Comorbidity of fibromyalgia and psychiatric disorders

Micro-inflammation related gene signatures are associated with clinical features and immune status of fibromyalgia

BACKGROUND

Fibromyalgia (FM) is a multifaceted disease. Along with the genetic, environmental and neuro-hormonal factors, inflammation has been assumed to have role in the pathogenesis of FM. The aim of the present study was to explore the differences in clinical features and pathophysiology of FM patients under different inflammatory status.

METHODS

The peripheral blood gene expression profile of FM patients in the Gene Expression Omnibus database was downloaded. Differentially expressed inflammatory genes were identified, and two molecular subtypes were constructed according to these genes used unsupervised clustering analysis. The clinical characteristics, immune features and pathways activities were compared further between the two subtypes. Then machine learning was used to perform the feature selection and construct a classification model.

RESULTS

The patients with FM were divided into micro-inflammation and non-inflammation subtypes according to 54 differentially expressed inflammatory genes. The micro-inflammation group was characterized by more major depression (p = 0.049), higher BMI (p = 0.021), more active dendritic cells (p = 0.010) and neutrophils. Functional enrichment analysis showed that innate immune response and antibacterial response were significantly enriched in micro-inflammation subtype (p < 0.050). Then 5 hub genes (MMP8, ENPP3, MAP2K3, HGF, YES1) were screened thought three feature selection algorithms, an accurate classifier based on the 5 hub DEIGs and 2 clinical parameters were constructed using support vector machine model. Model scoring indicators such as AUC (0.945), accuracy (0.936), F1 score (0.941), Brier score (0.079) and Hosmer-Lemeshow goodness-of-fit test (χ2 = 4.274, p = 0.832) proved that this SVM-based classifier was highly reliable.

CONCLUSION

Micro-inflammation status in FM was significantly associated with the occurrence of depression and activated innate immune response. Our study calls attention to the pathogenesis of different subtypes of FM.

Does Pain Acceptance Contribute to Improved Functionality through Walking in Women with Fibromyalgia? Looking at Depressive Comorbidity

In the last decade, research has pointed to physical exercise as an effective treatment in fibromyalgia patients. Some studies have highlighted the role of acceptance and commitment therapy in optimizing the benefits of exercise in patients. However, given the high comorbidity in fibromyalgia, it is necessary to value its possible influence on the effect of certain variables, such as acceptance, on the benefits of treatments, such as physical exercise. Our aim is to test the role of acceptance in the benefits of walking over functional limitation, further assessing whether this model is equally valid, considering depressive symptomatology as an additional differential diagnosis. A cross-sectional study with a convenience sample through contacting Spanish fibromyalgia associations was carried out. A total of 231 women with fibromyalgia (mean age 56.91 years) participated in the study. Data were analyzed with the Process program (Model 4, Model 58, Model 7). The results highlight the role of acceptance as a mediator between walking and functional limitation (B = -1.86, SE = 0.93, 95% CI = [-3.83, -0.15]). This model, when depression is incorporated as a moderator, is significant only in patients without depression, revealing the need for personalized treatments in fibromyalgia, considering their most prevalent comorbidity.

[Relationship between season of the year and severity of symptoms in patients with fibromyalgia]

BACKGROUND AND OBJECTIVE

Fibromyalgia patients often report that certain seasons aggravate their symptoms. The main objective was to determinate the association between key symptoms of fibromyalgia and the season of the year. A secondary objective was to determinate the existence of differences based on levels of anxiety or depression.

MATERIAL AND METHOD

Convenience sample made up of 471 participants with fibromyalgia evaluated before starting multidisciplinary treatment. Demographic and meteorological data were collected. Clinical data were assessed with standardized instruments of pain intensity, functionality, fatigue, stiffness, sleep quality, anxiety and depression.

RESULTS

The different groups of participants were homogeneous for age, gender, educational level, marital status and employment situation. No significant differences were found in pain intensity (F=1.334; P=.265), functionality (F=.402; P=.669), fatigue (F=.714; P=.490), stiffness (F=.299; P=.741), anxiety (F=.376; P=.687), depression (F=.608; P=.545), psychological distress (F=.261; P=.770), sleep quantity (F=1.507; P=.223) or sleep disturbances (F=.343; P=.710).

CONCLUSIONS

No differences were found in the intensity of fibromyalgia symptoms, nor in the percentages of severity among the different seasons of the year. Anxiety was more prevalent than depression, possibly due to the characteristics of the sample itself, with the majority of patients with a dysfunctional profile.

Knowledge, Perceptions, and Use of Psychedelics among Individuals with Fibromyalgia

Fibromyalgia (FM) is a difficult to treat chronic pain condition for which there is strong interest in alternative treatments. There is growing interest in the potential of psychedelic substances (e.g., psilocybin) in conjunction with psychotherapy to treat chronic pain. Via a cross-sectional, anonymous, online survey, we aimed to characterize knowledge, perceptions, and past use of serotonergic ("classic") and non-serotonergic psychedelics among a population of individuals with FM, and to investigate interest in psychedelic-based FM treatments. Among a North American population of 354 participants with FM, 29.9% reported past use of a psychedelic, with lysergic acid diethylamide (LSD) and psilocybin mushrooms being most commonly used. Perceptions of benefit from psychedelic use were generally neutral (59.4%) or positive (36.8%), with <3% reporting negative impacts on overall health or pain symptoms. Among 12 participants who used psychedelics with intentions of treating chronic pain, 11 reported improved symptoms. Regardless of past use, the majority of participants believed that psychedelics have potential for chronic pain treatments and would be willing to participate in a psychedelic-based clinical trial for their pain. These findings support the need for additional studies to understand the potential and effectiveness of psychedelic substances in managing FM symptoms.

Efficacy of acupuncture in the treatment of fibromyalgia

Purpose of Review

Fibromyalgia is a highly prevalent chronic pain syndrome that affects up to 4% of the population and causes significant morbidity and disability, with an increasing associated cost. Though many approaches for treatment have been tested, therapy regimens are still elusive, and efficacy is limited. This review summarizes the background of fibromyalgia and acupuncture and reviews the latest and seminal literature discussing the application of acupuncture in fibromyalgia.

Recent Findings

Fibromyalgia is hard to treat, owing both to its chronicity and poorly understood pathophysiology and etiology. Current treatments target symptoms primarily, and few attempt to address the source. Efficacious treatment requires long-term treatment by a multidisciplinary team. Though several treatments exist, they still fall short with a substantial number of patients. Acupuncture, a form of integrative medicine, has been a part of traditional Chinese medication for generations. Evidence shows that it effectively treats different kinds of pain conditions, including migraines and chronic musculoskeletal pain. Recent studies showed evidence to support its use in fibromyalgia. Clinical trials studying acupuncture in fibromyalgia have shown improvement in pain, quality of sleep, and quality of life, though the quality of evidence is mainly low to medium. Several studies were not able to provide evidence to support real over sham acupuncture. Weighing the overall evidence paints a picture of mixed results between equivocal results to positive. In analyzing these results, one must also consider publication bias supporting the dissemination of positive results.

Summary

An increasing number of studies support the utilization of acupuncture for the treatment of fibromyalgia. Though no head-to-head comparison was able to show the superiority of acupuncture to other therapies, mounting evidence supports its use as part of multimodal approaches to treatment with additive efficacy to traditional therapy. Further research will likely provide data on effective regimens and combination therapies.

Fibromyalgia: practical considerations for oral health care providers

Fibromyalgia is a syndrome characterized by chronic pain in the skeletal system accompanied by stiffness, sleep disturbance, fatigue, and psychiatric problems, such as anxiety and depression. Fibromyalgia commonly affects orofacial health, presenting with a variety of oral manifestations, including temporomandibular disorder, xerostomia, glossodynia, and dysgeusia. Therefore, oral healthcare providers need to be aware of this clinical entity to effectively manage oral symptoms and provide proper oral self-care modification and education on the nature of fibromyalgia. This review focuses on the epidemiology, pathophysiology, clinical manifestation, diagnosis, orofacial concerns, and treatment of fibromyalgia.

The 4 U's Rule of Fibromyalgia: A Proposed Model for Fatigue in a Sample of Women with Fibromyalgia: A Qualitative Study

Although fatigue usually goes unnoticed, it is a symptom that poses great challenges to patients with fibromyalgia and is a strong limitation. The aim of this study is to identify and describe the variables involved in fatigue in nine different situations of the Goal Pursuit Questionnaire (GPQ) that may occur in the daily lives of women with fibromyalgia, according to an ABC (Antecedents–Behaviors–Consequences) model. This study followed a qualitative descriptive research method and a deductive–inductive hybrid approach based on a phenomenological paradigm. Twenty-six women with fibromyalgia participated in focus group discussions between February and March of 2018. Thematic content analysis was carried out from transcribed verbatim interviews. We identified nine major themes that emerged from the participants’ conversations: self-imposed duties, muscle fatigue, overwhelming feeling of tiredness, difficulty thinking, difficulty concentrating, negative emotions, lifestyle changes, affected everyday activities, and lack of motivation for daily activities and social interactions. We conclude that the ABC model allowed certain elements to emerge regarding the fatigue experience, highlighting its importance as a symptom in fibromyalgia. This additional analysis of the ABC model showed that fatigue can be described through the 4 U’s Rule, which is integrated by these four adjectives: (1) Unpredictable, (2) Uncontrollable, (3) Unseen, and (4) Unintelligible. Identifying these characteristics can contribute to a better understanding of fibromyalgia in addition to better treatment for these patients.

Influence of depressive feelings in the brain processing of women with fibromyalgia: An EEG study

Depression is one of the most common mental health problems which affects more than 10% of the global population. The prevalence of this disorder is higher in fibromyalgia patients. However, the influence of the combination of depression and fibromyalgia in the brain processing is poorly understood.To explore the modifications of EEG power spectrum in women with fibromyalgia when depressive feelings are elicited.Twenty eight women with fibromyalgia participated in this cross-sectional study. They were classified as women with depression or women without depression according to the score in the Geriatric Depression Scale. This questionnaire was used to elicit depression symptoms during the EEG recording. Analyses were performed with the standardized LOw Resolution Electric Tomography (sLORETA) software. Power spectrum were compared in the following frequency bands: delta, theta, alpha-1, alpha-2, beta-1, beta-2, and beta-3.Fibromyalgia patients with untreated depression showed a hypoactivation of the left hemisphere when compared with fibromyalgia patients without depression. In addition, when compared fibromyalgia patients without depression and women with both fibromyalgia and depression who were taking antidepressant medications, differences in EEG power spectrum in the studied frequency bands were not found.The current study contributes to the understanding on the influence of the combination of fibromyalgia and depression in the brain activity patterns. Patients with untreated depression showed a hypoactivation of the left hemisphere while eliciting depression symptoms. However, further research is needed, antidepressant medication might reduce the differences between patients with depression and those who do not suffer from depression symptoms.

Gender Differences in the Prevalence of Fibromyalgia and in Concomitant Medical and Psychiatric Disorders: A National Veterans Health Administration Study

BACKGROUND

Fibromyalgia is a poorly understood, chronically disabling pain syndrome. While research has focused on its clinical presentation and treatment, less is known about fibromyalgia's clinical epidemiology in real-world healthcare systems. Gender differences have been difficult to study because relatively few males are diagnosed with fibromyalgia.

METHODS

Veterans Health Administration (VHA) patients diagnosed with fibromyalgia nationwide in FY 2012 were compared to Veterans with other pain diagnoses on sociodemographic characteristics, medical and psychiatric diagnoses, health service use, and opioid and psychotropic prescription fills. Additional analyses compared characteristics of men and women diagnosed with fibromyalgia. Risk ratios and Cohen's d were used for bivariate comparisons, followed by logistic regression analyses to identify independent factors associated with a diagnosis of fibromyalgia in the VHA.

RESULTS

Altogether, 77,087 of 2,216,621 Veterans with pain diagnoses (3.48%) were diagnosed with fibromyalgia. They were more likely to be female, younger than patients with other pain conditions, more likely to have multiple psychiatric comorbidities and other types of pain, and used more medical outpatient services. Women diagnosed with fibromyalgia were younger and more likely to have headaches, connective tissue diseases (CTD), and psychiatric comorbidities, while men had more comorbid medical conditions.

CONCLUSIONS

In this large, predominantly older male sample of Veterans with pain diagnoses, those with fibromyalgia were far more likely to be women. Gender comparisons showed women with fibromyalgia were more likely to be diagnosed with psychiatric disorders and CTD, while males were more likely to be diagnosed with medical conditions. Fibromyalgia shows a striking, gender-dependent picture of multimorbidity, which should be considered in treatment.

Fibromyalgia syndrome care of Iraq- and Afghanistan-deployed Veterans in Veterans Health Administration

Little is known regarding fibromyalgia syndrome (FMS) care among Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn (OIF/OEF/OND) Veterans. Current recommendations include interdisciplinary, team-based combined care approaches and limited opioid use. In this study of OIF/OEF/OND Veterans who accessed Veterans Health Administration services between 2002 and 2012, we hypothesized that combined care (defined as at least 4 primary care visits/yr with visits to mental health and/or rheumatology) versus <4 primary care visits/yr only would be associated with lower risk of at least 2 opioid prescriptions 12 mo following an FMS diagnosis. Using generalized linear models with a log-link, the Poisson family, and robust standard errors, we estimated risk ratios (RRs) and 95% confidence intervals (CIs). We found that 1% of Veterans had at least 2 FMS diagnoses (International Classification of Diseases-9th Revision-Clinical Modification code 729.1) or at least 1 FMS diagnosis by rheumatology. Veterans with (vs without) FMS were more likely to be female, older, Hispanic, and never/currently married. Combined primary, mental health, and rheumatology care was associated with at least 2 opioid prescriptions (RR [95% CI] for males 2.2 [1.1-4.4] and females 2.8 [0.4-18.6]). Also, combined care was associated with at least 2 nonopioid pain-related prescriptions, a practice supported by evidence-based clinical practice guidelines. In tandem, these results provide mixed evidence of benefit of combined care for FMS. Future studies of healthcare encounter characteristics, care coordination, and benefits for Veterans with FMS are needed.

Effects of 15 weeks of resistance exercise on pro-inflammatory cytokine levels in the vastus lateralis muscle of patients with fibromyalgia

Background

This study aimed at investigating the effect of a resistance exercise intervention on the interstitial muscle levels of pro-inflammatory cytokines in fibromyalgia (FMS) and healthy controls (CON).

Methods

Twenty-four female patients with FMS (54 ± 8 years) and 27 female CON (54 ± 9 years) were subjected to intramuscular microdialysis of the most painful vastus lateralis muscle before and after 15 weeks of progressive resistance exercise twice per week. Baseline dialysates were sampled in the resting muscle 140 min after insertion of the microdialysis catheter. The participants then performed repetitive dynamic contractions (knee extension) for 20 min, followed by 60 min rest. Pain intensity was assessed with a 0–100 mm visual analogue scale (VAS), and fatigue was assessed with Borg’s RPE throughout microdialysis. Dialysates were sampled every 20 min and analyzed with Luminex for interleukin (IL)-1β, tumor necrosis factor (TNF) alpha, IL-6, and IL-8.

Results

At both sessions and for both groups the dynamic contractions increased pain (P < 0.012) and fatigue (P < 0.001). The levels of TNF were lower in the FMS group than the CON group at both sessions (P < 0.05), but none of the other cytokines differed between the groups. IL-6 and IL-8 increased after the dynamic contractions in both groups (P < 0.010), while TNF increased only in CON (P < 0.05) and IL-1β did not change. Overall pain intensity was reduced after the 15 weeks of resistance exercise in FMS (P < 0.05), but there was no changes in fatigue or cytokine levels.

Conclusion

Progressive resistance exercise for 15 weeks did not affect the interstitial levels of IL-1β, TNF, IL-6, and IL-8 in the vastus lateralis muscle of FMS patients or CON.

Trial registration

Clinicaltrials.gov NCT01226784, registered 21 October 2010.

Can mastalgia be another somatic symptom in fibromyalgia syndrome?

OBJECTIVE

The purposes of this study were to determine the coexistence of mastalgia and fibromyalgia, to investigate the effects of this combination on pain patterns, and to discuss the status of breast pain in the diagnostic algorithm of fibromyalgia syndrome.

METHODS

Sixty-one female patients reporting breast pain during the last three months and 53 female patients diagnosed with fibromyalgia syndrome were enrolled in this study. The Breast Pain Questionnaire was administered to all participants in the mastalgia group and to those in the fibromyalgia syndrome group who had experienced mastalgia during the past three months. The patients in the fibromyalgia syndrome group were evaluated using the 2010 preliminary American College of Rheumatology classification criteria. All of the patients in the mastalgia group were evaluated for the diagnosis of fibromyalgia syndrome by a single physiatrist. The coexistence and pain patterns of mastalgia and fibromyalgia were assessed statistically.

RESULTS

Approximately half of the patients with fibromyalgia syndrome (47.2%) reported having mastalgia at the time of admission and 37.7% of the patients with mastalgia met the diagnostic criteria for fibromyalgia syndrome. The patients with mastalgia in the fibromyalgia syndrome group had significantly higher total breast pain scores compared with the women in the mastalgia group. In addition, the patients with fibromyalgia syndrome in the mastalgia group had significantly higher Widespread Pain Index and Symptom Severity Scale scores than the patients with fibromyalgia syndrome.

CONCLUSIONS

We suggest that mastalgia can be an aspect of the central sensitivity syndrome and can be added to the somatic symptoms of fibromyalgia.

Frequency of Migraine Headaches in Patients With Fibromyalgia

OBJECTIVE

The purpose of this study was to evaluate the frequency of migraine headache in a large cohort of patients with fibromyalgia using a brief migraine headache-screening tool.

BACKGROUND

Several studies report a high prevalence of fibromyalgia among patients with migraine headaches, but there is a dearth of research evaluating the frequency of migraine headaches in patients with fibromyalgia, despite clinical observations suggesting that migraine headaches are common in patients with fibromyalgia.

DESIGN AND METHODS

This was a cross-sectional survey study. Patients (N = 3717) with a previous diagnosis of fibromyalgia who were members of the Mayo Clinic Fibromyalgia Registry were contacted by electronic survey and asked to complete a brief demographic and medical history questionnaire and the validated ID-Migraine screener.

RESULTS

A total of 1730 patients (46.5%) completed the electronic survey. The majority of participants were white (97.2%), female (92.5%), with a mean age of 56.2 (±13.1) years. Of the respondents, 966 (55.8%) met criteria for migraine headaches. Hypertension (309 [32.3%] vs. 294 [40.1%], P = .004), asthma (312 [32.5%] vs. 189 [25.9%], P = .011), irritable bowel syndrome (520 [54.6%] vs. 348 [47.6], P = .017), chronic fatigue syndrome (486 [50.7%] vs. 271 [37.1], P < .0001), depression (634 [66.5%] vs. 413 [56.7%], P = .0002), anxiety (415 [43.5%] vs. 252 [34.7%], P = .0011), and post-traumatic stress disorder (172 [18.0%] vs. 96 [13.2%], P = .006) were all significantly more common in those who met criteria for migraine headaches than those who did not.

CONCLUSION

The results of this study suggest that migraine headaches are common in patients with fibromyalgia. Clinicians who care for either population must be aware that these conditions commonly overlap and can significantly increase a patient's cumulative disease burden.

[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.

A cross-sectional assessment of the prevalence of multiple chronic conditions and medication use in a sample of community-dwelling adults with fibromyalgia in Olmsted County, Minnesota

OBJECTIVES

The objective of this study was to evaluate the problem of multiple chronic conditions and polypharmacy in patients with fibromyalgia.

DESIGN

Retrospective medical record review.

SETTING

Olmsted County, Minnesota.

PARTICIPANTS

1111 adults with fibromyalgia.

PRIMARY AND SECONDARY OUTCOME MEASURES

Number and type of chronic medical and psychiatric conditions, medication use.

RESULTS

Medical record review demonstrated that greater than 50% of the sample had seven or more chronic conditions. Chronic joint pain/degenerative arthritis was the most frequent comorbidity (88.7%), followed by depression (75.1%), migraines/chronic headaches (62.4%) and anxiety (56.5%). Approximately, 40% of patients were taking three or more medications for symptoms of fibromyalgia. Sleep aids were the most commonly prescribed medications in our sample (33.3%) followed by selective serotonin reuptake inhibitors (28.7%), opioids (22.4%) and serotonin norepinephrine reuptake inhibitors (21.0%).

CONCLUSIONS

The results of our study highlight the problem of multiple chronic conditions and high prevalence of polypharmacy in fibromyalgia. Clinicians who care for patients with fibromyalgia should take into consideration the presence of multiple chronic conditions when recommending medications.

Vitamin D and central hypersensitivity in patients with chronic pain

BACKGROUND

Low vitamin D is implicated in various chronic pain conditions with, however, inconclusive findings. Vitamin D might play an important role in mechanisms being involved in central processing of evoked pain stimuli but less so for spontaneous clinical pain.

OBJECTIVE

This study aims to examine the relation between low serum levels of 25-hydroxyvitamin D3 (25-OH D) and mechanical pain sensitivity.

DESIGN

We studied 174 patients (mean age 48 years, 53% women) with chronic pain. A standardized pain provocation test was applied, and pain intensity was rated on a numerical analogue scale (0-10). The widespread pain index and symptom severity score (including fatigue, waking unrefreshed, and cognitive symptoms) following the 2010 American College of Rheumatology preliminary diagnostic criteria for fibromyalgia were also assessed. Serum 25-OH D levels were measured with a chemiluminescent immunoassay.

RESULTS

Vitamin deficiency (25-OH D < 50 nmol/L) was present in 71% of chronic pain patients; another 21% had insufficient vitamin D (25-OH D < 75 nmol/L). After adjustment for demographic and clinical variables, there was a mean ± standard error of the mean increase in pain intensity of 0.61 ± 0.25 for each 25 nmol/L decrease in 25-OH D (P = 0.011). Lower 25-OH D levels were also related to greater symptom severity (r = -0.21, P = 0.008) but not to the widespread pain index (P = 0.83) and fibromyalgia (P = 0.51).

CONCLUSIONS

The findings suggest a role of low vitamin D levels for heightened central sensitivity, particularly augmented pain processing upon mechanical stimulation in chronic pain patients. Vitamin D seems comparably less important for self-reports of spontaneous chronic pain.

A cross-sectional survey assessing sources of movement-related fear among people with fibromyalgia syndrome

Fear of movement may contribute to functional limitations and loss of well-being among individuals with fibromyalgia (FM). The objectives of this study were to assess factors contributing to movement-related fear and to explore relationships among these factors, function and wellness, in a widespread population of people with FM. This was an internet survey of individuals with FM. Respondents completed a battery of surveys including the Fibromyalgia Impact Questionnaire--Revised (FIQR), Tampa Scale of Kinesiophobia (TSK), Activities-Specific Balance Confidence Scale (ABC), Primary Care Posttraumatic Stress Disorder screen (PC-PTSD), Vertigo Symptom Scale (VSS-SF), a joint hypermobility syndrome screen (JHS), and screening questions related to obsessive-compulsive personality disorder (OCPD), physical activity, work status, and demographics. Analysis included descriptive statistics, Pearson product-moment correlations, and linear regression. Over a 2-year period, 1,125 people (97.6 % female) completed the survey battery. Kinesiophobia was present in 72.9 % of the respondents, balance confidence was compromised in 74.8 %, PTSD likely in 60.4 %, joint hypermobility syndrome likely in 46.6 %, and OCPD tendencies in 26.8 %. The total FIQR and FIQR perceived function subscores were highly correlated (p < 0.0005, r > 0.4) with pain, kinesiophobia, balance confidence, and vertigo. Reported activity level had poor correlation (r < 0.25) with all measured variables. Pain, ABC, VSS, and TSK predicted FIQR and FIQR-pf, explaining 65 and 48 % of the variance, respectively. Kinesiophobia, balance complaints, vertigo, PTSD, and joint hypermobility were common in this population of people with FM. Sources of movement-related fear correlated to overall wellness and perceived function as measured by the FIQR and FIQR-pf.

Do participation and personalization matter? A model-driven evaluation of an Internet-based patient education intervention for fibromyalgia patients

OBJECTIVES

To evaluate the effectiveness of an Internet-based patient education intervention, which was designed upon principles of personalization and participatory design.

METHODS

Fifteen months after the first release of the website, 209 fibromyalgia patients recruited through health professionals completed an online questionnaire to assess patients' use of the website, health knowledge, self-management behavior, and health outcomes. These constructs were combined into an a-priory model that was tested using a structural equation modeling approach.

RESULTS

Results show that the usage of certain tools of the website - designed and personalized involving the end users - impacts patients' health knowledge, which in turn impacts self-management. Improvements in self-management ultimately lower the impact of Fibromyalgia Syndrome leading to better health outcomes.

CONCLUSION

This study empirically confirmed that the adoption of a participatory approach to the design of eHealth interventions and the use of personalized contents enhance the overall effectiveness of systems.

PRACTICE IMPLICATIONS

More time and effort should be invested in involving patients in the preliminary phases of the development of Internet-based patient education interventions and in the definition of models that can guide the systems' evaluation beyond technology-related variables such as usability, accessibility or adoption.

Preliminary investigation of absent nociceptive flexion reflex responses among more symptomatic women with fibromyalgia syndrome

Fibromyalgia syndrome (FMS) is a widespread musculoskeletal pain condition with unclear physiologic mechanisms. The purpose of this investigation was to compare the responsiveness of nociceptive flexion reflex (NFR) pathways between women with and without FMS. A secondary purpose was to examine the influence of depression, fibromyalgia symptom severity, and cardiovascular health on NFR responses among women with FMS. Fifteen women with FMS and 14 healthy controls participated in an experimental session to assess NFR responses to sural nerve stimulation, resting mean arterial pressure (MAP) and heart rate (HR), and scores on the Beck Depression Inventory (BDI) and Fibromyalgia Impact Questionnaire (FIQ). NFR responses were successfully elicited from all healthy individuals, but only eight (53 %) of the women with FMS. These women did not differ in the minimum stimulus intensity required to elicit an NFR response compared to healthy controls (p ≥ 0.35). Further, these women had lower BDI (p = 0.04) and FIQ (p = 0.02) scores compared to women with FMS from whom NFR responses could not be elicited. Resting HR was higher in both groups of women with FMS compared to healthy individuals (p < 0.05), and MAP was strongly associated with NFR thresholds only among women with FMS (r = 0.88, p < 0.01). Findings from this preliminary investigation suggest that NFR pathways are impaired in women who are more severely impacted by symptoms of depression and fibromyalgia, potentially due to desensitization of NFR pathways with chronic autonomic arousal.

Milnacipran for fibromyalgia: a useful addition to the treatment armamentarium

INTRODUCTION

Antidepressants are used to treat a variety of chronic pain conditions including peripheral neuropathy, headache, and more recently, fibromyalgia. The antidepressant milnacipran blocks the reuptake of norepinephrine and serotonin and is used for the management of fibromyalgia.

AREAS COVERED

The article contains data primarily obtained from the MEDLINE database using a PubMed search of the keywords including milnacipran, fibromyalgia and depression. Of the available serotonin norepinephrine reuptake inhibitors, milnacipran has greater potency in inhibiting reuptake of norepinephrine relative to serotonin and is proposed to work by attenuating pain signals. Milnacipran is well tolerated and effective for fibromyalgia pain when given in divided doses of 100 - 200 mg daily. Studies show that milnacipran may be effective for fibromyalgia-associated symptoms including depression and fatigue.

EXPERT OPINION

Milnacipran provides modest fibromyalgia pain relief and is best used as part of a multidisciplinary treatment approach. While milnacipran was not studied in fibromyalgia patients with major depression, it may be a wise choice for fibromyalgia patients with depressive symptoms and patients for whom sedation, dizziness, edema or weight gain with gabapentin and pregabalin is a problem. Milnacipran has been found to be beneficial for treating some troublesome fibromyalgia-associated symptoms, including fatigue and cognitive dysfunction.

Direct medical costs and medication compliance among fibromyalgia patients: duloxetine initiators vs. pregabalin initiators

OBJECTIVES

To assess and compare direct medical costs and medication compliance between patients with fibromyalgia who initiated duloxetine and patients with fibromyalgia who initiated pregabalin in 2008.

METHODS

A retrospective cohort study design was used based on a large US national commercial claims database (2006 to 2009). Patients with fibromyalgia aged 18 to 64 who initiated duloxetine or pregabalin in 2008 and who had continuous health insurance 1 year preceding and 1 year following the initiation were selected into duloxetine cohort or pregabalin cohort based on their initiated agent. Medication compliance was measured by total supply days, medication possession ratio (MPR), and proportion of patients with MPR ≥ 0.8. Direct medical costs were measured by annual costs per patient and compared between the cohorts in the year following the initiation. Propensity score stratification and bootstrapping methods were used to adjust for distribution bias, as well as cross-cohort differences in demographic, clinical and economic characteristics, and medication history prior to the initiation.

RESULTS

Both the duloxetine (n = 3,033) and pregabalin (n = 4,838) cohorts had a mean initiation age around 49 years, 89% were women. During the postindex year, compared to the pregabalin cohort, the duloxetine cohort had higher totally annual supply days (273.5 vs. 176.6, P < 0.05), higher MPR (0.7 vs. 0.5, P < 0.05), and more patients with MPR ≥ 0.8 (45.1% vs. 29.4%, P < 0.05). Further, relative to pregabalin cohort, duloxetine cohort had lower inpatient costs ($2,994.9 vs. $4,949.6, P < 0.05), lower outpatient costs ($8,259.6 vs. $10,312.2, P < 0.05), similar medication costs ($5,214.6 vs. $5,290.8, P > 0.05), and lower total medical costs ($16,469.1 vs. $20,552.6, P < 0.05) in the postinitiation year.

CONCLUSIONS

In a real-world setting, patients with fibromyalgia who initiated duloxetine in 2008 had better medication compliance and consumed less inpatient, outpatient, and total medical costs than those who initiated pregabalin.

Review of somatic symptoms in post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is associated with both (1) 'ill-defined' or 'medically unexplained' somatic syndromes, e.g. unexplained dizziness, tinnitus and blurry vision, and syndromes that can be classified as somatoform disorders (DSM-IV-TR); and (2) a range of medical conditions, with a preponderance of cardiovascular, respiratory, musculoskeletal, neurological, and gastrointestinal disorders, diabetes, chronic pain, sleep disorders and other immune-mediated disorders in various studies. Frequently reported medical co-morbidities with PTSD across various studies include cardiovascular disease, especially hypertension, and immune-mediated disorders. PTSD is associated with limbic instability and alterations in both the hypothalamic- pituitary-adrenal and sympatho-adrenal medullary axes, which affect neuroendocrine and immune functions, have central nervous system effects resulting in pseudo-neurological symptoms and disorders of sleep-wake regulation, and result in autonomic nervous system dysregulation. Hypervigilance, a central feature of PTSD, can lead to 'local sleep' or regional arousal states, when the patient is partially asleep and partially awake, and manifests as complex motor and/or verbal behaviours in a partially conscious state. The few studies of the effects of standard PTSD treatments (medications, CBT) on PTSD-associated somatic syndromes report a reduction in the severity of ill-defined and autonomically mediated somatic symptoms, self-reported physical health problems, and some chronic pain syndromes.

Self-ratings of higher olfactory acuity contrast with reduced olfactory test results of fibromyalgia patients

BACKGROUND

Self-reports of fibromyalgia (FM) patients about an enhanced olfactory acuity have been used to characterize them as persons with a general increased sensitivity to sensory input consistent with a central sensitization. However, as reduced activations in some brain areas also seem to accompany FM, a multisensory hypersensitivity is not a necessary consequence.

METHODS

FM patients meeting ARA (American Rheumatism Association) criteria (16 women and one man, aged 23-56 years, spontaneous pain 32-91 mm visual analog scale [VAS], 14-18 tender points with a pressure pain threshold of 1.5±0.7 kg/cm(2)) received an olfactory test (Sniffn' Sticks) to assess their odor thresholds to n-butanol and their ability to discriminate and identify odors. Healthy controls were 14 age-matched women and one man.

RESULTS

Patients had poorer odor identification than controls (14.6±1.3 vs. 15.5±0.6; p<0.05) but did not differ in odor thresholds or odor discrimination. This test result contrasted with the patients' self-ratings of their olfactory sensitivity as higher than average.

CONCLUSIONS

The perception of FM patients as being multisensory hypersensitive is not supported by present results. In contrast to the subjects' self-ratings, measurements of olfactory function showed a slightly reduced odor identification, with a by-and-large normal performance.

Effects of functional interactivity on patients' knowledge, empowerment, and health outcomes: an experimental model-driven evaluation of a web-based intervention

BACKGROUND

The effectiveness of eHealth interventions in terms of reach and outcomes is now well documented. However, there is a need to understand not only whether eHealth interventions work, but also what kind of functions and mechanisms enhance their effectiveness. The present investigation contributes to tackling these challenges by investigating the role played by functional interactivity on patients' knowledge, empowerment, and health outcomes.

OBJECTIVES

To test whether health knowledge and empowerment mediate a possible relationship between the availability of interactive features on an eHealth application and individuals' health outcomes. We present an empirical, model-driven evaluation of the effects of functional interactivity implemented in an eHealth application, based on a brief theoretical review of the constructs of interactivity, health knowledge, empowerment, and health outcomes. We merged these constructs into a theoretical model of interactivity effects that we tested on an eHealth application for patients with fibromyalgia syndrome (FMS).

METHODS

This study used a pretest-posttest experimental design. We recruited 165 patients and randomly assigned them to three study groups, corresponding to different levels of functional interactivity. Eligibility to participate in the study required that patients (1) be fluent in Italian, (2) have access to the Internet, (3) report confidence in how to use a computer, and (4) have received a diagnosis of FMS from a doctor. We used structural equation modeling techniques to analyze changes between the pretest and the posttest results.

RESULTS

The main finding was that functional interactivity had no impact on empowerment dimensions, nor direct observable effects on knowledge. However, knowledge positively affected health outcomes (b = -.12, P = .02), as did the empowerment dimensions of meaning (b = -.49, P < .001) and impact (b = -.25, P < .001).

CONCLUSION

The theoretical model was partially confirmed, but only as far as the effects of knowledge and empowerment were concerned. The differential effect of interactive functions was by far weaker than expected. The strong impact of knowledge and empowerment on health outcomes suggests that these constructs should be targeted and enhanced by eHealth applications.

Sleep disturbance in Moroccan patients with ankylosing spondylitis: prevalence and relationships with disease-specific variables, psychological status and quality of life

Sleep disturbance is often reported by the patients with ankylosing spondylitis (AS), with awakenings produced by inflammatory pain. There are limited studies about sleep disturbance on these patients, and especially its association with psychological state and quality of life to examine the prevalence of sleep disturbance and to assess its association with disease-specific variables, psychological status and quality of life. One hundred and ten patients were included in this cross-sectional study according to the modified New York criteria for AS. Clinical and biological parameters were evaluated. Sleep disturbance was assessed by the fourth item of Hamilton Anxiety Scale. Psychological status was assessed by The Hospital Anxiety and Depression Scale including depression subscale and anxiety subscale. The quality of life was evaluated by the short form-36 (SF-36). Sleep disturbance was found in 64.5 %, depression in 55.5 % and anxiety in 60.9 % amongst our patients. Significantly, worse pain, higher disease activity and functional disability were present in patients with sleep disturbance. Likewise, sleep problems were significantly higher in patients with depression, anxiety and in patients with low scores of the SF36. Multivariate logistic regression analysis revealed that the pain (OR = 1.019) and depression (OR = 1.304) were independent risk factors that influenced sleep disturbance. Sleep problems are prevalent amongst Moroccan patients with AS. Our findings suggest that pain and depression were the independent risk factors that influenced the sleep disturbance and hence, the need for evaluation and optimal management of pain and depression to improve sleep quality in AS patients.

Chronic widespread pain: from peripheral to central evolution

Chronic pain can be classified as localised, regional or widespread, and its high prevalence in the general population seems to increase with age. The majority of cases present with musculoskeletal pain. The conditions associated with chronic widespread pain (CWP) are highly burdensome as their characteristic symptoms may include multifocal pain, fatigue, insomnia, memory difficulties and a higher rate of concomitant mood disorders. After many years of debate, it is still unclear whether CWP (central sensitisation) is an entirely explainable neurotransmitter-related process or is partially or totally due to individual cognitive experiences and evaluations. The two models (neurochemical and biopsychosocial) also affect our ability to find therapeutic answers.

Pain and post traumatic stress disorder - review of clinical and experimental evidence

Pain and Post Traumatic Stress Disorder (PTSD) are highly comorbid conditions. Patients with chronic pain have higher rates of PTSD. Likewise, patients with PTSD are often diagnosed with numerous chronic pain conditions. Despite the high pain-PTSD comorbidity, the neurobehavioral mechanisms underlying this phenomenon are incompletely understood and only recently researchers have started investigating it using experimental models. In this article, we systematically review the substantial clinical evidence on the co-occurrence of pain and PTSD, and the limited experimental evidence of pain processing in this disorder. We provide a detailed overview of the psychophysical and brain imaging experiments that compared somatosensory and pain processing in PTSD and non-PTSD populations. Based on the presented evidence, an extensive body of literature substantiates the clinical coexistence of pain and PTSD in patients but the limited experimental data show inconsistent results highlighting the need for well-controlled future studies. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

Nociceptive and anxiety-like behavior in reproductively competent and reproductively senescent middle-aged rats

BACKGROUND

Changes in levels of estradiol and progesterone that occur with the transition to reproductive senescence may influence nociception or affect.

OBJECTIVE

To ascertain whether nociceptive and affective processes change with reproductive senescence, this study examined pain and anxiety-like behaviors in middle-aged female rats that were reproductively competent, transitioning to reproductive senescence, or reproductively senescent.

METHODS

Middle-aged (12-14 months old) female rats (N = 46) were tested in the following tasks to assess pain and anxiety-like behavior: tail flick, elevated plus maze, elevated zero maze, mirror maze, Vogel punished drinking, and defensive burying. For the tail-flick task, the latency for rats to move their tail from a heat source, as an indication of pain sensitivity, was determined. In the elevated plus and elevated zero mazes, the time spent on the open arms or quadrants, respectively, were determined as measures of reduced anxiety behavior. In the mirror maze, the time spent in the mirrored portion of the chamber was used as an indicator of anxiety-like responding. In the Vogel task, the number of punished licks made was determined as a measure of reduced anxiety-like behavior. In the defensive burying task, the duration spent by rats burying an electrified prod postfootshock was utilized as an index of anxietylike responding. All rats were experimentally naive, retired breeders from our colony and had not had a litter or been lactating for 1 to 4 weeks before behavioral testing.

RESULTS

Although tail-flick latencies were not significantly different among rats that were reproductively competent or senescent, reproductively competent rats had less anxiety-like behavior in the elevated plus maze (more time spent on the open arms: F(2,43) = 5.93; P < 0.01), elevated zero maze (more time spent on the open quadrants: F(2,43) = 4.62; P = 0.01), and Vogel punished drinking task (more punished licks made: F(2,43) = 3.76; P = 0.03). There were no statistically significant differences in the mirror maze and defensive burying task.

CONCLUSION

In this study of adult female rats, nociceptive behavior did not vary significantly with reproductive senescence, but anxiety-like behavior of rats did.

The auspicious role of the 5-HT3 receptor in depression: a probable neuronal target?

The serotonergic mechanisms have been successfully utilized by the majority of antidepressant drug discovery programmes, while the search for newer targets remains persistent. The present review focused on the serotonin type-3 receptor, the only ion channel subtype in the serotonin family. Behavioural, neurochemical, electrophysiological and molecular analyses, including the results from our laboratory, provided substantial evidence that rationalizes the correlation between serotonin type-3 receptor modulation and rodent depressive-like behaviour. Nevertheless, the reports on polymorphism of serotonin type-3 receptor genes and data from clinical studies (on serotonin type-3 receptor antagonists) were insufficient to corroborate the involvement of this receptor in the neurobiology of depression. The preclinical and clinical studies that have contradicted the antidepressant-like effects of serotonin type-3 receptor antagonists and the reasons underlying such disagreement were discussed. Finally, this critical review commended the serotonin type-3 receptor as a candidate neuronal antidepressant drug target.

Mechanisms of fibromyalgia pain

Chronic musculoskeletal pain is highly prevalent in the United States and includes inflammatory and non-inflammatory syndromes, such as low back pain (reported by 59 million Americans in the past 3 months), neck pain (reported by 30.1 million Americans in the past 3 months), clinical osteoarthritis (reported by 27 million Americans in the past 3 months), and fibromyalgia (FM). FM affects between 2% to 4% of the US population or 12 million people. Inflammatory pain conditions commonly reported by patients include rheumatoid arthritis (2.5 million) and gout (3 million), among others. This article will focus primarily on FM, which is a chronic pain condition that predominately affects women.

The current diagnostic criteria for FM include chronic widespread pain for at least 3 months and the presence of widespread mechanical tenderness. A patient with suspected FM must report pain in all four body quadrants and have at least 11 of 18 tender points for a positive diagnosis to be made. Tender points are areas of the body where pressure is applied until pain threshold is achieved. In addition to pain and tenderness, FM patients very frequently describe widespread stiffness and fatigue, disrupted or poor sleep, dyscognition, and mild soft tissue swelling. Patients often also report symptoms of anxiety and depression.

The relationship between disease activity, sleep, psychiatric distress and pain sensitivity in rheumatoid arthritis: a cross-sectional study

Introduction

Despite recent advances in anti-inflammatory therapy, rheumatoid arthritis (RA) patients continue to rate pain as a priority. The etiology of RA pain is likely multifactorial, including both inflammatory and non-inflammatory components. In this study, we examine the association between disease activity, sleep, psychiatric distress and pain sensitivity in RA.

Methods

Fifty-nine female RA patients completed questionnaires and underwent pressure pain threshold testing to assess hyperalgesia/allodynia at joint and non-joint sites. Blood samples were taken to measure C-reactive protein (CRP). The association between disease activity, sleep problems, psychiatric distress and pain threshold was assessed using Pearson/Spearman correlations and multivariable linear regression. Disease activity levels, sleep problems and psychiatric distress were compared between RA patients with fibromyalgia and RA patients without fibromyalgia.

Results

In unadjusted analyses, CRP was not correlated with pain threshold, but tender joint count was inversely correlated with pain threshold at all sites (P ≤ 0.004). Sleep problems were associated with low pain threshold at all sites (P ≤ 0.0008). Psychiatric distress was associated with low pain threshold at the wrist and thumbnail (P ≤ 0.006). In multivariable linear regression models, CRP was inversely associated with wrist pain threshold (P = 0.003). Sleep problems were inversely associated with pain threshold at all sites (P ≤ 0.01), but psychiatric distress was not. Despite differences in pain threshold, CRP levels and sleep problems between RA patients with fibromyalgia and those without fibromyalgia, associations between these variables did not change when patients with fibromyalgia were excluded.

Conclusions

Multivariable models are essential in analyses of pain. Among RA patients, inflammation is associated with heightened pain sensitivity at joints. In contrast, poor sleep is associated with diffuse pain sensitivity, as noted in central pain conditions such as fibromyalgia. Future studies examining pain sensitivity at joint and non-joint sites may identify patients with different underlying pain mechanisms and suggest alternative approaches to treating RA pain.

Developments in the scientific and clinical understanding of fibromyalgia

Our understanding of fibromyalgia (FM) has made significant advances over the past decade. The current concept views FM as the result of central nervous system malfunction resulting in amplification of pain transmission and interpretation. Research done over the past years has demonstrated a role for polymorphisms of genes in the serotoninergic, dopaminergic and catecholaminergic systems in the etiopathogenesis of FM. Various external stimuli such as infection, trauma and stress may contribute to the development of the syndrome. The management of FM requires an integrated approach combining pharmacological and nonpharmacological modalities. The recent Food and Drugs Administration approval of pregabalin, duloxetine and milnacipran as medications for FM may herald a new era for the development of medications with higher specificity and efficacy for the condition. As our understanding of the biological basis and the genetic underpinning of FM increases, we hope to gain a better understanding of the true nature of the disorder, to better classify patients and to attain more rational therapeutic modalities.

Depression, abuse and its relationship to interstitial cystitis

This study evaluated the prevalence of depression, sexual abuse, and physical abuse among women diagnosed with interstitial cystitis (IC). One hundred forty-one subjects completed the validated Beck's Depression Inventory II Questionnaire (BDI-II) and the validated Drossman Abuse Questionnaire. Ninety-seven (69%) subjects scored 14 or higher on the BDI-II, corresponding to depression. When compared to the US prevalence of 9%, this was significantly higher. Fifty-one subjects (36%) reported sexual abuse which is higher than the US average. The prevalence of childhood sexual abuse in the sample was not significantly different than the US average. The prevalence of physical abuse in the sample was not statistically different than the US average. Women with IC appear to have a higher prevalence of depression and sexual abuse than the general population. Women with IC should be screened for depression and abuse and referred to a mental health expert as necessary for treatment.