Controversies and challenges in fibromyalgia: a review and a proposal

A randomized controlled trial of Eye Movement Desensitization and Reprocessing (EMDR) Therapy in the treatment of fibromyalgia

Background

In addition to pharmacological treatment, psychotherapeutic approaches are recommended for the treatment of fibromyalgia. There is a suggestion that eye movement desensitization and reprocessing (EMDR) therapy may be effective. This study aimed to investigate the impact of EMDR therapy on fibromyalgia symptoms, depression, sleep quality, and traumatic stress in fibromyalgia patients through a randomized controlled study (RCT).

Materials and methods

The sample for this study comprised 79 individuals diagnosed with fibromyalgia. Participants were randomly assigned to two groups: the "Treatment as Usual" (TAU) group and the TAU + EMDR group. Prior to the study and at six different time points (before starting the study, at the end of the 5th, 10th, and 15th sessions, 1 month later, and 3 months later), participants completed assessments, including the Fibromyalgia Impact Questionnaire (FIQ), Visual Analog Scale (VAS), Fibromyalgia ACR 2010 Diagnostic Criteria [Widespread Pain Index (WPI) and Symptom Severity Scale (SSS)], Beck Depression Inventory (BDI), Pittsburgh Sleep Quality Index (PSQI), and Trauma Symptom Checklist-40 (TSC-40).

Results

There were no differences in the sociodemographic variables between the study and experimental groups. Analysis of variance revealed a statistically significant group effect on VAS (p = 0.019), WPI (p = 0.018), BDI (p = 0.019), and TSC-40 (p = 0.21). After applying Bonferroni correction, EMDR was found to be effective for VAS, WPI, SSS, BDI, PSQI, and TSC-40 (p <0.05).

Conclusion

The results of the current study suggest that EMDR therapy is a viable alternative treatment for fibromyalgia. We believe these findings offer robust evidence supporting the efficacy of EMDR therapy in treating fibromyalgia, particularly in the context of a randomized controlled trial (RCT). The application of EMDR therapy for the treatment of patients with fibromyalgia is likely to be beneficial.

Clinical trial registration

ClinicalTrials.gov, identifier NCT06265194.

Prevalence of FMS Diagnosis According to ACR 2016 Revised Criteria in a Pain Therapy Centre in Italy: Observational Study

Background and Objectives: Fibromyalgia syndrome (FMS) is a multifaceted disease with a strong preference for the female sex. It is characterised by chronic widespread pain, sleep-wake disorders, fatigue, cognitive disturbances, and several other somatic symptoms. Materials and Methods: In this prospective observational study, we analysed data regarding 302 patients who were referred to our pain centre for a first clinical assessment evaluation and were then inspected for the physician-based 2016 revision of the ACR diagnostic criteria for FMS, regardless of the final diagnosis previously made by the pain therapist. Results: Among the 280 patients who adhered to the 2016 ACR questionnaire, 20.3% displayed positive criteria for FMS diagnosis. The level of agreement between the FMS discharge diagnosis made by the pain clinician and the ACR 2016 criteria-positivity was moderate (kappa = 0.599, with moderate agreement set at a kappa value of 0.6). Only four patients (1.7%) diagnosed as suffering from FMS at discharge did not satisfy the minimal 2016 ACR diagnostic criteria. Conclusions: This prospective observational study confirmed the diagnostic challenge with FMS, as demonstrated by the moderate grade of agreement between the FMS diagnosis at discharge and the positivity for 2016 ACR criteria. In our opinion, the use of widely accepted diagnostic guidelines should be implemented in clinical scenarios and should become a common language among clinicians who evaluate and treat patients reporting widespread pain and FMS-suggestive symptoms. Further methodologically stronger studies will be necessary to validate our observation.

Psoriasis and Fibromyalgia: A Systematic Review

Psoriasis is a chronic inflammatory cutaneous condition characterized by several comorbidities, including musculoskeletal disorders. While the association with psoriatic arthritis has been widely addressed in literature, the aim of the present systematic review was to identify all available evidence on the relationship between psoriasis and fibromyalgia, a musculoskeletal syndrome primarily characterized by chronic widespread pain. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and MedLine and Web of Science (WOS) databases were searched for literature up to March 2023. After the removal of duplicate records, a total of 11 articles were deemed eligible for inclusion in a qualitative synthesis. Our results suggested that psoriatic patients had a higher prevalence of fibromyalgia (8-30%), with a very high impact on symptoms of psoriasis. Moreover, fibromyalgic patients had a slightly increased prevalence of psoriasis (2.2-6.7%) compared to the control groups. Finally, several studies demonstrated the substantial impact of fibromyalgia on psoriatic outcome measures in patients with concomitant psoriatic arthritis. In conclusion, available data support a potential interplay between psoriasis and fibromyalgia, but further research is encouraged in this area.

Implication of intestinal microbiota in the etiopathogenesis of fibromyalgia: A systematic review

Fibromyalgia (FM) is a highly prevalent chronic disease. About 4.7% of the world's population suffers from generalized pain and hypersensitivity, in addition to a wide range of physical and psychological symptoms. The etiopathogenesis of this disease is multifactorial, which makes its diagnosis and treatment challenging. Recently, the increase in the number of studies on microbiota has provided new data that can help to understand the onset and development of FM. An updated systematic review of the causes of FM has been carried out in this work. Particularly in the last decade, research has focused on the gut-brain axis, which has emerged as a crucial mechanism for microbiota-host crosstalk. In FM patients, quantitative imbalances of the intestinal microbiota (dysbiosis) and bacterial metabolites with differential relative abundance have been found, especially short-chain fatty acids and lipopolysaccharides. Furthermore, the microbiota has been found to indirectly influence host neurotransmitter mechanisms, mainly through the serotonin precursor, glutamate, and gamma-aminobutyric acid. Thus, all these mechanisms and their influence on the etiopathogenesis of FM are discussed in this review.

Home-Based Treatment for Chronic Pain Combining Neuromodulation, Computer-Assisted Training, and Telemonitoring in Patients With Breast Cancer: Protocol for a Rehabilitative Study

BACKGROUND

Chronic pain is a disabling symptom frequently reported in patients with breast cancer with a prevalence ranging from 25% to 60%, representing a major health issue. It has negative consequences on health status, causing psychological distress and affecting quality of life. Furthermore, the clinical management of chronic pain is often inadequate, and many patients do not benefit from the administration of pharmacological treatments. Alternative therapeutic options have been implemented to improve the psychophysical well-being of patients, including neuromodulation and complementary interventions.

OBJECTIVE

We aimed to investigate the effectiveness of a home care strategy combining computerized rehabilitation, transcranial direct current stimulation (tDCS), and remote telemonitoring via a web-based platform in patients with breast cancer suffering for chronic pain.

METHODS

A web-based structured survey aimed at monitoring chronic pain and its effect on psychological functions will be delivered to patients with breast cancer through social media and email. In total, 42 patients with breast cancer affected by chronic pain will be recruited during the medical screening visit. The patients will be randomly divided into 3 treatment groups that will carry out either tDCS only, exercise therapy only, or a combination of both over a 3-week period. All the treatments will be delivered at the patients' home through the use of a system including a tablet, wearable inertial sensors, and a tDCS programmable medical device. Using web-based questionnaires, the perception of pain (based on the pain self-efficacy questionnaire, visual analogue scale, pain catastrophizing scale, and brief pain inventory) and psychological variables (based on the hospital and anxiety depression scale and 12-item short form survey) will be assessed at the beginning of treatment, 1 week after the start of treatment, at the end of treatment, 1 month after the start of treatment, and 3 months after the start of treatment. The system's usability (based on the mobile app rating scale and system usability scale) and its involvement in the decision-making process (based on the 9-item shared decision-making questionnaire) will be also evaluated. Finally, at the end of the treatment, a digital focus group will be conducted with the 42 patients to explore their unexpressed needs and preferences concerning treatment.

RESULTS

The study project is scheduled to start in June 2023, and it is expected to be completed by August 2025.

CONCLUSIONS

We expect that the combination of tDCS and telemedicine programs will reduce pain perceived by patients with breast cancer and improve their mental well-being more effectively than single interventions. Furthermore, we assume that this home-based approach will also improve patients' participation in routine clinical care, reducing disparities in accessing health care processes. This integrated home care strategy could be useful for patients with breast cancer who cannot find relief from chronic pain with pharmacological treatments or for those who have limited access to care due to poor mobility or geographical barriers, thus increasing the patients' empowerment and reducing health care costs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/49508.

Aetiological Understanding of Fibromyalgia, Irritable Bowel Syndrome, Chronic Fatigue Syndrome and Classificatory Analogues: A Systematic Umbrella Review

Background

This umbrella review systematically assesses the variety and relative dominance of current aetiological views within the scientific literature for the three most investigated symptom-defined functional somatic syndromes (FSS) and their classificatory analogues within psychiatry and psychology.

Method

An umbrella review of narrative and systematic reviews with and without meta-analyses based on a search of electronic databases (PubMed, Web of Science, Embase, PsychINFO) was conducted. Eligible reviews were published in English, focused on research of any kind of aetiological factors in adults diagnosed with fibromyalgia syndrome (FMS), irritable bowel syndrome (IBS), chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME), and somatic symptom disorder (SSD)/somatoform disorder (SFD).

Results

We included 452 reviews (132 systematic reviews including meta-analyses, 133 systematic reviews, 197 narrative reviews), of which 132 (29%) focused on two or more of the investigated health conditions simultaneously. Across diagnoses, biological factors were addressed in 90% (k = 405), psychological in 33% (k = 150), social in 12% (k = 54), and healthcare factors in 5% (k = 23) of the reviews. The methodological quality of the included systematic reviews (k = 255) was low (low/critically low: 41% [k = 104]; moderate: 49% [k = 126]; high quality: 10% [k = 25]). The high-quality systematic reviews suggest that deficient conditioned pain modulation, genetic factors, changes in the immune, endocrinological, gastrointestinal, cardiovascular, and nervous system, and psychosocial factors such as sexual abuse and pain catastrophizing increase the risk for FSS.

Conclusion

Only very few systematic reviews have used comprehensive, biopsychosocial disease models to guide the selection of aetiological factors in FSS research. Future research should strive for higher scientific standards and broaden its perspective on these health conditions.

Exploring attitudes of healthcare professionals towards those with fibromyalgia: A Q-methodological approach

Fibromyalgia remains a difficult condition to diagnose and treat. Research suggests that this leads to frustrating experiences for service users and healthcare professionals. This has led to negative healthcare professional attitudes towards working with those with fibromyalgia. The research to date reports negative attitudes and predominantly investigates attitudes of primary care physicians. This study explores the attitudes of a range of healthcare professionals towards those diagnosed with fibromyalgia. Using Q-methodology, 27 healthcare professionals completed a sorting task and questionnaire to prioritise statements relating to a range of different attitudes towards service users. All participants significantly loaded onto three factors that explained a total of 64% of the data variance. Factor 1 reflected the attitude 'Service users with fibromyalgia are no different to other service users and I enjoy working with them'. Factor 2 reflected the attitude 'Service users with fibromyalgia are inaccurate informants of their own condition due to lack of understanding of their condition and are not likely to engage in treatments'. Factor 3 reflected the attitude 'Service users with fibromyalgia are trustworthy with a lot of clinical problems [but I lack confidence in specialist skills to support them]'. Contrary to the current literature, there appears to be supportive attitudes from healthcare professionals towards service users diagnosed with fibromyalgia. Increased specialised training, clinical exposure to working with fibromyalgia and reflective practice spaces were identified as elements that could improve healthcare professional attitudes.

Improvement of Pain Symptoms in Musculoskeletal Diseases After Multimodal Spa Therapy in the Austrian Gastein Valley-A Study Based on Longitudinal Registry Data

Objective: The study aim was to investigate the course of pain in rest and motion in seven different rheumatic diseases (RMD), prior and after multimodal spa therapy including low-dose radon treatment and at 3-, 6-; and 9-month follow up. Methods: Complete data from the radon indication registry including information on 561 subjects with RMD were analysed to explore the association of timepoint of measurement with pain in rest and motion. For this purpose, linear regression models adjusted for RMD-type, age, sex and body mass index (BMI) were applied. Results: The mean age of the sample was 55 years, the average body mass index was 26.8, and 275 subjects were women. Pain scores were significantly improved at all-time points compared to baseline. Pain courses were different for each RMD with the largest improvement seen in fibromyalgia. Conclusion: Timing spa facility visits according to RMD-specific pain courses may result in sustained pain reduction.

Fibromyalgia Rapid Screening Tool (FiRST): Arabic Translation and Cross-Cultural Adaptation and Validation

Background: Fibromyalgia (FM), a complex neurological disorder, has multiple consequences for the patient. To diagnose patients, healthcare practitioners use multiple diagnostic questionnaires. However, Arabic translated or validated tools are lacking. This study aimed to translate and validate the Fibromyalgia Rapid Screening Tool (FiRST) into the Arabic language. Methods: Forward and backward translations of the FiRST were conducted by two Arabic translators and two English-certified translators. The survey was piloted (n = 5) and subjected to cognitive interviews and psychometric analysis. Patients were recruited from a university hospital in Riyadh and an FM support group in Saudi Arabia. The internal consistency, factor analysis, and test–retest correlations were evaluated. Results: This study included 46 patients. The stepwise translation process resulted in minor edits related to the use of synonyms to the survey items. The translated survey had a good internal consistency and test–retest correlation, with a Cronbach’s alpha of 0.7 and Pearson’s correlation coefficient of 0.79 (p-value < 0.001), respectively. The survey was factorable into two themes: generalized symptoms and more specific sensations. Conclusions: The Arabic FiRST is a simple, valid, and reliable tool to diagnose patients with FM in different settings.

The frequency of psychiatric disorder co-morbidities in patients with fibromyalgia: A cross-sectional study in Iran

AIM

This study aimed to investigate psychiatric disorders in Iranian female patients with fibromyalgia (FM).

DESIGN

Female patients, newly diagnosed with FM, were interviewed by a psychiatrist for psychiatric assessments during a 2-year period.

METHODS

The diagnosis of the psychiatric disorders was based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

In total, 159 patients with the mean age of 42.15 ± 9.89 were recruited in this study. Over 92% of the cases were also diagnosed with at least one type of psychiatric disorder. Sleep disorders (SDs, 90.57%), mood disorders (MDs, 52.83%), personality disorders (PDs, 40.25%) and anxiety disorders (ADs, 16.98%) were the most prevalent diagnoses among these patients. The logistic regression results correspondingly showed that suffering from Cluster-B PDs was associated with a higher prevalence rate of somatic symptom disorders (SSDs), with a p-value of 0.019 and an odds ratio (OR) of 2.7.

Pharmacological Interaction of Quercetin Derivatives of Tilia americana and Clinical Drugs in Experimental Fibromyalgia

Fibromyalgia (FM) is a pain syndrome characterized by chronic widespread pain and CNS comorbidities. Tilia americana var. mexicana is a medicinal species used to treat anxiety, insomnia, and acute or chronic pain. However, its spectrum of analgesic efficacy for dysfunctional pain is unknown. To investigate a possible therapeutic alternative for FM-type pain, an aqueous Tilia extract (TE) and its flavonoid fraction (FF) containing rutin and isoquercitrin were evaluated alone and/or combined with clinical drugs (tramadol—TRA and pramipexol—PRA) using the reserpine-induced FM model in rats. Chromatographic analysis allowed the characterization of flavonoids, while a histological analysis confirmed their presence in the brain. TE (10–100 mg/kg, i.p.) and FF (10–300 mg/kg, i.p.) produced significant and dose-dependent antihyperalgesic and antiallodynic effects equivalent to TRA (3–10 mg/kg, i.p.) or PRA (0.01–1 mg/kg, s.c.). Nevertheless, the combination of FF + TRA or FF + PRA resulted in an antagonistic interaction by possible competitive action on the serotonin transporter or µ-opioid and D₂ receptors, respectively, according to the in silico analysis. Flavonoids were identified in cerebral regions because of their self-epifluorescence. In conclusion, Tilia possesses potential properties to relieve FM-type pain. However, the consumption of this plant or flavonoids such as quercetin derivatives in combination with analgesic drugs might reduce their individual benefits.

Sensory Perception Quotient Reveals Visual, Scent and Touch Sensory Hypersensitivity in People With Fibromyalgia Syndrome

Background

Environmental sensitivity is commonly reported by people with fibromyalgia syndrome. People living with fibromyalgia syndrome frequently report hypersensitivity to noxious and non-noxious sensations. To date, there has been little empirical validation of sensory disturbance to non-noxious triggers. Environmental sensitivity is used as a diagnostic feature only in Bennet's alternative criteria for diagnosis of fibromyalgia, where it was ranked the second most important of the components for diagnosis, after number of pain sites. The aim of this study was to use a validated sensory measure to determine if people with fibromyalgia have greater sensory disturbances compared to people with other chronic pain conditions.

Methods

This study used the Sensory Perception Quotient (SPQ) 92 question survey in adults with chronic pain conditions. A fibromyalgia group (n = 135) and a non-fibromyalgia chronic pain control group (n = 45) were recruited. All participants completed the SPQ as a self-report measure of sensory processing. In addition to the original SPQ scoring method, the Revised Scoring of the Sensory Perception Quotient (SPQ-RS) method was used to investigate self-reported hypersensitivity and hyposensitivity and the vision, hearing, taste, touch, and smell subscales. Chi-squared tests were used for categorical variables and Mann Whitney U, or Kruskal-Wallis H test were used to compare groups.

Results

The fibromyalgia group reported significantly more sensitivity compared to the control group (p = 0.030). The fibromyalgia group reported significantly greater hypersensitivity (p = 0.038), but not more hyposensitivity (p = 0.723) compared to controls. The average fibromyalgia SPQ score (92.64 ± 23.33) was similar to that previously reported for adults with autism (92.95 ± 26.61). However, whereas adults with autism had broad range hypersensitivity, the fibromyalgia group reported significantly more hypersensitivity compared to the control group, but the range was restricted to vision (p = 0.033), smell (p = 0.049) and touch (0.040).

Conclusions

These findings demonstrate greater sensory hypersensitivity in people with fibromyalgia compared to people with other chronic pain disorders. Greater hypersensitivity was restricted to touch, vision, and smell, all of which have previously been demonstrated to crosstalk with nociception.

Dance for chronic pain conditions: A Systematic Review

OBJECTIVES

Globally, 20-25% of people will experience chronic pain in their lifetime. Dance is a physical activity with psychosocial benefits which may positively impact pain. This review aimed to investigate the effect of dance interventions on the experience of pain, by quantitative measures and qualitative themes.

METHODS

Seven major databases were searched from inception to January 2021. Two independent reviewers screened articles at each stage. Qualitative and quantitative studies were included if the dance interventions lasted over 6 weeks, participants reported pain longer than 3 months, and pain was an outcome of the study. All articles were critically appraised using appropriate Joanna Briggs Institute tools and data were collated using results-based convergent synthesis.

RESULTS

From 23,628 articles 34 full papers were included, with a total of 1254 participants (75.2% female). Studies predominantly investigated individuals with Fibromyalgia (26%) and generalised chronic pain (14%), with aerobic dance (20.7%) and Biodanza (20.7%) the most common dance genres investigated. Overall, 74% of studies noted either reduced pain through quantitative pain measures or qualitative themes of improved pain experience (88% for chronic primary pain and 80% for chronic secondary musculoskeletal pain).

DISCUSSION

There were positive effects of dance on chronic primary and secondary musculoskeletal pain across diverse populations. A variety of study designs and interventions noted improved pain measures and themes around pain coping and acceptance, with all dance therapies showing improvements, particularly when performed for 60-150 minutes duration weekly. Dance should be considered as an effective adjunct in the management of chronic pain.

Patient Perspectives of Disease Activity, Medications and Substance Use in People with Fibromyalgia

Objective

To explore patient perspectives on disease activity and experiences, as well as medication use of a group of fibromyalgia patients attending a single-centre rheumatology public hospital outpatient setting.

Methods

Patients seen in fibromyalgia clinic within a rheumatology unit from July 2016 to December 2019 were posted a voluntary survey with questionnaires pertaining to patient-reported measures of disease impact (FIQR), fatigue (MFI-20) and psychological distress (K10). A free-text section allowed description of disease impact. Patients were also asked to record medication use and comorbidities, which were then compared to the electronic medical records (EMR) of the overall clinic cohort.

Results

Forty-five patients responded to the survey (43/45, 95.6% female; mean age 56.5 years). Respondents had generally severe fibromyalgia (mean FIQR 67.1/100, range 23.7–92.8), moderate psychological distress (mean K10 27.5/50, range 14–45) and high fatigue (mean MFI 74.9/100, range 40–96). Free-text responses generated themes of pervasive disease impact and the necessity of adjusting life around unpredictable symptoms. Almost half reported opioid (21/45, 46.7%) and gabapentinoid (19/45, 42.2%) use. 16/41 (39%) use cannabinoids for their fibromyalgia symptoms. Comparing medication use with survey non-respondents (n=85), there was generally similar representation except for significantly greater NSAID use among survey respondents (33/45, 73.3% vs 22/85, 25.9%, p<0.001).

Conclusion

For patients living with fibromyalgia in this study, there were high levels of disease activity, psychological distress and fatigue. Patients described the need to accept disease-imposed limitations and life adjustments. Almost half reported opioid use, despite evidence suggesting poor efficacy and possible harm.

The autonomic aspects of the post-COVID19 syndrome

The SARS-CoV-2 outbreak, responsible for the widespread COVID-19, led to one of the most rogue pandemics in modern time, yet the major effects of the pandemic may still be ahead of us. SARS-CoV-2 had been found to possess autoimmune properties. Close to 20 distinct autoantibodies which target GPCR of the nervous system and renin-angiotensin system-related molecules were found significantly associated with the clinical severity of COVID-19. The new on-set of more than 10 various autoimmune disorders were documented as well. Additionally, clinical presentations of persisted symptoms were triggered in numerous recently recovered COVID-19 patients, which led to the formulation of the novel term “post-COVID19 syndrome”. Manifestations related to post-COVID-19 syndrome exist among approximately 50–80% of symptomatic COVID-19 patients who recovered, and among patients reported more than 50 different long-term effects of the SARS-CoV-2 infection. Many of the common symptoms of the post-COVID19 syndrome are not explained by the virus-related injury alone. Similarly to chronic fatigue syndrome and fibromyalgia, autoimmune-mediated autonomic nervous system dysfunction may play a significant part in the pathogenesis of such symptoms, including chronic fatigue, cognitive impairment, mood related disorders, and numerous more. Importantly, therapeutic options such as immunomodulatory and immunosuppressive therapy may favor some post-COVID19 patients, while plasmapheresis and IVIG could be considered in severe cases. Nevertheless, as physical exercise has been found to stabilize the autonomic nervous system, exercise therapy might be a safer and more effective remedy for the post-COVID19 syndrome.

The Frequency of Fibromyalgia in Migraine Patients

BACKGROUND: Fibromyalgia (FM) is a prevailing debilitating ailment that has been described in patients with migraines in several investigations. AIM: The study aimed to investigate the frequency of FM in migraine patients and to study the characteristics of migraine patients with comorbid FM. METHODS: This case–control study was piloted in the Neurology Unit, Department of Medicine in Ibn Sina Teaching Hospital in Mosul, Iraq, between March and November 2020. One hundred consecutive patients with migraine and 100 healthy controls were included in this study. The sociodemographic and headache characteristics of the patients were recorded. RESULTS: The frequency of FM was statistically higher among participants with migraines (27%) when compared to the controls (5%). Migraine patients with FM had a substantially older mean age and a higher ratio of female gender than migraine patients without FM. FM was found to be more common in patients without versus with aura. Patients with comorbid FM had greater headache frequency (p = 0.0002), headache intensity (p = 0.007), and higher scores on the “Headache Impact Test (HIT-6)” (p = 0.0001). CONCLUSIONS: There is a high frequency of FM in patients with migraines. Patients with coexistent “FM” and “migraine” tended to have more depressive symptoms, greater headache intensity, headache frequency, and when compared to healthy people, they are more likely to have a significant headache-related disability.

Fibromyalgia in social media: content and quality of the information analysis of videos on the YouTube platform

To evaluate the fibromyalgia (FM) content in YouTube videos and verify if American College of Rheumatology (ACR) guidelines are being met. The videos were searched with the keyword "Fibromyalgia." Two independent researchers evaluated and coded specific characteristics of the videos. The popularity of the videos, the presentation properties, and content related to FM according to the ACR criteria were analyzed. Of the 200 videos included, the majority were presented by health professionals, 61.5%. Most videos covered more than one subject, 38.5%. The videos presented by health professionals were the most viewed. Following the ACR guidelines, 38% defined FM, 24% described the etiology, 19.5% described the diagnostic criteria and 52% presented recommended management strategies. The results indicate that users mainly watch videos published by health professionals. Most of the published videos do not follow the information recommended by the ACR guidelines. Therefore, videos should be interpreted with caution, not being the most appropriate resource for health education for patients with FM. Most of the videos published on YouTube about FM do not meet the ACR guidelines for FM.

Effects of allopurinol on pain and anxiety in fibromyalgia patients: a pilot study

Allopurinol is a potent inhibitor of the enzyme xanthine oxidase used in the treatment of hyperuricemia and gout. The aim of this pilot study was to investigate the effects of allopurinol on pain and anxiety in women displaying fibromyalgia refractory to conventional therapy. This prospective case series enrolled 12 women with previous diagnosis of fibromyalgia refractory to conventional therapy. Patients received an add-on therapy with oral allopurinol 300 mg twice daily for 30 days. Patients were submitted to evaluation for pain and anxiety scores before treatment, 15 and 30 days thereafter. This pilot study has demonstrated that oral administration of allopurinol 300 mg twice daily caused a significant reduction on pain scores up to 30 days of treatment in women with fibromyalgia. No effect was observed regarding anxiety scores. Randomized clinical trials are warranted and should further investigate allopurinol and more selective purine derivatives in the management of acute or chronic pain conditions.

Metabolomic and proteomic characterization of sng and pain phenotypes in fibromyalgia

BACKGROUND

Fibromyalgia (FM) is characterized by chronic widespread pain. Its pathophysiological mechanisms remain poorly understood, and effective diagnosis and treatments are lacking. This study aimed to identify significantly changed biosignatures in FM and propose a novel classification for FM based on pain and soreness (sng) symptoms.

METHODS

Urine and serum samples from 30 FM patients and 25 controls underwent metabolomic and proteomic profiling.

RESULTS

Compared with controls, FM patients showed significant differential expression of three metabolites in urine and five metabolites and eight proteins in serum. Of them, DETP, 4-guanidinobutanoic acid, SM(d18:1/18:0), PC(20:1(11Z)/18:0), S100A7, SERPINB3, galectin-7 and LYVE1 were first reported as potential biomarkers for FM. Furthermore, lactate, 2-methylmaleate and cotinine in urine and lactate, SM(d18:1/25:1), SM(d18:1/26:1) and prostaglandin D2 (PGD2) and PCYOX1, ITIH4, PFN1, LRG1, C8G, C8A, CP, CDH5 and DBH in serum could differentiate pain- (PG) and sng-dominant groups (SG). Lactate, 2-methylmaleate, cotinine, PCYOX1, ITIH4, PFN1 and DBH have a higher level in SG. SM(d18:1/25:1), SM(d18:1/26:1), PGD2, LRG1, C8G, C8A, CP and CDH5 in SG are lower than PG. The omics results indicated disordered free radical scavenging, and lipid and amino acid metabolism networks and resulting NF-κB-dependent cytokine generation in FM. Lactate level was altered simultaneously in urine and serum and significantly higher in sng-dominant patients than others.

CONCLUSIONS

In this study, we identified potential biomarkers from FM patients. The selected biomarkers could discriminate sng and pain phenotypes in FM patients. These results could help elucidate the underlying pathological mechanisms for more effective diagnosis and therapy for FM.

Diagnostic Challenges and Management of Fibromyalgia

The World Health Organization regards chronic pain to be a public health concern. In clinical medicine, fibromyalgia (FM) is the most prevalent chronic widespread pain disease. In terms of impairment, consumption of health and social resources, and impact on primary and speciality care systems, it has reached worrisome proportions. This disease is frequently managed by primary care providers. Because of its intricacy, fibromyalgia diagnosis and treatment can be difficult. Fibromyalgia is a controversial condition. It might appear ill-defined in comparison to other pain conditions, with no clear knowledge of pathophysiology and hence no particular targeted therapy. This invariably sparks debates and challenges. There is no obvious cut-off point that distinguishes FM from non-FM. The diagnosis of fibromyalgia has been complicated by several factors, including patients' health-seeking behaviour, symptom identification, and physician labelling of the disease. Fibromyalgia is currently considered a centralized pain condition, according to research that has improved our understanding of its etiopathology. A multidisciplinary strategy combining pharmacological and non-pharmacological therapies based on a biopsychosocial paradigm can result in effective therapy. Cultural and psychosocial variables appear to be a recent development in fibromyalgia, and they appear to have a larger influence on physician diagnosis than severe symptom levels in FM patients. Although physicians rely on FM criteria as the only way to classify FM patients in research and clinical settings, some crucial elements of the diagnostic challenge of fibromyalgia remain unsolved - invalidation, psychosocial variables, and diverse illness manifestation are some examples. Beyond the existing constructional scores, physicians' judgment gained in real communicative contexts with patients, appears to be the only dependable route for a more accurate diagnosis for fibromyalgia. We have performed an exhaustive review of the literature using the keywords "Fibromyalgia", "challenges" and "diagnosis" in PubMed and Google Scholar indexes up to September 2021. This article aims to examine the causes, diagnosis, and current treatment protocols of FM, as well as discuss some continuing debates and diagnostic challenges which physicians face in accurately diagnosing fibromyalgia.

Veterans' Insights on Heart Rate Variability Biofeedback to Treat Fibromyalgia-Related Pain

BACKGROUND

Heart rate variability biofeedback (HRVB) is a self-management strategy that guides individuals to breathe at a designated resonance frequency of the cardiovascular system. Resonant breathing may reduce FM-related symptoms as well as improve physical functioning and quality of life. Although prior research recommends HRVB for chronic pain, we found no studies testing the feasibility for individuals with FM regarding protocol adherence or acceptability of the treatment.

AIMS

To determine the feasibility and acceptability of a heart rate variability biofeedback (HRVB) protocol in a group of Veterans with fibromyalgia (FM).

DESIGN

A multi-method feasibility and acceptability study.

SETTINGS

A Veterans Health outpatient pain medicine clinic.

PARTICIPANTS/SUBJECTS

We enrolled 7 women and 3 men between the ages of 33 and 68 years with a diagnosis of FM.

METHODS

We enrolled 10 veterans in a HRVB study using a recommended protocol to treat FM. Veterans were given a HRVB device, emWave2, and instructed to practice at home twice daily for 20 minutes per session. Following a 7-week intervention period, we conducted an end of study focus group. We used content analysis to develop themes to determine the feasibility of engaging in HRVB and adhering to the intervention protocol, as well as insights of veterans about the intervention.

RESULTS

Three common themes emerged: intervention implementation, protocol adherence, and self-awareness.

CONCLUSIONS

Results of this study suggest difficulties operating the emWave2 and scheduling challenges interfered with HRVB implementation. However, veterans reported self-awareness of the benefits of HRVB, positive physiological effects, and improved psychological effects. Future studies require a larger sample size to provide a deeper insight.

Allopurinol for fibromyalgia pain in adults: A randomized controlled trial

BACKGROUND

Allopurinol is a potent inhibitor of the enzyme xanthine oxidase used in the treatment of hyperuricemia and gout. Because it is well known that purines exert multiple affects on pain transmission, we hypothesized that the inhibition of xanthine oxidase by allopurinol could be a valid strategy to treat pain in humans. This study aimed to compare the analgesic efficacy of oral allopurinol versus placebo as an adjuvant therapy in patients displaying fibromyalgia.

METHODS

This randomized, double-blinded, placebo-controlled study included 60 women with the diagnosis of fibromyalgia. Patients were randomly assigned to receive either oral allopurinol 300 mg (n = 31) or placebo (n = 29) twice daily during 30 days. The patients were submitted to evaluation for pain sensitivity, anxiety, depression, and functional status before treatment, and 15 and 30 days thereafter.

RESULTS

Oral administration of allopurinol 300 mg twice daily was ineffective in improving pain scores measured by several tools up to 30 days of treatment (P > 0.05). Additionally, no significant effects of allopurinol over anxiety, depressive symptoms, and functional status of fibromyalgia patients were observed in the present study.

CONCLUSIONS

Although previous findings indicated that allopurinol could present intrinsic analgesic effects in both animals and humans, this study showed no benefit of the use of oral allopurinol as an adjuvant strategy during 30 days in women displaying fibromyalgia. However, considering previous promising results, new prospective studies are still valid to further investigate allopurinol and more selective purine derivatives in the management of pain syndromes.

Prevalence of Fibromyalgia in Pharmacy Professionals and Students: A Cross-Sectional Study

Background

The prevalence of fibromyalgia (FM) in pharmacy students and professionals is unknown. This study identifies the prevalence of FM in pharmacy students and professionals using three screening tools and factors associated with its development. Furthermore, this study assesses the level of agreement between the tools and the magnitude of the participants’ responses to each item in the screening tools.

Methods

This was a cross-sectional survey conducted on members of the Saudi Pharmaceutical Society using an online questionnaire. The participants were asked to fill three questionnaires: the London Fibromyalgia Epidemiology Study Screening Questionnaire (LFESSQ), Fibromyalgia Rapid Screening Tool (FiRST) and Fibromyalgia Survey Questionnaire (FSQ). Demographic data and factors affecting FM in pharmacy students and professionals were collected and analysed.

Results

Two hundred ninety-three participants accessed the survey: most of them were Saudi (93.5%) and females (78.8%) with a mean (standard deviation) age of 29 (8) years. Furthermore, 52% of the participants had generalised body pain. The prevalence of FM using FiRST, LFESSQ Pain, LFESSQ with fatigue criteria and FSQ was 27.1%, 34.9%, 50.9% and 68.4%, respectively. Fleiss’ kappa coefficient revealed fair agreement among all three screening tools (kappa = 0.350; p < 0.001). After adjusting for significant variables, the resulting adjusted odds ratio of developing FM was 4.86 in people working for 41–45 h weekly (95% confidence interval [CI], 1.32–17.84; p = 0.017), 5.16 in people who frequently wake up during sleep (95% CI, 1.85–14.40; p = 0.002) and 12.99 in people with sleep apnea or other sleeping disorders (95% CI, 2.07–81.68; p = 0.006).

Conclusion

FM was prevalent among pharmacy students and professionals and was much more than data reported on the general population or other healthcare workers. Traditional factors along with higher working hours were identified as significant variables.

Specialized, pro-resolving mediators as potential therapeutic agents for alleviating fibromyalgia symptomatology

OBJECTIVE

To present a hypothesis on a novel strategy in the treatment of fibromyalgia (FM).

DESIGN

A narrative review.

SETTING

FM as a disease remains a challenging concept for numerous reasons, including undefined etiopathogenesis, unclear triggers and unsuccessful treatment modalities. We hypothesize that the inflammatome, the entire set of molecules involved in inflammation, acting as a common pathophysiological instrument of gut dysbiosis, sarcopenia, and neuroinflammation, is one of the major mechanisms underlying FM pathogenesis. In this setup, dysbiosis is proposed as the primary trigger of the inflammatome, sarcopenia as the peripheral nociceptive source, and neuroinflammation as the central mechanism of pain sensitization, transmission and symptomatology of FM. Whereas neuroinflammation is highly-considered as a critical deleterious element in FM pathogenesis, the presumed pathogenic roles of sarcopenia and systemic inflammation remain controversial. Nevertheless, sarcopenia-associated processes and dysbiosis have been recently detected in FM individuals. The prevalence of pro-inflammatory factors in the cerebrospinal fluid and blood has been repeatedly observed in FM individuals, supporting an idea on the role of inflammatome in FM pathogenesis. As such, failed inflammation resolution might be one of the underlying pathogenic mechanisms. In accordance, the application of specialized, inflammation pro-resolving mediators (SPMs) seems most suitable for this goal.

CONCLUSIONS

The capability of various SPMs to prevent and attenuate pain has been repeatedly demonstrated in laboratory animal experiments. Since SPMs suppress inflammation in a manner that does not compromise host defense, they could be attractive and safe candidates for the alleviation of FM symptomatology, probably in combination with anti-dysbiotic medicine.

The Impact of Tinnitus on Fibromyalgia

Objective

Fibromyalgia (FM) is a disorder characterized by chronic diffuse pain and enhanced pain response to stimuli and is caused by central sensitization Tinnitus also is related to central sensitization So we investigated the impact of tinnitus on FM.

Methods

We included 22 FM patients with tinnitus and 25 FM patients without tinnitus We assessed a range of symptoms using the Widespread Pain Index; Symptom Severity Score scale; Visual Analogue Scale of pain; and the Korean versions of the Fibromyalgia Impact Questionnaire (FIQ), the Insomnia Severity Index, and the Short-form Health Survey (SF-36) Information about the severity of tinnitus in FM patients was evaluated using the Korean version of the Tinnitus Handicap Questionnaire (THQ-K).

Results

There were significant differences between the group that had mild tinnitus (THQ<38) and the group that had moderate-to-severe tinnitus (THQ≥38) for FIQ score (p=0025) and for the physical functioning (p=0003), social functioning (p=0035), and mental health (p=0017) components of the SF-36 Also, after dividing patients into 2 groups according to insomnia severity, significant differences were observed in FIQ score (p=0002) and in body pain (p=0001), general health (p=0008), vitality (p=0003), social functioning (p=0003), role limitation due to emotional condition (p=0001), and mental health (p<0001) components of the SF-36.

Conclusion

The FM patients with severe tinnitus had more functional impairments and lower quality of life than those with mild tinnitus Severe insomnia also was accompanied by worse health status and lower quality of life.

Okada Purifying Therapy in combination with duloxetine vs. duloxetine alone in patients with TMD and fibromyalgia: a randomized clinical study

OBJECTIVES

This randomized study was aimed at evaluating the additional analgesic effect of Okada Purifying Therapy (OPT) when administered in combination with duloxetine in patients with Temporomandibular Disorders (TMDs) and Fibromyalgia (FM).

METHODS

Patients with TMDs visited at Department of Oral and Maxillofacial Sciences, Sapienza University of Rome who were diagnosed with FM were selected for the study. The final sample was composed of 31 patients: 15 patients were treated only with duloxetine (Group I) and 16 patients underwent also OPT treatment (Group II), for eight weeks. Craniomandibular index, total tenderness score, Brief Pain Inventory Modified Short Form, Fibromyalgia Impact Questionnaire, Beck Depression Inventory and State and Trait Anxiety Inventory-1 were assessed at the beginning (T0), during the course (T1) and after therapy (T2). Descriptive and inferential statistics were performed.

RESULTS

In all the data analyzed, both groups showed an improvement in particular between T0 and T1. No statistically significant differences were observed between the two groups during the trial, except for the interaction between treatment and time as to the ability of walking at the BPI-I (F=7.57, p=0.002). No side effects due to the duloxetine were recorded in group II compared to group I.

CONCLUSION

The additional complementary treatment (OPT) did not appear to give the patients with TMDs and FM any further benefit but it might improve pharmacological tolerability of the traditional medication.

Suicidal Ideation Profiles in Patients with Fibromyalgia Using Transdiagnostic Psychological and Fibromyalgia-Associated Variables

Several studies have emphasized the heterogeneity of fibromyalgia patients. Furthermore, fibromyalgia patients are considered a high-risk suicide group. The ideation-to-action framework proposes a set of transdiagnostic psychological factors involved in the development of suicidal ideation. The present study aims to explore the existence of different subgroups according to their vulnerability to suicidal ideation through these transdiagnostic psychological variables and a set of variables typically associated with fibromyalgia. In this cross-sectional study, 151 fibromyalgia patients were assessed through the Revised Fibromyalgia Impact Questionnaire, Beck Depression Inventory-II, Plutchik Suicide Risk Scale, Interpersonal Needs Questionnaire, Defeat Scale, Entrapment Scale, Psychache Scale, and Beck Hopelessness Scale. A K-means cluster analysis identified two clusters, one (45.70%) according to a low vulnerability, and a second (54.30%) with a high vulnerability to suicidal ideation. These clusters showed statistically significant differences in suicidal ideation and suicide risk. However, no differences were observed in most socio-demographic variables. In conclusion, fibromyalgia patients who present a clinical condition characterized by a moderate-high degree of physical dysfunction, overall disease impact and intensity of fibromyalgia-associated symptoms, along with a high degree of perceived burdensomeness, thwarted belongingness, defeat, entrapment, psychological pain and hopelessness, form a homogeneous group at high risk for suicidal ideation.

Burden of Illness Due to Fibromyalgia in a Neurology Clinic

Background  Fibromyalgia (FM) is a common disorder in general population and it causes an increased patient load in hospitals and specialty clinics. FM attendance will be high in clinics dealing with neuropathic pain and other pain syndromes. Though prevalence of FM has been studied in community and pain clinics in other countries, it has not so far been studied in India. So, a study is relevant and hence it was planned in neurology clinic of a teaching government hospital. At present, they are treated mainly by nonsteroidal anti-inflammatory drugs (NSAIDs) which are public health hazard. Methods  Using 2016 revision of 2010/2011 American College of Rheumatology criteria of FM, patients were screened in neurology OPD. Proportion and clinical profile were noted. Study was continued for 6 months till the sample size was met. Results  A total of 2,300 patients were screened. Two hundred and ninety-eight FM patients were identified among them. Proportion was 12.96%. Delayed diagnosis of more than a year occurred in 55%. Only 29.2% were treated, but none was offered cognitive behavioral therapy (CBT) before. NSAIDs for pain were given for 51.01%. Conclusion  Proportion of FM detected is considerable. Affection of homemakers and manual laborers, delayed diagnosis, coexisting comorbid illness, and treatment of pain with NSAIDs are causes of concern. Clinicians should be sensitized to clinical profile and criteria of FM. Patients should be diagnosed and treated by CBT at the earliest and NSAIDs should be avoided as far as possible.

Effects of 24-Week Exergame Intervention on the Gray Matter Volume of Different Brain Structures in Women with Fibromyalgia: A Single-Blind, Randomized Controlled Trial

BACKGROUND

Exergame-induced changes in the volume of brain gray matter have not been studied in fibromyalgia (FM). This study evaluates the effects of a 24-week exergame-based intervention on the gray matter volume of different brain structures in patients with FM through magnetic resonance imaging (MRI).

METHODS

A total of 25 FM patients completed 24 weeks of intervention program, and another 25 FM patients did not receive any intervention. T1-weighted MRI was used to assess brain volume, and FreeSurfer software was used to segment the brain regions.

RESULTS

No significant effects on gray matter volume of different structures and total gray matter were found.

CONCLUSIONS

FM patients did not show significant changes in gray matter brain volume between the control and experimental groups after 24 weeks. FM patients showed significant relationships between peak oxygen consumption (pVO2) and the left and right regions of the hippocampus and the left and right regions of the amygdala.

What happens to muscles in fibromyalgia syndrome

BACKGROUND

The main somatic symptoms of fibromyalgia syndrome (FMS) are chronic musculoskeletal pain, stiffness, and fatigue, all of which are related to the muscle system and its functioning.

AIMS

The aim of this study was to evaluate whether the asymptomatic upper and lower extremity muscles evaluated using ultrasonography (US) were different from healthy controls in both newly diagnosed and established FMS and to assess whether muscle measurements were related to fatigue and disease severity, as well as quality of life.

METHODS

This study was conducted on 152 subjects (102 patients and 50 healthy controls) as a cross-sectional controlled trial. Real-time imaging of cross-sectional thickness (CST) (for deltoid, biceps brachii, triceps brachii, forearm flexor, tibialis anterior, and gastrocnemius medialis), and cross-sectional areas (CSAs) (quadriceps femoris (QF)) measurements were performed using US. Fatigue and disease severity as well as quality of life scales were given to all participants.

RESULTS

In both patient groups, decreased QF muscle CSA was significantly correlated with increased fatigue severity and decreased overall quality of life and energy levels. Moreover, in patients with established disease, there was a significant correlation between the decrease in QF muscle CSA and increased social isolation and between the decrease in biceps brachii muscle CST and increased fatigue severity.

CONCLUSIONS

Whether in newly diagnosed or established disease, muscle measurement values and quality of life parameters were significantly decreased in patients with FMS compared with healthy controls.

Heart Rate Variability Biofeedback to Treat Fibromyalgia: An Integrative Literature Review

OBJECTIVES

Fibromyalgia (FM) is associated with debilitating pain and a reduced heart rate variability (HRV), reflecting decreased emotional adaptability and resistance to stress. Common pharmacological treatments are ineffective, and opioids are highly addictive and cause an estimated 15,000 overdose deaths per year. Effective recommendations include patient-centered interventions like physical activity, cognitive behavioral therapy, and biofeedback. Heart rate variability biofeedback (HRVB) may be effective in improving HRV, thus increasing stress resistance and emotional adaptability and reducing pain.

DESIGN

This integrative literature review was conducted to examine the relationship between HRVB and FM-related chronic pain using the Theory of Symptom Self-Management and to identify available HRVB technology.

DATA SOURCES

We searched PubMed, EBSCOhost, and Google Scholar electronic databases for relevant publications. Manuscripts were selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses strategy, and study quality was assessed using the Critical Appraisal Skills Programme guidelines. The relationship between HRVB and FM was analyzed and evaluated based on the methodological framework proposed by Whittemore and Knafl.

REVIEW/ANALYSIS METHODS

We reviewed 22 articles and included six in this review. Five reported HRVB as a treatment for chronic pain, and one for FM pain.

RESULTS

Overall, the articles in this review support the claim that HRVB is related to decreased pain. The researchers evaluated five HRVB programs, three on handheld devices and two on desktop computers.

CONCLUSIONS

The reviewed studies had methodological flaws. However, HRVB is a promising treatment for chronic pain. Larger, randomized controlled studies are needed to thoroughly evaluate the relationship between HRVB and FM pain.

Fibromyalgia Increases the Risk of Surgical Complications Following Total Knee Arthroplasty: A Nationwide Database Study

BACKGROUND

Although fibromyalgia is a common comorbidity with knee osteoarthritis, the orthopedic literature on this population is limited. Therefore, the purpose of this study is to assess if fibromyalgia patients have a higher likelihood of developing surgical complications after total knee arthroplasty (TKA) than a matched control cohort.

METHODS

The Medicare Standard Analytical Files of the PearlDiver supercomputer was utilized to identify patients who underwent a TKA between 2005 and 2014. Patients were 1:1 propensity score matched based on the diagnosis of fibromyalgia, age, gender, and the Charlson Comorbidity Index, yielding a total of 305,510 patients. Odds ratios (ORs), 95% confidence intervals (95% CIs), and P-values (<.05) were calculated to examine the likelihood of developing any surgical complication, as well as specific surgical complications.

RESULTS

Compared to a matched cohort, fibromyalgia patients had increased odds of developing any surgical complication (OR 1.55, 95% CI 1.51-1.60, P < .001), such as bearing wear (OR 2.11, 95% CI 1.48-3.01, P < .0001) and periprosthetic osteolysis (OR 1.71, 95% CI 1.10-2.66, P = .018). Furthermore, these patients had significantly greater odds of developing revision of tibial insert (OR 1.5, 95% CI 1.14-2.05, P = .046), mechanical loosening (OR 1.34, 95% CI 1.26-1.53, P < .0001), infection/inflammation (OR 1.33, 95% CI 1.26-1.14, P < .0001), dislocations (OR 1.33, 95% CI 1.21-1.47, P < .0001), as well as other complications (OR 1.74, 95% CI 1.68-1.80, P < .0001).

CONCLUSION

This analysis of over 300,000 patients identified that fibromyalgia patients can have a greater risk of developing certain surgical complications after TKA. Therefore, fibromyalgia patients must be made aware of the increased postoperative risks and surgeons should consider enhanced preoperative medical and surgical optimization.

The Turkish Society of Physical Medicine and Rehabilitation (TSPMR) guideline recommendations for the management of fibromyalgia syndrome

In the present study, we aimed to establish a national guideline including recommendations of the Turkish Society of Physical Medicine and Rehabilitation (TSPMR) for the management of Fibromyalgia (FM) syndrome. This guideline was built mainly in accordance with the 2017 revised European League Against Rheumatism (EULAR) guideline recommendations for the management of FM. A total of 46 physical medicine and rehabilitation specialists were included. A systematic literature search was carried out in PubMed, Scopus, Cochrane, and Turkish Medical Index between 2000 and 2018. Evidence levels of the publications were evaluated, and the levels of recommendation were graded on the basis of relevant levels of evidence, The Assessment of Level of Agreement with opinions by task force members was established using the electronic Delphi technique. Recommendations were assessed by two Delphi rounds and 7 of 10 points were deemed necessary for agreement. The treatment recommendations were classified as non-pharmacological therapies (6 main items), pharmacological treatments (10 items), and complementary therapies (5 items). These were recommended in the light of evidence, depending on the clinical and general condition of each patient. This is the first national TSPMR guideline recommendations for the management of FM in Turkey. We believe our effort would be helpful for the physicians who are interested in the treatment of FM.

Opinion paper: the role of work in the management of medically unexplained physical symptoms

OBJECTIVES

Patients with medically unexplained physical symptoms suffer from chronic fatigue and/or pain in combination with a variety of other symptoms. A flexible, biopsychosocial approach is needed for diagnostic screening and global management. It is crucial to involve the direct patient environment, including family, friends, colleagues as well as health providers, evaluation, and reintegration sector. The aim of this paper is to review the importance of work in the management of medically unexplained physical symptoms.

METHODS

In this paper, different actors involved explain their views and handling concerning work in the management of MUPS.

RESULTS

Symptom severity and lack of understanding from the environment can negatively impact on earning an independent income from labor for years. Work, whether or not paid, is however, an important life domain with positive effects on physical, psychological, and social well-being. Therefore, health actors are pivotal in starting the professional reintegration process as soon as possible and should discuss this item from the early stage onward. Support services can be consulted in mutual interaction as required. A case manager, acting as a central intermediator within this multidisciplinary approach, may promote effective communication and coordination between the patients and their surrounding actors.

CONCLUSION

The professional reintegration process should start as soon as possible within the management of medically unexplained physical symptoms. As such, the care sector, the evaluation sector, and the professional integration sector should collaborate and effectively communicate with each other.

A nationwide comparative analysis of medical complications in fibromyalgia patients following total knee arthroplasty

Background

Fibromyalgia is a disease primarily characterized by chronic widespread pain and associated symptoms of fatigue, mild cognitive impairment, and sleep disturbance. The condition affects 1% to 6% of the general population in the United States and is more commonly diagnosed in women (2:1 ratio). There is evidence to suggest that fibromyalgia patients may be more at risk of postoperative complications. The rate of total knee arthroplasties (TKAs) performed worldwide is escalating and thus it is expected that the proportion of fibromyalgia patients under orthopaedic care will increase accordingly. However, the literature on TKA outcomes in this subpopulation is limited. We assessed whether fibromyalgia patients have a higher likelihood of developing medical complications compared to a matched cohort of non-fibromyalgia patients following TKA. Specifically, we assessed the likelihood of developing (I) any medical complication and (II) specific medical complications.

Methods

Using the Medicare Standard Analytical Files of the PearlDiver supercomputer, patients who underwent a TKA between 2005 and 2014 were queried. Propensity score matching was used to match patients with and without fibromyalgia in a 1:1 ratio based on age, sex, and the Charlson Comorbidity Index (CCI). A total cohort of 305,510 patients (female =242,198; male =59,810; and unknown =3,502) with (n=152,755) and without fibromyalgia (n=152,755) was identified. Statistical analyses involved the calculation of odds ratios, 95% confidence intervals (95% CI), and P values (<0.05) were utilized to evaluate the occurrence of any and specific medical complications.

Results

Compared to a matched cohort of non-fibromyalgia patients, fibromyalgia patients had increased odds of developing any medical complication following TKA [odds ratio (OR): 1.95, 95% CI: 1.86-2.04, P<0.001]. Furthermore, compared to a matched cohort, these patients had significantly greater odds of developing urinary tract infections (OR: 2.08, 95% CI: 1.89-2.29, P<0.001), acute post-hemorrhagic anemia (OR: 1.56, 95% CI: 1.41-1.73, P<0.001), thoracic or lumbosacral neuritis or radiculitis (OR: 5.85, 95% CI: 4.82-7.10, P<0.001), shortness of breath (OR: 3.02, 95% CI: 2.60-3.51, P<0.001), other diseases of lung not elsewhere classified (OR: 2.32, 95% CI: 1.77-3.03, P<0.001), other respiratory abnormalities (OR: 3.49, 95% CI: 2.87-4.24, P<0.001), transfusion of packed cells (OR: 1.69, 95% CI: 1.36-2.10, P<0.001), pneumonia (OR: 2.17, 95% CI: 1.71-2.76, P<0.001), acute kidney failure (OR: 1.27, 95% CI: 1.02-1.57, P<0.05), and neuralgia neuritis and radiculitis (OR: 5.29, 95% CI: 3.53-7.92, P<0.001).

Conclusions

As the number of fibromyalgia patients under orthopaedic care is expected to rise, it is imperative that the TKA outcomes of these patients are tracked in order to provide optimal patient care. This study identified fibromyalgia as a risk factor for a number of medical complications following TKA. Orthopaedic surgeons must be aware of the potential for poor TKA outcomes among these patients and should provide them with appropriate medical care and pre-operative guidance.

Milnacipran: serotonin-noradrenaline reuptake inhibitor approved for fibromyalgia may be a useful antidepressant

OBJECTIVE

Milnacipran is a serotonin noradrenaline reuptake inhibitor (SNRI) approved for treatment of fibromyalgia in Australia, but is used for depression in Europe and elsewhere. This paper will briefly review milnacipran and its utility in psychiatry for the treatment of depression.

CONCLUSION

Milnacipran is a dual reuptake inhibitor of noradrenaline and serotonin, with greater effect on noradrenaline than serotonin, in contrast to the related drugs venlafaxine, desvenlafaxine and duloxetine. Rapidly absorbed irrespective of food, milnacipran has a half-life of approximately 8 hours, reaches steady state in 2 days and is excreted renally. Milnacipran helps a minority of patients with fibromyalgia by reducing pain and fatigue. It is also an effective antidepressant with efficacy comparable to venlafaxine and duloxetine, and a side effect profile characteristic of SNRIs. The dose range is 50-200 mg, in divided doses. Milnacipran may be useful for patients with depression and pain, and endogenous depression characterised by anergia, psychomotor retardation and hypersomnia. Caution is necessary in the presence of heart disease, hypertension, renal impairment, epilepsy, glaucoma, bipolar disorder, and bleeding tendency. Milnacipran is likely to be a useful late antidepressant option in treatment-resistant patients, as well as those with chronic pain, anergia and hypersomnia.

Fibromyalgia: is it a neuropathic pain?

Fibromyalgia is a chronic pain syndrome of unclear pathophysiology. It is believed to be a dysfunction of the CNS, but no definite structural lesion has been identified so far. Despite a number of changes in the diagnostic criteria, diagnosis remains a clinical one. Since the 2011 revision of the IASP definition of neuropathic pain, fibromyalgia has been excluded from the diagnosis of neuropathic pain. More recent studies however found newer evidences of pathophysiology including small fiber neuropathy in patients with fibromyalgia. This may challenge the existing consensus and have implications on future diagnosis and management of this condition.