Poster Presentations
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| Poster Presentation from the American College
of Rheumatology's 62nd National Meeting November 8-12,
1998 Abstract: 1546 November 11, 1998 Poster Session E: ARHP Poster Session II Quality of Well-being in Patients with Osteoarthritis and Fibromyalgia
S. Schmidt, R. Olmedo, E. Groessl1, T. Cronan Chronic disease and age are both related to a patient's quality of life. It is important to understand the relationships among these variables to develop interventions that can improve quality of life. The present study compared quality of well-being scores for two groups of people with different chronic conditions, osteoarthritis (OA) and fibromyalgia syndrome (FMS). The group of 363 OA participants was 64% women, with 72.5% married, 92.3% caucasian, and a mean age of 69.2 (SD = 5.63). The group of 316 FMS participants was 95.9% women, with 69% married, 88.3% caucasian, and a mean age of 56.4 (SD = 10.51). The participants' quality of life was assessed using the Quality of Well-being (QWB) scale. An overall QWB score is calculated by combining 4 weighted subscales: symptom problem complex (CPX), mobility (MOB), physical activity (PAC), and social activity (SAC). Scores can range from 0 to 1 with 1 representing optimal asymptomatic functioning. A one-way analysis of variance was used to compare the two groups on overall QWB and on the 4 subscales. The group with OA scored significantly higher than the FMS group on overall QWB (F(1, 677) = 137.28, p < .0001) and on all 4 subscales. A one way analysis of variance was also use to compare the ages of the groups. The OA group was significantly older than the FMS group (F(1, 677) = 394.57, p < .0001). Increasing age is viewed as a primary factor associated with decreased quality of life, but the results of the present study indicate that a group of people who are 13 years older on average has a better quality of life thana younger group, although both groups suffer from a chronic health problem. Therefore, FMS appears to be a much more debilitating condition than osteoarthritis. Lower quality of life at an earlier age presents difficult challenges for people with FMS and indicates a special need for interventions to improve the quality of life for people with FMS. Disclosure: work reported in this abstract was supported by: National Institute of Arthritis and Musculoskeletal & Skin Diseases. Osteoarthritis: other, Fibromyalgia, Disability, Quality of life
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| Poster Presentation from the American College
of Rheumatology's 62nd National Meeting November 8-12, 1998
Abstract: 1365 November 11, 1998 A Survey of the Use and Effectiveness of Conventional snd Alternative Therapies for Fibromaylgia
Sumedha S. Dalvi, Patricia Bankes, Charles H. Pritchard Fibromyalgia (FM) pts may explore alternative therapies due to suboptimal results with conventional medications. We conducted a survey of FM pts to gain understanding of alternative modality utilization rates and efficacy of conventional and alternative therapies in relieving common symptoms. Pts were provided a checklist of nonprescription medications and nonpharmacological treatments (NPT) used for the treatment of FM and asked to grade the impact of each modality on pain, fatigue, sleep, well-being and function, using a Likert scale. Of the 117 surveys obtained (111 females, 6 males), majority of the pts (93%) had used alternative therapies: vitamins 68%, ointments 41%, herbs 38%, magnesium 35%, malic acid 25%, CoQ 21%, lecithin 15%, manganese 15%, selenium 13% and Gingko 12%. Use of NPT was noted; exercise 70%, meditation 34%, massage 54%, chiropractic 41% and acupuncture 20%. Melatonin, homeopathic/ayurvedic medications, magnets, myofascial release therapy etc. were used by <10% pts. Pain relief was provided by acetaminophen, NSAIDs, tramadol, aspirin, cyclobenzaprine and narcotics. Narcotics provided more pain relief than acetaminophen and had higher well-being scores than NSAIDs, acetaminophen and tramadol. Tricyclic antidepressants and cyclobenzaprine had higher sleep scores than SSRIs. Exercise and massage offered higher pain relief, sleep, well-being and function scores than acupuncture and better function scores than chiropractic treatments. Meditation and malic acid achieved higher scores with regard to well-being than acupuncture. As a significant proportion of FM pts use alternative therapies, more data is needed regarding benefits and risks. NPTs such as exercise, massage and meditation may offer significant symptom relief. Chiropractic manipulations have limited usefulness. Malic acid may be of some benefit. Acupuncture does not offer any significant benefit. No conclusions can be drawn on the usefulness of magnets, ointments, herbs, homeopathic and ayurvedic medications due to a small sample size.
Disclosure: work reported in this abstract was supported by:
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| Poster Presentation from the Physical Medicine
& Rehabilitation conference
Opioids for managing patients with chronic
pain: pharmacists’ perspectives and concerns Previous studies of pharmacists have elucidated unavailability of opioids and apprehension to dispense opioids. This study explores the perspectives and concerns pharmacists have towards dispensing opioids to manage patients with chronic pain. Fifty-two randomly selected New Jersey pharmacies were surveyed with a 69% (36/52) response rate. The results showed addiction to and diversion of opioids was considered a moderate to serious problem by 72% (26/36) of respondents. The definition of addiction was correctly identified by only 11% (4/36) of respondents. Moderate to complete reluctance to stock opioids was attributed to concerns about robbery by 14% (5/35) of respondents. Eight percent (3/36) of respondents had incurred a prior robbery. No correlation was found between those respondents who had a high degree of concern about robbery and those who had incurred previous robbery. Moderate to complete reluctance to stock opioids was attributed to concerns about federal or state investigation by 17% (6/36) of respondents. Interestingly, of the 20% (7/35) of the respondents who had incurred a prior federal or state investigation, none expressed more than minimal concern about opioid regulatory issues. The highest daily dose of oral morphine that respondents reported being comfortable dispensing ranged from 60 mg/day to 2000 mg/day, with an average of 411 mg/day, despite the fact that there is no pharmacologic ceiling on pure agonist opioids. Confidence in the acceptability of a physician prescribing opioids for chronic pain was 75% (27/36) for malignant pain in patients with no history of opioid abuse, and declined to 3% (1/36) for non-malignant pain in patients with a history of opioid abuse. Perceptions about dosing, addiction, and fear of regulatory scrutiny create barriers to effective pain management. Pharmacists may benefit from education regarding issues related to opioid analgesics.
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| 5-Hydroxytryptophan:
a clinically-effective serotonin precursor.
5-Hydroxytryptophan (5-HTP) is the intermediate metabolite of the essential amino acid L-tryptophan (LT) in the biosynthesis of serotonin. Intestinal absorption of 5-HTP does not require the presence of a transport molecule, and is not affected by the presence of other amino acids; therefore it may be taken with meals without reducing its effectiveness. Unlike LT, 5-HTP cannot be shunted into niacin or protein production. Therapeutic use of 5-HTP bypasses the conversion of LT into 5-HTP by the enzyme tryptophan hydroxylase, which is the rate-limiting step in the synthesis of serotonin. 5-HTP is well absorbed from an oral dose, with about 70 percent ending up in the bloodstream. It easily crosses the blood-brain barrier and effectively increases central nervous system (CNS) synthesis of serotonin. In the CNS, serotonin levels have been implicated in the regulation of sleep, depression, anxiety, aggression, appetite, temperature, sexual behaviour, and pain sensation. Therapeutic administration of 5-HTP has been shown to be effective in treating a wide variety of conditions, including depression, fibromyalgia, binge eating associated with obesity, chronic headaches, and insomnia.
Birdsall TC
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| Abnormal functional
activity of the central nervous system in fibromyalgia
syndrome.
The evaluation of pain is one of the major problems facing general practitioners and specialists in medicine. Although the source of pain can be usually be traced to specific abnormalities in a given organ system, some patients present with generalized pain syndromes, such as fibromyalgia, for which no specific source can be found. Some researchers have begun to consider that although there may be a somatic source of such pain at its initiation, over time the pain may be maintained or exacerbated by functional alterations in critical regions of the brain and spinal cord that are involved in pain processing or pain inhibition. This article describes the techniques currently used to measure regional cerebral blood flow (rCBF) in the brain by single photon emission computed tomography (SPECT) imaging, and reviews the SPECT and positron emission tomography literature concerning alterations in functional brain activity associated with pain in healthy individuals and in patients with chronic pain, including those with fibromyalgia. The article concludes by describing the implications of current knowledge about pain and abnormal functional brain activity in the understanding of the pathophysiology of fibromyalgia and in the development of therapeutic strategies to manage patients with this disorder.
Mountz JM, Bradley LA, Alarcon GS
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| Advances in
fibromyalgia: possible role for central neurochemicals.
The neurophysiologic term allodynia has been applied to fibromyalgia because people with that disorder experience pain from pressure stimuli which are not normally painful. The nociceptive neurotransmitters of animal studies are now relevant to this human model of chronic, widespread pain. Evidence is presented to implicate several chemical pain mediators (including serotonin, substance P, nerve growth factor, and dynorphin A) in the pathogenesis of fibromyalgia. This perception is hopeful because it offers many new options for the development of innovative therapy.
Russell IJ
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| Advances in the
treatment of fibromyalgia: current status and future
directions.
Despite significant efforts devoted to understanding the etiopathogenesis of fibromyalgia, its treatment still presents a challenge to practicing clinicians, who must recognize the disorder and quantify the different symptoms in order to treat it. This article discusses recent research to identify sensitive and reliable measures for determining response to treatment among patients with FM, and the elements of therapeutic programs (pharmacologic and nonpharmacologic) for patients with FM along with the empirical or theoretical basis for their use. Future directions, including the need for systematic, controlled outcome studies of therapies and evaluation of variables which may mediate the effects of treatment, as well as demonstration that the effects produced in outcome studies generalize to settings beyond those in which the studies are initially conducted, are also discussed.
Alarcon GS, Bradley LA
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| Affective distress in fibromyalgia syndrome
is associated with pain severity.
OBJECTIVE: Comparison of low back pain (LBP) patients with and without fibromyalgia syndrome (FMS) with regard to affective distress. METHODS: Patients with LBP who had been admitted to various clinics in Germany were examined upon admission. Comparisons were done by dividing the patients into groups with and without signs of FMS. Additionally, both groups were compared after being matched according to sex, age, and pain severity. RESULTS: 15 out of 135 LBP patients met the American College of Rheumatology criteria for fibromyalgia. Patients with FMS showed remarkably higher levels of pain severity and affective distress. After controlling for different levels of pain severity, these pronounced differences disappeared. CONCLUSION: Affective distress is not a unique feature of FMS, but seem to be caused entirely by higher levels of pain severity.
Walter B, Vaitl D, Frank R
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| The association of functional
gastrointestinal disorders and fibromyalgia.
Previous epidemiological studies have confirmed the clinical impression that functional gastrointestinal disorders typically overlap with fibromyalgia (FM) in the same patient, suggesting a common etiology. FM syndrome occurs in up to 60% of patients with functional bowel disorders. Up to 50% of patients with a diagnosis of FM syndrome complain of symptoms characteristic of functional dyspepsia and 70% have symptoms of IBS. These two conditions have common clinical characteristics: (1) the majority of patients associate stressful life events with the initiation or exacerbation of symptoms, (2) the majority of patients complain of disturbed sleep and fatigue, (3) psychotherapy and behavioral therapies are efficacious in treating symptoms, and (4) low-dose tricyclic antidepressant medication can improve symptoms. Despite these similarities, their perceptual responses to both somatic and visceral stimuli differ. While FM patients characteristically exhibit somatic hyperalgesia, IBS patients without coexistent FM have somatic hypoalgesia to mechanical stimuli. Visceral distention studies have also demonstrated perceptual alterations in patients with IBS and FM although these findings appear to differ in the two conditions. Further studies will help explore the mechanisms which are responsible for the similarities and differences in clinical symptoms and physiologic parameters seen in IBS and FM.
Chang L |
| The association
of soft-tissue rheumatism and hypermobility.
Soft-tissue rheumatism (STR--tendinitis, bursitis, fasciitis and fibromyalgia) accounts for up to 25% of referrals to rheumatologists. The estimated prevalence of generalized hypermobility in the adult population is 5-15%. There have previously been suggestions that hypermobile individuals may be predisposed to soft-tissue trauma and subsequent musculoskeletal pain. This study was designed to examine the mobility status and physical activity level in consecutive rheumatology clinic attendees with a primary diagnosis of STR. Of 82 patients up to age 70 yr with STR, 29 (35%) met criteria for generalized hypermobility. Hypermobile compared to non-hypermobile individuals reported significantly more previous episodes of STR (90% vs 51%, P < 0.01), and more recurrent episodes of STR at a single site (69% vs 38%, P < 0.001). Although we were unable to show any difference in the time spent carrying out physical activity between the two groups, the hypermobile patients were performing significantly more repetitive activities. When specific anatomical sites of STR were analysed, small joints (elbows, hands and feet) currently affected with STR were more likely to show localized hypermobility than if those joints were asymptomatic. These findings suggest that hypermobility may be a factor in the development of STR. Repetitive activity may be a contributing factor towards STR in some hypermobile individuals.
Hudson N, Fitzcharles MA, Cohen M, Starr MR, Esdaile JM
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| Biofeedback/relaxation
training and exercise interventions for fibromyalgia: a prospective
trial.
OBJECTIVE: To compare the effectiveness of biofeedback/relaxation, exercise, and a combined program for the treatment of fibromyalgia. METHODS: Subjects (n = 119) were randomly assigned to one of 4 groups: 1) biofeedback/relaxation training, 2) exercise training, 3) a combination treatment, or 4) an educational/attention control program. RESULTS: All 3 treatment groups produced improvements in self-efficacy for function relative to the control condition. In addition, all treatment groups were significantly different from the control group on tender point index scores, reflecting a modest deterioration by the attention control group rather than improvements by the treatment groups. The exercise and combination groups also resulted in modest improvements on a physical activity measure. The combination group best maintained benefits across the 2-year period. CONCLUSION: This study demonstrates that these 3 treatment interventions result in improved self-efficacy for physical function which was best maintained by the combination group.
Buckelew SP, Conway R, Parker J, Deuser WE, Read J, Witty TE, Hewett
JE, Minor M, Johnson JC, Van Male L, McIntosh MJ, Nigh M, Kay DR
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| Chronic fatigue and
chronic fatigue syndrome: shifting boundaries and
attributions.
The subjective symptom of "fatigue" is one of the most widespread in the general population and is a major source of healthcare utilization. Prolonged fatigue is often associated with neuropsychological and musculoskeletal symptoms that form the basis of several syndromal diagnoses including chronic fatigue syndrome, fibromyalgia, and neurasthenia, and is clearly not simply the result of a lack of force generation from the muscle. Current epidemiologic research in this area relies predominantly on self-report data to document the prevalence and associations of chronic fatigue. Of necessity, this subjective data source gives rise to uncertain diagnostic boundaries and consequent divergent epidemiologic, clinical, and pathophysiologic research findings. This review will highlight the impact of the case definition and ascertainment methods on the varying prevalence estimates of chronic fatigue syndrome and patterns of reported psychological comorbidty. It will also evaluate the evidence for a true postinfective fatigue syndrome.
Lloyd AR
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| Chronic fatigue
syndrome and fibromyalgia. Dilemmas in diagnosis and clinical
management.
There has been a resurgence of interest in recent years in both chronic fatigue syndrome and fibromyalgia. These perplexing and common clinical conditions are a source of significant patient morbidity and frame one of the more enduring dilemmas of contemporary Western medical thought, namely the ambiguous interface between mind and body. In this article, the current definitions are reviewed, and a framework for an emerging psychobiological model of these syndromes is presented. These issues are synthesized into a pragmatic approach to clinical management.
Demitrack MA
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| Chronic fatigue
syndrome differs from fibromyalgia. No evidence for elevated substance P
levels in cerebrospinal fluid of patients with chronic fatigue
syndrome.
Levels of substance P were determined in the cerebrospinal fluid (CSF) in 15 patients with chronic fatigue syndrome (CFS). All values were within normal range. This is in contrast to fibromyalgia (FM). The majority of patients with FM have increased substance P values in the CSF. The results support the notion that FM and CFS are different disorders in spite of overlapping symptomatology.
Evengard B, Nilsson CG, Lindh G, Lindquist L, Eneroth P, Fredrikson
S, Terenius L, Henriksson KG
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| Chronic myofascial pain: knowledge of
diagnosis and satisfaction with treatment.
OBJECTIVE: To examine the relation between pain patients' knowledge of pain diagnosis and their satisfaction with pain treatment. It was hypothesized that myofascial pain (MP) patients would be less knowledgeable regarding their diagnosis and less satisfied with the results of pain treatment. DESIGN: Cross-sectional. SETTING: Multidisciplinary pain clinic. PATIENTS: Patients (n=65) were divided into two groups after multidisciplinary assessment: MP patients (n=30) and a mixed group of chronic pain patients (MCP) (n=35) with neurologic or rheumatologic disorders. MAIN OUTCOME MEASURES: Patient self-report of their knowledge of pain diagnosis and scores on standardized measures of pain intensity, depressive symptoms, and functional disability. RESULTS: MP patients were significantly less accurate in identifying their diagnosis and the source of their pain and were more likely to believe they suffered a physiologic disturbance "more serious and different" than their physicians had suggested. MP patients were also significantly more dissatisfied with the treatment for pain by physicians and reported particular dissatisfaction with the informational aspects of physician-patient communication. No group differences were obtained for measures of pain severity, depression, disability, pain duration, or compensation/litigation status. CONCLUSION: MP patients appear to have less accurate beliefs regarding their pain symptoms and express more dissatisfaction with physician efforts to treat their pain. These findings emphasize the importance of patient education as a component of chronic pain intervention, particularly for MP patients.
Roth RS, Horowitz K, Bachman JE
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| Chronic orofacial muscle pain: a new approach
to diagnosis and management.
The initial data from this study indicate that there are clearly identifiable chronic muscle pain conditions in the form of localized pain; myofascial pain or regional pain conditions; and fibromyalgia or generalized pain conditions. A clear difference exists between the prevalence of these conditions in male and female patients, with a higher percentage of female patients suffering generalized pain problems and temporomandibular problems. Generalized or localized pain appears to be an individual variant of a similar problem and pain patients may have a genetically determined vulnerability associated with bacterial toxins, particularly within the genitourinary tract. It appears that in fibromyalgia there is an underlying genetic factor that causes abnormalities in the muscle metabolic cycle, and preliminary data suggest that lipid anomalies predispose to fibromyalgia and possibly chronic fatigue syndrome. Patients report infectious events at/or around onset in more than 60 percent of cases. Seventy percent of fibromyalgic cases report orofacial pain.
Klineberg I, McGregor N, Butt H, Dunstan H, Roberts T, Zerbes M
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| Chronic pain and
fatigue syndromes: overlapping clinical and neuroendocrine features and potential
pathogenic mechanisms.
Patients with unexplained chronic pain and/or fatigue have been described for centuries in the medical literature, although the terms used to describe these symptom complexes have changed frequently. The currently preferred terms for these syndromes are fibromyalgia and chronic fatigue syndrome, names which describe the prominent clinical features of the illness without any attempt to identify the cause. This review delineates the definitions of these syndromes, and the overlapping clinical features. A hypothesis is presented to demonstrate how genetic and environmental factors may interact to cause the development of these syndromes, which we postulate are caused by central nervous system dysfunction. Various components of the central nervous system appear to be involved, including the hypothalamic pituitary axes, pain-processing pathways, and autonomic nervous system. These central nervous system changes lead to corresponding changes in immune function, which we postulate are epiphenomena rather than the cause of the illnesses.
Clauw DJ, Chrousos GP
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| Clinical diagnosis
found in patients with Raynaud's phenomenon: a multicentre
study.
A multicentre observational study was conducted in order to detect the major clinical diagnosis found in 761 patients with Raynaud's phenomenon (RP) attending 50 Italian centres for rheumatology and internal medicine. Systemic sclerosis was the most frequent condition associated with secondary RP, occurring in 216 (28.4%) patients. The other most frequent clinical diagnoses included systemic lupus erythematosus (52 cases: 6.8%) and rheumatoid arthritis (38 cases: 5%). Other RP-related diseases (hypertension, Sjogren's syndrome, mixed connective tissue disease, undifferentiated connective tissue disease, fibromyalgia, carpal tunnel syndrome, cryoglobulinemia, dermatopolymyositis, vasculitis, thoracic outlet syndrome, hypothyroidism, diabetes mellitus) occurred in less than 5% of cases. A total of 130 (48%) out of 268 patients with primary RP showed one or more clinical features indicating a fairly high risk of evolving into fully established systemic sclerosis. None of these patients fulfilled the ACR criteria for systemic sclerosis. This study shows that over 50% of patients with RP attending 50 Italian centres for rheumatology and internal medicine had a connective tissue disease. The large number of patients with primary RP and isolated clinical features of connective tissue disease indicates that more efforts should be focused on developing new criteria for the classification of RP.
Grassi W, De Angelis R, Lapadula G, Leardini G, Scarpa R
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| [Clinical experiences
with the analgesic effects of citalopram].
Antidepressive drugs influencing the serotonin metabolism have shown some efficacy in treatment of generalised pain syndrome. The aim of the present study was to observe the analgesic effect of citalopram < 1-[3-(dimetilamino)propil]-1-(p-florofenil)-5-ftal+ ++ankarbonitin > in 20 non depressive patients with chronic pain syndrome (fibromyalgy and/or radicular pain). On the base of a short time (6 weeks) observation a limited clinical effect was observed, however, the Seropram seems to have some benefits in the treatment of chronic pain.
Baraczka K, Janko Z, Vargha K, Markus H
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| Collagen cross-links in fibromyalgia
syndrome.
OBJECTIVE: The acceptance of fibromyalgia as a disease entity and its definitive diagnosis have been hampered by a dearth of knowledge concerning the underlying pathophysiology of this disease and the lack of specific biochemical markers applicable to its diagnosis. To determine whether abnormal collagen metabolism is a characteristic of fibromyalgia, we have analyzed collagen metabolites in the urine and serum of patients with fibromyalgia. METHODS: The diagnosis of fibromyalgia was made according to the American College of Rheumatology criteria. Urine and serum were collected under standardized conditions from 39 patients and 55 age- and sex-matched controls. Pyridinoline (Pyd) and deoxypyridinoline (Dpyd), which represent products of lysyl oxidase-mediated cross-linking in collagen and are indicators of connective tissue and bone degradation, respectively, were analyzed by ion-paired and gradient HPLC method with fluorescence detection (HPLC). Levels of hydroxypyroline (Hyp), a collagen turnover marker, were also measured. The findings were related to creatinine levels and the Pyd/Dpyd ratio determined. RESULTS: The Pyd/Dpyd ratios in the urine and serum and the Hyp in the urine were significantly lower in patients with fibromyalgia than in healthy controls. CONCLUSION: Decreased levels of collagen cross-linking may contribute to remodeling of the extracellular matrix and collagen deposition around the nerve fibers in fibromyalgia and contribute to the lower pain threshold at the tender points. Analysis of altered collagen metabolism either by histologic examination on biopsy or, preferably, by HPLC analysis of collagen metabolites in urine or serum may aid to understand more about the pathogenesis of fibromyalgia.
Sprott H, Muller A, Heine H |
| Comorbidity between
myofascial pain of the masticatory muscles and fibromyalgia.
This study compared myofascial pain of the masticatory muscles to fibromyalgia. Study data show that, in both myofascial pain and fibromyalgia patients, facial pain intensity and its daily pattern and effect on quality of life are very similar. This indicates that fibromyalgia should be included in the differential diagnosis for myofascial pain of the masticatory muscles. However, with the higher prevalence of neurologic and gastrointestinal symptoms, and the stronger words used to describe the affective dimension of pain, it is apparent that fibromyalgia may be a more debilitating condition than myofascial pain of the masticatory muscles. Since the intensity of facial pain was strongly and significantly correlated to the body-pain index in fibromyalgia but not in myofascial pain patients, it can be concluded that facial pain may be part of the clinical manifestations of fibromyalgia, but it is unlikely to be related to body pain in myofascial pain patients. On the other hand, while body pain is episodic in most myofascial pain patients, it is constant and more severe in the majority of fibromyalgia patients. This difference in the pain patterns suggests that body pain in fibromyalgia and myofascial pain could have different etiologies. The lack of correlation between the intensity of pain and the length of time since onset also supports the concept that myofascial pain of the masticatory muscles and fibromyalgia are unlikely to be progressive disorders.
Dao TT, Reynolds WJ, Tenenbaum HC
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| Comparison of
integrated group therapy and group relaxation training for
fibromyalgia.
OBJECTIVE: The efficacy of an integrated, psychological treatment program was tested in a controlled study involving 27 patients with chronic musculoskeletal pain (fibromyalgia). DESIGN: The experimental treatment program consisted of instruction in various self-help techniques (e.g., cognitive behavioral strategies, relaxation, physical exercises) as well as information on chronic pain. Control groups were instructed only in autogenic training. Measures of pain, daily activities, general symptoms, and psychological functioning were assessed before and after treatment, as well as at 4 months after termination of therapy (follow-up). RESULTS: At the end of treatment, 7 patients from the experimental group and 2 from the control group showed significant clinical improvement in 3 of 6 parameters (NS). At follow-up, the improvement was still present in 5 experimental cases but in none of the controls (p = 0.024). Successful patients had been sick for a shorter period of time and were less impaired by their condition. CONCLUSIONS: Psychological interventions in combination with physiotherapy can be effective in treating fibromyalgia patients, especially if applied early.
Keel PJ, Bodoky C, Gerhard U, Muller W
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| Comparison of
clinical and psychologic features of fibromyalgia and masticatory myofascial
pain.
The aim of this study was to investigate common symptoms and divergent features in fibromyalgia (FS) and masticatory myofascial pain (MFP) in patients affected by craniomandibular disorders. Twenty-three women with MFP and 23 women with FS were studied. All patients were examined by a dentist and by a rheumatologist. Craniomandibular disorders were assessed with a subjective symptoms questionnaire, detailed history interview, joint function examination, and manual palpation of masticatory and cervical muscles. The Middlesex Hospital Questionnaire was used to obtain personality profiles of the patients. The craniomandibular disorders questionnaire revealed various similarities in the two groups, the most striking of which were pain during mandibular function, articular noises, and headache. Both groups had muscle pain upon palpation; the mean scores (on a 0 to 4 scale) did not differ significantly between the two groups and ranged between 1.39 (SD 1.2) and 2.86 (SD 0.75). The mean value of active mouth opening was 40.9 mm (SD 9.1) in MFP patients and 44.6 mm (SD 7.2) in FS patients, while the mean value of passive opening was 49.6 mm (SD 6.0) in MFP patients and 49.8 mm (SD 3.5) in FS patients. These values did not differ significantly between the two groups, but did differ from the normal population, similar to the trend of the psychologic profile. The authors conclude that the physician should be alert to the need to conduct interdisciplinary evaluations in the diagnosis and management of FS and of MFP.
Cimino R, Michelotti A, Stradi R, Farinaro C
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| A comparison
of three types of neck support in fibromyalgia patients.
OBJECTIVE: To determine the effectiveness of 3 types of neck support for patients with fibromyalgia (FMS) and their preference for the type of support. METHODS: Thirty-five patients with FMS chose the order of application and used each type of neck support for a 2-week period, followed by a 2-week washout. The same schedule was repeated a second time. The neck supports included a Shape of Sleep pillow, two neck ruffs with one standard pillow, and a single standard pillow. All subjects received a physiotherapy treatment and educational program in the home. Outcome measures included visual analog scales (VAS) for neck pain and quality of sleep, the Fibromyalgia Impact Questionnaire (FIQ), and a neck and shoulder pain distribution diagram. RESULTS: Analysis using Friedman's 2-way analysis of variance revealed no significant differences in any outcome measure, although there was a trend towards improvement in the FIQ and VAS neck pain and quality of sleep scores for some patients. Most participants (62.9%) preferred the Shape of Sleep pillow, 20.0% preferred cervical ruffs with one standard pillow, and 17.1% preferred a single standard pillow. CONCLUSIONS: The results of this study are inconclusive due to the small sample size. However, from a patient's perspective, neck support is an important part of a comprehensive physiotherapy program. Most participants preferred the more rigid support of a Shape of Sleep pillow. Further research into the efficacy of the use of neck support in people with FMS is warranted.
Ambrogio N, Cuttiford J, Lineker S, Li L
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| The connection
between chronic fatigue syndrome and neurally mediated
hypotension.
Research from several groups of investigators indicates that some patients with chronic fatigue syndrome have abnormal vasovagal or vasodepressor responses to upright posture. If confirmed, these findings may explain some of the symptoms of chronic fatigue syndrome. There is also speculation that neurally mediated hypotension may be present in fibromyalgia. This article discusses the original research in this area, the results of follow-up studies, and the current approach to treating patients with chronic fatigue syndrome in whom neurally mediated hypotension is suspected.
Wilke WS, Fouad-Tarazi FM, Cash JM, Calabrese LH
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| Current concepts
in the pathophysiology of abnormal pain perception in
fibromyalgia.
Fibromyalgia is a noninflammatory rheumatic disorder characterized by chronic widespread musculoskeletal pain. Although many studies have described the pain and other clinical symptoms associated with this disorder, the primary mechanisms underlying the etiology of fibromyalgia remain elusive. This article reviews recent data supporting the links among each of three systems--the musculoskeletal system, the neuroendocrine system, and the central nervous system (CNS), all of which appear to play major roles in fibromyalgia pathophysiology--and pain in fibromyalgia, and concludes by presenting a model of the pathophysiology of abnormal pain perception in fibromyalgia which integrates the research findings described.
Weigent DA, Bradley LA, Blalock JE, Alarcon GS
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| Daily activities in
women with rheumatoid arthritis. Aspects of patient education, assistive
devices and methods for disability and impairment assessment.
The major aims of the study were to identify the difficulties in daily activities (ADL) of women with rheumatoid arthritis (RA) and to demonstrate the effect of interventions. Methods were developed for measuring grip force, the Grippit instrument, and assessing ADL without and with assistive devices. Effects of interventions were explored, and the need for new solutions concerning daily activities was identified. Seventy-three women with RA participated in the study, 14 women with fibromyalgia were included in the grip force measurements, and 187 healthy women and 65 healthy men acted as a reference group. In describing the consequences of the disease with regard to daily activities, the patient's perspective was taken into account. RESULTS: Grip force (peak value and average value over 10 seconds) was reduced in women with RA compared to the reference values. With an elastic wrist orthosis, pain decreased and grip force increased significantly in defined ADL situations. After a patient education programme in joint protection, designed to influence knowledge, inspiration and action, on average 91% of the assistive devices provided were in use, most frequently for kitchen work and personal care. Pain also decreased significantly with the use of specially designed assistive devices like breadsaws, potato peelers, and scissors compared to using standard tools. The cost of these interventions could be judged to be low in relation to its effectiveness. Using an alternative model of the Health Assessment Questionnaire (HAQ) where the use of assistive devices did not influence the ratings, grip force was correlated to more ADL activities than disclosed by the ordinary HAQ ratings. The difference between these two models for rating HAQ items was demonstrated. The Evaluation of Daily Activity Questionnaire (EDAQ) was developed and can be used to evaluate both intrinsic (without assistive devices) and actual (with such assistance) disability. The EDAQ consists of 102 items arranged in 11 dimensions. The number of activities with perceived difficulty without assistive devices/altered working methods in RA women ranged between 13 and 99 and after interventions between 6 and 57. Assistive devices appeared most effective in the dimensions Eating, Cooking and Toileting. Only a few useful devices were identified in the dimensions Dressing, Washing/Clothes care and Cleaning. The ordinal score from EDAQ was transformed by the Rasch analysis to obtain linear measures. This allowed the construction of an acceptable model with items ranging from "hard" to "easy". The hardest items were found to be shopping and cleaning the kitchen floor, the easiest were walking indoors and using telephone. CONCLUSIONS: Women with RA have reduced grip force and pain, which affect their performance of daily activities. Usage of assistive devices and altered working methods reduced the perceived difficulty in various activities. The ADL items assessed with the EDAQ questionnaire, which also considers the individuals' own solutions to their problems, could be arranged hierarchically from "hard" to "easy".
Nordenskiold U
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| Depressed fibromyalgia
patients are equipped with an emphatic competence dependent
self-esteem.
Employing a recently developed questionnaire we studied the self-esteem structure of 61 female fibromyalgia (FM) patients by comparing them with i) 40 healthy psychology students and ii) 37 patients suffering from rheumatoid arthritis. Depressed FM patients (n=36) had a high need to gain self-esteem through competence and others' approval combined with a low basic sense of self-esteem. In this regard they differed significantly from the healthy controls who had a more equal amount of the two types of self-esteem. These patients had also a more demanding and "hard-driving" self-esteem structure than either control group and exhibited a lower self-assertiveness and less emotional candour than the healthy controls. The non-depressed FM patients did not display this self-esteem pattern. In conclusion, FM patients are probably not a homogeneous group. Furthermore, we suggest that an emphatic competence-dependent self-esteem is one vulnerability factor which, in proper genetic and environmental conditions, increases susceptibility to fibromyalgia and depression.
Johnson M, Paananen ML, Rahinantti P, Hannonen P
|
| The
detoxification enzyme systems.
The human body is exposed to a wide array of xenobiotics in one s lifetime, from food components to environmental toxins to pharmaceuticals, and has developed complex enzymatic mechanisms to detoxify these substances. These mechanisms exhibit significant individual variability, and are affected by environment, lifestyle, and genetic influences. The scientific literature suggests an association between impaired detoxification and certain diseases, including cancer, Parkinson's disease, fibromyalgia, and chronic fatigue/immune dysfunction syndrome. Data regarding these hepatic detoxification enzyme systems and the body s mechanisms of regulating them suggests the ability to efficiently detoxify and remove xenobiotics can affect these and other chronic disease processes. This article reviews the myriad detoxification enzyme systems, their regulatory mechanisms, and the dietary, lifestyle, and genetic factors influencing their activities, as well as laboratory tests available to assess their functioning.
Liska DJ
|
| Differential
responses by psychosocial subgroups of fibromyalgia syndrome patients to
an interdisciplinary treatment.
OBJECTIVES: To evaluate differential treatment responses among 3 empirically derived, psychosocial subgroups of patients with fibromyalgia syndrome to a standard interdisciplinary treatment program. METHOD: Patients were classified into 1 of 3 psychosocial groups on the basis of their responses to the Multidimensional Pain Inventory. Forty-eight patients completed a 6 one-half-day outpatient treatment program consisting of medical, physical, occupational, and psychological therapies spaced over a period of 4 weeks (3 sessions the first week followed by 1 session per week for the next 3 consecutive weeks). RESULTS: Statistically significant reductions were observed in pain, affective distress, perceived disability, and perceived inteference of pain in the patients characterized by poor coping and high level of pain ("dysfunctional" group). In contrast, individuals who were characterized by interpersonal difficulties ("interpersonally distressed" group) exhibited poor responses to the treatment. "Adaptive copers," the third group, revealed significant improvements in pain but due to low pretreatment levels of affective distress and disability showed little improvement on these outcomes. CONCLUSIONS: The results provided support for the hypothesis that customizing treatment based on patients' psychosocial needs will lead to enhanced treatment efficacy. They also emphasize the importance of using appropriate outcome criteria, as low levels of problems at baseline are not likely to show significant changes following any treatment.
Turk DC, Okifuji A, Sinclair JD, Starz TW
|
| Disordered growth hormone secretion
in fibromyalgia: a review of recent findings and a hypothesized
etiology.
Growth hormone (GH) deficiency occurs in about 30% of fibromyalgia patients. Treatment of GH deficient fibromyalgia patients with recombinant growth hormone improves several clinical features, including the tender point count. Defective GH secretion in these patients appears to be due to increased somatostatin tone in the hypothalamus. An hypothesis is presented which relates dysfunctional GH secretion to the effects of intermittent hypercortisolemia on upregulating the density of beta-adrenergic receptors in the hypothalamus. The resulting augmentation of beta-adrenergic tone stimulates the release of somatostatin, thus, impairing GH secretion.
Bennett RM
|
| Doctors' attitudes
to fibromyalgia: a phenomenological study.
Besides specific technical skills, successful encounters with patients require an understanding of the many ways in which patients may express themselves. This qualitative study reports on the clinical experiences of doctors when meeting patients with fibromyalgia (FM). Ten strategically chosen rheumatologists and 10 GPs in central Sweden were interviewed. The interviews were taped, transcribed and analysed in accordance with the empirical, phenomenological, psychological method. The analyses indicate that doctors try to comply with the wishes and demands of patients, and at the same time avoid perceptions of personal frustration.
They are inclined to be objective and to act instrumentally, apparently in
order to keep in touch with what gave biomedical meaning to an otherwise
incomprehensible phenomenon. The meaning structures revealed by doctors'
descriptions of FM and of relating to FM patients were characterized mainly
by the way in which the doctors were (i) managing their clinical uncertainty,
Hellstrom O, Bullington J, Karlsson G, Lindqvist P, Mattsson B
|
Dyspnea resulting from fibromyalgia.Two patients with chronic, severe, episodic dyspnea underwent prolonged, extensive, and invasive evaluations without a diagnosis being made. Both were subsequently diagnosed with fibromyalgia, and therapy directed at this condition resulted in resolution of their symptoms. Fibromyalgia is rarely included in the differential diagnosis of dyspnea, and timely diagnosis and treatment may be delayed. However, this condition must be considered because it can only be established by seeking the appropriate history and physical findings.
Weiss DJ, Kreck T, Albert RK
|
| Early life stress, negative paternal
relationships, and chemical intolerance in middle-aged women: support for
a neural sensitization model.
This study (ntotal = 35) compared early life stress ratings, parental relationships, and health status, notably orthostatic blood pressures, of middle-aged women with low-level chemical intolerance (CI group) and depression, depressives without CI (DEP group), and normals. Environmental chemical intolerance is a symptom of several controversial conditions in which women are overrepresented, that is, sick building syndrome, multiple chemical sensitivity, chronic fatigue syndrome, and fibromyalgia. Previous investigators have postulated that people with CI have variants of somatization disorder, depression, posttraumatic stress disorder (PTSD) initiated by childhood abuse or a toxic exposure event. One neurobehavioral model for CI, somatization disorder, recurrent depression, and PTSD is neural sensitization, that is, the progressive amplification of host responses (e.g., behavioral, neurochemical) to repeated intermittent stimuli (e.g., drugs, chemicals, endogenous mediators, stressors). Females are more vulnerable to sensitization than are males. Limbic and mesolimbic pathways mediate central nervous system sensitization. Although both CI and DEP groups had high levels of life stress and past abuse, the CI group had the most distant and weak paternal relationships and highest limbic somatic dysfunction subscale scores. Only the CI group showed sensitization of sitting blood pressures over sessions. Together with prior evidence, these data are consistent with a neural sensitization model for CI in certain women. The findings may have implications for poorer long-term medical as well as neuropsychiatric health outcomes of a subset of women with CI. Subsequent research should test this model in specific clinical diagnostic groups with CI.
Bell IR, Baldwin CM, Russek LG, Schwartz GE, Hardin EE
|
| Effect of
gamma-hydroxybutyrate on pain, fatigue, and the alpha sleep anomaly in patients
with fibromyalgia. Preliminary report.
OBJECTIVE: To evaluate the effects of using a gamma-hydroxybutyrate (GHB) administered in divided doses at night in 11 patients previously diagnosed with fibromyalgia (FM). METHODS: Subjects completed daily diaries assessing their pain and fatigue levels and slept in the sleep laboratory before and one month after initiating GHB treatment. Polysomnographic recordings were evaluated for sleep stages, sleep efficiency and the presence of the alpha anomaly in non-REM sleep. RESULTS: There was a significant improvement in both fatigue and pain, with an increase in slow wave sleep and a decrease in the severity of the alpha anomaly. CONCLUSION: Further controlled studies are needed to characterize the clinical improvement and the polysomnographic changes we observed.
Scharf MB, Hauck M, Stover R, McDannold M, Berkowitz D
|
| Effect of local
glucocorticoid injection on masseter muscle level of serotonin in patients
with chronic myalgia.
The aim of this study was to compare the effects on the level of serotonin (5-HT) in the masseter muscle by intramuscular glucocorticoid (GC) administration in patients with fibromyalgia (FM) and localized myalgia (LM), as well as to determine associated changes in pain, tenderness, and microcirculation. The study comprised 22 patients with pain and tenderness in the masseter muscle region. Ten patients (all women) had FNI, and 12 (1 man and 11 women) had LM involving the temporomandibular system. The patients were examined clinically and by microdialysis at 2 visits 2-3 weeks apart and received local glucocorticoid treatment at the first visit. The ratio (S1/S2) between the initial level of 5-HT (S1) and steady state level (S2) was used as a relative measure of the intramuscular release of 5-HT. This ratio decreased significantly after treatment in the FM group. In the FM group there was also a negative correlation regarding changes between visits of 5-HT and changes of intramuscular temperature. In the LM group there was a negative correlation regarding changes between visits of 5-HT and changes of pressure pain threshold and pressure pain tolerance level. This study indicates that there is a reduction of the ratio between initial 5-HT and steady state level in the painful masseter muscle after intramuscular GC administration to FM patients, a reduction not present in the LM patients. In addition, 5-HT seems to be involved in the modulation of local muscle microcirculation in FM patients and in hyperalgesia in LM patients.
Ernberg M, Hedenberg-Magnusson B, Alstergren P, Kopp S
|
| The effect of pain on memory for affective
words.
Memory is a key cognitive variable in pain management, but lacks extensive research. This study is a replication and extension of Seltzer and Yarczower's investigation of pain's influence on memory for affective words, which found fewer positive words and more negative words recalled if subjects were in acute pain (versus no pain). In the present study, two experiments were conducted: one with a recall memory test and one with a recognition memory test. One hundred sixty undergraduate subjects were randomly placed in one of four groups: two groups had the same condition (pain or no pain) for both the encoding task and memory test, and two groups had mixed conditions (pain at encoding-no pain at memory test or no pain at encoding-pain at memory test). Pain was induced by 0 degrees-2 degrees C water immersion. At encoding, subjects categorized words by judging them as either positive or negative. Results of both experiments show that pain impairs memory. In neither experiment were differences found on memory for positive and negative words. These results do not support Seltzer and Yarczower's discriminative effects of pain on word category, but they are consistent with other research using acute pain manipulations and chronic pain populations, suggesting that pain interferes with memory. It is hypothesized that pain depletes scarce attentional resources, thereby interfering with concurrent cognitive tasks such as thinking, reasoning, and remembering.
Kuhajda MC, Thorn BE, Klinger MR
|
| The effect of
reproductive events and alterations of sex hormone levels on the symptoms
of fibromyalgia.
The fibromyalgia syndrome (FS) is a chronic pain disorder frequently affecting women of fertile age. However, the relationship of FS and pregnancy has been given little attention. In the present retrospective analysis, based on personal interviews, the influence on FS symptomatology by pregnancy, abortion, menstruation, use of oral contraceptives, and breast feeding was investigated. Twenty-six women with an established diagnosis of FS and a total of 40 pregnancies during disease were included in the study. With the exception of one patient, all women described worsening fibromyalgia symptoms during pregnancy with the last trimester experienced as the worst period. A new change of fibromyalgia symptoms within 6 months after delivery was reported for 37 of the 40 pregnancies, to the better in four and to the worse in 33 cases, resulting in a prolonged sick leave for 14 patients. An increase in depression and anxiety was a prominent problem in the post partum period. FS had no adverse effect on the outcome of pregnancy or the health of the neonate. In the majority of patients with FS, hormonal changes connected with abortion, use of hormonal contraceptives, and breast feeding did not modulate symptom severity. A pre-menstrual worsening of symptoms was recorded by 72% of the patients. Comparing the 26 patients who had borne children during disease with 18 patients who had all their children before the onset of FS revealed a negative effect of pregnancy and the post partum period of FS and increased functional impairment and disability in the 26 patients.
Ostensen M, Rugelsjoen A, Wigers SH
|
| The effects of delta
wave sleep interruption on pain thresholds and fibromyalgia-like symptoms
in healthy subjects; correlations with insulin-like growth factor
I.
OBJECTIVE: To assess the effects of delta wave sleep interruption (DWSI) on pain thresholds and fibromyalgia-like symptoms. To examine the potential correlations between DWSI and serum insulin-like growth factor 1 (IGF-1). METHODS: Thirteen healthy volunteers were subjected to 3 consecutive nights of DWSI (Group 1). Pain thresholds were measured by dolorimetry and symptoms by visual analog scale. Six subjects not undergoing DWSI served as dolorimetry and symptom controls (Group 2). Serum IGF-1 was measured by competitive binding radioimmunoassay before and after DWSI. RESULTS: No significant differences in pain thresholds as a function of condition (baseline, DWSI, recovery) or overnight change were detected between or within groups (p>0.05). Morning mean dolorimeter scores were lower than evening scores in both groups during all 3 conditions, and were lower in Group 1 than in Group 2 during DWSI. Group 1 subjects had higher composite symptom scores during DWSI (p< or =0.005), attributed largely to increases in fatigue. Serum levels of IGF-1 from Group 1 subjects showed no significant change after DWSI (p>0.05). CONCLUSION: In our study subjects, 3 nights of DWSI caused no significant lowering of pain thresholds compared with a control group. Subjects appeared to have lower pain thresholds in the mornings, and DWSI appeared to augment this effect. Symptoms were more apparent during DWSI, but were primarily related to fatigue. IGF-1 was not altered by 3 nights of DWSI. The low levels of IGF-1 seen in patients with fibromyalgia syndrome may result from chronic rather than acute DWSI, or may be dependent on factors other than disturbances of delta wave sleep.
Older SA, Battafarano DF, Danning CL, Ward JA, Grady EP, Derman S,
Russell IJ
|
| The effects of
nutritional supplements on the symptoms of fibromyalgia and chronic fatigue
syndrome.
This article reports the results of a within-subject design. Fifty subjects with a physician diagnosis of fibromyalgia (FM) and/or chronic fatigue syndrome (CFS) were interviewed using a structured interview from. Each subject was interviewed initially, and again nine months later (follow-up). Subjects had, on their own, consumed nutritional supplements including freeze-dried aloe vera gel extract; a combination of freeze-dried aloe vera gel extract and additional plant-derived saccharides; freeze-dried fruits and vegetables in combination with the saccharides; and a formulation of dioscorea complex containing the saccharides and a vitamin/mineral complex. With medical treatments, approximately 25 percent of FM patients improve, but the beneficial effects of medical treatment rarely persist more than a few months. All subjects in this study had received some form of medical treatment prior to taking the nutritional supplements, but none with enduring success. Nutritional supplements resulted in a remarkable reduction in initial symptom severity, with continued improvement in the period between initial assessment and the follow-up. Further research is needed to verify these results, specifically crossover designs in well-defined populations.
Dykman KD, Tone C, Ford C, Dykman RA
|
| Ehlers-Danlos syndrome,
fibromyalgia and temporomandibular disorder: report of an unusual
combination.
An unusual case of temporomandibular disorder in the presence of both fibromyalgia and Ehlers-Danlos syndrome is presented. Some of the problems in treating these patients are discussed. It is suggested that early conservative treatment of the temporomandibular disorder with a stabilization splint and physical therapy is effective, and this approach should be attempted before any surgical intervention is chosen.
Miller VJ, Zeltser R, Yoeli Z, Bodner L
|
| Elevated levels
of hyaluronic acid in the sera of women with fibromyalgia.
OBJECTIVE: To evaluate serum levels of hyaluronic acid (HA) in patients with fibromyalgia (FM). METHODS: HA serum levels were evaluated by a radiometric assay in 42 women with FM (ACR criteria), 27 female patients with rheumatoid arthritis (RA) and 36 healthy female controls matched for age. RESULTS: HA serum levels (mean microg/l +/- SEM) were 41 +/- 8.7 in healthy controls; 113 +/- 15.9 in RA: and 420 +/- 26 in FM. CONCLUSION: HA serum levels in women with FM were significantly elevated compared to healthy controls and patients with RA. This observation suggests that FM is associated with a biochemical abnormality and that serum HA could be a laboratory marker for its diagnosis.
Yaron I, Buskila D, Shirazi I, Neumann L, Elkayam O, Paran D, Yaron
M
|
| Establishing
a research agenda for investigating alternative medical interventions for
chronic pain.
This article describes the University of Maryland School of Medicine's Center for Complementary Medicine Research approach to developing an agenda for investigating alternative medical treatments for chronic pain syndromes. This agenda includes conducting extensive literature searches and analyses to form a knowledge base for making clinical decisions on which chronic pain syndromes are in greatest need of better therapies, as well as which alternative medical therapies offer the greatest therapeutic promise for these specific chronic pain syndromes. To date, the Center has identified back pain, arthritis, and fibromyalgia as the chronic pain syndromes that contribute the greatest clinical and economic burden to overall chronic pain statistics. Not coincidentally, patients with these diagnoses are the greatest users of alternative therapies. The Center has identified acupuncture, homeopathy, manual/manipulative therapies, and mind-body therapies as the alternative medical therapies offering the greatest clinical potential for these three general chronic pain diagnoses. Preliminary data from the Center's ongoing clinical trials programs are presented.
Berman BM, Swyers JP
|
| Estimates of the
prevalence of arthritis and selected musculoskeletal disorders in the United
States.
OBJECTIVE: To provide a single source for the best available estimates of the national prevalence of arthritis in general and of selected musculoskeletal disorders (osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, the spondylarthropathies, systemic lupus erythematosus, scleroderma, polymyalgia rheumatica/giant cell arteritis, gout, fibromyalgia, and low back pain). METHODS: The National Arthritis Data Workgroup reviewed data from available surveys, such as the National Health and Nutrition Examination Survey series. For overall national estimates, we used surveys based on representative samples. Because data based on national population samples are unavailable for most specific musculoskeletal conditions, we derived data from various smaller survey samples from defined populations. Prevalence estimates from these surveys were linked to 1990 US Bureau of the Census population data to calculate national estimates. We also estimated the expected frequency of arthritis in the year 2020. RESULTS: Current national estimates are provided, with important caveats regarding their interpretation, for self-reported arthritis and selected conditions. An estimated 15% (40 million) of Americans had some form of arthritis in 1995. By the year 2020, an estimated 18.2% (59.4 million) will be affected. CONCLUSION: Given the limitations of the data on which they are based, this report provides the best available prevalence estimates for arthritis and other rheumatic conditions overall, and for selected musculoskeletal disorders, in the US population.
Lawrence RC, Helmick CG, Arnett FC, Deyo RA, Felson DT, Giannini EH,
Heyse SP, Hirsch R, Hochberg MC, Hunder GG, Liang MH, Pillemer SR, Steen
VD, Wolfe F
|
| Ethnocultural
and educational differences in Israeli women correlate with pain perception
in fibromyalgia.
OBJECTIVE: To compare the clinical features of patients with fibromyalgia (FM) in 2 ethnic groups in Israel. METHODS: One hundred women with FM participated in the study; 70 were of Sephardic (Mediterranean) origin and 30 of Ashkenazic (European-American) origin. Assessment of FM related symptoms, tenderness, quality of life, and physical functioning was conducted in all subjects. Analysis of covariance and multivariate regression were performed to study the association between these measures and ethnicity, controlling for age and education. RESULTS: Sephardic patients with FM reported more frequent and more severe symptoms than Ashkenazic patients. They had higher point counts and decreased quality of life. When the patients were divided into 2 age groups (age 45 being the cutoff point), the differences were observed only among the older subjects, most of whom were immigrants. Sephardic older patients had significantly higher point counts than Ashkenazic patients, and lower tenderness thresholds. They reported significantly higher levels of pain, fatigue, and stiffness, and were less satisfied with their life. However, these differences observed between the 2 ethnic groups in the univariate data analysis disappeared when age and education were jointly controlled in multivariate regression analysis. Age had significantly contributed to the variation in the point count, the reported pain, and physical functioning. Education made a significant contribution in explaining the point count, quality of life, pain, and fatigue. CONCLUSION: Education, rather than ethnic identity, has been found to be an important factor in clinical features of FM. Future studies should include ethnocultural and educational assessment, especially in countries with high immigration rates and diverse ethnic groups, such as the USA and Canada.
Neumann L, Buskila D
|
| [Etiologic factors
in temporomandibular joint disorders and pain].
Parallel to the construction of better classifications and the identification of subgroups of temporomandibular disorders, an important development has taken place in research concerning its etiology. The etiological factors implied in muscle problems refer to more generalised disorders as myofascial pain syndrome and fibromyalgia. The role of occlusal and articular factors has been brought down to realistic proportions, indicating a minor contribution. Similarly, doubt has arisen concerning the existence of a vicious cycle of pain/spasm/pain. With regard to internal derangements, emphasis has been put on the high prevalence in an otherwise normal population and the fluctuating character of the symptom. Also here, developments point towards constitutional and systemic factors, more than local influences. Trauma, however, seems to play an increasing role. The development of osteoarthrosis has been studied more in depth revealing local processes of inflammation, neurogenic inflammation and the existence of specific markers which might be important in the future. The relationship between disc derangement and the development of osteoarthrosis remains unclear.
De Laat A
|
| Evaluation of
multimodal treatment program for fibromyalgia.
A quasi-experimental design was used to assess a multimodal pain treatment program for female patients with fibromyalgia to ascertain immediate and long-term effects. Laboratory and self-report pain measures together with psychological measures were obtained from patients who were tested up to 6 months after treatment. Comparison data were also obtained from fibromyalgia patients who failed to qualify for the treatment program because of insurance coverage. Immediate and long-term treatment effects were evident with the psychological measures and the subjective pain measures but not with the laboratory pain measures. Participants who attended the month-long multimodal program achieved significant and positive changes on most of the outcome measures. However, relapse prevention must be addressed.
Mason LW, Goolkasian P, McCain GA
|
| Evidence for and
pathophysiologic implications of hypothalamic-pituitary-adrenal axis
dysregulation in fibromyalgia and chronic fatigue syndrome.
Chronic fatigue syndrome (CFS) is characterized by profound fatigue and an array of diffuse somatic symptoms. Our group has established that impaired activation of the hypothalamic-pituitary-adrenal (HPA) axis is an essential neuroendocrine feature of this condition. The relevance of this finding to the pathophysiology of CFS is supported by the observation that the onset and course of this illness is excerbated by physical and emotional stressors. It is also notable that this HPA dysregulation differs from that seen in melancholic depression, but shares features with other clinical syndromes (e.g., fibromyalgia). How the HPA axis dysfunction develops is unclear, though recent work suggests disturbances in serotonergic neurotransmission and alterations in the activity of AVP, an important co-secretagogue that, along with CRH, influences HPA axis function. In order to provide a more refined view of the nature of the HPA dusturbance in patients with CFS, we have studied the detailed, pulsatile characteristics of the HPA axis in a group of patients meeting the 1994 CDC case criteria for CFS. Results of that work are consistent with the view that patients with CFS have a reduction of HPA axis activity due, in part, to impaired central nervous system drive. These observations provide an important clue to the development of more effective treatment to this disabling condition.
Demitrack MA, Crofford LJ
|
| Evolving concepts
of diagnosis, pathogenesis, and therapy of Sjogren's
syndrome.
Differences in diagnostic criteria for Sjogren's Syndrome (SS) have led to confusion in the research literature and in clinical practice. A particular challenge is the clinical diagnosis of the patients with sicca symptoms, fibromyalgia, chronic fatigue, vague cognitive defects, and a low titer antinuclear antibody. Until recently, many of these patients would have been classified as primary SS using the European criteria. A suggested revision of the European criteria will require inclusion of anti SS-A antibody or characteristic minor salivary gland biopsy, leading to greater agreement between European and San Diego criteria. Recent studies have emphasized that lacrimal and salivary gland flow involves an entire "functioal" unit that includes the mucosal surface (the site of inflammation), efferent nerve signals sent to the midbrain (lacrimatory and salvatory nucleus), efferent neural signals from the brain, and acinal/ductal structures in the gland. Thus, symptoms of dryness or pain can result from interferences with any part of this functional unit. The initiating antigens in SS remain unknown, but immune reactivity against SS-A, SS-B, fodrin, alpha amylase, and carbonic anhydrase have been demonstrated in patients with established disease. The inflammatory process in the gland releases metalloproteinases that alter the relationship of epithelial cells to their matrix, an interaction that is necessary for glandular function and survival. Therapies for SS remain inadequate. In SS patients with immune-mediated extraglandular manifestation (ie, lung, kidney, skin, nerve), the therapeutic approach his similar to systemic lupus erythematosus, although these therapies have relatively little effect on tear or saliva flow.
Fox RI, Tornwall J, Maruyama T, Stern M
|
Examination for tenderness: learning to use 4 kg force.OBJECTIVE: To minimize interobserver variation in tender point examination, a training program was developed that focused on learning to deliver 4 kg force. METHODS: A 3 step process was designed to provide both measurement and feedback, serving both didactic and research functions. There were 5 repetitions within each step. During the first and 3rd steps, the subjects pressed on the footplate of a dolorimeter with no immediate feedback about the force measured. In the 2nd "training" step, they were given immediate feedback about the force delivered, and were taught to watch the amount and pattern of blanching beneath and around the thumbnail. RESULTS: Twenty-nine observers participated in 30 studies. Initial values varied from 1.78 to 8.92 kg (means within observers), although the mean value was 4.05 kg (means of all observers). The training step reduced observer variation by 65%, with reduction of mean absolute error from 1.25 to 0.44 kg. This improvement was sustained in the 3rd step, in which no feedback was given. Naive participants performed as well as experts, and there were no detectable sex differences. One observer was retested after an interval of 8 months, and performed no better during the the initial phase of the 2nd test than in the first. Each training session required 3 to 5 minutes. CONCLUSION: Specific training efficiently reduces interobserver variations in pressure used in tender point examinations. These skills should be periodically refreshed to prevent drift into error.
Smythe H
|
| Exteroceptive
suppression of temporalis muscle activity in patients with fibromyalgia,
tension-type headache, and normal controls.
Changes of the second suppressive period (ES2) of the exteroceptive suppression of the temporalis muscle activity are found in patients with chronic tension-type headache (TTH) and are suggested to reflect an abnormal endogenous pain control system. We investigated whether similar changes are found in patients with the fibromyalgia syndrome (FMS) that is also believed to result from disturbed central pain processing. The ES2 values of 27 patients with FMS were compared with those of 18 patients with TTH and 40 healthy volunteers. The duration of ES2 (+/-SD) in FMS patients was 30.6+/-7.5 ms and was not significantly different from the control group (33.1+/-7.8 ms), whereas it was significantly shortened in TTH patients (22.9+/-11.5 ms). Our results indicate that, despite similar concepts on the pathophysiology of the two chronic pain disorders, there are no comparable changes of this brain stem reflex activity in FMS.
Schepelmann K, Dannhausen M, Kotter I, Schabet M, Dichgans J
|
| Familial painful
restless legs syndrome correlates with pain dependent variation of blood
flow to the caudate, thalamus, and anterior cingulate gyrus.
To understand the relationship of caudate, thalamic, and anterior cingulate perfusion to pain states, we investigated familial restless legs syndrome in a father and daughter during the state of pain induced by immobility using semiquantitative regional cerebral blood flow (rCBF) brain single photon emission computed tomography (SPECT). The father underwent 4 brain SPECT scans using the rCBF tracer 99mTc-HMPAO several weeks apart, at different pain levels and after treatment with L-dopa. Caudate, thalamic, and anterior cingulate rCBF indices were measured. The caudate nuclei showed a 13% reduction in rCBF with increasing pain. The thalami and anterior cingulate showed a 7 and 6.6% increase in rCBF, respectively, with increasing pain. Compared to normal controls at rest, there was a decrease in caudate rCBF by 13% and an increase in thalamic rCBF by 3%. Linear regression for the caudate nuclei revealed a significant reduction in rCBF (p < 0.05), as pain increased. The daughter underwent an identical rCBF brain SPECT scan procedure at a high pain level induced by immobilization. Her scan showed a 12% reduction in caudate rCBF and a 1.2% increase in the anterior cingulate rCBF compared to healthy controls. The study supports the association between pain and decreased regional cerebral blood flow to the caudate nucleus as reported in fibromyalgia syndrome. There is increase in anterior cingulate rCBF with increasing pain. Our findings also corroborate that there is increased thalamic rCBF with pain stimulation.
San Pedro EC, Mountz JM, Mountz JD, Liu HG, Katholi CR, Deutsch G
|
| Fatigue in lupus
is not correlated with disease activity.
OBJECTIVE: The relationship between fatigue and disease activity in systemic lupus erythematosus (SLE) has been questioned. We examined whether self-reported fatigue in patients with SLE is correlated with disease activity. METHODS: Consecutive patients with SLE at the University of Toronto Lupus Clinic were evaluated for disease activity using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). They were also evaluated for fibromyalgia (FM) by American College of Rheumatology criteria. One hundred patients completed the following health status questionnaires: the Fatigue Severity Score (FSS), Center for Epidemiologic Studies Depression Scale (CES-D), and Medical Outcomes Study Short Form Health Survey (SF-20). Disease activity was measured by the SLEDAI. Statistical correlations were made using the Spearman test. RESULTS: No significant correlation was found between FSS scores and SLEDAI (p = NS). Fatigue was found to be highly correlated with the presence of FM (p < 0.05) and depression (p < 0.01). In addition, fatigue was significantly associated with lower performance in all 6 domains of the SF-20 (p < 0.001); disease activity correlated with decreases in social function, mental health, and health perception areas of the SF-20. SLEDAI was not found to correlate with FM (p = NS). CONCLUSION: Fatigue in patients with SLE does not correlate with disease activity. However, fatigue is correlated with FM, depression, and lower overall health status in this population. Fatigue is a manifestation of these conditions, which are commonly co-expressed in SLE, and may reflect a decreased overall coping ability in these patients, rather than active disease itself.
Wang B, Gladman DD, Urowitz MB
|
| [Fibromyalgia. A critical review].
Fibromyalgia is a chronic pain syndrome, more common in women. Its prevalence is estimated around 2% in the general population, and up to 20% among rheumatology outpatients. Besides musculoskeletal pain, symptoms as fatigue and sleep disturbance are considered characteristic. Research criteria have been set up, but their seemingly preciseness is unable to distinguish clearly between fibromyalgia and other functional somatic syndromes (chronic fatigue syndrome, irritable bowel syndrome) and psychiatric disorders (depression, anxiety), with which a striking comorbidity is documented. The diagnosis of fibromyalgia does not theoretically require the exclusion of muscle, joint, or metabolic diseases, but in clinical practice this problem proves to be of crucial importance. There are numbers of pathophysiological hypothesis for fibromyalgia, but none of them is fully satisfying: muscle is probably innocent; sleep disturbance, although sometimes considered a landmark of the syndrome, is unspecific; stress response studies show subtle anomaly; psychiatric disorders may represent factors of vulnerability and perpetuation rather than causes. We propose to include some of these etiological contributors in vicious circles leading to a "final common pathway" characterized by generalized hyperalgesia. Treatments of fibromyalgia, whether pharmacological (antidepressants) or psychological (cognitive-behavioral therapies) are of little efficacy, and the global prognosis of fibromyalgia is poor. However, the outcome might prove better outside the specialized clinics in which studies of chronic sufferers with severe abnormal illness behaviors are done. The social consequences of the popularization of the diagnosis of fibromyalgia should not be neglected.
Cathebras P, Lauwers A, Rousset H
|
| [Fibromyalgia--a
dispensable disease term]?
The term of "fibromyalgia" has been used increasingly in the last years for chronic widespread pain in particular concerning soft tissues, muscular and extra-articular system including pain in 11 of 18 tender point sites on digital palpation. Scientific proof of an organic disorder could not be established to this day. Psychological causes are more and more considered to be responsible for this problems. Nowadays a psychosomatic disorder is assumed although as well a depression with somatization or a neurosis are discussed. Therapeutical problems and pain coping strategies are described just as the medico-legal assessment for pension scheme. Because the term "fibromyalgia" suggests an organic disorder which does not exist, it seems instead useful to prefer the terms "somatization disorder" or "pain disorder" to make easier the approach to early psychotherapy and to prevent a further chronification.
Hausotter W
|
| Fibromyalgia--a
syndrome associated with decreased nocturnal melatonin
secretion.
OBJECTIVE: Most patients with fibromyalgic syndrome (FMS) complain of sleep disturbances, fatigue, and pain. These symptoms might be a consequence of changed melatonin (MT) secretion, since MT is known to have sleep promoting properties. Moreover, serum concentrations of two MT precursors (tryptophan and serotonin)--affecting both sleep and pain perception--appear to be low in patients with FMS. Therefore, the objective of this investigation was to study whether serum MT (s-MT) level is also low in these patients. DESIGN: Eight patients with FMS and 8 healthy sex-, BMI-, and age-matched controls were included in the study. s-MT concentrations were determined every second hour between 1800 and 0800 h. Urine was collected between 2200 and 0700 h for determination of urinary MT excretion. To evaluate total MT secretion between 1800 and 0800 h and MT secretion during the hours of darkness (between 23 and 07 h) individual MT areas under the curve (AUC) were calculated and expressed as group means. RESULTS: The FMS patients had a 31% lower MT secretion than healthy subjects during the hours of darkness (MT AUC 2300-0700 h (mean +/- SEM): 1.70 +/- 0.17 vs 2.48 +/- 0.38 nmol/l; P < 0.05). Also the s-MT peak value was significantly lower in the patient group: 0.28 +/- 0.03 vs 0.44 +/- 0.06 nmol/l; P < 0.05). CONCLUSION: Patients with fibromyalgic syndrome have a lower melatonin secretion during the hours of darkness than healthy subjects. This may contribute to impaired sleep at night, fatigue during the day, and changed pain perception.
Wikner J, Hirsch U, Wetterberg L, Rojdmark S
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| Fibromyalgia
and chronic fatigue: the holistic perspective.
Fibromyalgia syndrome (FMS) and chronic fatigue syndrome (CFS) are not new conditions, but they are receiving more attention as more research is conducted. These two conditions are primarily women's health problems. In some instances, there may be a genetic predisposition for these conditions. The impact of FMS and CFS can be devastating both physically and emotionally. The treatment plan must be interdisciplinary and holistic and include alternative therapies if the client and family are to be truly supported and helped in coping with these chronic conditions.
Kenner C
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| Fibromyalgia
and headache. Failure of serotonergic analgesia and N-methyl-D-aspartate-mediated
neuronal plasticity: their common clues.
A defect in serotonergic analgesia and a hyperalgesic state are proposed as features common to headache and fibromyalgia. The benefit to both migraine and fibromyalgia from inhibiting ionotropic N-methyl-D-aspartate receptor activity implies that redundant hyperalgesia-related neuroplastic changes are crucial for severe or chronic migraine and primary fibromyalgia. The fact that migraine and primary fibromyalgia share some pivotal set-up of serotonergic and excitatory amino acid systems led us to analyse epidemiological data supporting the hypothesis that analgesic disruption and a consequent hyperalgesic state are mechanisms of both migraine and fibromyalgia. Beyond demonstrating the comorbidity between migraine and primary fibromyalgia, the data suggest that migraine may represent a risk factor for fibromyalgia.
Nicolodi M, Volpe AR, Sicuteri F
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| Fibromyalgia
and its primary care implications.
Fibromyalgia is a complex condition affecting up to six million patients. In this literature review, the prevalence, proposed etiology, differential diagnosis, and signs and symptoms of the disorder are presented. Diagnostic criteria, treatment options, and the importance of patient education are explored.
Gordon S, Morrison C
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| Fibromyalgia
and the serotonin pathway.
Fibromyalgia syndrome is a musculoskeletal pain and fatigue disorder manifested by diffuse myalgia, localized areas of tenderness, fatigue, lowered pain thresholds, and nonrestorative sleep. Evidence from multiple sources support the concept of decreased flux through the serotonin pathway in fibromyalgia patients. Serotonin substrate supplementation, via L-tryptophan or 5-hydroxytryptophan (5-HTP), has been shown to improve symptoms of depression, anxiety, insomnia and somatic pains in a variety of patient cohorts. Identification of low serum tryptophan and serotonin levels may be a simple way to identify persons who will respond well to this approach.
Juhl JH
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Fibromyalgia and women's pursuit of personal goals: a daily process analysis.For 30 days, 50 women with primary fibromyalgia syndrome reported daily progress and effort toward a health-fitness and a social-interpersonal goal and the extent to which their pain and fatigue hindered their accomplishment. They also carried palmtop computers to assess their sleep and their pain, fatigue, and positive and negative mood throughout the day. Analyses of the person-day data set showed that on days during which pain or fatigue increased from morning to evening, participants perceived their goal progress to be more attenuated by pain and fatigue. Unrestorative sleep the night before predicted the following day's effort and progress toward accomplishing health-fitness goals, but not social-interpersonal goals. Finally, participants who reported more progress toward social-interpersonal goals on a given day were more likely to evidence improvements in positive mood across the day, regardless of any changes in pain or fatigue that day.
Affleck G, Tennen H, Urrows S, Higgins P, Abeles M, Hall C, Karoly
P, Newton C
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| Fibromyalgia, chronic fatigue syndrome,
and myofascial pain.
Epidemiologic studies continue to provide evidence that fibromyalgia is part of a spectrum of chronic widespread pain. The prevalence of chronic widespread pain is several times higher than fibromyalgia as defined by the 1990 American College of Rheumatology guidelines. There is now compelling evidence of a familial clustering of fibromyalgia cases in female sufferers; whether this clustering results from nature or nature remains to be elucidated. A wide spectrum of fibromyalgia-associated symptomatology and syndromes continues to be described. During the past year the association with interstitial cystitis has been explored, and neurally mediated hypotension has been documented in both fibromyalgia and chronic fatigue syndrome. Abnormalities of the growth hormone-insulin-like growth factor-1 axis have been also documented in both fibromyalgia and chronic fatigue syndrome. The commonly reported but anecdotal association of fibromyalgia with whiplash-type neck trauma was validated in a report from Israel. However, unlike North America, 100% of Israeli patients with posttraumatic fibromyalgia returned to work. Basic research in fibromyalgia continues to pinpoint abnormal sensory processing as being integral to understanding fibromyalgia pain. Drugs such as ketamine, which block N-methyl-D-aspartate receptors (which are often upregulated in central pain states) were shown to benefit fibromyalgia pain in an experimental setting. The combination of fluoxetine and amitriptyline was reported to be more beneficial than either drug alone in patients with fibromyalgia. A high prevalence of autoantibodies to cytoskeletal and nuclear envelope proteins was found in chronic fatigue syndrome, and an increased prevalence of antipolymer antibodies was found in symptomatic silicone breast implant recipients who often have fibromyalgia.
Bennett R
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| Fibromyalgia
in Behcet's syndrome.
OBJECTIVE: To ascertain the frequency of fibromyalgia (FM) in Behcet's syndrome (BS) and to evaluate the relationship of FM to Behcet's disease activity. METHOD: Self-questionnaires were completed by 108 patients with BS. Each patient was evaluated by an observer blinded to diagnosis; evaluation included assessment of tender points by palpation. Another observer determined the disease activity of patients at that time. RESULTS: Ten of 108 patients (9.2%) met the American College of Rheumatology criteria for FM. Nine of the patients who met the criteria for FM were women. In contrast to patients without FM, patients with FM had mild to moderate disease activity in which musculoskeletal complaints were common. CONCLUSION: There is a trend for an increased frequency of FM in female BS patients.
Yavuz S, Fresko I, Hamuryudan V, Yurdakul S, Yazici H
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| [Fibromyalgia (generalized
tendomyopathy) in expert assessment. Analysis of 158 cases].
MEDAS-agencies are medical institutions within the Swiss Disability Insurance, which specialize in assessing the working capacity of candidates who apply for a disability pension. Degenerative and other chronic pain disorders of the musculoskeletal system form the majority of cases that we investigate. Fibromyalgia is one of our most frequent diagnoses (8.6%). We become involved in cases on average 8.5 years after the first onset of painful symptoms and on average 2.5 years after the patients have ceased to work. Our experience, tells us that fibromyalgia is usually associated with psychological disturbances; thus our psychiatrists have found important psychological problems in 86.7% of applicants. They found mainly neurotic and depressive syndromes. Our investigations have shown that psychological disturbances precede the onset of musculoskeletal pain in about 70% of patients. Therefore, we don't consider fibromyalgia syndrome as an entity of its own, but regard it as a pain syndrome in which there are underlying psychological problems in most cases.
Kissel W, Mahnig P
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| Fibromyalgia
in hyperkalemic periodic paralysis.
A 43-year-old woman presented at the age of 38 with joint pains and muscle stiffness. Tender points were found fulfilling ACR criteria (1) for fibromyalgia. She had well developed muscles and decreasing muscle power since the age of 35. Muscle pains increased after exercise. Her 10-year-old son had similar symptoms and one paralytic attack. Muscle pain and fatigue increasing with age were found by history in three close relatives. Forearm cold water test produced myotonia in both mother and son. Electromyography was normal and muscle biopsy showed minor unspecific changes. Biochemical investigation of muscle mitochondrial function was normal. Peroral potassium load test produced complete muscle paralysis at a potassium serum level of 5.0 mmol/l. Autosomal dominant hyperkalemic periodic paralysis was diagnosed. Frequent carbohydrate enriched meals, peroral bendroflumethiazide and restriction to submaximal exercise improved muscle and joint pain. Salbutamol peroral spray relieved the periodic weakness.
Gotze FR, Thid S, Kyllerman M |