a few patients reported that the treatment did not improve welfare.

CONCLUSIONS

The LLLT by GaAlAs and anesthetic infiltration of lidocaine 2% were equally effective to control orofacial pain in FM individuals.

Assessment of medical practitioners' knowledge of fibromyalgia in Saudi Arabia

Background:

Fibromyalgia (FM), a relatively common disease, is difficult to diagnose owing to its subjective symptoms and poor knowledge among medical practitioners. The purpose of this study was to assess the knowledge regarding FM among medical practitioners in Saudi Arabia and the need for educational programs at the undergraduate level.

Subjects and Methods:

An online survey was administered to physicians, nurses, and technologist/technicians in different regions of the country. Responses were obtained from 104 medical practitioners. Knowledge regarding FM including clinical symptoms, diagnosis, and treatment was assessed.

Results:

Only 26% of the respondents reported that FM was part of their undergraduate curriculum, and only 8.7% attended educational programs about FM. (Approximately 50% of the medical practitioners either referred FM patients to unrelated specialty or did not know whom to refer these patients to). Only 33.7% of the respondents were familiar with the diagnostic criteria. Physiotherapy (69.4%) and pharmacological treatment (63.9%) were predominantly reported as the appropriate treatment.

Conclusions:

Knowledge regarding FM among medical practitioners in Saudi Arabia is poor. Further education at the undergraduate level is needed to improve knowledge and avoid delays in diagnosis and treatment.

Self-Efficacy for Adoption and Maintenance of Exercise Among Fibromyalgia Patients: A Pilot Study

Objective. While multimodal treatment approaches for fibromyalgia (FM), incorporating exercise, have been found most effective, information about factors associated with exercise adoption and maintenance is lacking. Design, Setting, and Methods. Women veterans with FM (N = 19) completed an anonymous Internet survey measuring FM impact (FI), adoption of exercise behavior, and self-efficacy for exercise. Using classifications of behavior specified by the transtheoretical model, the self-efficacy of participants classified in the action or maintenance (AM) stages was compared with those in earlier stages (precontemplation through preparation) of exercise readiness. Multivariate analysis of variance analyses examined differences in FI domains by stage of change. Analysis of covariance examined whether exercise self-efficacy differed by stage of change while controlling for FI. Results. Higher levels of self-efficacy were detected among participants in the AM stages. Participants in the AM stages also reported higher levels of FI symptoms. After controlling for FI, self-efficacy did not differ significantly between the 2 groups; however the effect size was large (η² = .11). Conclusions. Findings of this pilot study suggest a role for self-efficacy in exercise adoption and maintenance, even in the setting of higher FM symptoms. Replication of this study with a larger sample size is warranted.

Anatomical Basis of the Myofascial Trigger Points of the Gluteus Maximus Muscle

Myofascial pain syndrome is characterized by pain and limited range of motion in joints and caused by muscular contracture related to dysfunctional motor end plates and myofascial trigger points (MTrPs). We aimed to observe the anatomical correlation between the clinically described MTrPs and the entry point of the branches of the inferior gluteal nerve into the gluteus maximus muscle. We dissected twenty gluteus maximus muscles from 10 human adult cadavers (5 males and 5 females). We measured the muscles and compiled the distribution of the nerve branches into each of the quadrants of the muscle. Statistical analysis was performed by using Student's t-test and Kruskal-Wallis tests. Although no difference was observed either for muscle measurements or for distribution of nerve branching among the subjects, the topography of MTrPs matched the anatomical location of the entry points into the muscle. Thus, anatomical substract of the MTrPs may be useful for a better understanding of the physiopathology of these disorders and provide basis for their surgical and clinical treatment.

A comparison of the effectiveness of amitriptilin and pregabalin treatment in fibromyalgia patients

OBJECTIVE

The present study is a comparison of the effectiveness of amitriptyline and pregabalin on the symptoms of fibromyalgia patients.

METHODS

A total of 71 female patients aged ≥18 years were included in this study. The patients were divided into 2 groups. Pregabalin (n=36) or amitriptyline (n=35) treatment was initiated at daily oral dose of 450 mg and 25 mg, respectively for the indicated number of patients. The patients were evaluated at the start of treatment and at the end of 12 weeks. The Fibromyalgia Impact Questionnaire, Fatigue Severity Scale, Modified Fatigue Impact Scale, Hospital Anxiety Depression Scale, Nottingham Health Profile, Mini Mental State Test, and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) were administered to all study participants. Pain at all tender points was measured using a pressure algometer.

RESULTS

Significant improvement was observed in both groups after 12 weeks of treatment (p<0.05). Percent change in LANSS was greater in the pregabalin group compared with the amitriptyline group. Tender point pressure pain thresholds and total myalgic score improved significantly in both groups (p<0.05); however higher percentage change in these parameters was achieved in the amitriptyline group when compared with the pregabalin group (p<0.05).

CONCLUSION

Both drugs improved pain, fatigue, sleep disorder, disability, psychological evaluation, and cognitive function; however, amitriptyline was more effective at reducing experimentally measured pain than neuropathic pain. According to these results, preference for pregabalin may be recommended in fibromyalgia patients whose primary complaint is neuropathic pain.

The management of fibromyalgia from a psychosomatic perspective: an overview

Fibromyalgia (FM) is a central sensitization syndrome characterized by chronic widespread pain. FM is often comorbid with psychiatric disorders, as well as psychological distress that worsens the quality-of-life of people affected. The aim was to collect current evidence about the management of FM from a psychosomatic perspective. The literature was synthesized and summarized in a narrative format. The literature search was carried out in PubMed; review articles, meta-analysis, overview, and guidelines published in the last 10 years written in English were included. Five main topics (Diagnostic criteria of FM; Pathogenesis of chronic widespread pain in FM; Early stress and trauma as predisposing factors for central sensitization; FM and Psychiatric comorbidity; Implications for treatment) were pointed out and discussed. Much evidence underlies the importance of considering and treating the comorbidity of FM with psychiatric disorders and psychological factors that affect pain management. Validation of FM as a central sensitization syndrome by a clinician facilitates therapeutic strategies that involve patients as active participants in the pain management process, likely leading to improved outcomes.

Comparison of sleep structure and psychometric profiles in patients with fibromyalgia, osteoarthritis and healthy controls

While research indicates that both the macro- and microstructure of sleep may be altered in fibromyalgia syndrome, few studies have controlled for symptom duration or included pain-control participants (i.e. patients with chronic pain and sleep disturbance not associated with fibromyalgia syndrome). A frequently reported alteration found in the sleep microstructure of patients with fibromyalgia syndrome is the alpha-delta sleep anomaly. Although alpha waves have been observed during N3 sleep in healthy individuals, it has been proposed that there is an increase in alpha wave activity during slow-wave sleep in fibromyalgia syndrome. Originally considered a possible neurological contribution to fibromyalgia syndrome, whether the alpha-delta sleep anomaly is fundamental to the development of fibromyalgia syndrome, or results mainly from the pain experience remains unknown. The present study was designed to compare sleep macro- and microstructure, and psychometric profiles, in three broadly age-matched groups of female participants: patients with fibromyalgia syndrome (n = 19); patients with osteoarthritis with sleep disturbance (n = 17); and healthy adults (n = 10). Patients with fibromyalgia syndrome met the American College of Rheumatology diagnostic criteria and were recruited within 6 months of diagnosis. Subjective sleep quality was significantly lowest, and levels of anxiety and depressive symptoms were significantly highest for patients with fibromyalgia syndrome. However, the groups showed no significant differences in polysomnographic measures of total sleep time, sleep latency and total wake after sleep onset. Levels of alpha-delta sleep were statistically similar in both clinical (fibromyalgia syndrome and osteoarthritis) groups, indicating that it is not a specific abnormality of fibromyalgia syndrome. Overall, subjective measurements of anxiety, depression, fatigue and sleep quality better discriminated between the three groups than did objective measurements of sleep variables.

Personality disparity in chronic regional and widespread pain

Chronic pain has high comorbidity with psychiatric disorders, therefore, better understanding of the relationship between chronic pain and mental illness is needed. This study aimed to investigate the pathway relationships among parental attachment, personality characteristics, alexithymic trait and mental health in patients with chronic widespread pain, those with chronic regional pain, and controls. Two hundred and thirty participants were recruited. The parental Bonding Inventory, Eysenck Personality Inventory (EPI), 20-item Toronto Alexithymia Scale (TAS-20), Chinese Health Questionnaire, and Short-Form 36 were filled out. The pathway relationships revealed that patients of mothers who were more protective were more neurotic, had more difficulty identifying feelings (DIF), worse mental health, and a higher association with chronic widespread pain. No differences were found between patients with chronic regional pain and the controls. The predisposing factors for chronic widespread pain, when compared with chronic regional pain, may be more closely related to psychiatric disorders. The pathways to chronic regional pain and chronic widespread pain differ, with neuroticism and the alexithymic DIF trait being the main factors defining chronic widespread pain. Therefore, besides therapies targeting pain symptoms, psychiatric consultation, medication and psychotherapy are also recommended for those with chronic widespread pain to alleviate their mental health conditions.

Potential Mediators between Fibromyalgia and C-Reactive protein: Results from a Large U.S. Community Survey

BACKGROUND

Fibromyalgia, a potentially debilitating chronic pain syndrome of unknown etiology, may be characterized by inflammation. In this study, we investigated the relation of FMS to serum C-reactive protein (CRP) in a large population of adults (18+) and investigated the influence of other factors on this relationship, including BMI, comorbidities, as well as mood and sleep disturbance.

METHODS

Participants were 52,535 Ohio Valley residents (Fibromyalgia n = 1125). All participants completed a comprehensive health survey (2005-2006) part of the C8 Health Project; serum levels of CRP were obtained, as was history of Fibromyalgia physician diagnosis. Logistic and linear regressions were used for this cross-sectional analysis.

RESULTS

Mean CRP was higher among participants reporting Fibromyalgia than those without (5.54 ± 9.8 vs.3.75 ± 7.2 mg/L, p < .0001)). CRP level showed a strong, positive association with FMS (unadjusted odds ratio (OR) for highest vs. lowest quartile = 2.5 (CI 2.1,3.0;p for trend < .0001)); adjustment for demographic and lifestyle factors attenuated but did not eliminate this association (AOR for highest vs. lowest quartile = 1.4 (CI 1.1,1.6;p for trend < .0001)). Further addition of body mass index (BMI) and comorbidities to the model markedly weakened this relationship (AORs, respectively, for highest vs lowest CRP quartile = 1.2 (CI 1.0,1.4) and 1.1 (CI 0.9,1.3). In contrast, inclusion of mood and sleep impairment only modestly reduced the adjusted risk estimate (AORs for highest vs. lowest quartile = 1.3 (CI 1.1,1.5) for each)).

CONCLUSIONS

Findings from this large cross-sectional study indicate a significant positive cross-sectional association of Fibromyalgia to serum C-reactive protein may be explained, in part, by BMI and comorbidity. Prospective research is needed to confirm this, and clarify the potential mediating influence of obesity and comorbid conditions on this relationship.

Preliminary investigation of self-as-context in people with fibromyalgia

Acceptance and commitment therapy (ACT), based on the Psychological Flexibility (PF) model, has been recently applied to fibromyalgia (FM), and appeared effective in improving functioning. However, evidence for some of the processes within the PF model, self-as-context (SAC) in particular, is lacking within this population. The current study validates a measure of SAC, the Self Experiences Questionnaire (SEQ), and preliminarily investigates the role of SAC in relation to functioning in FM. Participants (N = 298, 93.3% women) self-reporting a diagnosis of FM were recruited via the Internet and completed an online survey. Measures included pain, pain acceptance and SAC, as processes, and pain interference, work and social adjustment, depression and depression-related interference, as outcomes. Confirmatory factor analysis of the SEQ suggested a bi-factor structure, with a general factor underlying all items and two sub-factors, self-as-distinction and self-as-observer (χ2 = 46.55, p = .06, comparative fit index (CFI) = .99, Tucker-Lewis Index (TLI) = .99, root mean square error of approximation (RMSEA) = .04). Component factors showed good reliability, Cronbach's α = .90, and construct validity, supported by significant Pearson's correlations between SEQ scores, acceptance and outcomes (r = -.14 to -.33). In multiple regression analyses, SEQ scores significantly predicted pain-related interference (β = -.17, p < .05), work and social adjustment (β = -.14, p < .05) and depression (β = -.21, p < .01), but not depression-related interference, after controlling for pain, but only significantly predicted depression after controlling pain acceptance. These preliminary results show potentially important associations between SAC and functioning in people with FM.

Work Ability in Fibromyalgia: An Update in the 21st Century

BACKGROUND

Fibromyalgia (FM) is characterized by persistent widespread pain, increased pain sensitivity and tenderness. People with FM also report activity limitations and impaired work ability.

OBJECTIVE

This article aims to compile the findings of recently published research on work ability in people with fibromyalgia, and to present how work ability is influenced by various aspects.

METHODS

A systematic search of the literature published from the year 2000 and onwards was conducted. Thirtyfour articles were included in the review.

RESULT

Symptom severity was found to influence work ability in people with FM. Physically demanding jobs and work tasks were especially troublesome and were reported to constitute higher risks pof work disability. Working people with FM seemed to hold a careful balancing act to manage the risk of overload where well-functioning strategies such as making a career change, working part-time, and developing personal skills were necessary for managing work, in the short- and long term. The support of management and colleagues enabled people with FM to manage the risk of overload at work. Treatment studies evaluating work disability as outcome in FM are scarce. None of the included studies presented any effects on measures of sick-leave or work disability compared with a control group.

CONCLUSION

More studies of treatment effects on outcomes related to work ability in people with FM, and more longitudinal studies to explore long-term effects of symptoms on work ability and sick leave, are needed in order to be able to plan evidence based rehabilitation to improve or maintain work ability in people with FM.

Fibromyalgia Outcomes Over Time: Results from a Prospective Observational Study in the United States

Background:

Longitudinal research on outcomes of patients with fibromyalgia is limited.

Objective:

To assess clinician and patient-reported outcomes over time among fibromyalgia patients.

Methods:

At enrollment (Baseline) and follow-up (approximately 2 years later), consented patients were screened for chronic widespread pain (CWP), attended a physician site visit to determine fibromyalgia status, and completed an online questionnaire assessing pain, sleep, function, health status, productivity, medications, and healthcare resource use.

Results:

Seventy-six fibromyalgia patients participated at both time points (at Baseline: 86.8% white, 89.5% female, mean age 50.9 years, and mean duration of fibromyalgia 4.1 years). Mean number of tender points at each physician visit was 14.1 and 13.5, respectively; 11 patients no longer screened positive for CWP at follow-up. A majority reported medication use for pain (59.2% at Baseline, 62.0% at Follow-up). The most common medication classes were opioids (32.4%), SSRIs (16.9%), and tramadol (14.1%) at Follow-up. Significant mean changes over time were observed for fibromyalgia symptoms (modified American College of Rheumatology 2010 criteria: 18.4 to 16.9; P=0.004), pain interference with function (Brief Pain Inventory-Short Form: 5.9 to 5.3; P=0.013), and sleep (Medical Outcomes Study-Sleep Scale: 58.3 to 52.7; P=0.004). Patients achieving ≥2 point improvement in pain (14.5%) experienced greater changes in pain interference with function (6.8 to 3.4; P=0.001) and sleep (62.4 to 51.0; P=0.061).

Conclusion:

Fibromyalgia patients reported high levels of burden at both time points, with few significant changes observed over time. Outcomes were variable among patients over time and were better among those with greater pain improvement.

Gender Differences in Symptoms, Health-Related Quality of Life, Sleep Quality, Mental Health, Cognitive Performance, Pain-Cognition, and Positive Health in Spanish Fibromyalgia Individuals: The Al-Ándalus Project

Objective. To test the gender differences in tenderness, impact of fibromyalgia, health-related quality of life, fatigue, sleep quality, mental health, cognitive performance, pain-cognition, and positive health in Spanish fibromyalgia patients and in age-matched nonfibromyalgia individuals from the same region. To test the optimal cut-off score of the different tender points for women and men. Methods. A total of 405 (384 women) fibromyalgia versus 247 (195 women) nonfibromyalgia control participants from southern Spain (Andalusia) took part in this cross-sectional study. The outcomes studied were assessed by means of several tests. Results. In the fibromyalgia group, men showed better working memory than women (all, P < 0.01), whereas sleep latency was lower in women compared to men (P = 0.013). In the nonfibromyalgia group, men showed higher pain threshold in all the tender points (all, P < 0.01), except in right and left lateral epicondyle. Furthermore, men showed better working memory than women (all, P < 0.01), whereas memory performance was better in women compared to men (all, P ≤ 0.01). Conclusion. The results of the present study do not support consistent evidence of gender differences in fibromyalgia-related symptoms. However, it seems that detriment of some symptoms (especially pain) in fibromyalgia men compared with their nonfibromyalgia counterparts is greater than those of fibromyalgia women compared with their nonfibromyalgia peers.

Progression of fibromyalgia: results from a 2-year observational fibromyalgia and chronic pain study in the US

Background

A previous fibromyalgia (FM) research reports that 20%–47% of diagnosed patients may not meet the study definition of FM 1–2 years after diagnosis. The aim of this study was to gain a better understanding of the progression of FM in a geographically diverse cohort over a 2-year time period.

Methods

This cohort study followed 226 subjects recruited online to assess FM and chronic widespread pain (CWP) diagnosis stability over time. At enrollment (baseline), subjects provided informed consent, completed an online questionnaire consisting of the London Fibromyalgia Epidemiology Study Screening Questionnaire to screen for CWP (bilateral pain above/below waist lasting ≥1 week in the past 3 months), visited a site for physician evaluation for FM, and completed a questionnaire with validated patient-reported outcome instruments. Subjects were classified into mutually exclusive groups: FM+CWP+ (screened positive for CWP and received physician diagnosis of FM), FM−CWP+ (screened positive for CWP but did not receive physician diagnosis of FM), and FM−CWP− (screened negative for CWP). Approximately 2 years later (follow-up), subjects were reassessed at the same study site and completed a questionnaire with the same patient-reported outcomes.

Results

Seventy-six FM+CWP+ subjects completed assessments at both time points; 56 (73.7%) met the FM study definition at follow-up. Twenty subjects no longer met the FM study definition (eleven became FM−CWP− and nine became FM−CWP+). Ten subjects (two from FM−CWP− and eight from FM−CWP+) transitioned into the FM+CWP+ group at follow-up; they reported more tender points and pain interference with sleep and worse physical function at baseline compared with subjects who did not transition to FM+CWP+. Most (76.7%) of the subjects who transitioned into/out of FM+CWP+ experienced changes in CWP, number of positive tender points, or both.

Conclusion

The results suggest that some FM+CWP+ patients experience fluctuation in symptoms over time, which may reflect the waxing and waning nature of FM and affect diagnosis and treatment.

Clinically Effective Treatment of Fibromyalgia Pain With High-Definition Transcranial Direct Current Stimulation: Phase II Open-Label Dose Optimization

Despite promising preliminary results in treating fibromyalgia (FM) pain, no neuromodulation technique has been adopted in clinical practice because of limited efficacy, low response rate, or poor tolerability. This phase II open-label trial aims to define a methodology for a clinically effective treatment of pain in FM by establishing treatment protocols and screening procedures to maximize efficacy and response rate. High-definition transcranial direct current stimulation (HD-tDCS) provides targeted subthreshold brain stimulation, combining tolerability with specificity. We aimed to establish the number of HD-tDCS sessions required to achieve a 50% FM pain reduction, and to characterize the biometrics of the response, including brain network activation pain scores of contact heat-evoked potentials. We report a clinically significant benefit of a 50% pain reduction in half (n = 7) of the patients (N = 14), with responders and nonresponders alike benefiting from a cumulative effect of treatment, reflected in significant pain reduction (P = .035) as well as improved quality of life (P = .001) over time. We also report an aggregate 6-week response rate of 50% of patients and estimate 15 as the median number of HD-tDCS sessions to reach clinically meaningful outcomes. The methodology for a pivotal FM neuromodulation clinical trial with individualized treatment is thus supported.

ONLINE REGISTRATION

Registered in Clinicaltrials.gov under registry number NCT01842009.

PERSPECTIVE

In this article, an optimized protocol for the treatment of fibromyalgia pain with targeted subthreshold brain stimulation using high-definition transcranial direct current stimulation is outlined.

Prevalence of fibromyalgia and co-morbid bipolar disorder: A systematic review and meta-analysis

BACKGROUND

Fibromyalgia (FM) is a chronic disorder with high morbidity and significant health service utilization costs. Few studies have reported on the phenotypic overlap of FM and bipolar disorder (BD). The aim of this review is to qualitatively and quantitatively summarize the results and clinical implications of the extant literature on the co-occurrence of FM and BD.

METHODS

A systematic search of PubMed/Medline, Cochrane, PsycINFO, CINAHL and Embase was conducted to search for relevant articles. Articles were included if incidence and/or prevalence of BD was determined in the FM sample. Results of prevalence were pooled from all studies. Pooled odds ratio (OR) was calculated based on case-control studies using standard meta-analytic methods.

RESULTS

A total of nine studies were included. The pooled rate of BD comorbidity in samples of FM patients was 21% (n=678); however, results varied greatly as a function of study methodology. Case-controlled studies revealed a pooled OR of 7.55 of BD co-morbidity in samples of FM patients [95% Confidence Interval (CI)=3.9-14.62, FM n=268, controls n=413] with low heterogeneity (I(2)=0%).

LIMITATIONS

The current study was limited by the low number of available studies and heterogeneity of study methods and results.

CONCLUSIONS

These data strongly suggest an association between BD and FM. Future studies employing a validated diagnostic screen are needed in order to more accurately determine the prevalence of BD in FM. An adequate psychiatric assessment is recommended in FM patients with suspected symptoms consistent with BD prior to administration of antidepressants in the treatment of FM.

Self-reported nonrestorative sleep in fibromyalgia - relationship to impairments of body functions, personal function factors, and quality of life

PURPOSE

The purpose of this study was: 1) to determine variables that might characterize good or bad sleep; and 2) to describe the relationship between sleep, impairment of body functions, personal function factors, and quality of life based on quality of sleep in women with fibromyalgia (FM).

METHODS

This cross-sectional descriptive study included 224 consecutive patients diagnosed at a specialist center. These patients were mailed a questionnaire concerning sleep, body functions, personal factors, and health-related quality of life. In total, 145 completed questionnaires were collected.

RESULTS

Using sleep variables (sleep quality, waking up unrefreshed, and tiredness when getting up), we identified two subgroups - the good sleep subgroup and the bad sleep subgroup - of women with FM. These subgroups exhibited significantly different characteristics concerning pain intensity, psychological variables (depressed mood, anxiety, catastrophizing, and self-efficacy), impairments of body functions, and generic and health-related quality of life. The good sleep subgroup reported a significantly better situation, including higher employment/study rate. The bad sleep subgroup reported a greater use of sleep medication. Five variables determined inclusion into either a good sleep or a bad sleep subgroup: pain in the evening, self-efficacy, anxiety, and according to the Short Form health survey role emotional and physical functioning.

CONCLUSION

This study found that it was possible to identify two subgroups of women with FM based on quality of sleep variables. The two subgroups differed significantly with respect to pain, psychological factors, impairments of body functions, and perceived quality of life, where the subgroup with bad sleep had a worse situation.

Fibromyalgia and disability adjudication: no simple solutions to a complex problem

BACKGROUND

Adjudication of disability claims related to fibromyalgia (FM) syndrome can be a challenging and complex process. A commentary published in the current issue of Pain Research & Management makes suggestions for improvement. The authors of the commentary contend that: previously and currently used criteria for the diagnosis of FM are irrelevant to clinical practice; the opinions of family physicians should supersede those of experts; there is little evidence that trauma can cause FM; no formal instruments are necessary to assess disability; and many FM patients on or applying for disability are exaggerating or malingering, and tests of symptoms validity should be used to identify malingerers.

OBJECTIVES

To assess the assertions made by Fitzcharles et al.

METHODS

A narrative review of the available research literature was performed.

RESULTS

Available diagnostic criteria should be used in a medicolegal context; family physicians are frequently uncertain about FM and⁄or biased; there is considerable evidence that trauma can be a cause of FM; it is essential to use validated instruments to assess functional impairment; and the available tests of physical effort and symptom validity are of uncertain value in identifying malingering in FM.

CONCLUSIONS

The available evidence does not support many of the suggestions presented in the commentary. Caution is advised in adopting simple solutions for disability adjudication in FM because they are generally incompatible with the inherently complex nature of the problem.

Fibromyalgia: epidemiology and risk factors, a population-based case-control study in Lebanon

AIM

To investigate the epidemiology of fibromyalgia (FM) and assess its risk factors.

METHODS

Using data from the 2009 Community Oriented Program for Control of Rheumatic Diseases (COPCORD) study conducted in Lebanon, a population-based case control study was performed. The sample included 34 FM patients, frequency matched with 136 controls free from any musculoskeletal complaints and randomly sampled from the population. The controls were frequency matched with cases by age and gender.

RESULTS

The 34 female FM cases were prevalent cases which existed for a long period of time and all those who consulted a doctor were previously misdiagnosed. Family history of joint problems (OR = 4.93, 95% CI: 1.56-15.58) and working status (OR = 2.69, 95% CI: 1.04-6.93) were significant risk factors for FM, after adjusting for body mass index, distress level, smoking status and residence location.

CONCLUSION

This was the first study to address the epidemiology of FM in Lebanon and the region. The chronic nature of FM that is characterized by frequent bouts of intense disabling pain and symptoms constitutes a significant health and economic burden. Clustering of cases in coastal areas was partially explained by other factors such as body mass index, distress level, smoking and work status. The high burden of FM found in our study calls for further investigation of potential risk factors of this condition.

[Evaluating the relation of premenstrual syndrome and primary dysmenorrhea in women diagnosed with fibromyalgia]

OBJECTIVE

In this study, we aimed to investigate the presence of premenstrual syndrome (PMS), primary dysmenorrhea (PD) and depression among women with fibromyalgia (FM) and healthy females and to determine possible factors related with PMS and PD in FM.

METHOD

The present study was conducted on 98 female patients diagnosed with FM and 102 age and sex-matched healthy controls. All patients were evaluated for premenstrual syndrome (PMS) and primary dysmenorrhea (PD). Premenstrual syndrome was assessed among the patients for the presence of one or more affective or somatic symptoms within the five days preceding menses. The diagnosis of primary dysmenorrhea was defined as having abdominal pain or lower back pain lasting at least two days during a menstrual period. Dysmenorrhea was assessed via visual analog scale. Dysmenorrhea was rated via Multidimensional Scoring System. The Hamilton depression scale was applied to all patients.

RESULTS

Primary dysmenorrhea was established in 41% of FM patients and 28% of the control group. A statistically significant difference was found in PD between the two groups (p=0.03). PMS was established in 42% of the FM patients and 25% of the control group. A statistically significant difference was found in PMS between the two groups (p=0.03).

CONCLUSION

There is an increased frequency of premenstrual syndrome and dysmenorrhea in FM patients. The patients with high symptom severity scores and high depression scores among the FM patients are at risk of PMS and PD.

Trigger points: an anatomical substratum

This study aimed to bring the trapezius muscle knowledge of the locations where the accessory nerve branches enter the muscle belly to reach the motor endplates and find myofascial trigger points (MTrPs). Although anatomoclinical correlations represent a major feature of MTrP, no previous reports describing the distribution of the accessory nerve branches and their anatomical relationship with MTrP are found in the literature. Both trapezius muscles from twelve adult cadavers were carefully dissected by the authors (anatomy professors and medical graduate students) to observe the exact point where the branches of the spinal accessory nerve entered the muscle belly. Dissection was performed through stratigraphic layers to preserve the motor innervation of the trapezius muscle, which is located deep in the muscle. Seven points are described, four of which are motor points: in all cases, these locations corresponded to clinically described MTrPs. The four points were common in these twelve cadavers. This type of clinical correlation between spinal accessory nerve branching and MTrP is useful to achieve a better understanding of the anatomical correlation of MTrP and the physiopathology of these disorders and may provide a scientific basis for their treatment, rendering useful additional information to therapists to achieve better diagnoses and improve therapeutic approaches.

Typology of patients with fibromyalgia: cluster analysis of duloxetine study patients

BACKGROUND

To identify distinct groups of patients with fibromyalgia (FM) with respect to multiple outcome measures.

METHODS

Data from 631 duloxetine-treated women in 4 randomized, placebo-controlled trials were included in a cluster analysis based on outcomes after up to 12 weeks of treatment. Corresponding classification rules were constructed using a classification tree method. Probabilities for transitioning from baseline to Week 12 category were estimated for placebo and duloxetine patients (Ntotal = 1188) using logistic regression.

RESULTS

Five clusters were identified, from "worst" (high pain levels and severe mental/physical impairment) to "best" (low pain levels and nearly normal mental/physical function). For patients with moderate overall severity, mental and physical symptoms were less correlated, resulting in 2 distinct clusters based on these 2 symptom domains. Three key variables with threshold values were identified for classification of patients: Brief Pain Inventory (BPI) pain interference overall scores of <3.29 and <7.14, respectively, a Fibromyalgia Impact Questionnaire (FIQ) interference with work score of <2, and an FIQ depression score of ≥5. Patient characteristics and frequencies per baseline category were similar between treatments; >80% of patients were in the 3 worst categories. Duloxetine patients were significantly more likely to improve after 12 weeks than placebo patients. A sustained effect was seen with continued duloxetine treatment.

CONCLUSIONS

FM patients are heterogeneous and can be classified into distinct subgroups by simple descriptive rules derived from only 3 variables, which may guide individual patient management. Duloxetine showed higher improvement rates than placebo and had a sustained effect beyond 12 weeks.