Fibromyalgia after motor vehicle collision: evidence and implications

Further evidence that peritraumatic 17β-estradiol levels influence chronic posttraumatic pain outcomes in women, data from both humans and animals

ABSTRACT

Chronic posttraumatic pain (CPTP) is common after traumatic stress exposure (TSE) and disproportionately burdens women. We previously showed across 3 independent longitudinal cohort studies that, in women, increased peritraumatic 17β-estradiol (E2) levels were associated with substantially lower CPTP over 1 year. Here, we assessed this relationship in a fourth longitudinal cohort and also assessed the relationship between E2 and CPTP at additional time points post-TSE. Furthermore, we used a well-validated animal model of TSE to determine whether exogenous E2 administration protects against mechanical hypersensitivity. Using nested samples and data from the Advancing Understanding of RecOvery afteR traumA study (n = 543 samples, 389 participants), an emergency department-based prospective study of TSE survivors, we assessed the relationship between circulating E2 levels and CPTP in women and men using multivariate repeated-measures mixed modeling. Male and ovariectomized female Sprague Dawley rats were exposed to TSE and administered E2 either immediately after or 3 days post-TSE. Consistent with previous results, we observed an inverse relationship between peritraumatic E2 and longitudinal CPTP in women only (β = -0.137, P = 0.033). In animals, E2 protected against mechanical hypersensitivity in female ovariectomized rats only if administered immediately post-TSE. In conclusion, peritraumatic E2 levels, but not those at post-TSE time points, predict CPTP in women TSE survivors. Administration of E2 immediately post TSE protects against mechanical hypersensitivity in female rats. Together with previous findings, these data indicate that increased peritraumatic E2 levels in women have protective effects against CPTP development and suggest that immediate post-TSE E2 administration in women could be a promising therapeutic strategy for reducing risk of CPTP.

The possible onset of fibromyalgia following acute COVID-19 infection

INTRODUCTION

The exact pathogenesis of fibromyalgia (FM) syndrome is unclear. However, various infectious have been implicated with the development of FM after their acute phase. We aimed to investigate the incidence of FM syndrome among convalesced individuals following hospitalization for Acute Coronavirus Disease-2019 (COVID-19).

METHODS

We performed a cross-sectional study on patients who were discharged after COVID-19 hospitalization from the Sheba Medical Center, Israel, between July 2020 to November 2020. A phone interview was performed consisting of the following questionnaires: the Fibromyalgia Survey Diagnostic Criteria Questionnaire, Sense of Coherence Questionnaire to evaluate resilience, and the Subjective Traumatic Outlook Questionnaire to assess the associated psychological aspects of the trauma. The incidence of post-COVID FM was calculated and regression models were performed to identify predictors.

RESULTS

The study population consisted of 198 eligible patients who completed the phone interview. The median age was 64 (52-72) and 37% were women. The median follow-up was 5.2 months (IQR 4.4-5.8). The incidence of FM was 15% (30 patients) and 87% (172 patients) had at least one FM-related symptom. Female gender was significantly associated with post-COVID FM (OR 3.65, p = 0.002). In addition, high median Subjective Traumatic Outlook scores and low median Sense of Coherence scores were both significantly associated with post-COVID FM (OR 1.19, p<0.001 and OR 0.92, p<0.001, respectively).

CONCLUSIONS

FM is highly prevalent among COVID-19 convalescent patients. Our finding suggests that a significant subjective traumatic experience and a low resilience are highly associated with post-COVID FM.

Fibromyalgia and Associated Disorders: From Pain to Chronic Suffering, From Subjective Hypersensitivity to Hypersensitivity Syndrome

The concept of fibromyalgia has progressed to achieve a certain consensus regarding the definition of the condition. We summarize what is known in 2020, be it in terms of diagnosis, with the criteria that have changed over the years, or at the level of the psychological profile, via the notions of "catastrophizing" and "coping" and post-traumatic syndrome. The importance of fatigue and sleep disorders is underlined, with the chronological sequence of post-traumatic syndrome, chronic fatigue, and then amplification of the pain and the onset of multiple associated symptoms. The etiopathogenic debate has been enriched thanks to neuro-imaging data to discover the start of the central neurological signature. The many associated symptoms are reanalyzed in the context of so-called sister conditions which form sometimes more or less separate entities, such as chronic fatigue syndrome or restless legs syndrome for example. What these conditions have in common is hypersensitivity, not just to pain, but also to all exteroceptive stimuli, from deep sensitivity in the neuro-vegetative system, the sense organs and certain functions of the central nervous system, to the psychological aspects and sleep control. In summary, it is possible to define fibromyalgia as a cognitive disorder of cortical integration of chronic pain, with amplification of painful and sensory nociception, decrease in the threshold for the perception of pain, and persistence of a stimulus that maintains the process in chronicity. Fibromyalgia is part of a group of chronic hypersensitivity syndromes of central origin, with a very wide range of means of expression.

Association Between Predeployment Optimism and Onset of Postdeployment Pain in US Army Soldiers

IMPORTANCE

Pain after deployment is a major health care concern. While risk factors have been previously studied, few studies have explored protective factors.

OBJECTIVE

To examine the prospective association between predeployment optimism and the onset of new pain after deployment in US Army soldiers.

DESIGN, SETTING, AND PARTICIPANTS

This prospective longitudinal cohort study examined US Army soldiers (active duty, Reserve, and National Guard) who deployed to Afghanistan or Iraq between February 12, 2010, and August 29, 2014, and completed the necessary psychological and health assessments before and after deployment. Analyses were performed in the Person-Event Data Environment between July 2016 and November 2018. This study relied exclusively on existing, secondary Army data. Of the 413 763 Army soldiers who met the specified deployment criteria, 385 925 soldiers were missing 1 or more of the required assessment forms. Of the remaining 27 838 soldiers who were examined for eligibility, 7104 soldiers were excluded because of preexisting back pain, joint pain, or frequent headaches. These exclusions resulted in a final analytic sample of 20 734 eligible soldiers.

MAIN OUTCOMES AND MEASURES

This study examined new reports of pain after deployment, including new back pain, joint pain, and frequent headaches.

RESULTS

Among 20 734 US Army soldiers (87.8% male; mean [SD] age, 29.06 [8.42] years), 37.3% reported pain in at least 1 new area of the body after deployment: 25.3% reported new back pain, 23.1% reported new joint pain, and 12.1% reported new frequent headaches. As a continuous measure, each 1-U increase in optimism was associated with 11% lower odds of reporting any new pain after deployment, even while adjusting for demographic, military, and combat factors (odds ratio, 0.89; 95% CI, 0.86-0.93). Tertile analyses revealed that compared with soldiers with high optimism (lowest odds of new pain) soldiers with low optimism had 35% greater odds of reporting new pain in any of the 3 sites evaluated (odds ratio, 1.35; 95% CI, 1.21-1.50). In addition, a larger increase in risk of new pain was observed when comparing the moderate-optimism and low-optimism groups rather than the high-optimism and moderate-optimism groups.

CONCLUSIONS AND RELEVANCE

Higher levels of optimism were associated with lower odds of reporting new pain after deployment, over and above other common determinants of pain, including demographic and military characteristics and combat experiences. Soldiers with low levels of optimism before deployment could benefit from programs geared toward enhancing optimism.

The juvenile fibromyalgia syndrome (JFMS): a poorly defined disorder

Juvenile fibromyalgia syndrome (JFMS) is a chronic condition characterized by symptoms of chronic diffuse musculoskeletal pain and multiple painful tender points on palpation. It is often accompanied by fatigue, disorders of sleep, chronic headaches, irritable bowel syndrome, and subjective soft tissue swelling. The complexity of the presenting clinical picture in JPFS has not been sufficiently defined in the literature. Similarities to adult fibromyalgia syndrome in JFMS are often difficult to compare, because many of the symptoms are "medically unexplained" and often overlap frequently with other medical conditions. However, a valid diagnosis of JFMS often decreases parents' anxiety, reduces unnecessary further investigations, and provides a rational framework for a management plan. The diagnostic criteria proposed by Yunus and Masi in 1985 to define JFMS were never validated or critically analyzed. In most cases, the clinical diagnosis is based on the history, the physical examination that demonstrates general tenderness (muscle, joints, tendons), the absence of other pathological conditions that could explain pain and fatigue, and the normal basic laboratory tests. Research and clinical observations defined that JFMS may have a chronic course that impacts the functional status and the psychosocial development of children and adolescents. This paper briefly reviews the existing knowledge on JFMS focusing on the diagnosis, clinical and the epidemiological characteristics in children and adolescents for better understanding of this disorder.

Prevalence of fibromyalgia in fourteen Korean tertiary care university hospital pain clinics

Purpose

We aimed to investigate the prevalence of fibromyalgia (FM) in patients who visited outpatient pain clinics in Korea, using the modified 2010 American College of Rheumatology (ACR) criteria and to evaluate comorbid conditions that may be associated with FM.

Patients and methods

Outpatients, aged ≥18 years, who first visited pain clinics at any of the 14 tertiary care university hospitals, were recruited for this study. Modified 2010 ACR criteria were used to diagnose FM. Participants’ demographic information and eleven comorbid measures (sleep disturbance, fatigue, irritable bowel syndrome, amnesia, hypothyroidism, headache, anxiety, depression, rheumatism, low back pain, and history of traffic accident) were also investigated via additional questionnaires.

Results

We recruited 1,233 outpatients (754 men and 479 women). Based on the modified 2010 ACR criteria, 13.38% (165/1,233 patients, 95% CI: 11.48–15.28) of patients had FM. As participants with a history of FM were excluded, the prevalence of FM was 11.0% (123/1,118 patients). Patients with FM were more likely to have one or more of the eleven predetermined comorbid conditions. Patients who were female and who had a previous history of FM, sleep disturbance, headache, or a history of traffic accident were more likely to have FM.

Conclusion

FM, according to the modified 2010 ACR criteria, appears to be a common disorder among chronic pain patients referred to tertiary care university hospital pain clinics. Therefore, physicians treating pain should consider this prevalence of FM among pain clinic patients.

Maternal and neonatal outcomes among pregnant women with fibromyalgia: a population-based study of 12 million births

PURPOSE

Fibromyalgia (FM) is a rheumatologic disorder marked by chronic, widespread pain and associated comorbid conditions. The purpose of our study was to evaluate the effect of FM on maternal and neonatal outcomes.

METHODS

Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1999 to 2013, we conducted a population-based retrospective cohort study consisting of women who delivered during that period. Logistic regression was used to compare maternal and neonatal outcomes among pregnancies in women with and without FM.

RESULTS

Of 12 584 918 births during the 15-year study period, 7758 (0.06%) were to women with FM with rates increasing over the study period. Women with FM were more commonly older in age, overweight or obese, and users of alcohol, tobacco, and illicit drugs. They were more likely to experience anxiety, depression, and bipolar disorder. Women with FM were at greater risk of gestational diabetes, preterm premature rupture of membranes, and placental abruption. Women with FM more commonly had cesarean deliveries (odds ratios (OR): 1.11, 95% CI: 1.05-1.16) and births complicated by venous thromboembolism (OR: 2.34, 95% CI: 1.91-2.86). Infants of women with FM were more likely to be premature (OR: 1.35, 95% CI: 1.25-1.46) and have intrauterine growth restriction (OR: 1.48, 95% CI: 1.30-1.68).

CONCLUSIONS

The prevalence of FM in pregnancy is rising in the US. FM is a high-risk pregnancy condition associated with adverse maternal and newborn outcomes.

Chronic widespread bodily pain is increased among individuals with history of fracture: findings from UK Biobank

SUMMARY

In this cross-sectional analysis of the UK Biobank cohort, a history of fracture was associated with increased risk of current widespread chronic pain.

PURPOSE/INTRODUCTION

We aimed to test the hypothesis that a history of fracture is associated with reporting chronic widespread bodily pain (CWBP), using baseline data from the UK Biobank cohort, comprising 502,656 people aged 40-69 years.

METHODS

The case definition of current chronic widespread bodily pain was based on a response of 'yes' to the question 'do you have pain all over the body?' and 'yes' to 'and have you experienced pain all over the body for more than 3 months?' Multivariable Poisson regression with robust standard errors was used to test the relationship between fracture (occurring within 5 years prior to the baseline interview, and recorded by self-report) at the spine, hip, upper limb or lower limb and CWBP, adjusting for confounders.

RESULTS

Of 501,733 participants (mean age 56.5 years), 7130 individuals reported CWBP and 23,177 had a history of fracture affecting the upper limb, lower limb, spine and/or hip. Individuals with prior fracture were significantly more likely to report CWBP than those without. After adjustment for potential risk factors (age, gender, demographic, lifestyle and socioeconomic, and psychological), risk ratios were attenuated but remained statistically significant with a more than doubling of risk for CWBP with spine fractures in men (risk ratio (RR) 2.67, 95% confidence interval (CI) 1.66-4.31; p < 0.001) and women (RR 2.13, 95% CI 1.35-3.37, p = 0.001) and with hip fractures in women (RR 2.19, 95% CI 1.33-3.59; p = 0.002).

CONCLUSIONS

In this cross-sectional analysis, previous fracture is associated with an increased likelihood of chronic widespread bodily pain, particularly with hip fractures in women, and spine fractures in both sexes. If replicated, these findings may help inform the identification of those most at risk of chronic widespread pain post-fracture, allowing preventative measures to be targeted.

Fibromyalgia and the Risk of a Subsequent Motor Vehicle Crash

OBJECTIVE

Motor vehicle crashes are a widespread contributor to mortality and morbidity, sometimes related to medically unfit motorists. We tested whether patients diagnosed with fibromyalgia (FM) have an increased risk of a subsequent serious motor vehicle crash.

METHODS

We conducted a population-based self-matched longitudinal cohort analysis to estimate the incidence rate ratio of crashes among patients diagnosed with FM relative to the population norm in Ontario, Canada. We included adults diagnosed from April 1, 2006, to March 31, 2012, excluding individuals younger than 18 years, living outside Ontario, lacking valid identifiers, or having only a single visit for the diagnosis. The primary outcome was an emergency department visit as a driver involved in a motor vehicle crash.

RESULTS

The patients (n = 137,631) accounted for 738 crashes during the first year of followup after diagnosis, equal to an incidence rate ratio of 2.44 compared with the population norm (95% CI 2.27-2.63, p < 0.001). The crash rate was more than twice the population norm for those with a new or a persistent diagnosis. The increased risk included patients with diverse characteristics, approached the rate observed among other patients diagnosed with alcoholism, and was mitigated among those who received dedicated FM care or a physician warning for driving safety.

CONCLUSION

A diagnosis of FM is associated with an increased risk of a subsequent motor vehicle crash that might justify medical interventions for traffic safety.

Fibromyalgia and Physical Trauma: The Concepts We Invent

Despite weak to nonexistent evidence regarding the causal association of trauma and fibromyalgia (FM), literature and court testimony continue to point out the association as if it were a strong and true association. The only data that appear unequivocally to support the notion that trauma causes FM are case reports, cases series, and studies that rely on patients’ recall and attribution — very low-quality data that do not constitute scientific evidence. Five research studies have contributed evidence to the FM-trauma association. There is no scientific support for the idea that trauma overall causes FM, and evidence in regard to an effect of motor vehicle accidents on FM is weak or null. In some instances effect may be seen to precede cause. Alternative causal models that propose that trauma causes “stress” that leads to FM are unfalsifiable and unmeasurable.

Incidence and predictors of neck and widespread pain after motor vehicle collision among US litigants and nonlitigants

Debate continues regarding the influence of litigation on pain outcomes after motor vehicle collision (MVC). In this study we enrolled European Americans presenting to the emergency department (ED) in the hours after MVC (n=948). Six weeks later, participants were interviewed regarding pain symptoms and asked about their participation in MVC-related litigation. The incidence and predictors of neck pain and widespread pain 6weeks after MVC were compared among those engaged in litigation (litigants) and those not engaged in litigation (nonlitigants). Among the 859 of 948 (91%) participants completing 6-week follow-up, 711 of 849 (83%) were nonlitigants. Compared to nonlitigants, litigants were less educated and had more severe neck pain and overall pain, and a greater extent of pain at the time of ED evaluation. Among individuals not engaged in litigation, persistent pain 6weeks after MVC was common: 199 of 711 (28%) had moderate or severe neck pain, 92 of 711 (13%) had widespread pain, and 29 of 711 (4%) had fibromyalgia-like symptoms. Incidence of all 3 outcomes was significantly higher among litigants. Initial pain severity in the ED predicted pain outcomes among both litigants and nonlitigants. Markers of socioeconomic disadvantage predicted worse pain outcomes in litigants but not nonlitigants, and individual pain and psychological symptoms were less predictive of pain outcomes among those engaged in litigation. These data demonstrate that persistent pain after MVC is common among those not engaged in litigation, and provide evidence for bidirectional influences between pain outcomes and litigation after MVC.

Fibromyalgia: A Clinical Update

Fibromyalgia is a common chronic syndrome defined by core symptoms of widespread pain, fatigue, and sleep disturbance. Other common symptoms include cognitive difficulty, headache, paresthesia, and morning stiffness. Fibromyalgia is increasingly understood as 1 of several disorders that are referred to as central sensitivity syndromes; these disorders share underlying causes and clinical features. Tender points are often detected in patients with fibromyalgia and were formerly required for diagnosis. Newly proposed criteria, however, rely on patients' reports of widespread pain and other somatic symptoms to establish the diagnosis of fibromyalgia. The management of fibromyalgia requires a multidimensional approach including patient education, cognitive behavioral therapy, exercise, and pharmacologic therapy. The present review provides an update on these various aspects of treating a patient with fibromyalgia.

Trauma and work-related pain syndromes: risk factors, clinical picture, insurance and law interventions

In the past decade, major progress has been made in our understanding of fibromyalgia syndrome (FMS). Various triggers have been implicated as contributing to symptom development in FMS when genetically susceptible individuals are challenged. A substantial amount of data points towards the association between trauma and chronic widespread pain/fibromyalgia syndrome (CWP/FMS). There is abundant data suggesting that the pathogenesis of CWP/FMS might be related to cervical spine injury. Furthermore, several persistent local pain conditions may progress to CWP/FMS. These conditions may share a common pathogenic mechanism namely, central sensitisation. Physical trauma and emotional trauma co-exist in many traumatic events and may interact in the pathogenesis of CWP/FMS.

Potential processes involved in the initiation and maintenance of whiplash-associated disorders: discussion paper 3

STUDY DESIGN

Nonsystematic review and discussion of the etiological processes involved in whiplash-associated disorders (WAD).

OBJECTIVE

To summarize the research and identify priorities for future research.

SUMMARY OF BACKGROUND DATA

Although there is convergent evidence of a peripheral lesion in some individuals after whiplash injury, in the majority of injured people, a lesion cannot be established with current imaging technology. Therefore, it is important to consider processes that underlie the initiation and maintenance of whiplash pain as this may allow for the development and testing of interventions to target these processes and improve outcomes.

METHODS

A nonsystematic review was performed to summarize current knowledge regarding potential etiological processes involved in the initiation and maintenance of WAD and to identify future research priorities.

RESULTS

There are several etiological processes potentially involved in the initiation and maintenance of WAD. These include augmented nociceptive processing, stress system responses, and psychosocial and sociocultural factors. Recent findings also indicate that morphological changes in the neck muscles of injured people show some association with poor recovery, but the mechanisms underlying these changes are not clear. Preliminary evidence indicates associations between these processes. Future research priorities include the following: more sophisticated investigation and analysis of interactions between the various processes; whether the modification of these processes is achievable and if modification can improve health outcomes; and to clarify factors involved in the initiation of whiplash pain versus those involved in symptom maintenance.

CONCLUSION

Research to date indicates that there are several physiological and psychological etiological processes that may underlie the initiation and maintenance of whiplash-related pain and disability. Further research is required to determine relationships and interactions between these factors and to determine whether their modification is possible and will improve outcomes after injury.

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.

A case-control study of cerebellar tonsillar ectopia (Chiari) and head/neck trauma (whiplash)

PRIMARY OBJECTIVE

Chiari malformation is defined as herniation of the cerebellar tonsils through the foramen magnum, also known as cerebellar tonsillar ectopia (CTE). CTE may become symptomatic following whiplash trauma. The purpose of the present study was to assess the frequency of CTE in traumatic vs non-traumatic populations.

STUDY DESIGN

Case-control.

METHODS AND PROCEDURES

Cervical MRI scans for 1200 neck pain patients were reviewed; 600 trauma (cases) and 600 non-trauma (controls). Half of the groups were scanned in a recumbent position and half were scanned in an upright position. Two radiologists interpreted the scans for the level of the cerebellar tonsils.

MAIN OUTCOMES AND RESULTS

A total of 1195 of 1200 scans were read. CTE was found in 5.7% and 5.3% in the recumbent and upright non-trauma groups vs 9.8% and 23.3% in the recumbent and upright trauma groups (p = 0.0001).

CONCLUSIONS

The results described in the present investigation are first to demonstrate a neuroradiographic difference between neck pain patients with and without a recent history of whiplash trauma. The results of prior research on psychosocial causes of chronic pain following whiplash are likely confounded because of a failure to account for a possible neuropathologic basis for the symptoms.

Association between fibromyalgia and coronary heart disease and coronary catheterization

BACKGROUND

Fibromyalgia (FM) has been associated with physical and emotional trauma including invasive medical procedures. Both FM and ischemic heart disease have been linked with depression. The purpose of this study was to retrospectively investigate the frequency of FM symptoms and physical findings among patients undergoing coronary catheterization.

METHODS

Consecutive patients who underwent coronary angiography during the previous 6 mo were recruited. Patients with major depression, bi-polar disorder, schizophrenia, or malignancy were excluded. Patients underwent dolorimetry for tender-point assessment and completed the fibromyalgia impact questionnaire (FIQ). Group A included patients with significant coronary pathology (n = 43), group B included patients with normal coronary arteries (n = 50), and group C included patients with normal controls (n = 51). A cardiological score incorporated the number of coronary arteries with significant pathology and left ventricular function. Chi-square or Fisher's exact test was used for categorical data and a one-way analysis of variance for continuous variables; a multivariate linear regression was performed to compare groups.

RESULTS

Significantly increased levels of tenderness were discovered among patients with coronary pathology compared with healthy controls. Significantly increased levels of depression were also found, as well as higher scores on the FIQ scale. On multivariate analysis, a positive correlation was demonstrated between tenderness/FIQ scores and a composite cardiological score.

CONCLUSION

Coronary angiography is associated with a significantly increased frequency of pain, tenderness, and depression after 6 mo, apparent in both patients undergoing coronary procedures and patients with normal coronaries. This association may impact the outcome of patients with significant coronary disease.

A systematic approach to clinical determinations of causation in symptomatic spinal disk injury following motor vehicle crash trauma

Clinical determinations of causation in cases of intervertebral disk (IVD) injury after a motor vehicle crash (MVC) are often disputed in medicolegal settings. No published systematic guidelines exist for making such determinations, which has resulted in infringement by nonclinical personnel into injury causation evaluations, a traditionally clinical activity. The result is causal determinations that are potentially disconnected from clinical observations of injury. The purpose of this review was to evaluate the current literature on causation, causal determinations after trauma and IVD injury after MVC, and to develop a practicable, logical, and literature-based approach to causation determinations of symptomatic IVD injury after MVC. The results of the review indicate IVD injury can result from any MVC regardless of magnitude, thus meeting the first criteria of causation, biologic plausibility. Individual determinations of causation depend entirely on the temporal association between the collision and the symptom onset (the second criterion) and a lack of a more probable explanation for the symptoms (the third). When these causal elements are met, clinicians can assert causation on a "more probable than not" or "reasonable probability" basis. Because of a lack of an established or reliable relationship between collision force and the probability of IVD injury the investigation of collision parameters is not a useful adjunct to causal determinations.

[Etiology and pathophysiology of fibromyalgia syndrome and chronic widespread pain]

OBJECTIVE

To write a systematic review on the etiology and pathophysiology of the fibromyalgia syndrome (FMS) and of chronic widespread pain (CWP).

METHODS

An interdisciplinary level-3 guideline (i.e. systematic literature search and assessment, logic analysis, formal consensus procedure) for the diagnosis and therapy of FMS was created in cooperation with 10 medical and psychological societies and 2 patient self-help organizations. A literature search was performed covering all available review articles on the etiology and pathophysiology of FMS and CWP using the Cochrane Collaboration Reviews (1993-12/2006), Medline (1980-2006), PsychInfo (1966-12/2006), and Scopus (1980-12/2006). For the assignment of evidence classes the system of the Oxford Centre for Evidence-Based Medicine was applied. Consensus was achieved by a multi-step nominal group procedure.

RESULTS

FMS aggregates in families (evidence level 2c). Physical and psychological stress at the workplace are risk factors for the development of CWP and FMS. Affective disorders are risk factors for the development and maintenance of FMS. Operant learning mechanisms and sensitization are risk factors for the chronification of FMS (evidence levels 2b). Several factors are associated with the pathophysiology of FMS, but the causal relationship is unclear. This includes alterations of central pain pathways, hyporeactivity of the hypothalamus-pituitary-adrenal axis, increased systemic pro-inflammatory and reduced anti-inflammatory cytokine profiles and disturbances in the dopaminergic and serotonergic systems.

CONCLUSIONS

FMS is the common final product of various etiological factors and pathophysiological mechanisms.

Acute stress response and recovery after whiplash injuries. A one-year prospective study

Chronic whiplash-associated disorder (WAD) represents a major medical and psycho-social problem. The typical symptomatology presented in WAD is to some extent similar to symptoms of post traumatic stress disorder. In this study we examined if the acute stress reaction following a whiplash injury predicted long-term sequelae. Participants with acute whiplash-associated symptoms after a motor vehicle accident were recruited from emergency units and general practitioners. The predictor variable was the sum score of the impact of event scale (IES) completed within 10 days after the accident. The main outcome-measures were neck pain and headache, neck disability, general health, and working ability one year after the accident. A total of 737 participants were included and completed the IES, and 668 (91%) participated in the 1-year follow-up. A baseline IES-score denoting a moderate to severe stress response was obtained by 13% of the participants. This was associated with increased risk of considerable persistent pain (OR=3.3; 1.8-5.9), neck disability (OR=3.2; 1.7-6.0), reduced working ability (OR=2.8; 1.6-4.9), and lowered self-reported general health one year after the accident. These associations were modified by baseline neck pain intensity. It was not possible to distinguish between participants who recovered and those who did not by means of the IES (AUC=0.6). In conclusion, the association between the acute stress reaction and persistent WAD suggests that post traumatic stress reaction may be important to consider in the early management of whiplash injury. However, the emotional response did not predict chronicity in individuals.

Forensic Epidemiology: a systematic approach to probabilistic determinations in disputed matters

Forensic medicine testimony often relies upon terms of probability to enhance the strength of the testimony. Such terms must have a demonstrably reliable and accurate basis; otherwise their use is speculative, unjustified, and potentially harmful. Forensic Epidemiology is introduced as a framework from which probabilistic testimony can be assessed in settings in which it is either proffered or encountered. In this paper, common forensic uses of probability are reviewed, appropriate methods for presenting such testimony are proposed, and inappropriate uses of probability and epidemiologic concepts and data, as well as a logical fallacies commonly observed in forensic settings are presented. A previously unpublished logical fallacy, the "Prior Odds" Fallacy, is also introduced.

Fibromyalgia and Overlapping Disorders: The Unifying Concept of Central Sensitivity Syndromes

OBJECTIVES

To discuss fibromyalgia syndrome (FMS) and overlapping conditions, eg, irritable bowel syndrome, headaches, and chronic fatigue syndrome, within the concept of central sensitivity syndromes (CSS).

METHODS

A critical overview of the literature and incorporation of the author's own views.

RESULTS

The concept of CSS seems viable. It is based on mutual associations among the CSS conditions as well as the evidence for central sensitization (CS) among several CSS members. However, such evidence is weak or not available in other members at this time, requiring further studies. The biology of CSS is based on neuroendocrine aberrations, including CS, that interact with psychosocial factors to cause a number of symptoms.

CONCLUSIONS

CSS is an important new concept that embraces the biopsychosocial model of disease. Further critical studies are warranted to fully test this concept. However, it seems to have important significance for new directions for research and patient care involving physician and patient education. Each patient, irrespective of diagnosis, should be treated as an individual considering both the biological and psychosocial contributions to his or her symptoms and suffering.

The development of persistent pain and psychological morbidity after motor vehicle collision: integrating the potential role of stress response systems into a biopsychosocial model

OBJECTIVES

Persistent pain and psychological sequelae are common after motor vehicle collision (MVC), but their etiology remains poorly understood. Such common sequelae include whiplash-associated disorders (WAD), fibromyalgia, and posttraumatic stress disorder (PTSD). Increasing evidence suggests that these disorders share overlapping epidemiologic and clinical features. A model is proposed in which central neurobiological systems, including physiologic systems and neuroanatomical structures involved in the stress response, are an important substrate for the development of all 3 disorders and interact with psychosocial and other factors to influence chronic symptom development.

METHODS

Epidemiologic and clinical characteristics regarding the development of these disorders after MVC are reviewed. Evidence suggesting a role for stress response systems in the development of these disorders is presented.

RESULTS

Contemporary evidence supports a model of chronic symptom development that incorporates the potential for interactions between past experience, acute stress responses to trauma, post-MVC behavior, and cognitive/psychosocial consequences to alter activity within brain regions which process pain and to result in persistent pain, as well as psychological sequelae, after MVC. Such a model incorporates factors identified in prior biopsychosocial theories and places them in the landscape of our rapidly developing understanding of stress systems and CNS pain-modulating pathways.

CONCLUSION

New models are needed to stimulate deeper examination of the interacting influences of initial tissue damage, acute pain, psychosocial contingencies, and central stress pathways during chronic symptom development after MVC. Deeper understanding could contribute to improved treatment approaches to reduce the immense personal and societal burdens of common trauma-related disorders.