Fibromyalgia: diagnosis, pathogenesis, and treatment

Fibromyalgia is characterized by chronic widespread pain and the presence of tender points, often accompanied by several non-specific symptoms, such as fatigue, depressive mood, and sleep disturbances. The apparent overlap between fibromyalgia and other syndromes, such as chronic fatigue and irritable bowel, is not sufficient cause to consider all these syndromes as manifestations of a single syndrome. Fibromyalgia is a multifaceted problem. Central afferent pain amplification and perhaps also impaired descending pain inhibition are supposed to underlie widespread pain. Neuroendocrine perturbations, sleep disturbances, health beliefs, mood disorder, and physical deconditioning play a role in the modulation and perseverance of pain and other symptoms. It is extremely difficult to mitigate chronic generalized pain and to deal with other symptoms in fibromyalgia. A uniform intervention strategy is missing. Essential in the tailored management of fibromyalgia are an enhancement of functional capacities and quality of life, and the symptomatic treatment of individual symptoms such as pain, distress, and sleep disturbances. Rather than analysing monotherapy per se, the objective in future evaluations should be to try to find the combined pharmacological or non-pharmacological treatment of choice for specific subgroups of patients.     

Efficacy and practical issues of repetitive transcranial magnetic stimulation on chronic medically unexplained symptoms of pain

Chronic pain is a common issue worldwide and remains a big challenge to physicians, particularly when the underlying causes do not meet any specific disease for settlement. Such medically unexplained somatic symptoms of pain that lack an integrated diagnosis in medicine have a high psychiatric comorbidity such as depression, and will require a multidisciplinary treatment strategy for a better outcome. Thus, most patients deserted management in spite of being inadequately treated and even presented with high resistance to analgesic drugs. Noninvasive brain stimulation, including repetitive transcranial magnetic stimulation (rTMS), has been used to treat refractory neuropathic pain and the analgesic efficacy is promising. So far, some case series and randomized rTMS studies have reported on patients with certain medically unexplained symptoms (MUSs) of pain (e.g., psychogenic pain or somatic symptoms in major depression and fibromyalgia). However, there is still no review article that is specific to the efficacy of rTMS on chronic unexplained symptoms of pain. Therefore, in the present review, we ventured to clarify the terminology and summarized the analgesic effects of rTMS on chronic MUSs of pain.     

Fibromyalgia: knowns, unknowns, and current treatment

Fibromyalgia is a chronic syndrome of diffuse musculoskeletal pain with tenderness at specific locations, often associated with persistent fatigue, cognitive and mood disorders, joint stiffness, and insomnia. Understanding the pathophysiology of fibromyalgia and the establishment of effective treatments have been complex endeavors that have not yielded simple answers. Nevertheless, recent studies have shed light on the roles of central pain processing, genetic abnormalities, and external factors on development of the fibromyalgia syndrome (FMS). These findings have led to the use of new therapies that have shown beneficial effects on symptoms. This review discusses ideas that have become accepted as well as novel associations under consideration in regard to the pathogenesis of fibromyalgia and the current and emerging therapeutics for its treatment.     

Development of an evidence-based cognitive behavioral treatment program for men with chronic prostatitis/chronic pelvic pain syndrome

Objectives Psychosocial factors reported by patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) promote greater pain, disability, and ultimately poorer quality of life (QOL). We targeted those parameters in the development of a cognitive-behavioral (CB) program designed specifically for CP/CPPS. Methods and materials Five NIH sponsored biopsychosocial studies examined predictors of pain, disability, and QOL in CP/CPPS men. Pain, urinary symptoms, QOL, depressive symptoms, catastrophic thinking about pain, perceived control over pain, pain-contingent resting as a pain coping measure, social support and interaction, sexual functioning, and relationship issues were assessed. These data showed that CB intervention for pain catastrophizing, pain contingent rest, social support and depressive symptoms is warranted for men with CP/CPPS Results An evidence based 8-week CB program was developed. The content of the CB sessions are defined in an instructional patient workbook for each of the weekly 1-h sessions. The CB program guides patients in examining the relationship between their symptom-based distress, their thinking at such times and the emotions linked with those thoughts, and their behavioral responses to their particular thinking style (e.g., illness vs. wellness focused). Patients complete such analyses by using a Reaction Record format, which also delineates new thinking/behavioral responses. Conclusions The CB program developed for CP/CPPS is the first comprehensive attempt to target specific evidence supported biopsychosocial variables for both symptom and QOL improvement in CP/CPPS and is expected to provide a useful tool for the clinical management of this chronic condition.     

Fibromyalgia: an update for oral health care providers.

Fibromyalgia (FM) is a syndrome characterized by chronic widespread pain, stiffness, nonrestorative sleep, fatigue, and comorbid conditions. Fibromyalgia has undergone a major paradigm shift in recent years. It is no longer considered a musculoskeletal disorder per se; rather, it represents one end of a spectrum of disorders characterized by chronic widespread pain. Hence, oral health care providers may be the first to recognize signs and symptoms of this complex disorder and are often consulted to participate in the management of FM patients. This medical management update will review the epidemiology, classification, etiology and pathophysiology, clinical presentation, and therapeutic advances in FM. This review will also highlight issues that are important to the oral health care provider, including orofacial manifestations and dental considerations for patients with FM.     

Altered neuromuscular control mechanisms of the trapezius muscle in fibromyalgia

Background  

fibromyalgia is a relatively common condition with widespread pain and pressure allodynia, but unknown aetiology. For decades, the association between motor control strategies and chronic pain has been a topic for debate. One long held functional neuromuscular control mechanism is differential activation between regions within a single muscle. The aim of this study was to investigate differences in neuromuscular control, i.e. differential activation, between myalgic trapezius in fibromyalgia patients and healthy controls.     

Fibromyalgia: mechanisms and potential impact of the ACR 2010 classification criteria

Fibromyalgia is a disorder characterized by chronic widespread pain in the presence of widespread tenderness, and multiple somatic symptoms. Since the publication of the American College of Rheumatology (ACR) 1990 classification criteria for fibromyalgia, research has proliferated and, in a relatively short period, investigators have begun to unravel the etiology and long-term impact of this complex condition. Although the ACR 1990 criteria have been central to fibromyalgia research during the past two decades, a number of practical and philosophical objections have been raised in relation to them. Principally these objections have centered on the use (or lack thereof) of the tender point examination, the lack of consideration of associated symptoms, and the observation that fibromyalgia might represent the extreme end of a pain continuum. In developing the ACR 2010 criteria, experts have sought to address these issues and to simplify clinical diagnosis. An implicit aim was to facilitate more rigorous study of etiology. The purpose of this Review is to summarize research to date that has described the epidemiology, pathology and clinical course of fibromyalgia, and to assess the probable impact of the ACR 2010 criteria on future research efforts.     

The development of occupational therapy-led groups for people with fibromyalgia

Fibromyalgia is a complex condition which can provide a challenge to healthcare professionals. Sufferers experience widespread body pain and debilitating fatigue in addition to cognitive difficulties and sleep disturbance. Group pain management programmes are an evidenced-based approach to providing pain management for people living with chronic pain. Occupational therapists are uniquely placed to provide a holistic approach to patients with chronic pain and a group programme specifically targeted at patients with fibromyalgia has been found to provide an additional benefit of meeting the wide range of challenges they experience. Patient education is an important part of the content of these groups. This article describes the background and development of the ‘Living Well with Fibromyalgia’ group programme.     

Clinical evidence for cervical myelopathy due to Chiari malformation and spinal stenosis in a non-randomized group of patients with the diagnosis of fibromyalgia

Objective While patients with fibromyalgia report symptoms consistent with cervical myelopathy, a detailed neurological evaluation is not routine. We sought to determine if patients with fibromyalgia manifest objective neurological signs of cervical myelopathy.Methods Two hundred and seventy patients, 18 years and older, who carried the diagnosis of fibromyalgia but who had no previously recognized neurological disease underwent detailed clinical neurological and neuroradiological evaluation for the prevalence of objective evidence of cervical myelopathy and radiological evidence of cerebellar tonsillar herniation (Chiari 1 malformation) or cervical spinal canal stenosis.Results Patients were primarily women (87%), of mean age 44 years, who had been symptomatic for 8 years (standard deviation, 6.3 years). The predominant complaints were neck/back pain (95%), fatigue (95%), exertional fatigue (96%), cognitive impairment (92%), instability of gait (85%), grip weakness (83%), paresthesiae (80%), dizziness (71%) and numbness (69%). Eighty-eight percent of patients reported worsening symptoms with neck extension. The neurological examination was consistent with cervical myelopathy: upper thoracic spinothalamic sensory level (83%), hyperreflexia (64%), inversion of the radial periosteal reflex (57%), positive Romberg sign (28%), ankle clonus (25%), positive Hoffman sign (26%), impaired tandem walk (23%), dysmetria (15%) and dysdiadochokinesia (13%). MRI and contrast-enhanced CT imaging of the cervical spine revealed stenosis. The mean antero-posterior (AP) spinal canal diameter at C2/3, C3/4, C4/5, C5/6, C6/7 and C7/T1 was 13.5 mm, 11.8 mm, 11.5 mm, 10.4 mm, 11.3 mm and 14.5 mm respectively, (CT images). In 46% of patients, the AP spinal diameter at C5/6 measured 10 mm, or less, with the neck positioned in mild extension, i.e., clinically significant spinal canal stenosis. MRI of the brain revealed tonsillar ectopia >5 mm in 20% of patients (mean=7.1±1.8 mm), i.e., Chiari 1 malformation.Conclusion Our findings indicate that some patients who carry the diagnosis of fibromyalgia have both signs and symptoms consistent with cervical myelopathy, most likely resulting from spinal cord compression. We recommend detailed neurological evaluation of patients with fibromyalgia in order to exclude cervical myelopathy, a potentially treatable condition.     

Douleur,souffrance et hyperlaxité articulaire

Pain, distress and joint hyperlaxity. — Pain dominates the lives of many patients with hyperlaxity syndromes, most commonly the Benign Joint Hypermobility Syndrome (BJHS/EDS). As a result they may experience psychosocial problems, which in many cases severely affects their healthy functioning. Above all is the overriding chronic pain in joints, muscles and ligaments, which arise from an inherent predisposition to the effects of everyday trauma, but other factors such as associated osteoarthritis or fibromyalgia are also important. There may also be neurophysiological factors at play producing nociceptive enhancement. Pain and distress of visceral origin can result from laxity of connective tissue within or providing support for the abdominal, thoracic or pelvic viscera leading to hernia uterine and/or rectal prolapse, mitral valve prolapse or spontaneous pneumothorax. In children joint hyperlaxity is an important (and often unrecognised) source of rheumatic symptoms, which may be ignored or erroneously ascribed to juvenile idiopathic arthritis. The management of pain and distress in the hyperlaxity syndromes requires skill, patience, compassion and understanding. Often the results of conventional anti-rheumatic therapy (including anti-rheumatic drugs and surgery) as applied to other rheumatic diseases are disappointing and innovative approaches are required. Amongst these, for which evidence of efficacy is available are physiotherapeutic and orthotic stabilisation of hyperlax joints, proprioceptive enhancement and the newer pain management techniques including cognitive behavioural therapy.     

Insomnia in a chronic musculoskeletal pain with disability population is independent of pain and depression

Background contextInsomnia is frequently experienced by patients suffering from chronic musculoskeletal disorders but is often seen as simply a symptom of pain or depression and not as an independent disorder. Compared with those who experience only chronic pain, patients with both chronic pain and insomnia report higher pain intensity, more depressive symptoms, and greater distress. However, insomnia has not yet been systematically studied in a chronic musculoskeletal pain with disability population.PurposesThis study assessed the prevalence and severity of patient-reported insomnia, as well as the relationship among insomnia, pain intensity, and depressive symptoms, in a chronic musculoskeletal pain with disability population.Study design/settingThis was a retrospective study of prospectively captured data.Patient sampleA consecutive cohort of 326 chronic musculoskeletal pain with disability patients (85% with spinal injuries) entered a functional restoration treatment program. All patients signed a consent form to participate in this protocol.Outcome measuresInsomnia was assessed with the Insomnia Severity Index, a validated patient-report measure of insomnia symptoms. Four patient groups were formed: no clinically significant insomnia (score, 0–7); subthreshold insomnia (score, 8–14); moderate clinical insomnia (score, 15–21); and severe clinical insomnia (score, 22–28). Three patterns of sleep disturbance were also evaluated: early, middle, and late insomnia. Additional validated psychosocial patient-reported data were collected, including the Pain Visual Analog Scale, the Beck Depression Inventory, the Oswestry Disability Index, and the Pain Disability Questionnaire.MethodsPatients completed a standard psychosocial assessment battery on admission to the functional restoration program. The program included a quantitatively directed exercise process in conjunction with a multimodal disability management approach. The four insomnia groups were compared on demographic and psychosocial variables. The shared variances among insomnia, depression, and pain were determined by partial correlational analyses.ResultsThe presence of no clinically significant insomnia, subthreshold insomnia, moderate clinical insomnia, and severe clinical insomnia was found in 5.5%, 21.2%, 39.6%, and 33.7% of the cohort, respectively. More than 70% of patients reported moderate to severe insomnia symptoms, which is a considerably higher prevalence than that found in most patient cohorts studied previously. A stepwise pattern was found, in which severe clinical insomnia patients reported the highest pain, the most severe depressive symptoms, and the greatest disability. The severe clinical insomnia patients also reported a higher number of sleep disturbance types (early, middle, and late insomnia) than the other three groups. In fact, 62.9% of them reported all three disturbance types. Although correlations were found between insomnia and depressive symptoms and between insomnia and pain, the shared variances were small (12.9% and 3.6%, respectively), indicating that depression and pain are separate constructs from insomnia.ConclusionThis research indicates that insomnia is a significant and pervasive problem in a chronic musculoskeletal pain with disability population. Most importantly, although insomnia has traditionally been assumed to be simply a symptom of pain or depression, the findings of the present study reveal that it is a construct relatively independent from both pain and depression. Specific insomnia assessment and treatment is therefore recommended for this chronic musculoskeletal pain with disability population.     

Efficacy of Low Power Laser Therapy in Fibromyalgia: A Single-blind, Placebo-controlled Trial

Low energy lasers are widely used to treat a variety of musculoskeletal conditions including fibromyalgia, despite the lack of scientific evidence to support its efficacy. A randomised, single-blind, placebo-controlled study was conducted to evaluate the efficacy of low-energy laser therapy in 40 female patients with fibromyalgia. Patients with fibromyalgia were randomly allocated to active (Ga-As) laser or placebo laser treatment daily for two weeks except weekends. Both the laser and placebo laser groups were evaluated for the improvement in pain, number of tender points, skinfold tenderness, stiffness, sleep disturbance, fatigue, and muscular spasm. In both groups, significant improvements were achieved in all parameters (p<0.05) except sleep disturbance, fatigue and skinfold tenderness in the placebo laser group (p>0.05). It was found that there was no significant difference between the two groups with respect to all parameters before therapy whereas a significant difference was observed in parameters as pain, muscle spasm, morning stiffness and tender point numbers in favour of laser group after therapy (p<0.05). None of the participants reported any side effects. Our study suggests that laser therapy is effective on pain, muscle spasm, morning stiffness, and total tender point number in fibromyalgia and suggests that this therapy method is a safe and effective way of treatment in the cases with fibromyalgia. Paper received 29 March 2001; accepted after revision 10 July 2001.     

Pathogenesis of fibromyalgia - a review

Fibromyalgia, a syndrome characterized by widespread pain and diffuse tenderness, is considered a multifactorial disorder. Central nervous system sensitization is a major pathophysiological aspect of fibromyalgia, while various external stimuli such as infection, trauma and stress may contribute to development of the syndrome. In addition, current evidence points towards the existence of a genetic basis for fibromyalgia and information has been accumulated regarding the role of a number of candidate genes in fibromyalgia pathogenesis. In the present review, we have summarized the clinical manifestations of fibromyalgia, as well as the necessary laboratory workup; subsequently we have attempted to cover various aspects of pathogenesis with special emphasis on the genetic aspects currently uncovered.     

Alternative Approaches to the Management of Prostatitis: Biofeedback,Progressive Relaxation and the Concept of Functional Somatic Syndromes

Specific mechanisms underlying chronic pelvic pain syndrome have yet to be identified. However, the disorder has features common to other chronic pain syndromes, such as fibromyalgia and chronic pelvic pain in women. Like other chronic pain patients, men presenting with chronic prostatitis may meet diagnostic criteria for other functional pain syndromes as well as affective disorders, which should be screened for. Finally, as with other chronic pain conditions, chronic nonbacterial prostatitis patients respond very well to non-specific modalities that act to reduce stress and/or muscle tension, including progressive relaxation and biofeedback.     

Neuropathische Schmerzen Der lange Weg vom Mechanismus zur mechanismenorientierten Therapie

Clinical characteristics of neuropathic pain, i.e. pain after nervous system lesions, are burning spontaneous pain, shooting pain attacks and evoked pains. Partly interacting pathophysiological mechanisms at the peripheral and central nervous system may be responsible for initiation and maintenance of chronic neuropathic pain. (1) Peripheral nociceptive fibers can be abnormally sensitized. (2) Central nociceptive second order neurons in the spinal cord dorsal horn can also be sensitized, i.e. they are hyperexcitable and start responding to non-noxious stimuli. (3) Degeneration of nociceptive neurons may trigger anatomical sprouting of low-threshold mechanosensitive terminals to central nociceptive neurons and may subsequently induce synaptic reorganization in the dorsal horn. By this mechanism activity in mechanosensitive neurons may be perceived as painful. (4) Peripheral nerve injury may induce a pathological interaction of the nociceptive system and the efferent sympathetic system. The different mechanisms can operate in concert in a single disease entity (e.g., postherpetic neuralgia) and also in one single patient. Distinct pathophysiological mechanisms lead to specific sensory symptoms (e.g., dynamic mechanical allodynia, cold hyperalgesia). Therefore, a thorough analysis of sensory symptoms may reveal the underlying mechanisms that are mainly active in a particular patient. In the next step novel drugs will be developed that address specifically the relevant mechanism combination. Drug therapies that are available today include NSAIDS, opioids, tricyclic antidepressants, anticonvulsives (carbamazepine, gabapentin), GABA-agonists, Capsaicin and NMDA-antagonists.     

胃癌术后化疗患者症状严重度与困扰度调查研究

目的分析基于症状困扰形成的症状群与基于症状严重程度形成的症状群的异同,为形成适合我国人群的胃癌管理方案奠定基础。方法采用安德森症状评估量表胃癌特异性模块对85例胃癌术后首次化疗患者进行调查,分别基于症状严重程度和症状困扰程度提取症状群,分析两者的异同。结果 18项症状中,严重程度得分前3位为疲乏、疼痛、苦恼;困扰程度得分前3位为疲乏、恶心、吞咽困难。因子分析,14项症状进入严重程度分析,形成病感症状群(3项)、消化道症状群(5项)、情绪症状群(3项)、胃癌特异性症状群(3项)4个因子,累计方差贡献率为83.49%;13项症状进入困扰程度分析,形成病感症状群(2项)、情绪症状群(4项)、消化道症状群(4项)、胃癌特异性症状群(3项)4个因子,累计方差贡献率为86.38%。结论两种分析模式均形成4种症状群;疲乏的严重度及困扰度均排第一,疼痛困扰度相对较轻,恶心等胃肠道症状困扰度高于严重度。在护理中除重视严重度及困扰度均高的疲乏等症状外,要特别关注严重度不高而困扰度较高的症状,以便采取措施缓解症状,利于患者顺利完成化疗疗程。     

Pain, distress and joint hyperlaxity

Pain dominates the lives of many patients with hyperlaxity syndromes, most commonly the Benign Joint Hypermobility Syndrome (BJHS/EDS). As a result they may experience psychosocial problems, which in many cases severely affects their healthy functioning. Above all is the overriding chronic pain in joints, muscles and ligaments, which arises from an inherent predisposition to the effects of everyday trauma, but other factors such as associated osteoarthritis or fibromyalgia are also important. There may also be neurophysiological factors at play producing nociceptive enhancement. Pain and distress of visceral origin can result from laxity of connective tissue within or providing support for the abdominal, thoracic or pelvic viscera leading to hernia, uterine and/or rectal prolapse, mitral valve prolapse or spontaneous pneumothorax. In children joint hyperlaxity is an important (and often unrecognised) source of rheumatic symptoms, which may be ignored or erroneously ascribed to juvenile idiopathic arthritis. The management of pain and distress in the hyperlaxity syndromes requires skill, patience, compassion and understanding. Often the results of conventional anti-rheumatic therapy (including anti-rheumatic drugs and surgery) as applied to other rheumatic diseases are disappointing and innovative approaches are required. Amongst these, for which evidence of efficacy is available, are physiotherapeutic and orthotic stabilisation of hyperlax joints, proprioceptive enhancement and the newer pain management techniques including cognitive behavioural therapy.