Review of pharmacological therapies in fibromyalgia syndrome

The efficacy, acceptability and safety of acceptance and commitment therapy for fibromyalgia - a systematic review and meta-analysis

Background

Fibromyalgia (FM) is a chronic pain disorder characterised by widespread pain, fatigue and cognitive symptoms. Acceptance and commitment therapy (ACT) aims to improve psychological flexibility and has been found to be beneficial in treating chronic pain; however, there are few studies evaluating its efficacy in treating FM.

Aim

This systematic review and meta-analysis evaluated the efficacy of acceptance and commitment therapy in patients with fibromyalgia.

Methods

PubMed, Embase and PsychInfo databases were searched. Randomised Controlled Trials (RCTs) were eligible for inclusion if participants had FM, and the intervention was based on the ACT framework/model, and not combined with any other active therapy; any non-ACT control was accepted. A meta-analysis was performed, with the primary outcomes pain acceptance (chronic pain acceptance questionnaire, CPAQ), health-related quality of life (fibromyalgia impact questionnaire, FIQ), attrition rate and frequency of adverse events, and the secondary outcomes pain intensity, disability, depression, anxiety, and fatigue.

Results

Six RCTs, with a total of 384, mostly-female, participants were included, with ACT being delivered online, in a group setting, or one-to-one. ACT was superior to controls in improving FIQ score at post-intervention (SMD -1.05, 95% CI -2.02, -0.09) and follow-up (SMD -1.43, 95% CI -2.17, -0.69) and CPAQ post-intervention (SMD 1.05, 95% CI 0.61, 1.49) and at follow-up (SMD 0.95, 95% CI 0.40, 1.49). Attrition was below 20% in 4/6 studies and no adverse events were reported as attributable to ACT. All secondary outcomes showed large-to-moderate pooled effect estimates post-intervention, indicating improvement in anxiety, depression, pain and disability. Fatigue also improved, with a large negative effect.

Conclusions

The results suggest ACT improved outcomes in patients with FM: there was an overall improvement in all outcomes post-intervention, with most maintained at follow-up. This review was, however, limited by the small body of evidence and differing methodologies of included studies.

A systematic review of EEG neurofeedback in fibromyalgia to treat psychological variables, chronic pain and general health

This paper is the first up-to-date review of the various EEG-neurofeedback treatments for fibromyalgia patients and their psychological, physiological and general health consequences. Searches were made of the PubMed, PsycNet, Google Scholar and Scopus databases according to PRISMA guidelines for empirical peer-reviewed articles on EEG-neurofeedback treatment of fibromyalgia, yielding a final selection of 17 studies that met the inclusion criteria: (1) published articles and doctoral theses; (2) conducted between 2000 and 2022; (3) reporting empirical and quantitative data. These articles show that there is a wide range of protocols with different designs and procedures to treat fibromyalgia using EEG-neurofeedback techniques. The main symptoms that showed improvement were anxiety, depression, pain, general health and symptom severity, whilst the most commonly used method was traditional EEG neurofeedback based on a sensorimotor rhythm protocol. It may be concluded from the review that the lack of consistency and uniqueness of the protocols makes it very difficult to generalise results, despite the individual improvements identified. This review provides instructions and information that could guide future research and clinical practise, with the data extracted helping to gain a deeper understanding of the state of the art and the needs of the technique for this population group.

Hyperbaric oxygen therapy vs. pharmacological intervention in adults with fibromyalgia related to childhood sexual abuse: prospective, randomized clinical trial

Fibromyalgia syndrome (FMS) is a chronic pain syndrome characterized by disruptions in pain processing within the central nervous system. It exhibits a high prevalence among patients with a history of traumatic experiences, notably childhood sexual abuse (CSA). This study compared the efficacy of hyperbaric oxygen therapy (HBOT) to the current pharmacological standard of care for individuals suffering from CSA-related FMS. Forty-eight participants diagnosed with FMS and a history of CSA were randomly assigned to either the HBOT group (60 sessions of 100% oxygen at 2 ATA for 90 min, with air breaks every 5 min) or the medication (MED) group (FDA-approved medications, Pregabalin and Duloxetine). The primary endpoint was the Fibromyalgia impact questionnaire (FIQ) score, while secondary endpoints encompassed emotional status and daily functioning questionnaires, as well as pain thresholds and conditioned pain modulation tests. Brain activity was evaluated through single photon emission computed tomography (SPECT). Results revealed a significant group-by-time interaction for the FIQ score favoring HBOT over MED (p < 0.001), with a large effect size (Cohen's d = - 1.27). Similar findings were observed in emotional symptoms and functional measures. SPECT imaging demonstrated an increase in activity in pre-frontal and temporal brain areas, which correlated with symptoms improvement. In conclusion, HBOT exhibited superior benefits over medications in terms of physical, functional, and emotional improvements among FMS patients with a history of CSA. This associated with increased activity in pre-frontal and temporal brain areas, highlighting the neuroplasticity effect of HBOT.

Trends in U.S. Medical Cannabis Registrations, Authorizing Clinicians, and Reasons for Use From 2020 to 2022

BACKGROUND

As medical cannabis availability increases, up-to-date trends in medical cannabis licensure can inform clinical policy and care.

OBJECTIVE

To describe current trends in medical cannabis licensure in the United States.

DESIGN

Ecological study with repeated measures.

SETTING

Publicly available state registry data from 2020 to 2022.

PARTICIPANTS

People with medical cannabis licenses and clinicians authorizing cannabis licenses in the United States.

MEASUREMENTS

Total patient volume and prevalence per 10 000 persons in the total population, symptoms or conditions qualifying patients for licensure (that is, patient-reported qualifying conditions), and number of authorizing clinicians.

RESULTS

In 2022, of 39 jurisdictions allowing medical cannabis use, 34 reported patient numbers, 19 reported patient-reported qualifying conditions, and 29 reported authorizing clinician numbers. Enrolled patients increased 33.3% from 2020 (3 099 096) to 2022 (4 132 098), with a corresponding 23.0% increase in the population prevalence of patients (175.0 per 10 000 in 2020 to 215.2 per 10 000 in 2022). However, 13 of 15 jurisdictions with nonmedical adult-use laws had decreased enrollment from 2020 to 2022. The proportion of patient-reported qualifying conditions with substantial or conclusive evidence of therapeutic value decreased from 70.4% (2020) to 53.8% (2022). Chronic pain was the most common patient-reported qualifying condition in 2022 (48.4%), followed by anxiety (14.2%) and posttraumatic stress disorder (13.0%). In 2022, the United States had 29 500 authorizing clinicians (7.7 per 1000 patients), 53.5% of whom were physicians. The most common specialties reported were internal or family medicine (63.4%), physical medicine and rehabilitation (9.1%), and anesthesia or pain (7.9%).

LIMITATION

Missing data (for example, from California), descriptive analysis, lack of information on individual use patterns, and changing evidence base.

CONCLUSION

Enrollment in medical cannabis programs increased overall but generally decreased in jurisdictions with nonmedical adult-use laws. Use for conditions or symptoms without a strong evidence basis continues to increase. Given these trends, more research is needed to better understand the risks and benefits of medical cannabis.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse of the National Institutes of Health.

A Cross-Sectional Survey Study of Cannabis Use for Fibromyalgia Symptom Management

OBJECTIVE

To assess the use of cannabis as a symptom management strategy for patients with fibromyalgia.

PATIENTS AND METHODS

An electronic, cross-sectional survey was conducted among patients diagnosed with fibromyalgia and treated in Integrative Medicine & Health at Mayo Clinic, Rochester, Minnesota. The survey was constructed with the Symptom Management Theory tool and was sent anonymously via web-based software to patients with a diagnosis of fibromyalgia.

RESULTS

Of 5234 patients with fibromyalgia sent the online survey, 1336 (25.5%) responded and met the inclusion criteria. Survey respondents had a median age of 48 (Q1-Q3: 37.5-58.0) years, and most identified as female. Nearly half of respondents (49.5%, n=661) reported cannabis use since their fibromyalgia diagnosis. The most common symptoms for which respondents reported using cannabis were pain (98.9%, n=654); fatigue (96.2%; n=636); stress, anxiety, or depression (93.9%; n=621); and insomnia (93.6%; n=619). Improvement in pain symptoms with cannabis use was reported by 82.0% (n=536). Most cannabis-using respondents reported that cannabis also improved symptoms of stress, anxiety, and depression and of insomnia.

CONCLUSION

Considering that cannabis is a popular choice among patients for managing fibromyalgia symptoms, clinicians should have adequate knowledge of cannabis when discussing therapeutic options for fibromyalgia with their patients.

Do FIQR Severity Categories and Symptoms, Differentiate Between Continuous, Intermittent and Non-Opioid Users in the Treatment of Fibromyalgia?

BACKGROUND

Many fibromyalgia patients utilize opioids to treat symptoms. It is important to better understand nuances regarding this treatment option and any stigma associated with this treatment modality.

AIM

This study: (1) assessed the prevalence of opioid use among continuous, intermittent, and non-opioid users in fibromyalgia patients; (2) determined whether the Revised Fibromyalgia Impact Questionnaire (FIQR) was useful in distinguishing opioid use and symptom burden; and (3) assessed whether fibromyalgia patients encountered stigma and/or invalidation.

DESIGN

A cross-sectional, observational study of 1,105 participants' responses to validated fibromyalgia and invalidation scales and demographic questions.

METHODS

The study employed online survey methodology.

RESULTS

A total of 45% of patients reported utilizing opioids (27% continuous, 18% intermittent, 55% non-users). FIQR disease categories (mild to most severe) strongly distinguished between opioid and non-opioid users with 59% of users falling in the most severe category and 68% of non-users falling in mild disease category (p < .0001). Interestingly, intermittent users were similar to non-users on FIQR severity (65.9 versus 65.7; p <0.60, 0-100) while continuous users reported greater severity than the former (73.9, p < .0001). Continuous users particularly reported more problems with daily activities (p < .0001), being overwhelmed (p < .0001), and being unable to accomplish goals (p < .0001). Stigma related to being 'drug seeking' and being 'judged'. Invalidation was infrequent.

CONCLUSIONS

Opioid use is common in fibromyalgia and increases monotonically with FIQR severity. Multidisciplinary approaches which help patients perform daily activities, decrease feelings of overwhelm, accomplish goals, and reduce stigma may be beneficial.

Effect of Hypnosis on Pain, Anxiety, and Quality of Life in Female Patients with Fibromyalgia: Prospective, Randomized, Controlled Study

This prospective, randomized, controlled study aimed to investigate the effects of standardized adjuvant hypnosis on pain, depression, anxiety, aerobic exercise practices, quality of life, and disease impact score in female patients with fibromyalgia syndrome (FMS). This study included 47 female patients with FMS who had been under treatment for at least six months. The hypnosis group (n = 24) received a total of three hypnosis sessions and was taught to patients' self-hypnosis. The patients in this group practiced self-hypnosis for six months. During this period, all patients also continued their medical treatment. The Visual Analogue Scale (VAS) was used to determine the intensity of pain. At the end of the six-month follow-up period, it was determined that the patients of FMS with hypnosis therapy had lower pain intensity, FMS symptoms, depression, and anxiety symptoms, and better well-being than those in the control group (p < .05). Standardized hypnosis is an effective method in reducing pain, depression and anxiety symptoms and improving quality of life in patients with FMS.

A Behavioral Characteristics Observational Measure of Youth with Somatic Symptom Disorder during Physical Rehabilitation

BACKGROUND

Youth with somatic symptom disorder (SSD) present unique behavioral characteristics.

AIMS

To develop and examine the psychometric properties of an observational measure of behavioral characteristics for youth with SSD (the Somatization Behavioral Characteristics Questionnaire, SBCQ).

METHODS

N = 80 youth with SSD and 31 with non-SSD impairments participated in this study (age = 13.91 ± 2.72, 14 ± 3.21, respectively; females: n = 61, 14, respectively). Symptom intensity (Children's Somatization Inventory-24; CSI-24), functional disability (Six-Minute Walk Test, walking rate of perceived exertion), and the SBCQ were assessed. SBCQ reliability and validity were examined.

RESULTS

SBCQ had acceptable reliability in both groups (Cronbach's α > 0.7). Exploratory factor analysis in the SSD group revealed a three-cluster solution. Significant associations were found between the SBCQ, CSI-24, and functional disability. Both groups differed in the prevalence of all SBCQ behaviors. The greatest differences were in the mismatch between etiology and clinical presentation, and in the exhibited lack of trust in the therapist and "la belle indifference". Receiver operating characteristic analysis showed that the SBCQ has moderate accuracy in discriminating between the two groups (area under the curve = 0.80). Sensitivity and specificity were 82.5% and 73.3%, respectively.

CONCLUSIONS

The SBCQ is psychometrically sound. Findings may aid in developing sensitive assessment tools for SSD and continuing education for therapists.

Acidosis-related pain and its receptors as targets for chronic pain

Sensing acidosis is an important somatosensory function in responses to ischemia, inflammation, and metabolic alteration. Accumulating evidence has shown that acidosis is an effective factor for pain induction and that many intractable chronic pain diseases are associated with acidosis signaling. Various receptors have been known to detect extracellular acidosis and all express in the somatosensory neurons, such as acid sensing ion channels (ASIC), transient receptor potential (TRP) channels and proton-sensing G-protein coupled receptors. In addition to sense noxious acidic stimulation, these proton-sensing receptors also play a vital role in pain processing. For example, ASICs and TRPs are involved in not only nociceptive activation but also anti-nociceptive effects as well as some other non-nociceptive pathways. Herein, we review recent progress in probing the roles of proton-sensing receptors in preclinical pain research and their clinical relevance. We also propose a new concept of sngception to address the specific somatosensory function of acid sensation. This review aims to connect these acid-sensing receptors with basic pain research and clinical pain diseases, thus helping with better understanding the acid-related pain pathogenesis and their potential therapeutic roles via the mechanism of acid-mediated antinociception.

Chronic pain in Chile: first prevalence report of noncancer chronic pain, fibromyalgia, and neuropathic pain and its associated factors

ABSTRACT

Although we know chronic pain (CP) affects approximately 30% of people in developed countries, data from Latin America are scarce. Moreover, prevalence of specific CP conditions, such as chronic noncancer pain (CNCP), fibromyalgia (FM), and neuropathic pain (NP), is unknown. To estimate them in Chile, we prospectively enrolled 1945 participants (61.4% women and 38.6% men), aged 38 to 74 years, from an agricultural town who answered a Pain Questionnaire, the Fibromyalgia Survey Questionnaire, and Douleur Neuropathique 4 (DN4) to identify CNCP, FM, and NP, respectively. The estimated prevalence of CNCP was 34.7% (95% CI 32.6; 36.8), with an average duration of 32.3 months (SD ± 56.3), producing deep impairments in daily activities, sleep, and mood. We estimated a prevalence of 3.3% for FM (95% CI 2.5; 4.1) and 12% for NP (95% CI 10.6; 13.4). Female sex, fewer school years, and depressive symptoms were associated with FM and NP, whereas diabetes was only associated with NP. We standardized the results from our sample against the whole Chilean population and found no significant difference to our crude estimates. This is in line with studies from developed countries, highlighting the idea that despite genetic and environmental differences, the conditions that confer risk to CNCP remain stable.

The role of cannabis in treatment-resistant fibromyalgia women

BACKGROUND

Fibromyalgia is a complex pain-focused syndrome. Previous studies showed that Cannabis is efficacious in promoting sleep, deepening and lengthening the sleep cycle, and good pain relief (compared with the SSRIs and SNRIs).

PURPOSE

This study aimed to use the World Health Organization Quality of Life Bref questionnaire (WhoQoL-bref) to characterize the impact of Cannabis Treatment initiation on the quality of life in women suffering from treatment-resistant fibromyalgia.

METHODS

A prospective cohort study involving 30 women aged 18-70 years old diagnosed with fibromyalgia, exhausted pharmacological fibromyalgia treatment, and started Cannabis treatment. Pregnant women were excluded. WhoQoL-bref was filled before Cannabis treatment initiation and 1 month following treatment.

RESULTS

Women's average age was 46 years (±5), with a poor general quality of life (1.47 ± 0.63), poor general health (1.47 ± 0.78), pain and discomfort, and dependence on medication (3.77 ± 1.3 and 3.07 ± 1.74, respectively) prior to Cannabis intervention. Cannabis treatment for 30 days showed a marked improvement in general quality of life (1.97 scores, p < 0.01), general health (1.83, p < 0.01), physical health (1.5, p < 0.01), and psychological domain (1.3, p < 0.01). Financial resources and home environment were not influenced by cannabis treatment (p = 0.07, p = 0.31, respectively).

CONCLUSION

Results suggest a potentially significant role of Cannabis in treatment-resistant Fibromyalgia women. Early Cannabis treatment may result in a beneficial short-term effect on the quality of life through its influence on pain, sleep, and physical and psychological domains. Further studies are still indicated to understand this potential and its long-term beneficial impact.

Emotion regulation and the salience network: a hypothetical integrative model of fibromyalgia

Fibromyalgia is characterized by widespread pain, fatigue, sleep disturbances and other symptoms, and has a substantial socioeconomic impact. Current biomedical and psychosocial treatments are unsatisfactory for many patients, and treatment progress has been hindered by the lack of a clear understanding of the pathogenesis of fibromyalgia. We present here a model of fibromyalgia that integrates current psychosocial and neurophysiological observations. We propose that an imbalance in emotion regulation, reflected by an overactive 'threat' system and underactive 'soothing' system, might keep the 'salience network' (also known as the midcingulo-insular network) in continuous alert mode, and this hyperactivation, in conjunction with other mechanisms, contributes to fibromyalgia. This proposed integrative model, which we term the Fibromyalgia: Imbalance of Threat and Soothing Systems (FITSS) model, should be viewed as a working hypothesis with limited supporting evidence available. We hope, however, that this model will shed new light on existing psychosocial and biological observations, and inspire future research to address the many gaps in our knowledge about fibromyalgia, ultimately stimulating the development of novel therapeutic interventions.

Predictors of Pain Reduction Among Fibromyalgia Patients Using Medical Cannabis: A Long-Term Prospective Cohort Study

OBJECTIVE

Many patients with fibromyalgia (FM) report using cannabis as a strategy to improve pain. Given that pain often co-occurs with symptoms of anxiety and depression (i.e., negative affect) and sleep problems among patients with FM, improvements in these symptoms might indirectly contribute to reductions in pain intensity following cannabis use. The main objective of the study was to examine whether changes in pain intensity following initiation of medical cannabis among patients with FM could be attributed to concurrent changes (i.e., reductions) in negative affect and sleep problems.

METHODS

This was a 12-month prospective cohort study among patients with FM (n = 323) initiating medical cannabis under the care of physicians. Patients were assessed at baseline, and follow-up assessment visits occurred every 3 months after initiation of medical cannabis. Patients' levels of pain intensity, negative affect, and sleep problems were assessed across all visits.

RESULTS

Multilevel mediation analyses indicated that reductions in patients' levels of pain intensity were partly explained by concurrent reductions in sleep problems and negative affect (both P < 0.001). This remained significant even when accounting for patients' baseline characteristics or changes in medical cannabis directives over time (all P > 0.05).

CONCLUSION

Our findings provide preliminary insight into the potential mechanisms of action underlying pain reductions among patients with FM who are using medical cannabis. Given the high attrition rate (i.e., 75%) observed in the present study at 12 months, our findings cannot be generalized to all patients with FM who are using medical cannabis.

U.S. Trends in Registration for Medical Cannabis and Reasons for Use From 2016 to 2020 : An Observational Study

BACKGROUND

Cannabis policy liberalization has increased cannabis availability for medical or recreational purposes. Up-to-date trends in medical cannabis licensure can inform clinical policy and care.

OBJECTIVE

To describe recent trends in medical cannabis licensure in the United States.

DESIGN

Ecological study with repeated measures.

SETTING

State registry data via state reports and data requests on medical cannabis licensure from 2016 to 2020.

PARTICIPANTS

Medical cannabis patients (persons with medical cannabis licenses) in the United States.

MEASUREMENTS

Total patient volume, patients per 10 000 of total population, and patient-reported qualifying conditions (that is, symptoms or conditions qualifying patients for licensure)-including whether these symptoms align with current therapeutic evidence of cannabis-cannabinoid efficacy.

RESULTS

In 2020, 26 states and Washington, DC reported patient numbers, and 19 states reported patient-reported qualifying conditions. Total enrolled patients increased approximately 4.5-fold from 678 408 in 2016 to 2 974 433 in 2020. Patients per 10 000 total population generally increased from 2016 to 2020, most dramatically in Oklahoma (927.1 patients per 10 000 population). However, enrollment increased in states without recreational legalization (that is, medical-only states), whereas enrollment decreased in 5 of 7 with recreational legalization (that is, recreational states). In 2020, 68.2% of patient-reported qualifying conditions had substantial or conclusive evidence of therapeutic value versus 84.6% in 2016. Chronic pain was the most common patient-reported qualifying condition in 2020 (60.6%), followed by posttraumatic stress disorder (10.6%).

LIMITATION

Missing state data; lack of rationale for discontinuing medical cannabis licensure.

CONCLUSION

Enrollment in medical cannabis programs approximately increased 4.5-fold from 2016 to 2020, although enrollment decreased in recreational states. Use for conditions or symptoms without a strong evidence basis increased from 15.4% (2016) to 31.8% (2020). Thoughtful regulatory and clinical strategies are needed to effectively manage this rapidly changing landscape.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse of the National Institutes of Health.

Dietary Supplements for Pain Relief in Patients with Fibromyalgia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Pain is the most frequently encountered symptom by patients with fibromyalgia (FM). Dietary supplements (DSs) in particular have a proven impact as a possible adjunctive therapy for symptom management in FM. However, there is currently no conclusive review outlining the evidence for DSs in pain management in FM. This study aims to assess currently available studies evaluating the use of DSs for pain relief in FM. Randomized controlled trials regarding the use of DSs on adult FM patients were included for evidence synthesis. Study results indicated that DSs significantly relieved pain in FM (SMD 1.23; 95% CI 0.02-2.43, P = 0.046) but did not improve quality of life (QoL) (SMD 0.73; 95% CI -0.07-1.53, P = 0.075) in the data. Adverse events of DSs varied from mild to severe, with the most common being gastrointestinal symptoms and androgenic side effects in 5.7% and 3.9% of patients, respectively. More well-designed RCTs are required in the future. The protocol for this review has been published on PROSPERO (CRD42020149941).

Effectiveness of a group intervention using pain neuroscience education and exercise in women with fibromyalgia: a pragmatic controlled study in primary care

BACKGROUND

Very positive effects have been described in the application of pain neuroscience education (PNE) to chronic pain and migraine. However, there are few data on the applicability of this therapeutic approach in actual clinical practice in a primary care (PC) setting. The aim of this study was to explore the efficacy in fibromyalgia (FM) of an intervention based on PNE and exercise compared to treatment as usual (TAU).

METHODS

Pragmatic nonrandomised controlled trial set in 5 healthcare centres and one physiotherapy centre in PC. Fifty-three women with FM (2010 American College of Rheumatology Diagnostic Criteria for Fibromyalgia) were studied, 35 in the intervention group (IG) and 18 in the control group (CG). The women in the IG were interviewed individually and then received 6 weekly sessions plus one review session (1 month later): those in the CG received their TAU. The subject assignation to the CG or the IG was determined according to their availability to attend the sessions. They all filled in several questionnaires (prior to and 1 year after the intervention) to evaluate the impact of FM in their daily lives, catastrophism, anxiety and depression, severity and impact of pain in daily personal performance and functional capacity.

RESULTS

The reductions (improvements) in the scores of all tests (baseline-final) were greater in the IG (p < 0.05) when adjusted for age and baseline values, with moderate or high effect size. After 1 year, 20% (CI - 1 to 42%) more women in the IG, compared to the CG, had a FIQ score < 39 (mild functional impairment). 17/38 (49%) women in the IG no longer met FM criteria at the end of follow-up.

CONCLUSIONS

An intervention based on PNE and exercise in patients with FM is feasible and seems effective in PC.

TRIAL REGISTRATION

The study was retrospectively registered at ClinicalTrials.gov (Trial Registration NCT04539171 ), on 04/09/2020.

Therapeutic Approaches to Nociplastic Pain Based on Findings in the Reserpine-Induced Fibromyalgia-Like Animal Model

Nociplastic pain, the third category of chronic pain, has emerged as a serious medical issue. Due to its significant negative influences on patients and society, high prevalence, and lack of sufficiently effective treatments, more efficacious therapies are required. This review highlights the potential therapeutic approaches identified in studies that used reserpine-induced myalgia (RIM) animal model that exhibits nociplastic pain-associated phenotypes. These studies have revealed that biological processes including the chronic reduction of monoamines, increase of oxidative/nitrosative stresses and inflammatory mediators, upregulation of pronociceptive neurotransmitters and their receptors, increase of trophic factors, enhancement of the apoptotic pathway, sensory nerve sensitization, and activation of immune cells in central and/or peripheral regions, underly the nociplastic pain-associated phenotypes in RIM animal model. Potential therapeutic approaches to nociplastic pain, i.e., 1) functional modification of specific molecules which expression is distinctly altered following monoamine reduction, 2) targeting the molecules which are responsible for other major categories of chronic pain (i.e., chronic inflammatory pain and neuropathic pain), 3) supplementation of nutrition to correct the disrupted nutritional balance, 4) improvement of physical constitution by natural substances, and 5) nonpharmacological interventions, have been identified. Significance Statement Studies in RIM animal model have revealed the pathologies that occur after the chronic reduction of monoamines and identified potential therapeutic approaches to nociplastic pain. Translation of their analgesic efficacy from RIM animal model to patients remains an issue to be addressed. Successful translation would lead to better therapies for nociplastic pain.

Fibromyalgia syndrome: epidemiology, diagnosis and treatment

Fibromyalgia syndrome (FMS) profoundly impacts patients' quality of life with its symptoms and clinical signs. Fibromyalgia syndrome impairs daily living activities, reduces work efficiency and raises health-related costs. Although the prevalence rates vary depending on geographical location and diagnostic criteria, it is a common disorder worldwide. Females have a higher prevalence of fibromyalgia syndrome, with varied rates, and there is an increase in prevalence rates with age. Although its etiopathogenesis has not been fully elucidated, various hypotheses have been proposed that central sensitization is at the core of the process. Fibromyalgia syndrome diagnostic approaches have advanced significantly over time, moving away from pain assessments alone and emphasizing multiple clinical signs of FMS. This condition has raised physicians' and researchers' awareness of non-pain symptoms. Considering the complicated etiopathogenesis of fibromyalgia syndrome, diverse pathways connected with symptoms, and multiple clinical presentations, it becomes clear that drug and non-drug treatments should be chosen in combination.

Does Low Grade Systemic Inflammation Have a Role in Chronic Pain?

One of the major clinical manifestations of peripheral neuropathy, either resulting from trauma or diseases, is chronic pain. While it significantly impacts patients’ quality of life, the underlying mechanisms remain elusive, and treatment is not satisfactory. Systemic chronic inflammation (SCI) that we are referring to in this perspective is a state of low-grade, persistent, non-infective inflammation, being found in many physiological and pathological conditions. Distinct from acute inflammation, which is a protective process fighting against intruders, SCI might have harmful effects. It has been associated with many chronic non-communicable diseases. We hypothesize that SCI could be a predisposing and/or precipitating factor in the development of chronic pain, as well as associated comorbidities. We reviewed evidence from human clinical studies indicating the coexistence of SCI with various types of chronic pain. We also collated existing data about the sources of SCI and who could have it, showing that those individuals or patients having SCI usually have higher prevalence of chronic pain and psychological comorbidities. We thus elaborate on the need for further research in the connection between SCI and chronic pain. Several hypotheses have been proposed to explain these complex interactions.

Pain neuroscience education combined with usual treatment for fibromyalgia syndrome: A randomized controlled trial

AIM

The aim of this study was to investigate the effectiveness of pain neuroscience education (PNE) in addition to usual treatment in patients with fibromyalgia syndrome.

METHODS

Forty patients were randomized into 2 groups. The experimental group underwent PNE sessions over 6 weeks in addition to pharmacological treatment, and the control group was given only pharmacological treatment. The primary outcome measure was functional status and the secondary outcome measures were widespread pain pressure threshold and kinesiophobia level. All assessments were conducted before the intervention and at the end of the 6th and 12th weeks by the same blinded researcher.

RESULTS

The intervention group had significantly greater improvement than the control group in terms of the mean total scores in the Fibromyalgia Impact Questionnaire (P = .001) and the Tampa Scale of Kinesiophobia (P = .001) with large effect sizes. The intervention group also had significantly greater improvement in the pain pressure threshold values of the cervical (P = .040), thoracic (P = .001), lumbar (P < .001), elbow (P = .005) and calf (P = .006) regions with moderate-to-large effect sizes.

CONCLUSION

This study showed that the addition of 6-week PNE sessions to pharmacological treatment was successful in improving functional status, widespread pain pressure threshold, and level of kinesiophobia in patients with fibromyalgia syndrome during a 12-week follow-up period.

Functional Magnetic Resonance Imaging Signal Variability Is Associated With Neuromodulation in Fibromyalgia

OBJECTIVES

Although primary motor cortex (M1) transcranial direct current stimulation (tDCS) has an analgesic effect in fibromyalgia (FM), its neural mechanism remains elusive. We investigated whether M1-tDCS modulates a regional temporal variability of blood-oxygenation-level-dependent (BOLD) signals, an indicator of the brain's flexibility and efficiency and if this change is associated with pain improvement.

MATERIALS AND METHODS

In a within-subjects cross-over design, 12 female FM patients underwent sham and active tDCS on five consecutive days, respectively. Each session was performed with an anode placed on the left M1 and a cathode on the contralateral supraorbital region. The subjects also participated in resting-state functional magnetic resonance imaging (fMRI) at baseline and after sham and active tDCS. We compared the BOLD signal variability (SD_BOLD ), defined as the standard deviation of the BOLD time-series, between the tDCS conditions. Baseline SD_BOLD was compared to 15 healthy female controls.

RESULTS

At baseline, FM patients showed reduced SD_BOLD in the ventromedial prefrontal cortex (vmPFC), lateral PFC, and anterior insula and increased SD_BOLD in the posterior insula compared to healthy controls. After active tDCS, compared to sham, we found an increased SD_BOLD in the left rostral anterior cingulate cortex (rACC), lateral PFC, and thalamus. After sham tDCS, compared to baseline, we found a decreased SD_BOLD in the dorsomedial PFC and posterior cingulate cortex/precuneus. Interestingly, after active tDCS compared to sham, pain reduction was correlated with an increased SD_BOLD in the rACC/vmPFC but with a decreased SD_BOLD in the posterior insula.

CONCLUSION

Our findings suggest that M1-tDCS might revert temporal variability of fMRI signals in the rACC/vmPFC and posterior insula linked to FM pain. Changes in neural variability would be part of the mechanisms underlying repetitive M1-tDCS analgesia in FM.

From human to mouse and back offers hope for patients with fibromyalgia

Fibromyalgia syndrome (FMS) is a highly prevalent, debilitating disease with heterogeneous symptoms of widespread pain and tenderness, fatigue, sleep disturbance, and impaired cognition. The cause of FMS is unknown, but the clinical constellation of symptoms and abnormalities in the neuroendocrine system, autonomic nervous system, and sleep implicate the nervous system in its pathogenesis. In this issue of the JCI, Goebel, Krock, et al. identified antibodies from patients with FMS that produce FMS in mice by binding to satellite glial cells (SGCs), which envelope sensory neurons. Because antibodies harvested from patients with FMS, but not controls, stimulated SGCs to an activated state known to mediate chronic pain by augmenting neuronal activity, these findings reveal a pivotal role for autoreactive IgG in the pathophysiology of FMS. These important findings pave a pathway to study mechanism-based experimental therapeutics targeting IgG titers or antibody binding to SGCs underlying the neuroimmune dysfunction of FMS.

Nortriptyline for pain in knee osteoarthritis: a double-blind randomised controlled trial in New Zealand general practice

BACKGROUND

Osteoarthritis (OA) of the knee is a common cause of chronic pain. Analgesics that are currently available have limited efficacy and may be poorly tolerated. Tricyclic antidepressants are used as analgesics for other chronic conditions, but they have not been evaluated as analgesics in OA.

AIM

To investigate the analgesic efficacy of nortriptyline in people with knee OA.

DESIGN AND SETTING

A two-arm, parallel-group, 1:1, double-blind, randomised, placebo-controlled trial in Christchurch, New Zealand.

METHOD

Participants were recruited from orthopaedic outpatient clinics, primary care, and through public advertising. Adults with knee OA and a pain score of ≥20 points on the 50-point Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain subscale were randomised to receive either nortriptyline or identical placebo for 14 weeks. The primary outcome was knee pain at 14 weeks measured using the WOMAC pain subscale. Secondary outcomes included: function; stiffness; non-steroidal anti-inflammatory drug, opioid, and/or paracetamol use; each participant's global assessment; and adverse effects at 14 weeks.

RESULTS

Of the 205 randomised participants, 201 (98.0%) completed follow-up at 14 weeks. The baseline-adjusted mean WOMAC pain subscale score at week 14 was 6.2 points lower (95% confidence interval = -0.26 to 12.6, P = 0.06) in the nortriptyline arm versus the placebo arm. Differences in secondary outcomes generally favoured the nortriptyline arm, but were small and unlikely to be clinically relevant. However, the following were all more commonly reported by participants taking nortriptyline than those taking a placebo: dry mouth (86.9% versus 51.0%, respectively, P<0.001), constipation (58.6% versus 30.4%, respectively, P<0.001), and sweating (31.3% versus 20.6%, respectively, P = 0.033).

CONCLUSION

This study suggests nortriptyline does not significantly reduce pain in people with knee OA. The adverse effect profile was as expected.

Psychoeducation for Patients with Fibromyalgia: A Systematic Review

This systematic review presents a brief and comprehensive summary of psychoeducational programs that have been designed for and tested in patients with fibromyalgia, with a focus on the features of the interventions and their main results regarding the patients’ clinical outcome. A bibliographical search performed in PubMed, Web of Science, Scopus, Cochrane Library and PsycInfo targeted publications, related to the terms “fibromyalgia” and “psychoeducation.” Information regarding the studies’ designs, age criterion, sample size, sex distribution and mean age of participants, and assessment time points, was recorded. If applicable, group distributions along with the main results regarding the patients’ clinical outcome, and features of the psychoeducational interventions were registered. Initial search eliciting 77 citations reduced to 10 relevant papers. Most of the reports come from two research projects from Spain (n = 6), worked with adult samples (n = 9), and most participants were females (88%–98%). Interventions reported significant improvements in the patients’ clinical outcomes in measures of pain intensity, fatigue, sleep quality, depression, anxiety, functional ability cognitive impairment, and quality of life. Results show not only that psychoeducational programs for the treatment of fibromyalgia are feasible, but also that they can be effective for managing physical and emotional symptoms, in particular, pain and depression.

Holistic Treatment of Fibromyalgia Based on Physiopathology: An Expert Opinion

Patients suffering from fibromyalgia have many vexing symptoms; in contrast, physicians do not have a logical physiopathological framework to explain the multiple complaints. The objective of this writing is to discuss a patient-centered holistic fibromyalgia therapy based on a coherent physiopathological model.The rationale proposing fibromyalgia as stress-related sympathetically maintained neuropathic pain syndrome has solid research foundations. Autoimmunity is evident in a subset of fibromyalgia cases. Dorsal root ganglia are likely the crucial sympathetic-nociceptive short circuit sites. Skin biopsy and corneal confocal microscopy have demonstrated small nerve fiber pathology in fibromyalgia cases.Patient empowerment through information and symptom validation is the first step for a successful fibromyalgia therapy.

POINTS TO HIGHLIGHT

Fibromyalgia is a genuine painful neuropathic pain syndrome. In fibromyalgia stress becomes pain. Autonomic (sympathetic) dysfunction explains the multiplicity of fibromyalgia symptoms.The well-informed patient (and her/his family) must take on the leading role in her/his own rehabilitation. Fibromyalgia treatment often requires important lifestyle changes. Physicians and allied health care personnel facilitate this adjustment. Specific fibromyalgia drivers are discussed. Common modern bad habits alter autonomic nervous system balance and worsen fibromyalgia symptoms. Currently used drugs for fibromyalgia are rudimentary and with low retention rates. Autoimmune fibromyalgia requires focused therapeutic approach.

CONCLUSION

A patient-centered holistic therapy aimed to regain autonomic nervous system resilience remains the most effective fibromyalgia therapy.

FUTURE DIRECTIONS

Corneal confocal microscopy will likely become an objective fibromyalgia diagnostic and follow-up procedure. More specific analgesic antineuropathic medications for fibromyalgia are on the horizon.

Green Light Exposure Improves Pain and Quality of Life in Fibromyalgia Patients: A Preliminary One-Way Crossover Clinical Trial

OBJECTIVE

Fibromyalgia is a functional pain disorder in which patients suffer from widespread pain and poor quality of life. Fibromyalgia pain and its impact on quality of life are not effectively managed with current therapeutics. Previously, in a preclinical rat study, we demonstrated that exposure to green light-emitting diodes (GLED) for 8 hours/day for 5 days resulted in antinociception and reversal of thermal and mechanical hypersensitivity associated with models of injury-related pain. Given the safety of GLED and the ease of its use, our objective is to administer GLED as a potential therapy to patients with fibromyalgia.

DESIGN

One-way crossover clinical trial.

SETTING

United States.

METHOD

We enrolled 21 adult patients with fibromyalgia recruited from the University of Arizona chronic pain clinic who were initially exposed to white light-emitting diodes and then were crossed over to GLED for 1 to 2 hours daily for 10 weeks. Data were collected by using paper surveys.

RESULTS

When patients were exposed to GLED, but not white light-emitting diodes, they reported a significant reduction in average pain intensity on the 10-point numeric pain scale. Secondary outcomes were assessed by using the EQ-5D-5L survey, Short-Form McGill Pain Questionnaire, and Fibromyalgia Impact Questionnaire and were also significantly improved in patients exposed to GLED. GLED therapy was not associated with any measured side effects in these patients.

CONCLUSION

Although the mechanism by which GLED elicits pain reduction is currently being studied, these results supporting its efficacy and safety merit a larger clinical trial.

Efficacy and Safety of Pregabalin for Fibromyalgia in a Population of Chinese Subjects

PURPOSE

Fibromyalgia (FM) may go underdiagnosed and untreated in China in part due to a lack of awareness and understanding of the condition, and limited available treatments.

PATIENTS AND METHODS

This randomized, double-blind, Phase III local registration trial compared the efficacy and safety of pregabalin (flexibly dosed 300-450 mg/day) versus placebo for the management of pain in Chinese adults diagnosed with FM according to American College of Rheumatology 1990 criteria, across 22 centers within China. Patients reported pain score of ≥40 mm on 100-mm scale (from 0 "no pain" to 100 "worst possible pain"). The primary efficacy endpoint was change from baseline to Week 14 in mean pain score (MPS). Secondary endpoints included measures of sleep and sleep interference. Safety and tolerability were monitored throughout.

RESULTS

Median pregabalin dose was 335 mg/day. A significant reduction from baseline to Week 14 in weekly MPS was seen for patients treated with pregabalin (n=170) versus placebo (n=164) (least-squares mean difference [95% confidence interval]: -0.73 [-1.10 to -0.36]; P=0.0001). Significantly greater proportions of patients experienced ≥30% and ≥50% reductions in MPS at Week 14 with pregabalin versus placebo. Pregabalin-treated subjects demonstrated improvements in measures of sleep and sleep interference. Pregabalin was generally well tolerated. The most common adverse events were dizziness and somnolence; no serious adverse events (SAEs) occurred in pregabalin-treated subjects. Nine placebo-treated subjects experienced SAEs.

CONCLUSION

Pregabalin (300-450 mg/day) is a safe and effective treatment for reducing pain and improving sleep in native Chinese subjects with FM.

CLINICALTRIALSGOV IDENTIFIER

NCT01387607.

Prioritizing Pain-Associated Targets with Machine Learning

While hundreds of genes have been associated with pain, much of the molecular mechanisms of pain remain unknown. As a result, current analgesics are limited to few clinically validated targets. Here, we trained a machine learning (ML) ensemble model to predict new targets for 17 categories of pain. The model utilizes features from transcriptomics, proteomics, and gene ontology to prioritize targets for modulating pain. We focused on identifying novel G-protein-coupled receptors (GPCRs), ion channels, and protein kinases because these proteins represent the most successful drug target families. The performance of the model to predict novel pain targets is 0.839 on average based on AUROC, while the predictions for arthritis had the highest accuracy (AUROC = 0.929). The model predicts hundreds of novel targets for pain; for example, GPR132 and GPR109B are highly ranked GPCRs for rheumatoid arthritis. Overall, gene-pain association predictions cluster into three groups that are enriched for cytokine, calcium, and GABA-related cell signaling pathways. These predictions can serve as a foundation for future experimental exploration to advance the development of safer and more effective analgesics.

Effectiveness of a structured group intervention based on pain neuroscience education for patients with fibromyalgia in primary care: A multicentre randomized open-label controlled trial

Background

There has been increased interest in pain neuroscience education (PNE) as a therapeutic approach for the management of fibromyalgia (FM).

Methods

A multicentre randomized, open‐label, controlled trial was conducted to assess the effectiveness of a structured group intervention based on PNE in patients with FM. A total of 139 patients were included in the study and randomized to the intervention group (7 group sessions of education in neurobiology of pain) or to the control group (treatment as usual only). The primary outcome was the improvement of functional status and pain measured with the Fibromyalgia Impact Questionnaire (FIQ), and secondary outcomes were the reduction in the impact of pain and other symptoms (catastrophizing, anxiety and depression) and number of patients reaching no worse than moderate functional impairment (FIQ score <39). Differences between groups were calculated by linear mixed‐effects (intention‐to‐treat approach) and mediational models through path analyses.

Results

At 1 year, improvements in FIQ scores were higher in the intervention group with moderate or high effect size, and decreases of ≥20% in 69.1% of patients (20.9% in the control group) and of ≥50% in 39.7% (4.5% in the control group). Also, 52.9% of patients had a FIQ <39 points (13.4% in the control group).

Conclusions

In this sample of patients with FM, the improvement in quality of life and control of symptoms obtained by adding a PNE intervention showed promising results, equalling or surpassing previously reported outcomes.

Significance

A structured group intervention based on pain neuroscience education for 1 year in patients with fibromyalgia was associated with significant amelioration of the impact of the disease on scores of the Fibromyalgia Impact Questionnaire, the Health Assessment Questionnaire, the Hospital Anxiety and Depression Scale, the Pain Catastrophizing Scale and the Polysymptomatic Distress Scale as compared with only treatment as usual. These findings are clinically relevant considering the challenges posed by fibromyalgia to clinicians and patients alike.

A KCa3.1 Channel Opener, ASP0819, Modulates Nociceptive Signal Processing from Peripheral Nerves in Fibromyalgia-Like Pain in Rats

Purpose

Although abnormal peripheral and central pain processing has been observed in fibromyalgia (FM) patients, the biomechanics and pathophysiology, surrounding the peripheral mechanism are not well understood. An intermediate conductance channel, K_Ca3.1, is expressed in peripheral sensory nerve fibers where it maintains the resting membrane potential and controls nerve firing, making it a plausible target for peripheral therapeutic interventions. ASP0819, a K_Ca3.1 channel opener, is an orally available molecular entity and is used in this investigation to elucidate the role of K_Ca3.1 in signal processing of pain in FM.

Methods

Human or rat K_Ca3.1 channel-expressing cells were used for evaluating the main action of the compound. Effects of the compound on withdrawal behavior by mechanical stimulation were examined in reserpine-induced myalgia (RIM) and vagotomy-induced myalgia (VIM) models of rats. In addition, in vivo electrophysiological analysis was performed to examine the peripheral mechanisms of action of the compound. Other pain models were also examined.

Results

ASP0819 increased the negative membrane potential in a concentration-dependent manner. Oral administration of ASP0819 significantly recovered the decrease in muscle pressure threshold in rat FM models of RIM and VIM. The in vivo electrophysiological experiments showed that Aδ- and C-fibers innervating the leg muscles in the RIM model demonstrated increased spontaneous and mechanically evoked firing compared with normal rats. Intravenous infusion of ASP0819 significantly reduced both the spontaneous activity and mechanically evoked responses in Aδ-fibers in the rat RIM model. ASP0819 significantly reduced the number of abdominal contractions as an indicator of abdominal pain behaviors in the rat visceral extension model and withdrawal responses in the osteoarthritis model, respectively.

Conclusion

These findings suggest that ASP0819 may be a promising analgesic agent with the ability to modulate peripheral pain signal transmission. Its use in the treatment of several pain conditions should be explored, chief amongst these being FM pain.

Cannabidiol Use for Fibromyalgia: Prevalence of Use and Perceptions of Effectiveness in a Large Online Survey

Cannabidiol (CBD) is widely advertised as helpful for chronic pain management but research is limited. Using a cross-sectional, anonymous survey, we examined patterns of naturalistic CBD use among individuals with fibromyalgia (FM) and other chronic pain conditions. Our objective was to better understand rates of CBD use, reasons for use and discontinuation, communication with healthcare professionals about CBD, and perceptions of CBD effectiveness and safety among people with FM. After excluding incomplete surveys, our study population consisted of N = 2,701 participants with fibromyalgia, primarily in the United States. Overall, 38.1% reported never using CBD, 29.4% reported past CBD use, and 32.4% reported current CBD use. Past-year cannabis use was strongly associated with past or current CBD use. Those using CBD typically did so due to inadequate symptom relief, while those not using CBD typically cited safety concerns as their reason for not using CBD. Two-thirds of participants disclosed CBD use to their physician, although only 33% asked for physician advice on using CBD. Participants used CBD for numerous FM-related symptoms (most commonly pain), and generally reported slight to much improvement across symptom domains. Around half of participants reported side effects, which were typically minor. Our findings are limited by selection bias and our cross-sectional design, which prevents causal associations. In conclusion, CBD use is common among individuals with FM and many individuals using CBD report improvements across numerous FM-related symptoms. Our findings highlight the need for additional rigorous studies to better understand CBD's potential for FM management. PERSPECTIVE: This article indicates that CBD use is common among people with fibromyalgia, and the results suggest that many derive benefit from using CBD across multiple symptoms domains. Clinicians should discuss CBD use with fibromyalgia patients, and future studies are needed to rigorously assess CBD's therapeutic value for fibromyalgia symptoms.

Therapeutic Drug Monitoring of Antidepressants for the Treatment of Chronic Musculoskeletal Pain With and Without Depression

BACKGROUND

Antidepressants are recommended for the treatment of chronic musculoskeletal pain; however, target serum concentrations based on therapeutic drug monitoring (TDM) have not been established. Therefore, the authors analyzed routine care TDM data of antidepressants in patients with chronic pain with and without depression in terms of treatment outcomes in an interdisciplinary multimodal pain treatment (IMPT) program.

METHODS

Patients with chronic musculoskeletal pain and TDM for amitriptyline (n = 45) or duloxetine (n = 30) were retrospectively included. The German pain questionnaire for pain intensity and the Depression Anxiety Stress scale were applied at T0 and at the end of the IMPT program (T1). A relief of pain intensity score ≥2 was considered as a positive outcome. Comorbid depression was diagnosed based on ICD-10 criteria. Serum concentrations of antidepressants were measured for routine clinical care TDM.

RESULTS

After IMPT, stress improved in all subgroups, and depressive symptoms improved only in the duloxetine group. Overall, 40% and 27% of patients in the amitriptyline and duloxetine subgroup, respectively, were responders in terms of maximum pain score relief. Responders with comorbid depression were treated with a dose that led to a 1.7-fold higher serum concentration of the active moiety of amitriptyline (amitriptyline + nortriptyline) compared with nonresponders. Similarly, a 2.3-fold higher serum concentration was observed in depressed responders than in nondepressed responders (at minimum 131.5 ng/mL).

CONCLUSIONS

Dosing of antidepressants for chronic pain relief should specifically take comorbid depression into account. TDM may provide better outcomes of pain relief in an IMPT setting in patients with comorbid depression.

Risk of hearing loss in patients with fibromyalgia: A nationwide population-based retrospective cohort study

Objectives

Our objectives are to examine whether patients with fibromyalgia (FM) present an increased risk of hearing loss (HL) compared with those without FM and to explore the relationship between comorbidities/drugs and development of HL in patients with FM. Furthermore, we investigated the incidence rate of different types of HL and the joint effects for HL with FM and comorbidities.

Methods

This population-based retrospective cohort study included patients with new-onset FM from 2000 to 2002 (the FM group) and age- and sex-matched randomized patients without FM (the non-FM group) from Taiwan’s National Health Insurance Research Database. Patients were followed up from baseline (3 months after FM diagnosis) until death, withdrawal, HL development, or December 31, 2013. The primary outcome was the risk of HL, which was assessed using Cox proportional-hazards analysis.

Results

The overall HL risk in the FM group was 1.46-fold (95% confidence interval [CI]: 1.38–1.55) higher than that in the non-FM group after adjustment for sex, age, and comorbidities (p < 0.0001). Patients with FM had significantly greater sensorineural HL (adjusted hazard ratio = 1.46, 95% CI: 1.37–1.56) than those without FM. Patients with FM having comorbidities of diabetes, hyperlipidemia, depression, and Meniere’s disease had a higher risk of HL than those without FM.

Conclusion

Our findings support the notion that FM influences HL and is in line with the hypothesis that the FM mechanism is related to a central nervous system abnormality in sensory processing. Health care professionals should provide appropriate screening for the risk of HL and prevention and counseling methods for patients with FM.

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.

Acupuncture for primary fibromyalgia: Study protocol of a randomized controlled trial

Background

Acupuncture is well recognized for its unique therapeutic effect for many diseases as a nonpharmacological therapy in traditional Chinese medicine (TCM). However, whether acupuncture can effectively treat fibromyalgia is currently unclear. Therefore, we aim to design a study protocol of a randomized controlled clinical trial and assess the effectiveness of acupuncture for patients with fibromyalgia, which may lead to alleviation of clinical symptoms and improvement of patients’ quality of life.

Methods

The study is designed as a randomized, blinded, placebo-controlled trial of two cohorts conducted at Guang’anmen Hospital of China Academy of Chinese Medical Sciences and Shenzhen Traditional Chinese Medicine Hospital, respectively. A total of 68 patients with primary fibromyalgia, diagnosed with the American College of Rheumatology criteria, are randomly allocated with a 1:1 ratio to acupuncture or sham acupuncture groups. All subjects will receive acupuncture intervention for 8 weeks with follow-up assessments every 4 weeks for 16 weeks. The primary outcome will be evaluated using the visual analogue scale (VAS) and revised fibromyalgia impact questionnaire (FIQR) for pain intensity. The secondary outcome measures will include: Multidimensional Assessment of Fatigue scale (MAF), Short Form-36 (SF-36), Beck Depression Inventory (BDI), Pittsburgh Sleep Quality Index (PSQI), Chinese perceived stress scales (pss-14), changes in the number of 18 tender points, patient satisfaction for the treatment and adverse events. The mentioned outcome measurements will be assessed every 4 weeks for 6 months.

Discussion

This clinical trial will use advanced research methods to evaluate the efficacy and safety of acupuncture on fibromyalgia. The results of this trial may provide clinical evidence on the beneficial effects of acupuncture in treating fibromyalgia.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1800016826: AMCTR-IOR-18000184. Registered 27 June 2018, http://www.acmctr.org/listbycreater.aspx

Impact of herbs and dietary supplements in patients with fibromyalgia: A protocol for a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Fibromyalgia (FM) is a common chronic pain condition that seriously affects the quality of patient lives. Its etiology, pathogenesis, and treatment still remain uncertain. Dietary supplements have been widely trialed for symptom relief for FM. The review aims to synthesize the previous literature publications to assess the impact of herbs and dietary supplements on FM patients.

METHODS

We will conduct a literature search in the following databases PubMed, MEDLINE, EMBASE, Cochrane Library, Scopus, and Global Health from database inception to December 2019. Clinical studies published in the English language that used human participants and address the efficacy, safety, and acceptability of herbs and dietary supplements on individuals with FM will be included. The risk of bias and quality assessment of each trial will be evaluated. If trials are enough, a meta-analysis will be conducted using software RevMan5.3, Cochrane Collaboration.

RESULT

Our review will be the first attempt to facilitate evidence-based management using herbs and dietary supplements to treat patients with FM.

CONCLUSION

The findings may provide a framework for future research and clinic practice in FM management.

PROSPERO REGISTRATION NUMBER

CRD42020149941.

Effects of Monopolar Dielectric Radiofrequency Signals on the Symptoms of Fibromyalgia: A Single-Blind Randomized Controlled Trial

Monopolar dielectric radiofrequency (MDR) is a non-invasive treatment for pain based on the local application of electromagnetic signals. The study’s goal was to analyze the effects of MDR on the symptoms of fibromyalgia. For this aim, a randomized controlled trial was conducted on 66 female participants (aged 47 ± 17.7) diagnosed with fibromyalgia. Participants were randomly allocated to either an experimental group (n = 23), which received eight 20-minute sessions of MDR; a sham group, which received the same number of sessions of a sham MDR therapy (n = 22); or a control group (n = 21), which received usual care. The outcome variables included pain measured by the visual analogue scale (VAS), score on the hospital anxiety and depression scale (HADS) and quality of life measured by the combined index of fibromyalgia severity (ICAF). A large effect size was observed for the local pain (R² = 0.46), total ICAF (R² = 0.42) and ICAF physical factor scores (R² = 0.38). Significant mean differences were found for the local pain (p = 0.025) and ICAF physical factor (p = 0.031) scores of the experimental group in comparison with the sham group. No statistically significant differences between groups were found in HADS. In conclusion, MDR is more effective than either sham treatment or usual care in the short-term improvement of pain and the physical wellbeing of participants with fibromyalgia.

Comparison between Acupuncture and Nutraceutical Treatment with Migratens® in Patients with Fibromyalgia Syndrome: A Prospective Randomized Clinical Trial

OBJECTIVES

Fibromyalgia syndrome (FMS) is a chronic clinical condition characterized by pain, fatigue, altered sleep, and cognitive disturbances. The purpose of this study was to compare two alternative treatments (nutraceutical and acupuncture) in FMS patients through a randomized clinical trial.

RESEARCH METHODS

A total of 60 FMS female patients were randomized for treatment with a nutritional combination containing coenzyme Q10, vitamin D, alpha-lipoic acid, magnesium, and tryptophan (Migratens® Group) or acupuncture treatment (Acupuncture Group) performed according the principles of traditional Chinese medicine (TCM), both for 3 months. Changes in pain and in quality of life (QoL) measured with a Fibromyalgia Impact Questionnaire Score-Revised (FIQ-R) and the Fibromyalgia Severity Scale (FSS) were performed at 1, 3, and 6 months after the start of treatments.

RESULTS

A total of 55 patient completed the study (21 in the Migratens® Group and 34 in the Acupuncture Group). Migratens® treatment shows a statistically significant reduction of pain 1 month after the start of therapy (T1, p = 0.025), strengthened after 3 months with maintenance of treatment (p = 0.012). The efficacy in reducing pain was apparent in the Acupuncture Group at all post-treatment determinations and at follow-up (T1 and T2 p = <0.001). Regarding QoL, improvement in FIQ-R and FSS values was revealed in both groups.

CONCLUSION

The nutraceutical approach with Migratens® seems to be an effective option to for patients with FMS. Our experience confirmed also the validity of acupuncture in these patients. Considering the complexity of the management of FMS patients, our results suggest a cyclical and sequential, or even concurrent treatment with different approaches, to improve the efficacy and the compliance of patients to long-term treatment.

Tramadol for management of fibromyalgia pain and symptoms: Systematic review

BACKGROUND

Fibromyalgia is a heterogeneous condition that appears to be associated with physiological and biochemical disturbances of pain modulation, and that consequently affects numerous other facets of life. Tramadol is currently being explored as an option to manage fibromyalgia pain and other symptoms because of its inhibitory activity of reuptake of neurotransmitters, but its safety and efficacy have not yet been established in these patients.

OBJECTIVE

To evaluate the effectiveness and safety of tramadol on the management of symptoms of the syndrome.

METHODS

We searched CENTRAL, MEDLINE, EMBASE, LILACS, Opengrey, ClinicalTrials.gov and WHO-ICTRP for randomised controlled trials analysing the association between tramadol used for fibromyalgia either single-agent or in combination with other drugs. Two reviewers independently extracted data and assessed risk of bias using the Cochrane risk-of-bias tool for all included studies. Quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Four RCTs comprising 459 patients were included. Tramadol-either as a single-agent or in combination with an antidepressant or analgesic-had a positive effect on pain. Tramadol combined with analgesic showed improved quality of life over placebo as measured by the Fibromyalgia Impact Questionnaire at 91 days. However, this difference did not hold for tramadol as a single agent against placebo. The evidence in these articles was rated "low" using the GRADE approach. No serious adverse events were reported. No improvement in depression and quality of sleep were observed.

CONCLUSIONS

This systematic review found a dearth of clinical trials on tramadol in patients with fibromyalgia. Although the combination of monoamine and opioid mechanism of tramadol has shown positive effects for fibromyalgia, the available evidence is not sufficient to support or refute the use of tramadol in clinical practice for pain or symptom management. Protocol registration number in the PROSPERO database: CRD42017062139.

[Effectiveness of pain neuroscience education in patients with fibromyalgia: Structured group intervention in Primary Care]

OBJECTIVE

To evaluate the effectiveness of a group intervention in Primary Care in patients with fibromyalgia (FM) based on pain neuroscience education (PNE).

DESIGN

Pre-post study.

LOCATION

Urban Primary Health Centre in Bilbao.

PARTICIPANTS

Patients with FM (2010 American College of Rheumatology Diagnostic Criteria for fibromyalgia), ≥18 years.

INTERVENTION

5 weekly sessions (2hours each), and a reminder session one month later.

MAIN MEASUREMENTS

Compliance with FM criteria, assessed using the WPI (Widespread Pain Index, number of pain areas) and the SS (severity of symptoms) questionnaires. An assessment was also made on the impact of FM on functional capacity (FIQ:≥20% and ≥50% reduction in the FIQ total score from baseline to after treatment, and proportion of patients with FIQ<39 at the end of the study). Assessments were made at baseline, one month following the 5th session, and during the 6- and 12-month follow-up.

RESULTS

All the study evaluations were completed by 85/98 patients. A statistically significant improvement was observed in the 3 studied categories (WPI, SS, and FIQ) since the first visit, and was maintained until the final visit (12 months later). A total of 45 patients (53%, 95% CI: 42%-63%), more than those at baseline, scored FIQ<39 (no worse than mild functional impairment). One month following the 5th session there were 44 patients (52%, 95% CI: 41%-62%) that no longer met FM criteria and, at the end of follow-up, there were 56 patients (66%, 95% CI: 55%-75%).

CONCLUSIONS

An intervention based on PNE has shown to be feasible in Primary Care, with results in the upper range of those published with other treatments for FM.

A Multicenter, Prospective, Randomized, Placebo-Controlled, Double-Blind Study of a Novel Pain Management Device, AT-02, in Patients with Fibromyalgia

Objectives

Existing treatments for fibromyalgia have limited efficacy, and only a minority of individuals clinically respond to any single intervention. This study was a prospective, multicenter, randomized, double-blind, controlled clinical trial to evaluate the feasibility of alternating magnetic field therapy in fibromyalgia patients by comparing the Angel Touch device (AT-02) with a sham control (S-01).

Methods

Two sites enrolled 44 subjects with diagnosed fibromyalgia. After informed consent, subjects taking prohibited concomitant drugs underwent a washout period of two or more weeks. All subjects then began a one-week run-in period. Numerical rating scale (NRS) pain scores were collected without device intervention for one day, followed by S-01 application to four or more painful sites for 10 minutes at each site, twice daily for six days. Subjects were then randomized to AT-02 or S-01, applied to four or more painful sites for 10 minutes at each site, twice daily for eight weeks. NRS scores were obtained twice daily during the entire treatment period.

Results

The primary end point (change in NRS ± SD at week 8 vs baseline) was –0.94 ± 1.33 in the AT-02 group and –0.22 ± 1.38 in the S-01 group. A trend toward a between-group difference in eight-week NRS scores favored the AT-02 group (–0.73, 95% confidence interval = –1.56 to 0.11, P = 0.086). An adjusted repeated measure analysis detected a significant difference in NRS scores (P = 0.039).

Conclusions

The reduction in NRS scores for AT-02 relative to sham was comparable to reductions observed in meta-analyses of fibromyalgia drug therapy. The unadjusted results and the persistence of the pain score reductions remain encouraging.

Optimised transcranial direct current stimulation (tDCS) for fibromyalgia-targeting the endogenous pain control system: a randomised, double-blind, factorial clinical trial protocol

INTRODUCTION

Fibromyalgia (FM) is a common debilitating condition with limited therapeutic options. Medications have low efficacy and are often associated with adverse effects. Given that FM is associated with a defective endogenous pain control system and central sensitisation, combining interventions such as transcranial direct current stimulation (tDCS) and aerobic exercise (AE) to modulate pain-processing circuits may enhance pain control.

METHODS AND ANALYSIS

A prospective, randomised (1:1:1:1), placebo-controlled, double-blind, factorial clinical trial will test the hypothesis that optimised tDCS (16 anodal tDCS sessions combined with AE) can restore of the pain endogenous control system. Participants with FM (n=148) will undergo a conditioning exercise period and be randomly allocated to one of four groups: (1) active tDCS and AE, (2) sham tDCS and AE, (3) active tDCS and non-aerobic exercise (nAE) or (4) sham tDCS and nAE. Pain inhibitory activity will be assessed using conditioned pain modulation (CPM) and temporal slow pain summation (TSPS)-primary outcomes. Secondary outcomes will include the following assessments: Transcranial magnetic stimulation and electroencephalography as cortical markers of pain inhibitory control and thalamocortical circuits; secondary clinical outcomes on pain, FM, quality of life, sleep and depression. Finally, the relationship between the two main mechanistic targets in this study-CPM and TSPS-and changes in secondary clinical outcomes will be tested. The change in the primary efficacy endpoint, CPM and TSPS, from baseline to week 4 of stimulation will be tested with a mixed linear model and adjusted for important demographic variables.

ETHICS AND DISSEMINATION

This study obeys the Declaration of Helsinki and was approved by the Institutional Review Board (IRB) of Partners Healthcare under the protocol number 2017P002524. Informed consent will be obtained from participants. Study findings will be reported in conferences and peer-reviewed journal publications.

TRIAL REGISTRATION NUMBER

NCT03371225.

Off-label uses of drugs for depression

The prescription of drugs for depression is rising rapidly. One of the reasons for this trend is their many off-label uses. Up to one third of all prescriptions are for non-indicated use, which in addition to drug repurposing includes different dosing or duration than those recommended. In this review, we elaborate on what antidepressants can treat besides depression. The five classes of drugs for depression are introduced, and their mechanisms of action and serious side effects are described. The most common off-label uses of antidepressants are discussed, with a special focus on treating eating disorders, sleep problems, smoking cessation and managing chronic pain. Depression is often a comorbidity when antidepressants are chosen as therapy, but good therapeutic effects have been observed for other conditions also when depression is not involved. Finally, a new type of antidepressant developed from the hallucinogenic "party drug" ketamine is briefly introduced. This recent development suggests that antidepressants will keep playing a central role in medicine for years to come.

Changes in inflammatory plasma proteins from patients with chronic pain associated with treatment in an interdisciplinary multimodal rehabilitation program – an explorative multivariate pilot study

It has been suggested that alterations in inflammation molecules maintain chronic pain although little is known about how these factors influence homeostatic and inflammatory events in common chronic pain conditions. Nonpharmacological interventions might be associated with alterations in inflammation markers in blood. This study of patients with chronic pain investigates whether an interdisciplinary multimodal rehabilitation program (IMMRP) was associated with significant alterations in the plasma pattern of 68 cytokines/chemokines 1 year after rehabilitation and whether such changes were associated with clinical changes. Blood samples and self-reports of pain, psychological distress, and physical activity of 25 complex chronic pain patients were collected pre-IMMRP and at 12-month follow-up. Analyses of inflammatory proteins (cytokines/chemokines/growth factors) were performed directly in plasma using the multiplex immunoassay technology Meso Scale Discovery. This explorative pilot study found that 12 substances, mainly pro-inflammatory, decreased after IMMRP. In two other relatively small IMMRP studies, four of these proinflammatory markers were also associated with decreases. The pattern of cytokines/chemokines pre-IMMRP was associated with changes in psychological distress but not with pain or physical activity. The present study cannot impute cause and effect. These results together with the results of the two previous IMMRP studies suggest that there is a need for larger and more strictly controlled studies of IMMRP with respect to inflammatory markers in blood. Such studies need to consider responders/non-responders, additional therapies, involved pain mechanisms and diagnoses. This and the two other studies open up for developing biologically measurable outcomes from plasma. Such biomarkers will be an important tool for further development of IMMRP and possibly other treatments for patients w ith chronic pain.

Unpredictable stress delays recovery from exercise-induced muscle pain: contribution of the sympathoadrenal axis

Introduction

Although stress is a well-establish risk factor for the development of chronic musculoskeletal pain, the underlying mechanisms, specifically the contribution of neuroendocrine stress axes, remain poorly understood.

Objective

To evaluate the hypothesis that psychological stress-induced activation of the sympathoadrenal stress axis prolongs the muscle pain observed after strenuous exercise.

Methods

Adult male Sprague-Dawley rats were exposed to unpredictable sound stress and eccentric exercise. The involvement of the sympathoadrenal stress axis was evaluated by means of surgical interventions, systemic administration of epinephrine, and intrathecal β₂-adrenergic receptor antisense.

Results

Although sound stress alone did not modify nociceptive threshold, it prolonged eccentric exercise-induced mechanical hyperalgesia. Adrenal medullectomy (ADMdX) attenuated, and administration of stress levels of epinephrine to ADMdX rats mimicked this effect of sound stress. Knockdown of β₂-adrenergic receptors by intrathecal antisense also attenuated sound stress-induced prolongation of eccentric exercise-induced hyperalgesia.

Conclusion

Together, these results indicate that sympathoadrenal activation, by unpredictable sound stress, disrupts the capacity of nociceptors to sense recovery from eccentric exercise, leading to the prolongation of muscle hyperalgesia. This prolonged recovery from ergonomic pain is due, at least in part, to the activation of β₂-adrenergic receptors on muscle nociceptors.