Management of fibromyalgia syndrome in 2016

Effectiveness of transcutaneous electrical nerve stimulation improves pain intensity, disability and quality of life in patients with fibromyalgia syndrome: a systematic review with meta-analysis

PURPOSE

The transcutaneous electrical nerve stimulation (TENS) is one of the most frequently electrophysical agents employed in reducing the impact of FMS. This meta-analysis intended to determine the effectiveness of TENS on pain, disability, and quality of life (QoL) in patients with FMS.

METHODS

According to PRISMA, we performed a meta-analysis (CRD42023456439), searching in PubMed Medline, PEDro, CINAHL Complete, Web of Science, and Scopus, since inception up to October 2023. This review focused on controlled clinical trials evaluating the effect of TENS on pain, disability, and QoL in patients with FMS. The pooled effect was estimated using Cohen's standardized mean difference (SMD) and its 95% confidence interval (95%CI).

RESULTS

Twelve studies, providing data from 944 patients, were included (PEDro score of 5.6 points). Meta-analyses showed that TENS interventions are effective in improving pain (SMD = -0.61; 95%CI -1 to -0.16); disability (SMD = -0.27; 95%CI -0.41 to -0.12); and physical dimension of QoL (SMD = 0.26; 95%CI 0.08 to 0.44). Additionally, when TENS is used as a unique therapy, it represents the best therapeutic option for improving pain, disability, and QoL.

CONCLUSIONS

This meta-analysis, including the largest number of studies, showed that TENS intervention is an effective therapy to reduce pain and disability and increase QoL in FMS patients.

Investigating the Influential Factors of Mild Water-Filtered Infrared-A Whole-Body Hyperthermia for Pain Relief in Fibromyalgia: A Mixed-Methods Approach Focusing on Predictors and Patient Perspectives

Fibromyalgia syndrome (FMS) is a chronic condition characterized by chronic widespread pain, persistent fatigue, and disrupted sleep, significantly impacting well-being. Mild water-filtered infrared-A (wIRA) whole-body hyperthermia (WBH) is emerging as a promising pain management approach to FMS. Within the present randomized controlled trial (ClinicalTrials ID: NCT05135936), FMS patients underwent six sessions of mild wIRA-WBH over 3 weeks. Their pain levels were assessed at baseline and at week 12, while body core temperature and plateau phase duration were monitored during WBH. Qualitative interviews were conducted at week 12. Results from this mixed-methods study revealed that baseline pain intensity and plateau phase duration significantly predicted pain intensity at week 12. Thematic analysis of the interviews revealed diverse patient experiences with the treatment, with all patients reporting improvements in perceived pain and overall well-being. The onset and duration of pain relief varied among individuals. Overall, the findings suggest that the duration of the plateau phase may serve as an indicator for long-term pain reduction, although individual factors may influence treatment outcomes. Despite varying experiences, a prevailing trend of positive patient evaluations emerged. This study sheds light on the potential of wIRA-WBH as a therapeutic option for alleviating pain for and enhancing the well-being of FMS patients.

Beyond the Pain: A Systematic Narrative Review of the Latest Advancements in Fibromyalgia Treatment

Fibromyalgia is a complex chronic pain disorder that significantly impacts the quality of life of affected individuals. The etiology of fibromyalgia remains elusive, necessitating effective treatment options. This review aims to provide an overview of current treatment options for fibromyalgia and highlight recent updates in managing the condition. The methodology employed in this systematic review comprised the following key steps. We conducted a comprehensive search across various databases to identify pertinent studies published between 2000 and 2023. Inclusion criteria were defined to specifically target studies involving adult individuals diagnosed with fibromyalgia, with a focus on both pharmacological and non-pharmacological interventions for managing the condition. The review encompassed a range of study types, including randomized controlled trials, observational studies, and systematic reviews. To ensure the quality of the selected studies, we employed appropriate assessment tools, and data extraction and synthesis adhered to established guidelines. This rigorous approach allowed for a robust analysis of the literature on fibromyalgia management. In the course of our review, it became evident that a spectrum of treatment approaches holds significant promise in the management of fibromyalgia. Specifically, pharmacological interventions, including selective serotonin-norepinephrine reuptake inhibitors, anticonvulsants, cannabinoids, tropisetron, and sodium oxybate, have exhibited substantial potential in alleviating fibromyalgia symptoms. Concurrently, non-pharmacological strategies, such as cognitive-behavioral therapy, exercise regimens, and complementary and alternative therapies, have yielded positive outcomes in improving the condition's management. Recent developments in the field have introduced innovative pharmacological agents like milnacipran and pregabalin, in addition to non-pharmacological interventions like mindfulness-based stress reduction and aquatic exercise, expanding the array of options available to enhance fibromyalgia care and alleviating patient symptoms. Fibromyalgia necessitates a multidisciplinary approach to treatment, encompassing both pharmacological and non-pharmacological interventions. Recent updates in fibromyalgia management offer additional options to alleviate symptoms and improve the quality of life for individuals with fibromyalgia. Healthcare professionals should remain informed about these advancements to provide evidence-based care, addressing the complex symptoms associated with fibromyalgia and enhancing patient outcomes.

Whole-Body Photobiomodulation Therapy for Fibromyalgia: A Feasibility Trial

Effective treatment for fibromyalgia (FM) is lacking and further treatment options are needed. Photobiomodulation therapy (PBMT) represents one potential treatment option. Whilst favourable findings have been reported using localised PBMT, no investigations have established the value of whole-body PBMT for the complete set of symptom domains in FM. A single-arm feasibility study was conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. A non-probability sampling method was used to access individuals with FM. The primary outcome measure was identified as the Revised Fibromyalgia Impact Questionnaire (FIQR). Forty-nine participants were screened and twenty-one trial participants entered the trial. Nineteen participants completed the intervention (18 whole-body PBMT sessions over approximately six weeks). Descriptive statistics and qualitative analysis was undertaken to represent feasibility outcomes. Acceptability of the trial device and processes were established. Outcome measures towards efficacy data were guided by core and peripheral OMERACT (outcomes measures in rheumatological clinical trials) domains, utilising a combination of participant-reported and performance-based outcome measures. Data for the embedded qualitative component of the trial were captured by participant-reported experience measures and audio-recorded semi-structured interviews. Positive changes were observed for FM-specific quality of life, pain, tenderness, stiffness, fatigue, sleep disturbance, anxiety, depression and cognitive impairment. Patient global assessment revealed improvements at 6 weeks, with continued effect at 24 weeks. FM-specific quality of life at 24 weeks remained improved compared with baseline scores. The findings provided evidence to support a full-scale trial and showed promise regarding potential efficacy of this novel non-invasive treatment in an FM population.

Effects of Combined Training Programs in Individuals with Fibromyalgia: A Systematic Review

Fibromyalgia is a rheumatic disease characterised by chronic widespread muscular pain and its treatment is carried out by pharmacological interventions. Physical exercise and a healthy lifestyle act as an important mechanism in reducing the symptoms of the disease. The aims of this study were to analyse and systematise the characteristics of combined training programs (i.e., type and duration of interventions, weekly frequency, duration and structure of training sessions and prescribed intensities) and to analyse their effects on people diagnosed with fibromyalgia. A systematic literature search was performed using the PRISMA method and then randomised controlled trial articles that met the eligibility criteria were selected. The Physiotherapy Evidence Database scale was used to assess the quality and risk of the studies. A total of 230 articles were selected, and in the end, 13 articles met the defined criteria. The results showed different exercise interventions such as: combined training, high-intensity interval training, Tai Chi, aerobic exercise, body balance and strength training. In general, the different interventions were beneficial for decreasing physical symptoms and improving physical fitness and functional capacity. In conclusion, a minimum duration of 14 weeks is recommended for better benefits. Moreover, combined training programs were the most effective for this population, in order to reduce the symptoms of the disease with a duration between 60 and 90 min, three times a week with a light to moderate intensity.

Effectiveness of eHealth therapeutic education interventions in the management of fibromyalgia: protocol for a systematic review and meta-analysis

INTRODUCTION

Non-pharmacological approaches have shown promising results in improving symptoms and quality of life of patients with fibromyalgia. However, these approaches may not be easily accessible or feasible for everyone. eHealth interventions may offer a more convenient and cost-effective approach to reach a wider range of patients with fibromyalgia and improve their outcomes. As eHealth tools become more prevalent in clinical practice, it is crucial to understand their effectiveness, limitations and how they can be integrated into standard care to optimise clinical outcomes. This systematic review aims to evaluate the effectiveness of eHealth therapeutic education interventions in managing fibromyalgia.

METHODS AND ANALYSIS

Randomised controlled trials including eHealth therapeutic education interventions for individuals ≥18 years old with fibromyalgia, published in English or Spanish, will be retrieved by searching the databases PubMed, CINAHL Plus, EMBASE, Scopus, ISI Web of Science, PsycINFO and the Cochrane Central Register of Controlled Trials. Covidence software will be used for the selection of studies and data extraction. The risk of bias and the certainty of evidence will be assessed using the Cochrane Risk of Bias Assessment tool. We plan to perform a meta-analysis contingent on the number of studies retrieved and the interstudy heterogeneity, which will be explored with I2 statistics.

ETHICS AND DISSEMINATION

This protocol and the subsequent systematic review will not collect individual-level data and do not require approval by an ethical committee. We intend to disseminate the study results via peer-reviewed scientific journals and relevant (inter)national conferences.

PROSPERO REGISTRATION NUMBER

CRD42022343373.

Mild Water-Filtered Infrared-A Whole-Body Hyperthermia Reduces Pain in Patients with Fibromyalgia Syndrome-A Randomized Sham-Controlled Trial

The challenging treatment situation of patients with fibromyalgia syndrome (FMS) requires additional therapy options. The effects of water-filtered infrared-A whole-body hyperthermia (WBH) versus sham hyperthermia on pain intensity were investigated in an outpatient setting within a two-armed randomized sham-controlled trial. n = 41 participants aged between 18 and 70 years with a medically confirmed diagnosis of FMS were randomized to WBH (intervention; n = 21) or sham hyperthermia (control; n = 20). Six treatments with mild water-filtered infrared-A WBH over a period of three weeks with at least one day in between treatments were applied. On average, the maximum temperature was 38.7 °C for a duration of approximately 15 min. The control group received exactly the same treatment except that an insulating foil between the patient and the hyperthermia device blocked most of the radiation. Primary outcome was pain intensity measured by the Brief Pain Inventory at week 4. Secondary outcomes included blood cytokine levels and FMS-related core symptoms and quality of life. Pain intensity at week 4 was significantly different between the groups in favor of WBH (p = 0.015). A statistically significant pain reduction in favor of WBH was also found at week 30 (p = 0.002). Mild water-filtered infrared-A WBH effectively reduced pain intensity at the end of treatment and follow-up.

Distress as a mediator for pain and activities of daily living in older adults with fibromyalgia

Introduction

Pain, distress, and activities of daily living impact the lives of those with chronic pain. This study investigated distress (depressive symptoms, anxiety) on the relationship between pain (intensity and pain interference) and activities of daily living in individuals with fibromyalgia while controlling for age.

Methods

The current cross-sectional investigation focused on data from 123 men and women with fibromyalgia. Pain intensity, pain interference and anxiety were measured on 0-10 Likert type scales from the National Fibromyalgia Assessment Questionnaire. Depressive symptoms were assessed using the Beck Depression Inventory II. Activities of daily living (basic, instrumental) were measured with the Physical Activity Inventory Scale.

Results

It was hypothesized that the relationships between pain intensity and pain interference and activities of daily living in individuals with fibromyalgia would be mediated by the construct of distress while controlling for age. Mediation significantly occurred in both models as predicted. However, those who were older reported lower levels of pain intensity and distress than their younger counterparts, which may be related to time since diagnosis or other factors.

Discussion

Results of this study suggest that individuals with chronic pain conditions would benefit from treatment options which address distress, specifically depressive symptoms and anxiety.

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

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

Lifestyle Redesign® Intervention for Psychological Well-Being and Function in People With Fibromyalgia: A Retrospective Cohort Study

IMPORTANCE

Fibromyalgia is a complex chronic pain condition for which effective nonpharmacological treatment interventions are lacking.

OBJECTIVE

To explore the effects of an occupational therapy intervention for fibromyalgia on client-reported outcomes of pain interference, self-efficacy, mood, and function.

DESIGN

Retrospective cohort study using a chart review method.

SETTING

Outpatient clinic.

PARTICIPANTS

Twenty-one adults with fibromyalgia (M age = 54 yr).

INTERVENTION

A 10-wk occupational therapy group intervention using a Lifestyle Redesign® (LRD) approach.

OUTCOMES AND MEASURES

The Brief Pain Inventory, Pain Self-Efficacy Scale, Beck Depression Inventory (BDI), and the Fibromyalgia Impact Questionnaire (FIQ) or the Revised Fibromyalgia Impact Questionnaire were administered at the first and last sessions of the program.

RESULTS

Between 2015 and 2018, 37 clients entered the program, and 21 completed it. Changes in group averages exceeded the minimal clinically important difference for the BDI and the FIQ. Eighty-one percent of clients who completed the program had a clinically significant improvement on one or more of the outcome measures.

CONCLUSIONS AND RELEVANCE

The findings demonstrate the potential benefit of occupational therapy as a complementary approach to pharmacological treatment for people with fibromyalgia. Preliminary evidence suggests that a 10-wk occupational therapy group intervention using an LRD approach may reduce symptoms of depression and decrease the impact on daily function for people with fibromyalgia. What This Article Adds: Occupational therapy should be considered as a nonpharmacological intervention for adults with fibromyalgia to improve psychological well-being and function.

Translating Outcomes from the Clinical Setting to Preclinical Models: Chronic Pain and Functionality in Chronic Musculoskeletal Pain

Fibromyalgia (FM) is a chronic pain disorder characterized by chronic widespread musculoskeletal pain (CWP), resting pain, movement-evoked pain (MEP), and other somatic symptoms that interfere with daily functioning and quality of life. In clinical studies, this symptomology is assessed, while preclinical models of CWP are limited to nociceptive assays. The aim of the study was to investigate the human-to-model translatability of clinical behavioral assessments for spontaneous (or resting) pain and MEP in a preclinical model of CWP. For preclinical measures, the acidic saline model of FM was used to induce widespread muscle pain in adult female mice. Two intramuscular injections of acidic or neutral pH saline were administered following baseline measures, 5 days apart. An array of adapted evoked and spontaneous pain measures and functional assays were assessed for 3 weeks. A novel paradigm for MEP assessment showed increased spontaneous pain following activity. For clinical measures, resting and movement-evoked pain and function were assessed in adult women with FM. Moreover, we assessed correlations between the preclinical model of CWP and in women with fibromyalgia to examine whether similar relationships between pain assays that comprise resting and MEP existed in both settings. For both preclinical and clinical outcomes, MEP was significantly associated with mechanical pain sensitivity. Preclinically, it is imperative to expand how the field assesses spontaneous pain and MEP when studying multi-symptom disorders like FM. Targeted pain assessments to match those performed clinically is an important aspect of improving preclinical to clinical translatability of animal models.

The role of physiotherapy in fibromyalgia: Current and future perspectives

Fibromyalgia is a chronic pain condition characterized by generalized musculoskeletal pain, hyperalgesia and allodynia, commonly associated with other symptoms such as fatigue, poor sleep quality, anxiety and depression. The clinical manifestations of this rheumatic disease have significant psychosocial and economic repercussions, with a substantial impact on health status, quality of life and social activities. Currently, recommendations for the management of fibromyalgia include patient education and non-pharmacological interventions, and among the indicated treatments, clinical guidelines include several physiotherapeutic resources, essential for individuals affected by this syndrome. Research in the physiotherapy field has demonstrated its effectiveness, but there is a need to update the literature. This study aims to identify the effectiveness of physiotherapy in the treatment of individuals with fibromyalgia. We performed a literature review looking for articles dated from March 2012 to March 2022 using the terms “fibromyalgia”, “physiotherapy”, “physical therapy”, “rehabilitation” in different languages in various databases and their main information was read and collected and presented in a descriptive way. The effects of physiotherapy interventions are summarized in order to provide a reference for future research and clinical application. Research on non-pharmacological physiotherapy-oriented treatments has grown in recent years as an alternative for fibromyalgia treatment. This review allows fibromyalgia patients to receive appropriate physical therapy interventions to promote their health.

Pregabalin administration in patients with fibromyalgia: a Bayesian network meta-analysis

Several studies investigated the effectiveness and the safety of different doses of pregabalin in fibromyalgia. However, the optimal protocol remains controversial. A Bayesian network meta-analysis comparing 300, 450, and 600 mg/daily of pregabalin for fibromyalgia was conducted. The literature search was conducted in January 2022. All the double-blind randomised clinical trials comparing two or more dose protocols of pregabalin for fibromyalgia were accessed. Studies enrolling less than 50 patients were not eligible, nor were those with a length of follow-up shorter than eight weeks. The outcomes of interests were: Fibromyalgia Impact Questionnaire (FIQ), sleep quality, and adverse events. The network meta-analyses were performed using the routine for Bayesian hierarchical random-effects model analysis, with log odd ratio (LOR) and standardized mean difference (SMD) effect measure. Data from 4693 patients (mean age 48.5 years) were retrieved. 93.1% (4370 of 4693 patients) were women. The median follow-up was 14.8 weeks. Pregabalin 450 mg/daily resulted in greater reduction in Fibromyalgia Impact Questionnaire (SMD − 1.83). Pregabalin 600 demonstrated the greatest sleep quality (SMD 0.15). Pregabalin 300 mg/daily evidenced the lowest rate of adverse events (LOR 0.12). The dose of pregabalin must be customised according to patients’ characteristics and main symptoms.

Low-energy Pulsed Electromagnetic Field Therapy Reduces Pain in Fibromyalgia: A Randomized Single-blind Controlled Pilot Study

OBJECTIVES

Fibromyalgia symptoms have a significant impact on the quality of life and respond poorly to medications. It has been hypothesized that the use of low-energy pulsed electromagnetic field (PEMF) induces neuroprotective effects that may interfere with pain perception. We explored the efficacy of PEMF in patients affected by fibromyalgia.

METHODS

Twenty-one females (median age 59 years, interquartile range [IQR] 16.5) affected by fibromyalgia were randomized to receive pulsed electromagnetic field-triple energy pain treatment (PEMF-TEPT) or placebo at T0 and at 4 weeks and 8 weeks. Fibromyalgia impact questionnaire (FIQ), widespread pain index (WPI), visual analog score (VAS) pain, symptom severity (SS) scale, and short form 36 (SF-36) health survey questionnaire have been evaluated.

RESULTS

Patients in the PEMF-TEPT group had a significantly higher reduction of WPI compared to placebo (mean difference -12.90 ± standard deviation [SD] 5.32 vs. -1.91 ± 4.55, difference in difference [DD] of -10.99; P < 0.001), of SS score (-4.10 ± 4.85 vs. -2.00 ± 2.32; DD = -2.1; P < 0.05), of VAS pain (-48 ± 30.75 vs. -16.82 ± 23.69; DD = -31.18; P < 0.01). They also reported a higher improvement of FIQ and SF-36, albeit not reaching statistical significance.

CONCLUSION

In our pilot controlled study, PEMF-TEPT appeared to be safe and improved fibromyalgia symptoms.

Cannabis for Rheumatic Disease Pain: a Review of Current Literature

PURPOSE OF REVIEW

Changing attitudes about marijuana have led to an increase in use of medicinal marijuana, especially for painful chronic conditions. Patients ask rheumatologists for guidance on this topic. This review provides up-to-date information on the safety and efficacy of medicinal cannabis for rheumatic disease pain.

RECENT FINDINGS

The number of publications related to rheumatic disease and cannabis has increased, but recent literature skews heavily toward reviews vs primary research. Data supporting a role for cannabinoids in rheumatic disease continue to grow. Observational and survey studies show increased use of medicinal cannabis, both by people with rheumatic disease and the general population, and suggest that patients find these treatments beneficial. Prospective studies, however, including randomized controlled clinical trials, are rare and sorely needed. As medicinal cannabis use for rheumatic diseases rises, despite lack of evidence, we review the sparse data available and provide tips for conversations about medicinal cannabis for rheumatologists.

Fibromyalgia: Recognition and Management in the Primary Care Office

Fibromyalgia is a chronic pain condition manifested by chronic generalized pain, fatigue, disordered sleep, and cognitive difficulties, persistent for at least 3 months. Other common complaints/conditions include symptoms of irritable bowel syndrome, headaches, intermittent paresthesias, and various mood disorders. Women are more commonly affected than men. The treatment approach should be individualized and focused on associated mood disorders, sleep, exercise, correction of maladaptive responses to pain, and coping with stress.

Individuals with fibromyalgia have a different gait pattern and a reduced walk functional capacity: a systematic review with meta-analysis

Background

The aim of the present study was to perform a systematic review and meta-analysis comparing walking test performance and gait pattern between individuals with and without fibromyalgia (FM).

Methodology

This systematic review was registered in PROSPERO with the following reference: CRD42018116200.The search for the scientific articles in this systematic review was carried out using the MEDLINE, SCOPUS, PEDRO, CINHAL and WEB OF SCIENCE databases. A combination of three conceptual groups of terms was used: (1) fibromyalgia; (2) walk (performance) tests; and (3) gait analysis. The included articles were analyzed for both functional and pattern of walking data of patients with FM. In order to provide a better estimate of the difference between individuals with and without FM on gait, a meta-analysis was performed on the 6MWT (6-minute walk test).

Results

Thirty-six studies were analyzed, with a total population of 4.078 participants (3.369 FM and 709 individuals without FM). From a functional point of view, the 6MWT distance covered by the group of individuals without FM was significantly greater than that of the individuals with FM in all the analyzed studies. In addition, when comparing the results obtained in the gait pattern analysis, it was observed that individuals with FM walked slower, with a shorter stride length and lower cadence compare to individuals without FM.

Conclusions

It is possible to affirm that individuals with FM perform walking tests differently than individuals without FM. It was observed that individuals with FM walk performing a cycle of shorter length and lower frequency, producing a slower gait, which results in a shorter distance traveled, in the same period of time, with respect to healthy subjects.

Use of Dietary Supplements and Perceived Knowledge among Adults Living with Fibromyalgia in Norway: A Cross-Sectional Study

Fibromyalgia syndrome (FMS) is a complex medical condition characterized by widespread musculoskeletal pain. To date, no gold standard treatment has been developed, and persons with FMS often seek alternative methods to control their symptoms, such as dietary supplements (DS). This study aimed to describe the use of DS in persons living with FMS and examine the associations between the use of DS and its potential predictors. We recruited a convenience sample of 504 participants (≥18 years) living with FMS. The main outcome variables included estimated expenditure on DS in the last 12 months in Norwegian kroner (NOK) and the differences between the groups of users and non-users of DS. Of the 504 participants, 430 reported having used DS, and the mean amount of money spent in the previous year was determined to be NOK 2300. The most common DS reported were vitamin D, magnesium, and omega-3 fatty acids. The predictors of being a DS user were high education, high self-reported knowledge of DS but low overall knowledge of health claims. Users of DS marketed for muscles/joints appear to spend more money on DS. The increasing availability of DS and aggressive advertising in the media through health claims stipulate the need for interventions that lead to informed decisions about DS.

Placebo Responses and Their Clinical Implications in Fibromyalgia: A Meta-Analysis Using SSRI and SNRI Trials

Background: Fibromyalgia (FM) is a chronic primary pain condition, associated with widespread musculoskeletal pain, disturbed sleep, fatigue, cognitive dysfunction, and a range of comorbid conditions such as irritable bowel syndrome, and depression. Despite its high prevalence of 2% in the general population, FM continues to pose scientific and clinical challenges in definition, etiology, and day-to-day management. In terms of treatment, FM can be treated with selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs). Objective: Patients with FM and other chronic primary pain syndromes are known to experience substantial and clinically relevant placebo effects. An update of the placebo responses for various outcomes in the FM population and especially a discussion about clinical implications is therefore needed. Methods: We used data from a large data pool that includes randomized controlled trials (RCTs) examining within-placebo mean change scores of baseline vs. follow-up assessments in FM trials of SSRIs and SNRIs. The primary outcomes were pain, functional disability, and depression and using different scales. We assessed heterogeneity of included trials. Results: A total of 29 RCTs with N = 8,453 patients suffering from FM were included in our analysis. Within-placebo mean change scores of baseline vs. follow-up assessments were large for pain (mean change = 2.31, 95% CI: 0.42-4.21, p = 0.017), functional disability (mean change = 3.31, 95% CI: 2.37-4.26, p < 0.000), and depression (mean change = 1.55, 95% CI: 0.92-2.18, p < 0.000). Heterogeneity was found to be large for all outcomes. Impact: Our results provide preliminary evidence that placebo responses, which also consist of non-specific effects, might play a role in the treatment of FM. Furthermore, we highlight limitations of our analyses and make suggestions for future studies.

Intensive Multicomponent Fibromyalgia Treatment: A Translational Study to Evaluate Effectiveness in Routine Care Delivery

OBJECTIVE

The current study was designed to evaluate the translation of clinical trial outcomes and clinical guidelines for the treatment of fibromyalgia (FM) into an intensive multicomponent clinical program embedded in routine care delivery. The study aimed to assess the adaptation of these recommended strategies into routine clinical care while evaluating their effectiveness and durability in improving functional status and level of distress in a large clinical sample of FM patients.

METHODS

Four hundred eighty-nine patients with FM completed a 2-day program that incorporated best practice recommendations for the treatment of FM. Patients completed the Fibromyalgia Impact Questionnaire-Revised, the Center for Epidemiologic Studies Depression Scale, and the Pain Catastrophizing Scale at admission to the program and at follow-up on average 5 months posttreatment.

RESULTS

Significant improvements were seen in functional status (p < 0.0001), depressive symptoms (p < 0.0001), and pain catastrophizing (p < 0.0001) after participation in the intensive multicomponent treatment program.

CONCLUSIONS

The present study shows that an intensive multicomponent treatment program embedded in routine care delivery is effective in significantly improving functional status and psychological distress in a large sample of FM patients. The significant improvements were durable and maintained at follow-up.

Serotonergic Neurotransmission System Modulator, Vortioxetine, and Dopaminergic D2/D3 Receptor Agonist, Ropinirole, Attenuate Fibromyalgia-Like Symptoms in Mice

Fibromyalgia is a disease characterized by lowered pain threshold, mood disorders, and decreased muscular strength. It results from a complex dysfunction of the nervous system and due to unknown etiology, its diagnosis, treatment, and prevention are a serious challenge for contemporary medicine. Impaired serotonergic and dopaminergic neurotransmission are regarded as key factors contributing to fibromyalgia. The present research assessed the effect of serotonergic and dopaminergic system modulators (vortioxetine and ropinirole, respectively) on the pain threshold, depressive-like behavior, anxiety, and motor functions of mice with fibromyalgia-like symptoms induced by subcutaneous reserpine (0.25 mg/kg). By depleting serotonin and dopamine in the mouse brain, reserpine induced symptoms of human fibromyalgia. Intraperitoneal administration of vortioxetine and ropinirole at the dose of 10 mg/kg alleviated tactile allodynia. At 5 and 10 mg/kg ropinirole showed antidepressant-like properties, while vortioxetine had anxiolytic-like properties. None of these drugs influenced muscle strength but reserpine reduced locomotor activity of mice. Concluding, in the mouse model of fibromyalgia vortioxetine and ropinirole markedly reduced pain. These drugs affected emotional processes of mice in a distinct manner. Hence, these two repurposed drugs should be considered as potential drug candidates for fibromyalgia. The selection of a specific drug should depend on patient’s key symptoms.

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.

Fibromyalgia: Recognition and Management in the Primary Care Office

Fibromyalgia is a chronic pain condition manifested by chronic generalized pain, fatigue, disordered sleep, and cognitive difficulties, persistent for at least 3 months. Other common complaints/conditions include symptoms of irritable bowel syndrome, headaches, intermittent paresthesias, and various mood disorders. Women are more commonly affected than men. The treatment approach should be individualized and focused on associated mood disorders, sleep, exercise, correction of maladaptive responses to pain, and coping with stress.

Assessing our approach to diagnosing Fibromyalgia

Introduction: Fibromyalgia represents the most prevalent of the group of conditions that are known as central sensitivity syndromes. Approximately 2-5% of the adult population in the United States is affected by Fibromyalgia. This pain amplification syndrome has an enormous economic impact as measured by work absenteeism, decreased work productivity, disability and injury compensation, and over-utilization of healthcare resources. Multiple studies have shown that early diagnosis of this condition can improve patient outlook, and redirect valuable health care resources toward more appropriate targeted therapy. Efforts have been made toward improving diagnostic accuracy through updated criteria. Areas Covered: Reviewed here are 1) reasons for the need for more accurate diagnosis of Fibromyalgia, (2) a review of the evolution of Fibromyalgia to current times, and (3) the proliferation of currently available diagnostic criteria and problems related to each of them. From initial literature review until October 2020, PubMed, Embase, and Scopus were searched for applicable literature. Expert Opinion: A discussion of ongoing efforts to obtain a biomarker to enhance diagnostic accuracy concludes this review. A need to include rheumatologists as part of the care team of patients with Fibromyalgia is emphasized.

Dietary Interventions in the Management of Fibromyalgia: A Systematic Review and Best-Evidence Synthesis

Fibromyalgia syndrome (FMS) is characterised by chronic widespread pain alongside fatigue, poor sleep quality and numerous comorbidities. It is estimated to have a worldwide prevalence of 1.78%, with a predominance in females. Treatment interventions for fibromyalgia have limited success, leading to many patients seeking alternative forms of treatment, including modifications to their diet and lifestyle. The effectiveness of dietary changes in fibromyalgia has not been widely researched or evaluated. This systematic review identified twenty-two studies, including 18 randomised control trials (RCTs) and four cohort studies which were eligible for inclusion. In total these studies investigated 17 different nutritional interventions. Significant improvements in reported pain were observed for those following a vegan diet, as well as with the low fermentable oligo di-mono-saccharides and polyols (FODMAP) diets. Supplementation with Chlorella green algae, coenzyme Q10, acetyl-l-carnitine or a combination of vitamin C and E significantly improved measures of pain. Interpretation of these studies was limited due to the frequent poor quality of the study design, the wide heterogeneity between studies, the small sample size and a high degree of bias. Therefore, there is insufficient evidence to recommend any one particular nutritional intervention for the management of fibromyalgia and further research is needed.

Magnesium and Pain

In terms of antinociceptive action, the main mode of action of magnesium involves its antagonist action at the N-methyl-d-aspartate (NMDA) receptor, which prevents central sensitization and attenuates preexisting pain hypersensitivity. Given the pivotal function of NMDA receptors in pain transduction, magnesium has been investigated in a variety of pain conditions. The oral and parenteral administration of magnesium via the intravenous, intrathecal, or epidural route may alleviate pain and perioperative anesthetic and analgesic requirements. These beneficial effects of magnesium therapy have also been reported in patients with neuropathic pain, such as malignancy-related neurologic symptoms, diabetic neuropathy, postherpetic neuralgia, and chemotherapy-induced peripheral neuropathy. In addition, magnesium treatment is reportedly able to alleviate fibromyalgia, dysmenorrhea, headaches, and acute migraine attacks. Although magnesium plays an evolving role in pain management, better understanding of the mechanism underlying its antinociceptive action and additional clinical studies is required to clarify its role as an adjuvant analgesic.

Attenuation of reserpine-induced fibromyalgia via ROS and serotonergic pathway modulation by fisetin, a plant flavonoid polyphenol

Fibromyalgia (FM) is a chronic complex musculoskeletal disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep disturbance, memory defects and mood changes. Fisetin, a plant flavonoid polyphenol, has been reported to possess potent antioxidant, antinociceptive and neuroprotective activities. The present study aimed to evaluate the efficacy of fisetin against reserpine-induced FM (RIF) in rats. RIF was induced in male Wistar rats (180–220 gm) using reserpine (1 mg/kg; subcutaneous; once daily for 3 consecutive days) and the rats were treated with fisetin (5, 10 and 25 mg/kg) for 21 days. Various behavioral, biochemical and molecular parameters were evaluated. Administration of reserpine induced allodynia, hyperalgesia and depression, which were significantly ameliorated (P<0.05) by fisetin (10 and 25 mg/kg), as reflected by an increase in paw and tail withdrawal latency, increased paw withdrawal threshold, and decreased immobility time. Reserpine led to decreased biogenic amine levels [5-hydroxytryptamine (5-HT), noradrenaline (NA) and dopamine (DA)] and increased the ratio to their metabolite 3,4-dihydroxyphenylacetic acid. 5-hydroxyindoleacetic acid in the spinal cord, thalamus and prefrontal cortex was significantly decreased (P<0.05) by fisetin. Immunohistological analysis of brain tissue revealed that fisetin significantly inhibited (P<0.05) reserpine-induced depletion of 5-HT. It also significantly inhibited (P<0.05) elevated oxido-nitrosative stress and reactive oxygen species (ROS) levels, as analyzed by flow cytometry in RIF rats. Fisetin exerts its antinociceptive and anti-depressive potential via modulation of decreased levels of biogenic amines (5-HT, NA and DA), elevated oxido-nitrosative stress and ROS to ameliorate allodynia, hyperalgesia, and depression in experimental RIF.

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.

The use of prescription medication in 239 patients with multiple functional somatic syndromes

OBJECTIVE

To describe the use of prescription drugs and their association with patient characteristics in patients with multiple functional somatic syndromes (FSS) focusing on drugs generally recommended and not recommended in FSS treatment.

METHOD

Using data from a national prescription registry, we describe the drug use during a two-year period for 239 trial participants. Using regression models, we analyse the associations of patient characteristics with the patterns of use of antidepressants, anticonvulsants, opioids and sedatives.

RESULTS

The use of prescription drugs was highly heterogeneous. Antidepressants were used at least temporarily by 34% (88/239), anticonvulsants by 7% (16/239), opioids by 26% (61/239) and sedatives by 20% (47/239) of the patients. Severe impairment due to multiple FSS was associated with use of opioids or sedatives (OR 6.49 (95% CI 2.68-15.68; p < 0.001)) but also with use of antidepressants or anticonvulsants (OR 3.42 (95% CI 1.35-8.65; p = 0.009)). Poor self-reported physical health, additional physical comorbidities and low socioeconomic status were associated with use of opioids or sedatives only.

CONCLUSION

Antidepressants and anticonvulsants were modestly used. Opioids and sedatives were especially used by the severely affected patients. Balancing treatment expectations and enhancing patients' understanding of FSS may direct treatments towards more generally recommended drugs.

Learning from our mistakes

The article by M.-A. Fitzcharles et al. appearing in this issue represents an attempt to elicit suggestions from a group of patients with fibromyalgia (FM) and a group of health professionals on the leading uncertainties in the treatment of FM. The sample of respondents in both these groups is not adequately representative, the methodology used is unduly complex, and the responses obtained do not represent new or useful information.

The management of fibromyalgia from a psychosomatic perspective: an overview

Fibromyalgia (FM) is a central sensitization syndrome characterized by chronic widespread pain. FM is often comorbid with psychiatric disorders, as well as psychological distress that worsens the quality-of-life of people affected. The aim was to collect current evidence about the management of FM from a psychosomatic perspective. The literature was synthesized and summarized in a narrative format. The literature search was carried out in PubMed; review articles, meta-analysis, overview, and guidelines published in the last 10 years written in English were included. Five main topics (Diagnostic criteria of FM; Pathogenesis of chronic widespread pain in FM; Early stress and trauma as predisposing factors for central sensitization; FM and Psychiatric comorbidity; Implications for treatment) were pointed out and discussed. Much evidence underlies the importance of considering and treating the comorbidity of FM with psychiatric disorders and psychological factors that affect pain management. Validation of FM as a central sensitization syndrome by a clinician facilitates therapeutic strategies that involve patients as active participants in the pain management process, likely leading to improved outcomes.