Fibromyalgia syndrome in need of effective treatments

Involvement of peripheral mast cells in a fibromyalgia model in mice

Fibromyalgia is a painful disorder of unknown aetiology that presents activation and recruitment of innate immune cells, including mast cells. Efforts have been made to understand its pathogenesis to manage it better. Thus, we explored the involvement of peripheral mast cells in an experimental model of fibromyalgia induced by reserpine. Reserpine (1 mg/kg) was subcutaneously (s.c.) injected once daily in the back of male Swiss mice for three consecutive days. We analysed mechanical and cold allodynia, muscle fatigue and number of mast cell in plantar tissue. The fibromyalgia induction produced mast cell infiltration (i.e., mastocytosis) in the mice's plantar tissue. The depletion of mast cell mediators with the compound 48/80 (0.5-4 mg/kg, intraperitoneal (i.p.)) or the mast cell membrane stabilizer ketotifen fumarate (10 mg/kg, oral route (p.o.) widely (80-90 %) and extensively (from 1 up to 10 days) prevented reserpine-induced mechanical and cold allodynia and muscle fatigue. Compound 48/80 also prevented the reserpine-induced mastocytosis. Finally, we demonstrated that PAR-2, 5-HT2A, 5-HT3, H1, NK1 and MrgprB2 receptors, expressed in neuronal or mast cells, seem crucial to mediate fibromyalgia-related cardinal symptoms since antagonists or inhibitors of these receptors (gabexate (10 mg/kg, s.c.), ENMD-1068 (10 mg/kg, i.p.), ketanserin (1 mg/kg, i.p.), ondansetron (1 mg/kg, p.o.), promethazine (1 mg/kg, i.p.), and L733,060 (5 mg/kg, s.c.), respectively) transiently reversed the reserpine-induced allodynia and fatigue. The results indicate that mast cells mediate painful and fatigue behaviours in this fibromyalgia model, representing potential therapy targets to treat fibromyalgia syndrome.

Effect of prebiotic and probiotic supplementation on reduced pain in patients with fibromyalgia syndrome: a double-blind, placebo-controlled randomized clinical trial

It has recently been observed that microorganisms in the gut can regulate brain processes through the gut microbiota-brain axis, affecting pain, depression, and sleep quality. Consequently, prebiotics and probiotics may potentially improve physical, psychological, and cognitive states in those with fibromyalgia syndrome (FMS) who have an altered microbiota balance. In a randomised, double-blind, placebo-controlled clinical trial to determine the effects of probiotic and prebiotic treatments on pain, sleep, quality of life, and psychological distress (depression and anxiety) in FMS, 53 female participants with FMS were randomised to receive either: 1) 4 × 1010 CFUs per day for the 18 patients in the probiotics group; 2) 10 g dose inulin per day for the 17 patients in the prebiotic group; or 3) a placebo for 8 weeks for the 18 patients in this group. The mean ages of the groups were similar and there was no significant difference between the groups. The impact of FMS on pain, sleep quality, quality of life, anxiety, and depressive symptoms were measured at baseline, 4 weeks, and 8 weeks post-intervention. Probiotic supplementation significantly decreased the Beck Depression Index (BDI), Beck Anxiety Index (BAI), and Pittsburgh Sleep Quality Index (PSQI) scores compared to baseline, while prebiotic supplementation only significantly decreased PSQI scores. Moreover, participants who received probiotic treatment presented a significantly reduced Visual Analogue Scale (VAS) score compared with those who received placebo treatment, after the interventions. Probiotic supplementation significantly improved sleep quality, depression, anxiety, and pain scores compared to those at baseline in FMS patients, while prebiotic supplementation significantly improved pain scores and sleep quality. The potential benefits of using probiotics for treatment management in FMS patients is supported by the results of the current study and might provide an important strategy to combat FMS-associated diseases.

Shockwave therapy and fibromyalgia and its effect on pain, blood markers, imaging, and participant experience - a multidisciplinary randomized controlled trial

BACKGROUND

Patients with fibromyalgia experience chronic, widespread pain. It remains a misunderstood disorder with multimodal treatments providing mixed results.

OBJECTIVES

To examine the effects of radial shockwave therapy (RSWT) compared to placebo on pain, pain catastrophizing, psychological indices, blood markers, and neuroimaging. Study-related experiences were also explored qualitatively.

METHODS

Quantitative sensory testing (QST), Visual Analog Scale (VAS), Beighton Scoring Screen (BSS), Pain Catastrophizing Scale (PCS), blood biomarker (Interleukin (IL)-6 and IL-10), and brain fMRI were measured pre- and post-treatment along with a post-treatment survey. The RSWT group received five treatments (one week apart over five-week period) to the three most painful areas (500 shocks at 1.5 bar and 15 Hz, then 1000 shocks at 2 bar and 8 Hz, and finally 500 shocks at 1.5 bar and 15 Hz) versus sham treatment for the placebo group.

RESULTS

There were no statistically significant differences in the BSS for hypermobility (p = .21; d = .74), PCS (p = .70; d = .22), VAS (p = .17-.61; d = .20-.83) scores, QST for skin temperature and stimuli (p = .14-.65; d = .25-.88), and for the pressure pain threshold (p = .71-.93; d = .05-.21). The VAS scores had clinically significant changes (MCID greater than 13.90) with improved pain scores in the RSWT group. Neuroimaging scans revealed no cortical thickness changes. Post-treatment surveys revealed pain and symptom improvements and offered hope to individuals.

CONCLUSION

RSWT was implemented safely, without any negative treatment effects reported, and acted as a pain modulator to reduce sensitivity.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identification number NCT02760212.

[Features of fibromyalgia in patients with rheumatoid arthritis]

OBJECTIVE

To determine the features of fibromyalgia (FM) in patients with rheumatoid arthritis (RA).

MATERIAL AND METHODS

Seventy-six patients participated in the study. The patients were divided into 2 groups: RA+FM (n=55), FM (n=21). Anamnesis of life and disease was carefully collected in all patients. The intensity (according to VAS) and phenotype (Pain DETECT, DN4) of pain syndrome (PS), the presence of symptoms of central sensitization (CSI), fatigue (FSS), signs of anxiety and depression (HADS), sleep quality (PSQI), cognitive functions (DSST) and quality of life (QoL) (EQ-5D, FIQR) were also evaluated.

RESULTS

The average age of patients in the FM group was significantly lower (42 [35; 53] vs. 50 [42.5; 59], p=0.042). Patients with «pure» FM without RA were more often divorced and had no children (p=0.045 and p=0.02, respectively). The duration of PS in the groups did not differ (11 [7; 17] vs. 8 [5; 13] years, p=0.429), however, patients with «pure» FM waited longer for diagnosis (115 [40; 198] vs. 20 [5.5; 59] months, p<0.001), and they also were less likely to be recognized as disabled (p=0.003). Patients of both groups had equally severe fatigue, anxiety, depression, sleep disorders and cognitive functions compared to the norms. Patients of the FM group noted a lower QoL (according to EQ-5D, p=0.041) then in RA+FM group, despite the comparable severity of FM and the intensity of the PS in both groups.

CONCLUSION

FM in patients with RA develops at a later age compared to «pure» FM. The clinical picture of FM with and without RA does not differ in the main manifestations, however, the QoL of patients with «pure» FM is lower. Accounting for fibromyalgia in the treatment of rheumatoid diseases can significantly improve the QoL of patients.

Hypocapnia in women with fibromyalgia

OBJECTIVES

The purpose of this study was to investigate whether people with fibromyalgia (FM) have dysfunctional breathing by examining acid-base balance and comparing it with healthy controls.

METHODS

Thirty-six women diagnosed with FM and 36 healthy controls matched for age and gender participated in this cross-sectional study. To evaluate acid-base balance, arterial blood was sampled from the radial artery. Carbon dioxide, oxygen, bicarbonate, base excess, pH and lactate were analysed for between-group differences. Blood gas analyses were performed stepwise on each individual to detect acid-base disturbance, which was categorized as primary respiratory and possible compensation indicating chronicity. A three-step approach was employed to evaluate pH, carbon dioxide and bicarbonate in this order.

RESULTS

Women with FM had significantly lower carbon dioxide pressure (p = 0.013) and higher lactate (p = 0.038) compared to healthy controls at the group level. There were no significant differences in oxygen pressure, bicarbonate, pH and base excess. Employing a three-step acid-base analysis, 11 individuals in the FM group had a possible renally compensated mild chronic hyperventilation, compared to only 4 among the healthy controls (p = 0.042).

CONCLUSIONS

In this study, we could identify a subgroup of individuals with FM who may be characterized as mild chronic hyperventilators. The results might point to a plausible dysfunctional breathing in some women with FM.

Effects of perceptive rehabilitation and mobilization methods on symptoms and disability in patients with fibromyalgia: A preliminary randomized control trial

BACKGROUND

Currently, there is no definitive cure for fibromyalgia. Instead, treatments focus of reducing symptoms and disability.

AIMS

This randomized controlled study aimed to evaluate the effectiveness of perceptive rehabilitation and soft tissue and joint mobilization on the severity of symptoms and disability in fibromyalgia compared with a control group.

METHODS

A total of 55 fibromyalgia patients were randomized into three groups: perceptive rehabilitation, mobilization, and control. The impact of fibromyalgia was evaluated using the Revised Fibromyalgia Impact Questionnaire (FIQR; primary outcome). Pain intensity, fatigue severity, depression, and sleep quality were secondary outcome measures. Data were collected at baseline (T0), the end of treatment (8 weeks; T1), and the end of 3 months (T2).

RESULTS

Statistically significant differences were found in between-groups comparisons at T1 for primary and secondary outcome measurements (p < .05), except for sleep quality. Both the perceptive rehabilitation and mobilization groups had statistically significant differences at T1 over the control group (p < .05). Between-group pairwise comparisons showed statistically significant differences between the perceptive and control groups for all outcome measures at T1 (p < .05). Similarly, statistically significant differences existed between the mobilization and control groups for all outcome measures at T1 (p < .05), except the FIQR overall impact scores. All other variables except depression were statistically similar between groups at T2.

CONCLUSION

This study shows that perceptive rehabilitation and mobilization therapy are similarly effective in improving fibromyalgia symptoms and disability, but the effects disappear within 3 months. Further research is needed to understand how the improvements could be maintained longer.

TRIAL REGISTRATION

Clinical Trial Registration number, ClinicalTrials.gov Identifier: NCT03705910.

Racial Disparities in Pain Among Women with Fibromyalgia: Secondary Data Analysis of Severity, Interference with Function, and Response to Guided Imagery

Background: Fibromyalgia syndrome (FMS) is characterized by widespread persistent musculoskeletal pain. Mostly prevalent among White women, little is known about FMS in other population cohorts. This study examined secondary data of a racially diverse sample of women with FMS that were collected as part of a randomized controlled clinical trial that examined the effect of a complementary therapy intervention over the course of a 10-week guided imagery intervention to identify demographic, social, or economic differences in self-reported pain. Materials and Methods: The Brief Pain Inventory (BPI), which measures pain severity and interference, was administered to 72 women (21 Black and 51 Whites) at baseline, 6 and 10 weeks. Student's t tests and time series regression models examined racial difference in pain dimensions and treatment response. Regression models accounted for age, race, income, duration of symptoms, treatment group, pain at baseline, smoking, alcohol use, comorbid conditions, and time. Results: Black women experienced significantly higher pain severity (β = 5.52, standard deviation [SD] = 2.13) and interference (β = 5.54, SD = 2.74) than Whites (severity β = 4.56, SD = 2.08; interference β = 4.72, SD = 2.76) (interference: t = 1.92, p = 0.05; severity: t = 2.95, p = 0.00). Disparities persisted over time. Controlling for differences in age, income, and previous pain levels, Black women had 0.26 (standard error [SE] = 0.065) higher pain severity and 0.36 (SE = 0.078) higher interference than Whites. Low-income earners also experienced 2.02 (SE = 0.38) and 2.19 (SE = 0.46) higher pain severity and interference, respectively, than other earners. Results were robust to inclusion of comorbidities. Conclusions: Black women and low-income earners experienced significantly higher levels of pain severity and interference and a lower dose response to the intervention. Differentials were robust to inclusion of demographic, health, and behavioral characteristics. Findings suggest that external factors may contribute to pain perception among women with FMS.

Efficacy of cupping therapy in individuals with fibromyalgia. A systematic review of randomized clinical trials

BACKGROUND

Fibromyalgia is a chronic and idiopathic condition and is among the most common causes of generalized chronic pain, even affecting psychological and cognitive aspects.

AIM

To evaluate the efficacy of cupping therapy on pain, quality of life, sleep disorders, and the impact of the disease in subjects with fibromyalgia.

METHODS

We searched the Pubmed, CINAHL, Epistemonikos, Scopus, and Web of Science databases. Randomized controlled trials involving adults with fibromyalgia undergoing cupping were included. Pain intensity, quality of life, sleep disturbances, and the impact of fibromyalgia were assessed. We have reported the results using descriptive statistics and narrative synthesis.

RESULTS

Two articles with a total of 155 participants were included. Large effect sizes were found for pain intensity, moderate for quality of life, and low for the impact of fibromyalgia and sleep disorders. However, the certainty of the evidence is low for most outcomes except for sleep disorders.

CONCLUSIONS

There is a discrepancy in the efficacy of cupping therapy in improving pain intensity, quality of life, sleep disturbances, and disease impact in people with fibromyalgia. Future high-quality randomized clinical trials are required.

Investigation of effectiveness of reformer pilates in individuals with fibromyalgia: A randomized controlled trial

INTRODUCTION AND OBJECTIVES

Fibromyalgia (FM) is a chronic condition characterized by widespread pain, sleep disorder, fatigue, other somatic symptoms. Clinical pilates method is therapeutic modality that can be used in improving the symptoms. The aim of this study was to investigate the effectiveness of reformer pilates exercises in individuals with FM and to compare with home mat pilates.

MATERIAL AND METHODS

Twenty-eight women (age mean=45.61±10.31) diagnosed with FM were included in this study. Participants were randomly divided into two groups as reformer pilates group (n=14) and home mat pilates group (n=14). Reformer and home mat pilates exercises were given 2 times a week for 6 weeks. The number of painful regions with Pain Location Inventory (PLI), clinical status with Fibromyalgia Impact Questionnaire (FIQ), lower extremity muscle strength with Chair Stand Test, functional mobility with The Timed Up and Go Test (TUG), biopsychosocial status with Cognitive Exercise Therapy Approach-Biopsychosocial Questionnaire (BETY-BQ) and quality of life with Short Form-36 (SF-36) were evaluated. All evaluations were assessed before and after treatment.

RESULTS

There was a significant difference in FIQ and chair stand test in reformer pilates group, while in PLI, FIQ, BETY-BQ vs. SF-36 Physical Component in home group (p<0.05) compared with baseline. There were no statistical differences between the groups in terms of delta value (p>0.05).

CONCLUSIONS

Reformer pilates exercises had positive effects on clinical status and muscle strength while home mat pilates exercises had positive effects on the number of painful regions, clinical status, biopsychosocial status and physical component quality of life. Clinical trial registration number NCT04218630.

Can Exercise Affect the Pain Characteristics in Patients with Fibromyalgia? A Randomized Controlled Trial

Exercise is often recommended for fibromyalgia. The aim of this study was to investigate the possible influence and change in the pain characteristics of fibromyalgia patients when breathing exercises were added to their exercise program. A total of 106 patients were included and randomly divided into two groups. Τhe first group of patients followed a program of active exercises up to the limits of pain, lasting 30 min with a repetition of two times a week. Patients of the second group followed the same program with the addition of diaphragmatic breaths when they reached the pain limit. The patients completed three questionnaires: the Fibromyalgia Rapid Screening Tool (FiRST), the Brief Pain Inventory (BPI), and the Pain Quality Assessment Scale (PQAS)-once at the beginning, once again after three weeks of exercise, and again 3 months since the beginning of the program. Independent t-tests for the mean total change scores in pain scales demonstrated that for the second group there was a greater improvement in all pain scales, except for the PQAS Deep Pain subscale (p = 0.38). In conclusion, both groups showed significant improvement in all characteristics of the pain scales; however, the improvement of the second group was significantly higher.

Subcategories of Fibromyalgia: A New Concept

Fibromyalgia has previously been categorized as primary, secondary, and juvenile fibromyalgia. However, these definitions do not adequately explain the etiopathology of disease, nor do they help direct new specific therapies. Herein, we review the previously known categorizations of fibromyalgia. Based on common patient characteristics and previously studied pathophysiologies, we propose new subcategorizations of fibromyalgia that we have self-narrated, including hormonal fibromyalgia, neuroendocrine fibromyalgia, psychologic fibromyalgia, inflammatory fibromyalgia, and lastly, neuropathic fibromyalgia. Future research needs to be done to verify, add to, and fully describe these self-narrated categories of fibromyalgia that we have proposed.

Gentle Touch Therapy, Pain Relief and Neuroplasticity at Baseline in Fibromyalgia Syndrome: A Randomized, Multicenter Trial with Six-Month Follow-Up

Background: Fibromyalgia (FM) is considered a stress-related disorder characterized mainly by chronic widespread pain. Its pathogenesis is unknown, but cumulative evidence points at dysfunctional transmitter systems and inflammatory biomarkers that may underlie the major symptoms of the condition. This study aimed to evaluate pain scores (primary outcome), quality of life, inflammatory biomarkers and neurotransmitter systems in women with FM (secondary outcomes) subjected to gentle touch therapy (GTT) or placebo. Methods: A total of 64 female patients with FM were randomly assigned to two groups, namely GTT (n = 32) or Placebo (n = 32). Clinical assessments were conducted at baseline and post-intervention with six-month follow-up. We measured serum catecholamines (dopamine), indolamines and intermediary metabolites (serotonin or 5-hydroxyindolacetic acid (5-HIAA)), as well as tetrahydrobiopterin (BH4), which is a cofactor for the synthesis of neurotransmitters and inflammatory biomarkers in women with FM. A group of healthy individuals with no intervention (control group) was used to compare biochemical measurements. Intervention effects were analyzed using repeated measures (RM) two-way ANOVA followed by Bonferroni post hoc test and mixed ANCOVA model with intention to treat. Results: Compared to placebo, the GTT group presented lower pain scores and brain-derived neurotrophic factor (BDNF) levels without altering the quality of life of women with FM. Changes in BDNF had a mediating role in pain. Higher baseline serum BDNF and 5-HIAA or those with a history of anxiety disorder showed a higher reduction in pain scores across time. However, women with higher serum dopamine levels at baseline showed a lower effect of the intervention across the observation period revealed by an ANCOVA mixed model. Conclusions: In conclusion, lower pain scores were observed in the GTT group compared to the placebo group without altering the quality of life in women with FM. Reductions in BDNF levels could be a mechanism of FM pain status improvement. In this sense, the present study encourages the use of these GTT techniques as an integrative and complementary treatment of FM.

Efficacy of Dry Needling and Acupuncture in Patients with Fibromyalgia: A Systematic Review and Meta-Analysis

Fibromyalgia (FM) is a syndrome that involves chronic pain, fatigue, sleep disturbance and impaired quality of life and daily functioning. In addition to medical and psychological therapies, other therapies including acupuncture and dry needling aim to reduce pain and disability in patients with FM. The aim of this study was to investigate the efficacy of dry needling and acupuncture in patients with FM regarding pain, function and disability in both the short and the long term. MEDLINE, PubMed, SCOPUS and Web of Science databases were systematically searched for randomized controlled trial studies evaluating efficacy data of dry needling or/and acupuncture treatments to improve pain, fatigue, sleep disturbance and impaired quality of life and/or daily function. A qualitative analysis including the methodological quality and a systematic data synthesis was performed. A total of 25 studies addressed the selection criteria. Most studies had an acceptable methodological quality. Four studies assessed the effect of dry needling, and twenty-one studies assessed the effect of acupuncture. In general, both interventions improved pain, anxiety, depression, fatigue, stiffness, quality of sleep and quality of life. However, both techniques were not compared in any study. Acupuncture and dry needling therapies seems to be effective in patients with FM, since both reduced pain pressure thresholds, anxiety, depression, fatigue, sleep disturbances and disability in the short term. It is still required to compare both techniques and their application in the long term.

Sex Differences in Comorbidity Combinations in the Swedish Population

High comorbidity rates, especially mental–physical comorbidity, constitute an increasing health care burden, with women and men being differentially affected. To gain an overview of comorbidity rates stratified by sex across a range of different conditions, this study examines comorbidity patterns within and between cardiovascular, pulmonary, skin, endocrine, digestive, urogenital, musculoskeletal, neurological diseases, and psychiatric conditions. Self-report data from the LifeGene cohort of 31,825 participants from the general Swedish population (62.5% female, 18–84 years) were analyzed. Pairwise comorbidity rates of 54 self-reported conditions in women and men and adjusted odds ratios (ORs) for their comparison were calculated. Overall, the rate of pairwise disease combinations with significant comorbidity was higher in women than men (14.36% vs. 9.40%). Among psychiatric conditions, this rate was considerably high, with 41.76% in women and 39.01% in men. The highest percentages of elevated mental–physical comorbidity in women were found for musculoskeletal diseases (21.43%), digestive diseases (20.71%), and skin diseases (13.39%); in men, for musculoskeletal diseases (14.29%), neurological diseases (11.22%), and digestive diseases (10%). Implications include the need for integrating mental and physical health care services and a shift from a disease-centered to an individualized, patient-centered focus in clinical care.

Short-Term Magnesium Therapy Alleviates Moderate Stress in Patients with Fibromyalgia: A Randomized Double-Blind Clinical Trial

Patients suffering from fibromyalgia often report stress and pain, with both often refractory to usual drug treatment. Magnesium supplementation seems to improve fibromyalgia symptoms, but the level of evidence is still poor. This study is a randomized, controlled, double-blind trial in fibromyalgia patients that compared once a day oral magnesium 100 mg (Chronomag®, magnesium chloride technology formula) to placebo, for 1 month. The primary endpoint was the level of stress on the DASS-42 scale, and secondary endpoints were pain, sleep, quality of life, fatigue, catastrophism, social vulnerability, and magnesium blood concentrations. After 1 month of treatment, the DASS-42 score decreased in the magnesium and placebo groups but not significantly (21.8 ± 9.6 vs. 21.6 ± 10.8, respectively, p = 0.930). Magnesium supplementation significantly reduced the mild/moderate stress subgroup (DASS-42 stress score: 22.1 ± 2.8 to 12.3 ± 7.0 in magnesium vs. 21.9 ± 11.9 to 22.9 ± 11.9 in placebo, p = 0.003). Pain severity diminished significantly (p = 0.029) with magnesium while the other parameters were not significantly different between both groups. These findings show, for the first time, that magnesium improves mild/moderate stress and reduces the pain experience in fibromyalgia patients. This suggests that daily magnesium could be a useful treatment to improve the burden of disease of fibromyalgia patients and calls for a larger clinical trial.

ROLE OF MANUAL THERAPY AND MASSAGE IN THE TREATMENT OF FIBROMYALGIA: TESTING THE HYPOTHESIS

Fibromyalgia syndrome (FMS) is a chronic rheumatic disease in which pain is predominant and accompanied by fatigue, anxiety, depression, sleep disturbance and cognitive dysfunction. Although there are numerous pharmacological and non-pharmacological therapeutic alternatives, symptom control is frequently problematic. Manual therapy covers manipulating soft tissue and various joints using the hands. It is organized by mapping of soft tissue structures with rhythmically applied pressure to improve physical function, facilitate daily activities, promote rehabilitation procedures and decrease pain.  Massage is generally accepted as an essential component of manual therapy. Stretching and mobilizations are also part of manual therapy. Although numerous beneficial effects of manual therapy and massage on the musculoskeletal system and pain have been proven, the data in FMS patients studies are inconclusive. We hypothesize that manual therapy and massage are beneficial therapeutic options for the control of symptoms of FMS patients. Furthermore, these strategies can be employed in conjunction with well-established and high-evidence therapeutic procedures. Future research should focus on establishing standardized protocols for manual therapy and massage, which is one of the major limitations. To ensure a high level of evidence, research studies with large sample sizes, long follow-up periods and methodologically complete are needed.

MAO-A Inhibition by Metaxalone Reverts IL-1β-Induced Inflammatory Phenotype in Microglial Cells

Experimental and clinical studies have suggested that several neurological disorders are associated with the occurrence of central nervous system neuroinflammation. Metaxalone is an FDA-approved muscle relaxant that has been reported to inhibit monoamine oxidase A (MAO-A). The aim of this study was to investigate whether metaxalone might exert antioxidant and anti-inflammatory effects in HMC3 microglial cells. An inflammatory phenotype was induced in HMC3 microglial cells through stimulation with interleukin-1β (IL-1β). Control cells and IL-1β-stimulated cells were subsequently treated with metaxalone (10, 20, and 40 µM) for six hours. IL-1β stimulated the release of the pro-inflammatory cytokines tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6), but reduced the anti-inflammatory cytokine interleukin-13 (IL-13). The upstream signal consisted of an increased priming of nuclear factor-kB (NF-kB), blunted peroxisome proliferator-activated receptor gamma (PPARγ), and peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) expression. IL-1β also augmented MAO-A expression/activity and malondialdehyde levels and decreased Nrf2 mRNA expression and protein levels. Metaxalone decreased MAO-A activity and expression, reduced NF-kB, TNF-α, and IL-6, enhanced IL-13, and also increased PPARγ, PGC-1α, and Nrf2 expression. The present experimental study suggests that metaxalone has potential for the treatment of several neurological disorders associated with neuroinflammation.

Effects of Neurofeedback on Fibromyalgia: A Randomized Controlled Trial

BACKGROUND

Fibromyalgia is a chronic widespread pain condition that is associated with sleep disturbances and cognitive impairments. Neurofeedback has been demonstrated to improve pain, sleep quality, and fatigue. However, few studies have examined the effect of neurofeedback for patients with fibromyalgia.

AIM

To determine the effects of neurofeedback on pain intensity, symptom severity, sleep quality, and cognitive function in patients with fibromyalgia.

DESIGN

This study was a randomized controlled trial.

METHOD

Eighty participants were randomized to a neurofeedback group (N = 60), receiving sensorimotor and alpha rhythm feedback for 8 weeks, or a telephone support group (N = 20).

RESULTS

Results from the generalized estimating equation modelling revealed significant group-by-time interactions for Brief Pain Inventory pain severity (B = -1.35, SE = 0.46, p = .003) and pain interference (B = -1.75, SE = 0.41, p < .001), Revised Fibromyalgia Impact Questionnaire total scores (B = -16.41, SE = 3.76, p < .001), sleep onset latency (B = -25.33, SE = 9.02, p = .005), and Psychomotor Vigilance Test error (B = -1.38, SE = 0.55, p = .013) after adjustments for age, sex, duration of illness, and group differences at baseline.

CONCLUSIONS

An 8-week neurofeedback training regimen of sensorimotor rhythm and alpha brain waves significantly improved pain severity and interference, fibromyalgia symptom severity, sleep latency, and sustained attention in patients with fibromyalgia.

Food Implications in Central Sensitization Syndromes

Fibromyalgia (FM), chronic fatigue syndrome (CFS) and multiple chemical sensitivity (MCS) are some of the central sensitization syndromes (CSSs). The complexity of their diagnosis, the high interindividual heterogeneity and the existence of multi-syndromic patients requires a multifaceted treatment. The scientific literature is contradictory regarding the role of food in CSS, and evidence on the role of nutrition in MCS is particularly scarce. This review consists in gathering information about the current status of dietary recommendations (i.e., special dietary interventions, the role of additives, presence of micronutrient deficiencies, nutritional supplements and elimination of other nutrients and substances) and discussing the scientific evidence in depth to shed light on appropriate nutritional treatment managements for CSS patients. Current indications show that dietary modifications may vastly improve the patients’ quality of life at a low cost. We suggest personalized treatment, taking into consideration the severity of the disease symptoms, quality of life, coexistence with other diseases, pharmacological treatment, changing clinical characteristics, nutritional status, energy requirements and food tolerances, among others, as the best ways to tailor specific dietary interventions. These approaches will partially overcome the lack of scientific and clinical research on MSC. Patients should also be advised on the serious consequences of following dietary guidelines without a dietitian’s and clinician’s supervision.

Serum proteome profiles revealed dysregulated proteins and mechanisms associated with fibromyalgia syndrome in women

Fibromyalgia syndrome (FM) is a multifactorial disorder whose pathogenesis and diagnosis are poorly understood. This study investigated differential serum proteome profiles in patients with FM and healthy pain-free controls and explored the association between serum proteome and clinical profiles in patients with FM. Twenty patients with FM (according to the American College of Rheumatology criteria, 2010) and 20 healthy pain-free controls were recruited for optimized quantitative serum proteomics analysis. The levels of pain, pressure pain threshold, sleep, anxiety, depression, and functional status were evaluated for patients with FM. We identified 22 proteins differentially expressed in FM when compared with healthy pain-free controls and propose a panel of methyltransferase-like 18 (METTL18), immunoglobulin lambda variable 3–25 (IGLV3–25), interleukin-1 receptor accessory protein (IL1RAP), and IGHV1OR21-1 for differentiating FM from controls by using a decision tree model (accuracy: 0.97). In addition, we noted several proteins involved in coagulation and inflammation pathways with distinct expression patterns in patients with FM. Novel proteins were also observed to be correlated with the levels of pain, depression, and dysautonomia in patients with FM. We suggest that upregulated inflammation can play a major role in the pathomechanism of FM. The differentially expressed proteins identified may serve as useful biomarkers for diagnosis and evaluation of FM in the future.

Fibromyalgia syndrome and the eye-A review

Fibromyalgia is a chronic, widespread pain syndrome of unclear etiology characterized by fatigue, sleeping problems, cognitive disorders, somatic complaints, and severe pain in parts of the body at the time of physical activity, with no laboratory findings specific to the disease or diagnostic tests. Fibromyalgia can be associated with ocular symptoms (foreign body sensation, irritation) and visual disturbances (blurred vision), coexisting with dry eye syndrome and reduced corneal sensitivity. Cases of scleritis, including the necrotizing form, accompanying fibromyalgia have been reported. Changes in the eye may contribute to the pathogenesis of fibromyalgia. Research shows the choroid to be significantly thinner in patients with fibromyalgia, revealing changes in optic disc perfusion and a decreased retinal nerve fiber layer thickness. There are also thin corneal stromal nerves with diminished sub-basal plexus nerve density. Pathological changes and functional abnormalities of small nerve fibers are observed in patients with fibromyalgia. Corneal confocal bio-microscopy is a new noninvasive method to evaluate small nerve fiber morphology, serving as an alternative for skin biopsies, and reveals new possibilities in diagnostics and finding innovative therapies for this disease. Fibromyalgia remains a challenge for ophthalmologists, and further studies are required to evaluate ocular involvement. It may be that future diagnostic criteria for fibromyalgia will contain ophthalmic examination modalities. Observed ocular changes and their pathomechanisms may constitute new targets for therapy to improve the quality of life of patients with fibromyalgia.

T Cell Subpopulations in the Physiopathology of Fibromyalgia: Evidence and Perspectives

Fibromyalgia is one of the most important “rheumatic” disorders, after osteoarthritis. The etiology of the disease is still not clear. At the moment, the most defined pathological mechanism is the alteration of central pain pathways, and emotional conditions can trigger or worsen symptoms. Increasing evidence supports the role of mast cells in maintaining pain conditions such as musculoskeletal pain and central sensitization. Importantly, mast cells can mediate microglia activation through the production of proinflammatory cytokines such as IL-1β, IL-6, and TNFα. In addition, levels of chemokines and proinflammatory cytokines are enhanced in serum and could contribute to inflammation at systemic level. Despite the well-characterized relationship between the nervous system and inflammation, the mechanism that links the different pathological features of fibromyalgia, including stress-related manifestations, central sensitization, and dysregulation of the innate and adaptive immune responses is largely unknown. This review aims to provide an overview of the current understanding of the role of adaptive immune cells, in particular T cells, in the physiopathology of fibromyalgia. It also aims at linking the latest advances emerging from basic science to envisage new perspectives to explain the role of T cells in interconnecting the psychological, neurological, and inflammatory symptoms of fibromyalgia.

Serum Vascular Endothelial Growth Factor and Vascular Endothelial Growth Factor Receptor-1 Levels in Patients With Fibromyalgia Syndrome

Objectives

This study aims to compare the serum vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor-1 (VEGFR-1) levels between patients with fibromyalgia syndrome (FMS) and healthy controls.

Patients and methods

The study included 40 female patients (mean age 39.9±10.2 years; range, 22 to 52 years) diagnosed with primary FMS according to the American College of Rheumatology criteria (1990) and 40 healthy female volunteers (mean age 40.9±8.3 years; range, 25 to 53 years). The sociodemographic data of both groups were recorded. The disease duration and the number of tender points were recorded for patients with FMS, and venous blood samples were collected from the two groups for the measurement of serum VEGF and VEGFR-1 levels.

Results

The FMS and control groups were comparable in terms of age and body mass index (p>0.05). A comparison of the serum VEGF levels of the FMS and control groups revealed a statistically insignificant difference (p>0.05), while a comparison of the serum VEGF-1 levels of the FMS and control groups revealed a statistically significant difference (p<0.05).

Conclusion

Serum VEGFR-1 levels were higher in patients with FMS, while the serum VEGF levels of the FMS patients did not differ from those of the healthy controls.

Effects of attachment-based compassion therapy (ABCT) on brain-derived neurotrophic factor and low-grade inflammation among fibromyalgia patients: A randomized controlled trial

Fibromyalgia (FM) is a disabling syndrome characterized by chronic pain associated with fatigue. Its pathogenesis is unknown, but alterations in central sensitization, involving an imbalance of brain-derived neurotrophic factor (BDNF) and inflammatory biomarkers, appear to be implicated. The aim of this study was to evaluate the impact of attachment-based compassion therapy (ABCT) on levels of BDNF, the inflammatory markers TNF-α, IL-6, IL-10, and the C-reactive protein (CRP), analysing whether biomarkers play a mediating/moderating role in improvements in FM functional status. Thirty-four female patients with FM participated in a RCT and were assigned to ABCT or relaxation therapy. Blood extractions were conducted at baseline and post-intervention, with self-report assessments of functional status (FIQ) at baseline, post-intervention and 3-month follow-up. A pro-inflammatory composite was obtained by summing up IL-6, TNF-α and CRP normalized values. Non-parametric tests, analysis of variance and regression models were used to evaluate treatment and mediation/moderation. Compared to relaxation therapy, ABCT showed significant improvements in FIQ and decreases in BDNF, CRP, and pro-inflammatory composite. Changes in BDNF had a mediating role in FIQ. ABCT seems to reduce BDNF and appears to have anti-inflammatory effects in FM patients. Reductions in BDNF could be a mechanism of FM functional status improvement.

Clinical Trial Registration:http://ClinicalTrials.gov, identifier NCT02454244. Date: May 27th, 2015.

CSF levels of apolipoprotein C1 and autotaxin found to associate with neuropathic pain and fibromyalgia

Objective

Neuropathic pain and fibromyalgia are two common and poorly understood chronic pain conditions that lack satisfactory treatments, cause substantial suffering and societal costs. Today, there are no biological markers on which to base chronic pain diagnoses, treatment choices or to understand the pathophysiology of pain for the individual patient. This study aimed to investigate cerebrospinal fluid (CSF) protein profiles potentially associated with fibromyalgia and neuropathic pain.

Methods

CSF samples were collected from 25 patients with neuropathic pain (two independent sets, n=14 patients for discovery, and n=11 for verification), 40 patients with fibromyalgia and 134 controls without neurological disease from two different populations. CSF protein profiling of 55 proteins was performed using antibody suspension bead array technology.

Results

We found increased levels of apolipoprotein C1 (APOC1) in CSF of neuropathic pain patients compared to controls and there was a trend for increased levels also in fibromyalgia patients. In addition, levels of ectonucleotide pyrophosphatase family member 2 (ENPP2, also referred to as autotaxin) were increased in the CSF of fibromyalgia patients compared to all other groups including patients with neuropathic pain.

Conclusion

The increased levels of APOC1 and ENPP2 found in neuropathic pain and fibromyalgia patients may shed light on the underlying mechanisms of these conditions. Further investigation is required to elucidate their role in maintaining pain and other main symptoms of these disorders.

Efficacy of baths with mineral-medicinal water in patients with fibromyalgia: a randomized clinical trial

The layout of this study, designed as a randomized crossover clinical trial, is to evaluate the efficacy of an intervention with mineral-medicinal water from As Burgas (Ourense) in patients suffering from fibromyalgia. This sample was randomly divided into two groups: group A and group B. In phase 1, group A had 14 baths in thermal water for a month and standard pharmacological treatment; group B, standard pharmacological treatment. Washout period is 3 months. In phase 2, group A had standard treatment and group B had 14 baths in thermal water for a month plus standard treatment. The Fibromyalgia Impact Questionnaire (FIQ) was used; this grades the impact of the illness from 1 (minimum) to 10 (maximum), which was measured in both phases. Twenty-five patients were included in each group and the study was concluded with 20 patients in group A and 20 in group B. The intervention group obtained, once the baths finished, a mean score of 60.3 (± 11.8) and the control group of 70.8 (± 13.0) (p < 0.001). Three months later, the intervention group presented a mean score of 64.4 (± 10.6) and the control group of 5.0 (± 11.3) (p < 0.001). We can therefore conclude that the simple baths with mineral-medicinal water from As Burgas can make an improvement on the impact caused by fibromyalgia.

Types of pain and their psychosocial impact in women with rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disease predominantly affecting middle-aged women. Very commonly, pain is a manifestation of active disease and because untreated RA can result in joint deformities, the current evaluation of pain has largely focused on inflammation. In addition, treatment has centered on the premise of reducing disease activity with the hopes of halting worsening damage, preventing future deformities, and ultimately providing pain relief for the patient. Yet research shows that all patients with RA, but women in particular, often suffer from increased mechanical pain and fibromyalgia, as well as anxiety, depression, sleep disturbances, sexual dysfunction, and disability, which add to the burden of the illness. Determining and addressing alternative pain triggers as well as understanding the psychosocial burden of RA is key in treating patients, especially in those who may not improve with traditional pharmacotherapy.

Mast Cells, Neuroinflammation and Pain in Fibromyalgia Syndrome

Fibromyalgia Syndrome (FMS) is a disorder of chronic, generalized muscular pain, accompanied by sleep disturbances, fatigue and cognitive dysfunction. There is no definitive pathogenesis except for altered central pain pathways. We previously reported increased serum levels of the neuropeptides substance P (SP) and its structural analogue hemokinin-1 (HK-1) together with the pro-inflammatory cytokines IL-6 and TNF in FMS patients as compared to sedentary controls. We hypothesize that thalamic mast cells contribute to inflammation and pain, by releasing neuro-sensitizing molecules that include histamine, IL-1β, IL-6 and TNF, as well as calcitonin-gene related peptide (CGRP), HK-1 and SP. These molecules could either stimulate thalamic nociceptive neurons directly, or via stimulation of microglia in the diencephalon. As a result, inhibiting mast cell stimulation could be used as a novel approach for reducing pain and the symptoms of FMS.

Effects of imidazoline I2 receptor agonists on reserpine-induced hyperalgesia and depressive-like behavior in rats

Pharmacotherapies for fibromyalgia treatment are lacking. This study examined the antinociceptive and antidepressant-like effects of imidazoline I2 receptor (I2R) agonists in a reserpine-induced model of fibromyalgia in rats. Rats were treated for 3 days with vehicle or reserpine. The von Frey filament test was used to assess the antinociceptive effects of I2 receptor agonists, and the forced swim test was used to assess the antidepressant-like effects of these drugs. 2-BFI (3.2-10 mg/kg, intraperitoneally), phenyzoline (17.8-56 mg/kg, intraperitoneally), and CR4056 (3.2-10 mg/kg, intraperitoneally) all dose-dependently produced significant antinociceptive effects, which were attenuated by the I2R antagonist idazoxan. Only CR4056 significantly reduced the immobility time in the forced swim test in both vehicle-treated and reserpine-treated rats. These data suggest that I2R agonists may be useful to treat fibromyalgia-related pain and comorbid depression.

Effects of an Extract of Salmon Milt on Symptoms and Serum TNF and Substance P in Patients With Fibromyalgia Syndrome

PURPOSE

The aim of this study was to evaluate the effects of a dietary supplement containing primarily an extract of salmon's milt (semen) on symptoms and blood levels of proinflammatory molecules in patients with fibromyalgia syndrome (FMS), a chronic, painful musculoskeletal disease without a distinct pathogenesis or treatment. We recently reported increased serum levels of the proinflammatory molecules substance P (SP) and tumor necrosis factor (TNF) in patients with FMS as compared to those in normal controls.

METHODS

This prospective, open-label study was conducted in patients with FMS (n = 87; 80 women, 7 men; age range, 18-80 years) selected from 2 clinical centers in Spain. Patients were administered the supplement and were evaluated at weeks 1 (before treatment), 4, 8, and 12 (end of treatment) for clinical parameters of functioning, fatigue, and pain, as well as overall impression. Patients were directed to take 1 capsule per day in the morning for the first 4 weeks, followed by 1 capsule in the morning and 1 capsule in the evening for the remaining 8 weeks. Differences in symptom scores in patients with FMS between weeks 1 and weeks 4, 8, and 12 were evaluated using ANOVA. Blood was obtained and serum separated in patients with FMS at 1 and 12 weeks and in a separate population of healthy controls (n = 20; 15 women, 5 men; age range, 25-65 years). Serum levels of SP and TNF were measured in patients with FMS at 1 and 12 weeks and in healthy controls by ELISA. TNF and SP levels in patients with FMS were compared between weeks 1 and 12, as well as between patients with FMS and untreated controls, using the Mann-Whitney U test.

FINDINGS

Clinical parameters of functioning, fatigue, and pain, as well as overall impression, were improved significantly at 4 weeks as compared to 1 week and remained unchanged for the duration of the study (all, P < 0.0001). Serum TNF and SP levels were significantly elevated at 1 week in patients with FMS compared to controls and were decreased significantly at 12 weeks as compared to 1 week (all, P < 0.0001).

IMPLICATIONS

Our findings indicate that this dietary supplement may significantly improve symptoms in patients with FMS. This is the first time to our knowledge that any molecule has been reported to be associated with a reduction in serum SP level. Consequently, the supplement or its hypothesized main active ingredient, spermine, may be developed as a novel treatment approach to FMS or other neuroinflammatory conditions. ClinicalTrials.gov identifier: NCT03911882.

Recent advances in our understanding of mast cell activation - or should it be mast cell mediator disorders?

INTRODUCTION

An increasing number of patients present with multiple symptoms affecting many organs including the brain due to multiple mediators released by mast cells. These unique tissue immune cells are critical for allergic reactions triggered by immunoglobulin E (IgE), but are also stimulated (not activated) by immune, drug, environmental, food, infectious, and stress triggers, leading to secretion of multiple mediators often without histamine and tryptase. The presentation, diagnosis, and management of the spectrum of mast cell disorders are very confusing. As a result, neuropsychiatric symptoms have been left out, and diagnostic criteria made stricter excluding most patients. Areas covered: A literature search was performed on papers published between January 1990 and November 2018 using MEDLINE. Terms used were activation, antihistamines, atopy, autism, brain fog, heparin, KIT mutation, IgE, inflammation, IL-6, IL-31, IL-37, luteolin, mast cells, mastocytosis, mediators, mycotoxins, release, secretion, tetramethoxyluteolin, and tryptase. Expert opinion: Conditions associated with elevated serum or urine levels of any mast cell mediator, in the absence of comorbidities that could explain elevated levels, should be considered 'Mast Cell Mediator Disorders (MCMD).' Emphasis should be placed on the identification of unique mast cell mediators, and development of drugs or supplements that inhibit their release.

Bioactive peptides and proteins as alternative antiplatelet drugs

Antiplatelet drugs reduce the risks associated with atherothrombotic events and show various applications in diverse cardiovascular diseases including myocardial infarctions. Efficacy of the current antiplatelet medicines including aspirin, clopidogrel, prasugrel and ticagrelor, and the glycoprotein IIb/IIIa antagonists, are limited due to their increased risks of bleeding, and antiplatelet drug resistance. Hence, it is important to develop new effective antiplatelet drugs, with fewer side-effects. The vast repertoire of natural peptides can be explored towards this goal. Proteins and peptides derived from snake venoms and plants represent exciting candidates for the development of novel and potent antiplatelet agents. Consequently, this review discusses multiple peptides that have displayed antiplatelet aggregation activity in preclinical drug development stages. This review also describes the antiplatelet mechanisms of the peptides, emphasizing the signaling pathways intervened by them. Also, the hurdles encountered during the development of peptides into antiplatelet drugs have been listed. Finally, hitherto unexplored peptides with the potential to prevent platelet aggregation are explored.

Psychological impact of fibromyalgia: current perspectives

Fibromyalgia syndrome (FMS) is a chronic disorder characterized by widespread and persistent musculoskeletal pain and other frequent symptoms such as fatigue, insomnia, morning stiffness, cognitive impairment, depression, and anxiety. FMS is also accompanied by different comorbidities like irritable bowel syndrome and chronic fatigue syndrome. Although some factors like negative events, stressful environments, or physical/emotional traumas may act as predisposing conditions, the etiology of FMS remains unknown. There is evidence of a high prevalence of psychiatric comorbidities in FMS (especially depression, anxiety, borderline personality, obsessive-compulsive personality, and post-traumatic stress disorder), which are associated with a worse clinical profile. There is also evidence of high levels of negative affect, neuroticism, perfectionism, stress, anger, and alexithymia in FMS patients. High harm avoidance together with high self-transcendence, low cooperativeness, and low self-directedness have been reported as temperament and character features in FMS patients, respectively. Additionally, FMS patients tend to have a negative self-image and body image perception, as well as low self-esteem and perceived self-efficacy. FMS reduces functioning in physical, psychological, and social spheres, and also has a negative impact on cognitive performance, personal relationships (including sexuality and parenting), work, and activities of daily life. In some cases, FMS patients show suicidal ideation, suicide attempts, and consummated suicide. FMS patients perceive the illness as a stigmatized and invisible disorder, and this negative perception hinders their ability to adapt to the disease. Psychological interventions may constitute a beneficial complement to pharmacological treatments in order to improve clinical symptoms and reduce the impact of FMS on health-related quality of life.

Acupuncture therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials

Purpose

Fibromyalgia (FM) can cause chronic widespread pain and seriously affect the quality of patient lives. Acupuncture therapy is widely used for pain management. However, the effect of acupuncture on FM is still uncertain. The aim of this review was to determine the effect and safety of acupuncture therapy on the pain intensity and quality of life in patients with FM.

Materials and methods

We searched PubMed, the Cochrane Library, Embase, the China National Knowledge Infrastructure, the Chinese Science and Technology Periodical Database, and the Chinese Biomedical Literature Database to collect randomized controlled trials (RCTs) of acupuncture for FM published before May 2018. A meta-analysis was performed according to the Cochrane systematic review method by using RevMan 5.3 software, and GRADE was used to evaluate the quality of the evidence.

Results

We identified 12 RCTs that compared acupuncture therapy to sham acupuncture or conventional medication. Meta-analysis showed that acupuncture was significantly better than sham acupuncture for relieving pain (MD =−1.04, 95% CI [−1.70, –0.38], P=0.002, I²=78%) and improving the quality of life (MD =−13.39, 95% CI [−21.69, –5.10], P=0.002, I²=82%), with low- to moderate-quality evidence in the short term. At follow-up in the long term, the effect of acupuncture was also superior to that of sham acupuncture. No serious adverse events were found during acupuncture.

Conclusion

Acupuncture therapy is an effective and safe treatment for patients with FM, and this treatment can be recommended for the management of FM.

Effectiveness of health education in patients with fibromyalgia: a systematic review

INTRODUCTION

Fibromyalgia (FM) is a chronic illness characterized by the presence of generalised musculoskeletal pain among other symptoms, which reduce the quality of life of the patient. Clinical interventions such as patient education on central pain management could lead to promising results. The aim of this study is to evaluate the effectiveness of education techniques on the main symptoms such as pain, quality of life, anxiety, functionality or catastrophization in the treatment of FM.

EVIDENCE ACQUISITION

The bibliographic search was carried out on PubMed, Web of Science, Scopus, CINAHL, EMBASE, Medline, ProQuest, Cochrane Plus and PEDro databases. The quality assessment of the selected studies was carried out by means of the PEDro scale, obtaining external and internal validity scores to evaluate the generalizability and the appropriateness of design, conduction, and reporting.

EVIDENCE SYNTHESIS

The electronic search produced 2,050 articles up to February 2018. After applying the inclusion criteria, 12 articles were identified, without the presence of any RCT of high methodological quality (PEDro≤8; Internal Validity Score [PVI] ≤4). Despite the heterogeneity of the interventions, a significant reduction in the perception of the disease, the catastrophization, pain intensity and anxiety was observed.

CONCLUSIONS

Patient education is considered to be the first step in self-management for a patient with FM, but the scientific evidence that supports the effectiveness of education in the reduction of the main symptoms is limited. Future research designed on more solid and homogeneous interventions is required.

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome-Metabolic Disease or Disturbed Homeostasis due to Focal Inflammation in the Hypothalamus?

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex disease characterized by debilitating fatigue, lasting for at least 6 months, with associated malaise, headaches, sleep disturbance, and cognitive impairment, which severely impacts quality of life. A significant percentage of ME/CFS patients remain undiagnosed, mainly due to the complexity of the disease and the lack of reliable objective biomarkers. ME/CFS patients display decreased metabolism and the severity of symptoms appears to be directly correlated to the degree of metabolic reduction that may be unique to each individual patient. However, the precise pathogenesis is still unknown, preventing the development of effective treatments. The ME/CFS phenotype has been associated with abnormalities in energy metabolism, which are apparently due to mitochondrial dysfunction in the absence of mitochondrial diseases, resulting in reduced oxidative metabolism. Such mitochondria may be further contributing to the ME/CFS symptomatology by extracellular secretion of mitochondrial DNA, which could act as an innate pathogen and create an autoinflammatory state in the hypothalamus. We propose that stimulation of hypothalamic mast cells by environmental, neuroimmune, pathogenic and stress triggers activates microglia, leading to focal inflammation in the brain and disturbed homeostasis. This process could be targeted for the development of novel effective treatments.

Ocular Surface Alterations in the Context of Corneal In Vivo Confocal Microscopic Characteristics in Patients With Fibromyalgia

PURPOSE

To quantify the morphology of corneal basal epithelium and subbasal nerves and to evaluate the ocular surface alterations in patients with fibromyalgia (FM).

METHODS

Patients with FM (n = 34) and healthy controls (n = 42) were enrolled. All participants underwent ocular surface tests in the following order: corneal sensitivity, tear film breakup time, lissamine green staining, Schirmer test, and the Ocular Surface Disease Index questionnaire. Basal epithelial cells and subbasal nerves were evaluated using in vivo confocal microscopy (IVCM). Demographic characteristics, Visual Analog Scale for Pain (VAS), American College of Rheumatology 1990, the Widespread Pain Index (WPI), and the Symptom Impact Questionnaire (SIQR) scores of patients with FM were obtained.

RESULTS

Corneal sensitivity was 0.4 g/mm (fiber length: 6.0 cm) in all eyes. Patients with FM had a higher Ocular Surface Disease Index (42.2 ± 18.9 vs. 1.2 ± 1.7, P < 0.001), higher lissamine green staining scores (0.5 ± 0.5 vs. 0.05 ± 0.2, P < 0.001), and lower tear breakup time scores (9.0 ± 3.6 vs. 10.3 ± 1.5, P = 0.003) than the controls. Basal epithelial cell density (2709 ± 494 vs. 4491 ± 724), total nerve density (1563 ± 620 vs. 2545 ± 973), long nerve fibers (3.4 ± 1.3 vs. 4.5 ± 1.0), and the number of nerves (5.0 ± 1.8 vs. 10.3 ± 2.1) were all lower in patients with FM compared with those of the controls (P < 0.001 for all). There was a statistically significant negative correlation between the WPI score and Schirmer test results (rho = -0.374, P = 0.03) and between WPI and total nerve density (rho = -0.334, P = 0.054).

CONCLUSIONS

To the best of our knowledge, this is the first study that evaluated ocular surface alterations in the context of corneal IVCM characteristics. Patients with FM should be evaluated in terms of ocular surface diseases. IVCM may be used in FM to assess small fiber neuropathy.

Saffron (Crocus sativus) versus duloxetine for treatment of patients with fibromyalgia: A randomized double-blind clinical trial

OBJECTIVE

Saffron was found efficient and safe in treatment of neuropsychiatric disorders, in particular depression. We compared the efficacy of saffron with duloxetine in treatment of patients with fibromyalgia.

MATERIALS AND METHODS

In this double-blind parallel-group clinical trial, outpatients with fibromyalgia were randomized to receive either saffron 15 mg or duloxetine 30 mg starting with 1 capsule per day in the first week followed by 2 capsules per day from week 2 until the end of week 8. Participants were men and women aged 18-60 years diagnosed with fibromyalgia based on the American College of Rheumatology 2010 criteria who also had a pain score≥40 based on visual analogue scale. Participants were excluded in case they had rheumatologic diseases, inflammatory/infectious/autoimmune arthritis, comorbid neuropsychiatric disorders except depressive disorders, pain due to traumatic injuries, drug history of duloxetine or saffron use, current use of psychoactive medications, recent use of muscle relaxants, steroids, opioid analgesics, benzodiazepines, anti-epileptics, or injective analgesics. Primary outcomes included differences in mean score changes from baseline to endpoint between the treatment arms for Hamilton Rating Scale for Depression, Fibromyalgia Impact Questionnaire, and Brief Pain Inventory.

RESULTS

Socio-demographic characteristics and baseline scores were similarly distributed between the two treatment arms (2n=46). No significant difference was detected for any of the scales neither in terms of score changes from baseline to endpoint between the two treatment arms (Mean score changes: -4.26 to 2.37; p-values: 0.182-0.900) nor in terms of timetreatment interactions (p-values: 0.209-0.964).

CONCLUSIONS

Saffron and duloxetine demonstrated comparable efficacy in treatment of fibromyalgia symptoms.

A mimetic of the mSin3-binding helix of NRSF/REST ameliorates abnormal pain behavior in chronic pain models

The neuron-restrictive silencing factor NRSF/REST binds to neuron-restrictive silencing elements in neuronal genes and recruits corepressors such as mSin3 to inhibit epigenetically neuronal gene expression. Because dysregulation of NRSF/REST is related to neuropathic pain, here, we have designed compounds to target neuropathic pain based on the mSin3-binding helix structure of NRSF/REST and examined their ability to bind to mSin3 by NMR. One compound, mS-11, binds strongly to mSin3 with a binding mode similar to that of NRSF/REST. In a mouse model of neuropathic pain, mS-11 was found to ameliorate abnormal pain behavior and to reverse lost peripheral morphine analgesia. Furthermore, even in the less well epigenetically defined case of fibromyalgia, mS-11 ameliorated symptoms in a mouse model, suggesting that fibromyalgia is related to the dysfunction of NRSF/REST. Taken together, these findings show that the chemically optimized mimetic mS-11 can inhibit mSin3-NRSF/REST binding and successfully reverse lost peripheral and central morphine analgesia in mouse models of pain.

Signs of ongoing inflammation in female patients with chronic widespread pain: A multivariate, explorative, cross-sectional study of blood samples

This cross-sectional study investigates the plasma inflammatory profile of chronic widespread pain (CWP) patients compared to healthy controls (CON). Rather than analyzing a relatively few substances at a time, we used a new multiplex proximity extension assay (PEA) panel that enabled the simultaneous analysis of 92 inflammation-related proteins, mainly cytokines and chemokines.Seventeen women with CWP and 21 female CON participated and a venous blood sample was drawn from all subjects. Pain intensity and pain thresholds for pressure, heat, and cold were registered. A PEA panel (92 proteins) was used to analyze the blood samples. Multivariate data analysis by projection was used in the statistical analyses.Eleven proteins significantly differentiated the CON and CWP subjects (R = 0.58, Q = 0.37, analysis of variance of cross-validated predictive residuals P = 0.006). It was not possible to significantly regress pain thresholds within each group (CON or CWP). Positive significant correlations existed between several proteins and pain intensities in CWP, but the model reliability of the regression was poor.CWP was associated with systemic low-grade inflammation. Larger studies are needed to confirm the results and to investigate which alterations are condition-specific and which are common across chronic pain conditions. The presence of inflammation could promote the spreading of pain, a hallmark sign of CWP. As it has been suggested that prevalent comorbidities to pain (e.g., depression and anxiety, poor sleep, and tiredness) also are associated with inflammation, it will be important to determine whether inflammation may be a common mediator.

Functional MRI of the Reserpine-Induced Putative Rat Model of Fibromyalgia Reveals Discriminatory Patterns of Functional Augmentation to Acute Nociceptive Stimuli

Functional neuroimaging, applied to pre-clinical models of chronic pain, offers unique advantages in the drive to discover new treatments for this prevalent and oppressive condition. The high spatial and temporal resolution of fMRI affords detailed mapping of regional pharmacodynamics that underlie mechanisms of pain suppression by new analgesics. Despite evidence supporting the translational relevance of this approach, relatively few studies have investigated fMRI abnormalities in rodent models of chronic pain. In this study, we used fMRI to map the BOLD response in a recently developed putative rat model of fibromyalgia to innocuous and acute nociceptive stimuli by applying a step-wise graded electrical forepaw stimulation paradigm, with comparison to healthy controls. We observed discriminatory functional signatures (p < 0.001) to 2 mA electrical forepaw stimulation, found to be innocuous in the control group. As such, this translational approach provides sensitive and quantitative neural correlates of the underlying chronic disease. The regional patterns of functional augmentation were found to be concordant with previous studies of nociception in the anaesthetised rat brain, supporting the specificity of this approach in the study of altered central pain processing in reserpine induced myalgia. The methodology introduced in this work represents a novel platform for emerging treatment evaluation in highly experimentally controlled conditions.