Diagnostic confounders of chronic widespread pain: not always fibromyalgia

Physiotherapists' adherence to Clinical Practice Guidelines in fibromyalgia: a cross-sectional online survey

To evaluate the level of knowledge and adherence to Clinical Practice Guidelines on fibromyalgia of physiotherapists in Spain. A cross-sectional study using an ad-hoc online survey was implemented to assess aspects on the assessment, treatment, and decision of the length of the therapeutic approach on fibromyalgia. Based on the results, professionals were classified as adherent, partially adherent, or non-adherent. The level of agreement with several statements on the condition was also evaluated across the professionals surveyed to evaluate the potential consensus. A total of 240 physiotherapists met inclusion criteria, amongst which 68 (28.33%) were adherent. The academic level of studies (Chi-square = 48.601, p-value = 0.001) and having had previous training in fibromyalgia (Chi-square = 151.011, p-value = 0.001) displayed statistically significant differences across adherence-based groups. Consensus was reached for 15 out of 24 statements. Our findings highlight the presence of an acceptable level of knowledge and adherence to clinical practice guidelines in the field of fibromyalgia among physiotherapists in Spain.Practice implicationsOur results also reveal the existence of an evidence-to-practice gap in the field, with potential room for improvement: further efforts on promoting and reinforcing the importance of evidence-based therapies are needed, from university teaching plans to clinical updates for daily practice.

Climacteric and fibromyalgia: a review

Fibromyalgia (FM) and climacteric conditions share common epidemiological and clinical features, with FM symptoms often beginning during menopause. Musculoskeletal pain, arthralgia, myalgia and other symptoms are frequently seen in both conditions. Some research suggests a link between the cessation of sex hormones and FM symptoms. Women with FM tend to experience more severe symptoms after menopause, and the severity of FM symptoms can worsen in women who have had a hysterectomy with or without oophorectomy. Despite these similarities, it is essential to treat FM and climacteric conditions separately and follow established guidelines for management. However, it is also important to recognize that both conditions can coexist in the same patient. It is crucial to note that there is limited evidence supporting the effectiveness of menopausal hormone therapy for primary FM management. Therefore, menopausal hormone therapy should not be recommended for FM unless the patient also has climacteric syndrome.

Chronic Overlapping Pain Conditions and Nociplastic Pain

Chronic Overlapping Pain Conditions (COPCs) are a subset of chronic pain conditions commonly comorbid with one another and more prevalent in women and assigned female at birth (AFAB) individuals. Pain experience in these conditions may better fit with a new mechanistic pain descriptor, nociplastic pain, and nociplastic type pain may represent a shared underlying factor among COPCs. We applied GenomicSEM common-factor genome wide association study (GWAS) and multivariate transcriptome-wide association (TWAS) analyses to existing GWAS output for six COPCs in order to find genetic variation associated with nociplastic type pain, followed by genetic correlation (linkage-disequilibrium score regression), gene-set and tissue enrichment analyses. We found 24 independent single nucleotide polymorphisms (SNPs), and 127 unique genes significantly associated with nociplastic type pain, and showed nociplastic type pain to be a polygenic trait with significant SNP-heritability. We found significant genetic overlap between multisite chronic pain and nociplastic type pain, and to a smaller extent with rheumatoid arthritis and a neuropathic pain phenotype. Tissue enrichment analyses highlighted cardiac and thyroid tissue, and gene set enrichment analyses emphasized potential shared mechanisms in cognitive, personality, and metabolic traits and nociplastic type pain along with distinct pathology in migraine and headache. We use a well-powered network approach to investigate nociplastic type pain using existing COPC GWAS output, and show nociplastic type pain to be a complex, heritable trait, in addition to contributing to understanding of potential mechanisms in development of nociplastic pain.

Temporomandibular Disorders and Fibromyalgia Prevalence: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the prevalence of chronic widespread pain (CWP) and fibromyalgia syndrome (FMS) in TMD patients and the prevalence of TMDs in patients with FMS.

METHOD

A systematic search was performed in electronic databases. Studies published in English examining the prevalence of comorbid TMDs and CWP/FMS were included. The Newcastle-Ottawa Scale was used to assess study quality, and meta-analyses using defined diagnostic criteria were conducted to generate pooled prevalence estimates.

RESULTS

Nineteen studies of moderate to high quality met the selection criteria. Meta-analyses yielded a pooled prevalence rate (95% CI) for TMDs in FMS patients of 76.8% (69.5% to 83.3%). Myogenous TMDs were more prevalent in FMS patients (63.1%, 47.7% to 77.3%) than disc displacement disorders (24.2%, 19.4% to 39.5%), while a little over 40% of FMS patients had comorbid inflammatory degenerative TMDs (41.8%, 21.9% to 63.2%). Almost a third of individuals (32.7%, 4.5% to 71.0%) with TMDs had comorbid FMS, while estimates of comorbid CWP across studies ranged from 30% to 76%.

CONCLUSIONS

Despite variable prevalence rates among the included studies, the present review suggests that TMDs and CWP/FMS frequently coexist, especially for individuals with painful myogenous TMDs. The clinical, pathophysiologic, and therapeutic aspects of this association are important for tailoring appropriate treatment strategies.

Pain in Parkinson disease: mechanistic substrates, main classification systems, and how to make sense out of them

ABSTRACT

Parkinson disease (PD) affects up to 2% of the general population older than 65 years and is a major cause of functional loss. Chronic pain is a common nonmotor symptom that affects up to 80% of patients with (Pw) PD both in prodromal phases and during the subsequent stages of the disease, negatively affecting patient's quality of life and function. Pain in PwPD is rather heterogeneous and may occur because of different mechanisms. Targeting motor symptoms by dopamine replacement or with neuromodulatory approaches may only partially control PD-related pain. Pain in general has been classified in PwPD according to the motor signs, pain dimensions, or pain subtypes. Recently, a new classification framework focusing on chronic pain was introduced to group different types of PD pains according to mechanistic descriptors: nociceptive, neuropathic, or neither nociceptive nor neuropathic. This is also in line with the International Classification of Disease-11 , which acknowledges the possibility of chronic secondary musculoskeletal or nociceptive pain due to disease of the CNS. In this narrative review and opinion article, a group of basic and clinical scientists revise the mechanism of pain in PD and the challenges faced when classifying it as a stepping stone to discuss an integrative view of the current classification approaches and how clinical practice can be influenced by them. Knowledge gaps to be tackled by coming classification and therapeutic efforts are presented, as well as a potential framework to address them in a patient-oriented manner.

Evaluation of the agreement between the ACR 1990 fibromyalgia tender points and an enthesitis score in patients with axial spondyloarthritis

OBJECTIVES

Coexistence of FM represents a challenge in the evaluation of enthesitis in patients with axial spondyloarthritis (axSpA) due to a possible overlap between the tender points (TP) due to enthesitis and those of FM. The objective was to assess the agreement between the MASES enthesitis score and the tender points of the ACR 1990 criteria in patients with axSpA.

METHODS

This was a cross-sectional ancillary analysis of the Predict-SpA study (NCT03039088). Patients had a diagnosis of axSpA according to their rheumatologist and an indication to start a TNFα blocker. All patients were screened for FM according to the FiRST questionnaire. A physician was asked to assess 31 anatomically described sites in a random order without knowing to which instrument the site belonged (i.e. the 18 ACR 1990 TP and the 13 MASES sites). Agreement between the MASES and the ACR 1990 TPs by the intraclass correlation coefficient (ICC), also stratified by the presence/absence of concomitant FM according to the FiRST.

RESULTS

Among the 526 patients, 53% were men and 202 (38%) had FM. Radiographic sacroiliitis and MRI sacroiliitis were present in 56% and 68% patients, respectively. Patients were mostly men (53.4%) with radiographic and MRI sacroiliitis in 56% and 68% patients, respectively. Mean number of ACR 1990 TP was 5.4 (s.d. 4.6) and mean MASES was 4.2 (s.d. 3.6). ICC between both scores was 0.7 [95% CI (0.6, 0.8)]. ICC between both scores was 0.6 [95% CI (0.3, 0.8)] and 0.7 [95% CI (0.6, 0.7)] for patients with and without FM, respectively.

CONCLUSION

These results suggest a significant overlap between both scores in patients with axSpA, including in those without concomitant FM.

TRIAL REGISTRATION

clinicaltrials.gov, https://clinicaltrials.gov, NCT03039088.

Do Chronic Low Back Pain and Chronic Widespread Pain differ in their association with Depression Symptoms in the 1958 British Cohort?

OBJECTIVE

Depression frequently coexists with chronic pain. Contemporary models suggest that these conditions share pathobiological mechanisms, prompting a need to investigate their temporal association. This investigation aimed to explore two distinctly different chronic pain conditions, and their cross-sectional and prospective associations with depression.

METHODS

Self-reported information was available on chronic widespread pain (CWP), chronic low back pain (CLBP) (45 years), and depression symptoms (45 and 50 years) from up to 9,377 participants in the 1958 British cohort. Depression symptom outcomes were derived by "Clinical Interview Schedule-Revised" (45 years) and "Short Form-36" (50 years). Relationships between both chronic pain conditions and depression symptoms were investigated by fitting four separate logistic regression models, each with varying levels of covariate adjustment, including depression at baseline.

RESULTS

CWP was associated with depression symptoms cross-sectionally (odds ratio [OR] = 2.04, 95% confidence interval [CI] 1.65, 2.52; P < 0.001, n = 7,629), and prospectively when fully adjusted for baseline, sociodemographic, lifestyle, and health covariates (OR = 1.45, 95% CI 1.17, 1.80; P = < 0.001, n = 6,275). CLBP was associated with depression symptoms prospectively (full model: OR = 1.28, 95% CI 1.01, 1.61; P = 0.04, n = 6,288). In fully adjusted models the prospective association of CWP with depression symptoms was more heavily influenced by our covariates than CLBP with depression symptoms.

CONCLUSION

Pain may be a stressor from which depression can arise. Development of depression may be differentially dependant upon the type of pain experienced. Screening for depression symptoms among individuals with both chronic pain conditions is indicated and should be repeated over time.

Assessing workers with fibromyalgia: what should occupational physicians know?

Fibromyalgia is a chronic pain syndrome with a complex multifactorial etiopathogenesis that more frequently affects women. Although widespread pain is the dominant feature, fibromyalgia incorporates a wide variety of symptoms, such as fatigue, unrefreshed sleep, and cognitive and mood disorders. Central sensitization to pain is a key element in the pathophysiology of this syndrome. Due to its prevalence and repercussions on quality of life and work productivity, fibromyalgia is a common condition in occupational medicine outpatient clinics. Thus, physicians must be attentive to its symptoms to facilitate diagnosis and management. This article will address basic topics about fibromyalgia, including: epidemiology, predisposing factors, pathophysiological considerations, clinical manifestations, classification criteria, differential diagnosis, basic principles of treatment, and the contribution of occupational physicians.

Could the fibromyalgia syndrome be triggered or enhanced by COVID-19?

Fibromyalgia (FM) is a complex disease with an uncertain aetiology and intricate pathophysiology. Although its genesis is not fully explained, potential environmental factors, such as viral infections might trigger FM or worsen patients' clinical outcomes. The SARS-CoV-2 virus may affect central and peripheral nervous systems, leading to musculoskeletal, neurological, and psychological disturbances. These symptoms might persist at least 12 months beyond the recovery, often referred to as post-COVID syndrome, which resembles FM syndrome. In this sense, we argued the potential consequences of COVID-19 exclusively on FM syndrome. First, we have described post-COVID syndrome and its painful symptoms. Afterwards, we argued whether FM syndrome could be triggered or enhanced by COVID-19 infection or by numerous and persistent stressors imposed daily by the pandemic setting (isolation, uncertainty, depression, mental stress, generalized anxiety, and fear of the virus). In addition, we have demonstrated similarities between pathophysiological mechanisms and cardinal symptoms of FM and COVID-19, speculating that SARS-CoV-2 might represent a critical mediator of FM or an exacerbator of its symptoms once both syndromes share similar mechanisms and complaints. Therefore, pharmacologic and non-pharmacological approaches commonly used to treat FM could serve as strategic therapies to attenuate painful and neurological manifestations of post-COVID syndrome. Although it is still theoretical, clinicians and researchers should be alert of patients who develop symptoms similar to FM or those who had their FM symptoms increased post-COVID to manage them better.

Kinins and their B1 and B2 receptors as potential therapeutic targets for pain relief

Kinins are endogenous peptides that belong to the kallikrein-kinin system, which has been extensively studied for over a century. Their essential role in multiple physiological and pathological processes is demonstrated by activating two transmembrane G-protein-coupled receptors, the kinin B₁ and B₂ receptors. The attention is mainly given to the pathological role of kinins in pain transduction mechanisms. In the past years, a wide range of preclinical studies has amounted to the literature reinforcing the need for an updated review about the participation of kinins and their receptors in pain disorders. Here, we performed an extensive literature search since 2004, describing the historical progress and the current understanding of the kinin receptors' participation and its potential therapeutic in several acute and chronic painful conditions. These include inflammatory (mainly arthritis), neuropathic (caused by different aetiologies, such as cancer, multiple sclerosis, antineoplastic toxicity and diabetes) and nociplastic (mainly fibromyalgia) pain. Moreover, we highlighted the pharmacological actions and possible clinical applications of the kinin B₁ and B₂ receptor antagonists, kallikrein inhibitors or kallikrein-kinin system signalling pathways-target molecules in these different painful conditions. Notably, recent findings sought to elucidate mechanisms for guiding new and better drug design targeting kinin B₁ and B₂ receptors to treat a disease diversity. Since the kinin B₂ receptor antagonist, Icatibant, is clinically used and well-tolerated by patients with hereditary angioedema gives us hope kinin receptors antagonists could be more robustly tested for a possible clinical application in the treatment of pathological pains, which present limited pharmacology management.

A possible alternative to Opiorphin and its stable analogues for treating fibromyalgia pain: A clinical hypothesis

The work aimed to explore the clinical hypothesis on the possible alternative to Opiorphin and its stable analogues for treating fibromyalgia pain. Fibromyalgia is a condition characterized by chronic pain triggered by an interplay of biological and psychosocial variables, although the exact pathogenesis is still controversial. Standard therapy for low threshold tender point pain includes NSAIDs and opioid analgesics, both of which have serious adverse profiles after long-term exposure, highlighting the need for an intermediate compound capable of bridging the gap between NSAIDs and opioid analgesics. Opiorphin is an anti-nociceptive modulator which inhibits the enzyme responsible for the degradation of natural endogenous opioid neuropeptides. This paper hypothesizes and concludes that Opiorphin and its stable analogues (Sialorphine, STR-324) can be an alternative for the treatment of chronic long-standing low-threshold tender point pain associated with fibromyalgia.

A Link Between Inflammatory Mechanisms and Fibromyalgia

Fibromyalgia (FM) is a condition characterized by chronic widespread pain, which has traditionally been considered psychogenic in nature due to lack of known underlying organic pathophysiology. In more recent years, inflammation of the nervous system has become increasingly recognized as a sign of neuropsychiatric conditions, and this association may enhance our knowledge of conditions such as FM. Emerging evidence has suggested inflammation, particularly neuroinflammation, as a potential contributor underlying the etiology of FM. Studies have searched for linked biomarkers with mixed results, though the literature is beginning to point to increased systemic levels of pro-inflammatory cytokines such as IL-6 and IL-8 in patients with FM relative to healthy controls. A multicenter imaging study has also reported results suggestive of microglial activation related to the presence of FM. Given the consistency in neuroinflammatory effects implicated in "sickness behavior" characteristic of chronic systemic inflammatory conditions such as cancer or rheumatic diseases, therein springs the hypothesis for a connection between FM and neuroinflammation as discussed in this chapter.

Characterization of the Dahl salt-sensitive rat as a rodent model of inherited, widespread, persistent pain

Animal models are essential for studying the pathophysiology of chronic pain disorders and as screening tools for new therapies. However, most models available do not reproduce key characteristics of clinical persistent pain. This has limited their ability to accurately predict which new medicines will be clinically effective. Here, we characterize the Dahl salt-sensitive (SS) rat strain as the first rodent model of inherited widespread hyperalgesia. We show that this strain exhibits physiological phenotypes known to contribute to chronic pain, such as neuroinflammation, defective endogenous pain modulation, dysfunctional hypothalamic-pituitary-adrenal axis, increased oxidative stress and immune cell activation. When compared with Sprague Dawley and Brown Norway rats, SS rats have lower nociceptive thresholds due to increased inflammatory mediator concentrations, lower corticosterone levels, and high oxidative stress. Treatment with dexamethasone, the reactive oxygen species scavenger tempol, or the glial inhibitor minocycline attenuated the pain sensitivity in SS rats without affecting the other strains while indomethacin and gabapentin provided less robust pain relief. Moreover, SS rats presented impaired diffuse noxious inhibitory controls and an exacerbated response to the proalgesic mediator PGE₂, features of generalized pain conditions. These data establish this strain as a novel model of spontaneous, widespread hyperalgesia that can be used to identify biomarkers for chronic pain diagnosis and treatment.

Plasma and interstitial levels of endocannabinoids and N-acylethanolamines in patients with chronic widespread pain and fibromyalgia: a systematic review and meta-analysis

The endocannabinoid system (ECS) is an essential endogenous signaling system that may be involved in the pathophysiology of chronic widespread pain (CWP) and fibromyalgia syndrome (FMS). Further research is required to understand the role of ECS in the development and maintenance of CWP and FMS. We provided the first systematic review and meta-analysis exploring the clinical relevance of ECS alterations in patients with CWP and FMS by comparing plasma and interstitial levels of endocannabinoids and N-acylethanolamines in patients and healthy controls. A systematic search was conducted to identify studies that measured plasma and/or interstitial levels of endocannabinoids and N-acylethanolamines in patients with CWP or FMS and healthy controls. A total of 8 studies were included for qualitative review, and 7 studies were included for meta-analysis. The findings identified increased plasma levels of oleoylethanolamide and stearoylethanolamide in patients with FMS compared with those in controls (P = 0.005 and P < 0.0001, respectively) and increased plasma levels of palmitoylethanolamide and interstitial levels of stearoylethanolamide in patients with CWP compared with those in controls (P = 0.05 and P = 0.001, respectively). There were no significant differences in other ECS parameters. Most studies did not account for variables that may influence ECS function, including cannabis use, concomitant medication, comorbidities, physical activity, stress levels, circadian rhythm, sleep quality, and dietary factors, suggesting that future studies should explore the correlation between these variables and endocannabinoid activity. We highlight the importance of investigating endocannabinoid activity in CWP and FMS because it will underpin future translational research in the area.

Prevalence and municipal variation in chronic musculoskeletal pain among independent older people: data from the Japan Gerontological Evaluation Study (JAGES)

BACKGROUND

Urbanization and population aging may affect prevalence of chronic pain from various causes. This cross-sectional study aimed to investigate the prevalence of chronic musculoskeletal pain, including some subtypes, in independent Japanese older people, and whether population density and population aging rate explained prevalence and differences in pain levels between municipalities.

METHODS

We analyzed data from 12,883 independent older people living in 58 municipalities who completed mailed questionnaires and did not need support for daily living. We identified three types of pain: "chronic musculoskeletal pain" lasting ≥ 3 months (overall and in each part of the body), "chronic widespread-type pain" in the spinal and peripheral area, and "chronic multisite pain" in at least three sites. The latter two were measured using new definitions. These types of pain are correlated with depressive symptoms and we therefore examined the construct validity of the definitions by comparing the Geriatric Depression Scale score. We also used analysis of covariance to compare the prevalence of these three types of pain between municipalities. Odds ratios, median odds ratios, and the municipal variance in prevalence of chronic musculoskeletal pain were estimated by Bayesian multilevel logistic regression analysis using the Markov Chain Monte Carlo method.

RESULTS

The construct validity of the definitions of chronic widespread-type pain and chronic multisite pain was confirmed. The prevalence of the three types of pain (chronic musculoskeletal, widespread, and multisite pain) was 39.0%, 13.9%, and 10.3%, respectively. Chronic musculoskeletal pain showed a higher prevalence among older people and women. Individuals in underpopulated, suburban, or metropolitan areas tended to have more pain than those in urban areas, but this was not statistically significant (odds ratio [95% credible interval] 1.15 [0.86-1.51], 1.17 [0.93-1.43], 1.17 [0.94-1.46]). Population density and population aging rate did not explain the differences between municipalities.

CONCLUSIONS

The prevalence of chronic musculoskeletal pain was consistent with previous global reports. Areas with overpopulation and depopulation tended to have higher pain prevalence, but population density and population aging rate did not explain municipal variance. Further research is needed to identify other factors that contribute to regional variance.

Inflammation and Interferon Signatures in Peripheral B-Lymphocytes and Sera of Individuals With Fibromyalgia

Fibromyalgia (FM) is an idiopathic chronic disease characterized by widespread musculoskeletal pain, hyperalgesia and allodynia, often accompanied by fatigue, cognitive dysfunction and other symptoms. Autoimmunity and neuroinflammatory mechanisms have been suggested to play important roles in the pathophysiology of FM supported by recently identified interferon signatures in affected individuals. However, the contribution of different components in the immune system, such as the B-lymphocytes, in the progression to FM are yet unknown. Furthermore, there is a great need for biomarkers that may improve diagnostics of FM. Herein, we investigated the gene expression profile in peripheral B-cells, as well as a panel of inflammatory serum proteins, in 30 FM patients and 23 healthy matched control individuals. RNA sequence analysis revealed 60 differentially expressed genes when comparing the two groups. The group of FM patients showed increased expression of twenty-five interferon-regulated genes, such as S100A8 and S100A9, VCAM, CD163, SERPINA1, ANXA1, and an increased interferon score. Furthermore, FM was associated with elevated levels of 19 inflammatory serum proteins, such as IL8, AXIN1, SIRT2 and STAMBP, that correlated with the FM severity score. Together, the results shows that FM is associated with an interferon signature in B-cells and increased levels of a set of inflammatory serum proteins. Our findings bring further support for immune activation in the pathogenesis of FM and highlight candidate biomarkers for diagnosis and intervention in the management of FM.

An Assessment of Naturopathic Treatments, Health Concerns, and Common Comorbid Conditions in Fibromyalgia Patients: A Retrospective Medical Record Review

Background: Fibromyalgia (FM) is characterized by chronic pain, with allodynia and hyperalgesia being the most common signs. Many patients with FM explore, express interest, and use complementary and alternative medicine to help manage symptoms and improve quality of life. However, little is known about the clinical recommendations provided by naturopathic doctors (NDs). Objective: To describe trends in assessment and treatment of patients with FM by NDs. Methods: Retrospectively, medical records of 200 patients with the FM ICD-10 code were reviewed from the Robert Schad Naturopathic Clinic. Of these records, 70 met inclusion criteria and were further analyzed. Comorbid conditions, health concerns, physical and psychological examinations, and treatment were recorded. Patients were excluded if informed consent for research was not signed. The project was approved by the Research Ethics Board of the Canadian College of Naturopathic Medicine. Results: Seventy patients met criteria and were included in the current analysis. Most patients identified as female (96%). Vitamin D (57%), magnesium (54%), omega-3 fish oil (53%), acupuncture by an acupuncturist (53%) or an ND (40%), B12 orally or by injection (40%), and probiotics (40%) were highly utilized treatments. A past/current medical history of digestive complaints (64%) and depression/mental illness (63%) were common comorbidities, alongside a history of arthritic conditions (53%) and anxiety (43%). A family history of arthritic conditions (47%) was also prevalent. The Widespread Pain Index and Symptom Severity tool (43%) was used to assess pain and other symptoms. No adverse effects of treatment were readily identifiable. Conclusion: Findings from this study reveal elements of both consistency and variability in the treatment recommendations from NDs in a teaching clinic environment. Future research that assesses or compares treatment recommendations for FM in other settings may be informative to better understand health services, the nature of individualized care, and patient experiences.

Validity and Diagnosis in Physical and Rehabilitation Medicine: Critical View and Future Perspectives

ABSTRACT

Obtaining a diagnosis is an essential and integral part of physical and rehabilitation medicine in practice and research. Standardized psychometric properties are required of any classifications, diagnostic criteria, and diagnostic rules used. Physicians and researchers, in physical and rehabilitation medicine, need to understand these properties to determine the accuracy and consistency of their diagnosis. Although chronic musculoskeletal pain disorders are among the highly prevalent disorders seen in physical and rehabilitation medicine, limitations regarding existing diagnostic criteria for chronic musculoskeletal pain disorders still exist. Hence, the quest for developing diagnostic tools for chronic musculoskeletal pain that align with the standard properties remains open. These are discussed with an example for existing diagnostic criteria for fibromyalgia. This article primarily aimed to provide an overview of standard psychometric properties. A secondary aim was to critically appraise the tools currently used to diagnose chronic musculoskeletal pain disorders. The challenges and limitations of existing diagnostic tools are discussed. Potential approaches on how to improve the conceptualization of the construct of musculoskeletal pain disorders are also discussed. Adopting a network perspective, for example, can better constitute the disease instead of a single known underlying etiology for persistent or recurrent pain symptoms.

Psychosomatic Approach to Fibromyalgia Syndrome: Concept, Diagnosis and Treatment

Fibromyalgia syndrome (FMS) has chronic widespread pain (CWP) as a core symptom and a variety of associated somatic and psychological symptoms such as fatigue, sleep problems, cognitive disturbances, multiple somatic pain, and depression. FMS is the subject of considerable controversy in the realm of nosology, diagnosis, pathophysiology, and treatment.Moreover, the fact that FMS and mental illness are closely associated with each other might intensify the confusion for the distinction between FMS and mental disorders. This narrative literature review aims to provide the concept, diagnosis, and treatment of FMS from the integrative biopsychosocial and psychosomatic perspective. This article first explains the concepts of FMS as a disease entity of biopsychosocial model, and then summarizes the changes of diagnostic criteria over past three decades, differential diagnosis and comorbidity issue focused on mental illnesses. In addition, an overview of treatment of FMS is presented mainly by arranging the recommendations from the international guidelines which have been developed by four official academic associations.

Differences and similarities among questionnaires to assess pain status in chronic widespread pain population: a quantitative analysis

Objective

In clinical practice, multiple questionnaires are often used as part of the diagnosis of chronic widespread pain. Body Surface Area (BSA), Visual Analogue Scale (VAS), Fibromyalgia Diagnostic Criteria (FDC) and Central Sensitization Inventory (CSI) have all been used as screening tools to assess pain status in individuals with widespread pain. However, substantial overlap can be observed among these commonly employed questionnaires. This study aimed to quantitatively determine the most independent and dependent clinical characteristics obtained through these questionnaires and to examine potential redundancies.

Methods

Seventy-nine participants with widespread pain, 61 females and 18 males, from a chronic pain outpatient clinic were recruited. The FDC, BSA, VAS and the CSI were measured for all participants. A principal component analysis (PCA) using a varimax rotation was used to determine which clinical measures represented separate constructs of widespread pain. This was followed by a regression analysis to assess redundancy between the constructs and related pain characteristics.

Results

The identified three-component PCA solution was characterized by (1) the FDC and CSI score, (2) the VAS score and (3) the BSA score. This indicates that the BSA and the VAS scores capture independent patient information. From the regression analysis, the FDC and CSI scores shared approximately 80% of the variance, indicative of substantial overlap between scores.

Conclusion

Our findings demonstrated that BSA and VAS scores were independent clinical measures of widespread chronic pain, while the FDC and CSI scores were not independent, were highly correlated and provided redundant information. Clinicians should continue using both the BSA and VAS; however, either only FDC or CSI will be beneficial during clinical assessment of widespread chronic pain.

Vitamin D and Rheumatic Diseases: A Review of Clinical Evidence

Vitamin D plays an important role in maintaining a healthy mineralized skeleton. It is also considered an immunomodulatory agent that regulates innate and adaptive immune systems. The aim of this narrative review is to provide general concepts of vitamin D for the skeletal and immune health, and to summarize the mechanistic, epidemiological, and clinical evidence on the relationship between vitamin D and rheumatic diseases. Multiple observational studies have demonstrated the association between a low level of serum 25-hydroxyvitamin D [25(OH)D] and the presence and severity of several rheumatic diseases, such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), spondyloarthropathies, and osteoarthritis (OA). Nevertheless, the specific benefits of vitamin D supplements for the treatment and prevention of rheumatic diseases are less accepted as the results from randomized clinical trials are inconsistent, although some conceivable benefits of vitamin D for the improvement of disease activity of RA, SLE, and OA have been demonstrated in meta-analyses. It is also possible that some individuals might benefit from vitamin D differently than others, as inter-individual difference in responsiveness to vitamin D supplementation has been observed in genomic studies. Although the optimal level of serum 25(OH)D is still debatable, it is advisable it is advisable that patients with rheumatic diseases should maintain a serum 25(OH)D level of at least 30 ng/mL (75 nmol/L) to prevent osteomalacia, secondary osteoporosis, and fracture, and possibly 40–60 ng/mL (100–150 nmol/L) to achieve maximal benefit from vitamin D for immune health and overall health.

Animal models of fibromyalgia: What is the best choice?

Fibromyalgia (FM) is a complex syndrome, with an indefinite aetiology and intricate pathophysiology that affects 2 - 3% of the world population. From the beginning of the 2000s, experimental animal models have been developed to mimic clinical FM and help obtain a better understanding of the relevant neurobiology. These animal models have enabled a broad study of FM symptoms and mechanisms, as well as new treatment strategies. Current experimental FM models include the reserpine-induced systemic depletion of biogenic amines, muscle application of acid saline, and stress-based (cold, sound, or swim) approaches, among other emerging models. FM models should: (i) mimic the cardinal symptoms and complaints reported by FM patients (e.g., spontaneous nociception, muscle pain, hypersensitivity); (ii) mimic primary comorbidities that can aggravate quality of life and lead to worse outcomes (e.g., fatigue, sleep disturbance, depression, anxiety); (iii) mimic the prevalent pathological mechanisms (e.g., peripheral and central sensitization, inflammation/neuroinflammation, change in the levels of the excitatory and inhibitory neurotransmitters); and (iv) demonstrate a pharmacological profile similar to the clinical treatment of FM. However, it is difficult for any one of these models to include the entire spectrum of clinical FM features once even FM patients are highly heterogeneous. In the past six years (2015 - 2020), a wide range of experimental FM studies has amounted to the literature reinforcing the need for an updated review. Here we have described, in detail, several approaches used to experimentally study FM, with a focus on recent studies in the field and in previously less discussed mechanisms. We highlight each model's challenges, limitations, and future directions, intending to help preclinical researchers establish the correct experimental FM model to use depending on their goals.

Fibromyalgia in Older Individuals

Fibromyalgia (FM) is a condition of chronic widespread pain (CWP) that can occur throughout the life cycle and is likely underrecognized in older patients. FM is associated with considerable suffering and reduction in quality of life and may occur as a unique condition, but in older patients is most likely to be associated with another medical illness. Understood mechanistically to be a sensitization of the nervous system, recently identified as nociplastic pain, FM is accepted as a valid medical illness that requires a positive diagnosis and directed treatments. The cornerstone of treatments for FM are nonpharmacologic interventions, with the understanding that medications provide only modest benefit for most patients, and with particular concern about adverse effects in older patients. If FM is not recognized, treatments may be misdirected to the other medical condition, with failure to address FM symptoms, leading to overall poor outcome. In contrast, new complaints in older patients should not immediately be attributed to FM, and physicians should be vigilant to ensure that onset of a new illness is not ignored. As FM is most often a lifelong condition, patients should be encouraged to identify their own personal strategies that can attenuate symptoms, especially when symptoms flare. Continued life participation should be the outcome goal.

Refractory fibromyalgia

In the medical literature, there are only a few references on refractory fibromyalgia and there is no consensus definition available on this concept. Some definitions of refractory fibromyalgia have been proposed based on the lack of response to a number of medications, and perhaps the most appropriate term is treatment-refractory fibromyalgia. To achieve the definition of treatment-refractory fibromyalgia, it is necessary to consider several previous steps, such as making sure the diagnosis has been made properly and a differential diagnosis with entities that can mimic fibromyalgia symptoms (including complete physical examination and laboratory test) has been made. The possibility that another factor that alters the response to treatment should be investigated, and in particular review all prescribed medication and search for some non-medical reasons that could mask the response to treatment (e.g., legal compensation). The definition of refractory fibromyalgia is complex and probably should include a lack of response to a specified number of drugs or to combination therapy with at least two non-pharmacological measures. In this article, it is not our purpose to present a formal definition, but to raise the possible bases for this purpose. We believe that it is a subject that must be discussed extensively before reaching a consensus definition. Key Points • There is no appropriate definition to classify fibromyalgia patients who do not respond to the usual pharmacological and non-pharmacological measures according to the national or international guidelines. • A consensus definition is required to classify these patients, which could help standardize future management strategies. In this article, we propose the bases on which refractory fibromyalgia could be defined.

The Effects of Mindfulness-Based Mandala Coloring, Made in Nature, on Chronic Widespread Musculoskeletal Pain: Randomized Trial

This study aimed to investigate the effects of mindfulness-based mandala coloring made within nature on individuals with chronic widespread musculoskeletal pain (CWP). Thirty-six participants were randomly allocated. In the experimental group, identical interventions and procedures were administered for each experiment. The control group members were untreated and remained in an urban environment. Overall, the experiment showed significant improvements in tender points (f = 8.791, p = 0.006), total stress level (f = 14.570, p = 0.001), depressive symptoms (f = 15.205, p = 0.001), anger symptoms (f = 7.263, p = 0.011) and salivary cortisol (f = 10.619, p = 0.003) in the experimental group. The results reflect that MBMC within nature is effective in reducing pain, psychological stress responses, and cortisol levels in individuals with CWP. The positive results could be a product of the experimental design rather than the treatment itself. A rigorous experimental design provides better understanding of MBMC within nature.

Genome-wide association study identifies RNF123 locus as associated with chronic widespread musculoskeletal pain

Background and objectives

Chronic widespread musculoskeletal pain (CWP) is a symptom of fibromyalgia and a complex trait with poorly understood pathogenesis. CWP is heritable (48%–54%), but its genetic architecture is unknown and candidate gene studies have produced inconsistent results. We conducted a genome-wide association study to get insight into the genetic background of CWP.

Methods

Northern Europeans from UK Biobank comprising 6914 cases reporting pain all over the body lasting >3 months and 242 929 controls were studied. Replication of three independent genome-wide significant single nucleotide polymorphisms was attempted in six independent European cohorts (n=43 080; cases=14 177). Genetic correlations with risk factors, tissue specificity and colocalisation were examined.

Results

Three genome-wide significant loci were identified (rs1491985, rs10490825, rs165599) residing within the genes Ring Finger Protein 123 (RNF123), ATPase secretory pathway Ca²⁺transporting 1 (ATP2C1) and catechol-O-methyltransferase (COMT). The RNF123 locus was replicated (meta-analysis p=0.0002), the ATP2C1 locus showed suggestive association (p=0.0227) and the COMT locus was not replicated. Partial genetic correlation between CWP and depressive symptoms, body mass index, age of first birth and years of schooling were identified. Tissue specificity and colocalisation analysis highlight the relevance of skeletal muscle in CWP.

Conclusions

We report a novel association of RNF123 locus and a suggestive association of ATP2C1 locus with CWP. Both loci are consistent with a role of calcium regulation in CWP. The association with COMT, one of the most studied genes in chronic pain field, was not confirmed in the replication analysis.

Vitamin D Sources, Metabolism, and Deficiency: Available Compounds and Guidelines for Its Treatment

Studies on vitamin/hormone D deficiency have received a vast amount of attention in recent years, particularly concerning recommendations, guidelines, and treatments. Moreover, vitamin D’s role as a hormone has been confirmed in various enzymatic, metabolic, physiological, and pathophysiological processes related to many organs and systems in the human body. This growing interest is mostly due to the evidence that modest-to-severe vitamin D deficiency is widely prevalent around the world. There is broad agreement that optimal vitamin D status is necessary for bones, muscles, and one’s general health, as well as for the efficacy of antiresorptive and anabolic bone-forming treatments. Food supplementation with vitamin D, or the use of vitamin D supplements, are current strategies to improve vitamin D levels and treat deficiency. This article reviews consolidated and emerging concepts about vitamin D/hormone D metabolism, food sources, deficiency, as well as the different vitamin D supplements available, and current recommendations on the proper use of these compounds.

Impact of the COVID-19 pandemic on the pharmacological, physical, and psychological treatments of pain: findings from the Chronic Pain & COVID-19 Pan-Canadian Study

INTRODUCTION

Multimodal treatment is recognized as the optimal paradigm for the management of chronic pain (CP). Careful balance between pharmacological and physical/psychological approaches is thus desirable but can be easily disrupted.

OBJECTIVES

This study aimed at exploring the impact of the COVID-19 pandemic on pharmacological and physical/psychological treatments of CP.

METHODS

A Pan-Canadian cross-sectional web-based study was conducted between April 16th and May 31st 2020 among adults living with CP when the country was in the ascending slope of the first COVID-19 pandemic wave.

RESULTS

A total of 2864 participants shared their treatment experience (mean age: 49.7 years and women: 83.5%). Among medication users (n = 2533), 38.3% reported changes in their pharmacological pain treatment. The main reasons were as follows: (1) changes in pain symptoms, (2) lack of access to prescribers/cancellation of medical appointments, and (3) increased medication intake in compensation for stopping physical/psychological treatments because of the pandemic. Among participants who used physical/psychological pain management approaches before the pandemic (n = 2467), 68.3% had to modify their treatments or self-management strategies. Common reasons were lack of access to clinics/exercise facilities and the need to compensate for having to stop another type of physical/psychological treatment because of the pandemic-related public health safety measures.

CONCLUSIONS

Our study underlines the negative impact of the COVID-19 pandemic on access to pain relief, which is considered a fundamental human right. Results will help to justify resource allocation and inform the development of interventions to be better prepared for waves to come and future health crises.

Effects of fibromyalgia on the disease activity and treatment of patients with axial spondyloarthritis

OBJECTIVES

To investigate whether patients with radiologically positive spondyloarthritis (SpA), suffer from comorbid fibromyalgia (FM), and to explore the impact of FM on the clinical manifestations and blood test results of patients with ankylosing spondylitis (AS).

METHODS

121 patients with spondyloarthritis (SpA) were enrolled in the study. The body function of the patients was evaluated using the Bath Ankylosing Spondylitis Functional Index (BASFI); the mental health was evaluated using the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Out of 121 patients with SpA, 111 patients were with axial spondyloarthritis (axSpA) and 11 patients with FM; 10 patients with peripheral SpA and 1 patient with FM. In axSpA, 107 were radiologically positive axSpA patients, 11 were complicated by FM, and 4 were radiologically negative axSpA (nr-axSpA). Among radiologically positive axSpA, the proportion of female patients in the FM group was higher (63.6%, P<0.05). The ASDAS-C-reactive protein (CRP), ASDAS-erythrocyte sedimentation rate (ESR), BASDAI, BASFI, and HADS-anxiety score, and HADS-depression score of the FM group were all significantly higher than those of the non-FM group.

CONCLUSIONS

When determining the treatment plan for SpA, the possibility of coexistence of FM should be considered, and adjuvant treatment should be given when necessary.

Not All Pain is Created Equal: Basic Definitions and Diagnostic Work-Up

Chronic pain is considered a public health priority by the World Health Organization and European health institutions. It has reached alarming proportions in terms of disability, consumption of health and social resources, and impact on primary and specialist care services. Primary care physicians are often called on to manage this condition. Chronic pain management can be challenging due to its complexity. It has traditionally been considered to include nociceptive pain that that persists longer than the normal healing time, neuropathic pain lasting more than 3 months, or a combination of these. More recently, a third descriptor, nociplastic (primary) pain, was added to classify patients with chronic pain conditions such as fibromyalgia, nonspecific back pain, or mixed pain that persists or other conditions in which altered central pain modulation results in central sensitization and chronic pain in the absence of actual or threatened damage to tissues, including in the somatosensory nervous system. This document provides an overview of pain types and their underlying mechanisms. Successful pain management is facilitated by identification of the pain type. A set of diagnostic tools and a pain algorithm are presented to guide the clinician toward the correct diagnosis. The algorithm identifies cases that may require referral to a pain specialist. Once the site of origin of the pain (the "pain generator") is identified, or a primary pain syndrome is suspected, the accompanying article provides information and rationale to support treatment decisions based on patient characteristics.

Adverse outcomes of chronic widespread pain and common mental disorders in individuals with sickness absence - a prospective study of Swedish twins

Background

Chronic widespread pain (CWP) and common mental disorders (CMDs) are common public health problems, but little is known about the role of CWP and CMDs on future adverse outcomes among work disabled individuals. The aims of the study were to investigate the associations between CWP and CMDs with subsequent disability pension (DP), long-term unemployment (> 90 days) and all-cause mortality in individuals with sickness absence (SA) and whether the associations were explained by familial factors.

Methods

In this prospective cohort study, 7884 Swedish twins born between 1933 and 1985 were included and baseline data were gathered from a questionnaire in 1998 to 2006. Register data were used for obtaining information regarding demographics, SA, DP, unemployment and mortality. Cox proportional hazards regressions were used to calculate Hazard Ratios (HR) with 95% Confidence Intervals (CI) for the associations between CWP and/or CMDs with DP, unemployment and mortality, while conditional Cox models for twin pairs provided control for familial confounding.

Results

Having either CWP or CMDs among those with a history of SA was associated with a higher risk of DP and all-cause mortality than individuals without CWP and CMDs after controlling for socio-demographic and health factors. Moreover, sick-listed individuals with both CWP and CMDs had a higher risk of DP while those who only had CMDs had a higher risk of long-term unemployment compared to those without CWP and CMDs. The association between CMDs with DP and long-term unemployment was no longer significant when controlling for familial factors.

Conclusions

CMDs was a risk factor for DP, unemployment and mortality among individuals with SA, while CWP seems to be important in relation to future DP and mortality. Familial factors played a role in the associations between CMDs and DP and CMDs and unemployment.

Ehlers-Danlos Syndrome and Hypermobility Syndrome Compared with Other Common Chronic Pain Diagnoses-A Study from the Swedish Quality Registry for Pain Rehabilitation

Although chronic pain is common in patients with Ehlers–Danlos syndrome (EDS) and hypermobility syndromes (HMS), little is known about the clinical characteristics of these groups. The main aim was to compare EDS/HMS with common local and generalized pain conditions with respect to Patient Reported Outcome Measures (PROMs). Data from the Swedish Quality Register for Chronic Pain (SQRP) from 2007 to 2016 (n = 40,518) were used, including patients with EDS/HMS (n = 795), fibromyalgia (n = 5791), spinal pain (n = 6693), and whiplash associated disorders (WAD) (n = 1229). No important differences in the PROMs were found between EDS and HMS. Women were represented in > 90% of EDS/HMS cases and fibromyalgia cases, and in about 64% of the other groups. The EDS/HMS group was significantly younger than the others but had a longer pain duration. The pain intensity in EDS/HMS was like those found in spinal pain and WAD; fibromyalgia had the highest pain intensity. Depressive and anxiety symptoms were very similar in the four groups. Vitality—a proxy for fatigue—was low both in EDS/HMS and fibromyalgia. The physical health was lower in EDS/HMS and fibromyalgia than in the two other groups. Patients with EDS/HMS were younger, more often female, and suffered from pain for the longest time compared with patients who had localized/regional pain conditions. Health-care clinicians must be aware of these issues related to EDS/HMS both when assessing the clinical presentations and planning treatment and rehabilitation interventions.

Peripheral immune aberrations in fibromyalgia: A systematic review, meta-analysis and meta-regression

The objective was to identify immune alterations in patients with fibromyalgia syndrome (FMS) compared to healthy controls (HC) using meta-analysis and meta-regression. Six electronic databases were searched for suitable original articles investigating immune biomarkers in FMS in comparison to HC. We extracted outcomes and variables of interest, such as mean and SD of peripheral blood immune biomarkers, age or sex. A random-effects model with restricted maximum-likelihood estimator was used to compute effect sizes (standardized mean difference and 95% CI, Hedges' g) and meta-analysis, group meta-analysis and meta-regressions were conducted. Forty-three papers were included in this systematic review, of which 29 were suitable for meta-analysis. Interleukin (IL)-6 (g = 0.36 (0.09-0.63); I² = 85.94; p = 0.01), IL-4 (g = 0.50 (0.03-0.98); I² = 81.87; p = 0.04), and IL-17A (g = 0.53 (0.00-1.06); I² = 87.15; p = 0.05), were significantly higher in FMS compared to HC while also combinations of cytokines into relevant phenotypes were significantly upregulated including M1 macrophage (g = 0.23 (0.03-0.43); I² = 77.62; p = 0.02), and immune-regulatory (g = 0.40 (0.09-0.72); I² = 84.81; p = 0.01) phenotypes. Heterogeneity levels were very high and subgroup and meta-regression analyses showed that many covariates explained part of the heterogeneity including medication washout, sex, time of blood sampling and exclusion of patients with major depressive disorder. In conclusion, FMS is accompanied by a disbalance between upregulated pro-inflammatory (M1 and Th-17) and immune-regulatory cytokines although effect sizes are small-to-moderate. Based on our results we provide specific methodological suggestions for future research, which should assess Th-1, Th-17, chemokines, and Th-2 phenotypes while controlling for possible confounding variables specified in this study.

Acupuncture for Fibromyalgia: An Open-Label Pragmatic Study on Effects on Disease Severity, Neuropathic Pain Features, and Pain Catastrophizing

The treatment of fibromyalgia syndrome (FMS) is still far from being optimally coded, and pharmacological strategies are often unsatisfactory. Acupuncture plays a role among nonpharmacological intervention approaches; however, there is still no clarity as to when to integrate it into therapy. The objective of this study is to explore the role of acupuncture, in terms of efficacy on main disease severity measures and pain features, in patients with nonresponsive disease, defining nonresponsive FMS characterized by a revised Fibromyalgia Impact Questionnaire (FIQ-R) ≥39 and a Patient Health Questionnaire 15-item (PHQ15) ≥5 despite optimal drug therapy. Patients were treated with weekly sessions, for a total of eight acupuncture sessions. At the baseline and at the end of the treatment cycle, a comprehensive clinical evaluation was carried out to evaluate improvements in terms of disease severity and impact on neuropathic pain features (measured with the painDETECT questionnaire (PDQ)) and pain catastrophizing (measured with the Pain Catastrophizing Scale (PCS)). At the end of the eight-week treatment, patients experienced a significant improvement in all evaluated parameters (for FIQ-R, PDQ, and PHQ15 p < 0.0001, for PCS p=0.001). Of particular note is the effectiveness on manifestations that are difficult to treat such as neuropathic pain features and on negative psychological perceptions such as pain catastrophizing. It can be stated that acupuncture can be proposed also in phases of high severity of disease. Intervention with multimodal strategies, including acupuncture, could be of great benefit to patients.

Impacts of Fatigue, Stress, and Perceived Health Status on Women With Rheumatic Diseases: A Comparison Study

BACKGROUND

Rheumatic conditions, which increase in prevalence as populations age, are a growing public health problem that disproportionately affects women. Understanding the influences of rheumatic diseases (RDs) on fatigue, stress, and perceived health status is deemed important to the improvement of physical and mental health for women with RDs.

PURPOSE

This study was designed to compare the fatigue, stress, and perceived physical and mental health status of women with RDs (RD group) with those of peers who did not have chronic illnesses (comparison group).

METHODS

A cross-sectional, purposive sample and comparative design was used. Four hundred forty-three women with a mean age of 46.2 years participated in this study. Those with physician-diagnosed RDs (n = 212) were enrolled in the RD group, and those without chronic disease were enrolled in the comparison group (n = 231). Measures used included a demographic datasheet, Fatigue Severity Scale, Perceived Stress Scale, and Short Form-12 Items Health Survey. Analysis of covariance was used to examine the intergroup differences for major variables based on demographic covariates.

RESULTS

The RD group reported significantly more fatigue and stress than the comparison group. Moreover, the RD group reported significantly poorer perceived physical health status, significantly poorer physical functioning and general health, and greater bodily pain compared with the comparison group. Conversely, the RD group reported significantly better perceived mental health status, significantly lower vitality, and better role emotional status than the comparison group.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The findings support the theory that RDs have a negative impact on perceived stress and fatigue in women. Physical function, bodily pain, and general health may be the most significantly affected domains of perceived physical health in women with RDs. Of note, with the exception of the vitality subscale, RDs did not adversely affect the perceived mental health of participants with RD in this study. Healthcare professionals should cooperate with clinical rheumatologists, psychologists, and physiotherapists to provide comprehensive care that includes long-term education to help patients with RD self-manage stress, restore vitality, relieve pain, and increase physical function.

Neuroimmune interactions in chronic pain - An interdisciplinary perspective

It is widely accepted that communication between the nervous and immune systems is involved in the development of chronic pain. At each level of the nervous system, immune cells have been reported to accompany and frequently mediate dysfunction of nociceptive circuitry; however the exact mechanisms are not fully understood. One way to speed up progress in this area is to increase interdisciplinary cross-talk. This review sets out to summarize what pain research has already learnt, or indeed might still learn, from examining peripheral and central nociceptive mechanisms using tools and perspectives from other fields like immunology, inflammation biology or the study of stress.

Motivational Non-directive Resonance Breathing as a Treatment for Chronic Widespread Pain

Chronic widespread pain (CWP) is one of the most difficult pain conditions to treat due to an unknown etiology and a lack of innovative treatment design and effectiveness. Based upon preliminary findings within the fields of motivational psychology, integrative neuroscience, diaphragmatic breathing, and vagal nerve stimulation, we propose a new treatment intervention, motivational non-directive (ND) resonance breathing, as a means of reducing pain and suffering in patients with CWP. Motivational ND resonance breathing provides patients with a noninvasive means of potentially modulating five psychophysiological mechanisms imperative for endogenously treating pain and increasing overall quality of life.

High-frequency spinal cord stimulation at 10 kHz for widespread pain: a retrospective survey of outcomes from combined cervical and thoracic electrode placements

OBJECTIVE

To report on the long-term outcomes for patients receiving paraesthesia-free high-frequency spinal cord stimulation (HF10-SCS) at 10 kHz for the treatment of combined upper and lower body neuropathic/nociplastic pain syndromes including chronic widespread pain/fibromyalgia.

MATERIALS AND METHODS

Forty-five patients with widespread (both upper and lower body) neuropathic/nociplastic pain syndromes underwent a trial of combined cervical and thoracic HF10-SCS leads placed over the C2/T2 or C2/T9 vertebral levels, or three leads placed over the C2/T2/T9 vertebral levels. Thirty-eight patients proceeded to permanent implant, resulting in a trial to implant conversion rate of 84.4%. Patients were followed up an average of 2.3 ± 1.7 years post-permanent implant. Patient outcomes were recorded.

RESULTS

A statistically significant reduction of 3.5 ± 1.6 on the 10-point numerical rating scale (NRS) at 2.3 ± 1.7 years post-permanent implant was observed (baseline: 7.1 ± 0.8 vs. follow up: 3.7 ± 1.3) (p ≤ 001). Likewise, a reduction in disability (Roland Morris Disability Questionnaire) was also observed; baseline: 12.3 ± 5.1 vs. follow up: 7.8 ± 5.9. Similar trends were observed in a working capacity, with 20/31 (64.5%) of the work eligible patients employed at follow-up, compared with only 8/31 (25.8%) at baseline. Opioid pain medication use reduced and over 90% of patients were satisfied with their treatment outcome. No long-term adverse events were observed.

CONCLUSIONS

HF10-SCS at 10 kHz provides long-term widespread pain relief when leads are staggered across the cervical and thoracic spine. The improved return to work outcomes and opiate reductions suggest that cost-effectiveness as well as clinical effectiveness may be achieved with this treatment approach.

The Problematic Nature of Fibromyalgia Diagnosis in the Community

Background

Recently, some studies suggested that clinical diagnosis of fibromyalgia is inaccurate and does not reflect current definitions. However, this hypothesis has not been tested. We examined whether fibromyalgia was accurately diagnosed in the community.

Methods

We surveyed 3276 primary care patients to determine current fibromyalgia status by criteria (CritFM). We also determined whether the patients had a physician's diagnosis of fibromyalgia (MDFM) and the level of symptom severity as measured by the polysymptomatic distress scale (PSD).

Results

The prevalence of MDFM and CritFM was 6.1% (95% confidence interval [CI] 5.3%, 6.9%) and 5.5% (95% CI 4.8%, 6.3%), respectively. However, only 32.2% with MDFM met 2016 criteria (CritFM), and only 35.4% with CritFM also had MDFM. The kappa statistic for diagnostic agreement was 0.296 (minimal agreement). The mean PSD score was 12.4 and 18.4 in MDFM and CritFM, respectively. The odds ratio for being a woman compared with being a man was 3.2 for MDFM versus 1.9 for CritFM, P = 0.023. Of the patients with MDFM, 68.3% received specific fibromyalgia pharmacotherapy.

Conclusions

There is little agreement between MDFM and CritFM. Only one‐third of MDFM satisfy fibromyalgia criteria, and only one‐third of patients who meet the criteria have a clinical diagnosis of fibromyalgia. Physician diagnosis is biased and more likely in women. Fibromyalgia treatment is common in MDFM (70.7%). Overall, MDFM appears subjective and unrelated to fibromyalgia criteria. There appears to be no common definition of fibromyalgia in the community.

Vitamin D for skeletal and non-skeletal health: What we should know

Vitamin D plays an essential role in regulating calcium and phosphate metabolism and maintaining a healthy mineralized skeleton. Humans obtain vitamin D from sunlight exposure, dietary foods and supplements. There are two forms of vitamin D: vitamin D₃ and vitamin D₂. Vitamin D₃ is synthesized endogenously in the skin and found naturally in oily fish and cod liver oil. Vitamin D₂ is synthesized from ergosterol and found in yeast and mushrooms. Once vitamin D enters the circulation it is converted by 25-hydroxylase in the liver to 25-hydroxyvitamin D [25(OH)D], which is further converted by the 25-hydroxyvitamin D-1α-hydroxylase in the kidneys to the active form, 1,25-dihydroxyvitamin D [1,25(OH)₂D]. 1,25(OH)₂D binds to its nuclear vitamin D receptor to exert its physiologic functions. These functions include: promotion of intestinal calcium and phosphate absorption, renal tubular calcium reabsorption, and calcium mobilization from bone. The Endocrine Society's Clinical Practice Guideline defines vitamin D deficiency, insufficiency, and sufficiency as serum concentrations of 25(OH)D of <20 ng/mL, 21-29 ng/mL, and 30-100 ng/mL, respectively. Vitamin D deficiency is a major global public health problem in all age groups. It is estimated that 1 billion people worldwide have vitamin D deficiency or insufficiency. This pandemic of vitamin D deficiency and insufficiency is attributed to a modern lifestyle and environmental factors that restrict sunlight exposure, which is essential for endogenous synthesis of vitamin D in the skin. Vitamin D deficiency is the most common cause of rickets and osteomalacia, and can exacerbate osteoporosis. It is also associated with chronic musculoskeletal pain, muscle weakness, and an increased risk of falling. In addition, several observational studies observed the association between robust levels of serum 25(OH)D in the range of 40-60 ng/mL with decreased mortality and risk of development of several types of chronic diseases. Therefore, vitamin D-deficient patients should be treated with vitamin D₂ or vitamin D₃ supplementation to achieve an optimal level of serum 25(OH)D. Screening of vitamin D deficiency by measuring serum 25(OH)D is recommended in individuals at risk such as patients with diseases affecting vitamin D metabolism and absorption, osteoporosis, and older adults with a history of falls or nontraumatic fracture. It is important to know if a laboratory assay measures total 25(OH)D or only 25(OH)D₃. Using assays that measure only 25(OH)D₃ could underestimate total levels of 25(OH)D and may mislead physicians who treat patients with vitamin D₂ supplementation.

Facts and myths pertaining to fibromyalgia

Fibromyalgia (FM) is characterized by chronic widespread pain, unrefreshing sleep, physical exhaustion, and cognitive difficulties. It occurs in all populations throughout the world, with prevalence between 2% and 4% in general populations. Definition, pathogenesis, diagnosis, and treatment of FM remain points of contention, with some even contesting its existence. The various classification systems according to pain medicine, psychiatry, and neurology (pain disease; persistent somatoform pain disorder; masked depression; somatic symptom disorder; small fiber neuropathy; brain disease) mostly capture only some components of this complex and heterogeneous disorder. The diagnosis can be established in most cases by a general practitioner when the symptoms meet recognized criteria and a somatic disease sufficiently explaining the symptoms is excluded. Evidence-based interdisciplinary guidelines give a strong recommendation for aerobic exercise and cognitive behavioral therapies. Drug therapy is not mandatory. Only a minority of patients experience substantial symptom relief with duloxetine, milnacipran, and pregabalin.

Facts and myths pertaining to fibromyalgia

Fibromyalgia (FM) is characterized by chronic widespread pain, unrefreshing sleep, physical exhaustion, and cognitive difficulties. It occurs in all populations throughout the world, with prevalence between 2% and 4% in general populations. Definition, pathogenesis, diagnosis, and treatment of FM remain points of contention, with some even contesting its existence. The various classification systems according to pain medicine, psychiatry, and neurology (pain disease; persistent somatoform pain disorder; masked depression; somatic symptom disorder; small fiber neuropathy; brain disease) mostly capture only some components of this complex and heterogeneous disorder. The diagnosis can be established in most cases by a general practitioner when the symptoms meet recognized criteria and a somatic disease sufficiently explaining the symptoms is excluded. Evidence-based interdisciplinary guidelines give a strong recommendation for aerobic exercise and cognitive behavioral therapies. Drug therapy is not mandatory. Only a minority of patients experience substantial symptom relief with duloxetine, milnacipran, and pregabalin.