Toward an integrated understanding of fibromyalgia syndrome. II. Psychological and phenomenological aspects

A systematic review and meta-analysis of voxel-based morphometric studies of fibromyalgia

Objective

Although neuroimaging investigations have revealed significant changes in brain structure in fibromyalgia (FM) patients, these findings are inconsistent. The current study conducted a systematic review and meta-analysis of voxel-based morphometric studies in order to comprehend those alterations in brain structure in FM patients.

Methods

Voxel-based morphometric (VBM) studies published up to January 17, 2023 were searched in the Web of Science, PubMed, EMBASE, Cochrane Library (CENTRAL), China National Knowledge Infrastructure (CNKI), Chongqing VIP, Wanfang Database. Two independent researchers carried out study screening, quality assessment, clinical data and neuroimaging data extraction. The whole-brain voxel-based gray matter (GM) data of FM patients were collected from eligible studies, and meta-analyzed using anisotropic effect size-signed differential mapping (AES-SDM).

Results

Twelve researches were included in this study, including 289 FM patients (mean age: 47.36 years) and 272 HS (mean age: 47.34 years). According to the meta-analysis, FM patients had increased GM in the right postcentral gyrus and left angular gyrus, and decreased GM in the right cingulate gyrus, right paracingulate gyrus, left cerebellum, and left gyrus rectus.

Conclusion

Our study suggests that fibromyalgia patients have altered gray matter in several brain regions that are involved in affective, cognitive functions, and in motor adaptations to pain processing.

Individuals’ Descriptions of Living With Fibromyalgia

Fibromyalgia (FM) is a chronic pain syndrome with no known etiology, cure, prognosis, or clear diagnostic criteria. This interpretive descriptive study was focused on the experience of living with FM. Using a constant comparative inductive analytic method, the researcher collected and analyzed data from in-depth, semistructured interviews with eight participants. This study’s findings offer insights into the experience of living with and managing FM and identify social, policy, and health care issues that profoundly affect those suffering from it. Participants believe that people with FM would benefit if more health care professionals, as well as family and friends, would validate their condition and provide them with better support. More research could clarify ways in which health care providers may provide more effective interventions, appropriate care, and ongoing support for those affected with FM.

Optimized Treatment of Fibromyalgia Using System Identification and Hybrid Model Predictive Control

The term adaptive intervention is used in behavioral health to describe individually-tailored strategies for preventing and treating chronic, relapsing disorders. This paper describes a system identification approach for developing dynamical models from clinical data, and subsequently, a hybrid model predictive control scheme for assigning dosages of naltrexone as treatment for fibromyalgia, a chronic pain condition. A simulation study that includes conditions of significant plant-model mismatch demonstrates the benefits of hybrid predictive control as a decision framework for optimized adaptive interventions. This work provides insights on the design of novel personalized interventions for chronic pain and related conditions in behavioral health.

Perfectionism and health functioning in women with fibromyalgia

OBJECTIVE

The purpose of this study was to examine the associations between dimensions of perfectionism (self-oriented, other-oriented, and socially prescribed perfectionism) and health functioning in a sample of 489 women with fibromyalgia.

METHODS

Hierarchical multiple regression was used to determine whether dimensions of perfectionism were differentially associated with health functioning among women with fibromyalgia after accounting for broader personality traits related to both perfectionism and health functioning.

RESULTS

The results confirmed that both socially prescribed perfectionism and self-oriented perfectionism were associated with lower health functioning. Moreover, these associations were found after accounting for the effects of conscientiousness, extraversion, and neuroticism. The findings involving self-oriented perfectionism were particularly complex and suggested that moderate self-oriented perfectionism may be somewhat adaptive, but too much or too little self-oriented perfectionism is associated with substantial reductions in health functioning among women with fibromyalgia.

CONCLUSION

Collectively, these findings clarify that overall levels of perfectionism are not elevated among women with fibromyalgia, but those women who are exceptionally high in levels of self-oriented perfectionism or high in socially prescribed perfectionism are particularly likely to suffer lower health functioning. These results suggest that perfectionism should be specifically assessed and targeted for intervention among women with fibromyalgia and there should be a particular emphasis on the pressure to meet perceived or actual expectations imposed on the self.

Psychosomatic pain in children: A psychomuscular tension reaction?

Although recurrent psychosomatic pain is a common paediatric condition, our understanding of it is still limited. In this article, the clinical picture is presented and the concept of psychosomatic pain is discussed. Some recent scientific data are presented including a controlled blind study of pain pressure thresholds showing significantly reduced mean values over common pain areas in a group of children with psychosomatic pain. According to another study, these children also have significantly reduced concentrations of the hypothalamic hormone oxytocin and cortisol. With these data as a point of departure, a model for psychosomatic pain reaction is outlined in which stress is assumed to induce muscular tension, in turn triggering the nociceptive process. In this psychosomatic reaction, the hypothalamus is believed to have a central regulatory function.

Fibromyalgia: from pathophysiology to therapy

Individuals with fibromyalgia generally experience chronic widespread pain, which can be accompanied by further symptoms including fatigue, sleep disturbances, cognitive dysfunction, anxiety and depressive episodes. As the recognition and diagnosis of fibromyalgia has improved, the availability of therapeutic options for patients has increased. Furthermore, research into the neurobiological mechanisms that contribute to the chronic pain and concomitant symptoms experienced by patients with fibromyalgia has advanced our understanding of this debilitating disorder. In this Review, we aim to provide an overview of existing pathophysiological concepts. The roles of biological and psychological stress, genetic factors, and pain and sensory processing in the pathophysiology of fibromyalgia and related conditions are discussed. In addition, pharmacological treatments, including monoamine modulators, calcium channel modulators and γ-aminobutyric acid modulators, as well as nonpharmacological treatment options are considered.

Is chronic pain associated with somatization/hypochondriasis? An evidence-based structured review

STUDY DESIGN

This is an evidence-based structured review.

OBJECTIVES

The objectives of this review were to answer the following questions: (1) Are somatization/hypochondriasis associated with chronic pain? (2) Is the degree of somatization/hypochondriasis related to pain levels? (3) Does pain treatment improve somatization/hypochondriasis? (4) Are some pain diagnoses differentially associated with somatization/hypochondriasis?

METHODS

Fifty-seven studies which fulfilled inclusion criteria and had high quality scores were sorted by the above-mentioned objectives. Agency for health care policy and research guidelines were utilized to type and characterize the strength/consistency of the study evidence within each objective.

RESULTS

Somatization and hypochondriasis were both consistently associated with chronic pain (consistency ratings B and A, respectively). Study evidence indicated a correlation between pain intensity and presence of somatization and hypochondriasis (consistency rating A and B, respectively). Pain treatment improved somatization and hypochondriasis (consistency rating B and A, respectively). Some chronic pain diagnostic groups somatized more (consistency rating B).

CONCLUSIONS

Somatization is commonly associated with chronic pain and may relate to pain levels.

HPA axis reactivity and lymphocyte glucocorticoid sensitivity in fibromyalgia syndrome and chronic pelvic pain

OBJECTIVE

Chronic pelvic pain (CPP) and fibromyalgia syndrome (FMS) have been associated with hypothalamic-pituitary-adrenal (HPA) axis alterations, i.e., mild hypocortisolism and enhanced feedback sensitivity. We tested the hypothesis of reduced cortisol release in response to a psychosocial stressor and pharmacological stimulation. Furthermore, glucocorticoid (GC) sensitivity was evaluated.

METHODS

Plasma total and salivary-free cortisol concentrations were measured in response to a standardized social laboratory stressor, the Trier Social Stress Test, and to adrenocorticotropin (ACTH)(1-24) stimulation. In the Trier Social Stress Test, we additionally measured ACTH. GC sensitivity was measured by dexamethasone inhibition of lipopolysaccharide-induced interleukin-6 and tumor necrosis factor-alpha production in whole blood.

RESULTS

There were no HPA axis alterations in women with CPP (N = 18) in these tests. Patients with FMS (N = 17) showed lower total cortisol release in response to the social stressor and exogenous ACTH, but normal free cortisol and ACTH levels compared with controls (N = 24). GC sensitivity was similar in all groups.

CONCLUSIONS

Our results suggest normal HPA responses to stress and ACTH stimulation in patients with CPP but reduced adrenal reactivity in patients with FMS, namely in total cortisol release. Free cortisol on the other hand was unaltered, possibly reflecting an adaptation to reduced circulating total cortisol.

Cognitive behavioral therapy for fibromyalgia

Cognitive behavioral therapy (CBT) techniques offer short-term, goal-oriented psychotherapy. In this respect, it differs from classical psychoanalysis in emphasizing changes in thought patterns and behaviors rather than providing 'deep insight'. Importantly, the beneficial effects of CBT can be achieved in 10-20 sessions, compared with the many years required for classical psychoanalysis. Although CBT is often done on a one-to-one basis, it also lends itself to a group therapeutic setting. CBT was initially used in the treatment of mood disorders, but its use has subsequently been expanded to include various other medical conditions, including chronic pain states. Over the past 18 years, several chronic pain treatment programs have used CBT techniques in the management of fibromyalgia. In this review, the results from 13 programs using CBT, alone or in combination with other treatment modalities, are analyzed. In most studies, CBT provided worthwhile improvements in pain-related behavior, self-efficacy, coping strategies and overall physical function. Sustained improvements in pain were most evident when individualized CBT was used to treat patients with juvenile fibromyalgia. The current data indicate that CBT, as a single treatment modality, does not offer any distinct advantage over well-planned group programs of education or exercise, or both. Its role in the management of fibromyalgia patients needs further research.

Differences in unpleasantness induced by experimental pressure pain between patients with fibromyalgia and healthy controls

Pain possesses both sensory and affective dimensions, which are highly correlated yet distinct. Comparison of these dimensions within experimental pain settings has resulted in the construct of relative unpleasantness. Relative unpleasantness is defined as the amount of affective unpleasantness elicited for a given sensory magnitude. The aim of this study was to determine the relationship between affective and sensory components of evoked pain in subjects with fibromyalgia (FM) and healthy controls. Here we show that patients with FM unexpectedly display less relative unpleasantness than healthy controls in response to random noxious pressure stimuli. Relative unpleasantness was not correlated with distress, anxiety, or depression, which were pronounced in the FM group. Clinical pain in patients with FM was perceived to be more unpleasant than the evoked pain stimuli. These results are consistent with the concept that chronic pain may reduce the relative unpleasantness of evoked pain sensations.

TOS pathophysiology and clinical features

The authors present 280 patients operated on for thoracic outlet syndrome (TOS). In a first group of patients anatomical variants were the striking findings. The underlying factor for TOS development is therefore a well defined structural condition and its pathogenetic mechanism is known to be a nerve fibre compression. In a second group there was no specific salient finding but a postural deviation. The unique pathological features were adhesions of the brachial plexus to the scalenus muscle. Consequently its pathogenetic mechanism is generally recognized as nerve fibre distraction. In all patients neurological, vascular and myofascial pain symptoms were observed before the operation. Neurological and vascular pain disappeared after surgery, while the myofascial pain remained. The authors believe that especially in the second, larger group of patients enhancement of the pain-immobility-fibrosis loop is the central pathogenetic factor on which surgical therapy is successful, and that myofascial hemisyndrome--probably arising from a long-standing postural deviation--is not a TOS dependent symptom. In TOS, therefore, there is a pain loop that cannot be resolved by surgical therapy alone. The connection between myofascial pain syndrome and TOS might explain the many controversial opinions regarding frequency, results and surgical possibilities of this lesion.

Employment and Quality of Life Outcomes Among Women with Fibromyalgia Compared to Healthy Controls

The purpose of this study was to assess the effects of paid employment on health related quality of life among women with fibromyalgia compared to a group of women who were otherwise healthy. Participants were recruited from 118 rheumatology practices randomly sampled from the membership of the American College of Rheumatology. Three hundred and sixty-five patients were referred to the study and 287 completed a telephone interview. At the end of each interview, participants were asked to nominate 2 individuals to serve as control subjects. Because of lagging enrollment of control subjects, we initiated an additional method of asking control subjects to nominate controls. Of 381 control subjects nominated for the study, 286 or 75% completed the initial interview. As with patients, controls completed a computer assisted phone interview with a trained interviewer similar to that of the patient. The mean age of women with FMS was 47 years, most were married (59.6%), 87.8% were of white race and non-Hispanic ethnicity, 47.7% were employed, had an average of 14 years of education and household annual incomes generally exceeded $20,000, with 40.4% having incomes in excess of $50,000. There we no significant differences between women with FMS and those without FMS on these characteristics. Women with FMS had significantly worse physical and mental health related quality of life measured by SF-12 Physical (PCS) and Mental (MCS) Component Summary Scores; those who were not employed had significantly worse PCS scores but there were no differences by employment for MCS. Ordinal regression analysis adjusting for demographic characteristics showed that there were significant main effects for condition and employment on PCS in that those with FMS and those who were not employed had worse PCS scores. Initially, we also found an interaction effect between condition and employment in that the beneficial effects of employment was restricted to the FMS cases. However, when adjustments were made for the double nesting design, the interaction effect was no longer significant. For MCS, FMS cases had significantly worse health related quality of life, but there were no main effects for employment and no interactions were significant. Our results concur with findings in community studies that employed women report better quality of life than those not employed, but only for the physical dimension of quality of life. The findings regarding MCS are intriguing in that women with FMS are not very different from controls and that employment has little effect on the mental health component of quality of life.

Familial aggregation of depression in fibromyalgia: a community-based test of alternate hypotheses

Numerous studies report that fibromyalgia (FM), a syndrome characterized by widespread pain and generalized tender points, is comorbid with major depressive disorder (MDD). The current study tests two alternate explanations for their comorbidity using a family study methodology. The first is that FM is a depression spectrum disorder. The second is that depression is a consequence of living with FM. We recruited potential probands by initially screening by telephone for FM and MDD among women in the NY/NJ metropolitan area, randomly selecting telephone numbers from a list of households with women. Eligible women were invited for second stage physical examinations for FM diagnosis and psychiatric interviews for MDD diagnosis. All available adult, first-degree relatives received psychiatric interviews. Relatives of probands were divided into four groups on the basis of the probands' FM and MDD diagnoses (FM+/MDD+ (n = 156), FM+/MDD- (n = 51), FM-/MDD+ (n = 351) and FM-/MDD- (n = 101)). Results indicated that rates of MDD in the relatives of probands with FM but without personal histories of MDD were virtually identical to rates of MDD in relatives of probands with MDD themselves. This outcome is consistent with the hypothesis that FM is a depression spectrum disorder, in which FM and MDD are characterized by shared, familially mediated risk factors. The implications of these findings for a stress-vulnerability model of FM are discussed.

[Psychosomatic aspects in the diagnosis and treatment of fibromyalgia]

The fibromyalgia syndrome (FMS) is a chronic pain condition of the musculoskeletal system defined by criteria of the American College of Rheumatology in 1990. Despite this definition, etiology and pathogenesis of FMS are still unknown, and consequently the therapy aims mainly at relieving symptoms. The favourite hypothesis is a multietiological concept including genetic, central nervous, muscular, and psychological issues. This article focuses on current psychological aspects as to etiology, process of chronification, and therapy of FMS. Regarding etiology there are diverging hypotheses rather than a general agreement, e.g. specific personality traits, traumatic events, psychodynamic explanations on the basis of a depressive conflict, or the subsumption under somatoform disorders. However, psychological aspects are evident to influence the course and treatment of FMS. In the chronification process behavioural aspects like avoidance behaviour with subsequent physical impairment, attitudes towards subjective theories of illness and therapeutic options, social factors like effects on work, interpersonal conditioning, and coping strategies play an important role. Therapeutic options of FMS comprise exercise, drugs, and psychotherapy. An integrated approach combining these options, a sustainable doctor-patient relationship, and a continuous support of the patient seem to be beneficial.

Coping with fibromyalgia. A qualitative study

This study aims to describe, from the perspective of patients with fibromyalgia themselves, their experiences of having to live with chronic pain and how they manage their situation. The sample consists of 22 female patients (22-60 years). Open-ended in-depth interviews were analysed by a method directed by the tradition of Grounded Theory. Three descriptive categories were grounded in the data, labelled subjective pain language, diversified pain coping, and pain communication. These descriptive categories formed the higher-order, or core, concept preoccupied with pain. Having to live with chronic pain seems to include that the sufferer becomes self-centred and preoccupied with the pain: the pain is mostly present and affects every aspect of life, leading to a continuous awareness of and coping with the pain. Pain tends to interrupt normal life, demands attention and is difficult to disengage from. Although coping should not be evaluated in terms of good and bad, passivity, escape behaviours, and resignation/catastrophizing, which dominated in the present study sample, might affect social and psychological functioning negatively. Patients with fibromyalgia might benefit from psychological support in coping with their pain and from reinforcement of healthy behaviours.

Relationship between stress and pain in work-related upper extremity disorders: the hidden role of chronic multisymptom illnesses

BACKGROUND

Pain and fatigue are commonly associated with work-related upper extremity disorders. Occasionally these symptoms persist beyond a reasonable healing period. One potential explanation for prolonged symptom expression is the concurrent development of a stress-mediated illness or CMI (Chronic Multi-Symptom Illness). In such a scenario, the chronic regional pain and other symptoms that the individual is experiencing would be attributable to the CMI rather than to tissue damage or a biomechanical dysfunction of the upper-extremity.

METHODS

This article critically reviews the case definitions of the new class of CMI disorders and evaluates the existing evidence supporting centrally mediated physiological changes (e.g., sensory hypervigilance, dysautonomia) that manifest as symptoms of pain and fatigue in some individuals experiencing chronic stressors.

RESULTS

While explanations for prolonged pain and fatigue have historically focused on mechanisms involving peripheral pathology or psychiatric explanations, ample evidences support the role of altered Central Nervous System function in accounting for symptom manifestation in CMI.

CONCLUSIONS

A model is presented that unites seemingly disparate findings across numerous investigations and provides a framework for understanding how genetics, triggering events, stressors, and early life events can affect CNS activity. Resultant symptom expression (e.g., pain and fatigue) from central dysregulation would be expected to occur in a subset of individuals in the population, including a subset of individuals with work-related upper extremity disorders. Thus when symptoms such as pain and fatigue persist beyond a reasonable period, consideration of CMI and associated assessment and interventions focused on central mechanisms may be worthwhile.

Restricted emotional processing and somatic attribution in fibromyalgia

OBJECTIVE

Medically unexplained symptoms or syndromes, such as fibromyalgia (FM), might be partly caused or sustained by a mechanism involving restricted emotional processing (REP) and the subsequent attribution of emotional arousal to somatic or syndrome-consistent causes. In this study, it was hypothesized that FM patients, compared to healthy individuals, would be higher on trait measures of REP (defensiveness and alexithymia), and would show affective-autonomic response dissociation, that is, higher standardized scores of heart rate responses than affective responses, during negative emotional stimulation. Additionally, FM patients were expected to attribute their bodily symptoms more to somatic than to psychological causes.

METHOD

Emotional movie excerpts were shown to 16 female FM patients and 17 healthy women. Affective response and heart rate were monitored continuously, while symptoms and their causal attributions were measured before and after the excerpts. Repressor coping style and alexithymia were measured, along with negative affectivity and habitual attributions of somatic complaints.

RESULTS

FM patients nearly all showed the relatively uncommon combination of high defensiveness and high anxiousness. Compared with healthy women FM patients were more alexithymic, showed a higher level of affective-autonomic response dissociation, and lower within-subject emotional variability. The groups showed opposite attributional patterns, with FM patients attributing symptoms less to psychological causes and more to somatic causes. There was no evidence of a shift in these attributions caused by the emotional stimuli.

CONCLUSIONS

The results provide preliminary support for the hypotheses. Both at trait and at state level, FM showed restricted emotional processing on most of the parameters measured, and a high ratio of somatic to psychological symptom attribution, coupled with high negative affectivity.

Women's pursuit of personal goals in daily life with fibromyalgia: a value-expectancy analysis

Eighty-nine women with fibromyalgia completed the Life Orientation Test, identified health and social goals, and answered questions from the Goal Systems Assessment Battery (P. Karoly & L. Ruehlman, 1995) about their valuation of, and self-efficiency in attaining, each goal. For 30 days, they responded to palm-top computer interviews about their pain and fatigue and rated their goal effort, goal progress, and pain- and fatigue-related goal barriers. Goal barriers increased and goal efforts and progress decreased on days with greater pain and fatigue; goals valued more highly were pursued more effortfully and successfully; more optimistic individuals were less likely to perceive goal barriers and, on days that were more fatiguing than usual, were less likely to reduce their effort and to retreat from progress in achieving their health goal; and more pessimistic individuals perceived greater goal barriers on days that were less painful than usual.

Psychological distress in chronic craniomandibular and cervical spinal pain patients

Recent studies to chronic pain have shown that the number of painful body areas is related to the level of psychological distress. Therefore, the first aim of this study was to analyse differences in level of psychological distress between craniomandibular pain patients with or without cervical spinal pain. In this analysis, the number of painful body areas below the cervical spine was also taken into account. The second aim was to determine psychological differences between subgroups of craniomandibular pain patients. In this study, 103 out of 250 persons with or without craniomandibular pain were included in the final analyses. Patients who suffered from both craniomandibular and cervical spinal pain showed higher levels of psychological distress, as measured with the Symptom Checklist 90 (SCL-90) than patients with local craniomandibular pain and persons without pain. Further, a positive relationship was found between the number of painful body areas below the cervical spine, as measured on a body drawing, and the SCL-90 scores. No psychological differences were found between myogenous and arthrogenous craniomandibular pain patients. In conclusion, chronic craniomandibular pain patients with a coexistent cervical spinal pain showed more psychological distress compared to patients with only a local craniomandibular pain and asymptomatic persons.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A comparative evaluation of a fibromyalgia rehabilitation program

OBJECTIVE

To compare an evidence-based clinical fibromyalgia program, referred to as Fibro-Fit, with results of controlled clinical trials.

METHODS

An interdisciplinary group education and exercise program with 36 sessions over 12 weeks was used. Demographic, clinical, and outcome variables were collected on 149 participants, of whom 71% completed the program. Outcomes included measures of self-efficacy, pain, physical fitness, function, and coping skills.

RESULTS

Results of the prospective before-after evaluation showed statistically significant (P < 0.005) improvements in all outcomes except for grip strength. These results were comparable with controlled clinical trials found in the literature. Data suggest that smoking, fibromyalgia support groups, and medications may be important modifiable factors.

CONCLUSIONS

Results suggest that Fibro-Fit was effective in improving physical impairments and function. Further investigation is required to refine the effective components of these programs and determine how modifiable factors can be used to improve outcomes.

A meta-analysis of fibromyalgia treatment interventions

OBJECTIVE

To evaluate and compare the efficacy of pharmacological and nonpharmacological treatments of fibromyalgia syndrome (FMS).

METHODS

This meta-analysis of 49 fibromyalgia treatment outcome studies assessed the efficacy of pharmacological and nonpharmacological treatment across four types of outcome measures-physical status, self-report of FMS symptoms, psychological status, and daily functioning.

RESULTS

After controlling for study design, antidepressants resulted in improvements on physical status and self-report of FMS symptoms. All nonpharmacological treatments were associated with significant improvements in all four categories of outcome measures with the exception that physically-based treatment (primarily exercise) did not significantly improve daily functioning. When compared, nonpharmacological treatment appears to be more efficacious in improving self-report of FMS symptoms than pharmacological treatment alone. A similar trend was suggested for functional measures.

CONCLUSION

The optimal intervention for FMS would include nonpharmacological treatments, specifically exercise and cognitive-behavioral therapy, in addition to appropriate medication management as needed for sleep and pain symptoms.

Chronic benign pain

Chronic benign pain (CBP) can be defined as a type of unpleasant sensory experience that arises from inflammation, visceral stress or damage, or other such pathophysiologic process(es), and that is not associated with a metastatic process. A patient's complaint of pain should be taken seriously by the practitioner, both in terms of the discomfort evoked and the likelihood that the potential cause of the pain requires diagnostic evaluation. This article reviews the diagnosis and treatment of the following common conditions associated with CBP syndromes: fibromyalgia, lower back pain syndrome, sickle-cell disease, reflex sympathetic dystrophy syndrome, and peripheral neuropathies.

A comparison of three types of neck support in fibromyalgia patients

OBJECTIVE

To determine the effectiveness of 3 types of neck support for patients with fibromyalgia (FMS) and their preference for the type of support.

METHODS

Thirty-five patients with FMS chose the order of application and used each type of neck support for a 2-week period, followed by a 2-week washout. The same schedule was repeated a second time. The neck supports included a Shape of Sleep pillow, two neck ruffs with one standard pillow, and a single standard pillow. All subjects received a physiotherapy treatment and educational program in the home. Outcome measures included visual analog scales (VAS) for neck pain and quality of sleep, the Fibromyalgia Impact Questionnaire (FIQ), and a neck and shoulder pain distribution diagram.

RESULTS

Analysis using Friedman's 2-way analysis of variance revealed no significant differences in any outcome measure, although there was a trend towards improvement in the FIQ and VAS neck pain and quality of sleep scores for some patients. Most participants (62.9%) preferred the Shape of Sleep pillow, 20.0% preferred cervical ruffs with one standard pillow, and 17.1% preferred a single standard pillow.

CONCLUSIONS

The results of this study are inconclusive due to the small sample size. However, from a patient's perspective, neck support is an important part of a comprehensive physiotherapy program. Most participants preferred the more rigid support of a Shape of Sleep pillow. Further research into the efficacy of the use of neck support in people with FMS is warranted.

Doctors' attitudes to fibromyalgia: a phenomenological study

Besides specific technical skills, successful encounters with patients require an understanding of the many ways in which patients may express themselves. This qualitative study reports on the clinical experiences of doctors when meeting patients with fibromyalgia (FM). Ten strategically chosen rheumatologists and 10 GPs in central Sweden were interviewed. The interviews were taped, transcribed and analysed in accordance with the empirical, phenomenological, psychological method. The analyses indicate that doctors try to comply with the wishes and demands of patients, and at the same time avoid perceptions of personal frustration. They are inclined to be objective and to act instrumentally, apparently in order to keep in touch with what gave biomedical meaning to an otherwise incomprehensible phenomenon. The meaning structures revealed by doctors' descriptions of FM and of relating to FM patients were characterized mainly by the way in which the doctors were (i) managing their clinical uncertainty, (ii) adhering to the biomedical paradigm, (iii) prioritizing diagnostics, (iv) establishing an instrumental relationship, and (v) avoiding recognizing FM as a possible biomedical anomaly.

Depressed fibromyalgia patients are equipped with an emphatic competence dependent self-esteem

Employing a recently developed questionnaire we studied the self-esteem structure of 61 female fibromyalgia (FM) patients by comparing them with i) 40 healthy psychology students and ii) 37 patients suffering from rheumatoid arthritis. Depressed FM patients (n=36) had a high need to gain self-esteem through competence and others' approval combined with a low basic sense of self-esteem. In this regard they differed significantly from the healthy controls who had a more equal amount of the two types of self-esteem. These patients had also a more demanding and "hard-driving" self-esteem structure than either control group and exhibited a lower self-assertiveness and less emotional candour than the healthy controls. The non-depressed FM patients did not display this self-esteem pattern. In conclusion, FM patients are probably not a homogeneous group. Furthermore, we suggest that an emphatic competence-dependent self-esteem is one vulnerability factor which, in proper genetic and environmental conditions, increases susceptibility to fibromyalgia and depression.

Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: I. Psychiatric diagnoses and functional disability

OBJECTIVE

Recent studies of the relationship between fibromyalgia and psychiatric disorders have yielded conflicting findings, and many of these inconsistencies seem to result from methodological differences.

METHOD

We compared 36 patients with fibromyalgia and 33 patients with rheumatoid arthritis from a tertiary care clinic using physician-administered, structured psychiatric interviews and self-reported measures of illness appraisal, coping, and functional disability.

RESULTS

Patients with fibromyalgia had significantly higher lifetime prevalence rates of mood and anxiety disorders, as well as higher mean numbers of medically unexplained physical symptoms across several organ systems. Ninety percent of the patients with fibromyalgia had a prior psychiatric diagnosis compared with less than half of the patients with rheumatoid arthritis.

CONCLUSIONS

Despite the absence of organic pathology, the patients with fibromyalgia had equal or greater functional disability and were less well adapted to their illness. Although the pathophysiology of fibromyalgia remains unclear, co-morbid psychiatric disorders and functional disability remain an important focus of treatment in this population.

The relationship between fibromyalgia and interstitial cystitis

Interstitial cystitis (IC) is a relatively uncommon and enigmatic disorder characterized by pain in the bladder and pelvic region, typically accompanied by urinary urgency and frequency. Fibromyalgia is a more common disorder, with the prominent symptoms being diffuse musculoskeletal pain and fatigue, and it has been well established that there is substantial clinical overlap between fibromyalgia and chronic fatigue syndrome (CFS). Although genitourinary and musculoskeletal symptoms predominate in IC and fibromyalgia respectively, both disorders share a number of features, including similar demographics, "allied conditions" (e.g. irritable bowel syndrome, headaches, etc.), natural history, aggravating factors, and efficacious therapy. We hypothesized that there was substantial clinical overlap between fibromyalgia and IC, and examined cohorts of individuals with these two disorders in parallel, to compare the spectrum of symptomatology. Sixty fibromyalgia patients, 30 IC patients, and 30 age-matched healthy controls were questioned regarding current symptomatology. A dolorimeter examination was also performed in the three groups to assess peripheral nociception. We found that the frequency of current symptoms was very similar for the fibromyalgia and IC groups. Both the fibromyalgia and IC patients displayed increased pain sensitivity when compared to healthy individuals, at both tender and control points. These data suggest that IC and fibromyalgia have significant overlap in symptomatology, and that IC patients display diffusely increased peripheral nociception, as is seen in fibromyalgia. Although central mechanisms have been suspected to contribute to the pathogenesis of fibromyalgia for some time, we speculate that these same types of mechanisms may be operative in IC, which has traditionally been felt to be a bladder disorder.

Tender points, depressive and functional symptoms: comparison between fibromyalgia and major depression

The degree of symptomatic overlap between fibromyalgia and major depression should be estimated by assessing the amount of local tenderness and the frequency and severity of depressive and functional symptoms. Tender points were assessed by palpation and symptoms by psychometric scales in 30 patients with fibromyalgia and 26 patients with major depression. The patients with fibromyalgia had markedly more tender points (16.5) than the depressive patients (1.3). In contrast, depressive and functional symptoms were present in both groups of patients, and some depressive patients (26%) also suffered from clinical pain. An increased sensitivity to pressure pain clearly distinguishes fibromyalgia from depression even if there is an overlap of other symptoms.

Sequential daily relations of sleep, pain intensity, and attention to pain among women with fibromyalgia

Fifty women with fibromyalgia syndrome (FS) recorded their sleep quality, pain intensity, and attention to pain for 30 days, using palm-top computers programmed as electronic interviewers. They described their previous night's sleep quality within one-half hour of awakening each day, and at randomly selected times in the morning, afternoon, and evening rated their present pain in 14 regions and attention to pain during the last 30 min. We analyzed the 30-day aggregates cross-sectionally at the across-persons level and the pooled data set of 1500 person-days at the within-persons level after adjusting for between-persons variation and autocorrelation. Poorer sleepers tended to report significantly more pain. A night of poorer sleep was followed by a significantly more painful day, and a more painful day was followed by a night of poorer sleep. Pain attention and sleep were unrelated at the across-persons level of analysis. But there was a significant bi-directional within-person association between pain attention and sleep quality that was not explained by changes in pain intensity.

Dilemmas in the treatment of chronic pain

Chronic pain affects millions of people and results in activity limitations and psychologic and social problems. Even with the armamentarium of analgesics currently available, patients continue to receive inadequate relief of their painful conditions. One of the primary factors that limits appropriate utilization of analgesics is the spectrum of adverse effects that often results following acute and chronic use. In addition, legal and regulatory barriers, inability of physicians and other healthcare professionals to accurately assess pain, societal attitudes toward selected classes of pain medications, and other factors complicate pain management. Understanding how these barriers contribute to the undertreatment of pain and incorporating effective pharmacologic and nonpharmacologic measures into a treatment plan are required to manage patients with chronic pain.

Impact of fibromyalgia on everyday life: a study of women in the USA and Sweden

The study investigated how 39 women with fibromyalgia (FM), living in two countries (USA or Sweden), report the consequences of fibromyalgia on everyday life activities. Data were collected using questionnaires, diaries and interviews. The result showed that the impact on everyday life was considerable. The majority of the women experienced pain and fatigue for more than 90% of their time awake. There were no significant differences between the national groups in time use, problems with everyday activities, or quality of life. Overall, the differences between individuals were greater than between the national groups. The majority of the employed patients in the Swedish group had reduced their working time, while the employed patients in the USA group worked mainly full-time. Patients who were able to reduce their working hours to fit their perceived capacity were less exhausted during their leisure, and reported higher satisfaction with daily activities.

Health promotion and clinical dialogue

Clinical medicine would gain from a discussion of the significance of health promotion. Some central concepts are discussed: the diagnostic process; disease prevention vs. health promotion; the practical importance of the understanding of the difference between the 2 concepts health and absence-of-disease. The concept of health catches the intra-personal level, the undisrupted self, whereas absence of disease concerns the proper functioning of the organism, the human biology. By means of comparing 2 diagnoses, multiple sclerosis (MS) and fibromyalgia syndrome (FS), it is argued that there are diagnoses of at least 2 distinct kinds. The diagnosis of MS is similar to a scientific discovery, whereas the diagnosis of FS is constructed more like criminal law. Consequently, diagnosis-based disease prevention and health promotion have to comply with a wide range of reality. Finally, clinical dialogue is pointed out as a method that successfully combines diagnostic, preventive and promotive efforts, as well as clinical care and cure.

Work disability evaluation and the fibromyalgia syndrome

Fibromyalgia syndrome (FMS) is a common and costly cause of work disability. Patients with FMS, nevertheless, encounter considerable difficulties in their assessment of claims for disability payments. Factors that contribute to FMS as an important cause of disability are its high prevalence, the patients' perception of severe discomfort, and poor function. Disability evaluation in FMS is controversial for several reasons including lack of acceptance of the diagnosis, concurrent psychological abnormalities, difficulties in objectifying disability, deficiencies in instruments of evaluation, the uncertain efficacy of treatment, and physician attitudes. Third parties appear to have inappropriate expectations of the physician's role in determining disability. We suggest that the process of disability evaluation be improved by more objective assessments and by the inclusion of other health professionals in assessing disability and necessary retraining. Further research is needed to develop better instruments for measuring disability, to assess the long-term effects of various treatments, and to clarify the contributions of the work place and of compensation in causing or aggravating FMS.

The pathogenesis of chronic pain and fatigue syndromes, with special reference to fibromyalgia

Syndromes characterized by chronic pain and fatigue have been described in the medical literature for centuries. Fibromyalgia is the term currently used to describe this symptom complex, and considerable research has been performed in the last decade to delineate the epidemiology, pathophysiology, and genesis of this entity. Although fibromyalgia is defined by its musculoskeletal features, it is clear that there are a large number of non-musculoskeletal symptoms, such that we now understand that there is considerable overlap with allied conditions such as the chronic fatigue syndrome, migraine and tension headaches, irritable bowel syndrome, and affective disorders. This article will review our current state of knowledge regarding fibromyalgia and these allied conditions, and present a unifying hypothesis that describes both the pathophysiology of symptoms and the genesis of these disorders.

Struggling to maintain balance: a study of women living with fibromyalgia

Thirty-six women with fibromyalgia (FM) were asked to describe how they live with their FM. Data were analysed using the constant comparative method. The goal was understanding the process of living with FM through theory development. The women described living with FM as struggling to maintain balance; this involves recalling perceived normality, searching for a diagnosis, finding out and moving on (transcending the illness). Several women relinquished the struggle because of situations that may or may not be under their control (e.g. depression and feeling imprisoned by treatment). Over time the illness moves from being a primary life focus to being part of the backdrop of the lives of women with FM.

Chronic muscular pain: aetiology and pathogenesis

The conclusion is that no one single mechanism can explain FMS and is thus in that sense a compromise. FMS in some patients may start in the muscle, in other patients in the brain. The combination of peripheral and central factors is the key to the pathogenesis of FMS as long as FMS is defined as a pain syndrome.

[Clinical features, pathophysiology and treatment of fibromyalgia.]

In rheumatology, all of the more than 400 specified syndromes are associated with pain. In the conceptual discussion on the multidimensional influences postulated to explain the development of chronic pain, fibromyalgia has gained increasing interest. Fibromyalgia (fibrositis) is an unspecific soft-tissue disorder with chronic wide-spread musculoskeletal pain and palpable hypersensitivity at fibrositic tender points. Fibromyalgia is often associated with fatigue, nonrestorative sleep and other symptoms. The syndrome has a high prevalence in women, but in most cases it has a long course with unsatisfactory attempts at therapy before the diagnosis is made. Though diagnostic criteria have been defined to describe it as a distinct clinical syndrome, speculations on its aetiology and pathogenetic mechanisms are still controversial. Histochemical investigations on muscle biopsy and biochemical tests have revealed unspecific changes but no characteristic muscle abnormality. It is supposed that the clinical features may result from central neurohumoral dysfunction combining with peripheral mechanisms to result in hyperalgesia. An integrated therapeutic concept with a reassuring and positive doctor-patient relationship can be helpful in achieving satisfactory treatment results.