Accuracy of the diagnosis of fibromyalgia by family physicians: is the pendulum shifting?

Medication use and factors associated with opiate use among patients with diagnosed fibromyalgia from two ethnic sectors in southern Israel

BACKGROUND

Our aims were to compare fibromyalgia (FM) rate, drug treatment and factors associated with the use of opiates in two ethnic sectors.

METHODS

A retrospective cross-sectional study in southern district of Israel was performed on diagnosed FM patients in 2019-2020 [7686 members (1.50%)]. Descriptive analyses were conducted and multivariable models for the use of opiates were developed.

RESULTS

There were significant differences between the two ethnic groups in FM prevalence at 1.63% and 0.91% in the Jewish and Arab groups, respectively. Only 32% of the patients used recommended medications and about 44% purchased opiates. Age, BMI, psychiatric co-morbidity, and treatment with a recommended drug were similarly associated with an increased risk for opiate use in both ethnic groups. However, male gender was associated with × 2 times reduced risk to use opiates only among the Bedouins (aOR = 0.552, 95%CI = 0.333-0.911). In addition, while in both of ethnic groups the existence of another localized pain syndrome was associated with an increased risk for opiates use, this risk was 4 times higher in the Bedouin group (aOR = 8.500, 95%CI = 2.023-59.293 and aOR = 2.079, 95%CI = 1.556-2.814).

CONCLUSIONS

The study showed underdiagnosis of FM in the minority Arab ethnicity. Female Arab FM patients in low or high, compared to middle socio-economic status, were a risk group for excess opiate use. Increased use of opiates and very low rate of purchase of recommended drugs point to a lack of effectiveness of these drugs. Future research should assess whether the treatment of treatable factors can reduce the dangerous use of opiates.

Fibromyalgia-Like Syndrome Associated with Parkinson's Disease-A Cohort Study

Parkinson’s disease (PD) and fibromyalgia (FM) are two relatively common disorders that are considered distinct diagnoses. The aim of this study was to investigate the epidemiological characteristics of patients with both PD and FM, as well as their comorbidities and medication use. We performed a population-based retrospective cohort study in Israel from 2000 to 2015. We identified patients with PD according to a refined medication tracer algorithm and patients with FM according to their medical records. Using the algorithm, we identified 2606 patients diagnosed with PD, 60 of them (2.3%) were also diagnosed with FM. Most of the patients were females (88.3%) and the mean age of FM diagnosis was 63.95 ± 12.27 years. These patients had a higher prevalence of depression, anxiety, and dementia. Of the patients diagnosed with PD + FM, 46 (76.7%) were diagnosed with FM after the diagnosis of PD. Patients with PD + FM used analgesics of distinct kinds in higher rates, as well as more anti-PD medications. We suggest that patients with PD + FM represent a distinct subgroup with a fibromyalgia-like syndrome associated with Parkinson’s disease (FLISPAD). Their PD is more treatment resistant, and they take more medications, both analgesics and anti-PD.

New guidelines for the diagnosis of fibromyalgia

OBJECTIVE

To establish guidelines based on scientific evidence for the diagnosis of fibromyalgia.

MATERIAL AND METHODS

Evidence collection was performed based on 9 questions regarding the diagnosis of fibromyalgia, structured using the Patient, Intervention or Indicator, Comparison and Outcome (P.I.C.O.), with searches in the main, primary databases of scientific information. After defining the potential studies to support the recommendations, they were graded according to evidence and degree of recommendation.

Relationship between nongenital tender point tenderness and intravaginal muscle pain intensity: ratings in women with provoked vestibulodynia and implications for treatment

BACKGROUND

Vulvodynia is a chronic vulvar pain disorder and fibromyalgia is a chronic widespread musculoskeletal pain disorder, both of unknown etiology. Association of these conditions is well documented. Intravaginal algometer measurement of tenderness to pressure applied to the pelvic floor muscles helps define vulvodynia associated with musculoskeletal factors. Women with both vulvodynia and fibromyalgia might have increased pelvic muscle pain compared to women with vulvodynia alone, defining the possible link of these 2 conditions.

OBJECTIVE

We sought to: (1) correlate pain intensity during the nongenital tender point tenderness examination to pain intensity with the vaginal algometer in women with provoked vestibulodynia, and (2) determine whether subjects with provoked vestibulodynia and fibromyalgia had higher pain intensity scores with the vaginal algometer than those without fibromyalgia.

STUDY DESIGN

In all, 92 subjects referred for vulvar pain were confirmed to have provoked vestibulodynia using the cotton swab test. A diagnosis of fibromyalgia was made if pain was present (numeric rating scale >1) in at least 11 sites of the 18-point nongenital tender point tenderness exam. Vaginal pain sensitivity was measured using an intravaginal pressure algometer, where 0.1, 0.3, and 0.5 kg/cm² forces were applied digitally in random assignment by force and location to the right and left iliococcygeus muscle regions and the posterior vaginal wall. Both tender point tenderness and algometer pain intensity were reported on a 0 (no pain) to 10 (worse pain) numeric rating scale. Correlations were computed between the composite pain intensity (total of rating scale from each pressure threshold at specified site) of nongenital and those of iliococcygeus regions and the posterior vaginal wall. Independent t tests were used to determine differences in iliococcygeus regions and the posterior vaginal algometer pain ratings and presence or absence of fibromyalgia. The significance level was at P < .05. The data were expressed as mean ± SD.

RESULTS

A significant correlation was found between numeric rating scale pain scores on the nongenital tender point tenderness exam and algometer testing on the iliococcygeus region (r = 0.44, P < .0001) and the posterior vaginal wall (r = 0.45, P < .0001). Subjects with fibromyalgia by tender point tenderness had significantly higher iliococcygeal pain (6.14 ± 2.07 vs 3.74 ± 2.22, P = .0001) and posterior vaginal wall pain (5.67 ± 2.10 vs 3.07 ± 2.16, P < .0001) than women without fibromyalgia by tender point tenderness.

CONCLUSION

Women with provoked vestibulodynia who experience more severe pain with nongenital tender point palpation also experience more deep vaginal pain on pelvic exam. Those who fulfill the diagnosis of fibromyalgia show significantly more intense deep vaginal pain to palpation of iliococcygeus muscles and posterior vaginal wall. Further research using a more precise definition of fibromyalgia is necessary to confirm this relationship, but findings suggest that women with provoked vestibulodynia coexisting with fibromyalgia have greater risk of superimposed vaginal muscle pain and may be candidates for early adjunctive pelvic floor physical therapy. These findings need to be explored in women with generalized, nonprovoked vulvodynia.

A systematic review and meta-analysis of the percentage of revised diagnoses in functional somatic symptoms

BACKGROUND

Functional somatic symptoms (FSS) are bodily complaints of unclear etiology, which are (currently) not fully explained by well-recognized somatic pathology. Doctors are often hesitant to diagnose FSS, due to the risk to miss a somatic disease. The purpose of this study is to review available literature on the percentage of patients diagnosed with FSS reported to have an underlying somatic disease that explains their symptoms previously labeled as FSS.

METHODS

We performed a systematic search of Medline, Embase and PsycINFO databases and reference lists of selected articles. We included studies published between January 1980 and July 2014 without language restrictions. Studies that measured the percentage of underlying somatic diseases after a diagnostic evaluation or naturalistic follow-up period in adult patients initially diagnosed with FSS were included. As primary outcome measure the weighted percentage of revised diagnoses was calculated using meta-analyses.

RESULTS

Six diagnostic evaluation studies (total N=1804 patients) and 16 follow-up studies (total N=2440 patients) were included. The percentage of revised diagnosis in patients initially diagnosed with FSS was 8.8% (95% CI 1.0 to 22.2, p=0.007) in diagnostic evaluation studies and 0.5% (95% CI 0.01 to 1.5, p=0.03) in follow-up studies. Partially or possibly related diagnoses were rarely found. No specific somatic diagnosis seemed to be missed systematically.

CONCLUSIONS

The percentage of underlying somatic diseases in patients previously diagnosed with FSS is relatively small but unneglectable.

2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary

BACKGROUND

Recent neurophysiological evidence attests to the validity of fibromyalgia (FM), a chronic pain condition that affects >2% of the population.

OBJECTIVES

To present the evidence-based guidelines for the diagnosis, management and patient trajectory of individuals with FM.

METHODS

A needs assessment following consultation with diverse health care professionals identified questions pertinent to various aspects of FM. A literature search identified the evidence available to address these questions; evidence was graded according to the standards of the Oxford Centre for Evidence-Based Medicine. Drafted recommendations were appraised by an advisory panel to reflect meaningful clinical practice.

RESULTS

The present recommendations incorporate the new clinical concepts of FM as a clinical construct without any defining physical abnormality or biological marker, characterized by fluctuating, diffuse body pain and the frequent symptoms of sleep disturbance, fatigue, mood and cognitive changes. In the absence of a defining cause or cure, treatment objectives should be patient-tailored and symptom-based, aimed at reducing global complaints and enhancing function. Healthy lifestyle practices with active patient participation in health care forms the cornerstone of care. Multimodal management may include nonpharmacological and pharmacological strategies, although it must be acknowledged that pharmacological treatments provide only modest benefit. Maintenance of function and retention in the workforce is encouraged.

CONCLUSIONS

The new Canadian guidelines for the treatment of FM should provide health professionals with confidence in the complete care of these patients and improve clinical outcomes.

A medicolegal analysis of worker appeals for fibromyalgia as a compensable condition following workplace soft-tissue injury

OBJECTIVE

Workplace injuries may be implicated in the causation of fibromyalgia (FM), hence linking FM to compensation. We examined the appeals by workers directed to an appeals tribunal for causation of FM following soft-tissue injury sustained in the workplace.

METHODS

One hundred fifty tribunal decisions relevant to FM were examined using a predetermined protocol. New-onset FM was appealed in 123, and aggravation of preexisting FM in 15.

RESULTS

All injuries were of a soft-tissue type, without persistent physical findings to explain continued symptoms. The tribunal accepted 67% of appeals for aggravation of FM, and 59% for new-onset FM. Time from injury to FM diagnosis was 4.3 ± 4.1 years, with 6.3 ± 2.8 physicians cited for each worker, and with previous health status not reported for 26%. Injuries were a single event in 68%, with location in low back for 44%, and shoulder/upper limb in 40%. The FM diagnosis was based on a rheumatologist report in 74%.

CONCLUSION

Over half of appeals for aggravation or causation of FM following a work-related soft-tissue injury were accepted by the tribunal, with importance ascribed to a rheumatologist diagnosis. Concerns are raised regarding lengthy duration from injury to diagnosis, claimants' high healthcare use, and neglect of mention of previous health status. The attribution of causation of FM to a soft-tissue workplace traumatic event is contentious and requires further examination.

Fibromyalgia syndrome: an overview of pathophysiology, diagnosis and management

Fibromyalgia Syndrome (FMS) is a chronic condition causing pain, stiffness, and tenderness of the muscles, tendons, and joints. It is also characterized by restless sleep, tiredness, fatigue, anxiety, depression, and disturbances in bowel functions. The etiology of fibromyalgia remains unknown, but recent advances and discoveries have helped to unravel some of the mysteries of this disease. Research highlights some of the biochemical, metabolic, and immunoregulatory abnormalities associated with fibromyalgia. Management of FMS at the present time is very difficult as it has multiple etiological factors and psychological predispositions; however, a patient centered approach is essential to handle this problem.

Treatment patterns among physician specialties in the management of fibromyalgia: results of a cross-sectional study in the United States

BACKGROUND

Fibromyalgia (FM) is characterized by persistent and widespread pain and often associated with other symptoms and comorbidities. Thus, FM patients seek care from multiple physician specialties. This study compared prescribing patterns, patient-reported outcomes (PROs), healthcare resource use (HRU), and direct costs related to FM in routine clinical practice across physician specialties.

METHODS

This cross-sectional, observational study recruited 203 FM subjects from 20 community-based physician offices (eight primary care, six rheumatology, three neurology, three psychiatry). Subjects completed questions about pain, other symptoms, quality of life, productivity, treatment effectiveness and satisfaction, and out-of-pocket expenses related to FM; site staff recorded subjects' treatment and HRU based on medical chart review. Results were compared across specialties. Statistical significance was evaluated at the 0.05 level. Annual direct costs associated with FM were calculated in 2009 US dollars.

RESULTS

Subject demographic and clinical characteristics were not significantly different across physician specialties, except psychiatry subjects had the highest mean number of co-morbid conditions; p < 0.001. PROs were similar across physician specialties except fatigue; neurology subjects reported the highest levels. There were no significant differences in subject-reported outcomes of medication effectiveness (p = 0.782) and medication satisfaction (p = 0.338) for FM. Psychiatry subjects had more FM-related physician visits compared to other specialties (p = 0.013) and a higher proportion received diagnostic tests related to FM (p = 0.013). The mean (SD) number of FM prescription medications prescribed per subject was highest in the primary care and lowest in the neurology group; p = 0.024. The proportion of hypnotic (p = 0.001), muscle relaxant (p = 0.005), anxiolytic (p = 0.005), anti-epileptic (p = 0.007), and other medications (p = 0.044) prescribed for FM were significantly different across specialties. Overall direct medical costs did not differ significantly (p = 0.284) across specialties.

CONCLUSIONS

Patient characteristics were similar across specialties, except with regards to comorbidity burden. This study noted significant differences among physician specialties in HRU and treatment patterns among medications, diagnostics, and outpatient visits. Consistent with other studies, this study did not identify a dominant strategy for FM management across physician specialties as overall per patient medical costs and subject-reported treatment satisfaction were similar. Future research to better characterize differences among physician specialties in FM management, as well as the reasons for these differences, would be useful.

Clinical Aspects and Management of Fibromyalgia Syndrome

Fibromyalgia syndrome (FMS) is a chronic and debilitating musculoskeletal pain disorder of unknown aetiology with usual accompanying features of fatigue, sleep disturbances and stiff- ness. Its place in medical textbooks was controversial with rheumatologists holding the helm of its management for many years. Over the last decade, abnormalities have been identified at multiple levels in the peripheral, central, and sympathetic nervous systems as well as the hypothalomo-pitutary-adrenal axis stress response system. With the elucidation of these pathways of pain, FMS is known more as a central sensitivity syndrome. This led to tremendous increment in interest in both pharmacological and non-pharmacological treatment of FMS. The United States Food and Drug Administration (FDA) has also successively approved 3 drugs for the management of fibromyalgia – pregabalin, duloxetine and milnacipran. Non-pharmacological modalities showed aerobic exercise, patient education and cognitive behavioural therapy to be most effective. Overall, management of FMS requires a multi-disciplinary approach. Key words: Aetiology, Fibromyalgia-Fibromyositis Syndromes, History, Pain syndrome