FibroAction News Feed

The role of central dopamine

Fri, 30 May 2008 12:00:00 +0100

Dr Patrick Wood MD has had an article published in the May edition of the journal Expert Review of Neurotherapeutics in which he discusses the role of central dopamine in pain and analgesia [1].

Dr Wood is a respected authority on the cause and treatment of Fibromyalgia Syndrome (Fibro), who has twice been recognised by the American National Institutes of Health for his innovative research. He is Chief Medical Officer for Angler Biomedical Technologies, a private company whose primary focus is improving the understanding and treatment of fibromyalgia, and he formerly directed the Fibromyalgia Research Program and Fibromyalgia Care Clinic at Louisiana State University. Dr Wood is the originator of the Dopamine Theory of Fibromyalgia and he spearheaded the use of advanced imaging technologies, including Positron Emission Tomography (PET scans) and Magnetic Resonance Spectroscopy (MRI) to investigate fundamental changes within the central nervous system relating to Fibro. [2]

In the article, Dr Wood says that recent insights have shown that dopamine has a central role in modulating pain perception and natural analgesia within parts of the brain. Also, while the role of the neurotransmitters, serotonin and norepinephrine, in inhibiting pain (through spinal descending inhibition) is well known, it has now been shown that dopamine has a critical role in this respect too.

Decreased levels of dopamine likely contribute to the painful symptoms that frequently occur in Parkinson's disease and Dr Wood notes that abnormalities in dopamine related neurotransmission have been found in other painful clinical conditions, including burning mouth syndrome, fibromyalgia syndrome and restless legs syndrome. Evidence from animal models and indirect evidence from pharmaceutical trials apparently also suggests a role for dopamine in chronic regional pain syndrome and painful diabetic neuropathy.

The Dopamine Theory of Fibromyalgia, which Dr Wood instigated, proposes that a combination of genetic and environmental factors, such as stress and trauma, causes a reduction in the production of dopamine in the brain of people with Fibromyalgia Syndrome and the reduced levels of dopamine then go on to cause other abonormalities and cause the symptoms of Fibromyalgia Syndrome. [3]

Studies carried out by Dr Wood and his colleagues have shown that people with Fibromyalgia Syndrome have both reduced dopamine activity in the central nervous system [4] and an abnormal dopamine response to pain [5] where people with Fibromyalgia Syndrome do not release dopamine in response to pain, meaning that pain stimuli are felt as being more painful than for healthy controls.

Dr Wood says that several new classes of medication with analgesic properties have an effect on dopamine, as is shown by the capacity of dopamine antagonists to reduce their analgesic capacity. [1] The dopamine agonist, Pramipexole, has also been found to be extremely promising as a treatment for Fibromyalgia Syndrome and has been mostly studied by Dr Andrew Holman MD, who is based in Seattle. [6]

Dr Wood and Dr Holman both feature in the DVD 'Fibromyalgia: Show Me Where It Hurts' which discusses the Dopamine Theory of Fibromyalgia and the studies behind it.

In the DVD, Dr Holman says: "The study of fibromyalgia is doing so much to uncover new areas of human physiology, it’s almost unfathomable."

In the Expert Review of Neurotherapeutics article, Dr Wood says that: "An expanded appreciation for the role of dopamine in natural analgesia provides the impetus for further study ...which may lead to the development of novel therapeutic strategies."

The role of dopamine in Fibromyalgia Syndrome, the potential treatments relating to that and the knowledge that is being discovered in these studies is extremely exciting and could lead to more effective use of medications to treat Fibromyalgia Syndrome. Some doctors (mostly in the US, but including Professor John Davies at Guys Hospital, London) are already using medications that affect dopamine to treat Fibromyalgia Syndrome patients, with a promising level of success.

References:

Wood PB. Role of central dopamine in pain and analgesia. Expert Rev Neurother. 2008 May;8(5):781-97.
Kuchinad A, Schweinhardt P, Seminowicz DA, Wood PB, Chizh BA, Bushnell MC. Accelerated brain gray matter loss in fibromyalgia patients: premature aging of the brain? J Neurosci. 2007 Apr 11;27(15):4004-7.
Wood PB. Stress and dopamine: implications for the pathophysiology of chronic widespread pain. Med Hypotheses. 2004;62(3):420-4.
Wood PB, Patterson JC 2nd, Sunderland JJ, Tainter KH, Glabus MF, Lilien DL. Reduced presynaptic dopamine activity in fibromyalgia syndrome demonstrated with positron emission tomography: a pilot study. J Pain. 2007 Jan;8(1):51-8. Epub 2006 Oct 4.
Wood PB, Schweinhardt P, Jaeger E, Dagher A, Hakyemez H, Rabiner EA, Bushnell MC, Chizh BA. Fibromyalgia patients show an abnormal dopamine response to pain. Eur J Neurosci. 2007 Jun;25(12):3576-82.
Holman AJ, Myers RR. A randomized, double-blind, placebo-controlled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications. Arthritis Rheum. 2005 Aug;52(8):2495-505.

Fibromyalgia and normalising behaviours

Fri, 30 May 2008 12:00:00 +0100

A new study has reported that Fibromyalgia Syndrome patients may not seek help to manage their symptoms because the symptoms seem normal to them. [1]

Fibromyalgia Syndrome often takes a long time to diagnose, with some patients even reporting that they had symptoms for decades before diagnosis. The attitudes and actions of the healthcare professionals seen by the patient are obviously involved in this delay, but so too can be patient attitudes and actions. A problem with invisible illnesses, such as Fibromyalgia Syndrome, which have no outward sign of illness, is that even the patient can doubt whether the symptoms are really there. The symptoms of Fibromyalgia Syndrome have been shown in research to have a number of physiological causes, but with nothing visible, some patients end up wondering if everyone feels the same as them. Many patients try to lead a normal life for some time after the onset of Fibromyalgia Syndrome, maintaining careers, relationships and lifestyles as far as possible for as long as they physically can, despite the immense struggle this can be. This struggle to remain “normal” can continue after diagnosis.

The study, carried out by a Turkish doctor, investigated whether Fibromyalgia Syndrome sufferers who didn’t seek medical help had a different level of normalising attributes than patients who sought medical help. Thirty-seven Fibromyalgia Syndrome patients who were seeing consultants about their condition were compared with 38 Fibromyalgia Syndrome sufferers who weren’t seeing a doctor, as well as 34 healthy controls. They were assessed for anxiety, depression, alexithymia (a relatively new term meaning the inability to express feelings in words) and normalising attributes.

The Fibromyalgia Syndrome sufferers who weren’t seeing a doctor were found to have the highest normalizing scores, with the Fibromyalgia Syndrome patients who were seeing a doctor having even lower normalizing scores than the healthy controls.

The article concluded that “normalization may negatively influence help-seeking behavior and contribute to non-help-seeking behavior.”

Reference:

Gulec H. Normalizing Attributions May Contribute to Non-Help-Seeking Behavior in People With Fibromyalgia Syndrome. Psychosomatics. 2008 May;49(3):212-217.

Myofascial Trigger Points In Whiplash Patients

Sun, 08 Jun 2008 12:00:00 +0100

Swiss researchers from the Reha Rheinfelden Rehabilitation Center and the Department of Neurology, University Hospital Basel, have had an article e-published ahead of print in the journal Archives of physical medicine and rehabilitation in which they describe a study that found a distinct pattern of myofascial findings in patients after whiplash injury. [1]

The objective of the study was to identify objective clinical signs for the diagnosis of whiplash syndrome, focusing on myofascial trigger points. Twenty-four healthy controls and 124 patients took part, including 47 patients with whiplash-associated disorders, 21 with Fibromyalgia Syndrome, 17 with nontraumatic chronic cervical syndrome and 15 with endogenous depression. Each participant was manually examined for myofascial trigger points of the semispinalis capitis, trapezius pars descendens, levator scapulae, scalenus medius, sternocleidomastoideus, and masseter muscles bilaterally.

The study found that 40 of the patients with whiplash (85.1%) had myofascial trigger points in the semispinalis capitis muscle, which was a significantly higher prevalence than any of the control groups (P

The researchers concluded that:

"Patients with whiplash showed a distinct pattern of trigger point distribution that differed significantly from other patient groups and healthy subjects. The semispinalis capitis muscle was more frequently affected by trigger points in patients with whiplash, whereas other neck and shoulder muscles and the masseter muscle did not differentiate between patients with whiplash and patients with nontraumatic chronic cervical syndrome or fibromyalgia."

Myofascial pain frequently co-exists with Fibromyalgia Syndrome, but it often unrecognised and left untreated [2]. It is important that Fibromyalgia Syndrome patients are checked out for myofascial problems, especially if they mention localised pain patterns and localised reductions in mobility. The results of this study suggest that it is even more important to check out patients with a whiplash injury for myofascial problems. The study also suggests that examinations for trigger points could be a way of differentiating between whiplash and other conditions that could give similar symptoms.

References:

Ettlin T, Schuster C, Stoffel R, Brüderlin A, Kischka U. A Distinct Pattern of Myofascial Findings in Patients After Whiplash Injury. Arch Phys Med Rehabil. 2008 Jun 3. [Epub ahead of print]

Starlanyl DJ, Copeland ME. Fibromyalgia and Chronic Myofascial Pain Syndrome: A Survival Manual. New Harbinger Publications: 2001.

Pregabalin for Fibromyalgia Syndrome

Tue, 10 Jun 2008 12:00:00 +0100

Researchers from the University of Cincinnati College of Medicine, Ohio, USA e-published an article on June 2nd, ahead of the print in the Journal of Pain, discussing a 14 week trial of pregabalin in patients with Fibromyalgia Syndrome. [1]

In 2007, Pregabalin (brand name Lyrica) was the first medication to be approved by the American Food and Drug Administration (FDA) for "on-label" use as a treatment for Fibromyalgia Syndrome.

Some of the researchers involved in the latest study were also involved in a 13 week Phase III trial of Pregabalin for Fibromyalgia Syndrome that was reported in the Journal of Rheumatology earlier this year. [2]

Both of these randomised, double-blinded, placebo-controlled trials aimed to assess the efficacy and safety of pregabalin in patients with Fibromyalgia Syndrome. They both used end point mean pain scores (as derived from daily diary ratings of pain intensity on an 0 to 10 scale) as the primary outcome variable, with other outcome variables being the Patient Global Impression of Change (PGIC) and the Fibromyalgia Impact Questionnaire (FIQ) total score. Other variables considered were assessments of sleep, fatigue, and mood disturbance. [1][2]

In the latest trial, 750 patients meeting American College of Rheumatology criteria for Fibromyalgia Syndrome had 1 week of single-blinded administration of placebo. After this, the participants were randomly pregabalin (at doses of 300 mg/d, 450 mg/d and 600 mg/d) or placebo, administered twice daily for 14 weeks. [1]

The trial found that, mean changes in pain scores at the end point in pregabalin-treated patients were significantly greater (P < .001: 300 mg/d, -0.71; 450 mg/d, -0.98; 600 mg/d, -1.00), compared with placebo-treated patients. Compared with placebo, significantly more pregabalin-treated patients reported improvement on PGIC (P < .01 for all 3 pregabalin doses) and significant improvements in total FIQ score for the 450 mg/d (P = .004) and the 600 mg/d (P = .003) doses. Compared with placebo, all 3 doses of pregabalin were associated with significant improvement in sleep. [1] This mainly reflects the findings of the Phase III trial [2], except that in that trial, improvements in FIQ-Total Score for the pregabalin groups were numerically but not significantly greater than those for the placebo group.

The most commonly reported pregabalin-related adverse events in both trials were dizziness and somnolence, which tended to be dose-related. [1][2]

The researchers from the latest trial said that:

"This randomized, placebo-controlled trial of 300, 450, and 600 mg/d of pregabalin monotherapy demonstrated that all 3 doses were efficacious for up to 14 weeks for the treatment of fibromyalgia and were well tolerated by most patients. These results provide evidence that pregabalin is an important treatment option for patients with fibromyalgia."

Some of the researchers involved in both trials were also involved in a 6 month trial to evaluate the efficacy of pregabalin monotherapy for durability of effect on the pain from Fibromyalgia Syndrome, the results of which were published in the June edition of the journal pain. [3]

This trial started with a 6-week open-label pregabalin-treatment period, where, during weeks 1-3, 1051 patients received escalating dosages of pregabalin to determine their optimal dosages and, during weeks 4-6, patients received their optimal fixed dosages (either 300, 450 or 600mg/d). To be randomised, patients must have had 50% decrease in pain Visual Analogue Score and a self-rating of "much" or "very much" improved on Patient Global Impression of Change (PGIC) at the end of this 6-week period. [3]

There then followed a 26-week double-blinded trial with participants receiving either placebo (287 partcipants) or their optimal fixed dosage of pregabalin (279 participants). The primary outcome was time to loss of therapeutic response (LTR), defined as a less than 30% reduction in pain (from the open-label baseline) or worsening of the Fibromyalgia Syndrome. [3]

The trial found that time to LTR was longer for pregabalin versus placebo (P<.0001) and that, whereas half the placebo group had LTR by Day 19, half the pregabalin group still had not lost response by the end of the trial. At the end of the trial, 174 (61%) placebo patients met LTR criteria versus 90 (32%) pregabalin patients. [3]

The researchers considered that pregabalin was well tolerated, though 178 (17%) discontinued during the open-label stage for treatment-related adverse events, and more pregabalin than placebo patients discontinued for adverse events during the doubled-blinded stage. [3]

The researchers concluded that:

"In those who respond, pregabalin demonstrated durability of effect for relieving FM pain."

In the trial described above, 54% of initial participants made it through the open-label stage and achieved 50% decrease in pain on the Visual Analogue Score and a self-rating of "much" or "very much" improved on the Patient Global Impression of Change. [3]

When the FDA approved pregabalin (Lyrica) for the treatment of Fibromyalgia Syndrome, Steven Galson MD MPH, director of the FDA's Center for Drug Evaluation and Research, cautioned that the drug was not a panacea because response to the drug was not universal. [4]

Response rates to pregabalin in patients with Fibromyalgia Syndrome have varied widely [4] meaning that, although for some patients Pregabalin is an efficient and well tolerated treatment, there are quite a large proportion of Fibromyalgia Syndrome patients who either do not respond or who suffer from adverse side effects.

References:

Arnold LM, Russell IJ, Diri EW, Duan WR, Young JP Jr, Sharma U, Martin SA, Barrett JA, Haig G. A 14-week, Randomized, Double-Blinded, Placebo-Controlled Monotherapy Trial of Pregabalin in Patients With Fibromyalgia. J Pain. 2008 Jun 2. [Epub ahead of print]

Mease PJ, Russell IJ, Arnold LM, Florian H, Young JP Jr, Martin SA, Sharma U. A randomized, double-blind, placebo-controlled, phase III trial of pregabalin in the treatment of patients with fibromyalgia. J Rheumatol. 2008 Mar;35(3):502-14. Epub 2008 Feb 15.

Crofford LJ, Mease PJ, Simpson SL, Young JP Jr, Martin SA, Haig GM, Sharma U. Fibromyalgia relapse evaluation and efficacy for durability of meaningful relief (FREEDOM): a 6-month, double-blind, placebo-controlled trial with pregabalin. Pain. 2008 Jun;136(3):419-31. Epub 2008 Apr 8.

Peck P. Pregabalin (Lyrica) Is First Drug Approved for Fibromyalgia. June 22, 2007. MedPage Today. http://www.medpagetoday.com/ProductAlert/Prescriptions/tb/5992

Cannabinoids for Fibromyalgia Syndrome

Tue, 10 Jun 2008 12:00:00 +0100

An article has been e-published ahead of print in the journal Nature Clinical Practice. Rheumatology by Fibromyalgia Syndrome expert, Dr Roland Staud MD, and EB Koo, an undergraduate student at the University of Florida, discussing whether cannabinoids are a new treatment option for Fibromyalgia Syndrome. [1] Dr Staud, author of 'Fibromyalgia for Dummies', is Professor of Medicine at the College of Medicine and Director of the Center for Musculoskeletal Pain Research at the University of Florida.

The article discusses cannabinoids as a treatment option for Fibromyalgia Syndrome in light of the study by Skrabek et al, discussed in an article in the February issue of the Journal of Pain. [2]

Skrabek et al carried out what was apparently the first randomized, controlled trial to assess the benefit of nabilone, a synthetic cannabinoid, on pain reduction and quality of life improvement in patients with Fibromyalgia Syndrome. [2]

The randomized, double-blind, placebo-controlled trial was carried out on 40 patients with Fibromyalgia Syndrome. The primary outcome measure, visual analog scale (VAS) for pain, and the secondary outcome measures, number of tender points, the average tender point pain threshold, and the Fibromyalgia Impact Questionnaire (FIQ), were evaluated at 2 and 4 weeks into the trial and then again after a 4-week washout period. [2]

Skrabek et al's trial found that there were significant decreases in the VAS (-2.04, P < .02), FIQ (-12.07, P < .02), and anxiety (-1.67, P < .02) in the nabilone treated group at 4 weeks, and that after the 4-week wash-out period, all benefits were lost, with the nabilone treated group returning to their baseline levels of pain and quality of life. There were no significant improvements in the placebo group. The treatment group experienced more side effects per person at 2 and 4 weeks (1.58, P < .02 and 1.54, P < .05), respectively, and although nabilone was not associated with serious adverse effects, some patients did experience drowsiness, dry mouth, vertigo and ataxia. [2]

Skrabek et al said that:

"Nabilone appears to be a beneficial, well-tolerated treatment option for fibromyalgia patients, with significant benefits in pain relief and functional improvement. ... As nabilone improved symptoms and was well-tolerated, it may be a useful adjunct for pain management in fibromyalgia."

Nabilone, a synthetic cannabinoid, is used to treat chemotherapy-induced nausea and vomiting in patients who do not respond well to other anti-emetics. However, it has also been studied for use in treating cancer pain and neuropathic pain.

Cannabinoids are chemicals that are structurally similar to cannabis or THC (the main psychoactive substance found in cannabis), or that bind to cannabinoid receptors.

References:

Staud R, Koo EB. Are cannabinoids a new treatment option for pain in patients with fibromyalgia? Nat Clin Pract Rheumatol. 2008 Jun 3. [Epub ahead of print].

Skrabek RQ, Galimova L, Ethans K, Perry D. Nabilone for the treatment of pain in fibromyalgia. J Pain. 2008 Feb;9(2):164-73. Epub 2007 Nov 5.

Fibromyalgia in Post Menopausal Women

Sun, 15 Jun 2008 12:00:00 +0100

A medication to help prevent osteoporosis and invasive breast cancer in post-menopausal women may also help those who have Fibromyalgia Syndrome (Fibro), according to a recently published study. [1]

The article, from a group of Iranian researchers, was published in the July edition of the European journal of internal medicine (e-published last November), and discusses a study looking at Raloxifene (Evista) in the treatment of Fibro.

Raloxifene is a type of medication called a selective oestrogen receptor modulator. It is licensed in the USA and UK for the treatment of osteoporosis in post-menopausal women and also for the prevention of invasive cancer in post-menopausal women who either have osteoporosis or are at high risk of invasive breast cancer. Raloxifene is not a form of Hormone Replacement Therapy (HRT), but is rather an oestrogen agonist/antagonist, which means that it works like oestrogen in some tissues in the body, and has the opposite effect in other tissues.

The double-blind randomized study was carried out from Feb 2005 until Oct 2006 and enrolled one hundred menopausal women with Fibro. Fifty study participants were given Raloxifen 60mg every other day over 16 weeks, with the other 50 being given a placebo. [1]

The primary outcome measure used was a mean score from: the Stanford Health Assessment Questionnaire (HAQ); the Iranian version of Hospital Anxiety and Depression questionnaire (IHAD); sleep disturbance; number of tender points; and the reduction of pain and fatigue based on Visual Analogue Score (VAS).

Forty-nine (98%) of the participants receiving Raloxifen and 47 (94%) of the participants receiving placebo completed the study. [1]

The study group taking the Raloxifen had a significantly higher response rate than the placebo group, with reduced pain and fatigue, reduced tender point count, reduced sleep disturbance and recovery of usual activities as measured by the Stanford Health Assessment Questionnaire (HAQ). No significant effect on the Hospital Anxiety and Depression questionnaire score was seen. [1]

The researchers concluded that:

"Raloxifen was superior to placebo in the treatment of menopausal patients with fibromyalgia." [1]

Anecdotal reports and some studies suggests that, although abnormalities in reproductive hormone levels are not associated with Fibro [2], the reproductive hormones may have an effect on Fibro symptoms, with the menopause worsening symptoms in some patients [3][4]. However, some studies have also suggested that the use of HRT, and specifically oestrogen HRT, may increase the risk of suffering from Fibro and other chronic pain conditions. [5][6][7] The selective modulation of oestrogen by Raloxifene, as opposed to the replacement of oestrogen by HRT, may be an important factor and could be a novel way of managing both some of the health risks associated with the menopause and also Fibro, in post-menopausal women with Fibromyalgia Syndrome.

References:

Sadreddini S, Molaeefard M, Noshad H, Ardalan M, Asadi A. Efficacy of Raloxifen in treatment of fibromyalgia in menopausal women. Eur J Intern Med. 2008 Jul;19(5):350-5. Epub 2007 Nov 28.
Samborski W, Sobieska M, Pieta P, Drews K, Brzosko M. Normal profile of sex hormones in women with primary fibromyalgia. Ann Acad Med Stetin. 2005;51(2):23-6.

Pamuk ON, Cakir N. The variation in chronic widespread pain and other symptoms in fibromyalgia patients. The effects of menses and menopause. Clin Exp Rheumatol. 2005 Nov-Dec;23(6):778-82.

Okifuji A, Turk DC. Sex hormones and pain in regularly menstruating women with fibromyalgia syndrome. J Pain. 2006 Nov;7(11):851-9.

Macfarlane TV, Blinkhorn A, Worthington HV, Davies RM, Macfarlane GJ. Sex hormonal factors and chronic widespread pain: a population study among women. Rheumatology (Oxford). 2002 Apr;41(4):454-7.

Benediktsdóttir B, Tómasson K, Gíslason T. [Climateric symptoms and hormone replacement treatment among 50 years old Icelandic women.] Laeknabladid. 2000 July/August;86(7/8):501-507.

Meisler JG. Chronic pain conditions in women. J Womens Health. 1999 Apr;8(3):313-20.

City of Hope Fibro Study

Wed, 25 Jun 2008 12:00:00 +0100

Dr. R. Paul St. Amand, Cladia Craig Marek, Dr John (Jack) Shively PhD and a team of researchers working on the "City of Hope Fibromyalgia Study" have e-published a paper ahead of print in the journal Experimental biology and medicine. [1]

Dr. R. Paul St. Amand is the originator of the Guaifenesin Protocol for Fibromyalgia Syndrome (Fibro), a much debated treatment protocol that is not widely accepted by the medical community. Claudia Craig Marek, his medical assistant, is the author of 'Fibromyalgia: The First Year'. The "City of Hope Fibromyalgia Study" is a three-year investigation involving patients of Dr St Amand, which is taking place at City of Hope Hospital in California, USA, where Dr Shively PhD is Chair of the Division of Immunology.

The purpose of the City of Hope Fibro study is to compare the blood of Fibro patients with that of healthy participitants in terms of autoinflammatory genes (genes involved with an inflammatory response when there is no obvious infection) and response to inflammatory stimuli. Other purposes are to determine if there are polymorphisms of the autoinflammatory genes and to look for evidence of links between Fibro and immune or genetic factors.

In the study discussed in the recently e-published article, blood plasma levels of 25 cytokines and chemokines in 92 female Fibro patients and 69 family members were measured, compared to 77 control samples taken from the City of Hope blood bank. The patient group included: patients whose parents did not have Fibro; patients who had one parent with Fibro; patients who had one parent with Fibro but a sibling that did not; and, in one case, a patient whose mother and maternal grandmother both had Fibro. Fifty-six (61%) of the patient group had been treated with the Guaifenesin Protocol for at least 3 months. [1] The control samples were known to be from females without Fibro, although it is not known how well they were screened for signs of the condition, or other conditions.

Cytokines are extensively within the body for communication between cells, like hormones and neurotransmitters, but with a greater diversity than either hormones (which are usually transported in the blood) or neurotransmitters (which are related to the nervous system). Cytokines are involved in the development and functioning of the immune system, as well as with a variety of immunological, inflammatory and infectious diseases. Chemokines are a group of small Cytokines, some of which are considered to promote inflammation.

The movement of leukocytes, a type of white blood cell, across membranes within the body, and the cytokine profile of skeletal muscle cells, were also analysed.

The study found that the Fibro patients and their family members had high levels of MCP-1 and eotaxin compared to controls. [1] However, it was not known how many of the family members might also have had Fibro themselves.

MCP-1, or Monocyte chemotactic protein-1, is a chemokine with a role in getting various immune system cells to the site of infection or injurys. Eotaxin is another chemokine, with a role in recruiting eosinophils, other immune system cells with a relation to inflammation, which are responsible for combating infection and parasites and also control mechanisms associated with allergy and asthma. MCP-1 and Eotaxin gene polymorphisms have been reported to contribute to susceptibility to several immune and inflammatory conditions.[2][3][4]

The City of Hope study article also said that they had found that the patient group on the Guaifenesin Protocol had higher levels of eotaxin than those not being treated. [1]

The article says that "[d]iluted plasma from patients increased the migration of normal eosinophils and monocytes, but not neutrophils, through an endothelial/Matrigel barrier only when mast cells are included in the lower wells". [1] In other words, when compared to the controls, the samples from Fibro patients increased the amount of eosinophils and monocytes crossing barriers similar to those surrounding the internal vessels of the body, such as blood vessels: i.e. they increased the rate of movement of eosinophils and monocytes.

The study also found that skeletal muscle cells can, when tested in the laboratory (in vitro), secrete MCP-1, eotaxin, and IP-10, while treatment with MCP-1 caused secretion of IL-1beta, eotaxin and IP-10 (another cytokine). [1]

In the discussion, the researchers note that there are some possibly conflicting findings in their results, notably the raised levels of both MCP-1 and eotaxin. As eotaxin is a natural antagonist for the main receptor (CCR2) for MCP-1, the raised levels of eotaxin may be in response to the high levels of MCP-1 found, as the body tries to offset the damage caused by the MCP-1. This could also explain the high levels of IP-10 found, as IP-10 is the natural antagonist for both MCP-1 and eotaxin.

The researchers concluded that:

"the [Fibro group] studied here is associated with elevated levels of inflammatory chemokines, MCP-1 and eotaxin may contribute to the symptoms of [Fibro], parents of these patients share the expression profile, and [muscle cells] are a potential source of eotaxin and MCP-1. Therefore reduction of eotaxin and MCP-1 levels or blockade of their receptors may be a reasonable treatment strategy for [Fibro]. We also found evidence that treatment with guifenesin accentuates eotaxin production and reduces IL-13 and IFN-gamma [(other cytokines/chemokines)]. While only a few studies have shown elevated cytokine levels in [Fibro], our data suggests that elevated chemokine levels may play a causative role in [Fibro] and should be investigated further."

However, Hellhammer et al [5] found that chronic stress, such as that experienced by chronic pain patients, e.g. Fibro patients, disrupts the HPA axis and leads to low levels of cortisol. In the long-term, the low cortisol levels may lead to increased levels of other substances, such as leukocytes and cytokines. [5] Thus it could be argued that the raised levels of cytokines found in the Fibro patients in this study may be caused by the Fibro, rather than causing the Fibro in the first place. Or it could be a chicken-and-egg situation where the one worsens the other, making the first worse, and it is very hard to separate cause from effect.

There may also be a fault in the way the results are compared, which would mean that the raised levels of eotaxin in the patient group on the Guaifenesin Protocol compared to the patient group not on Guaifenesin may not be significant.

In summary, the study found that people with Fibro, whether they were on the Guaifenesin protocol or not, had high levels of substances that are usually associated with autoimmune and inflammatory conditions, suggesting that they may be an inflammatory or autoimmune connection with Fibro. Family members of the Fibro patients also had raised levels of some of these substances, suggesting that Fibro might have a family or genetic link. Dr St Amand has suggested that the raised levels of one of the immune system substances found in the patients on the Guaifenesin Protocol, as opposed to those who were not, may be of significance for the validity of the Guaifenesin Protocol. However, there were some flaws in the study and possibly in the conclusion, such as it not being known whether the family members themselves had Fibro and the difference between the Fibro patients on the Guaifenesin Protocol and those who were not, not in itself being significant.

This study remains a very interesting piece of research, but its significance may unfortunately be diluted by the flaws in the study and its significance to proponents of the Guaifenesin Protocol as evidence of the protocol is debatable.

References:

Zhang Z, Cherryholmes G, Mao A, Marek C, Longmate J, Kalos M, St Amand RP, Shively JE. High plasma levels of MCP-1 and eotaxin provide evidence for an immunological basis of fibromyalgia. Exp Biol Med (Maywood). 2008 Jun 5. [Epub ahead of print]
Amoli MM, Salway F, Zeggini E, Ollier WE, Gonzalez-Gay MA. MCP-1 gene haplotype association in biopsy proven giant cell arteritis. J Rheumatol. 2005 Mar;32(3):507-10.
Chae SC, Park YR, Shim SC, Lee IK, Chung HT. Eotaxin-3 gene polymorphisms are associated with rheumatoid arthritis in a Korean population. Hum Immunol. 2005 Mar;66(3):314-20.
Bugeja MJ, Booth D, Bennetts B, Heard R, Rubio J, Stewart G. An investigation of polymorphisms in the 17q11.2-12 CC chemokine gene cluster for association with multiple sclerosis in Australians. BMC Med Genet. 2006 Jul 26;7:64.
Hellhammer DH, Ehlert U, Heim C. The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology 25 (2000) 1–35

Fibrofog mimics 20 years of aging

Sun, 29 Jun 2008 12:00:00 +0100

An article has been published recently suggesting that the cognitive problems associated with Fibrofog mimic around 20 years of aging. [1]

The article, Fibromyalgia and cognition, by JM Glass, was published in the Journal of clinical psychiatry.

Cognitive difficulties are a common symptom of Fibromyalgia Syndrome (Fibro), including problems with memory and difficulty concentrating. These cognitive difficulties are often nicknamed "Fibrofog". The existence of these symptoms has been confirmed, according to the article, by studies that were looking at the incidence of cognitive problems in Fibro patients. These studies included objective tests of metamemory (knowing about your own memories, such as how accurate they are), working (short-term) memory, semantic memory (such as remembering facts and the meanings of words), everyday attention, task switching (i.e. being able to change from one task to another), and selective attention (when you purposely focus on one thing). The studies show that the problems with working (short-term) memory, episodic (relating to a specific event) memory and semantic memory associated with Fibro mimic the effects of around 20 years of aging. [1]

According to the article, the cognitive difficulties associated with Fibro may be exacerbated by the presence of depression, anxiety, sleep problems, endocrine disturbances, and pain, but the relationship of these factors to the cognitive difficulties is unclear. [1]

Glass notes that standardised tests and treatment have not yet been established for the cognitive difficulties associated with Fibro. [1] These cognitive difficulties can be extremely hard for patients to cope with and they can have a significant impact on Fibro patients' ability to function and especially to continue working. Proving the cognitive difficulties is often complicated and this can cause issues with family and carers, employers and benefits agencies. Standardised testing for these cognitive problems would be useful and could provide validation for patients. Having accepted treatment protocols for "Fibrofog" would likely make a huge difference to the impact Fibro can have on patients' lives.

References:

Glass JM. Fibromyalgia and cognition. J Clin Psychiatry. 2008;69 Suppl 2:20-4.

An Internet based Self Management Program

Mon, 30 Jun 2008 12:00:00 +0100

An internet based Self Management Program can help people with Fibromyalgia Syndrome (Fibro) or arthritis, according to a recent article. [1]

The article, by a group of researchers at Stanford University School of Medicine, California, USA, was recently e-published ahead of print in the journal Arthritis and Rheumatism. In it, they discuss the results of a 1-year trial of an internet-based arthritis self-management program for patients with arthritis or Fibro.

The researchers note that small-group arthritis self-management programs have proven effective in changing health-related behaviors and improving health status measures. The study specifically aimed to determine the efficacy of an Internet-based Arthritis Self-Management Program as a resource for patients who were either unable or unwilling to attend such a small-group program. [1]

For the study, 855 patients with either rheumatoid arthritis, osteoarthritis, or Fibro, and Internet and e-mail access, were randomized to an intervention or usual care control group. Outcome measures included 6 health status variables (pain, fatigue, activity limitation, health distress, disability, and self-reported global health), 4 health behaviors (aerobic exercise, stretching and strengthening exercise, practice of stress management, and communication with physicians), 5 utilization variables (physician visits, emergency room visits, chiropractic visits, physical therapist visits, and nights in hospital), and self-efficacy. The participants assigned to the intervention group were compared with usual care controls at 6 months and 1 year.

At 1 year, the group assigned to the internet based Arthritis Self Management Program had significantly improved in 4 of 6 health status measures and self-efficacy. No significant differences in health behaviors or health care utilization were found. [1]

The researchers concluded that:

"The Internet-based [Arthritis Self-Management Program] proved effective in improving health status measures at 1 year and is a viable alternative to the small-group [Arthritis Self-Management Program]." [1]

Variations on the Expert Patient Program are used in many countries as a means of helping patients with chronic illnesses. However, having to attend regular meetings often puts some people off, especially those with more severe conditions. The use of an Internet based self-management program could be very useful to a number of patients.

References:

Lorig KR, Ritter PL, Laurent DD, Plant K. The internet-based arthritis self-management program: A one-year randomized trial for patients with arthritis or fibromyalgia. Arthritis Rheum. 2008 Jun 24;59(7):1009-1017. [Epub ahead of print]

Sleep disturbances and Fibro

Mon, 30 Jun 2008 12:00:00 +0100

A recent article discusses a study that looked at the relationship between sleep problems, pain, depression, and physical functioning in patients with Fibromyalgia Syndrome (Fibro). [1]

The article, Sleep disturbances in fibromyalgia syndrome: Relationship to pain and depression, from researchers at Indiana University and Purdue University, Indianapolis, USA, was e-published ahead of print in the journal Arthritis and Rheumatism.

The study involved a baseline assessment and then 1-year follow up of Fibro patients, diagnosed according to the 1990 ACR criteria. who were recruited from a Southern California health maintenance organization. Measures used to evaluate sleep, pain, depression, and physical functioning included the Center for Epidemiologic Studies Depression Scale, the McGill Pain Questionnaire, the Pittsburgh Sleep Quality Index, and the Fibromyalgia Impact Questionnaire. Six hundred patients completed the baseline assessment and 492 completed the 1-year assessment. [1]

The majority of the participants (96% at baseline and 94.7% at 1 year) were found to have problems sleeping. The results were analysed to find if there was a link between any of the variables at the baseline measurement and a change in another variable at the 1-year measurement. No variable was found to be significantly linked to a worsening of sleep problems, but poor sleep at the baseline measurement was linked to more pain at the 1-year measurement. More pain at the baseline measurement was also linked to poorer physical functioning at the 1-year measurement, and poorer physical functioning at the baseline measurement was linked to higher depression scores at the 1-year measurement. [1]

The researchers concluded that:

"These findings highlight the high prevalence of sleep problems in this population and suggest that they play a critical role in exacerbating [Fibromyalgia Syndrome] symptoms. Furthermore, they support limited existing findings that sleep predicts subsequent pain in this [the Fibro patient] population, but also extend the literature, suggesting that sleep may be related to depression through pain and physical functioning." [1]

This study is interesting in that, as well as highlighting how prevalent sleep problems are with Fibro, it also suggests a pathway for the development of depression as a result of Fibro. It is often thought that many Fibro patients have symptoms of depression, but it is not always considered whether problems due to the Fibro were the direct cause of the depression. [2] This study suggests that this is so, corroborating many anecdotal reports that depression is a result of Fibro. [1]

Fibro patients need to keep in mind that a lack of restorative sleep, no matter how much sleep is got overall, is in itself a sleep problem. When you could sleep for much of the day, it can seem unintuitive to say that you have a problem sleeping, but the lack of restorative sleep was one of the first recorded symptoms of Fibro. [3] And as this study suggests, poor sleep can lead to more pain, which can then lead to further problems. [1]

References:

Bigatti SM, Hernandez AM, Cronan TA, Rand KL. Sleep disturbances in fibromyalgia syndrome: Relationship to pain and depression. Arthritis Rheum. 2008 Jun 24;59(7):961-967. [Epub ahead of print]

Arnold LM. Management of fibromyalgia and comorbid psychiatric disorders. J Clin Psychiatry. 2008;69 Suppl 2:14-9.

Moldofsky H. Sleep and fibrositis syndrome. Rheum Dis Clin North Am. 1989 Feb;15(1):91-103.

Another aspect of Fibrofog measured

Mon, 21 Jul 2008 12:00:00 +0100

People with Fibromyalgia Syndrome (Fibro) have trouble reading words and naming colours quickly, according to a recently published article. [1] This is yet another aspect of the cognitive difficulties, nicknamed "Fibrofog", experienced by Fibro patients, that has actually been measured.

The article, e-published ahead of print in the Journal of Clinical Rheumatology, discusses a study carried by 2 researchers at Rush Medical College, Chicago, USA, that aimed to examine the speed of mental operations in people with Fibro under the pressure of time. [1]

The study involved 67 Fibro patients with a history of memory complaints and 51 controls without Fibro presenting with complaints of memory loss. They were asked to carry out 10 timed tasks designed to measure various aspects of the brain's processing speed. [1]

The researchers found that the majority (more than 70%) of the Fibro patients were not significantly different to the norm in performing 7 or more of the tasks. However, more than 49% of FMS patients tested as impaired on the specific tasks of reading words and naming colours. Compared with controls, the number of FMS patients showing impairment was 2.0 times greater for reading speed, and 1.6 times greater for color naming speed. The time delays involved were small, with an average time delay of 203 milliseconds for reading words and 285 milliseconds for naming colors, but these delays represent a significant increase in the time taken: 48% increase in time for Fibro patients to read the same stimulus word as controls. [1]

The researchers concluded that:

"Abnormalities in naming speed are an unappreciated feature of [Fibro]." [1]

They also concluded that abnormalities in naming speed, associated with otherwise good processing speeds, set Fibro patients apart from those with memory complaints but not Fibro. The researchers go on to suggest that clinicians request adding a rapid naming test (such as the Stroop Test) to the battery of cognitive tests in order to show up "cognitive dysfunction in [Fibro] patients who otherwise appear to test normally, despite often intense complaints of memory and concentration difficulties that can affect job performance and increase disability". [1]

An article published last month suggested that the cognitive problems associated with Fibrofog mimic around 20 years of aging. The author of that article noted that standardised tests and treatment have not yet been established for the cognitive difficulties associated with Fibro. [2] This new study suggests one test at least that could be a good cognitive test for Fibro, if not so much a measure of the severity of cognitive symptoms.

References:

Leavitt F, Katz RS. Speed of Mental Operations in Fibromyalgia: A Selective Naming Speed Deficit. J Clin Rheumatol. 2008 Jul 17. [Epub ahead of print]

Glass JM. Fibromyalgia and cognition. J Clin Psychiatry. 2008;69 Suppl 2:20-4.

GPs can treat Fibro just as well as consultants

Tue, 22 Jul 2008 12:00:00 +0100

Fibromyalgia Syndrome (Fibro) can be treated within the primary care setting, and getting treatment quickly leads to better outcomes, according to an article recently e-published ahead of print in the journal Arthritis Research & Therapy. [1]

The study aimed to compare the efficacy of the treatments for Fibro available in both primary care and specialised settings, as well as to look at variables that improve the outcome of treatment. [1] Primary care would normally be medical care with a GP, and specialised care would be with a specialist clinic or a hospital consultant.

The researchers looked at reports of randomized controlled trials researching pharmacological and non-pharmacological treatments for Fibro, available in the research resources MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and PsychInfo, with the most recent electronic search being carried out in June 2006. Of the 594 articles identified by abstract and title, 102 full articles were retrieved and 33 of these met the inclusion criteria. These randomised controlled trials assessed 120 treatment interventions on 7789 patients diagnosed with primary Fibromyalgia Syndrome, of which 4505 (57.8%) were included in the primary care group and 3284 (42.2%) in the specialised intervention group. The patients were mostly middle-aged women who had been suffering from Fibro for 6-10 years. [1]

The researchers found that the treatments used in the studies were on average effective, but that there was no significant difference in treatment efficiacy between the patients treated in a primary care setting and those treated in a specialised care setting. They concluded that there was no particular need for specialised care in treating Fibro. [1] The main factor affecting how efficient treatment for Fibro from different doctors is, is often how much knowledge of the condition they have. As Fibro does not fall properly into any one medical discipline, little training is given about the condition, even at consultant level. Primary care practitioners or General Practitioners (GPs) can therefore have as much information and knowledge as their more specialised colleagues.

The researchers also found that variables (that were not affected by the differences in the trials) that improved the outcome of patients receiving treatment were younger age of the patients and shorter duration of the disorder. In other words, the patients who were more likely to do well were young and hadn't been suffering from Fibro for very long. [1]

There were a number of issues with the trials used in this study, such as the varying quality of the trials and the different length of time the treatments were trialled impacting on the results. [1] The number of trials that fit the inclusion criteria was also relatively small.

Past studies have had mixed results as to whether duration of illness is a factor in how well Fibro patients respond to treatment. [2] However, anecdotal evidence suggests that on average, Fibro patients worsen over time, especially during the first few years of the condition. Timely treatment may mean that the condition is less severe, so that less improvement is needed to return the patient to a reasonable level of functionality and symptom relief. It may also make it less likely that reactive depression because of the Fibro develops [3] and psychiatric comorbidities negatively impact the severity and course of Fibro [4] so preventing these developing could lead to a better outcome for patients.

References:

Garcia-Campayo J, Magdalena J, Magallon R, Fernandez-Garcia E, Salas M, Andres E. Efficacy of fibromyalgia treatment according to level of care: a meta-analysis. Arthritis Res Ther. 2008 Jul 15;10(4):R81. [Epub ahead of print]

Wigers SH. Fibromyalgia outcome: the predictive values of symptom duration, physical activity, disability pension, and critical life events--a 4.5 year prospective study. J Psychosom Res. 1996 Sep;41(3):235-43.

Bigatti SM, Hernandez AM, Cronan TA, Rand KL. Sleep disturbances in fibromyalgia syndrome: Relationship to pain and depression. Arthritis Rheum. 2008 Jun 24;59(7):961-967. [Epub ahead of print]

Arnold LM. Management of fibromyalgia and comorbid psychiatric disorders. J Clin Psychiatry. 2008;69 Suppl 2:14-9.

Fibro is not the same as Major Depressive Disorder

Wed, 23 Jul 2008 12:00:00 +0100

A recent article says that Major Depressive Disorder (MDD) and Fibromyalgia Syndrome (Fibro) do not have the same underlying causes and are not subsets of the same disease concept, despite similarities between their characteristics and treatments. [1]

The article, which was e-published ahead of print in the journal Current medical research and opinion, reviewed research on the prevalence, etiology and pathogenesis, clinical characterization, and treatment of Fibro and MDD, as well as studies that examined the relationship between these disorders. The studies reviewed were identified via the PubMed literature search.

In discussing the objective of the review, the researchers said that:

"A large body of evidence suggests that the relationship between major depressive disorder (MDD) and [Fibro] is complex. Improved understanding of this relationship promises to provide clinicians with better assessment and treatment options for both disorders."

They found that there were substantial similarities between Fibro and MDD when considering neuroendocrine abnormalities, psychological characteristics, physical symptoms and treatments. However, they also found that "currently available findings do not support the assumption that MDD and FM refer to the same underlying construct or can be seen as subsidiaries of one disease concept."

The article concludes that new approaches may lead to a better understanding of the link betweem Fibro and MDD and also to more effective psychological and psychopharmacological therapies for Fibro. Medications that are also used as anti-depressants and anti-anxiety medications are already widely used as treatments for Fibro.

The researchers suggested that "clinicians should carefully screen for a history of MDD in patients with Fibro".

References:

Pae CU, Luyten P, Marks DM, Han C, Park SH, Patkar AA, Masand PS, Van Houdenhove B. The relationship between fibromyalgia and major depressive disorder: a comprehensive review. Curr Med Res Opin. 2008 Jul 4. [Epub ahead of print]

ATP calcium and magnesium levels in Fibro

Thu, 24 Jul 2008 12:00:00 +0100

A recent article from a group of Italian researchers has suggested that abnormal ATP levels within blood cells, along with disturbances in calcium and magnesium transport, may be a part of Fibromyalgia Syndrome (Fibro). [1]

The article, which was e-published ahead of print in the journal Clinical biochemistry, discusses a study in which the concentrations of ATP and positively charged ions (cations) were measured in 25 Fibro patients and 25 healthy controls through a chemiluminescent and a fluorimetric assay, respectively. The cation concentration was used as a measure of the concentration of calcium and magnesium, as these are present within cells as positively charged ions. [1]

ATP or Adenosine Triphosphate is a high energy a multifunctional nucleotide, whose most important function is the transport of chemical energy within cells for metabolism. It is the main energy source for the majority of cellular functions.

The preliminary study from the group of Italian researchers found that significantly lower ATP levels were observed inside the platelets of Fibro patients compared to the healthy controls. Fibro patients also showed a trend towards higher calcium concentrations in platelets, along with significantly increased magnesium levels. [1]

The researchers concluded that:

"This preliminary study suggests that disturbances in the homeostasis of platelet ATP metabolism-signaling and calcium-magnesium flows might have a relevance in the pathogenesis of [Fibro]." [1]

However, altered levels in intracellular levels have previously been associated with both aging and other conditions such as high blood pressure, so the results seen here in this preliminary study may be influenced by other factors. [2]

References:

Bazzichi L, Giannaccini G, Betti L, Fabbrini L, Schmid L, Palego L, Giacomelli C, Rossi A, Giusti L, De Feo F, Giuliano T, Mascia G, Bombardieri S, Lucacchini A. ATP, calcium and magnesium levels in platelets of patients with primary fibromyalgia. Clin Biochem. 2008 Jul 2. [Epub ahead of print]

Barbagallo M, Gupta RK, Dominguez LJ, Resnick LM. Cellular ionic alterations with age: relation to hypertension and diabetes. J Am Geriatr Soc. 2000 Sep;48(9):1111-6.

Online Group Lurkers may not get the most benefit

Sun, 27 Jul 2008 12:00:00 +0100

If you go to an online support group but "lurk" rather than participating, it may be preventing you from getting the most benefit out of the group, according to the recently published results of a Dutch study.

The study, results of which were published in the Journal of medical internet research, followed up on an earlier study that indicated that participation in online support groups had a profound effect on the participants’ feelings of “being empowered.” [1]

The earlier study, and indeed most previous studies of online patient support groups, focused on active members of these groups, who contribute by posting messages (posters). This new study explored whether people who read the messages, but do not actively contribute by posting themselves, (lurkers) profit to the same extent from use of online patient support groups as posters do.

The researchers noted, although little is known about lurkers in online patient support groups, some studies have been conducted on lurkers in other online communities. Opinions about lurking and lurkers vary considerably, with some poeple considering it negative bahaviour, using the resources of online groups without giving back to them, whilst others consider lurking to be acceptable or even beneficial, encouraging new members and discouraging an overload of posting. Lurking rates on various online groups are highly variable, but with an average of 45.5% of lurkers in health-related online support groups being reported. [1][2]

For the latest study, the researchers used Google to identify all Dutch online support groups for patients with breast cancer, Fibromyalgia Syndrome (Fibro), and arthritis. The owners of 19 groups then sent out invitations to complete an online survey, including questions demographic and health characteristics, use of and satisfaction with the online support group, empowering processes, and empowering outcomes. The online questionnaire was completed by 528 individuals, of which 109 (21%) identified themselves as lurkers. [1]

Lurkers were found to be slightly older than posters, with a shorter disease history and reported lower mental well-being. [1]

Posters were found to be visiting the online support groups significantly more often for social reasons, such as curiosity about how other members were doing, to enjoy themselves, as a part of their daily routine, and because other members expected them to be there. Lurkers and posters did not differ in their information-related reasons for visiting the online support group. [1]

Lurkers were significantly less satisfied with the online support group compared to posters. Although the researchers found that lurkers did not differ significantly from posters with regard to most empowering outcomes, such as “being better informed,” “feeling more confident in the relationship with their physician,” “improved acceptance of the disease,” “feeling more confident about the treatment,” “enhanced self-esteem,” and “increased optimism and control”, lurkers scored significantly lower for “enhanced social well-being”.

The researchers concluded that:

"[The] study revealed that participation in an online support group had the same profound effect on lurkers’ self-reported feelings of being empowered in several areas as it had on posters. Apparently, reading in itself is sufficient to profit from participation in an online patient support group."

However, actively contributing to an online support group could enhance lurker's social well-being.

References:

van Uden-Kraan CF, Drossaert CH, Taal E, Seydel ER, van de Laar MA. Self-reported differences in empowerment between lurkers and posters in online patient support groups. J Med Internet Res. 2008 Jun 30;10(2):e18.

Nonnecke B, Preece J. Lurker demographics: counting the silent. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems April 1-6; The Hague, The Netherlands. New York: ACM Press 2000:73-80.

High Dose Amitriptyline not for Fibro

Thu, 14 Aug 2008 12:00:00 +0100

An article by Spanish researchers discussing amitriptyline as a treatment for Fibromyalgia Syndrome (Fibro) was this week e-published ahead of print in the journal Rheumatology. The researchers concluded that there was no evidence to support the use of amitriptyline for Fibro at higher doses or for longer than 8 weeks.

In order to assess the efficacy and safety of amitriptyline as a treatment for Fibro, a comprehensive computerized search in Medline (Pubmed), EMBASE and The Cochrane Library was carried out, looking for randomized controlled trials (RCTs) that compared amitriptyline vs placebo in adult patients suffering from Fibro. Ten study of moderate to high quality were identified, although the variability of the studies precluded a quantitative meta-analysis being carried out (i.e. the results could not simply be integrated).

Amitriptyline 25 mg/day (six RCTs) was found to be of benefit compared to placebo when considering pain, sleep, fatigue and overall patient and investigator impression. However, this benefit was generally seen at 6-8 weeks of treatment, with no benefit being noted at 12 weeks.

Amitriptyline 50 mg/day (four RCTs) did not demonstrate a benefit compared to placebo.

Neither dose of amitriptyline had an effect on the number of tender points the study participants were measured as having.

The researchers concluded that:

"A definitive clinical recommendation regarding the efficacy of amitriptyline for [Fibro] symptoms cannot be made. There is some evidence to support the short-term efficacy of amitriptyline 25 mg/day in FM. There is no evidence to support the efficacy of amitriptyline at higher doses or for periods [greater than] 8 weeks. "

The researchers went on to suggest that more stringent RCTs with follow-up periods are needed in order to determine the long-term efficacy and safety of amitriptyline and to define its role in the management of Fibro.

References:

Nishishinya B, Urrútia G, Walitt B, Rodriguez A, Bonfill X, Alegre C, Darko G. Amitriptyline in the treatment of fibromyalgia: a systematic review of its efficacy. Rheumatology (Oxford). 2008 Aug 12. [Epub ahead of print]

Waon Heat Therapy for Fibro

Thu, 21 Aug 2008 12:00:00 +0100

A recent article from Japanese researchers has shown that Waon Therapy, a specific kind of soothing warmth therapy, can be effective at helping to treat Fibromyalgia Syndrome (Fibro). [1]

For the Waon therapy, 13 female Fibro patients, spent 15 minutes relaxing in far infrared-ray dry sauna maintained at an even temperature of 60 degrees C, folowing which they were transferred to a room maintained at 26-27 degrees C where they were covered with a blanket from the neck down to keep them warm for 30 minutes. [1]

The pain Visual Analog Scale (VAS) and the Fibromyalgia Impact Questionnaire (FIQ) were used to assess subjective pain levels and symptom impact due to Fibro. After the first session of Waon therapy, all the patients experienced significant pain reduction of 11-70% and after 10 sessions of the therapy, the effects stabilised at 20-78% of pain reduction. Significant reductions in pain and symptoms were determined using the pain Visual Analog Scale (VAS) and the Fibromyalgia Impact Questionnaire (FIQ), and these reductions in pain and symptoms were seen throughout the observation period. [1]

The researchers concluded that:

"Waon therapy is effective for the treatment of Fibromyalgia Syndrome." [1]

Heat therapies of various forms are often used by Fibro patients, with heated pool treatment being included in the EULAR evidence-based recommendations for the management of Fibromyalgia Syndrome. [2] Heat was also rated as one of the most effective management modalities by an internet survey of 2,596 people with Fibro that was carried out last year. [3]

References:

Matsushita K, Masuda A, Tei C. Efficacy of Waon therapy for fibromyalgia. Intern Med. 2008;47(16):1473-6. Epub 2008 Aug 15.
Reference: Carville SF, Arendt-Nielsen S, Bliddal H, Blotman F, Branco JC, Buskila D, Da Silva JA, Danneskiold-Samsøe B, Dincer F, Henriksson C, Henriksson KG, Kosek E, Longley K, McCarthy GM, Perrot S, Puszczewicz M, Sarzi-Puttini P, Silman A, Späth M, Choy EH; EULAR. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008 Apr;67(4):536-41. Epub 2007 Jul 20.
Bennett RM, Jones J, Turk DC, Russell IJ, Matallana L. An internet survey of 2,596 people with fibromyalgia. BMC Musculoskelet Disord. 2007 Mar 9;8:27

Statins and muscle pain

Mon, 25 Aug 2008 12:00:00 +0100

A recently e-published article from a team of researchers at a Harvard teaching hospital has suggested that statin users are more likely to have musculoskeletal pain. [1]

Statins (3-hydroxy-3-methylglutaryl coenzyme A or HMG-CoA inhibitors) are a class of medications that are used to lower cholesterol levels in people with or at risk of cardiovascular disease. They work by inhibiting an HMG-CoA enzyme, stimulating LDL receptors, resulting in more low-density lipoprotein (LDL - often known as "bad cholesterol") being taken from the bloodstream and a decrease in blood cholesterol levels.

Muscle effects are the most commonly reported side effects of statins, with muscle cramps, myalgia (muscle pain), myopathy (muscle problems with the primary symptom of muscle weakness due to dysfunction of the muscle fibers), rhabdomyolysis (the breakdown of muscle fibers) and arthralgias (joint pains) being reported. Non-urgent myalgias are relatively common, with rhabdomyolysis being rare.

However, in placebo-controlled trials the incidence of muscle pain is often similar for placebo and active control groups.

This study sought to evaluate whether statin use was associated with a higher prevalence of musculoskeletal pain in a nationally (USA) representative sample. [1]

Data from the US National Health and Nutrition Examination Survey (NHANES) 1999-2002 was used. This gave 3,580 adult "participants", 40 years of age or over, without arthritis, who were interviewed at home and examined in a mobile examination center. They were asked about sociodemographic characteristics, health conditions, medication use, and musculoskeletal pain. Height, weight, blood pressure, ankle brachial index, and cholesterol were measured. The ankle brachial index is a measure of the reduction in blood pressure between arteries in the upper arms and the ankles, and as such, it is used to detect evidence of blockages in the circulatory system. [1]

The study analysed the data to determine the prevalence and adjusted odds ratios of any musculoskeletal pain and musculoskeletal pain in 4 different anatomical regions (neck/upper back, upper extremities, lower back, and lower extremities) by statin use during the last 30 days. [1]

There were 402 statin users in the data used and the study found that 22% of these reported musculoskeletal pain in at least 1 anatomical region during the 30 days previous to the data being collected, compared to 16.7% of those who did not use a statin. Compared to persons who did not use statins, those who used statins had multivariable-adjusted odds ratios of 1.50 for any musculoskeletal pain, 1.59 for lower back pain, and 1.50 for lower extremity pain. [1]

The researchers concluded that musculoskeletal pain is common in adults 40 years of age or over, without arthritis, and that:

"In this nationally representative sample, statin users were significantly more likely to report musculoskeletal pain."

One of the researchers from the team that carried out this study has also co-authored another paper that was published this month in the journal Pharmacogenomics. In this it is suggested that a gene required for muscle atrophy is implicated in the pathophysiology of statin-induced muscle injury, such as rhabdomyolysis. [3]

Statin use may be problematic for Fibromyalgia Syndrome patients because of the risk of increased pain. [4] However, an article published earlier this year suggests that the risk of myalgia and other potentially treatment-limiting muscle effects can be reduced through: proper monitoring; statin dosage reduction, discontinuation, and rechallenge; and the use of treatment alternatives, such as statins which are less likely to cause side effects. Statins can thus be used for their cardiovascular benefits whilst minimising the risk of muscle effects. [5]

References:

Buettner C, Davis RB, Leveille SG, Mittleman MA, Mukamal KJ. Prevalence of musculoskeletal pain and statin use. J Gen Intern Med. 2008 Aug;23(8):1182-6. Epub 2008 May 1.
Silva MA, Swanson AC, Gandhi PJ, Tataronis GR. Statin-related adverse events: a meta-analysis. Clin Ther. 2006 Jan;28(1):26-35.
Buettner C, Lecker SH. Molecular basis for statin-induced muscle toxicity: implications and possibilities. Pharmacogenomics. 2008 Aug;9(8):1133-42.
Mascitelli L, Pezzetta F, Goldstein MR. Detrimental effect of statin therapy in women with fibromyalgia. Arch Intern Med. 2008 Jun 9;168(11):1228-9.
Jacobson TA. Toward "pain-free" statin prescribing: clinical algorithm for diagnosis and management of myalgia. Mayo Clin Proc. 2008 Jun;83(6):687-700.

Pain Related Cognitive Behavioral Mechanisms and Fibro

Wed, 27 Aug 2008 12:00:00 +0100

An article by Dutch researchers has suggested that screening for pain persistance and pain avoidance patterns in patients with Fibromyalgia Syndrome (Fibro) can lead to finding more effective treatments for individual patients. [1]

In the article, published in the International Journal of Behavioural Medicine, the researchers say that the variations between Fibro patients as regards pain-related cognitive-behavioral mechanisms, has been proposed as a reason why some patients do better than others with some treatments. [1]

Pain-related cognitive-behavioral mechanisms include pain avoidance, characterised by avoiding activities because they may cause pain (even though, in some cases, e.g. with exercise, this can lead to more pain in the long-term), and pain persistance, characterised by continuing with activities in spite of pain (even though this may lead to more pain).

The Dutch researchers used a self-reported screening instrument, that assesses pain-avoidance behavior, to distinguish betweenpatients with pain-persistence and pain-avoidance patterns. [1]

The two resultant groups of patients were then compared with regard to several pain-related cognitive-behavioral factors, as well as their performance on a physical fitness test. They were also compared with regard to the judgments of trained therapists based on a semi-structured interview. [1]

They found that the results of the self-reported screening instrument they used corresponded with the other results in terms of which patients were assessed as having pain-avoidance and pain-persistence patterns.

The researchers concluded that:

"...a short self-report screening instrument can be used to distinguish between pain-avoidance and pain-persistence patterns within the heterogeneous population of [Fibro] patients, which offers promising possibilities to improve treatment efficacy by tailoring treatment to specific patient patterns." [1]

A previous article published earlier this year discussed 2 case studies where cognitive behavioural therapy (CBT) and exercise therapy for patients with Fibro were tailored for whether the patients fell into pain-avoidance or pain-persistence pattern groups. [2]

That study found that tailoring the CBT and exercise therapy to take the pain-avoidance/pain-persistence patterns into account can contribute to the improvement of the care of Fibro patients. [2]

References:

van Koulil S, Kraaimaat FW, van Lankveld W, van Helmond T, Vedder A, van Hoorn H, Cats H, van Riel PL, Evers AW. Screening for pain-persistence and pain-avoidance patterns in fibromyalgia. Int J Behav Med. 2008;15(3):211-20.
van Koulil S, van Lankveld W, Kraaimaat FW, van Helmond T, Vedder A, van Hoorn H, Cats H, van Riel PL, Evers AW. Tailored cognitive-behavioral therapy for fibromyalgia: two case studies. Patient Educ Couns. 2008 May;71(2):308-14. Epub 2008 Jan 9.

Juvenile Fibro and Anxiety

Wed, 27 Aug 2008 12:00:00 +0100

A recent article has suggested that children with Fibromyalgia Syndrome (Fibro) are more likely to suffer from anxiety disorders, and that anxiety is linked to poorer functioning in these patients. [1]

The article, from a group of researchers in the Division of Behavioral Medicine and Clinical Psychology at the University of Cincinnati College of Medicine, Ohio, USA, was published in the September issue of The Clinical Journal of Pain.

Their study aimed to assess the prevalence of mood, anxiety, and behavioral disorders in children and adolescents with juvenile primary fibromyalgia syndrome (JPFS) and to assess the relationship between psychiatric disorders and the severity of their Fibro. [1]

The study looked at 76 children and adolescents diagnosed with JPFS (ages 11 to 18 years) in pediatric rheumatology clinics at 4 hospitals in the Midwest area of the USA. Standardized psychiatric interviews were conducted with the children/adolescents and their parents or primary caregivers, and measures of symptom severity, including pain intensity and physician global ratings, were obtained for the patients. [1]

The researchers found that 67.1% of the patients had at least 1 current psychiatric diagnosis and 71.5% had at least 1 lifetime psychiatric diagnosis, with the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-fourth edition) being used to define psychiatric diagnoses. [1]

The most frequent psychiatric diagnosis was anxiety disorder (57.5% of patients). [1]

Although mood difficulties were also common, the researchers found that the presence of major depression in the young participants was lower than has been reported for adults with Fibro. [1]

Physicians' global assessment of functioning was significantly lower for patients with a current anxiety disorder. However, it was found that there were no significant differences in pain severity among patients with and without anxiety, mood, or behavioral disorders. [1]

The researchers concluded that:

"There seems to be a high prevalence of anxiety disorders in patients with JPFS, and presence of anxiety disorder is associated with poorer physician-rated functioning. Future research should explore whether early anxiety symptoms are predictive of long-term functioning."

According to an article published in an Icelandic journal earlier this year, the estimated prevalence of juvenile primary fibromyalgia syndrome (JPFS) is 1.2%-6.2%, with prevalence being higher in girls than in boys, and peaking at the time of puberty. The development of JPFS is related to many factors, such as genetic and anatomic factors, disordered sleep and psychological distress. [2]

The diagnosis of JPFS is based on the criteria defined by Yunus and Masi in 1985, which include generalised musculoskeletal aching at three or more regions for at least three months and at least five of eighteen typical tender points. [2][3]

Although there is an emerging understanding of JPFS and its treatment, [2] the situation in the UK hasn't improved much since 1985, when Masi and Yunus (the now legendary Fibro expert, Dr. Muhammad B. Yunus), wrote that:

"Juvenile PFS is often misdiagnosed. Recognition of this common rheumatologic condition in juveniles is important in order to avoid unwarranted investigations and improper management."

References:

Kashikar-Zuck S, Parkins IS, Graham TB, Lynch AM, Passo M, Johnston M, Schikler KN, Hashkes PJ, Banez G, Richards MM. Anxiety, mood, and behavioral disorders among pediatric patients with juvenile fibromyalgia syndrome. Clin J Pain. 2008 Sep;24(7):620-6.
Baldursdóttir S. [Juvenile primary fibromyalgia syndrome--review] Laeknabladid. 2008 Jun;94(6):463-72.
Yunus MB, Masi AT. Juvenile primary fibromyalgia syndrome. A clinical study of thirty-three patients and matched normal controls. Arthritis Rheum. 1985 Feb;28(2):138-45.

Hydrotherapy for Fibromyalgia Syndrome

Sun, 31 Aug 2008 12:00:00 +0100

Hydrotherapy is useful in managing Fibromyalgia Syndrome (Fibro), according to a recently e-published study from researchers at the Health and Rehabilitation Sciences Research Institute at the University of Ulster. [1]

The researchers carried out a systematic review of the published results of previous trials to examine the effectiveness of hydrotherapy in the management of Fibro. [1] A number of databases of scientific articles (AMED, BNI, CINAHL, The Cochrane Library, EMBASE, MEDLINE, ProQuest, PubMed, Science Direct and Web of Science) were searched for articles published between 1990 and July 2006 that contained the keywords: 'fibromyalgia' and 'hydrotherapy', 'balneotherapy', 'aqua therapy', 'pool therapy', 'water therapy', 'swimming', 'hydrogalvanic', 'spa therapy', 'physiotherapy', 'physical therapy' and 'rehabilitation'. [1]

The randomised controlled trials (RCTs) found in the search were then assessed for methodological quality using the van Tulder scale and 10 RCTs were found that met the inclusion criteria. [1]

These 10 RCTS showed that the use of hydrotherapy as a treatment for Fibro caused positive outcomes to be reported for pain, health-status and tender point count. [1]

The researchers concluded that:

"There is strong evidence for the use of hydrotherapy in the management of [Fibromyalgia Syndrome]". [1]

The EULAR evidence based recommendations for the management of Fibromyalgia Syndrome recommend that

"Heated pool treatment, with or without exercise, is effective." [2]

References:

McVeigh JG, McGaughey H, Hall M, Kane P. The effectiveness of hydrotherapy in the management of fibromyalgia syndrome: a systematic review. Rheumatol Int. 2008 Aug 27. [Epub ahead of print]
Carville SF, Arendt-Nielsen S, Bliddal H, Blotman F, Branco JC, Buskila D, Da Silva JA, Danneskiold-Samsøe B, Dincer F, Henriksson C, Henriksson KG, Kosek E, Longley K, McCarthy GM, Perrot S, Puszczewicz M, Sarzi-Puttini P, Silman A, Späth M, Choy EH; EULAR. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008 Apr;67(4):536-41. Epub 2007 Jul 20.

Physical functioning limitations with Fibromyalgia Syndrome

Sun, 31 Aug 2008 12:00:00 +0100

Women with Fibro may have more physical functional limitations than the average 80-year old woman, according to a survey carried out by the American National Fibromyalgia Association (NFA). [1]

For an article recently e-published ahead of print in the journal Womens Health Issues, researchers including NFA founder and president, Lynne Matallana, carried out a secondary analysis using data from an Internet-based survey posted on the National Fibromyalgia Association website. [1]

The data used included 1,735 women aged 31-78 years who reported being diagnosed with Fibromyalgia Syndrome (Fibro). [1]

More than 25% of the women reported having difficulty taking care of personal needs and bathing. [1]

More than 60% reported difficulty doing light household tasks, going up/down 1 flight of stairs, walking half a mile, and lifting or carrying 10 lbs. [1]

More than 90% of the women reported having difficulty doing heavy household tasks, lifting or carrying 25 lbs, and doing strenuous activities. [1]

The researchers also found that women with lower functional ability reported higher levels of fatigue, pain, spasticity, depression, restless legs, balance problems, dizziness, fear of falling, and bladder problems. [1]

They concluded that:

"The average woman in this sample reported having less functional ability related to activities of daily living and instrumental activities of daily living than the average community-dwelling woman in her 80s." [1]

They also noted that several symptoms and secondary conditions were found to be associated with limited functioning. Targeting these symptoms/conditions specifically may be important in terms of future interventions. [1]

References:

Jones J, Rutledge DN, Jones KD, Matallana L, Rooks DS. Self-Assessed Physical Function Levels Of Women With Fibromyalgia A National Survey. Womens Health Issues. 2008 Aug 22. [Epub ahead of print]

Specialist Nurses can diagnose Fibromyalgia Syndrome

Sun, 07 Sep 2008 12:00:00 +0100

A recent article has suggested that the use of specialised nurses in the diagnostic process of Fibromyalgia Syndrome (Fibro) is a trustworthy, successful and cost-effective approach that saves waiting time and provides greater patient satisfaction. [1]

The article, e-published ahead of print in the journal Arthritis and Rheumatism discussed a study that aimed to evaluate the substitution of specialised rheumatology nurses for rheumatologists in diagnosing Fibro. [1]

One hundred and ninety-three patients with Fibro like symptoms, who were referred for diagnosis, were randomly allocated to either a study group to be diagnosed by a specialised rheumatology nurse (SRN group) or to a control group to be diagnosed by a rheumatologist (RMT group). [1]

The patients allocated to the specialised rheumatology nurse group were seen within 3 weeks by a nurse who took a structured patient history and initiated routine laboratory tests. During a 5-minute supervision session, the rheumatologist was informed by the nurse about medical history, performed a brief physical examination, and confirmed or rejected the nurse's diagnosis. [1]

The patients allocated to the rheumatologist group were seen by a rheumatologist after a regular waiting period of 3 months. [1

The outcome measures used were an initial agreement between the nurse and rheumatologist in the group of patients allocated to the specialised rheumatology nurse group, final diagnosis after 12-24 months of follow-up, patient satisfaction, and diagnostic costs. [1]

The study found that the average waiting times were 2.8 weeks for the patients allocated to the specialised rheumatology nurse group and 12.1 weeks for the patients allocated to the rheumatologist group. Eight of the patients allocated to the rheumatologist group cancelled their appointments because of the waiting time. [1]

There was excellent agreement between the diagnoses made by the rheumatologist and the diagnoses made by the specialised rheumatologist nurse. After 12-24 months of followup, none of the initial diagnoses were recalled in either group. [1]

The patients allocated to the specialised rheumatology nurse group were significantly more satisfied and average diagnostic were lower for this group (219 Euros vs 281 Euros) compared to the patients allocated to the rheumatologist group . [1]

The researchers concluded that:

"Substituting specialized nurses for rheumatologists in the diagnostic process of [Fibro] is a trustworthy and successful approach that saves waiting time, provides greater patient satisfaction, and is cost-effective."

Specialist nurses are used for a number of conditions, including neurological conditions such as Multiple Sclerosis. In general, they are found to decrease costs and increase patient satisfaction.

References:

Kroese ME, Schulpen GJ, Bessems MC, Severens JL, Nijhuis FJ, Geusens PP, Landewé RB. Substitution of specialized rheumatology nurses for rheumatologists in the diagnostic process of fibromyalgia: A randomized controlled trial. Arthritis Rheum. 2008 Aug 29;59(9):1299-1305. [Epub ahead of print]

Fibromyalgia Syndrome has greater impact on patients

Sun, 07 Sep 2008 12:00:00 +0100

Three articles that were first published in late 2007 concluded that Fibromyalgia Syndrome (Fibro) has more of an impact on patients' lives and has more consequences for patients than many other chronic conditions and forms of widespread pain. [1] [2] [3]

The first article, on a study by reseachers Cöster et al at Linköping University, Sweden, was published in the European Journal of Pain. The study found that Fibro was associated with more severe symptoms/consequences for daily life and higher pain severity than chronic widespread pain without widespread allodynia. [1]

Allodynia is “Pain from stimuli which are not normally painful”, such as pain from a stroking motion on the skin.

The researchers said that Fibro is currently classified as chronic widespread pain with widespread allodynia to pressure pain, and that there have been few studies comparing Fibro with chronic widespread pain that does not have associated widespread allodynia. [1]

The study used a randomly selected sample from the general population, with a postal questionnaire and pain mannequin being sent to 9952 people. The response rate was 76.7% and the pain drawings showed that 345 people had widespread pain (in all four extremities and axially). Clinical examination, including a manual tender point examination, was performed in 125 subjects and these people answered commonly used questionnaires on pain, quality of life, coping strategies, depression, and anxiety. [1]

Chronic widespread pain without widespread allodynia to pressure pain was found in 4.5% in the population and Fibro was found in 2.5% of the population. [1]

The study found that, compared with chronic widespread pain without widespread allodynia, Fibro was associated with more severe symptoms/consequences for daily life and higher pain severity. Similar coping strategies were found in both groups. [1]

The second article, describing a study by Hoffman and Dukes in Connecticut, USA, was published in the International journal of clinical practice. [2]

They carried out a review of 37 studies of Fibro that measured health status with the 36-item Medical Outcomes Study Short-Form Health Survey (SF-36) or the 12-item Short-Form Health Survey (SF-12), describing how the health status profile of people with Fibro compares to that of people in the general population and patients with other health conditions. [2]

Hoffman and Dukes found that studies performed worldwide showed that people with Fibro were significantly more impaired than people in the general population in terms of all of the eight health factors assessed. [2]

These factors include:

Physical functioning
Role functioning difficulties caused by physical problems
Bodily pain
General health
Vitality (energy vs. fatigue)
Social functioning
Role functioning difficulties caused by emotional problems and mental health.

Groups of Fibro patients in the studies reviewed had both mental health and physical health scores below the general population and poorer overall health status compared to those with other specific pain conditions. Fibro patients had similar or significantly lower (poorer) physical and mental health status scores compared to those with rheumatoid arthritis, osteoarthritis, osteoporosis, systemic lupus erythematosus, myofacial pain syndrome, primary Sjögren’s syndrome and others. [2]

Hoffman and Dukes concluded that people with Fibro had an overall health status burden greater than that of people with other specific pain conditions that are widely accepted as impairing. [2]

The third article, from researchers Perruccio et al at the Toronto Western Research Institute, was published in the Journal of epidemiology and community health. [3]

Their study examined the relative impact of 13 chronic conditions using 3 outcome measures:

Activity limitations
Self-rated health
Physician visits

They found that, at the individual level, Fibro or Chronic Fatigue Syndrome and cancer (and to a lesser extent stroke and heart disease) were associated with an increased risk of both activity limitations and a self-rated health status of fair or poor (as opposed to good). [3]

These studies may be useful in demonstrating that Fibro can have a significant effect on a Fibro patient's life.

References:

Cöster L, Kendall S, Gerdle B, Henriksson C, Henriksson KG, Bengtsson A. Chronic widespread musculoskeletal pain - a comparison of those who meet criteria for fibromyalgia and those who do not. Eur J Pain. 2008 Jul;12(5):600-10. Epub 2007 Nov 19.
Hoffman DL, Dukes EM. The health status burden of people with fibromyalgia: a review of studies that assessed health status with the SF-36 or the SF-12. Int J Clin Pract. 2008 Jan;62(1):115-26. Epub 2007 Nov 24.
Perruccio AV, Power JD, Badley EM. The relative impact of 13 chronic conditions across three different outcomes. J Epidemiol Community Health. 2007 Dec;61(12):1056-61.

Hippocampal Dysfunction in Fibromyalgia Syndrome

Tue, 30 Sep 2008 12:00:00 +0100

The symptoms of Fibromyalgia Syndrome (Fibro) may be explained by the dysfunction of an area of the brain called the Hippocampus, according to recent research.

In May, an article was published in the American Journal of Neuroradiology describing a study evaluating the cerebral metabolism of patients with Fibro using Proton MR spectroscopy. [1] The study was carried out by a team of researchers at the University of Michigan Hospitals, Michigan, USA, which included FibroAction Professional Advisory Board (PAB) member Daniel Clauw MD.

The study was carried out in order to test the hypotheses:

Widespread pain sensitivity in patients with Fibro suggests a central nervous system (CNS)-processing problem.
Therefore, it is conceivable that metabolic alterations exist in pain-processing brain regions of people with Fibro compared with healthy controls and that such metabolic data could correlate with clinical symptoms.

Twenty-one patients with Fibro and 27 healthy controls underwent conventional structural MR imaging (MRI) and additional 2D-chemical shift imaging (CSI) MR-spectroscopy sequences. [1]

For the 2D-CSI spectroscopy, larger volumes of interest were centered at the level of the basal ganglia and the supraventricular white matter (i.e. the white brain matter above the ventricles). Within these larger areas, 16 smaller voxels were placed in a number of regions previously implicated in pain processing. N-acetylaspartate (NAA)/Creatine(Cr), Choline (Cho)/Creatine(Cr) and -acetylaspartate (NAA)/Choline (Cho) ratios were calculated for each voxel, these substances being metabolites of the brain. Study participants also underwent clinical and experimental pain assessment. [1]

The average metabolite ratios and the ratio variability were analysed for each region and correlations between clinical symptoms and metabolite ratios were assessed. [1]

The researchers found that Cho/Cr variability in the right dorsolateral prefrontal cortex (a specific area of the brain) was significantly different in the 2 groups. A significant correlation between Cho/Cr in this location and clinical pain was also found to be present in the Fibro patients group. It was also found that the evoked pain threshold correlated significantly with NAA/Cho ratios in the left insula and left basal ganglia. [1]

The researchers concluded that:

"Our data suggest that there are baseline differences in the variability of brain metabolite relative concentrations between patients with [Fibro] and [healthy controls], especially in the right [dorsolateral prefrontal cortex]. Furthermore, there are significant correlations between metabolite ratios and clinical and experimental pain parameters in patients with [Fibro]." [1]

In July, an article was published in the Journal of Rheumatology describing a study, by a team of reseachers from Cairo University Hospital, Egypt, that used proton magnetic resonance spectroscopy to investigate hippocampal metabolism in patients with Fibro. [2]

The study aimed to:

investigate dysfunction of hippocampus in patients with Fibro using proton magnetic resonance spectroscopy (1H-MRS), and to compare these findings with healthy controls.
correlate levels of metabolites obtained with aspects of cognition, depression, and sleep symptoms in the patient group.

The study participants were 15 female patients, who met American College of Rheumatology criteria for the classification of Fibro, and 10 healthy age-matched female controls. Participants were receiving no medications known to affect cognitive functioning or central nervous system metabolites before their participation in the study. [2]

In all patients and controls, 1H-MRS was used to assess N-acetylaspartate (NAA), choline (Cho), creatine (Cr), and their ratios from both hippocampi, with levels of these metabolites and their ratios being determined and the findings compared between the groups. All patients and controls underwent psychological assessment to assess cognitive function and depression, and had a structured sleep interview with sleep diary. The Fibromyalgia Impact Questionnaire (FIQ), the number of tender points, and the visual analog scale (VAS) for pain were also assessed in all patients. [2]

The researchers found that the NAA levels of the right and left hippocampi differed significantly between patients and controls. Cho levels in the right hippocampus were also higher in the patient group than in controls, but no differences were found with respect to Cr levels in both hippocampi. Analysis also showed that the NAA/Cho and NAA/Cr ratios differed significantly between patients and controls, while the Cho/Cr ratio showed no differences. Significant correlations were found between language score and right Cho and right Cr levels, but no significant correlations were found between metabolites and their ratios with FIQ, VAS for pain, or the number of tender points. [2]

The researchers concluded that:

"The hippocampus was dysfunctional in patients with [Fibro], as shown by lower NAA levels compared to controls, representing neuronal or axonal metabolic dysfunction. As the hippocampus plays crucial roles in maintenance of cognitive functions, sleep regulation, and pain perception, we suggest that metabolic dysfunction of hippocampus may be implicated in the appearance of these symptoms associated with this puzzling syndrome." [2]

This month, an article was e-published ahead of print in the Journal of Pain describing a study by a team of researchers including FibroAction Professional Advisory Board (PAB) member Patrick Wood MD. [3]

For this study, the researchers investigated the bilateral hippocampus of 16 female Fibro patients in comparison to 8 age- and gender-matched healthy control subjects using single voxel proton magnetic resonance spectroscopy. [3]

They found that there was a significant reduction in the ratio of N-acetylaspartate to creatine (NAA/Cr) in Fibro patients versus matched control subjects, specifically in the right temporal lobe from a voxel centered on the right hippocampus. [3]

Moreover, correlation analysis demonstrated a significant negative correlation between patient scores on the Fibromyalgia Impact Questionnaire and NAA/Cr ratio within the right hippocampus - i.e. as the NAA/CR ratio decreased, the Fibro had more of an impact on patients.

The researchers concluded that:

"Our results indicate that [Fibro] is associated with brain metabolite abnormalities within the right hippocampus that correlate with patient symptoms." [3]

All these studies have demonstrated an abnormality in hippocampal brain metabolites in patients with Fibro. The correlation between the patients' experiences of symptoms and altered ratios of these metabolites suggests a role for the hippocampus in the pathology of Fibro.

Although the pathology of Fibro is poorly understood, a growing body of evidence suggests involvement of the central nervous system.

The hippocampus is a brain center that is sensitive to the effects of stress exposure, when talking about stress as physical stressors, which can be related to either physical trauma, mental stress or both, and the hippocampus has been demonstrated to be affected in a variety of disorders whose onset, like Fibro, are associated with stressful experience. [3]

The hippocampus plays major roles in short term memory and spatial navigation, so its role in the pathology of Fibro would explain two of the previously less well understood symptoms of Fibro: cognitive difficulties (including memory problems) and clumsiness.

References:

Petrou M, Harris RE, Foerster BR, McLean SA, Sen A, Clauw DJ, Sundgren PC. Proton MR spectroscopy in the evaluation of cerebral metabolism in patients with fibromyalgia: comparison with healthy controls and correlation with symptom severity. AJNR Am J Neuroradiol. 2008 May;29(5):913-8. Epub 2008 Mar 13.
Emad Y, Ragab Y, Zeinhom F, El-Khouly G, Abou-Zeid A, Rasker JJ. Hippocampus dysfunction may explain symptoms of fibromyalgia syndrome. A study with single-voxel magnetic resonance spectroscopy. J Rheumatol. 2008 Jul;35(7):1371-7. Epub 2008 May 15.
Wood PB, Ledbetter CR, Glabus Deceased MF, Broadwell LK, Patterson JC 2nd. Hippocampal Metabolite Abnormalities in Fibromyalgia: Correlation With Clinical Features. J Pain. 2008 Sep 2. [Epub ahead of print]

Exercise helpful for children with Fibromyalgia Syndrome

Wed, 01 Oct 2008 12:00:00 +0100

Exercise can be helpful for children with Fibromyalgia Syndrome (Fibro) according to a team of researchers from The Hospital for Sick Children, Toronto, Canada. [1]

The researchers carried out a pilot trial to determine the feasibility of conducting a randomized controlled trial of a 12-week exercise intervention in children with Fibro and to explore the effectiveness of aerobic exercise on physical fitness, function, pain, Fibro symptoms, and quality of life (QOL).

Thirty Fibro patients, aged 8 to 18 years, participated in the trial and were randomized to a 12-week exercise intervention with 3 times a week training sessions of either aerobics or qigong. Program adherence and safety were monitored at each session and data were collected at 3 testing sessions, 2 prior to and 1 after the intervention. The data collected included Fibro symptoms, function, pain, QOL, and fitness measures.

Twenty-four patients completed the program; 4 patients dropped out prior to training and 2 dropped out of the aerobics program. Slightly better adherence to the exercise program was reported in the aerobics group than in the qigong group (67% versus 61%).

The pilot trial found that significant improvements in physical function, functional capacity, QOL, and fatigue were observed in the aerobics group. Anaerobic function, tender point count, pain, and symptom severity improved similarly in both groups.

The researchers concluded that:

It is feasible to conduct an exercise intervention trial in children with [Fibromyalgia Syndrome]. Children with [Fibromyalgia Syndrome] tolerate moderate-intensity exercise without exacerbation of their disease. Significant improvements in physical function, [Fibromyalgia Syndrome] symptoms, QOL, and pain were demonstrated in both exercise groups; the aerobics group performed better in several measures compared with the qigong group. Future studies may need larger sample sizes to confirm clinical improvement and to detect differences in fitness in childhood [Fibromyalgia Syndrome].

References:

Stephens S, Feldman BM, Bradley N, Schneiderman J, Wright V, Singh-Grewal D, Lefebvre A, Benseler SM, Cameron B, Laxer R, O'brien C, Schneider R, Silverman E, Spiegel L, Stinson J, Tyrrell PN, Whitney K, Tse SM. Feasibility and effectiveness of an aerobic exercise program in children with fibromyalgia: Results of a randomized controlled pilot trial. Arthritis Rheum. 2008 Sep 29;59(10):1399-1406. [Epub ahead of print]

Family factors in children with Fibromyalgia Syndrome

Wed, 01 Oct 2008 12:30:00 +0100

According to a recent article, families of adolescents with juvenile primary fibromyalgia syndrome have greater health problems themselves and family relationships are affected. This in turn then has an effect on the health of the adolescents with juvenile primary fibromyalgia syndrome. [1]

Family factors and emotional functioning can play an important role in the ability of adolescents with juvenile primary fibromyalgia syndrome (JPFS) to cope with their condition and function in their everyday lives. [1]

The primary objectives of the study, carried out by a team of researchers at Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Ohio, USA, were to determine:

whether adolescents with juvenile primary fibromyalgia syndrome and their caregivers differed from healthy age-matched comparison peers and their caregivers in terms of emotional distress and functional impairment;
whether there were any differences in the family environment of adolescents with juvenile primary fibromyalgia syndrome compared with healthy comparison peers;
which individual-, caregiver-, and family-level variables were associated with functional impairment in adolescents with juvenile primary fibromyalgia syndrome.

The study compared 47 adolescents with juvenile primary fibromyalgia syndrome recruited from a pediatric rheumatology clinic and 46 healthy peers matched for age, sex, and race. The study participants and their caregivers (all mothers) completed a battery of standardized measures administered in their homes.

The researchers found that adolescents with juvenile primary fibromyalgia syndrome had greater internalizing and externalizing symptoms than healthy comparison peers. Mothers of adolescents with juvenile primary fibromyalgia syndrome reported twice as many pain conditions and significantly greater depressive symptoms than mothers of comparison peers. The juvenile primary fibromyalgia syndrome group also had poorer overall family functioning and more conflicted family relationships. In adolescents with juvenile primary fibromyalgia syndrome, maternal pain history was associated with significantly higher functional impairment. [1]

The researchers concluded that:

"Increased distress and chronic pain are evident in families of adolescents with JPFS, and family relationships are also impacted. Implications for child functional impairment and the need for inclusion of caregivers in treatment are discussed." [1]

This comes after a related team of researchers at University of Cincinnati College of Medicine, Ohio, USA, published an article in the September issue of The Clinical Journal of Pain in which they concluded that:

Although there is an emerging understanding of JPFS and its treatment, [3] the situation in the UK hasn't improved much since 1985, when Masi and Yunus (the now legendary Fibro expert, Dr. Muhammad B. Yunus), wrote that:

"Juvenile PFS is often misdiagnosed. Recognition of this common rheumatologic condition in juveniles is important in order to avoid unwarranted investigations and improper management."

References:

Kashikar-Zuck S, Lynch AM, Slater S, Graham TB, Swain NF, Noll RB. Family factors, emotional functioning, and functional impairment in juvenile fibromyalgia syndrome. Arthritis Rheum. 2008 Sep 29;59(10):1392-1398. [Epub ahead of print]
Kashikar-Zuck S, Parkins IS, Graham TB, Lynch AM, Passo M, Johnston M, Schikler KN, Hashkes PJ, Banez G, Richards MM. Anxiety, mood, and behavioral disorders among pediatric patients with juvenile fibromyalgia syndrome. Clin J Pain. 2008 Sep;24(7):620-6.
Baldursdóttir S. [Juvenile primary fibromyalgia syndrome--review] Laeknabladid. 2008 Jun;94(6):463-72.
Yunus MB, Masi AT. Juvenile primary fibromyalgia syndrome. A clinical study of thirty-three patients and matched normal controls. Arthritis Rheum. 1985 Feb;28(2):138-45.

Subgroups identified using the Fibromyalgia Impact Questionnaire

Wed, 01 Oct 2008 12:30:00 +0100

Psychological distress is a feature present only in some patients with Fibromyalgia Syndrome (Fibro), and the Fibromyalgia Impact Questionnaire can be used to differentiate these patients from others, according to a recent article from a group of Canadian researchers. [1]

The main goal of the study, by researchers at the Université de Sherbrooke, Canada, was to identify the presence of Fibro subgroups using a simple and frequently used clinical tool, the Fibromyalgia Impact Questionnaire (FIQ). [1]

A total of 61 women diagnosed with Fibro participated in the study and were asked to fill in a FIQ. The researchers also recorded experimental pain, psychosocial functioning and demographic characteristics. [1]

Fibro subgroups were identified by applying a hierarchical cluster analysis on selected items of the FIQ (pain, fatigue, morning tiredness, stiffness, anxiety and depressive symptoms) and group differences were also tested for on experimental pain, psychosocial functioning and demographic characteristics. [1]

The researchers found that two cluster profiles best fit the data: FM-Type I was characterized by the lowest levels of anxiety, depressive and morning tiredness symptoms, while FM-Type II was characterized by elevated levels of pain, fatigue, morning tiredness, stiffness, anxiety and depressive symptoms. Both of the Fibro subgroups showed hyperalgesic responses to experimental pain.

The researchers concluded that:

"These results suggest that pain and stiffness are universal symptoms of the disorder but that psychological distress is a feature present only in some patients."

References:

de Souza JB, Goffaux P, Julien N, Potvin S, Charest J, Marchand S. Fibromyalgia subgroups: profiling distinct subgroups using the Fibromyalgia Impact Questionnaire. A preliminary study. Rheumatol Int. 2008 Sep 27. [Epub ahead of print]

Cognitive Issues correlate with changes in Brain Structure

Sun, 05 Oct 2008 12:00:00 +0100

People with Fibromyalgia Syndrome (Fibro) suffer from neurocognitive deficits that correlate with changes in brain structure, according to an article recently e-published ahead of print in the journal Brain.

The team of German researchers behind the article sought to determine whether neuropsychological deficits found in Fibro patients may be correlated with changes in local brain morphology (structure), specifically in the frontal, temporal or cingulate cortices. [1]

Twenty Fibro patients underwent extensive testing for potential neuropsychological deficits, which demonstrated significantly reduced working memory and impaired non-verbal long-term memory (limited to free recall condition) in comparison with data from age- and education-matched healthy control groups. [1]

Voxel-based morphometry (VBM) was used to evaluate whether there was any correlation between the neuropsychological test results and local brain morphology.

The researchers found that non-verbal working memory performance was positively correlated with grey matter values in the left dorsolateral prefrontal cortex, whereas performance on verbal working memory (digit backward) was positively correlated with grey matter values in the supplementary motor cortex. On the other hand, pain scores were negatively correlated with grey matter values in the medial frontal gyrus. White matter analyses revealed comparable correlations for verbal working memory and pain scores in the medial frontal and prefrontal cortex and in the anterior cingulate cortex. [1]

An accumulating body of evidence suggests that Fibro is associated with dysfunction of the Central Nervous System (CNS) and with altered brain morphology and function. This study provides more evidence for this, and also for the link between changes in the brain and the cognitive difficulties experienced by Fibro patients.

References:

Luerding R, Weigand T, Bogdahn U, Schmidt-Wilcke T. Working memory performance is correlated with local brain morphology in the medial frontal and anterior cingulate cortex in fibromyalgia patients: structural correlates of pain-cognition interaction. Brain. 2008 Sep 26. [Epub ahead of print]

Fibromyalgia Syndrome Diagnosis by Symptoms

Mon, 06 Oct 2008 12:00:00 +0100

Diagnosis of Fibromyalgia Syndrome (Fibro) is possible without the tender point test, or so suggests an article recently published in the German journal Zeitschrift für Rheumatologie.

A symptom-based diagnosis method for Fibro without needing the tender point examination would be helpful, especially as most examining physicians have had little to no training in how to best perform the tender point examination. The researchers aimed to test whether a symptom-based diagnosis of Fibro can be based on the symptoms of musculoskeletal pain and fatigue. [1]

The most frequent and severe symptoms in Fibro patients from four different settings were assessed using the Giessen Subjective Complaints List GBB 24. Of the respondents who filled in the list, 464 came from a self-help organisation, 162 from medical expertise, 33 from a private rheumatology practice and 36 from a tertiary-care pain department. The most frequent and severe symptoms were assessed and compared to those of a representative German population sample and a k-means cluster analysis was performed to identify sub-groups within the total sample of Fibro patients.[1]

The researchers found that the most frequent and severe symptoms in all four sub-samples were low back pain, limb pain and fatigue. The greatest difference between the Fibro patients and the healthy controls was with the symptoms "limb pain" and "fatigue". [1]

Cluster analysis identified three sub-groups of patients which were all characterized by severe limb pain and fatigue, as well as varying degrees of cognitive symptoms. [1]

The researchers concluded that:

"Following the exclusion of inflammatory rheumatoid, endocrinological and neurological diseases, a symptom-based clinical diagnosis of FMS can be based on of the key symptoms of chronic widespread musculoskeletal pain, as well as chronic fatigue." [1]

No mention is made however, of specific diagnoses that have been ruled out. Chronic myofascial pain for example is often confused with Fibro and one of the difficulties in accurately performing the tender point examination is the need for the examiner to be able to differentiate between myofascial trigger points and tender points. This suggested diagnosis by symptoms may not even try to exclude this condition. Multiple regional pain conditions, such as carpal tunnel and a back problem, could also be mis-diagnosed as Fibro with the suggested diagnosis here.

The tender point examination is far from ideal as a diagnostic tool: it biases diagnosis towards women; is often relied on despite being extremely badly performed; and needs an expert examiner in order to avoid false positive results. However, it is a relatively simple way of checking for the hyperalgesia (hypersensitivity to pain) that is a core symptom of Fibro.

If diagnosis of Fibro is to be made by symptoms alone, then exclusion of differential conditions needs to be far stricter than it currently is. Using a questionnaire looking for phrases such as "hypersensitive to pain", "even hugs hurt", "everything hurts, even my skin" and "pain that is unpredictable and moves around" would be far more accurate than simply looking for chronic widespread pain, which could be due to a number of causes that do not show up on regular test results.

References:

Häuser W, Akritidou I, Felde E, Klauenberg S, Maier C, Hoffmann A, Köllner V, Hinz A. [Steps towards a symptom-based diagnosis of fibromyalgia syndrome : Symptom profiles of patients from different clinical settings.] Z Rheumatol. 2008 Oct;67(6):511-5.

Duloxetine as a treatment for Fibromyalgia Syndrome

Tue, 07 Oct 2008 12:00:00 +0100

Another article has been published concluding that Duloxetine is beneficial in the treatment of Fibromyalgia Syndrome (Fibro). [1]

Duloxetine is a new selective serotonin and norepinephrine reuptake inhibitor (SNRI) that is licensed for the treatment of pain in diabetic neuropathy in the EU. [1] Duloxetine was approved for the treatment of Fibro by the American Food & Drug Administration (FDA) earlier this year.

The recent article discusses two randomized, placebo-controlled trials investigating the short-term safety and efficacy of duloxetine 60 mg/day and 120 mg/day in patients suffering from Fibro over a period of 12 weeks. [1]

Both dosages were found to be superior to placebo in pain relief, and improvement in quality of life and depressive symptoms, although the analgesic effect was largely independent of the antidepressant action of duloxetine. The higher dose of 120 mg/day further reduced the tender point count and elevated the tender point pain thresholds. In both studies, only mild to moderate adverse effects were reported. [1]

Last year, a group of researchers from the University of Cincinnati College of Medicine, Cincinnati, USA published an article examining the pooled results from the two randomized, placebo-controlled clinical trials of Duloxetine as a treatment for Fibro in women who met the American College of Rheumatology criteria for Fibro. [2]

They found that, compared with the patients receiving placebo, duloxetine-treated patients demonstrated a significantly greater improvement in the Brief Pain Inventory (BPI), average pain severity score and in the Fibromyalgia Impact Questionnaire (FIQ) total score, beginning at week 1 and continuing through week 12. Duloxetine was superior to placebo on all efficacy measures, including mean tender point threshold, Clinical Global Impression of Severity, Patient Global Impression of Improvement, and average interference from pain scores. The duloxetine-treated group was superior to placebo on all quality of life and functional measures, including each domain of the Medical Outcomes Study Short Form-36 (SF-36). [2]

A direct treatment effect of duloxetine on pain reduction was demonstrated and shown to be independent of secondary improvement in mood (based on BPI average pain score). [2]

The researchers found that significantly more duloxetine-treated patients reported treatment-emergent adverse events, but the rates of serious adverse events were similar between duloxetine-treated and placebo-treated patients. [2]

Duloxetine 60 mg/day and 120 mg/day has proven to be beneficial in the treatment of the pain and functional impairment associated with Fibro in female patients, while significantly improving quality of life. As is true for other antidepressants further studies are needed to assess the long-term efficacy and safety of duloxetine as an additional pharmacological treatment option in Fibro. [1][2] This is particularly true given research has shown that amitriptyline is not effective as a treatment for Fibro long-term. Amitriptyline, a tricyclic anti-depressants, works in a different way to the SNRIs such as Duloxetine, but they target the same two neurotransmitters: serotonin and norepinephrine. [3]

References:

Uçeyler N, Offenbächer M, Petzke F, Häuser W, Sommer C. New treatment options for fibromyalgia: critical appraisal of duloxetine. Neuropsychiatr Dis Treat. 2008 Jun;4(3):525-9.
Arnold LM, Pritchett YL, D'Souza DN, Kajdasz DK, Iyengar S, Wernicke JF. Duloxetine for the treatment of fibromyalgia in women: pooled results from two randomized, placebo-controlled clinical trials. J Womens Health (Larchmt). 2007 Oct;16(8):1145-56.
Nishishinya B, Urrútia G, Walitt B, Rodriguez A, Bonfill X, Alegre C, Darko G. Amitriptyline in the treatment of fibromyalgia: a systematic review of its efficacy. Rheumatology (Oxford). 2008 Aug 12. [Epub ahead of print]

Altered brain activity during pain processing in Fibromyalgia Syndrome

Tue, 14 Oct 2008 12:00:00 +0100

A study by a group of researchers at a German university hospital has found more evidence that central mechanisms of pain processing in the brain play an important role in Fibromyalgia Syndrome (Fibro). [1]

The article, published in the journal NeuroImage, describes an fMRI study designed to test the hypothesis that "brain areas related to the "medial" pain system and the amygdalae will present different activation in [Fibro] patients compared to healthy subjects".

fMRI stands for functional Magnetic Resonance Imaging and is a type of MRI scan that looks at how the brain works, specifically which areas of the brain are being used and how much.

For this study, an fMRi scan was taken of both Fibro patients and healthy controls before, during and after acute pain as caused by means of an incision. [1]

The researchers found differences of activation in the fronto-cingulate cortex, the supplemental motor areas, and the thalamus between both groups, even during anticipation of pain. They concluded that.

"Our results support the hypothesis that central mechanisms of pain processing in the medial pain system, favourable cognitive/affective factors even during the anticipation of pain, may play an important role for pain processing in patients with FMS."

The medial pain system processes the emotional aspects of pain, including fear and stress. The team of researchers were from the Department of Psychosomatics and Psychotherapy at University Hospital Münster, Germany.

This research suggests that emotional aspects of pain play an important role in Fibro. However, other research has shown that, although anticipation of pain worsens the perception of pain in Fibro and anticipation of analgesia (pain-relief) improves perception of pain in Fibro, it does not change the physical aspects of the hyperalgesia. [2]

References:

Burgmer M, Pogatzki-Zahn E, Gaubitz M, Wessoleck E, Heuft G, Pfleiderer B. Altered brain activity during pain processing in fibromyalgia. Neuroimage. 2008 Sep 24. [Epub ahead of print]
Goffaux P. 2008. Fibromyalgia: Impaired Top-Down Control during Anticpatory Pain Relief. IASP 12th World Congress on Pain. Glasgow, UK. 17-22th August 2008.

Twin Study suggests that Fibromyalgia Syndrome has a strong genetic background

Sat, 25 Oct 2008 12:00:00 +0100

Fibromyalgia Syndrome symptoms seem to have a strong genetic background, according to an article e-published ahead of print in the European Journal of Pain. [1]

A team of researchers from the Pain Clinic at Helsinki University Central Hospital, Finland studied the prevalence and heritability of symptoms associated with Fibromyalgia Syndrome (Fibro) in a population-based working-age twin sample. The study was based on the 12,502 like-sexed twins of the Finnish Twin Cohort and 49 diagnosed fibromyalgia patients who answered the same questionnaire in 1990-1992. [1]

Questions that were considered to best match symptoms of Fibro were validated between the twins and the Fibro patients, with responses to all Fibro-related items being obtained from 10,608 twins. [1]

Latent class analysis was used to classify the subjects into more homgenous groups consisting of subjects that were virtually symptom free, subjects with some symptoms and subjects with a similar symptom profile as the diagnosed Fibro patient group, but less severely affected. [1]

A similar proportion of men (12%) and women (13%) was placed in the third group, which best represented possible Fibromyalgia Syndrome patients. The heritability of liability to symptom class membership was estimated to be 51% (95% CI 45-56%). [1]

The prevalence of symptoms associated with Fibro in the other groups was comparable to the prevalence of widespread pain reported in population based studies. [1]

The researchers concluded that:

"The symptoms known to be associated with fibromyalgia seem to have a strong genetic background." [1]

References:

Markkula R, Järvinen P, Leino-Arjas P, Koskenvuo M, Kalso E, Kaprio J. Clustering of symptoms associated with fibromyalgia in a Finnish Twin Cohort. Eur J Pain. 2008 Oct 18. [Epub ahead of print]

Brain SPECT perfusion abonormalities correlate with severity of Fibromyalgia Syndrome

Sat, 25 Oct 2008 12:00:00 +0100

Abnormalities in the blood flow in the brain correlate with symptom severity in patients with Fibromyalgia Syndrome (Fibro), according to a recent article. [1]

The article, e-published ahead of print in the Journal of Nuclear medicine, describes a study by a team of researchers in France, which set out to investigate the specific clinical correlate of brain SPECT perfusion (blood/fluid flow) abnormalities reported in Fibro. [1]

The researchers performed a whole-brain voxel-based correlation analysis involving regional cerebral blood flow and various parameters related to pain (Visual Analog Scale, Tubingen Pain Behavior Scale, and Questionnaire Douleur de Saint-Antoine Scale), disability (Fibromyalgia Impact Questionnaire [FIQ]), and anxiety and depression status (Hospital Anxiety and Depression scale) in 20 patients with Fibro and 10 healthy control women (included in order to determine areas of significant hypo- and hyperperfusions in patients). [1]

They found that the FIQ total score in patients was positively correlated with blood flow in the area of the brain known as the parietal lobe, including the postcentral cortex. This correleation was seen in the areas of significant hyperfusion (extra blood flow). [1]

They also found that the FIQ total score was negatively correlated with blood flow in a left anterior temporal cluster, one of the areas of significant hypoperfusions (less blood flow). [1]

The researchers concluded that:

"These results show that brain perfusion abnormalities in patients with fibromyalgia are correlated with the clinical severity of the disease." [1]

References:

Guedj E, Cammilleri S, Niboyet J, Dupont P, Vidal E, Dropinski JP, Mundler O. Clinical Correlate of Brain SPECT Perfusion Abnormalities in Fibromyalgia. J Nucl Med. 2008 Oct 16. [Epub ahead of print]

Fibromyalgia Syndrome and physical trauma

Fri, 31 Oct 2008 12:00:00 +0000

There is still no agreement among experts as to whether physical trauma can cause Fibromyalgia Syndrome (Fibro) say a group of Israeli researchers in a recent article. [1]

According to the researchers, from Soroka Medical Center, Ben Gurion University, Israel, 25-50% of Fibro patients report the occurrence of a physical trauma that preceded the onset of their symptoms by anything from several weeks to several months. The severity of the injury described varies, but is usually milder than that seen in patients with post-traumatic stress syndrome. The researchers note in the article that road accidents, and, in particular, whiplash injuries, or accumulated injury inherent in some occupations have been described as causes of Fibro. [1]

However, the only two prospective studies that assessed the incidence of Fibromyalgia Syndrome following accidents, such as whiplash injuries, were conducted by Israeli researchers and they reported opposite results. [1][2]

The researchers note that, although possible mechanisms for the development of the syndrome following trauma have not been elucidated sufficiently to date, stressful conditions are known to contribute to the development of Fibro. The researchers gone on to say that, although some investigators have reported a worse prognosis in post-traumatic cases, in most likelihood, there is no significant difference between idiopathic Fibro (Fibro from no known cause) and post traumatic Fibro in terms of clinical course, symptom severity and prognosis. [1]

According to the article, Israel has seen an increase in the number of suits filed against private insurance companies and the National Insurance system for post-traumatic Fibromyalgia Syndrome. [1]

The researchers say that it is probable that the number of cases that involve malingering or secondary gain is low, but conclude that:

"[the] ongoing controversy among medical experts as to whether there is an association between [Fibro] and physical trauma has made it very difficult, in the absence of guidelines and objective tools, for the legal and administrative systems to deal with this difficult issue." [1]

According to another article published this month by a different group of researchers also at Soroka Medical Center:

"Environmental and genetic factors play a role in the pathogenesis of [Fibro]. Various triggers including trauma and stress as well as infections, may precipitate the development of [Fibro]." [3]

FibroAction Professional Advisory Board member, Daniel Clauw MD, was one of the authors of an article published 3 years ago, which said that:

"Contemporary evidence supports a model of chronic symptom development [after motor vehicle collision] that incorporates the potential for interactions between past experience, acute stress responses to trauma, post-[motor-vehicle-collision] behavior, and cognitive/psychosocial consequences to alter activity within brain regions which process pain and to result in persistent pain, as well as psychological sequelae, after [motor vehicle collision]." [4]

Possibly factors such as genetic pre-disposition, past experience, acute stress responses to trauma, post-[motor-vehicle-collision] behavior, and cognitive/psychosocial consequences have such an effect that larger studies of patients post-whiplash injury are needed. In the meantime, the evidence for a direct link between whiplash injury and Fibro remains unclear.

References:

Sukenik S, Abu-Shakra M, Flusser D. [Physical trauma and fibromyalgia--is there a true association?] Harefuah. 2008 Aug-Sep;147(8-9):712-6, 749.
Tishler M, Levy O, Maslakov I, Bar-Chaim S, Amit-Vazina M. Neck injury and fibromyalgia-- are they really associated? J Rheumatol. 2006 Jun;33(6):1183-5. Epub 2006 May 1.
Buskila D, Atzeni F, Sarzi-Puttini P. Etiology of fibromyalgia: The possible role of infection and vaccination. Autoimmun Rev. 2008 Oct;8(1):41-3. Epub 2008 Aug 13.
McLean SA, Clauw DJ, Abelson JL, Liberzon I. The development of persistent pain and psychological morbidity after motor vehicle collision: integrating the potential role of stress response systems into a biopsychosocial model. Psychosom Med. 2005 Sep-Oct;67(5):783-90.

Significance of trigger points and tender points

Wed, 19 Nov 2008 12:00:00 +0000

An article has been e-published ahead of print in the German publication 'Zeitschrift fur Rheumatologie' discussing the significance of the differences between tender points and trigger points.

Tender points (TPs) are part of the American College of Rheumatology criteria for the diagnosis of Fibromyalgia Syndrome (Fibro), whereas trigger points (TrPs) are typically found in Myofascial Pain Syndrome, also known as Chronic Myofascial Pain (CMP). [1]

The main difference until recently was that tender points could only be defined in terms of their local position, whereas trigger points can be found upon palpation which may cause a specific referred pain pattern. [1]

However, analysis of trigger points by microdialysis demonstrated elevated levels of pro-inflammatory substances at these sites. [1]

Chronic Myofascial Pain and TrPs are even more under-diagnosed than Fibro, despite myofascial pain being probably the most common cause of musculoskeletal pain in medical practice. A doctor or healthcare provider in almost any field will see some patients with Fibro and/or TrPs. [2][3]

These conditions often, but not always, occur in the same patients although TrPs, which are thought to develop after trauma, overuse or prolonged spasm of muscles, can occur in otherwise healthy patients. [4]

It is important that in patients with Fibro and CMP, both conditions be diagnosed, as their treatment is very different and they may be affecting and/or amplifying and perpetuating each other. [2][4]

Fibro is a central disorder, with an increasing body of evidence relating it to Central Nervous System Dysfunction. [5] It often requires a multidisciplinary treatment, utilising medications that target the nervous systems - local treatment applied to TePs is ineffective. [4]

However, local, specific treatment of TrPs, either by manipulative therapy or injection, is often dramatically effective with prompt relief of symptoms. [2][4]

For more information on tender points and trigger points, please see the FibroAction patient article 'Tender Points, Trigger Points and Pressure Points'.

References:

Brezinschek HP. [Mechanisms of muscle pain : Significance of trigger points and tender points.] [Article in German] Z Rheumatol. 2008 Nov 19. [Epub ahead of print]
Starlanyl DJ, 2003. Fibromyalgia and Chronic Myofascial Pain: Keys to Diagnosis and Treatment [website]. Available at: http://www.sover.net/~devstar/physinfo.htm
Pongratz DE, Späth M. [Myofascial pain syndrome--frequent occurrence and often misdiagnosed] [Article in German] Fortschr Med. 1998 Sep 30;116(27):24-9.
Schneider MJ. Tender points/fibromyalgia vs. trigger points/myofascial pain syndrome: a need for clarity in terminology and differential diagnosis. J Manipulative Physiol Ther. 1995 Jul-Aug;18(6):398-406.
Kuchinad A, Schweinhardt P, Seminowicz DA, Wood PB, Chizh BA, Bushnell MC. Accelerated brain gray matter loss in fibromyalgia patients: premature aging of the brain? J Neurosci. 2007 Apr 11;27(15):4004-7.

Older simpler treatments effective for IBS

Wed, 19 Nov 2008 12:00:00 +0000

A recent article in the British Medical Journal (BMJ), reported on by the BBC, has suggested that old and often overlooked treatments for Irritable Bowel Syndrome (IBS) may be as effective as newer medications.

Older treatments for IBS, such as peppermint oil and soluble fibre, are often recommended by patient experts, but are frequently overlooked or not considered properly by gastroenterologists. The supposed lack of scientific evidence for the use of these treatments, particularly when compared to modern medications, is one reason for this. The BBC has quoted a "UK expert" as saying that there had been a general feeling among doctors that the therapies "didn't work".

A group of researchers led by Dr Alex Ford, a gastroenterologist who has recently moved from Canada - where he did the research - to St James University Hospital in Leeds, carried out a systematic review and retrospective analysis of randomised controlled trials, and their results were published in the BMJ this month.

They looked at randomised controlled trials comparing fibre, antispasmodics, and peppermint oil with placebo or no treatment in adults with IBS. In total, the trials included considered more than 2,500 patients.

The effect of therapy compared with placebo or no treatment was reported as the relative risk of symptoms persisting.

Twelve studies compared fibre with placebo or no treatment in 591 patients. They found that the relative risk of persistent symptoms was less with treatment instead of with placebo or no treatment. This beneficial effect was limited to ispaghula, a form of soluble fibre supplement and was not seen when using bran, a form of insoluble fibre. [1]

Twenty two trials compared antispasmodics with placebo in 1778 patients. Various antispasmodics were studied, but otilonium and hyoscine showed consistent evidence of efficacy. [1] Hyoscine was the most successful antispasmodic drug looked at and, according to the BBC, the researchers said this should be the first choice out of the antispasmodics.

Four trials compared peppermint oil with placebo in 392 patients, with results also showing a decreased risk of symptoms persisting with treatment.

The conclusion of the researchers was that:.

"Fibre, antispasmodics, and peppermint oil were all more effective than placebo in the treatment of irritable bowel syndrome."

Both peppermint oil and hyoscine - an antispasmodic which is not currently widely prescribed in the UK - are available from the pharmacy and isphagula husks or other forms of soluble fibre supplement are widely available in health food stores.

For more information on the use of this kind of treatment for IBS, the book 'IBS: The First Year', by American patient-expert Heather Van Vorous may be helpful.

References:

Ford AC, Talley NJ, Spiegel BM, Foxx-Orenstein AE, Schiller L, Quigley EM, Moayyedi P. Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis. BMJ. 2008 Nov 13;337:a2313. doi: 10.1136/bmj.a2313.

Autonomic Dysfunction in Fibromyalgia Syndrome

Mon, 24 Nov 2008 12:00:00 +0000

Dysfunction of the autonomic nervous system is common in Fibromyalgia Syndrome (Fibro) and may play a part in a number of symptoms, according to a recent article by American Fibro expert Roland Staud MD. [1]

The autonomic nervous system regulates many important biological functions, such as heart rate, blood pressure, respirations, and bowel function.

Dr Staud notes in the article that, although Fibro is defined by chronic widespread pain and tenderness, additional symptoms, including disabling fatigue and dizziness, are often reported by patients. [1]

Whilst nonrestorative sleep may play an important role in the chronic fatigue of Fibro, dysfunction of the autonomic nervous system should be considered as a possible cause of fatigue. [1]

Dysfunction of the autonomic nervous system can be a condition in its own right - Dysautonomia - and it is usually characterised by either Neurocardiogenic Syncope (fainting) and/or Postural Orthostatic Tachycardia (heart beat racing when moving from lying down to sitting or sitting to standing). Palpitations and dizziness are part of this condition and are also possible symptoms of Fibro.

Head-up tilt table testing can be used to evaluate autonomic dysfunction and Dr Staud states that this is frequently helpful when investigating possible symptoms of Fibro, including fatigue, dizziness, and palpitations. [1]

Dr Staud notes that one of the most common events experienced by Fibro patients during tilt table testing is Postural Orthostatic Tachycardia Syndrome (POTS), which is defined as a heart rate increase of more than 30 beats per minute after more than 3 minutes of standing upright. [1]

For more information on Dysautonomia, try the Dysautonomia Information Network

References:

Staud R. Autonomic dysfunction in fibromyalgia syndrome: postural orthostatic tachycardia. Curr Rheumatol Rep. 2008 Dec;10(6):463-6.

Spa Therapy in Fibromyalgia Syndrome

Tue, 25 Nov 2008 12:00:00 +0000

Spa therapy can be useful as part of a multidisciplinary approach to treating Fibromyalgia Syndrome, a recent article concludes.

A team of Italian researchers carried out a review of the data from 2000 to 2007 concerning the use of spa therapy as a treatment for Fibromyalgia Syndrome (Fibro). [1]

This data confirmed that spa therapy should be a valid tool in the multidisciplinary approach of Fibro, as it may be useful for the chronic widespread musculoskeletal pain that patients experience. [1]

The researchers note that the mechanisms of action of spa therapy are not completely known, but most probably the benefits could be derived from mechanical, physical and chemical factors. Muscle tone and pain intensity can be positively influenced by mud packs and thermal baths. [1]

Various spa therapies are more widely used in continental Europe, where medical spa resorts still operate and where complmentary therapies are often far more widely used alongside medications by conventional healthcare professionals.

The EULAR evidence based recommendations for the management of Fibromyalgia Syndrome recommend that:

"Optimal treatment of FMS mandates a multidisciplinary approach, which should include a combination of nonpharmacologic and pharmacologic interventions." [2]

Specific recommendations on the nonpharmacologic management of Fibro include:

"Heated pool treatment, with or without exercise, is effective." [2]

"Based on the specific needs of the patient, relaxation, rehabilitation, physiotherapy, psychological support, and other modalities may be indicated." [2]

References:

Giannitti C, Bellisai B, Iacoponi F, Petraglia A, Fioravanti A. [New evidences on spa therapy in fibromyalgia.][Article in Italian] Clin Ter. 2008 Sep-Oct;159(5):377-380.
Carville SF, Arendt-Nielsen S, Bliddal H, Blotman F, Branco JC, Buskila D, Da Silva JA, Danneskiold-Samsøe B, Dincer F, Henriksson C, Henriksson KG, Kosek E, Longley K, McCarthy GM, Perrot S, Puszczewicz M, Sarzi-Puttini P, Silman A, Späth M, Choy EH; EULAR. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008 Apr;67(4):536-41. Epub 2007 Jul 20.

Muscle characteristics of persons with Fibromyalgia Syndrome

Wed, 28 Jan 2009 12:00:00 +0000

A study has shown that Fibromyalgia Syndrome patients and patients with other chronic pain conditions have unusual muscle activity when compared to healthy controls.¹

The study aimed to explore the muscle characteristics, depression and physical functioning of patients with Fibromyalgia Syndrome (Fibro).

Thirty-four individuals with Fibro and 36 individuals with chronic pain were recruited for the study from a chronic pain management program. Thirty-seven healthy controls were recruited from the general community.

Demographic data (age, gender, marital status, ethnicity, and employment status) was collected for each study participant. The participants were asked to self-report on their physical and psychological functioning, current level of pain and level of depression. Agonist (positive action) and antagonist (negative action) muscle activity was measured with sEMG (surface Electromyogram, a test of muscle activity) for the Sternocleidomastoid muscle(SCM), the Biceps/triceps, the Forearm flexor/extensor muscles and the Lower leg tibialis anterior/Gastrocnemius muscles.

It was found that there was a significant difference in upper arm muscle contra-activation between the Fibro patients and the healthy controls but not between the non-Fibro chronic pain patients and the healthy controls.¹

When compared to the healthy controls, the Fibro group reported more depression and a higher level of physical functioning problems, but it was not significantly different from the mean score for the non-Fibro chronic pain group.v

The researchers also found that problems with physical functioning and depression did not predict strength of contra-activation in the upper arm muscle.¹

The researchers concluded that:

"These findings suggest presence of unusual muscle activity occurring in the bicep muscle of FMS and non-FMS chronic pain patients, which establishes a possible link between muscle dysfunction, mood and pain."¹

It is not mentioned whether the study participants were assessed for myofascial trigger points in the muscles measured. Myofascial trigger points, as well as causing pain and other symptoms, can affect muscle function. They are also likely to be more common in people with a chronic pain condition.²

References:

Jegede AB, Gilbert C, Tulkin SR. Muscle characteristics of persons with fibromyalgia syndrome. NeuroRehabilitation. 2008;23(3):217-30.
Wolfe F, et al. The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease. J Rheumatol. 1992 Jun;19(6):944-51.

Fibromyalgia Syndrome and cervical trauma in patients with cervical myofascial pain syndrome

Fri, 30 Jan 2009 12:00:00 +0000

A study looking at other findings in patients with cervical myofascial pain syndrome came to the conclusion that patients with previous cervical trauma (e.g. whiplash injuries) who are also displaying autonomic symptoms, should be examined for cervical myofascial pain syndrome and also Fibromyalgia Syndrome.¹

The study aimed to explore the demographic features, clinical findings and functional status of a group of patients presenting with myofascial pain of the cervical (neck) muscles.¹

Ninety-four patients with cervical myofascial pain syndrome were recruited for the study from an out-patient clinic and 82 patients with a diagnosis of cervical myofascial syndrome were included in the study. They were evaluated using the short form health survey (SF-36), visual analog scale of pain, Beck Depression Inventory, patient demographics and physical examinations.

All of the patients were relatively young, aged 37.4 years +/- 9 years, and 87.8% were female.

The researchers found that 53.1% of the patients had trigger points in the trapezius muscle with high percentage of them also suffering from autonomic phenomena like skin reddening, lacrimation (weeping eyes), tinnitus and vertigo. Of the patient group, 58.5% had suffered from former cervical trauma, 40.2% also had Fibromyalgia Syndrome (Fibro) and 18.5% had benign Joint hypermobility syndrome (BJHS).

The researchers concluded that:

"Younger female patients presenting with autonomic phenomena and early onset cervical injury should be examined for cervical myofascial pain syndrome and also for Fibromyalgia Syndrome since this study demonstrated a high percentage of Fibromyalgia Syndrome in these patients."

References:

Sahin N et al. Demographics features, clinical findings and functional status in a group of subjects with cervical myofascial pain syndrome. Agri. 2008 Jul;20(3):14-9.

Identifying and prioritising clinical domains in Fibromyalgia Syndrome

Fri, 30 Jan 2009 12:00:00 +0000

A research study found that clinicians and patients mostly agreed on the domains affected by Fibromyalgia Syndrome and their priority, with pain consistently being the highest ranked domain.¹

The aim of the study was to identify and prioritise the key domains impacted by Fibromyalgia Syndrome that should be evaluated as outcome measures in clinical trials relating to Fibromyalgia Syndrome, and to also approach consensus among clinicians and patients on the priority of those domains to be assessed in clinical care and research.¹

Group consensus was achieved using the Delphi method, a structured process of consensus building via questionnaires together with systematic and controlled opinion feedback.

For this study, the Delphi exercises involved 23 clinicians with expertise in Fibromyalgia Syndrome and 100 patients with Fibromyalgia Syndrome as defined by American College of Rheumatology criteria. .¹

The study revealed that clinicians and patients ranked similar domains highly.¹

Pain was consistently ranked highest by both clinicians and patients. Fatigue, impact on sleep, health-related quality of life, comorbid depression, and cognitive difficulty were also ranked highly. However, stiffness was ranked highly by patients but not clinicians and side effects were important to clinicians but not so much to patients.¹

The researchers concluded that:

"The clinician and patient Delphi exercises identified and ranked key domains that need to be assessed in [Fibromyalgia Syndrome] research. Based on these results, a conceptual framework for measuring patient-reported outcomes is proposed."

Pain is the most commonly used primary outcome measure for research trials into Fibromyalgia Syndrome and it is also what many clinicians concentrate on when treating patients. However, it is important that the other domains are taken into account. The Fibromyalgia Impact Questionnaire is sometimes used as a secondary outcome measure to pain in research studies in an attempt to address this issue.

References:

Mease PJ et al. Identifying the clinical domains of fibromyalgia: contributions from clinician and patient Delphi exercises. Arthritis Rheum. 2008 Jul 15;59(7):952-60.

Positional cervical spinal cord compression and Fibromyalgia Syndrome

Sat, 31 Jan 2009 12:00:00 +0000

FibroAction Professional Advisory Board member Dr Andrew Holman MD is investigating a possibly important new factor in Fibromyalgia Syndrome: positional cervical spinal cord compression (compression of the spine in the neck when the head is tilted back). His initial paper on the research was published in the Journal of Pain last year.

Dr Holman says in this paper

"...fundamental concerns about defining [Fibromyalgia Syndrome] as a single entity abound, but little consideration has been apportioned to the concept that variability in patient presentation and treatment response may be relatedto unsuspected comorbidities."¹

Dr Holman believes that positional cervical spinal cord compression is one unsuspected comorbidity that has important implications for Fibromyalgia Syndrome and its treatment.¹

Recognition of cervical comorbidity with Fibromyalgia Syndrome was describedby Rosner and Heffez when decompression of Chiari I deformity (where the brainstem extends into the spinal canal, compressing the spinal cord) was found to reduce fatigue and global pain in some patients with both conditions. However, Chiari malformations are not common in the general population and many people with Fibromyalgia Syndrome do not have any evidence to suggest that surgery could be beneficial. There are also genuine concerns about the promotion of any surgical intervention for Fibromyalgia Syndrome.¹

What began as an attempt by Heffez to document spinal cord compression from a congenital abnormality, Chiari I, developed into an initiative to recognize cord compression and abutment related to cervical position. Heffez foudn that, by including flexion and extension views (tilting the patient's head forward and back) when doing a cervical spine MRI, he was able to view and document cord compression and abutment that was not visible on a traditional MRI view (where the patient lies flat).¹

Since January 2003, these 2 extra views have been done as well when doing a traditional cervical spine MRI in order to identify the presence of positional cervical spinal cord compression among patients referred for rheumatology consultation with Dr Holman.¹

For the pilot study, Dr Holman carried out a retrospective chart review, looking at a randomly selected 2-month period (January and February 2006).¹

This pilot study was undertaken to evaluate the concept of positional cervical spinal cord compression in patients that did not require surgery (e.g. for Chiari I), promote discussion of its possible relevance, and consider future research initiatives related to this potential comorbidity with Fibromyalgia Syndrome.¹

Positional cervical spinal cord compression was defined as cord abutment, compression or flattening with a spinal canal diameter of less than 10 mm when measured by flexion, neutral, and extension MRI images.¹

Of 107 referrals during the 2-month period, 53 had Fibromyalgia Syndrome, 32 had a connective tissue disease (CTD) without Fibromyalgia Syndrome, and 22 had chronic widespread pain (CWP) without meeting the criteria for Fibromyalgia Syndrome.¹

These patients were then assessed as to whether a cervical MRI was required to check for cervical spinal cord issues, using questions and examinations, such as an extended Hoffmann test (feet together, eyes closed and see if the patient wobbles or falls) and whether they got pain from a haidressers sink.¹

The dynamic cervical spine images were obtained in 70 patients: 49 out of 53 with Fibromyalgia Syndrome, 20 of 22 with CWP and 1 of 32 with CTD.¹

Among those who received magnetic resonance imaging [MRI], 52 patients met the criteria for positional cervical spinal cord compression (71% of FM group [35/49], 85% of CWP group [17/20]). Two Fibromyalgia Syndrome patients were found to have a Chiari malformation, 1 Chronic Widespread Pain patient had multiple sclerosis, and 1 Chronic Widespread Pain patient had multiple myeloma.¹

The new extension views (where the patient's head is tilted back) were required for diagnosis of positional cervical spinal cord compression for 71% of the subjects, as well as for 8 patients who also had cervical spinal cord flattening. With a normal MRI view, these findings would have been missed.¹

Dr Holman concluded that:

"It is not yet clear whether recognition of positional cervical spinal cord compression will be considered as an intriguing source of widespread pain or as an important comorbidity among patients with FM or as a common incidental finding. But, these preliminary data suggest that additional resources should be allocated to evaluate this concept further."

For further discussion of this research by Dr Holman, including some of the MRI images, please see the Videos and Podcast section here where there is a recording of a lecture Dr Holman made on December 22nd 2008 at Guy's Hospital, London.

References:

Holman AJ. Positional cervical spinal cord compression and fibromyalgia: a novel comorbidity with important diagnostic and treatment implications. J Pain. 2008 Jul;9(7):613-22. Epub 2008 May 22.

Efficiacy of multicomponent treatment for Fibromyalgia Syndrome

Sat, 31 Jan 2009 12:00:00 +0000

An article, e-published ahead of print in the journal Arthritis and Rheumatism, discusses a review of the efficiacy of multicomponent treatment for Fibromyalgia Syndrome, where exercise therapy is combined with one or more educational or psychological therapies.

The study aimed to systematically review the efficacy of multicomponent treatment of Fibromyalgia Syndrome.

For the study, the researchers screened the databases Medline, PsychINFO, Scopus, and the Cochrane Library (through December 2007), as well as reference sections of original studies, reviews, and evidence-based guidelines. Randomised controlled trials (RCTs) of multicomponent treatments (that included at least 1 educational or psychological therapy with at least 1 exercise therapy) of Fibromyalgia Syndrome were also analysed.

Nine out of 14 RCTs were included in the analysis and the effects were standardised using standardized mean differences or weighted mean differences.¹

The researchers found that there was strong evidence that multicomponent treatment reduces pain, fatigue, depressive symptoms, and limitations to health-related quality of life, as well as improving self-efficacy pain and physical fitness at posttreatment.¹

However, there was no evidence of its long-term efficacy on pain, fatigue, sleep disturbances, depressive symptoms, HRQOL, or self-efficacy pain.¹

There was strong evidence that positive effects on physical fitness can be maintained in the long term (median followup 7 months)..¹

The researchers concluded that:

"There is strong evidence that multicomponent treatment has beneficial short-term effects on the key symptoms of [Fibromyalgia Syndrome]. Strategies to maintain the benefits of multicomponent treatment in the long term need to be developed."

References:

Häuser W, Bernardy K, Arnold B, Offenbächer M, Schiltenwolf M. Efficacy of multicomponent treatment in fibromyalgia syndrome: A meta-analysis of randomized controlled clinical trials. Arthritis Rheum. 2009 Jan 29;61(2):216-224. [Epub ahead of print]

Evaluating obesity in Fibromyalgia Syndrome patients

Sat, 31 Jan 2009 12:00:00 +0000

A study conducted at the University of Utah Pain Management and Research Center has found that many patients with Fibromyalgia Syndrome are overweight or obese.

The aim of the study was to investigate the associations between obesity and Fibromyalgia Syndrome.

Thirty-eight patients with Fibromyalgia Syndrome were included in the study. Neuroendocrine factors (levels of: catecholamines, including the neurochemicals epinephrine, norepinephrine, and dopamine; cortisol; C-reactive protein [CRP], a measure of inflammation; and interleukin-6 [IL-6], a cytokine with many functions involved with immunology), symptom measures (as measured by the Fibromyalgia Impact Questionnaire), sleep factors (as measured by an Actigraph), and physical functioning (as measured by treadmill testing) were studied. Body mass index (BMI) provided the primary indicator of obesity.

The researchers found that approximately 50% of the patients were obese and an additional 21% were overweight.¹

Strong positive associations were found between BMI and levels of IL-6 and epinephrine, and somewhat weaker associations with cortisol and CRP. BMI was also related to maximal heart rate and inversely related to distance walked. BMI was associated with disturbed sleep: total sleep time and sleep efficiency. No associations between self-reported symptoms and BMI were found.

The researchers concluded that:

"This study provides preliminary evidence suggesting that obesity plays a role in [Fibromyalgia syndrome] related dysfunction."

However, there is a theory that the changes in the Central Nervous System that happen with Fibro could cause some of the results found in this study, and that these could contribute to obesity in Fibromyalgia Syndrome patients, rather than the other way round.

This study also makes no reference as to medications the patients may have been on - many medications recommended as treatments for Fibromyalgia Syndrome have weight gain as a side effect - nor is it clear whether other conditions may have been involved.

References:

Okifuji A, Bradshaw DH, Olson C. Evaluating obesity in fibromyalgia: neuroendocrine biomarkers, symptoms, and functions. Clin Rheumatol. 2009 Jan 27. [Epub ahead of print]

Fibromyalgia Syndrome in primary headache patients

Mon, 02 Feb 2009 12:00:00 +0000

People with Fibromyalgia Syndrome are more likely to have frequent headaches, according to a recent research article.¹

The aim of the study was to assess the prevalence and clinical features of Fibromyalgia Syndrome in patients with the different forms of primary headaches, in a tertiary headache centre.

For the study, 217 primary headache patients were selected and assessed using the Total Tenderness Score, anxiety and depression scales, Migraine Disability Assessment, allodynia questionnaire, Short Form 36 Health Survey and the Medical Outcomes Study-Sleep Scale. In patients with Fibromyalgia Syndrome, the Multidimensional Assessment of Fatigue, the Pain Visual Analog Scale, the Manual Tender Point Survey and the Fibromyalgia Impact Questionnaire were also used for assessment.

The researchers found that Fibromyalgia Syndrome was present in 36.4% of patients and prevailed significantly in patients with tension-type headache and in patients with higher headache frequency.¹

Headache frequency, pericranial muscle tenderness, anxiety and sleep inadequacy were especially associated with the patients also having Fibromyalgia Syndrome.¹

In the Fibromyalgia Syndrome patients, fatigue and pain at tender points were significantly correlated with headache frequency.

The researchers concluded that:

"[Fibromyalgia Syndrome] seems increasingly prevalent with increased headache frequency, for the facilitation of central sensitization phenomena favoured by anxiety and sleep disturbances."¹

Fibromyalgia Syndrome has been described as a Central Sensitivity Syndrome, as have headache & migraine.²

References:

de Tommaso M et al. Fibromyalgia comorbidity in primary headaches. Cephalalgia. 2008 Dec 15. [Epub ahead of print]
Yunus MB. Fibromyalgia and Overlapping Disorders: The Unifying Concept of Central Sensitivity Syndromes. Semin Arthritis Rheum. 2007 Jun;36(6):339-56. Epub 2007 Mar 13. Review.

Early menopause and hysterectomy may contribute to the development of Fibromyalgia Syndrome

Mon, 02 Feb 2009 12:00:00 +0000

Early menopause and hysterectomy may be one of the factors that can contribute to the development of Fibromyalgia Syndrome, according to an article e-published this month ahead of print in the journal Clinical Rheumatology. ¹

The aim of the study was to determine the relationship between symptoms of Fibromyalgia Syndrome and early menopause and hysterectomy.

For the study, 115 postmenopausal patients with Fibromyalgia Syndrome and 67 rheumatoid arthritis (RA) patients were questioned about the severity of their symptoms of Fibromyalgia Syndrome, anxiety, and depression by using a visual analog scale and FM impact questionnaire. Patients' history of menopause and hysterectomy were recorded.

The average age of the patients with Fibromyalgia Syndrome was 54.6 years +/- 7.6 and the average age of the patients with RA was 55.5 years +/- 9.

Menopause at 45 years old or younger was considered to be early menopause.

The frequencies of early menopause and hysterectomy in Fibromyalgia Syndrome patients were significantly higher than in RA patients.¹

Fibromyalgia Syndrome related symptoms started in 30 of the patients with Fibromyalgia Syndrome (26.1%) at the same time as menopause or within the first postmenopausal year. When the clinical features of Fibromyalgia Syndrome patients whose symptoms started within the first menopausal year were compared to other Fibromyalgia Syndrome patients; it was observed that the frequency of early menopause was higher in the group that had symptoms start at the same time as menopause or within the first postmenopausal year.¹

The Duke anxiety and depression score was also higher in patients with hysterectomy whose Fibromyalgia Syndrome symptoms started within the first year of post-hysterectomy, compared with other Fibromyalgia Syndrome patients.

The researchers concluded that:

"Early menopause and hysterectomy may be one of the factors contributing to the development of FM."¹

References:

Pamuk ON, Dönmez S, Cakir N. Increased frequencies of hysterectomy and early menopause in fibromyalgia patients: a comparative study. Clin Rheumatol. 2009 Jan 24. [Epub ahead of print]

Impaired mobility in Fibromyalgia Syndrome patients

Mon, 02 Feb 2009 12:00:00 +0000

A study by Spanish researchers has found that people with Fibromyalgia Syndrome have more mobility problems than healthy controls, and that the more impact their Fibromyalgia Syndrome has on their life, the more their gait is affected.¹

The aim of the study was to determine if there are differences in parameters relating to gait among patients affected by Fibromyalgia Syndrome compared to healthy subjects and whether the severity of the Fibromyalgia Syndrome was related to problems with gait.

For the study, 55 women with Fibromyalgia Syndrome and 44 healthy controls were assessed.

Gait analysis was performed using an instrumented walkway for measurement of the kinematic parameters of gait (GAITRite system), and the Fibromyalgia Syndrome patients also completed a Spanish version of the Fibromyalgia Impact Questionnaire (FIQ).

Significant differences were found between the group of Fibromyalgia Syndrome patients and the control group in velocity, stride length, cadence, single support ratio, double support ratio, stance phase ratio, and swing phase ratio. There were significant inverse correlations between FIQ and velocity, stride length, swing phase, and single support, whereas significant direct correlations were found with stance phase and double support. In other words, a patient whose Fibromyalgia Syndrome had a large impact on their life, was more likely to walk slower, more irregularly and hestitantly, with smaller steps.

The researchers concluded that:

"Gait parameters of women affected by FM were severely impaired when compared to those of healthy women. Different factors such as lack of physical activity, bradikinesia, overweight, fatigue, and pain together with a lower isometric force in the legs can be responsible for the alterations in gait and poorer life quality of women with FM."¹

References:

Heredia Jiménez JM et al. Spatial-temporal parameters of gait in women with fibromyalgia. Clin Rheumatol. 2009 Jan 24. [Epub ahead of print]

Sexual Dysfunction and Fibromyalgia Syndrome

Mon, 02 Feb 2009 12:00:00 +0000

Two articles have been e-published this month discussing sexual dysfunction in Fibromyalgia Syndrome.^{1 2}

The first article, e-published ahead of print in the journal Clinical Rheumatology, aimed to review the association between Fibromyalgia Syndrome and sexual dysfunction in women and possible mechanisms of such association.

For the study, the medical literature databases PubMed, MEDLINE, and EMBASE databases (1950-2008) were searched for the key words "fibromyalgia", "chronic pain", "sexual dysfunction", "female", "sexuality", "depression", and "quality of life". All relevant articles in English and secondary references were reviewed.

All of the reviewed studies showed that Fibromyalgia Syndrome is associated with sexual dysfunction in women.¹

The major findings were as follows: decreased sexual desire and arousal, decreased experience of orgasm, and increased pain with intercourse.¹

The researchers concluded that:

"[Fibromyalgia Syndrome], sexual dysfunction, and depression may be interrelated with the depressive mood responsible for desire and arousal problems. On the other hand, in [Fibromyalgia Syndrome] patients, the threshold at which sensory input becomes painful is lower than normal that can explain pain on intercourse. Additional studies are needed to evaluate the casual relationship and mechanism of association between FM and sexual dysfunction in women"¹

The second article, e-published ahead of print in the journal Rheumatology International, was an overview of the impact that rheumatic diseases have on sexual function.

According to the article, the reasons that rheumatic diseases may disturb sexual function are multifactorial and comprise disease-related factors as well as therapy. ²

The researchers concluded that:

"In rheumatoid arthritis and ankylosing spondylitis patients, pain and depression could be the principal factors contributing to sexual dysfunction. On the other hand, in women with Sjögren's syndrome, systemic lupus erythematosus and systemic sclerosis sexual dysfunction is apparently most associated to vaginal discomfort or pain during intercourse. Finally, sexual dysfunction in patients with Fibromyalgia Syndrome could be principally associated with depression, but the characteristic symptoms of Fibromyalgia Syndrome (generalized pain, stiffness, fatigue and poor sleep) may contribute to the occurrence of sexual dysfunction."²

The article went on to say that the treatment of sexual dysfunction will depend on the specific patient's symptoms. However, there are some general recommendations made in the article, including: exploring different positions, using analgesics drug, heat and muscle relaxants before sexual activity and exploring alternative methods of sexual expression.²

References:

Kalichman L. Association between fibromyalgia and sexual dysfunction in women. Clin Rheumatol. 2009 Jan 23. [Epub ahead of print]
Tristano AG. The impact of rheumatic diseases on sexual function. Rheumatol Int. 2009 Jan 20. [Epub ahead of print]

Impact of tobacco use on people with Fibromyalgia Syndrome

Mon, 02 Feb 2009 12:00:00 +0000

Tobacco use is associated with more pain and other symptoms in people with Fibromyalgia Syndrome, according to an article has been published in the January edition of the Clinical journal of Pain by a team of researchers from the Mayo Clinic and Mayo Foundation in the USA.¹

The study aimed to examine the relationship between the severity of Fibromyalgia Syndrome symptoms and current tobacco use in patients evaluated at a specialized Fibromyalgia Syndrome treatment program.

For the study, demographic and clinical data from 984 consecutive patients evaluated at the Mayo Clinic Fibromyalgia Treatment Program including the Fibromyalgia Impact Questionnaire (FIQ) were prospectively collected and stored in an electronic medical record and an electronic database. Tobacco users and nonusers were compared.

One hundred and forty-five patients (14.7%) were identified as tobacco users.

The researchers found that tobacco use was associated with greater pain intensity as measured by pain scales and the pain component of the FIQ. Tobacco users had a greater FIQ composite score, higher scores on all the FIQ components and fewer good days and more days of work missed per week. ¹

Tobacco use was associated with several confounding clinical and demographic variables including lower education, higher unemployment, not being married or widowed, and history of abuse.¹

After adjusting for these confounding variables, tobacco users continued to have greater pain intensity, a higher total and component FIQ scores except for fatigue.¹

Smoking was not associated with a higher number of tender points.^{1 1}

The researchers concluded that:

"Current tobacco use was associated with more severe [Fibromyalgia Syndrome] symptoms in patients presenting to a specialized fibromyalgia treatment program."¹

References:

Weingarten TN, et al. Impact of tobacco use in patients presenting to a multidisciplinary outpatient treatment program for fibromyalgia. Clin J Pain. 2009 Jan;25(1):39-43

Fibromyalgia Syndrome and Food

Wed, 04 Mar 2009 12:00:00 +0000

Fibromyalgia Syndrome: is there a link between symptoms and foods consumed? - a survey of Fibromyalgia Syndrome sufferers

Extended Abstract

Introduction

There have been many studies looking at diet and Fibromyalgia Syndrome (Fibro) and much anecdotal evidence from both Fibro patients and practitioners that the consumption of certain foods or food groups worsen or ameliorate the symptoms of Fibro. This research study aims, via the use of a questionnaire, to investigate the link between foods consumed and Fibro patients’ perception of their affect on Fibro symptoms.

Methods

Research was carried out through the use of a questionnaire which was emailed to qualifying members of Fibro support groups and also included on the websites of these support groups. To qualify for inclusion in the study, participants had to be female, living in the SE of England, aged between 25 and 60 years old, who had suffered with the symptoms of Fibro for at least 1 year and had been diagnosed by a medical professional. Members of the Fibromyalgia Association UK support groups of South Buckinghamshire, Hampshire, Berkshire and Surrey & Sussex, Fibro Action and the Tried and Tested Fibromyalgia group took part in the research.

The questionnaire asked participants about 31 different foods and beverages, some of which were known to be possible triggers and some of which had no such information concerning their consumption.

Results & Analysis

Of those participants who responded to ‘worse’, the foods which brought the highest rates of response were; potatoes 40%, artificial sweetener 43%, beer/cider 45%, white wine 50%, aspartame 50%, sugar 53%, red wine 55%, mono-sodium glutamate 56%, coffee 58%, and bread 59%.

This was not a surprising result as these are the foods which many of the websites and books regarding Fibro detail as possible triggers for Fibro and perhaps this is a confounding factor in itself.

When looking at which symptoms were affected, the spread of negatively affected symptoms was broad, possibly suggesting that foods affect sufferers’ individual symptoms differently. However, the symptoms that were most affected upon consumption of these foods were, in descending order; fatigue, pain, stiffness, sleep and memory/concentration.

Chicken, oily fish, white fish, nuts (unsalted) and seeds all positively affected the perceived symptoms of more than 10% of participants who answered these questions. 37.5% of participants who answered the oily fish question stated that consuming oily fish made their pain, stiffness, memory/concentration and fatigue better. 29% of participants stated that the consumption of white fish improved their memory/concentration and fatigue but not pain or stiffness. Unsalted nuts brought a greater response to improving symptoms than salted nuts with 17% and 9% respectively of participants who answered this question seeing improvement. Salt is also recommended as a food to be avoided by Fibro patients and perhaps the negative effect of the salt outweighs the positive effect of the essential fatty acids which might explain the difference in response. 22% of participants answering the seeds question stated that they felt improvement to symptoms however only one participant detailed which symptoms were affected, these being pain and stiffness.

Conclusions

A large proportion of the Fibro patients surveyed in this study perceived that many of the foods contained in the survey affected their Fibro symptoms either negatively or positively. This finding conflicts with the opinions of many conventional healthcare providers who maintain that there is no link between the symptoms of Fibromyalgia Syndrome and foods consumed by the sufferer. This small pilot study has highlighted some interesting points which would need further investigation in a larger study to confirm participants’ perception that the consumption of certain foods or food groups does in fact contribute to the worsening or amelioration of their Fibro symptoms.

©Jacqui Mayes 2008

The full text of this study can be downloaded from ‘Articles’ at www.jacquimayes.co.uk.

Myers Cocktail for Fibromyalgia Syndrome

Wed, 04 Mar 2009 12:00:00 +0000

A recent pilot study has established the safety and feasability of an intraveneous micronutrient therapy (IVMT) for Fibromyalgia Syndrome (Fibro) that is commonly known as a Myer's Cocktail. However, the pilot study could not establish the efficiacy of the treatment.

The randomized, double-blind, placebo-controlled pilot study was carried out by a team from the Yale University School of Medicine and the article was e-published ahead of print in the Journal of Alternative & Complementary Medicine,

For the pilot study, 34 adults with Fibro (as defined by the American College of Rheumatology (ACR) criteria for the diagnosis of Fibro) were randomly assigned either to treatment (weekly infusions of IVMT) or to placebo (weekly infusions of lactated Ringer's solution) for 8 weeks.

The primary outcome measure used was change in the Tender Point Index, assessed at 8 and 12 weeks after the start of the pilot study. Secondary outcomes measures used included a Visual Analog Scale to assess global pain, and validated measures of physical function (Fibromyalgia Impact Questionnaire), mood (Beck Depression Index), and quality of life (Health Status Questionnaire 2.0).

Clinically significant improvements were noted (of a magnitude similar to other effective interventions). However, in part because of the high placebo response and the small sample size, no statistically significant differences were seen between groups, in any outcome measure, at 8 and 16 weeks. Statistically significant within-group differences were seen in both the intervention and placebo groups, demonstrating a treatment effect for both IVMT and placebo. ¹

At 8 weeks, the IVMT group experienced significantly improved tender points, pain, depression, and quality of life directly following treatment, while the placebo group experienced significantly improved tender points only. The treatment effects of IVMT persisted at 4 weeks postintervention for tender points, pain, and quality of life, while placebo effects persisted only for tender points. ¹

A single minor adverse event was noted in one subject in the intervention group.¹

The researchers concluded that:

"This first controlled pilot study established the safety and feasibility of treating FMS with IVMT. Most subjects experienced relief as compared to baseline, but no statistically significant differences were seen between IVMT and placebo. The efficacy of IVMT for fibromyalgia, relative to placebo, is as yet uncertain." ¹

A larger study may be able to determine the efficiacy of this treatment more conclusively. In research studies, the larger the participant group, the easier it is to prove that a small difference is significant.

The term "Myers Cocktail" is most commonly known by UK patients in reference to a modified version of the Myer's cocktail that is given at some private clinics. This modified Myer's Cocktail is an intra-muscular injection, rather than an intraveneous therapy, and is also given with an injection of lidocaine for pain reduction.

References:

Ali A, Njike VY, Northrup V, Sabina AB, Williams AL, Liberti LS, Perlman AI, Adelson H, Katz DL. Intravenous Micronutrient Therapy (Myers' Cocktail) for Fibromyalgia: A Placebo-Controlled Pilot Study. J Altern Complement Med. 2009 Feb 28. [Epub ahead of print]

Prevalence of Fibromyalgia Syndrome in five European Countries

Thu, 05 Mar 2009 12:00:00 +0000

An article has been e-published this month discussing the results of a Fibromyalgia Syndrome prevalence survey carried out 5 European countries (France, Germany, Italy, Portugal, and Spain).

In each of the 5 countries, the London Fibromyalgia Epidemiological Study Screening Questionnaire (LFESSQ) was administered by telephone to a representative sample of the community over 15 years of age. The questionnaire was also submitted to all outpatients referred to the 8 participating rheumatology clinics for 1 month. These patients were examined by a rheumatologist to confirm or exclude the diagnosis of Fibromyalgia Syndrome according to the 1990 American College of Rheumatology (ACR) classification criteria.

The questionnaire includes 4 pain criteria and 2 fatigue criteria. A positive screen was defined as either meeting the 4-pain criteria alone (LFESSQ-4), or meeting both the 4-pain and the 2-fatigue criteria (LFESSQ-6).

The proportion of rheumatology outpatients with a positive screen who had the diagnosis of Fibromyalgia Syndrome confirmed was then used to calculate the prevalence of Fibromyalgia Syndrome in the general population from the number of people who had a positive screen with a telephone interview.

Among rheumatology outpatients, 46% screened positive for chronic widespread pain (LFESSQ-4), 32% for pain and fatigue (LFESSQ-6), and 14% were confirmed cases of Fibromyalgia Syndrome.

In the general population, 13% screened positive for chronic widespread pain (LFESSQ-4) and 6.7% for pain and fatigue (LFESSQ-6).

The estimated overall prevalence of of Fibromyalgia Syndrome in the general population was 4.7% (95% CI: 4.0 to 5.3) and 2.9% (95% CI: 2.4 to 3.4) depending on which questionnaire (LFESSQ-4 or LFESSQ-6) was used.

The prevalence of Fibromyalgia Syndrome was age- and sex-related and varied among countries.

The article concluded that:

"[Fibromyalgia Syndrome] appears to be a common condition in these 5 European countries, even if data derived from the most specific criteria set (LFESSQ-6) are considered."

References:

Branco JC, Bannwarth B, Failde I, Abello Carbonell J, Blotman F, Spaeth M, Saraiva F, Nacci F, Thomas E, Caubère JP, Le Lay K, Taieb C, Matucci-Cerinic M. Prevalence of Fibromyalgia: A Survey in Five European Countries. Semin Arthritis Rheum. 2009 Feb 26. [Epub ahead of print]

Resistance Training and Chiropractic Treatment in Women with Fibromyalgia Syndrome

Thu, 05 Mar 2009 01:00:00 +0000

A recent study has found that resistance training is more helpful for women with Fibromyalgia Syndrome if it is combined with chiropractic treatment.

The randomised controlled study aimed to evaluate resistance training and resistance training combined with chiropractic treatment on the impact and functionality of Fibromyalgia Syndrome (Fibro) in women.

Twenty-one women with Fibro, who had an average age of 48 years, took part in the study. They were randomly assigned to either resistance training or resistance training combined with chiropractic treatment, with 10 women in the first group and 11 in the second.

Both groups completed 16 weeks of resistance training consisting of 10 exercises performed two times per week. The group assigned to receive both resistance training and chiropractic treatment also received chiropractic treatment two times per week.

Strength was assessed using one repetition maximum for the chest press and leg extension. Fibromyalgia Syndrome impact was measured using the Fibromyalgia Impact Questionnaire, myalgic (pain) score, and the number of recorded tender points. Functionality was assessed using the 10-item Continuous Scale Physical Functional Performance test.

Six participants discontinued the study: 5 from the group receiving resistance training only and 1 from the group receiving resistance training combined with chiropractic treatment. Adherence to training was therefore significantly higher in the latter group.

Both groups increased upper and lower body strength and there were similar improvements in Fibromyalgia Syndrome impact in both groups as well as the strength domains of the functionality assessment.

However, only the group receiving resistance training combined with chiropractic treatment significantly improved in the pre- to postfunctional domains of flexibility, balance and coordination, and endurance.

The article concludes that:

"In women with [Fibromyalgia Syndrome], resistance training improves strength, [Fibromyalgia Syndrome] impact, and strength domains of functionality. The addition of chiropractic treatment improved adherence and dropout rates to the resistance training and facilitated greater improvements in the domains of functionality."

One factor in the beneficial effects of the chiropractic treatment may have been that many chiropractors perform some Myofascial Release as part of their treatments. Myofascial Pain is a common problem with Fibro and it can cause exercise to be more painful and less effective. If you think you may have myofascial trigger points, then a specialist doctor, or a physiotherapist or massage therapist with the specialist training in myofascial issues, should be able to check you out for these and help release them.

References:

Panton LB, Figueroa A, Kingsley JD, Hornbuckle L, Wilson J, John NS, Abood D, Mathis R, Vantassel J, McMillan V. Effects of Resistance Training and Chiropractic Treatment in Women with Fibromyalgia. J Altern Complement Med. 2009 Feb 28. [Epub ahead of print]

Manual lymph drainage therapy and connective tissue massage in women with Fibromyalgia Syndrome

Fri, 06 Mar 2009 12:00:00 +0000

A recently published study has suggested that massage may be helpful for women with primary Fibromyalgia Syndrome and that manual lymph drainage therapy may be more effective than connective tissue massage.

The randomised controlled trial aimed to analyse and compare the effects of manual lymph drainage therapy (MLDT) and connective tissue massage (CTM) in women with primary Fibromyalgia Syndrome (Fibro).

For the study, 50 women with Fibro were divided randomly into 2 groups: 25 of them receiving MLDT, and the other 25 undergoing CTM.

The treatment program was carried out 5 times a week for 3 weeks in each group.

The participants pain was evaluated by a visual analogue scale and algometry (a pain pressure test). The Fibromyalgia Impact Questionnaire (FIQ) and Nottingham Health Profile were used to describe health status and health-related quality of life (HRQoL). Wilcoxon signed rank test and Mann-Whitney U test were used to analyse the data.

In both groups, significant improvements were found regarding pain intensity, pain pressure threshold, and HRQoL.

However, the scores of the Fibromyalgia Impact Questionnaire using 7 questions (FIQ-7), the FIQ using 9 questions (FIQ-9), and the total FIQ (FIQ-total) were significantly lower in the MLDT group than they were in the CTM group at the end of treatment.

The article concludes that:

"For this particular group of patients, both MLDT and CTM appear to yield improvements in terms of pain, health status, and HRQoL. The results indicate that these manual therapy techniques might be used in the treatment of [Primary Fibromyalgia Syndrome]. However, MLDT was found to be more effective than CTM according to some sub-items of FIQ (morning tiredness and anxiety) and FIQ total score. Manual lymph drainage therapy might be preferred; however, further long-term follow-up studies are needed."

References:

Ekici G, Bakar Y, Akbayrak T, Yuksel I. Comparison of manual lymph drainage therapy and connective tissue massage in women with fibromyalgia: a randomized controlled trial. J Manipulative Physiol Ther. 2009 Feb;32(2):127-33.

Impulse Control Disorder Behaviors Associated with Pramipexole Used to Treat Fibromyalgia

Fri, 06 Mar 2009 02:00:00 +0000

Dr Andrew Holman MD, a member of the FibroAction Professional Advisory Board, has published the first report of compulsive gambling and shopping among patients taking dopamine agonists for the treatment of FIbromyalgia Syndrome.

Compulsive behavioural problems (compulsivity) have been associated with use of dopamine agonists used to treat Parkinson's disease (PD). Increasing use of these agents to treat Fibromyalgia Syndrome (Fibro) raises concern for this unexpected toxicity in a new group of patients.

Dr Holman carried out a retrospective chart review of all patients in his large, active Fibro research practice in order to identify compulsivity associated with dopamine agonists and describe its remission following drug withdrawal.

Of 3006 patients with Fibro treated between 2002 and 2006, 1356 had taken at least 1 dose of a dopamine agonist, with this medication being pramipexole in more than 95% of cases.¹

Of these patients, 21 - 1.5% of the patients taking a dopamine agonist - had been identified as exhibiting compulsivity. Of these, 3 were male and 18 female; 33% of them were identified with compulsive gambling, 40% with compulsive shopping and 27% with both.¹

They had been taking an average dose of 4.5 mg pramipexole salt at bedtime for varying lengths of time, some over a year.¹

For 19 out of the 21 patients, compulsivity resolved in 3-10 days following a monitored, compulsory tapered discontinuation over 7 days. For the remaining 2 patients, it took a little longer: 3 months.¹

The article concludes that:

"While biologic aspects of [Parkinson's disease] and [Fibromyalgia Syndrome] differ considerably, compulsive gambling and shopping have become important, yet unexpected concerns related to use of dopamine agonists for patients with [Fibromyalgia Syndrome] and their treating clinicians."¹

For a subset of people with Fibro, who have neither obstructive sleep apneoa nor positional cervical cord compression, Pramipexole has been shown to be an extremely effective medication. A study by Dr Holman and a colleague showed that 42% of these patients acheived a 50% or greater reduction in pain whilst on Pramipexole for the study.² Pramipexole remains a useful medication for the management of Fibro in a specific subset of the patient population.

References:

Holman AJ. Impulse Control Disorder Behaviors Associated with Pramipexole Used to Treat Fibromyalgia. J Gambl Stud. 2009 Feb 25. [Epub ahead of print]
Holman AJ, Myers RR. A randomized, double-blind, placebo-controlled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications. Arthritis Rheum. 2005 Aug;52(8):2495-505.

The economic burden of Fibromyalgia Syndrome compared with arthritis

Fri, 06 Mar 2009 03:00:00 +0000

A recently published study has concluded that the economic burden of illness in Fibromyalgia Syndrome is substantial and comparable to that of rheumatoid arthritis.

The study aimed to quantify and compare direct costs, utilisation of resources, and the rate of comorbidities, in a sample of patients with Fibromyalgia Syndrome (Fibro) to patients with rheumatoid arthritis (RA).

The researchers carried out retrospective cohort analysis of Thomson Reuters MarketScan administrative healthcare claims and employer-collected absence and disability data for adult patients with a diagnosis of Fibro and/or RA on at least one inpatient or two outpatient claims during 2001-2004. The 12-month healthcare utilisation, expenditures, and rates of comorbidities were quantified for all study-eligible patients; absence and short-term disability days and costs were quantified for the subset of participants that were employed.

The sample included 14,034 Fibro patients, 7,965 RA patients, and 331 patients with Fibro and RA.

The researchers found that the patients with Fibro had a higher prevalence of several comorbidities and greater emergency department (ED) utilisation than those with RA.

Average annual expenditures for patients with Fibro or RA were similar: $10,911 and $10,716 respectively. Annual expenditures were almost double that in patients with both FIbro and RA at $19,395.

A greater proportion of patients with Fibro had any short-term disability days than those with RA (20 vs. 15%); and a greater proportion of patients with RA had any absence days (65 vs. 80%).

Mean costs for absence from work and short-term disability in the Fibro and RA groups were substantial and similar. The group of patients with both Fibro and RA was of insufficient sample size to report on work loss.

The article concludes that:

"The burden of illness in [Fibromyalgia Syndrome] is substantial and comparable to RA. Patients with [Fibromyalgia Syndrome] incurred direct costs approximately equal to RA patients. Patients with [Fibromyalgia Syndrome] had more ED, physician, and physical therapy visits than RA patients. Patients in both groups had several comorbidities. Patients with [Fibromyalgia Syndrome] and RA incurred direct costs almost double those of the patients with either diagnosis alone. [Fibromyalgia Syndrome] and RA patients incurred similar overall absence and short-term disability costs."¹

The researchers note that the availability of newer and more expensive FDA-approved medications since 2004 is not reflected in their findings. This analysis was also restricted to commercially insured patients and therefore may not be applicable to the entire U.S. population.

References:

Silverman S, Dukes EM, Johnston SS, Brandenburg NA, Sadosky A, Huse DM. The economic burden of fibromyalgia: comparative analysis with rheumatoid arthritis. Curr Med Res Opin. 2009 Feb 17. [Epub ahead of print]

Use of resources and costs profile in patients with Fibromyalgia Syndrome

Fri, 06 Mar 2009 06:00:00 +0000

A recently published study has found that a considerable use of health resources and costs was observed in patients with Fibromyalgia Syndrome in a primary care setting.

The study aimed to determine the use of services and costs in patients with Fibromyalgia Syndrome (Fibro) or Generalized Anxiety Disorder (GAD), followed up in Primary Care.

The retrospective multicenter population-based study took place in 5 primary care clinics managed by Badalona Health Service in Spain. The study looked at patients of 18 years old and over, seen in these 5 clinics during 2006, noting general facts about the patients, their diagnoses, health care use and primary care cost (visits, diagnostic/therapeutic tests and drugs).¹

Of a total of 63,349 patients, 1.4% had a diagnosis of Fibro, and 5.3% had a diagnosis of GAD.¹

The average episodes/year and visits /year was higher in the Fibro group compared to the GAD group, with a marked difference when compared to those patients without either diagnosis.¹

A statistical relationship was found between Fibro and gender (16.8 women: 1 man), dyslipidemia (a disruption in the amount of lipids in the blood, e.g. an elevation of the total cholesterol levels), and depressive syndrome.¹

A statistical relationship was found between GAD and age, female gender, high blood pressure, dyslipidemia, smoking, depressive syndrome, and cardiovascular events.¹

After adjusting for age, gender and co-morbidities, mean annual direct ambulatory (outpatient) cost was 555.58 Euros for the reference group, 817.37 Euros for GAD, and 908.67 Euros for Fibro.

The article concludes that:

""Compared with [the] reference group, a considerable use of health resources and costs was observed in patients with [Fibro]... in [primary care] settings.¹

References:

Sicras-Mainar A, Blanca-Tamayo M, Navarro-Artieda R, Rejas-Gutiérrez J. [Use of resources and costs profile in patients with fibromyalgia or generalized anxiety disorder in primary care settings.] [Article in Spanish] Aten Primaria. 2009 Feb;41(2):77-84. Epub 2009 Feb 3

Objective evidence that Fibromyalgia Syndrome patients are as disabled as they say they are

Fri, 06 Mar 2009 09:00:00 +0000

A recently published study has found that patients with RA and Fibromyalgia Syndrome, displaying similar levels of self-reported disability. have objective evidence of similar levels of activity.

Both Fibromyalgia Syndrome (Fibro) and Rheumatoid Arthritis (RA) patients self-report similar disability, but these diseases are viewed differently by the medical profession as one has ample evidence of tissue damage and inflammation and the other does not.

The study aimed to see if an objective measure of disability produced similar results to a patients self-report of disability.

For the study, 12 patients with RA were matched with 12 Fibro patients by sex, age, and Health Assessment Questionnaire (HAQ) score. ¹

The 24-hour ambulatory activity of these patients was recorded using the Numact monitor.

Statistical analysis was performed using independent group t test for the ambulatory activity data and Spearman's correlation coefficients for HAQ and total energy.

The researchers found that there were no significant differences between the two groups in terms of total activity. Other compared analyses for activity included the number of steps taken, vigor of steps, and time spent standing, which were not statistically different.¹

The article concludes that:

"Patients with RA and [Fibromyalgia Syndrome] displaying similar levels of self-reported disability have objective evidence of similar levels of total ambulatory activity. There is a statistically significant correlation between self-reported and objective measurements of disability for the [Fibromyalgia Syndrome] patients. Either of these measures merits further study as outcome measures for [Fibromyalgia Syndrome]."¹

References:

Raftery G, Bridges M, Heslop P, Walker DJ. Are fibromyalgia patients as inactive as they say they are? Clin Rheumatol. 2009 Feb 20. [Epub ahead of print]

Outcome and Predictor Relationships in Fibromyalgia and Rheumatoid Arthritis

Fri, 06 Mar 2009 12:00:00 +0000

A recent article suggests that Fibro is part of a continuum of severity, rather than a discrete condition.

The study aimed to compare outcome-predictor relationships in Fibromyalgia Syndrome (Fibro) and Rheumatoid Arthritis (RA), in order to provide information regarding the competing hypotheses that: 1, Fibro is a continuum; or 2, that Fibro is a discrete disorder.

The researchers studied 3 outcome variables (work disability, opioid use, depression) and 12 clinical predictor variables in 2,046 patients with Fibro and 20,374 with RA.¹

They determined whether outcome predictor relationships were stronger in the Fibro patient group or in the RA patient group by measuring the areas under the receiver-operating curves. The researchers also used fractional polynomial logistic regression to create graphic models for the outcome-predictor relationships.¹

All measures of status and outcome measured in the study were more abnormal in the Fibro patient group than in the RA patient group.¹

Depression was reported in 33.4% of patients with Fibro compared with 15.1% of those with RA.¹

The predictor-outcome relationship was significantly stronger in RA in 28 of the 36 tests, and not different in the remainder. The relationship between outcome and predictor variables was generally similar in patients with Fibro and RA. However, unmodeled depression that was not explained by study variables was noted in the Fibro patient group.¹

The article concludes that:

"Our data are consistent with the hypothesis that [FIbromyalgia Syndrome] is the end of a severity continuum, but that additional psychological factors are an integral part of the syndrome."¹

Some of the worlds top Fibro researchers have previously suggested that Fibro is at the end of the spectrum of chronic pain disorders or central sensitivity syndromes^{2 3}. It has also been suggested that there isn't a clear defining line between people with Fibro and people without Fibro, but a continuum of people with varying degrees of pain, hypersensitivity to pain, symptoms of central sensitivity (e.g. migraine, Irritable Bowel Syndrome) and non-restorative sleep and it is only the severe end of this continuum that can be diagnosed with Fibro^{2 4}.

References:

Wolfe F, Michaud K. Outcome and Predictor Relationships in Fibromyalgia and Rheumatoid Arthritis: Evidence Concerning the Continuum versus Discrete Disorder Hypothesis. J Rheumatol. 2009 Feb 17. [Epub ahead of print]
Clauw DJ. Mechanistic studies and their implication for the Management of Fibromyalgia Syndrome. J Musc Pain. 2008. Vol 16, 1/2: 59-66
Yunus MB. Fibromyalgia and Overlapping Disorders: The Unifying Concept of Central Sensitivity Syndromes. Semin Arthritis Rheum. 2007 Jun;36(6):339-56. Epub 2007 Mar 13. Review.
Fibromyalgia in 2009: A lecture by Andrew Holman MD. 2009. [DVD] UK: FibroAction. (Available on application to FibroAction).

Review of Guidelines for the management of Fibromyalgia Syndrome

Sat, 21 Mar 2009 12:00:00 +0000

An article has been e-published ahead of print in the European Journal of Pain discussing a review of evidence based guidelines for the management of Fibromyalgia Syndrome (Fibro).

The review aimed to compare the methodology and the recommendations of evidence-based guidelines for the management of Fibro so that the differences between them can be properly understood. ¹

Three evidence-based guidelines for the management of Fibro published by professional organisations were identified: The American Pain Society (APS) (2005) ², the European League Against Rheumatism (EULAR) (2007) ³, and the AWMF (2008) ⁴.

According to the review article, the steering committees and panels of APS and AWMF were comprised of multiple disciplines engaged in the management of Fibro and included patients, whereas the task force of EULAR only consisted of physicians, predominantly rheumatologists. However, this is not quite true as at least one member of the EULAR task force - Kathy Longley - was a patient and researcher, not a rheumatologist.

APS and AWMF ascribed the highest level of evidence to systematic reviews and meta-analyses, whereas EULAR credited the highest level of evidence to randomised controlled studies. ¹

According to the review, both APS and AWMF assigned the highest level of recommendation to aerobic exercise, cognitive-behavioral therapy, amitriptyline, and multicomponent treatment, whilst EULAR assigned the highest level of recommendation to a set of pharmacological treatments. Plus, although there was some consistency in the recommendations regarding pharmacological treatments among the three guidelines, the APS and AWMF guidelines assigned higher ratings to CBT and multicomponent treatments. ¹ Whilst this is true, it is worth noting that the EULAR guideline does include:

"Optimal treatment of FMS mandates a multidisciplinary approach, which should include a combination of nonpharmacologic and pharmacologic interventions." ³

The EULAR Guidelines also include a number of specific recommendations on nonpharmacologic (non-medication) approaches.

The review authors note that:

"The inconsistencies across guidelines are likely attributable to the criteria used for study inclusion, weighting systems, and composition of the panels."

References:

Häuser W, Thieme K, Turk DC. Guidelines on the management of fibromyalgia syndrome - A systematic review. Eur J Pain. 2009 Mar 3. [Epub ahead of print]
Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17;292(19):2388-95.
Carville SF et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008 Apr;67(4):536-41. Epub 2007 Jul 20. Review.
Eich W, Häuser W, Friedel E, Klement A, Herrmann M, Petzke F, Offenbächer M, Schiltenwolf M, Sommer C, Tölle T, Henningsen P. [Definition, classification and diagnosis of fibromyalgia syndrome] [Article in German] Schmerz. 2008 Jun;22(3):255-66.

Intravenous lidocaine for Fibromyalgia Syndrome

Mon, 23 Mar 2009 12:00:00 +0000

A recent study has found that intravenous lidocaine infusions are safe and effective in the management of Fibromyalgia Syndrome. ¹

The study aimed to investigate the effect of intravenous infusions of lidocaine on both pain and quality of life of patients with Fibromyalgia Syndrome (Fibro).

Twenty-three Fibro patients took part in the study, and received 5 intravenous infusions, one a day for 5 days, of a 2% lidocaine solution. The dosages of lidocaine given in the infusion were increased over the 5 day period from 2mg per kilogram bodyweight to 5mg per kilogram of bodyweight.

Fibromyalgia Impact Questionnaire (FIQ), Health Assessment Questionnaire, and a visual pain analog scale (VAS) were used to measure the pain levels and quality if life of the patients. These assessments were carried out before the first lidocaine infusion, immediately after the fifth infusion and 30 days after the fifth infusion.

A significant improvement was observed in the FIQ scores after the fifth infusion, with FIQ scores dropping from 73.52 (out of 100) +/- 16.56 to 63.29 +/- 21.21 (p = 0.02). This improvement was maintained after 30 days, when the FIQ scores were 63.85 +/- 24.59 (p = 0.04). Similar results were seen with the VAS scores, which dropped from 8.19 (on a 0 to 10 scale) +/- 1.76 to 6.84 +/- 2.44 (p = 0.01) after the fifth infusion and remained lower than before the infusions, 30 days after the fifth infusion, when the VAS scores were 7.17 +/- 2.35 (p = 0.05). ¹

The researchers concluded that:

"Intravenous lidocaine infusions are safe and effective in the management of fibromyalgia." ¹

It should be noted that this was not a placebo controlled trial, so some of the beneficial effect seen may be due to a placebo effect.

References:

Schafranski MD, Malucelli T, Machado F, Takeshi H, Kaiber F, Schmidt C, Harth F. Intravenous lidocaine for fibromyalgia syndrome: an open trial. Clin Rheumatol. 2009 Mar 5. [Epub ahead of print]

Decreased corneal sensitivity and tear production in Fibromyalgia Syndrome

Tue, 31 Mar 2009 12:00:00 +0100

A recent study by researchers in Spain has shown that people with Fibromyalgia Syndrome suffer from dry eyes, with decreased corneal sensitivity to a number of stimuli. ¹

The aim of the study was to investigate corneal sensitivity various stimuli in Fibromyalgia Syndrome (Fibro) patients.

Twenty Fibro patients and 18 control subjects participated in the study. Of the Fibro patients, 18 were female and 2 male, with an average age of 51.9 years old +/- 2.3 years. Of the control subjects, 16 were female and 2 male, with an average age of 51.7 years old +/- 2.4 years old.

Subjective symptoms of ocular dryness were explored and Schirmer's 1 test (where tear production is measured using paper test strips) was performed. The response to selective stimulation of the central cornea with the Belmonte gas esthesiometer was measured.

The majority (18 out of 20) of the Fibro patients reported dry eye symptoms, with the ocular dryness score being significantly higher than in healthy subjects (2.3 +/-0.1 vs. 0.05 +/-0/02; p<0.001). ¹

Schirmer's test values were significantly reduced in the Fibro patients compared to those of the control group (10.5 +/- 0.2 mm and 30.6 +/- 1.6 mm, respectively; p<0.001). ¹

The Fibro patients were found to have a raised average threshold of corneal sensitivity (so decreased sensitivity) to chemical stimulation (31.16 +/- 2.04 % CO2 vs. 15.72 +/- 0.67 % CO2 for controls), heating (1.87 +/- 0.11 degrees C vs. 0.99 +/- 0.05 degrees C for controls) and cooling (-2.53 +/- 0.11 degrees C vs. -0.76 +/- 0.05 degrees C for controls). The threshold to mechanical stimulation did not vary significantly for Fibro patients (123.0 +/- 8.0 ml/min vs. 107.8 +/- 4.4 ml/min for controls). ¹

The researchers concluded that:

"The reduced corneal sensitivity of patients with fibromyalgia is attributable to a moderate decrease of corneal polymodal and cold nociceptor sensitivity, that may be the consequence or the cause of the chronic reduction in tear secretion also observed in these patients." ¹

References:

Gallar J, Morales C, Freire V, Acosta MC, Belmonte C, Duran JA. Decreased corneal sensitivity and tear production in fibromyalgia. Invest Ophthalmol Vis Sci. 2009 Mar 25. [Epub ahead of print]

Health related Internet use by patients

Tue, 31 Mar 2009 01:00:00 +0100

A recent study by Dutch researchers has found that, although about half of patients use the internet for health-related reasons, this is mostly restricted to seeking information about their condition and use of online patient support groups isn't common. ¹

The aim of the study was to explore the percentage of Dutch patients using the Internet to search for information about their illness. In addition, the researchers studied patients' usage of health-related Internet applications, such as online patient support groups, and explored which demographic, health and psychological characteristics were related to patients' health-related Internet use.

For the study, a written questionnaire was sent to a representative sample of around 1,000 patients with breast cancer, rheumatoid arthritis and Fibromyalgia Syndrome. The overall total response rate was 69% (N = 679).

In total, 52% of the patients used the Internet to search for information about their illness. However, only 15% of the respondents had ever read posts from an online patient support group. An even smaller proportion of the patients (4%) had themselves posted messages to such a group. Online communication with health professionals was not commonly practiced. ¹

A younger age, a higher education and employment appeared to be the only significant predictors of patients' health-related Internet use. Patients' health-related Internet use could not be predicted by health and psychological characteristics. ¹

The article concluded that:

"Although, about half of the patients made use of the Internet for health-related reasons, mostly their health-related Internet use was restricted to seeking information about their illness." ¹

According to another study by Dutch researchers, that was published last year, if you go to an online support group but "lurk" rather than participating, it may be preventing you from getting the most benefit out of the group. However, just reading posts ("lurking") is sufficient to profit from participation in an online patient support group. ²

References:

van Uden-Kraan CF, Drossaert CH, Taal E, Smit WM, Moens HB, Siesling S, Seydel ER, van de Laar MA. Health-related Internet use by patients with somatic diseases: Frequency of use and characteristics of users. Inform Health Soc Care. 2009 Jan;34(1):18-29.
van Uden-Kraan CF, Drossaert CH, Taal E, Seydel ER, van de Laar MA. Self-reported differences in empowerment between lurkers and posters in online patient support groups. J Med Internet Res. 2008 Jun 30;10(2):e18.

Sleep Apnoea can cause Fibromyalgia Syndrome type symptoms in partners

Wed, 01 Apr 2009 12:00:00 +0100

A recent study by researchers in Brazil has shown that the partners of men with sleep apnoea are at risk of developing disturbed sleep and symptoms of Fibromyalgia Syndrome. ¹

Obstructive sleep apnea (OSA) has been recognised as be a distressing experience to the female partners of OSA patients, but the reason for this remains controversial. Furthermore, a growing body of evidence supports a relationship of distress and sleep disruptions with musculoskeletal pain, also prevalent in middle-aged women.

To test the hypothesis that sharing a bed with an OSA man may contribute to manifestations of distress and impaired sleep, the researchers carried out a case-controlled study of 17 women whose husbands had OSA and 17 women whose husbands were healthy sleepers.

The Fibromyalgia Impact Questionnaire (FIQ) and visual analog scales (VAS), tender point (TP) count and algometric index (a measure of pain pressure threshold) were used to measure pain, tenderness and function. Sleep quality was measured using VAS scores for sleep quality and polysomnographic (PSG) parameters. Other outcome measures used were VAS scores for distress and marital relationship and coping strategies adopted by OSA wives. The clinical assessment and PSG scoring were conducted blindly, with the examiners not knowing who had an OSA partner and who didn't.

The researchers found that, after controlling for age and menopausal status, OSA wives exhibited lower sleep quality and higher distress scores than controls. ¹

Increase in pain threshold (TP count and algometric index) and in FIQ score were also observed, and in their PSG, there was an increase in awaken period and stage 1 amount during sleep, as well as in alpha power during slow wave sleep (where a burst of fast brainwaves disrupts the slow brainwaves of deep sleep). These sleep parameters had substantial correlation with tiredness and poor sleep quality and were moderately correlated to pain assessments and distress scores. ¹

In other words, the women whose partners had OSA showed more signs of Fibromyalgia Syndrome, including disrupted sleep patterns typical of the condition.

The researchers concluded that:

"Thus, independently of age and menopausal status of the group, wives of OSA patients exhibited an increase in pain threshold, distress and impaired sleep in comparison to controls." ¹

References:

Smith AK, Togeiro SM, Tufik S, Roizenblatt S. Disturbed sleep and musculoskeletal pain in the bed partner of patients with obstructive sleep apnea. Sleep Med. 2009 Mar 18. [Epub ahead of print]

Use of complementary and alternative medicine among patients with Arthritis or Fibromyalgia Syndrome

Thu, 02 Apr 2009 12:00:00 +0100

A recent study has found that patients with Fibromyalgia Syndrome use Complementary and Alternative Medicine more often than patients with Rheumatoid Arthritis, Osteoarthritis, or chronic joint symptoms. ¹

The article notes that previous studies suggest that people with various forms of Arthritis and Fibromyalgia Syndrome have high rates of using complementary and alternative medicine (CAM) approaches for managing their symptoms, in addition to conventional treatments such as prescription medications. However, little is known about the use of CAM by diagnosis, or which forms of CAM are most frequently used by these patients.

This study was designed to provide detailed information about use of CAM for symptoms associated with various forms of Arthritis or Fibromyalgia Syndrome in patients followed in primary care and specialty clinics in North Carolina, USA.

Over 2,000 patients from both primary care (n = 1,077) and specialist (n = 1,063) physician offices took part in the study.

Summary statistics were used to calculate differences within and between diagnostic groups, practice settings, and other characteristics. Logistic regression models clustered at the site level were used to determine the effect of patient characteristics on ever and current use of 9 CAM categories and an overall category of "any use."

The researchers found that most of the participants followed by specialists (90.5%) and a slightly smaller percentage of those in the primary care sample (82.8%) had tried at least 1 complementary therapy for Arthritis or Fibromyalgia symptoms. ¹

Participants with Fibromyalgia Syndrome used complementary therapies more often than those with Rheumatoid Arthritis, Osteoarthritis, or chronic joint symptoms. More than 50% of patients in both samples used over-the-counter topical pain relievers, more than 25% used meditation or drew on religious or spiritual beliefs, and more than 19% used a chiropractor. ¹

Women and participants with higher levels of education were more likely to report current use of alternative therapies. ¹

The researchers concluded that:

"Most arthritis patients in both primary care and specialty settings have used CAM for their...symptoms. Health care providers (especially musculoskeletal specialists) should discuss these therapies with all arthritis patients." ¹

References:

Callahan LF, Wiley-Exley EK, Mielenz TJ, Brady TJ, Xiao C, Currey SS, Sleath BL, Sloane PD, DeVellis RF, Sniezek J. Use of complementary and alternative medicine among patients with arthritis. Prev Chronic Dis. 2009 Apr;6(2):A44. Epub 2009 Mar 16.

Low levels of antioxidant vitamins in plasma of patients with Fibromyalgia Syndrome

Thu, 02 Apr 2009 12:00:00 +0100

A recent study has found that the concentrations of vitamins A and E in the blood plasma of patients with Fibromyalgia Syndrome are significantly lower than in healthy controls. ¹

The aim of the study by a team of researchers in Turkey was to investigate plasma antioxidant vitamins, lipid peroxidation (LP), and nitric oxide (NO) levels in patients with Fibromyalgia Syndrome and controls.

The study was performed on the blood plasma of 30 female patients and 30 age-matched controls.

After a fast of 12 hours, blood samples were taken, and plasma samples were obtained for measurement of vitamins A, C, E, and beta-carotene concentrations and levels of LP and NO.

The researchers found that concentrations of vitamins A (p < 0.01) and E (p < 0.001) were significantly lower in patients with Fibromyalgia Syndrome than in controls, and LP levels were significantly (p < 0.05) higher in the plasma of the patients than in controls. Concentrations of vitamin C and beta-carotene and levels of NO did not change significantly. ¹

The researchers concluded that:

"These results provide some evidence for a potential role of LP and fat-soluble antioxidants in the patients with [Fibromyalgia Syndrome]." ¹

References:

Akkuş S, Nazıroğlu M, Eriş S, Yalman K, Yılmaz N, Yener M. Levels of lipid peroxidation, nitric oxide, and antioxidant vitamins in plasma of patients with fibromyalgia. Cell Biochem Funct. 2009 Mar 24. [Epub ahead of print]

Problems experienced by people with Arthritis and Fibro when using a computer

Wed, 29 Apr 2009 12:00:00 +0100

A team of researchers from the University of Pittsburgh, USA have have found that people with people with Fibromyalgia Syndrome have more problems with computer use than people with Osteoarthritis or Rheumatoid Arthritis.

They carried out a study, which aimed to describe the prevalence of computer use problems experienced by a sample of people with arthritis (including Fibromyalgia Syndrome), and to determine anu differences in the magnitude of these problems among people with Rheumatoid Arthritis (RA), Osteoarthritis (OA), and Fibromyalgia Syndrome (Fibro).

Study participants were recruited from the Arthritis Network Disease Registry and asked to complete a survey, the Computer Problems Survey, which was developed for this study.

Descriptive statistics were calculated for the total sample and the 3 diagnostic subgroups (RA, OA and Fibro). Ordinal regressions were used to determine differences between the diagnostic subgroups with respect to each equipment item while controlling for confounding demographic variables. In other words, they checked to see whether one of the patient groups (Oa, RA or Fibro) had more issues with 4 specific items of equipment: the chair, keyboard, mouse, and monitor.

A total of 359 respondents completed a survey, of which 315 reported using a computer. Of these, 84% reported a problem with computer use attributed to their underlying disorder, and approximately 77% reported some discomfort related to computer use. ¹

Equipment items most likely to account for problems and discomfort were the chair, keyboard, mouse, and monitor.

Of the 3 subgroups,significantly more respondents with FM reported more severe discomfort, more problems, and greater limitations related to computer use than those with RA or OA for all 4 equipment items.

The article concludes that:

"Computer use is significantly affected by arthritis [including Fibromyalgia Syndrome]. This could limit the ability of a person with arthritis to participate in work and home activities. Further study is warranted to delineate disease-related limitations and develop interventions to reduce them." ¹

References:

Baker NA, Rogers JC, Rubinstein EN, Allaire SH, Wasko MC. Problems experienced by people with arthritis when using a computer. Arthritis Rheum. 2009 Apr 29;61(5):614-622. [Epub ahead of print]

Changes in Gray Matter Density in Fibromyalgia Correlate with Changes in Dopamine Metabolism

Wed, 22 Apr 2009 12:00:00 +0100

An article has been e-published ahead of print in the Journal of Pain linking Fibromyalgia Syndrome with changes in the brain and suggesting that alterations in dopamine metabolism may contribute to these changes.

The work was carried out by a team of researchers at Louisiana State University Health Sciences Center, including Dr Patrick Wood, a member of FibroAction's Professional Advisory Board and the originator of the Dopamine Theory of Fibromyalgia.

The article notes that Fibromyalgia Syndrome has been associated with alterations in brain morphometry (i.e. changes in the brain) and abnormal dopaminergic neurotransmission. Also, evidence from preclinical models has demonstrated that dopamine plays a role in promoting neuronal integrity. The team of researchers sought to confirm previous findings of reduced gray matter density in subjects with Fibromyalgia Syndrome and to determine whether variations in dopamine metabolism might affect gray matter density.

Voxel-based morphometry was used to evaluate anatomical magnetic resonance imaging data from 30 female FM subjects in comparison with 20 age- and gender-matched healthy control subjects.

In addition, data from a subset of subjects from both groups who had previously participated in a positron emission tomography study using radiolabeled DOPA (n = 14; 6 Fibromyalgia Syndrome subjects and 8 control subjects) was used to determine whether correlation might exist between gray matter density and dopamine metabolism.

The researchers found a significant reduction in gray matter density within certain areas of the brain: the bilateral parahippocampal gyri, right posterior cingulate cortex, and left anterior cingulate cortex. In addition, a positive correlation was demonstrated between an index of dopamine metabolism from the ventral tegmental area wherein cell bodies of corticolimbic projection neurons originate and gray matter density, specifically in the bilateral parahippocampal gyri and left pregenual cortex.

The article notes that:

"The current results confirm our previous findings that [Fibromyalgia Syndrome] is associated with altered brain morphometry. Alterations in dopamine metabolism might contribute to the associated changes in gray matter density."

Perspective

Fibromyalgia is associated with reductions in gray matter density within brain regions ostensibly involved in phenomena related to the disorder, including enhanced pain perception, cognitive dysfunction, and abnormal stress reactivity. Given mounting evidence of abnormal dopaminergic neurotransmission associated with the disorder, the strong correlation between dopamine metabolism and gray matter density provides insight as to the pathophysiology that might contribute to these changes.

Dr Wood features on the DVD'Fibromyalgia: Show Me Where It Hurts' discussing the Dopamine Theory of Fibromyalgia. This DVD will shortly be available through FibroAction. Please check back soon if you are interested in seeing this.

To read the full article, please click here.

References:

Wood PB, Glabus MF, Simpson R, Patterson JC 2nd. Changes in Gray Matter Density in Fibromyalgia: Correlation With Dopamine Metabolism. J Pain. 2009 Apr 22. [Epub ahead of print]

Executive function and decision making in women with Fibromyalgia Syndrome

Wed, 22 Apr 2009 12:00:00 +0100

A study by researchers in Spain has shown that the cognitive difficulties suffered by women with Fibromyalgia Syndrome impact on their neuropsychological performance.

The researchers note that patients with Fibromyalgia Syndrome (Fibro) typically report cognitive problems that are disturbing in everyday life. Despite these substantial subjective complaints by Fibro patients, very few studies have addressed objectively the effect of such problems on neuropsychological performance.

The study aimed to examine possible impairment of executive function and decision-making in a sample of 36 women diagnosed with Fibro and 36 healthy women matched in age, education, and socio-economic status.

For the study, the researchers contrasted performance of both groups on two measures of executive functioning: the Wisconsin Card Sorting Test (WCST), which assesses cognitive flexibility skills, and the Iowa Gambling Tasks (IGT; original and variant versions), which assess emotion-based decision-making.

The researchers also examined the relationship between executive function performance and pain experience, and between executive function and personality traits of novelty-seeking, harm avoidance, reward dependence, and persistence (measured by the Temperament and Character Inventory-Revised).

Results showed that on the WCST, the women with Fibro showed poorer performance than healthy comparison women on the number of categories and non-perseverative errors, but not on perseverative errors.

The Fibro patients also showed an altered learning curve in the original IGT (where reward is immediate and punishment is delayed), suggesting compromised emotion-based decision-making; but not in the variant IGT (where punishment is immediate but reward is delayed), suggesting hypersensitivity to reward. Personality variables were very mildly associated with cognitive performance in FM women

In summary, the women with Fibro had reduced cognitive flexibility compared to the healthy controls, and also had compromised emotion-based decision-making.

References:

Verdejo-García A, López-Torrecillas F, Calandre EP, Delgado-Rodríguez A, Bechara A. Executive function and decision-making in women with fibromyalgia. Arch Clin Neuropsychol. 2009 Feb;24(1):113-22. Epub 2009 Mar 11.

Traditional Chinese Acupuncture affects mu Opioid Receptors differently to Sham Acupuncture

Mon, 15 Jun 2009 12:00:00 +0100

A team of researchers at the University of Michigan, including FibroAction Professional Advisory Board member, Daniel Clauw MD, have used Positron emission tomography to determine that traditional chinese acupuncture activates certain pain relieving systems in the body better than sham acupuncture.

Controversy remains regarding the mechanisms of acupuncture analgesia or pain relief. A prevailing theory, largely unproven in humans, is that it involves the activation of endogenous opioid antinociceptive systems and mu-opioid receptors - i.e. the body's natural pain-killing mechanisms. This is also a neurotransmitter system that mediates the effects of placebo-induced analgesia. This overlap in potential mechanisms may explain the lack of differentiation between traditional acupuncture and either non-traditional or sham acupuncture in multiple controlled clinical trials. In other words, the systems that acupuncture activates to relieve pain are the same systems activated by the placebo effect of pain relief, which would explain why it is so hard to prove that traditional chinese acupuncture works better than the placebo of sham acupuncture.

The researchers compared both short-and long-term effects of traditional Chinese acupuncture versus sham acupuncture treatment on the binding availability of mu-opioid receptors in chronic pain patients diagnosed with fibromyalgia syndrome.

Patients were randomized to receive either traditional Chinese acupuncture or sham acupuncture treatment over the course of four weeks.

Positron emission tomography (PET) with (11)C-carfentanil was performed once during the first treatment session and then repeated a month later following the eighth treatment.

The researchers found that acupuncture therapy evoked short-term increases in mu-opioid receptor binding potential, in multiple pain and sensory processing regions including the cingulate (dorsal and subgenual), insula, caudate, thalamus, and amygdala. Acupuncture therapy also evoked long-term increases in mu-opioid receptor binding potential in some of the same structures including the cingulate (dorsal and perigenual), caudate, and amygdala.

These short-and long-term effects were absent in the sham group where small reductions were observed, an effect more consistent with previous placebo PET studies.

Long-term increases in mu-Opioid receptor binding potential following traditional Chinese acupuncture were also associated with greater reductions in clinical pain.

In conclusion:

"These findings suggest that divergent [mu-Opioid receptor] processes may mediate clinically relevant analgesic effects for acupuncture and sham acupuncture."

References:

Harris RE, Zubieta JK, Scott DJ, Napadow V, Gracely RH, Clauw DJ. Traditional Chinese Acupuncture and Placebo (Sham) Acupuncture Are Differentiated by Their Effects on mu-Opioid Receptors (MORs). Neuroimage. 2009 Jun 4. [Epub ahead of print]

Fibromyalgia Syndrome Patients Newly Prescribed Gabapentin or Pregabalin

Tue, 16 Jun 2009 12:00:00 +0100

A study, e-published ahead of print in Pain Practice, the official journal of the World Institute of Pain, has found that Fibromyalgia Syndrome patients newly prescribed with either pregabalin or gabapentin tend to have an increase in the cost of their healthcare.

The study aimed to characterise comorbidities, pain-related pharmacotherapy, and healthcare resource use among patients with Fibromyalgia Syndrome (Fibro) newly prescribed pregabalin or gabapentin in clinical practice.

Using the PharMetrics Database, Fibro patients who had been newly prescribed pregabalin and gabapentin on or after July 1, 2007 were identified. There were 1,606 patients newly prescribed pregabalin, of which 87.9% were female, with an average age of 49.9 years +/- 9.6 years. And there were 930 patients newly prescribed gabapentin, of which 86.6% were female, with an average age of 49.5 years +/- 9.6 years.

Prevalence of comorbidities, pharmacotherapy, and healthcare resource use/costs (pharmacy, outpatient, inpatient, total) were examined during the 6 months preceding (preindex) and following (postindex) the date of their first pregabalin or gabapentin (index) prescription.

The study found that patients in both groups had a variety of comorbidities and used multiple medications.

There were significant decreases in the use of nonsteroidal anti-inflammatory drugs (32.1% vs. 29.5%), anticonvulsants (27.0% vs. 22.0%), and combination therapies in the pregabalin group in the postindex period.

However there were significant increases in the use of short-acting opioids (58.8% vs. 63.7%), any opioids (61.5% vs. 65.6%), serotonin-norepinephrine reuptake inhibitors (22.5% vs. 24.5%), anticonvulsants (16.3% vs. 26.2%), benzodiazepines (33.2% vs. 36.6%), topical agents (6.6% vs. 9.0%), and combination therapies in the gabapentin group.

Although there were no changes in units of healthcare resources used, there were increases in the postindex period in hospitalization, medications, and total costs for the pregabalin group, and in office visits and medication costs for the gabapentin group.

In conclusion:

"Results suggest a high comorbidity and medication use burden in [Fibro] patients in this study. Further evaluation is warranted to clarify differences in resource utilization/costs observed with these two anticonvulsants. "

References:

Gore M, Sadosky AB, Zlateva G, Clauw DJ. Clinical Characteristics, Pharmacotherapy and Healthcare Resource Use among Patients with Fibromyalgia Newly Prescribed Gabapentin or Pregabalin. Pain Pract. 2009 Jun 4. [Epub ahead of print]

Prevalence of Fibromyalgia Syndrome in low socioeconomic status population

Mon, 08 Jun 2009 12:00:00 +0100

A study in Brazil has found that Fibromyalgia Syndrome is prevalent in a low socioeconomic status population and that prevalanece is similar to that in a more diverse population.

The aim of the study was to estimate the prevalence of Fibromyalgia Syndrome, as well as to assess the major symptoms of this syndrome in an adult, low socioeconomic status population assisted by the primary health care system in a city in Brazil.

The researchers cross-sectionally sampled 768 individuals assisted by the public primary health care system, with an age range of 35-60 years old. Participants were interviewed by phone and screened about pain. They were then invited to be clinically assessed and 304 accepted.

Pain was estimated using a Visual Analogue Scale (VAS) and Fibromyalgia Syndrome was assessed using the Fibromyalgia Impact Questionnaire (FIQ), as well as screening for tender points using dolorimetry.

From the phone-interview screening, the researchers divided the participants into three groups: No Pain (NP), Regional Pain (RP) and Widespread Pain (WP). Of the 768 participants, 185 were in the NP group, 388 were in the RP group and 106 were in the WP group.

Among the 304 participants taking part in the clinical assessments, the prevalence of Fibromyalgia Syndrome was 4.4% (95% confidence interval [2.6%; 6.3%]).

The researchers also found that the symptoms of pain (VAS and FIQ), feeling well, job ability, fatigue, morning tiredness, stiffness, anxiety and depression were statically different among the groups.

Analysis also showed that the individuals with Fibromyalgia Syndrome and WP had significantly higher levels of impairment than those with RP and NP. Fibromyalgia Syndrome and WP (not Fibromyalgia Syndrome) were similarly disabling.

In conclusion:

"Fibromyalgia [Syndrome] is prevalent in the low socioeconomic status population assisted by the public primary health care system. Prevalence was similar to other studies (4.4%) in a more diverse socioeconomic population. Individuals with [Fibromyalgia Syndrome] and WP have significant impact in their well being."

References:

Assumpcao A, Cavalcante AB, Capela CE, Sauer JF, Chalot SD, Pereira CA, Marques AP. Prevalence of fibromyalgia in low socioeconomic status population. BMC Musculoskelet Disord. 2009 Jun 8;10(1):64. [Epub ahead of print]

A Study of Sickness Absence and Transition to Disability Pension in Norway

Tue, 16 Jun 2009 12:00:00 +0100

A Norwegian study has found that age, diagnoses, and socioeconomic variables were important predictors of an adverse outcome among workers with a sickness absence of 8 or more weeks.

The aim of the population-based, 5-year study was to assess the incidence of musculoskeletal disorders (MSDs) in sickness absence longer than 8 weeks in Norway, and to identify diagnostic and socioeconomic predictors of the transition to disability pension.

For the study, 37,942 females and 26,307 males with an episode of sickness absence of greater than 8 weeks in 1997, who were diagnosed with a certified with a musculoskeletal disorder were followed up for 5 years.

Diagnostic and sociodemographic data were obtained from a national database. The cases were divided into 9 diagnostic subgroups, based on the International Classification of Primary Health Care, including:

fractures & injuries;
upper limb problems;
back problems;
osteoarthrosis;
myalgia/fibromyalgia;
rheumatoid arthritis.

Overall, 20% of cases obtained disability pension during the follow-up.

Among those aged 50 to 62, and among those with only basic education, 46% obtained the disability pension.

The proportion of cases in each diagnostic subgroup obtaining disability pension was highest for osteoarthrosis (47%), rheumatoid arthritis (46%), and myalgia/fibromyalgia (38%). Fractures/injuries had the lowest rate.

Controlled for age, education and income, the relative risk of getting disability pension was:

1.0 for fractures & injuries;
1.5 for upper limb problems;
2.0 for back problems;
2.8 for osteoarthrosis;
3.3 for myalgia/fibromyalgia;
4.2 for rheumatoid arthritis.

In conclusion:

"Age, diagnoses, and socioeconomic variables were important predictors of an adverse outcome among workers with a sickness absence of 8 or more weeks."

Further research is needed to determine whether differentiated follow-up strategies might prevent permanent disability.

References:

Gjesdal S, Bratberg E, Mæland JG. Musculoskeletal Impairments in the Norwegian Working Population: The Prognostic Role of Diagnoses and Socioeconomic Status: A Prospective Study of Sickness Absence and Transition to Disability Pension. Spine. 2009 Jun 15;34(14):1519-1525.

fMRI in Fibromyalgia Syndrome and the response to milnacipran

Tue, 16 Jun 2009 12:00:00 +0100

A scientist from Pierre Fabre has used Functional magnetic resonance imagery to show that Fibromyalgia Syndrome patients treated with milnacipran exhibit a reduction in pain sensitivity and a parallel increase in activity in brain regions implicated in the descending pain inhibitory pathways .

Pharmaceutical firm Pierre Fabre originally developed milnacipran and sells the medication outside the United States. In the US, Milnacipran is marketed as Savella by Cypress Bioscience and Forest Laboratories. Savella was approved as a treatment for Fibromyalgia Syndrome by the American Food & Drug Administration (FDA) in January 2009 and was made available commercially in the US as a treatment for Fibromyalgia Syndrome at the end of April 2009.

Functional imaging has been used to study the response to pain in Fibromyalgia Syndrome (Fibro) patients. Functional magnetic resonance imagery (fMRI), which tracks local changes in blood flow, has a higher spatial and temporal resolution than other techniques such as positron emission tomography (PET) or single-photon emission tomography (SPECT). The speed of fMRI machines allow them to be used to track changes in real time, rather than taking a static snapshot, as with conventional MRI.

fMRI studies in Fibro patients suggest that similar levels of subjective pain result in similar central nervous system (CNS) activation in both Fibro patients and controls. For a similar stimulus, however, Fibro patients have a greater subjective sensation of pain.

This increased sensitivity is accompanied with a decreased activity in brain regions implicated in the descending pain inhibitory pathways, which would usually work to dampen pain signals.

The hypothesis that increased sensitivity to pain is due to decreased activity of the descending inhibitory pathways is supported by results with milnacipran. As a serotonin and noradrenaline reuptake inhibitor, milnacipran boosts levels of the neurotransmitters - serotonin & norepinephrine - involved in the descending inhibitory pain pathways.

Using fMRI, the study found that Fibro patients treated with milnacipran exhibited a reduction in pain sensitivity and a parallel increase in activity in brain regions implicated in the descending pain inhibitory pathways compared to placebo-treated patients.

References:

Mainguy Y. Functional magnetic resonance imagery (fMRI) in fibromyalgia and the response to milnacipran. Hum Psychopharmacol. 2009 Jun;24 Suppl 1:S19-23.

Pain relief through expectation in Fibromyalgia Syndrome patients

Thu, 11 Jun 2009 12:00:00 +0100

A team of Canadian researchers have found that, although positive expectations can affect the pain signals of people with Fibromyalgia Syndrome, they does not do so by influencing spinal activity in the same way as in healthy individuals.

In healthy adults, expectations can modulate pain signals, with an expectation of analgesia or pain-relief triggering descending inhibition, a response that mediates pain signals.

Since descending inhibition is known to be deficient in Fibromyalgia Syndrome patients, the researchers tested the possibility that expectancy-mediated analgesia would improve, or even kick-start, the deficient inhibitory responses of Fibromyalgia Syndrome patients.

By measuring subjective pain ratings, spinal withdrawal reflexes, and somatosensory evoked potentials (SEP), it was possible to test whether or not expectancy-mediated analgesia involved descending inhibition in Fibromyalgia Syndrome patients.

The researchers found that expectations of analgesia reduced subjective pain ratings and decreased SEP amplitudes, confirming that expectations influence thalamocortical processes.

However, even when analgesia was experienced, the spinal activity of Fibromyalgia Syndrome patients was abnormal, showing heightened reflex responses.

This demonstrates that, unlike with healthy subjects, the modulation of pain by expectations in people with Fibromyalgia Syndrome fails to influence spinal activity.

These results indicate that people with Fibromyalgia Syndrome are capable of expectancy-induced analgesia but that, for them, this form of analgesia does not depend on the recruitment of descending inhibitory projections.

References:

Goffaux P, de Souza JB, Potvin S, Marchand S. Pain relief through expectation supersedes descending inhibitory deficits in fibromyalgia patients. Pain. 2009 Jun 11. [Epub ahead of print]

The Psychiatrist confronted with a Fibromyalgia Syndrome patient

Wed, 17 Jun 2009 12:00:00 +0100

A psychiatrist at the Medical University of Vienna, Austria has written an article concluding that psychiatrists are well placed to initiate treatment for Fibromyalgia Syndrome patients they encounter, as the treatment of Fibromyalgia Syndrome involves a multidisciplinary approach and the use of medications that are typically well known to psychiatrists.¹

The author notes that Fibromyalgia Syndrome (Fibro) is usually treated by rheumatologists but since co-morbid depression and anxiety are frequently found, psychiatrists are likely to be confronted with patients suffering from the syndrome.

The symptoms associated with Fibro vary from patient to patient but there is one common symptom - they ache all over. In addition to pain, patients report headaches, poor sleep, fatigue, depressed mood and irregular bowel habits, which are also all also symptoms of depression. For a formal diagnosis of Fibro, the American College of Rheumatology (ACR) criteria require the patient to have widespread pain for at least 3 months together with tenderness at 11 or more of 18 specific tender points.

The article notes that treatment of Fibro requires a comprehensive approach involving education, aerobic exercise and cognitive behavioural therapy in addition to pharmacotherapy. Psychiatrists are accustomed to initiating this kind of treatment for their patients who only have mental health issues.

Some of the most effective drugs available for the treatment for Fibro, such as the serotonin noradrenaline reuptake inhibitors (SNRIs), milnacipran and duloxetine, and the anti-epileptic, pregabalin, are well known to psychiatrists.

The article therefore concludes:

"Thus the psychiatrist is well placed to initiate treatment in these patients."

It could be noted here that neurologists would be even better placed to initiate treatment of Fibro. However, not many neurologist realise how much they would already know about the processes and treatments involved with Fibro.

References:

Kasper S. The psychiatrist confronted with a fibromyalgia patient. Hum Psychopharmacol. 2009 Jun;24 Suppl 1:S25-30.

Relationships between Fibromyalgia Syndrome impact and muscle strength

Mon, 15 Jun 2009 12:00:00 +0100

A study, recently published in the journal Arthritis and Rheumatism, has found that more than half of Fibromyalgia Syndrome patients had significantly reduced knee muscle strength, but that muscle strength was not was not an indicator of how severe their Fibro was.

The aim of the study was to test the hypothesis that Fibromyalgia Syndrome (Fibro) patients with reduced lower extremity strength are more symptomatic and tender than Fibro patients with normal muscle strength.¹

For the study, a total of 840 Fibro patients and 122 healthy subjects were evaluated between 1998 and 2005.

All of the patients completed version 1 of the Fibromyalgia Impact Questionnaire (FIQ) and were assessed for tender points and knee muscle strength. All subjects underwent bilateral isokinetic knee muscle strength testing in flexion and extension.

Normative knee muscle strength values were calculated from the healthy subjects, and the Fibro patient group was divided in 2 groups: 1) patients with normal muscle strength and 2) patients with low muscle strength (2 SDs below normal). The clinical characteristics of these 2 groups were compared.

Significantly reduced knee muscle strength was found in 52% of the patients.¹

The researchers found that there were no clinically significant differences between patients with low versus normal muscle strength.¹

They also found that there were no clinically significant correlations between total FIQ score, tender point count, and muscle strength. Only 4.6% of the FIQ scores and 5.1% of the tender point counts could possibly be explained by muscle strength.¹

In conclusion:

"Significantly reduced knee muscle strength was found in more than half of the patients. Patients with subnormal muscle strength were not more symptomatic or tender than patients with normal muscle strength. There were no clinically significant correlations between FIQ, tender point count, and muscle strength; therefore, reduced knee muscle strength appears to be a common objective abnormality in [Fibromyalgia Syndrome] that is independent of measurements of disease activity. The implication of this finding in regard to the clinical assessment of [Fibromyalgia Syndrome] needs further study."

References:

Henriksen M, Lund H, Christensen R, Jespersen A, Dreyer L, Bennett RM, Danneskiold-Samsøe B, Bliddal H. Relationships between the fibromyalgia impact questionnaire, tender point count, and muscle strength in female patients with fibromyalgia: A cohort study. Arthritis Rheum. 2009 Jun 15;61(6):732-9.

Normalizing memory recall in Fibromyalgia Syndrome with rehearsal

Mon, 15 Jun 2009 12:00:00 +0100

A recently published study has found that patients with Fibromyalgia Syndrome have a significant level of cognitive deficit that could be missed by conventional measures and that rehearsal is a useful tool for Fibro patients to overcome recall difficulties with distraction.

The aim of the study was to examine the impact of distraction on the retention of rehearsed information in patients with Fibromyalgia Syndrome (Fibro).

For the study, a neurocognitive examination was performed on 134 patients presenting with memory loss: 91 with Fibro and 43 control subjects.

Four neurocognitive measures free of distraction, along with 2 measures with added distraction, were completed.

Differences in the retention of rehearsed and unrehearsed information with a source of distraction present were calculated.

The researchers found that patients with Fibro showed normal cognitive functioning on verbal memory tests free of distraction.

However, they also found that adding a source of distraction caused unrefreshed information to be lost at a disproportionate rate in patients with Fibro.

Over 87% of patients with Fibro scored in the impaired range on a task of unrehearsed verbal memory.

But adding a source of distraction to well-rehearsed information produced a normal rate of recall in the Fibro patients.

In conclusion:

"Rehearsal mechanisms are intact in patients with [Fibromyalgia Syndrome] and play beneficial roles in managing interference from a source of distraction.

In the absence of rehearsal, a source of distraction added to unrefreshed information signals a remarkable level of cognitive deficit in [Fibromyalgia Syndrome] that goes undetected by conventionally relied-upon neurocognitive measures.

We present a theory to promote understanding of the cognitive deficit of people with [Fibromyalgia Syndrome] based on reduced speed of lexical activation and poor recall after distraction."

As well as indicating that rehearsal is a useful tool to help Fibro patients deal with the cognitive difficulties associated with condition, this piece of research is interesting because it highlights that conventionally relied-upon neurocognitive measures will often miss significant cognitve difficulties in Fibro patients.

Physicians looking to assess the neurocognitive difficulties of Fibro patients should learn from this study that a wider range of measures than normal will be needed. The neurocognitive difficulties associated with Fibro can be severe and can be very distressing to patients: they should not be underestimated or ignored by physicians.

References:

Leavitt F, Katz RS. Normalizing memory recall in fibromyalgia with rehearsal: A distraction-counteracting effect. Arthritis Rheum. 2009 Jun 15;61(6):740-4.

Depression and pain in patients with Fibromyalgia Syndrome and neuropathic pain

Mon, 25 May 2009 12:00:00 +0100

A team of researchers at the Department of Neurology at the Danish Pain Research Centre carried out a staudy to examine whether the mechanisms associated with mental distress are different between Fibromyalgia Syndrome patients and other chronic pain patients.

Chronic pain is often associated with comorbidities such as anxiety and depression, resulting in a low health-related quality of life. The mechanisms underlying this association are not clear, but a disturbance in the pain control systems from the brain stem has been suggested and this was the hypothesis explored by this study.

Thirty neuropathic pain patients, 28 Fibromyalgia Syndrome patients and 26 pain-free age- and gender-matched controls were included and examined with respect to mental distress (self-rated Symptom Checklist-92), depression (doctor-rated Hamilton Depression Scale and self-rated Major Depression Inventory), and anxiety (doctor-rated Hamilton Anxiety Scale and self-rated Anxiety Inventory).

In addition, patients assessed their health-related quality of life (SF-36).

The researchers found that chronic pain patients with both Fibromyalgia Syndrome and Neuropathic Pain had significantly more mental distress, including depression and anxiety, than healthy controls, both by self-rating and by a professional rating.

However, these scores are low compared to other studies on mental distress in chronic pain patients.

Only a few chronic pain patients in this study met the diagnostic criteria for depression: 3.3% of the Neuropathic Pain patients (1 patient) and 7.1% of the Fibromyalgia Syndrome patients (2 patients).

Associations between pain and mental symptoms were only found in the Fibromyalgia Syndrome group despite similar pain intensities.

The researchers concluded that: "The findings suggest that different mechanisms are responsible for the development of mood disorders in the two patient groups."

However, the small sample sizes used in this study and the very small number of particpants who met the criteria for depression, mean that the study provided little significant data.

References:

Gormsen L, Rosenberg R, Bach FW, Jensen TS. Depression, anxiety, health-related quality of life and pain in patients with chronic fibromyalgia and neuropathic pain. Eur J Pain. 2009 May 25. [Epub ahead of print]

Tegaserod for IBS with constipation improved patients Fibromyalgia Syndrome

Tue, 26 May 2009 12:00:00 +0100

A pilot study of Irritable Bowel Syndrome medication tegaserod (Zelnorm) in Fibromyalgia Syndrome patients has found that their Fibromyalgia Syndrome symptoms were also alleviated.

The symptoms of irritable bowel syndrome (IBS) are commonly seen in Fibromyalgia Syndrome (Fibro) patients. This study aimed to evaluate the effect of a 5-hydroxytryptamin-4 receptor partial agonist (tegaserod) on the symptoms of Fibro among the patients who receive the medicine because of IBS.

Tegaserod works by increasing the action of serotonin in the intestines, which speeds up the movement of stools (bowel movements) through the bowels.

Tegaserod was approved by the American Food and Drug Administration as a medication for the treatment of irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) in young women in 2002. However, this approval was withdrawn in 2007 over safety concerns, with some people voicing concerns that it had been wrongly prescribed: for example, to women suffering from alternating IBS (IBS-A, which is IBS with both constipation and diarrhoea). However, it is available in the US in emergency situations and is available in some other counties.

For this study, 41 female patients with IBS and constipation, which were subjects to tegaserod treatment, were examined by rheumatologist and 14 were found to suffer from Fibromyalgia Syndrome.

The fibromyalgia impact questionnaire (FIQ) and clinical examination were performed before tegaserod treatment and 1 month after.

The researchers found that the IBS status, the total FIQ score, the number of tender points and pain in tender points were lowered significantly after the treatment

In conclusion:

"The results of this pilot study provide the preliminary evidence that [Fibromyalgia Syndrome] patients can benefit from treatment by 5-hydroxytryptamin-4 receptor partial agonist. Additional studies are needed to support this conclusion."

A number of medications that boost the action of serotonin are already used for the treatment of Fibromyalgia Syndrome.

One interesting aspect not addressed by this pilot study is whether the benefit to the Fibromyalgia Syndrome patients comes directly from the medication or from the relief to the patients' IBS symptoms.

References:

Reitblat T, Zamir D, Polishchuck I, Novochatko G, Malnick S, Kalichman L. Patients treated by tegaserod for irritable bowel syndrome with constipation showed significant improvement in fibromyalgia symptoms. A pilot study. Clin Rheumatol. 2009 May 26. [Epub ahead of print]

DRD3 Ser9Gly Polymorphism Related to Thermal Pain Perception and Modulation in Fibromyalgia Syndrome

Fri, 26 Jun 2009 12:00:00 +0100

A study e-published ahead of print in the Journal of Pain has found that genetic polymorphisms of a dopamine receptor appear to influence 2 core features of Fibromyalgia Syndrome.

Experimental studies showed that dopamine influences pain perception in healthy volunteers. Dopamine dysfunctions have been linked to the physiopathology of Fibromyalgia Syndrome (Fibro), which is associated with hyperalgesia and deficient pain inhibition.

In this study, the researchers, from the University of Sherbrooke, Canada, sought to investigate the relationships between catecholamine-related genetic polymorphisms [dopamine-D(3) receptor (DRD3) Ser9Gly and catechol-O-methyltransferase (COMT) Val158Met] and thermal pain measures in healthy subjects and Fibro patients.

Catecholamines are a group of sympathomimetic hormones and neurotransmitters (including dopamine, epinephrine, and norepinephrine) involved in the stress "fight-or-flight" response.

There were 73 participants in the study: 37 Fibro patients and 36 healthy controls.

Thermal pain thresholds (TPTs) were measured using a Peltier thermode.

Inhibitory systems were elicited using a thermal tonic pain stimulation administered before and after activation of the diffuse noxious inhibitory controls (DNIC) by means of a cold-pressor test.

Genetic analyses were performed using polymerase chain reaction. Regression analyses were performed across and within groups.

The researchers found that Fibro was associated with lower TPTs and deficient pain inhibition.

They also found that DRD3 Ser9Gly polymorphism predicted (1) DNIC efficacy across groups and (2) thermal TPTs in Fibro patients.

COMT Val158Met and thermal pain measures were not related.

In conclusion:

"These preliminary results suggest that the DRD3 Ser9Gly polymorphism influences DNIC efficacy and TPTs and that this latter relationship is present only in [Fibromyalgia Syndrome] patients. Two core psychophysical features of [Fibromyalgia Syndrome] appear to be significantly influenced by limbic dopamine functioning."

This experimental study is the first to relate DNIC and TPTs to a functional polymorphism of limbic dopamine-D3 receptors. As lowered pain thresholds and deficient pain inhibition are 2 core features of Fibromyalgia Syndrome, these preliminary results may help identify a subgroup of Fibro patients who require closer medical attention.

References:

Potvin S, Larouche A, Normand E, de Souza JB, Gaumond I, Grignon S, Marchand S. DRD3 Ser9Gly Polymorphism Is Related to Thermal Pain Perception and Modulation in Chronic Widespread Pain Patients and Healthy Controls. J Pain. 2009 May 21. [Epub ahead of print]

Cognitive resources and stress recovery in Fibromyalgia Syndrome

Mon, 27 Jul 2009 12:00:00 +0100

A team of researchers at a Spanish university have suggested that several cognitive-behavioural techniques commonly employed in the treatment of Fibromyalgia Syndrome may help patients to find the correct equilibrium between stress and recovery and that the modification of self-efficacy beliefs and pain control expectancies are fundamental in managing the condition.¹

One hundred and thirty women with Fibromyalgia Syndrome (Fibro) took part in the study. The researchers evaluated a structural equation model (SEM) of linkages between the cognitive control resources (illness-specific efficacy beliefs and internal pain control expectancies) of the women, their stress/recovery state, and their affective discomfort.

The results were consistent with the proposal that stress/recovery balance mediates the relationship between cognitive resources and affective discomfort. ¹

In addition, direct effects of cognitive resources on function limitation were observed - in other words, the women with Fibro who were considered to have good cognitive resources had less functional limitations. ¹

The researchers also noted that pain intensity and symptoms were direct predictors of the affective discomfort.

Based on the results, the researchers concluded that several cognitive-behavioural techniques commonly employed in the treatment of Fibro are indicated as strategies aimed at finding the correct equilibrium between stress and recovery.

They also concluded that the modification of self-efficacy beliefs and pain control expectancies are fundamental in managing Fibro. Catastrophisation is widely accepted to be a problem amongst all kinds of pain patents because of the effects it has on the inhibitory/excitatory pain pathways and the pain centres of the brain. Catastrophisation is where you think the worst about your symptoms - e.g. hurting a little bit, panicking that the pain will become severe, won't ease and can't be managed and then getting stressed and adapting your behaviour, possibly stopping exercise or social activities, even though you are not yet in severe pain and may not have been in severe pain if you hadn't castrophised. Cognitive behavioural therapy is widely used in chronic pain management to help prevent this problem and part of this is the modification of self-efficacy beliefs and pain control expectancies.

References:

González Gutiérrez JL, Peñacoba Puente C, Velasco Furlong L, López-López A, Mercado Romero F, Barjola Valero P. [Cognitive resources of perceived control, stress-recovery processes and affective discomfort in fibromyalgia.][Article in Spanish] Psicothema. 2009 Aug;21(3):359-68.

Serum vitamin D levels in patients with Fibromyalgia Syndrome

Wed, 26 Aug 2009 12:00:00 +0100

A team of researchers at Ben-Gurion University, Israel have carried out a study that found no link between Fibromyalgia Syndrome and low levels of vitamin D.

The results of the article were published in the June edition of the Israel Medical Association Journal. In the article, the researchers explain the background, saying that the association between low levels of 25-hydroxyvitamin D (25OHD or vitamin D) and non-specific musculoskeletal pain, including Fibromyalgia Syndrome, is controversial with several past studies reporting a "positive association" and two others finding "no association".

This latest study tested levels of 25OHD in patients with Fibromyalgia Syndrome and in matched controls. The study population comprised 68 premenopausal women with a diagnosis of Fibromyalgia Syndrome and 82 age-matched premenopausal women without. The former were identified from the computerized medical databases of five primary care urban clinics in the south of Israel, and the control subjects were attending the participating clinics for regular periodic blood tests.

For each patient, the interview and blood test with the matched control subject were performed within a week or two from the patient's interview and blood test, thus controlling for expected seasonal variations. Serum 25OHD was measured using different cutoff levels (< 30 ng/ml, < 20 ng/ml and <15 ng/ml) and compared between the groups.

The researchers found that no statistically significant differences were found between the groups regardless of the cutoff level used. A logistic regression model for predicting women with 25OHD levels 20 ng/ml showed that all the variables examined in both groups (age, country of birth, education) were not statistically significant. The researchers found the expected seasonal variations of 25OHD levels, but these were not statistically significant.

The researchers found that the prevalence of low vitamin D was particularly high in the study participants, whether or not they had Fibromyalgia Syndrome, with 48% having 25OHD levels < 20 ng/ml.

The conclusion of the team of researchers was that they found no association between Fibromyalgia Syndrome and low 25OHD levels as had been previously suggested in other studies. However, the researchers discussed the problems with carrying out studies of this kind, partly because of large variations in the prevalence of low vitamin D even in one population group.

To read the full article, click here.

References:

Tandeter H, Grynbaum M, Zuili I, Shany S, Shvartzman P. Serum 25-OH vitamin D levels in patients with fibromyalgia. Isr Med Assoc J. 2009 Jun;11(6):339-42.

Stretch exercises increase tolerance to stretches in patients with chronic musculoskeletal pain

Thu, 20 Aug 2009 12:00:00 +0100

A team of researchers from the Physiotherapy Department of a Sydney hospital conducted a study that found stretch exercises increase tolerance to the discomfort associated with the stretches in patients with chronic musculoskeletal pain.

The randomized controlled trial aimed to investigate the effects of a 3-week stretch program on muscle extensibility and stretch tolerance in patients with chronic musculoskeletal pain.

A within-subject design was used, with one leg of each participant randomly allocated to an experimental (stretch) condition and the other leg randomly allocated to a control (no-stretch) condition.

For the study, 30 adults with pain of musculoskeletal origins persisting for at least 3 months were recruited from patients enrolled in a multidisciplinary pain management program at a hospital in Sydney, Australia.

The hamstring muscles of the experimental leg were stretched daily for 1 minute over 3 weeks; the control leg was not stretched. This intervention was embedded within a pain management program and supervised by physical therapists.

Primary outcomes were muscle extensibility and stretch tolerance, reflected by passive hip flexion angles measured with standardized and nonstandardized torques, respectively.

Initial measurements were taken before the first stretch on day 1, and final measurements were taken 1 to 2 days after the last stretch. A blinded assessor was used for testing.

The researchers found that the stretch exercises did not increase muscle extensibility (mean between-group difference in hip flexion was 1 degrees , 95% confidence interval=-2 degrees to 4 degrees ), but it did improve stretch tolerance (mean between-group difference in hip flexion was 8 degrees , 95% confidence interval=5 degrees to 10 degrees ).

The researchers concluded that:

"Three weeks of stretch increases tolerance to the discomfort associated with stretch but does not change muscle extensibility in patients with chronic musculoskeletal pain."

References:

Law RY, Harvey LA, Nicholas MK, Tonkin L, De Sousa M, Finniss DG. Stretch Exercises Increase Tolerance to Stretch in Patients With Chronic Musculoskeletal Pain: A Randomized Controlled Trial. Phys Ther. 2009 Aug 20. [Epub ahead of print]

Review of complementary and alternative medicine treatments in Fibromyalgia Syndrome

Mon, 17 Aug 2009 12:00:00 +0100

An article e-published ahead of print in the journal Rheumatology International has reviewed the published evidence for complementary and alternative medicine in the treatment of Fibromyalgia Syndrome and found that there is best evidence for the use of balneotherapy/hydrotherapy.

The objectives of the study were identification, quality evaluation and summary of randomised controlled trials (RCTs) on complementary and alternative medicine, as defined by the National Institute of Health, with the exception of dietary and nutritional supplements.

A computerized search of databases from 1990 (year of publication of the ACR criteria for Fibromyalgia Syndrome) to July 2007 was performed. The RCTs found in this search were assessed by a methodological quality score.

A total of 23 RCTs issued from 1992 to 2007 on acupuncture, balneotherapy, thermotherapy, magnetic therapy, homeopathy, manual manipulation, mind-body medicine, diet therapy and music therapy were identified.

The RCTs had an average group size of 25 with the number of groups ranging from two to four. The quality score assessment of the RCTs yielded a mean score of 51 out of 100 and the researchers found that the average methodological quality of the identified studies was fairly low.

Best evidence was found for balneotherapy/hydrotherapy in multiple studies.

Positive results were also noted for homeopathy and mild infrared hyperthermia in 1 RCT in each field. Mindfulness meditation showed mostly positive results in two trials and acupuncture mixed results in multiple trials with a tendency toward positive results. Tendencies for improvement were furthermore noted in single trials of the Mesendieck system, connective tissue massage and to some degree for osteopathy and magnet therapy.

No positive evidence could be identified for Qi Gong, biofeedback, and body awareness therapy.

References:

Baranowsky J, Klose P, Musial F, Haeuser W, Dobos G, Langhorst J. Qualitative systemic review of randomized controlled trials on complementary and alternative medicine treatments in fibromyalgia. Rheumatol Int. 2009 Aug 12. [Epub ahead of print]