Is fibromyalgia a distinct clinical entity? Historical and epidemiological evidence

A distinctive profile of family genetic risk scores in a Swedish national sample of cases of fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome compared to rheumatoid arthritis and major depression

BACKGROUND

Functional somatic disorders (FSD) feature medical symptoms of unclear etiology. Attempts to clarify their origin have been hampered by a lack of rigorous research designs. We sought to clarify the etiology of the FSD by examining the genetic risk patterns for FSD and other related disorders.

METHODS

This study was performed in 5 829 186 individuals from Swedish national registers. We quantified familial genetic risk for FSD, internalizing disorders, and somatic disorders in cases of chronic fatigue syndrome (CFS), fibromyalgia (FM), and irritable bowel syndrome (IBS), using a novel method based on aggregate risk in first to fifth degree relatives, adjusting for cohabitation. We compared these profiles with those of a prototypic internalizing psychiatric - major depression (MD) - and a somatic/autoimmune disorder: rheumatoid arthritis (RA).

RESULTS

Patients with FM carry substantial genetic risks not only for FM, but also for pain syndromes and internalizing, autoimmune and sleep disorders. The genetic risk profiles for IBS and CFS are also widely distributed although with lower average risks. By contrast, genetic risk profiles of MD and RA are much more restricted to related conditions.

CONCLUSION

Patients with FM have a relatively unique family genetic risk score profile with elevated genetic risk across a range of disorders that differs markedly from the profiles of a classic autoimmune disorder (RA) and internalizing disorder (MD). A similar less marked pattern of genetic risks was seen for IBS and CFS. FSD arise from a distinctive pattern of genetic liability for a diversity of psychiatric, autoimmune, pain, sleep, and functional somatic disorders.

Suggesting a mechanism for acupuncture as a global percutaneous needle fasciotomy that respects tensegrity principles for treating fibromyalgia

Acupuncture is a minimally invasive therapeutic method that uses small caliber needles while inserting them through the skin into various areas of the body. Some empirical studies find evidence to support the use of acupuncture as a treatment for certain medical conditions, however, this peculiar practice is widely considered as the domain of alternative and non-evidence-based medicine. Several mechanisms have been suggested in an attempt to explain the therapeutic action of acupuncture, but the way in which acupuncture alleviates chronic non-cancer pain or psychosomatic and psychiatric disorders is not fully understood. A recent study suggested a theoretical model (coined "Fascial Armoring") with a cellular pathway to help explain the pathogenesis of myofascial pain/fibromyalgia syndrome and functional psychosomatic syndromes. It proposes that these syndromes are a spectrum of a single medical entity that involves myofibroblasts with contractile activity in fascia and aberrant extracellular matrix (ECM) remodeling, which may lead to widespread mechanical tension and compression. This can help explain diverse psycho-somatic manifestations of fibromyalgia-like syndromes. Fascia is a continuous interconnected tissue network that extends throughout the body and has qualities of bio-tensegrity. Previous studies show that a mechanical action by needling induces soft tissue changes and lowers the shear modulus and stiffness in myofascial tissue. This hypothesis and theory paper offers a new mechanism for acupuncture therapy as a global percutaneous needle fasciotomy that respects tensegrity principles (tensegrity-based needling), in light of the theoretical model of "Fascial Armoring." The translation of this model to other medical conditions carries potential to advance therapies. These days opioid overuse and over-prescription are ubiquitous, as well as chronic pain and suffering.

Effects of Antioxidants on Pain Perception in Patients with Fibromyalgia-A Systematic Review

In recent years, antioxidant supplements have become popular to counteract the effects of oxidative stress in fibromyalgia and one of its most distressing symptoms, pain. The aim of this systematic review was to summarize the effects of antioxidant supplementation on pain levels perceived by patients diagnosed with fibromyalgia. The words used respected the medical search terms related to our objective including antioxidants, fibromyalgia, pain, and supplementation. Seventeen relevant articles were identified within Medline (PubMed), Scopus, Web of Science (WOS), the Cochrane Database of Systematic Review, and the Cochrane Central Register of Controlled Trials. This review found that antioxidant supplementation is efficient in reducing pain in nine of the studies reviewed. Studies with a duration of supplementation of at least 6 weeks showed a benefit on pain perception in 80% of the patients included in these studies. The benefits shown by vitamins and coenzyme Q10 are remarkable. Further research is needed to identify the effects of other types of antioxidants, such as extra virgin olive oil and turmeric. More homogeneous interventions in terms of antioxidant doses administered and duration would allow the effects on pain to be addressed more comprehensively.

Central Sensitivity and Fibromyalgia

Fibromyalgia presents with symptoms of widespread pain, fatigue, sleeping and cognitive disturbances as well as other somatic symptoms. It often overlaps with other conditions termed 'central sensitivity syndromes' such as irritable bowel syndrome, chronic fatigue syndrome and temporomandibular disorder. Central sensitisation, mediated by amplified processing in the central nervous system, has been identified as the key pathogenic mechanism in these disorders. The term 'central sensitivity' can be used to collectively describe the clinical presentation of these disorders. Fibromyalgia is highly prevalent in most rheumatic diseases as well as non-rheumatic chronic diseases and if unrecognised results in high morbidity. It is diagnosed clinically after excluding important differential diagnoses. Diagnostic criteria have been developed as tools to help identify and diagnose fibromyalgia. Such tools can fulfill an important need when managing patients with rheumatic disease and other chronic diseases as a way to identify fibromyalgia and improve patient outcomes. Treatment involves an integrated approach including education, exercise, stress reduction and pharmacological therapies targeting the central nervous system. This approach is suitable for all presentations of central sensitivity and some central sensitivity syndromes have additional treatment options specific to the clinical presentation. This article is protected by copyright. All rights reserved.

Numeric Rating Scales Show Prolonged Post-exertional Symptoms After Orthostatic Testing of Adults With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Introduction: Muscle pain, fatigue, and concentration problems are common among individuals with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). These symptoms are commonly increased as part of the phenomenon of postexertional malaise (PEM). An increase in the severity of these symptoms is described following physical or mental exercise in ME/CFS patients. Another important symptom of ME/CFS is orthostatic intolerance, which can be detected by head-up tilt testing (HUT). The effect of HUT on PEM has not been studied extensively. For this purpose, we assessed numeric rating scales (NRS) for pain, fatigue, and concentration pre- and post-HUT. As pain is a core symptom in fibromyalgia (FM), we subgrouped ME/CFS patients by the presence or absence of FM. Methods and Results: In eligible ME/CFS patients who underwent HUT, NRS of pain, fatigue, and concentration were obtained pre-HUT, immediately after HUT, at 24 and 48 h, and at 7 days posttest. We studied 174 ME/CFS patients with FM, 104 without FM, and 30 healthy controls (HC). Values for all symptoms were unchanged for HC pre- and post-HUT. Compared with pre-HUT, the three NRS post-HUT were significantly elevated in both ME/CFS patient groups even after 7 days. NRS pain was significantly higher at all time points measured in the ME/CFS patients with FM compared with those without FM. In ME/CFS patients, the maximum fatigue and concentration scores occurred directly post-HUT, whereas pain perception reached the maximum 24 h post-HUT. Conclusion: NRS scores of pain, fatigue, and concentration were significantly increased even at 7 days post-HUT compared with pre-HUT in ME/CFS patients with and without FM, suggesting that orthostatic stress is an important determinant of PEM.

Premorbid and concurrent predictors of TMD onset and persistence

BACKGROUND

Multiple risk factors predict temporomandibular disorders (TMD) onset, but temporal changes in risk factors and their contribution to risk of TMD have not been evaluated. The study aims were to (a) describe changes occurring in premorbid TMD risk factors when re-measured at TMD onset and 6 months later, and (b) determine if measures of change improve accuracy in predicting TMD incidence compared to premorbid measures alone.

METHODS

In this observational prospective cohort study at four university research clinics, 3,258 community-based, 18- to 44-year-olds without TMD were enrolled. During the 3-year median follow-up, 260 incident cases of first-onset TMD were identified, and 196 TMD-free subjects were selected as matched controls. Six-months later, 147 of 260 incident cases (56.6%) were re-examined revealing 72 (49%) with 'persistent TMD' and 75 (51%) whose condition had resolved ('transient TMD'). Virtually all (126) of the 127 re-examined controls remained without TMD. Questionnaires and clinical measurements evaluated risk factors from clinical, health, psychological and behavioural and neurosensory domains.

RESULTS

Most risk factors across all four domains increased with TMD onset, remained elevated in the persistent group and declined in the transient group (i.e., significant ANOVA interactions, p < .05). Accuracy in predicting first-onset TMD, quantified as area under the receiver operating characteristic curve was 0.71 (95% CL 0.68, 0.73) using only premorbid measures of risk factors, which increased to 0.91 (95% CL 0.89, 0.94) after addition of change measures.

CONCLUSIONS

TMD pain onset and persistence appear to be determined by enduring characteristics of the person as well as mutually interactive with temporally evolving variables.

SIGNIFICANCE

TMD is known to be a complex disorder, in which onset and persistence are associated with disease-related variables in multiple domains, including environmental exposure, clinical, psychological, health status, and pain processing variables. Using a more dynamic approach in order to capture change across time, many aspects of those domains were found to worsen prior to the reporting of pain, with bidirectional influences between domains and pain emergence likely. TMD onset appears to represent the cumulative effect of multiple system dysregulation.

Cognitive Impairment in Fibromyalgia: A Meta-Analysis of Case-Control Studies

OBJECTIVE

Cognitive dysfunction has been reported in individuals with fibromyalgia. However, findings regarding cognitive function examined using neuropsychological tests have been inconsistent. The aim of the study was to determine domain-specific cognitive impairment in patients with fibromyalgia compared with healthy controls.

METHODS

We conducted a meta-analysis that systematically searched six databases (PubMed, Ovid MEDLINE, Embase, CINAHL, PsycINFO, and Web of Science) for articles published before September 2017.

RESULTS

Twenty-three case-control studies with a total of 2096 participants were included in the meta-analysis. Cognitive function was significantly lower (g = 0.87, 95% confidence interval [CI] = 0.60-1.15) in individuals with fibromyalgia than in healthy controls. Large effect sizes were found in learning/memory and attention/psychomotor speed (g = 0.94, p = .013; g = 1.22, p < .001, respectively); medium effect sizes were reported in executive function and working memory (g = 0.72, p < .001; g = 0.75, p < .001, respectively). Depression and anxiety scores were associated with the effect size of group differences in cognitive function (B = 0.11, p < .001, 95% CI = 0.09-0.13; B = 0.02, p < .001, 95% CI = 0.01-0.02, respectively).

CONCLUSIONS

Cognitive impairment across different cognitive domains was found in individuals with fibromyalgia compared with healthy controls. Mood states (depression and anxiety) may explain the heterogeneity across studies.

Fibromyalgia and the Prediction of Two-Year Changes in Functional Status in Rheumatoid Arthritis Patients

OBJECTIVE

Previous cross-sectional studies have shown that rheumatoid arthritis (RA) patients with fibromyalgia (FM) have higher disease activity, greater medical costs, and worse quality of life compared to RA patients without FM. We determined the impact of FM on 2-year changes in the functional status of RA patients in a prospective study.

METHODS

Subjects included participants in the Brigham Rheumatoid Arthritis Sequential Study who were enrolled in a substudy of the effects of pain in RA. Subjects completed questionnaires, including the Multi-Dimensional Health Assessment Questionnaire (MDHAQ) and Polysymptomatic Distress (PSD) scale, semiannually, and underwent physical examination and laboratory tests yearly.

RESULTS

Of the 156 included RA subjects, 16.7% had FM, while 83.3% did not. In a multivariable linear regression model adjusted for age, sex, race, baseline MDHAQ score, disease duration, rheumatoid factor/cyclic citrullinated peptide antibody seropositivity, disease activity, and psychological distress, RA patients with FM had a 0.14 greater 2-year increase in MDHAQ score than RA patients without FM (P = 0.021). In secondary analyses examining the association between continuous PSD scale score and change in MDHAQ, higher PSD scale scores were significantly associated with greater 2-year increases in MDHAQ score (β coefficient 0.013, P = 0.011).

CONCLUSION

Both the presence of FM and increasing number of FM symptoms predicted worsening of functional status among individuals with RA. Among individuals with RA and FM, the magnitude of the difference in changes in MDHAQ was 4- to 7-fold higher than typical changes in MDHAQ score among individuals with established RA.

Sleep disturbances in fibromyalgia: A meta-analysis of case-control studies

OBJECTIVE

Sleep disturbances are common in fibromyalgia, but the features of sleep disturbances are not well understood. We performed a systematic review and meta-analysis of case-control studies to compare the sleep outcomes of individuals with fibromyalgia and healthy controls.

METHODS

We systematically searched eight databases (PubMed, Ovid MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, Airiti Library and Wanfang Data) for articles published before April 2016.

RESULTS

Twenty-five case-controlled studies and a total of 2086 participants were included in the meta-analysis. Sleep was assessed using polysomnography and the Pittsburgh Sleep Quality Index. When sleep was assessed using polysomnography (19 studies), significant differences were observed in wake time after sleep onset (g=0.81, 95% confidence interval [CI] 0.21-1.41), total sleep time (g=-0.78, 95% CI=-1.34 to -0.15), sleep efficiency (g=-0.78, 95% CI=-1.23 to -0.32), percentage of stage 1 sleep (g=0.55, 95% CI=0.15-0.95), and percentage of slow-wave sleep (g=-0.66, 95% CI=-1.21 to -0.12) between participants with fibromyalgia and healthy controls. When sleep was assessed using the Pittsburgh Sleep Quality Index (7 studies), significant differences were observed in global scores (g=2.19, 95% CI 1.58-2.79), sleep onset latency (g=1.75, 95% CI 0.80-2.70), and sleep efficiency (g=-1.08, 95% CI -1.65 to -0.51) between participants with fibromyalgia and healthy controls.

CONCLUSION

Individuals with fibromyalgia experience lower sleep quality and sleep efficiency; longer wake time after sleep onset, short sleep duration, and light sleep when objectively assessed and more difficulty in initiating sleep when subjectively assessed. Sleep difficulties in fibromyalgia appear to be more when reported subjectively than when assessed objectively.

COMPLIANCE WITH ETHICAL STANDARDS

This study received no funding from any source. All authors declare that they have no conflict of interest. This article does not contain any studies with human participants performed by any of the authors.

Are persons with fibromyalgia or other musculoskeletal pain more likely to report hearing loss? A HUNT study

BACKGROUND

Leading theories about the pathogenesis of fibromyalgia focus on central nervous dysregulation or sensitization, which can cause altered perception. There is growing evidence that fibromyalgia involves altered perception not only of pain, but also other sensory stimuli. On this basis, we investigated whether individuals with fibromyalgia are more likely to report subjective loss of hearing, adjusted for audiometrically measured loss of hearing, compared to persons without any musculoskeletal pain disorders. In addition, we studied persons with other musculoskeletal pain than fibromyalgia and persons who did not have any musculoskeletal pain.

METHODS

The study includes 44 494 persons from the second health survey in Nord-Trøndelag (HUNT2) who had undergone audiometry and answered a comprehensive questionnaire that mapped fibromyalgia, musculoskeletal pain at various sites and subjective hearing loss. Respondents with other musculoskeletal pain problems than fibromyalgia were divided into two groups with respectively localized and widespread musculoskeletal pain. Data were analyzed with logistic regression models adjusting for age, education, anxiety, depression and hearing thresholds.

RESULTS

In adjusted analysis, individuals with fibromyalgia had increased likelihood to report subjective hearing loss, compared to persons without fibromyalgia or other musculoskeletal pain (OR 4.578, 95% CI 3.622-5.787 and OR 4.523, 95% CI 3.077-6.647 in women and men). Furthermore, people with local and widespread musculoskeletal pain not diagnosed with fibromyalgia, also had increased likelihood to report subjective hearing loss, compared to people with no musculoskeletal pain. This relationship was greater for widespread pain than for localized pain (OR 1.915, 95% CI 1.627-2.255, and 1.796, 95% CI 1.590-2.029, in women and men with local musculoskeletal pain and OR 3.073, 95% CI 2.668-3.539, OR 3.618, 95% CI 3.225-4.058, in women and men with widespread pain, respectively).

CONCLUSIONS

Our findings are consistent with the hypothesis that fibromyalgia is related to a general dysregulation of the central nervous system. The same might also be the case for other local and, in particular, other widespread, musculoskeletal pain.

Big Five personality traits and medically unexplained symptoms in later life

BACKGROUND

Personality dysfunction has been postulated as the most clinically salient problem of persons suffering from medically unexplained symptoms (MUS) but empirical studies are scarce. This study aims to compare the personality profile of older patients suffering from MUS with two comparison groups and a control group.

METHODS

Ninety-six older patients with MUS were compared with 153 frequent attenders in primary care suffering from medically explained symptoms (MES), 255 patients with a past-month depressive disorder (DSM-IV-TR), and a control group of 125 older persons. The Big Five personality domains (NEO-Five-Factor Inventory) were compared between groups by multiple ANCOVAs adjusted for age, sex, education, partner status and cognitive functioning. Linear regression analyses were applied to examine the association between health anxiety (Whitley Index) and somatization (Brief Symptom Inventory).

RESULTS

The four groups differed with respect to neuroticism (P<0.001), extraversion (P<0.001), and agreeableness (P=0.045). Post hoc analyses, showed that MUS patients compared to controls scored higher on neuroticism and agreeableness, and compared to depressed patients lower on neuroticism and higher on extraversion as well agreeableness. Interestingly, MUS and MES patients had a similar personality profile. Health anxiety and somatization were associated with a higher level of neuroticism and a lower level of extraversion and conscientiousness, irrespective whether the physical symptom was explained or not.

CONCLUSIONS

Older patients with MUS have a specific personality profile, comparable to MES patients. Health anxiety and somatization may be better indicators of psychopathology than whether a physical symptom is medically explained or not.

Towards Tailored Patient's Management Approach: Integrating the Modified 2010 ACR Criteria for Fibromyalgia in Multidimensional Patient Reported Outcome Measures Questionnaire

Objectives. To assess the validity, reliability, and responsiveness to change of a patient self-reported questionnaire combining the Widespread Pain Index and the Symptom Severity Score as well as construct outcome measures and comorbidities assessment in fibromyalgia patients. Methods. The PROMs-FM was conceptualized based on frameworks used by the WHO Quality of Life tool and the PROMIS. Initially, cognitive interviews were conducted to identify item pool of questions. Item selection and reduction were achieved based on patients as well as an interdisciplinary group of specialists. Rasch and internal consistency reliability analyses were implemented. The questionnaire included the modified ACR criteria main items (Symptom Severity Score and Widespread Pain Index), in addition to assessment of functional disability, quality of life (QoL), review of the systems, and comorbidities. Every patient completed HAQ and EQ-5D questionnaires. Results. A total of 146 fibromyalgia patients completed the questionnaire. The PROMs-FM questionnaire was reliable as demonstrated by a high standardized alpha (0.886-0.982). Content construct assessment of the functional disability and QoL revealed significant correlation (p < 0.01) with both HAQ and EQ-5D. Changes in functional disability and QoL showed significant (p < 0.01) variation with diseases activity status in response to therapy. There was higher prevalence of autonomic symptoms, CVS risk, sexual dysfunction, and falling. Conclusions. The developed PROMs-FM questionnaire is a reliable and valid instrument for assessment of fibromyalgia patients. A phased treatment regimen depending on the severity of FMS as well as preferences and comorbidities of the patient is the best approach to tailored patient management.

The Prevalence and Characteristics of Fibromyalgia in the 2012 National Health Interview Survey

BACKGROUND

Most knowledge of fibromyalgia comes from the clinical setting, where healthcare-seeking behavior and selection issues influence study results. The characteristics of fibromyalgia in the general population have not been studied in detail.

METHODS

We developed and tested surrogate study specific criteria for fibromyalgia in rheumatology practices using variables from the US National Health Interview Survey (NHIS) and the modification (for surveys) of the 2010 American College of Rheumatology (ACR) preliminary fibromyalgia criteria. The surrogate criteria were applied to the 2012 NHIS and identified persons who satisfied criteria from symptom data. The NHIS weighted sample of 8446 persons represents 225.7 million US adults.

RESULTS

Fibromyalgia was identified in 1.75% (95% CI 1.42, 2.07), or 3.94 million persons. However, 73% of identified cases self-reported a physician's diagnosis other than fibromyalgia. Identified cases had high levels of self-reported pain, non-pain symptoms, comorbidity, psychological distress, medical costs, Social Security and work disability. Caseness was associated with gender, education, ethnicity, citizenship and unhealthy behaviors. Demographics, behaviors, and comorbidity were predictive of case status. Examination of the surrogate polysymptomatic distress scale (PSD) of the 2010 ACR criteria found fibromyalgia symptoms extending through the full length of the scale.

CONCLUSIONS

Persons identified with criteria-based fibromyalgia have severe symptoms, but most (73%) have not received a clinical diagnosis of fibromyalgia. The association of fibromyalgia-like symptoms over the full length of the PSD scale with physiological as well as mental stressors suggests PSD may be a universal response variable rather than one restricted to fibromyalgia.

Central sensitization syndrome and the initial evaluation of a patient with fibromyalgia: a review

In both primary care and consultative practices, patients presenting with fibromyalgia (FM) often have other medically unexplained somatic symptoms and are ultimately diagnosed as having central sensitization (CS). Central sensitization encompasses many disorders where the central nervous system amplifies sensory input across many organ systems and results in myriad symptoms. A pragmatic approach to evaluate FM and related symptoms, including a focused review of medical records, interviewing techniques, and observations, is offered here, giving valuable tools for identifying and addressing the most relevant symptoms. At the time of the clinical evaluation, early consideration of CS may improve the efficiency of the visit, reduce excessive testing, and help in discerning between typical and atypical cases so as to avoid an inaccurate diagnosis. Discussion of pain and neurophysiology and sensitization often proves helpful.

Chronic fatigue syndrome is associated with the risk of fracture: a nationwide cohort study

PURPOSE

Chronic fatigue syndrome (CFS) is a complex disorder that is associated with unreasonable persistent fatigue. CFS has also been reported to be a possible risk factor for osteopathy. We propose that CFS might be associated with an increased risk of fracture.

METHODS

We used the National Health Insurance Research Database to conduct a prospective cohort study, identifying 3744 patients with a CFS diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification code 780.71) and 14 976 patients without CFS until 2006, with follow-up observed until the end of 2010.

RESULTS

The incidence rate of fracture was higher in the CFS cohort than in the non-CFS cohort (17.44 vs. 14.53 per 1000 person-year, respectively), with an adjusted hazard ratio of 1.14 (95% confidence interval = 1.00-1.30). The risks of fracture between CFS and non-CFS were shown without comorbidity for each would be elevated than with other comorbidities, particularly in osteoporosis. The patients without osteoporosis in the CFS cohort exhibited a 1.16-fold higher risk of fracture than did those in the non-CFS cohort.

CONCLUSIONS

We propose that CFS-related fracture might not be associated with osteoporosis. The mechanism for developing CFS-related fracture remains unclear; however, we recommend noticing the prevention of fracture for CFS patients before clarifying the aetiology of CFS-related fracture.

A Questionnaire Using the Modified 2010 American College of Rheumatology Criteria for Fibromyalgia: Specificity and Sensitivity in Clinical Practice

Objective.

To determine the specificity and sensitivity of the Modified 2010 American College of Rheumatology (ACR) Diagnostic Criteria for Fibromyalgia (given as a self-administered questionnaire) in clinical practice.

Methods.

A cohort of patients with widespread pain, referred by primary care physicians to rheumatologists, completed the questionnaire for the Modified ACR 2010 criteria. Prior to completion of the questionnaire, patients were diagnosed by at least 1 rheumatologist as either having fibromyalgia (FM) or not having FM, using the rheumatologist’s clinical assessment as the gold standard for diagnosis of FM. The Modified ACR 2010 criteria were then applied to determine whether a diagnosis of FM was satisfied by the criteria. Sensitivity and specificity were determined, using the rheumatologist’s clinical assessment as the gold standard. A score ≥ 12 on the Modified ACR 2010 criteria questionnaire was also tested as the criterion to satisfy a diagnosis of FM, and subsequently to determine sensitivity and specificity. We examined the effect of using a cutoff score ≥ 13, as previous research indicated that this may be a more useful cutoff value.

Results.

A total of 451 subjects completed the questionnaire: 174 with an a priori diagnosis of FM by a rheumatologist and 277 with widespread pain who did not have an a priori clinical diagnosis of FM by a rheumatologist. The Modified ACR 2010 criteria were satisfied by 90.2% of patients with an a priori diagnosis of FM, and by 10.5% of subjects who had widespread pain, but were not diagnosed with FM when previously assessed by a rheumatologist. Thus, sensitivity and specificity are 90.2% and 89.5%, respectively, using the Modified ACR 2010 criteria. A score ≥ 12 on the Modified ACR 2010 criteria was observed in 97.4% of patients with an a priori diagnosis of FM, and 14.8% of subjects who had widespread pain, but were not diagnosed with FM when previously assessed by a rheumatologist. Thus, the sensitivity and specificity are 97.4% and 85.2%, respectively, using a cutoff score ≥ 12. Using a score of ≥ 13, however, the sensitivity was 93.1% and the specificity was 91.7%.

Conclusion.

The Modified ACR 2010 criteria questionnaire can be used in primary care as a tool to assist physicians in the diagnosis of FM with high specificity and sensitivity. Calculating the total score on a Modified ACR 2010 criteria questionnaire, and setting the value of ≥ 13 as the cutoff for a diagnosis of FM appears to be the most effective approach. The Modified ACR 2010 criteria may reduce the need for rheumatology referral simply for the diagnosis of FM.

Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polysymptomatic distress: results from a survey of the general population

OBJECTIVE

To evaluate fibromyalgia in the general population with emphasis on prevalence, dimensionality, and somatic symptom severity.

METHODS

We studied 2,445 subjects randomly selected from the German general population in 2012 using the American College of Rheumatology 2010 preliminary diagnostic criteria for fibromyalgia, as modified for survey research, and the polysymptomatic distress scale (PSD). Anxiety, depression, and somatic symptom severity were assessed with the Patient Health Questionnaire (PHQ) series, and measures of symptoms and quality of life were assessed with the European Organization for Research and Treatment of Cancer questionnaire.

RESULTS

The prevalence of fibromyalgia was 2.1% (95% confidence interval [95% CI] 1.6, 2.7), with 2.4% (95% CI 1.5, 3.2) in women and 1.8% (95% CI 1.1, 2.6) in men, but the difference was not statistically significant. Prevalence rose with age. Fibromyalgia subjects had markedly abnormal scores for all covariates. We found smooth, nondisordered relationships between PSD and all predictors, providing additional evidence against the hypothesis that fibromyalgia is a discrete disorder and in support of a dimensional or spectrum disorder. There was a strong correlation (r = 0.790) between the PSD and the PHQ somatic symptom severity scale; 38.5% of persons with fibromyalgia satisfied the proposed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for a physical symptom disorder.

CONCLUSION

The modified 2010 diagnostic criteria do not result in high levels of fibromyalgia. PSD and fibromyalgia are strongly related to somatic symptom severity. There is evidence in support of fibromyalgia as a dimensional or continuum disorder. This has important ramifications for neurobiologic and epidemiology research, and for clinical diagnosis, treatment, and ascertainment of disability.

Clinical findings and pain symptoms as potential risk factors for chronic TMD: descriptive data and empirically identified domains from the OPPERA case-control study

Clinical characteristics might be associated with temporomandibular disorders (TMD) because they are antecedent risk factors that increase the likelihood of a healthy person developing the condition or because they represent signs or symptoms of either subclinical or overt TMD. In this baseline case-control study of the multisite Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) project, 1,633 controls and 185 cases with chronic, painful TMD completed questionnaires and received clinical examinations. Odds ratios measuring association between each clinical factor and TMD were computed, with adjustment for study-site as well as age, sex, and race/ethnicity. Compared to controls, TMD cases reported more trauma, greater parafunction, more headaches and other pain disorders, more functional limitation in using the jaw, more nonpain symptoms in the facial area, more temporomandibular joint noises and jaw locking, more neural or sensory medical conditions, and worse overall medical status. They also exhibited on examination reduced jaw mobility, more joint noises, and a greater number of painful masticatory, cervical, and body muscles upon palpation. The results indicated that TMD cases differ substantially from controls across almost all variables assessed. Future analyses of follow-up data will determine whether these clinical characteristics predict increased risk for developing first-onset pain-related TMD PERSPECTIVE: Clinical findings from OPPERA's baseline case-control study indicate significant differences between chronic TMD cases and controls with respect to trauma history, parafunction, other pain disorders, health status, and clinical examination data. Future analyses will examine their contribution to TMD onset.

Nonrestorative sleep: symptom or unique diagnostic entity?

Nonrestorative sleep (NRS) refers to the subjective experience of sleep as insufficiently refreshing, often despite the appearance of normal sleep according to traditionally assessed objective parameters. This has led researchers to pursue alternative physiological markers of nonrestorative or unrefreshing sleep, though much of this research remains controversial and inconclusive. This review summarizes the recent findings on NRS in the literature and discusses some of the issues inherent in current efforts to define and measure NRS. We offer a summary of recommended clinical approaches to NRS and discuss a new potential paradigm for the assessment of NRS-an approach modelled on current diagnosis of insomnia.

Fibromyalgia diagnosis and diagnostic criteria

Abstract Criteria for fibromyalgia developed from the conceptualization and hypotheses of Smythe and Moldofsky in 1977 and gradually evolved to a set of classification criteria endorsed by the American College of Rheumatology that emphasized tender points and widespread pain, measures of decreased pain threshold. In 2010, American College of Rheumatology fibromyalgia diagnostic criteria were published that abandoned the tender point count and placed increased emphasis of patient symptoms. The 2010 criteria also contained severity scales and offered physicians the opportunity to assess polysymptomatic distress on a continuous scale. This enabled physicians who were opposed to the idea of fibromyalgia to also assess and diagnose patients using an alternative nomenclature.

Do We Need Core Sets of Fibromyalgia Domains? The Assessment of Fibromyalgia (and Other Rheumatic Disorders) in Clinical Practice

Objective.

An OMERACT consensus process recommended domains for investigation in fibromyalgia (FM) clinical trials. We used patient data to investigate variable importance in the determination of patient global and health-related quality of life (HRQOL) in FM and non-FM patients to determine whether variables were valued differently in FM compared with non-FM states.

Methods.

We used ACR 2010 diagnostic FM criteria modified for epidemiological and clinical research to identify patients with rheumatoid arthritis (RA; N = 5884) with and without FM, and also characterized previously diagnosed patients with FM (N = 808) as to current criteria status. We measured variable importance by multivariable regression, decomposing regression variance by averaging over model orderings. We examined the distributions of key variables in the various disorders, and the distributions as a function of a FM severity index (fibromyalgianess).

Results.

Out of 9 measures, pain, Health Assessment Questionnaire disability index, and fatigue explained more than 50% of explainable variance (50.49%–56.59%). Explained variance was similar across all disorders and diagnostic groups. In addition, the SF-36 physical component summary score varied across disorders as a function of fibromyalgianess.

Conclusion.

The main determinants of global severity and HRQOL in FM are pain, function, and fatigue. But these variables are also the main determinants in RA and other rheumatic diseases. The content and impact of FM, whether measured by discrete variables or a fibromyalgianess scale, seems to be independent of diagnosis. These data argue for a common set of variables rather than disease-specific variables. Clinical use is supported and enhanced by simple measures.

The development of fibromyalgia--I: examination of rates and predictors in patients with rheumatoid arthritis (RA)

We determined rates and predictors of future development of fibromyalgia in patients with rheumatoid arthritis (RA). After excluding patients with fibromyalgia and those with high levels of fibromyalgia symptoms (fibromyalgianess score>10) at baseline, we studied fibromyalgia development in 9739 RA patients during 42,591 patient-years of follow-up. We defined fibromyalgia using a modification of the ACR 2010 fibromyalgia criteria. We used Cox regression to predict future fibromyalgia, and examined the accuracy of predictions using Harrell's C concordance coefficient. At the last observation, 7.4% of patients satisfied criteria, although 19.8% satisfied criteria at some point during follow-up, an incidence rate of 5.3 (95% CI 5.1, 5.6) per 100 patients years, and at rates that were similar in men (7.0%) and women (8.1%). Among those satisfying criteria, during 11,363 years of follow-up from the time of first fibromyalgia diagnosis, half of follow-up time was fibromyalgia+and was associated with markedly abnormal RA variable and FM variable scores. Demographic factors were weak predictors of fibromyalgia (C=0.604). Demographic plus RA variables (C=0.720) and demographic plus fibromyalgia variables (C=0.765), and all predictors (C=0.782) increased accuracy. Clinically important hazard ratios were noted for cognition, depression, comorbidity, and high levels of RA and FM continuous variables Overall, study results indicate that multiple, inter-correlated factors that include social disadvantage, psychological distress, comorbidity, RA severity, and fibromyalgia variables predict future development of fibromyalgia, but there is little evidence of the effect of underlying causes. After diagnosis, patients move in both directions across the diagnostic criteria cut points.

Reliability of ACR criteria over time to differentiate classic fibromyalgia from nonspecific widespread pain syndrome: a 6-month prospective cohort study

American College of Rheumatology (ACR) 1990 criteria, initially introduced to classify fibromyalgia (FM) syndrome, has gained popularity in research and clinical grounds for diagnostic purposes. The objectives of this study were designed to assess the consistency of ACR criteria against the time in classifying FM. This was a prospective cohort study performed in a multidisciplinary pain clinic from October 2002 to June 2005. Patients who were clinically suspected of having FM and had a normal screening laboratory evaluation were scheduled for dolorimetry. Those found to have 6 or more tender points were considered eligible and labeled as either classic or atypical FM if they did or did not, respectively, fulfil ACR criteria. The 2 groups were assessed using the Fibromyalgia Impact Questionnaire (FIQ) and compared using baseline characteristics. We reassessed dolorimetric exam and FIQ 6 months later. Of 91 patients who participated in this study,70 completed the follow-up. Of them, 34 (49%) patients were identified as atypical, and 36 (51%) were labeled as classic FM. At first visit, the classic FM group had higher scores on sleep quality, stiffness, anxiety, depression, and total FIQ score (p\0.05) but not for other variables. At 6 months, there was no significant difference between the 2 groups in all measured variables. Labeling shift from classic to atypical FM and vice versa occurred at a rate of 36.1 and 32.4%, respectively. This study showed the ACR 1990 criteria was not able to consistently classify affected patients with FM syndrome within a group of patients having nonspecific body pain and multiple tender points over 6 months of follow-up.

Chronic conditions and health problems in rheumatic diseases: comparisons with rheumatoid arthritis, noninflammatory rheumatic disorders, systemic lupus erythematosus, and fibromyalgia

OBJECTIVES

To describe and compare the prevalence of lifetime and current self-reported comorbidity and associated quality of life in 4 rheumatic diseases, and to investigate comorbid conditions in light of the overlap between the index condition and comorbid conditions (CC), and in the context of symptom-type diagnoses.

METHODS

We studied comorbidity in 11,704 patients with fibromyalgia (FM), systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and noninflammatory rheumatic disorders (NIRD). Patients completed semiannual self-reports relating to 22 present and past illnesses and completed the EuroQol (EQ-5D) utility index.

RESULTS

CC were most common in FM, followed by SLE. FM comorbidity was dominated by depression, mental illness, and symptom-type comorbidity (e.g., gastrointestinal and genitourinary disorders). In SLE, there were substantial increases in hypertension, depression, cataract, fractures, and cardiovascular and cerebrovascular, neurologic, lung, gall bladder and endocrine disorders compared with RA. Any current CC reduced the EQ-5D utility by 0.08 to 0.16 units. The lowest EQ-5D score was noted for current psychiatric illness (0.55) and current depression (0.60).

CONCLUSION

Four patterns of comorbidity emerged: that associated with aging; that associated with aging but enhanced by the index condition, as in SLE and cardiovascular disease; comorbidity that is part of the symptoms complex of the index condition; and CC that represent lifetime traits or manifestations of the underlying illness. Depression was the most strongly associated correlate of EQ-5D quality of life, and current depression was present in about 15% of patients with RA or NIRD and 34% to 39% of those with SLE and FM.

Fibromyalgia, systemic lupus erythematosus (SLE), and evaluation of SLE activity

OBJECTIVE

To determine if fibromyalgia (FM) or fibromyalgia-ness (the tendency to respond to illness and psychosocial stress with fatigue, widespread pain, general increase in symptoms, and similar factors) is increased in patients with compared to those without systemic lupus erythematosus (SLE); to determine whether FM or fibromyalgia-ness biases the SLE Activity Questionnaire (SLAQ); and to determine if the SLAQ is overly sensitive to FM symptoms.

METHODS

We developed a 16-item SLE Symptom Scale (SLESS) modeled on the SLAQ and used that scale to investigate the relation between SLE symptoms and fibromyalgia-ness in 23,321 patients with rheumatic disease. FM was diagnosed by survey FM criteria, and fibromyalgia-ness was measured using the Symptom Intensity (SI) Scale. As comparison groups, we combined patients with rheumatoid arthritis and noninflammatory rheumatic disorders into an "arthritis" group and also utilized a physician-diagnosed group of patients with FM.

RESULTS

FM was identified in 22.1% of SLE and 17.0% of those with arthritis. The SI scale was minimally increased in SLE. The correlation between SLAQ and SLESS was 0.738. SLESS/SLAQ scale items (Raynaud's phenomenon, rash, fever, easy bruising, hair loss) were significantly more associated with SLE than FM, while the reverse was true for headache, abdominal pain, paresthesias/stroke, fatigue, cognitive problems, and muscle pain or weakness. There was no evidence of disproportionate symptom-reporting associated with fibromyalgia-ness. Self-reported SLE was associated with an increased prevalence of FM that was unconfirmed by physicians, compared to SLE confirmed by physicians.

CONCLUSION

The prevalence of FM in SLE is minimally increased compared with its prevalence in patients with arthritis. Fibromyalgia-ness does not bias the SLESS and should not bias SLE assessments, including the SLAQ.

Outcome and Predictor Relationships in Fibromyalgia and Rheumatoid Arthritis: Evidence Concerning the Continuum versus Discrete Disorder Hypothesis

Objective.

To compare outcome-predictor relationships in fibromyalgia (FM) and rheumatoid arthritis (RA), to provide information regarding the competing hypotheses that FM is a continuum or a discrete disorder.

Methods.

We studied 3 outcome variables (work disability, opioid use, depression) and 12 clinical predictor variables in 2,046 patients with FM and 20,374 with RA. We determined whether outcome-predictor relationships were stronger in FM or RA by measuring the areas under the receiver-operating curves. We used fractional polynomial logistic regression to create graphic models for the outcome-predictor relationships.

Results.

All measures of status and outcome were more abnormal in FM than in RA. Depression was reported in 33.4% of patients with FM compared with 15.1% of those with RA. The predictor-outcome relationship was significantly stronger in RA in 28 of the 36 tests, and not different in the remainder. The relationship between outcome and predictor variables was generally similar in patients with FM and RA. However, unmodeled depression that was not explained by study variables was noted in FM.

Conclusion.

Our data are consistent with the hypothesis that FM is the end of a severity continuum, but that additional psychological factors are an integral part of the syndrome.

Basic and clinical aspects of gastrointestinal pain

The gastrointestinal (GI) tract is a system of organs within multicellular animals which facilitates the ingestion, digestion, and absorption of food with subsequent defecation of waste. A complex arrangement of nerves and ancillary cells contributes to the sensorimotor apparatus required to subserve such essential functions that are with the exception of the extreme upper and lower ends of the GI tract normally subconscious. However, it also has the potential to provide conscious awareness of injury. Although this function can be protective, when dysregulated, particularly on a chronic basis, the same system can lead to considerable morbidity. The anatomical and molecular basis of gastrointestinal nociception, conditions associated with chronic unexplained visceral pain, and developments in treatment are presented in this review.

Pain experience and the imagined researcher

Little attention has been paid to what happens communicatively when members of the general population attempt to complete a postal survey. The questions - here, on the experience of pain - encapsulate health researchers' views of useful indicators of the scope of pain experience, hence displaying an 'official' representation of experienced pain, limitation, and disability. The respondent faces the double task of aligning their personal experience with this representation in a way that is meaningful and true both to their own experience and to the perceived demands of the questionnaire. For this to succeed, context is often crucial. The paper explores sources and indications of tension in this endeavour as part of a communicative process. Beginning from the observation that respondents frequently write unsolicited comments on their questionnaires, the paper proposes that the need for communication beyond the requested tick in the box treats the questionnaire as an attempt at dialogue with a figure I call 'the imagined researcher'. The paper discusses the communicative task that confronts respondents and the implications of 'the imagined researcher' for the research process.

Long-term effects of a shared decision-making intervention on physician-patient interaction and outcome in fibromyalgia. A qualitative and quantitative 1 year follow-up of a randomized controlled trial

OBJECTIVE

Fibromyalgia syndrome (FMS) patients and their doctors frequently complain on interaction difficulties. We investigated the effects of a shared decision-making (SDM) intervention on physician-patient interaction and health outcome.

METHODS

Sixty-seven FMS patients of an outpatient university setting that had been included in a randomized controlled trial were followed up. They were either treated in an SDM group or in an information group. Both groups saw a computer based information tool on FMS, but only the SDM group was treated by doctors which underwent a special SDM communication training. A comparison group of 44 FMS patients receiving treatment as usual was recruited in rheumatological practices. We assessed patients and their doctors using a combined qualitative and quantitative approach. Patients and doctors were followed-up after 3 months (T2) and after 1 year (T3).

RESULTS

The significantly best quality of physician-patient interaction was reported by patients and doctors of the SDM group, followed by the information group. Coping had more often improved in the SDM group than in the information group. However directly health related outcome variables had not improved in any of the groups at T3.

CONCLUSION

An SDM intervention can lead to an improved physician-patient relationship from the patients' and from the doctors' perspective.

PRACTICE IMPLICATIONS

It should be considered to include SDM in standard care for FMS patients.

The Chronic Fatigue Syndrome Activities and Participation Questionnaire (CFS-APQ): An overview

Chronic fatigue syndrome (CFS) is characterized by severe fatigue and a reduction in activity levels. The purpose of this study was to provide an overview of design, reliability, and validity of the CFS Activities and Participation Questionnaire (CFS-APQ). The CFS-APQ was constructed based on a retrospective analysis of the Karnofsky Performance Status Questionnaire and the Activities of Daily Living Questionnaire (n = 141). In a reliability study of 34 participants the test-retest reliability coefficient of the CFS-APQ was 0.95. In two different studies, the Cronbach alpha coefficient for internal consistency varied between 0.87 (n = 88) and 0.94 (n = 47). The CFS-APQ was administered to 47 patients who listed 183 activities that had become difficult due to their chronic symptoms, and 157 (85.8%) answers matched the content of the CFS-APQ. The outcome of a cross-sectional study (n = 88) studying the correlations between the Medical Outcomes Short Form 36 Health Status Survey subscale scores and the CFS-APQ supported the validity of the CFS-APQ. The CFS-APQ scores correlated with a behavioural assessment of the patients' performance of activities encompassed by the questionnaire (r = 0.29-0.55; n = 63), and correlated with exercise capacity parameters (r = 0.26-0.39; n = 77) obtained during a maximal exercise capacity stress test. Finally, the CFS-APQ correlated with visual analogue scales for pain (r = 0.51) and fatigue (r = 0.50; n = 47). It is concluded that the CFS-APQ generates reliable and valid data, and can be used as a clinical measure of disease severity in patients with CFS. Future studies should aim at examining the sensitivity of the CFS-APQ.

Can epidemiology clear the fog of war? Lessons from the 1990-91 Gulf War

Despite over US $200 million having been spent researching illnesses following the 1990-91 Persian Gulf War, the nature and cause of such illnesses remains controversial. In this narrative review, we discuss some of the methodological issues that have affected epidemiological studies on this topic. These include low-response rates, ascertainment bias, recall bias, problems identifying suitable control groups, and problems defining the outcomes to study. From this we argue that difficulties have arisen partly owing to the significant delay between the point at which illnesses were first identified by veterans and the reporting of epidemiological studies and that health surveillance should be routine following future deployments.

Fibromyalgia diagnosis: A comparison of clinical, survey, and American College of Rheumatology criteria

OBJECTIVE

The American College of Rheumatology (ACR) criteria for fibromyalgia are the de facto criteria used for research. However, ACR criteria are not generally utilized by nonrheumatologists, and rheumatologists may diagnose fibromyalgia in patients who do not satisfy the ACR criteria. We undertook this study to determine concordance between ACR criteria and clinician diagnosis and between proposed survey criteria and clinician diagnosis.

METHODS

Consecutive patients in a clinical practice setting were evaluated by tender point examination, survey criteria for fibromyalgia (Regional Pain Scale score > or =8 and fatigue score > or =6), and clinical diagnosis.

RESULTS

Among the 206 patients, the clinician diagnosed fibromyalgia in 49.0%, while 29.1% satisfied ACR criteria and 40.3% satisfied survey criteria. Clinical and survey criteria were concordant in 74.8% of cases (kappa = 0.49 [95% confidence interval 0.36, 0.60]). Clinical criteria and ACR criteria were concordant in 75.2% of cases (kappa = 0.50 [95% confidence interval 0.35, 0.59]), and survey criteria and ACR criteria were concordant in 72.3% (kappa = 0.40 [95% confidence interval 0.25, 0.51]). The ACR tender point criterion (> or =11) was not a factor in clinical and survey criteria. However, the tender point count was useful in clinical diagnosis.

CONCLUSION

Clinical diagnosis and ACR and survey criteria are moderately concordant (72-75%) and address a common pool of symptoms and physical findings. Because there is no gold standard for fibromyalgia diagnosis and because fibromyalgia is often viewed as a trait diagnosis, all methods of diagnosis have utility. The survey method has the advantage that it does not require physical examination.

[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.