The fibrositis syndrome: diagnosis, differential diagnosis and pathogenesis

Non-spinal low back pain: Global epidemiology, trends, and risk factors

Background and Aims

Low back pain (LBP) is one of the most debilitating and prevalent disorders. The prevalence of LBP ranges from 30% to 80%, depending on the population, and increases with age. Causes of LBP are typically classified as spinal and non-spinal. The main goal of this study was to investigate the non-spinal causes of LBP, since neglecting these factors leads to increases in the financial, psychological, and physical burden of LBP on individuals as well as on society.

Methods

The data were extracted after searching the PubMed database and Google Scholar search engine up to October 27, 2021. We included all studies that were conducted on a human population and assessed the effects of epidemiological, biological, psychological, and sociodemographic factors on the incidence or progression of LBP.

Results

The most common causes of non-spinal LBP were diseases such as nephrolithiasis, endometriosis, tumors, fibromyalgia, and conditions like psychological disorders and pregnancy. Nevertheless, the perceived intensity of the pain can be affected by factors such as socioeconomic level, genetics, age, habits, diet, and psychological status.

Conclusion

The epidemiology, etiologies, and risk factors associated with LBP should be more clearly recognized to better prevent, diagnose, and treat the underlying disease and to reduce the burden of LBP.

Chronic widespread pain in patients with occupational spinal disorders: prevalence, psychiatric comorbidity, and association with outcomes

STUDY DESIGN

A prospective study assessing chronic widespread pain (CWP) and psychiatric comorbidities in patients with chronic disabling occupational spinal disorders (CDOSDs).

OBJECTIVE

To assess the prevalence of CWP, demographic characteristics, and associated psychiatric comorbidity among CDOSD patients, as well as determine if CWP is a risk factor for less successful one-year postrehabilitation socioeconomic outcomes.

SUMMARY OF BACKGROUND DATA

CWP is an essential criterion for diagnosing fibromyalgia. CWP is estimated to affect between 4.1% to 13.5% of the general population and it is associated with higher rates of psychiatric disorders and growing rates of disability. The prevalence of CWP, or its associations as a comorbidity, in patients with CDOSDs are unknown.

METHODS

The socioeconomic outcomes, demographic characteristics, and psychiatric comorbidity of CDOSD patients with CWP were compared to non-CWP patients within a cohort of consecutive CDOSD patients (n = 2730), treated in an interdisciplinary functional restoration program. CWP was determined according to American College of Rheumatology criteria. Psychiatric comorbidity was assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-fourth Edition at the beginning of the rehabilitation program. RESULTS.: In the CDOSD cohort, 32% of the patients (N = 878) met American College of Rheumatology criteria for CWP, relative to 4.1% to 13.5% within the general population. CWP patients (82%) were much more likely than non-CWP patients (16%) to have multisite pain complaints, leading to the finding that CDOSD patients with multisite pain showed a CWP prevalence of 70%. CWP patients were 1.5 times more likely to be female, more likely to have multiple compensable injuries, and had slightly elevated rates of pre- and postinjury Axis I psychopathology. Nevertheless, CWP was not associated with less successful 1-year socioeconomic outcomes.

CONCLUSION

A surprisingly high frequency of CDOSD patients participating in interdisciplinary rehabilitation met criteria for CWP, though the diagnosis was generally unknown to the patient. In this large workers' compensation cohort, CWP was not associated with longer periods of disability, more prerehabilitation surgery or higher pain self-report. With appropriate rehabilitation, CWP patients can have equally successful work return and health utilization outcomes compared to non-CWP patients, despite having significantly higher rates of certain psychiatric disorders.

Awareness and Perceptions of Fibromyalgia Syndrome: A Survey of Southeast Asian Rheumatologists

BACKGROUND

Fibromyalgia syndrome (FMS) is a common but controversial condition. There appears to be different level of belief of its existence and awareness. We set out to explore the variations of perceptions and awareness of this condition among rheumatologists from the Southeast Asia (SEA) region.

METHODS

One hundred eight rheumatologists from the participating countries; 28 from Malaysia, 20 from Singapore, 26 from Thailand, 2 from Brunei, and 42 from Indonesia were approached to participate in this survey by answering specific questions regarding their beliefs in relation to FMS; 82% respondents from Malaysia, 100% from Singapore, 92% from Thailand, 100% from Brunei, and 90% from Indonesia completed the questionnaires.

RESULTS

Most rheumatologists (92.5%) from SEA believe that FMS is a distinct clinical entity, and also this condition is considered an illness rather than a disease. Eighty-seven percent rheumatologists from SEA believe that FMS is a mixture of medical and psychological illness, 9% believe that FMS is primarily a psychological illness, and 3% believe that it is a medical illness. Only 60% of those in a university setting include FMS in their undergraduate teaching. Eighty-five percent of the respondents ordered blood tests to exclude other serious pathologic conditions, and 100% of the respondents from SEA countries also prescribed some form of drugs to FMS patients.

CONCLUSION

FMS is apparently seen worldwide. This study confirmed that there was a variation of perceptions and knowledge of FMS among rheumatologists from SEA countries. However, most rheumatologists agreed that FMS is a distinct clinical entity with a mixture of medical and psychological factors.

Epidemiology of fibromyalgia

Chronic widespread pain, the cardinal symptom of fibromyalgia (FM), is common in the general population, with comparable prevalence rates of 7.3% to 12.9% across different countries. The prevalence of FM in the general population was reported to range from 0.5% to 5% and up to 15.7% in the clinic. The common association of FM with other rheumatic disorders, chronic viral infections, and systemic illnesses has been well documented in several studies. Up to 65% of patients with systemic lupus erythematosus meet the criteria for FM. FM is considered a member of the family of functional somatic syndromes. These syndromes are very common and share a similar phenomenology, epidemiologic characteristics, high rates of occurrence, a common pathogenesis, and similar management strategies. A high prevalence of FM was demonstrated among relatives of patients with FM and it may be attributed to genetic and environmental factors.

Classification, epidemiology, and natural history of fibromyalgia

Fibromyalgia (FM), also known as fibromyalgia syndrome (FMS) and fibrositis, is a common form of nonarticular rheumatism that is associated with chronic generalized musculoskeletal pain, fatigue, and a long list of other complaints. Some have criticized the classification of FM as a distinct medical entity, but existing data suggest that individuals meeting the case definition for FM are clinically somewhat distinct from those with chronic widespread pain who do not meet the full FM definition. Clinic studies have found FM to be common in countries worldwide; these include studies in specialty and general clinics. The same is true of general population studies, which show the prevalence of FM to be between 0.5% and 5%. Knowledge about risk factors for FM is limited. Females are at greater risk, and risk appears to increase through middle age, then decline. Although some authors claim that an epidemic of FM has been fueled by an over-generous Western compensation system, there are no data that demonstrate an increasing incidence or prevalence of FM; moreover, existing data refute any association between FM prevalence and compensation. Claims that the FM label itself causes illness behavior and increased dependence on the medical system also are not supported by existing research. This article reviews the classification, epidemiology, and natural history of FM.

The prevalence of musculoskeletal pain and fibromyalgia in patients hospitalized on internal medicine wards

OBJECTIVES

To estimate the prevalence of nonarticular pain complaints (chronic widespread pain, chronic localized pain, transient pain) and fibromyalgia in hospitalized patients and to study utilization patterns of health services associated with pain related problems.

METHODS

Five hundred twenty-two patients hospitalized on internal medicine wards were enrolled. Data were collected with a questionnaire covering demographic background, information on pain and other symptoms, utilization of health services, and drug consumption. All subjects were classified into four pain groups: those with no pain, transient pain, chronic regional pain, and chronic widespread pain. Tenderness was assessed by thumb palpation, and patients were diagnosed as having fibromyalgia if they met the 1990 American College of Rheumatology criteria.

RESULTS

Sixty-two percent of the patients reported pain; 36% reported chronic regional pain, 21% reported chronic widespread pain, and 5% reported transient pain. Fifteen percent of all patients had fibromyalgia, most of whom (91%) were women. The prevalence of chronic widespread pain and of fibromyalgia in women increased with age. Sleep problems, headache, and fatigue were highly prevalent, especially among those with chronic widespread pain. Patients with chronic widespread pain reported more visits to family physicians (6.2 visits per year) and more frequent use of drugs. They also were more frequently referred to rheumatologists, and they reported more hospitalizations.

CONCLUSIONS

Pain syndromes and related symptoms are prevalent among hospitalized patients on the medicine wards. The internist taking care of these patients should be aware of the presence of these syndromes and realize that some of the reported symptoms are partly related to these (undiagnosed) pain syndromes rather than to the cause of hospitalization.

Trauma and fibromyalgia: is there an association and what does it mean?

OBJECTIVES

The primary objective is to review current research with respect to the role of trauma in fibromyalgia (FM). A secondary objective is to hypothesize which steps need to be taken, first to determine whether such an association truly exists, and second to clarify what such an association might mean.

METHODS

An extensive literature review was undertaken, including Medline from 1979 to the present.

RESULTS

The strongest evidence supporting an association between trauma and FM is a recently published Israeli study in which adults with neck injuries had greater than a 10-fold increased risk of developing FM within 1 year of their injury, compared with adults with lower extremity fractures (P= .001). Several other studies provide a hypothetical construct for such an association. These include studies on (1) postinjury sleep abnormalities; (2) local injury sites as a source of chronic distant regional pain; and (3) the concept of neuroplasticity. There are, however, several primary arguments against such an association: (1) FM may not be a distinct clinical entity; (2) FM may be a psychological, rather than physical, disease; (3) the evidence supporting any association is limited and not definitive; (4) the Israeli study, itself, has some methodological limitations; and (5) other factors may be more important than the injurious event in determining chronic symptoms after an acute injury.

CONCLUSIONS

Although there is some evidence supporting an association between trauma and FM, the evidence is not definitive. Further prospective studies are needed to confirm this association and to identify whether trauma has a causal role.

The occurrence and impact of generalized pain

A major problem with estimating the impact of chronic generalized pain is that the term remains undefined. It appears to encompass several distinct clinical entities, including rheumatoid arthritis and fibromyalgia, which can exist alone or together in a given individual. Nonetheless, chronic generalized pain appears to have a sizable impact on both the individual and society. Although little is known about causal relationships, demographic risk factors for chronic generalized pain are female sex, age in the forties and fifties, lower income, lower education, and being divorced or separated. Chronic generalized pain affects the individual in several ways, including physical and psychological distress, losses of function, quality of life, employment and income, and prolonged litigation for many. Its impact on society includes increased utilization of health care resources, loss of work productivity, disability and insurance costs, costs of litigation and social policy. Future research into the impact of chronic generalized pain must begin by defining this term in a way that is both valid in construct and convenient to use. Research is also warranted to develop and validate diagnostic tools that may better distinguish various subsets of chronic generalized pain, both to better understand the pathological processes involved and to allow for estimates of the relative contribution of each subset to societal costs.

The causality field (extrinsic and intrinsic factors) in industrial subacute low back pain patients

In a prospective, randomized study, primarily designed to test the efficacy of activation on consecutive blue-collar workers sick-listed for 6 weeks due to subacute low back pain, 25% of the workers were excluded for medical reasons. In the intervention study (n = 103), only a minority of cases (6%) had 'true' subacute complaints, i.e. no prior history of low back pain. Subjective reports on general well-being, health status and work-related ergonomic factors were significantly lower or worse in patients than in reference samples. The randomized intervention study could establish a significant effect of graded activation on work return, but the effect seemed to be restricted to patients moderately disabled, i.e. one-third of the subacute low back pain patients included. A predictive four-factor model on work return increased the possibility of identifing nonresponders (chronic low back pain) more than threefold with a specificity (91%) and sensitivity (74%) comparable to that of clinical disc herniation. The history of a prolonged disablement process, cognitive factors, pain behavior and mentally straining ergonomic factors seemed to be of importance. Psychological reactions, or 'barriers to recovery', were slightly different in treatment and control groups but the type of intervention did not significantly alter the predictive model, suggesting that subsets of the study sample may benefit from other optional functional approaches. Descriptive characteristics of the study sample emphasized that subacute low back pain patients cannot be conceptualized as a homogeneous group. Four sub-groups could be identified: (a) specific medical disorders; (b) spontaneous recovery group; (c) moderately disabled back pain patients; and (d) nonresponders. The results support proposals that treatment should be tailored according to individual needs and that better case management should have priority for those belonging to the nonresponder group.

The frequency of transition of chronic low back pain to fibromyalgia

In a retrospective study, the outcome of the chronic low back pain syndrome was investigated in a group of 53 patients. Average time since the diagnosis was established was 18 years. 25% of the patients--all female but one--developed fibromyalgia. The criteria of Yunus and Wolfe, modified by Müller and Lautenschläger, were applied to establish the diagnosis of fibromyalgia. In 60% of the patients chronic low back pain persisted at the time of final examination, while 8 patients were asymptomatic. Predictive parameters for the chance of getting fibromyalgia were sex and postural disorders such as scoliosis. Other radiological findings, for example degenerative changes of the spine, did not coincide with the group of patients who developed fibromyalgia. The predictive value of pain localisation, number of tender points, presence and severity of functional and vegetative symptoms, and the psychosocial situation is uncertain and should be investigated in further long term prospective studies.

Neuromediator and hormonal perturbations in fibromyalgia syndrome: results of chronic stress?

Since the first comprehensive description of the symptoms of FMS by Yunus et al (1981), numerous investigations have confirmed that FMS is a clinical entity. However, the aetiology of the syndrome is still not fully elucidated. It seems, however, logical to place the origin of the disorder in the muscle. Muscle pain, especially at the muscle-tendon junctions, fatigue and stiffness are the first symptoms. A malfunction of energy metabolism has been detected in part of the muscle fibres. However, it has to be considered that the muscle is not an isolated entity. Its activity is controlled by segmentally arranged motor units of the ventral horn of the spinal cord in response to proprioceptive afferent signals arising in the muscle spindles or in other sensory elements including nociceptors. Together with supraspinal descending inputs, the spinal motor neurone pool is the common final pathway for segmental and suprasegmental inputs, making the motor system extremely powerful for adaptive adjustments but also vulnerable if deficits occur in either of these input levels. A second, recently discovered abnormality seen in FMS is a lowered serotonin level in peripheral and most likely also central structures. The underlying mechanism seems to be defective absorption of the precursor amino acid tryptophan from the gut. Serotonin is involved centrally in the regulation of the sleep pattern, and at the spinal level it acts as a 'gain setter' of motoneurone excitability and suppresses signal transmission of noxious stimuli in dorsal horn neurones. Either of these two disturbances, muscle energy depletion or serotonin deficiency, could by itself evoke many of the symptoms of FMS, and their combined appearance will perpetuate the disease. Depressed levels of somatomedin C, caused by a deficit of stage 4 sleep-dependent release of GH, might represent an additional factor in preventing proper development or repair of myoskeletal structures. Malabsorption of certain amino acids, possibly due to a genetic disorder of gut transport mechanisms, may constitute an additional deleterious factor. The abnormalities found in the HPA and HPT axis may be seen as an attempt of the organism to restore homeostasis. The stimulus eliciting this counter-regulatory reaction may be pain or other afferent signals which normally do not reach the central nervous system. It is doubtful whether the unspecific activation of the HPA axis in a non-inflammatory disease is beneficial.(ABSTRACT TRUNCATED AT 400 WORDS)

[Clinical features, pathophysiology and treatment of fibromyalgia.]

In rheumatology, all of the more than 400 specified syndromes are associated with pain. In the conceptual discussion on the multidimensional influences postulated to explain the development of chronic pain, fibromyalgia has gained increasing interest. Fibromyalgia (fibrositis) is an unspecific soft-tissue disorder with chronic wide-spread musculoskeletal pain and palpable hypersensitivity at fibrositic tender points. Fibromyalgia is often associated with fatigue, nonrestorative sleep and other symptoms. The syndrome has a high prevalence in women, but in most cases it has a long course with unsatisfactory attempts at therapy before the diagnosis is made. Though diagnostic criteria have been defined to describe it as a distinct clinical syndrome, speculations on its aetiology and pathogenetic mechanisms are still controversial. Histochemical investigations on muscle biopsy and biochemical tests have revealed unspecific changes but no characteristic muscle abnormality. It is supposed that the clinical features may result from central neurohumoral dysfunction combining with peripheral mechanisms to result in hyperalgesia. An integrated therapeutic concept with a reassuring and positive doctor-patient relationship can be helpful in achieving satisfactory treatment results.

Cold-induced vasospasm in patients with fibromyalgia and chronic low back pain in comparison to healthy subjects

Using capillary videomicroscopy of the nail fold, the frequency of cold-induced vasospasm and capillary hemodynamic parameters were studied after application of cold in 50 patients with primary fibromyalgia, 50 patients with chronic low back pain, and 50 healthy controls. Cold-induced vasospasm was detected in 38% of the patients with fibromyalgia. In this group it was significantly more frequent than in the patients with chronic low back pain (20%, p < 0.05) and healthy subjects (8%, p < 0.001). In the fibromyalgia group, the magnitude of vasospasm as measured by the capillary blood flow deceleration after cold application correlated negatively with the pain intensity as measured by pain score (r = -0.3839, p < 0.01). No differences in clinical appearance were found between patients with and without cold-induced vasospasm in both the fibromyalgia and low back pain group.

Toward an integrated understanding of fibromyalgia syndrome. I. Medical and pathophysiological aspects

Fibromyalgia syndrome (FS) is a chronic pain disorder characterized by diffuse musculoskeletal soreness, stiffness, non-restorative sleep and psychological disturbance. At present, much about the etiology, pathological mechanisms and course of FS are unknown. Indeed, standardized diagnostic criteria have only been recently agreed upon. The present paper is the first of a two-part series which reviews the extant empirical literature concerning FS, with a view to arriving at an integrated understanding of the syndrome. The present paper describes the clinical presentation of FS and historical conceptualizations of the disorder. Available research on pathophysiological mechanisms in FS is then presented. In this section we have included literature concerning histology of muscle, sleep architecture, neurotransmitter anomalies and neuropeptide involvement in FS symptomatology.

Summary of the first 100 patients seen at a Lyme disease referral center

PURPOSE AND PATIENTS AND METHODS

Lyme disease is a major clinical problem in a number of endemic areas in the United States. In areas where anxiety about the disease is high, patients and physicians often ascribe clinical concerns to Lyme disease. Incorrect diagnosis often leads to unnecessary antibiotic treatment (often prolonged or repeated intravenous therapy). This report summarizes the cases of the first 100 patients referred to the Lyme Disease Center at Robert Wood Johnson Medical School.

RESULTS

In only 37 of the patients referred was Lyme disease, either current or preceding, the explanation for the complaints. Many of the patients had another definable arthropathy. Twenty-five of the patients had fibromyalgia, which has not previously been reported in Lyme disease. Three of these patients had active Lyme disease at the time of evaluation, and 17 had a history suggesting preceding Lyme disease. Approximately half of the 91 courses of antibiotic therapy given to these 100 patients before referral were probably unwarranted.

CONCLUSIONS

Anxiety about possible late manifestations of Lyme disease has made Lyme disease a "diagnosis of exclusion" in many endemic areas. Persistence of mild to moderate symptoms after adequate therapy and misdiagnosis of fibromyalgia and fatigue may incorrectly suggest persistence of infection, leading to further antibiotic therapy. Attention to patient anxiety and increased awareness of these musculoskeletal problems after therapy should decrease unnecessary therapy of previously treated Lyme disease.