Fibromyalgia: Perrot S

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, Anonymous00148. · Academic Rheumatology Unit, King's College London, Weston Education Centre, Cutcombe Road, London SE5 9RJ, UK. · Ann Rheum Dis. · Pubmed #17644548 No free full text.

Abstract: OBJECTIVE: To develop evidence-based recommendations for the management of fibromyalgia syndrome. METHODS: A multidisciplinary task force was formed representing 11 European countries. The design of the study, including search strategy, participants, interventions, outcome measures, data collection and analytical method, was defined at the outset. A systematic review was undertaken with the keywords "fibromyalgia", "treatment or management" and "trial". Studies were excluded if they did not utilise the American College of Rheumatology classification criteria, were not clinical trials, or included patients with chronic fatigue syndrome or myalgic encephalomyelitis. Primary outcome measures were change in pain assessed by visual analogue scale and fibromyalgia impact questionnaire. The quality of the studies was categorised based on randomisation, blinding and allocation concealment. Only the highest quality studies were used to base recommendations on. When there was insufficient evidence from the literature, a Delphi process was used to provide basis for recommendation. RESULTS: 146 studies were eligible for the review. 39 pharmacological intervention studies and 59 non-pharmacological were included in the final recommendation summary tables once those of a lower quality or with insufficient data were separated. The categories of treatment identified were antidepressants, analgesics, and "other pharmacological" and exercise, cognitive behavioural therapy, education, dietary interventions and "other non-pharmacological". In many studies sample size was small and the quality of the study was insufficient for strong recommendations to be made. CONCLUSIONS: Nine recommendations for the management of fibromyalgia syndrome were developed using a systematic review and expert consensus.

Perrot S. · Service de Médecine Interne et Centre de la Douleur, Hôtel-Dieu, Paris, France. · Curr Opin Support Palliat Care. · Pubmed #18685409 No free full text.

Abstract: PURPOSE OF REVIEW: Fibromyalgia is considered the most common chronic pain syndrome. This syndrome is poorly understood and not widely accepted as a distinct clinical entity but an increasing number of pharmacological and nonpharmacological treatments are being developed for its management. RECENT FINDINGS: The clinical description of fibromyalgia is now well established, but controversies on diagnostic criteria are increasing. Pathophysiological studies suggest that fibromyalgia is a painful rheumatic disorder in which pain primarily stems from central sensitization and from other neuronal changes, including alterations in peripheral neuronal systems. Central sensitization may also underlie associated symptoms, including anxiety, sleep disorders, fatigue, and other dysfunctions such as irritable bowel syndrome and bladder instability.Several agents, including serotonin-norepinephrine reuptake inhibitors (duloxetine and milnacipran), weak opioids (tramadol), and anticonvulsants (pregabalin), as well as nonpharmacological approaches, have been recently evaluated in clinical trials, demonstrating benefit in terms of pain reduction and improvement of core symptoms (i.e., fatigue and sleep disturbance). SUMMARY: Despite the fact that pathophysiology and diagnostic criteria remain unclear, the level of scientific data collected on this recently described condition should convince clinicians of the existence of this syndrome, allowing improved management of the many patients suffering from chronic pain.

Perrot S, Javier RM, Marty M, Le Jeunne C, Laroche F, Anonymous00080. · Internal Medicine Department and Pain Clinic, Hotel Dieu Hospital, Paris. ; · Rheumatology (Oxford). · Pubmed #18445628 No free full text.

Abstract: The aim of this study was to review the evidence supporting the use of anti-depressants in painful rheumatological conditions. A systematic review of papers published between 1966 and 2007, in five European languages, on anti-depressants in rheumatological conditions was performed. Papers were scored using Jadad method and analgesic ES was calculated. We selected 78 clinical studies and 12 meta-analyses, from 140 papers. The strongest evidence of an analgesic effect of anti-depressants has been obtained for fibromyalgia. A weak analgesic effect is observed for chronic low back pain, with an efficacy level close to that of analgesics. In RA and AS, there is no analgesic effect of anti-depressants, but these drugs may help to manage fatigue and sleep disorders. There is no clear evidence of an analgesic effect inOA, but studies have poor methodological quality. Analgesic effects of anti-depressants are independent of their anti-depressant effects. Tricyclic anti-depressants (TCAs), even at low doses, have analgesic effects equivalent to those of serotonin and noradrenalin reuptake inhibitors (SNRIs), but are less well tolerated. Selective serotonin reuptake inhibitors (SSRIs) have modest analgesic effects, but higher doses are required to achieve analgesia. Anti-depressant drugs, particularly TCAs and SNRIs, have analgesic effects in chronic rheumatic painful states in which analgesics and NSAIDs are not very efficient, such as fibromyalgia and chronic low back pain. In inflammatory rheumatic diseases, anti-depressants may be useful for managing fatigue and sleep disorders. Further studies are required to compare anti-depressants with other analgesics in the management of chronic painful rheumatological conditions.

Perrot S, Dickenson AH, Bennett RM. · Center de la Douleur et Service de Médecine Interne, Hôtel-Dieu, University Paris 5 Descartes, Paris, France. · Pain Pract. · Pubmed #18363616 No free full text.

Abstract: This review summarizes the present and emerging knowledge base on the pathophysiology, diagnosis, and management of fibromyalgia. EPIDEMIOLOGY: Fibromyalgia is the most common chronic pain syndrome encountered in general medicine and rheumatology. Historically, contemporary concepts of fibromyalgia have evolved in terms of its clinical description and parallel advances in the understanding of its pathophysiology. PATHOPHYSIOLOGY: A generally accepted paradigm postulates that fibromyalgia is the clinical expression of a rheumatologic disorder in which the associated pain is driven primarily by central sensitization and possibly through changes in several neuronal systems but not necessarily reliant on peripheral processes. MANAGEMENT: Several agents, including serotonin-norepinephrine reuptake inhibitors (ie, duloxetine and milnacipran), opioids (ie, tramadol), and the alpha2-delta ligand pregabalin, which recently received U.S. regulatory approval for the treatment of fibromyalgia, have been evaluated in clinical trials, demonstrating benefit in terms of pain reduction and improvement in core symptoms (ie, fatigue and sleep disturbance). The European League Against Rheumatism has developed updated guidelines for the management of fibromyalgia.

Auquier L, Bontoux D, Löo H, Godeau P, Menkès CJ, Paolaggi JB, Perrot S. · No affiliation provided · Rev Med Interne. · Pubmed #17976867 No free full text.

Abstract: PURPOSE: We review the current knowledge about fibromyalgia, adding to the clinical aspects, the nosology, epidemiology and pathogenesis. The therapeutic and social management of these suffering patients are discussed. KEY POINTS: The limitations of the American College of Rheumatology classification criteria used as diagnostic criteria are discussed. Fibromyalgia is not a simple psychiatric disorder, even if psychiatric symptoms are constantly found. Based on functional brain imaging, there is some evidence pointing to an abnormal function of the supra-spinal centres for pain regulation. CONCLUSION: Fibromyalgia is a clinical autonomous entity. Physiopathology knowledge is improving, but must be confirmed by new research. Patients will take profit of multimodal individualized treatment programs, including explanations about the diagnosis. In most cases, fibromyalgia is compatible with the maintenance of a professional activity, possibly adapted to the patient. Recognized disability requiring compensation is infrequent.

Perrot S, Javier RM, Marty M, Le Jeunne C, Laroche F. · Service de Médecine Interne et Thérapeutique, Consultation de la Douleur, Hôtel Dieu, Université Paris Descartes, 1 Place du Parvis Notre Dame, 75004 Paris, France. · Rheum Dis Clin North Am. · Pubmed #18638685 No free full text.

Abstract: This article reviews the pharmacologic and clinical evidence supporting the use of antidepressant drugs for treating painful rheumatologic conditions. Clinical studies have shown that tricyclic antidepressants, even at low doses, have analgesic effects in rheumatologic conditions equivalent to those of serotonin and noradrenalin reuptake inhibitors, but are less well tolerated. Selective serotonin reuptake inhibitors may also have analgesic effects, but higher doses are required to achieve analgesia in conditions such as fibromyalgia and low back pain. Antidepressant drugs may be useful in painful rheumatologic conditions, but in some studies the analgesic effects of antidepressants may be associated with functional impairment, sleep disorders, and fatigue. Further studies are required to determine antidepressants' analgesic mechanism of action and the specific role they should play in the management of chronic painful rheumatologic conditions.

Passard A, Attal N, Benadhira R, Brasseur L, Saba G, Sichere P, Perrot S, Januel D, Bouhassira D. · INSERM U-792, Boulogne-Billancourt F-92100 France. · Brain. · Pubmed #17872930 links to  free full text

Abstract: Non-invasive unilateral repetitive transcranial magnetic stimulation (rTMS) of the motor cortex induces analgesic effects in focal chronic pain syndromes, probably by modifying central pain modulatory systems. Neuroimaging studies have shown bilateral activation of a large number of structures, including some of those involved in pain processing, suggesting that such stimulation may induce generalized analgesic effects. The goal of this study was to assess the effects of unilateral rTMS of the motor cortex on chronic widespread pain in patients with fibromyalgia. Thirty patients with fibromyalgia syndrome (age: 52.6 +/- 7.9) were randomly assigned, in a double-blind fashion, to two groups, one receiving active rTMS (n = 15) and the other sham stimulation (n = 15), applied to the left primary motor cortex in 10 daily sessions. The primary outcome measure was self-reported average pain intensity over the last 24 h, measured at baseline, daily during the stimulation period and then 15, 30 and 60 days after the first stimulation. Other outcome measures included: sensory and affective pain scores for the McGill pain Questionnaire, quality of life (assessed with the pain interference items of the Brief Pain Inventory and the Fibromyalgia Impact Questionnaire), mood and anxiety (assessed with the Hamilton Depression Rating Scale, the Beck Depression Inventory and the Hospital Anxiety and Depression Scale). We also assessed the effects of rTMS on the pressure pain threshold at tender points ipsi- and contralateral to stimulation. Follow-up data were obtained for all the patients on days 15 and 30 and for 26 patients (13 in each treatment group) on day 60. Active rTMS significantly reduced pain and improved several aspects of quality of life (including fatigue, morning tiredness, general activity, walking and sleep) for up to 2 weeks after treatment had ended. The analgesic effects were observed from the fifth stimulation onwards and were not related to changes in mood or anxiety. The effects of rTMS were more long-lasting for affective than for sensory pain, suggesting differential effects on brain structures involved in pain perception. Only few minor and transient side effects were reported during the stimulation period. Our data indicate that unilateral rTMS of the motor cortex induces a long-lasting decrease in chronic widespread pain and may therefore constitute an effective alternative analgesic treatment for fibromyalgia.

Perrot S. · Service de médecine interne et consultation de la douleur, Hôtel Dieu, 75004 Paris, France. · Rev Med Suisse. · Pubmed #17727168 No free full text.

Abstract: The present therapeutic approach is aimed at controlling central sensitisation that is supposed to be the core of fibromyalgia's physiopathological mechanisms. The tricyclic antidepressants have some effects on sleep and the improvement of physical activities. Encouraging results have been observed with the serotonin and noradrenaline reuptake inhibitors such as venlafaxine, milnacipran or duloxetine. New Dopamine D3 receptor agonists as well as the new anticonvulsivants such as gabapentine and pregabalin are equally promising. However the prescription of any medication should take place within a multidisciplinary approach.

Perrot S, Dumont D, Guillemin F, Pouchot J, Coste J, Anonymous00463. · Centre de la Douleur and the Service de Rhumatologie, Hôpital Cochin, Paris, France. · J Rheumatol. · Pubmed #12734906 No free full text.

Abstract: OBJECTIVE: To validate a translated and adapted version of the Fibromyalgia Impact Questionnaire (FIQ) for use in French-speaking populations. METHODS: The FIQ was translated into French by 2 independent translators and then back-translated into English to assess the conceptual equivalence. The translated version was tested and adapted by an expert committee to obtain the Questionnaire de mesure d'Impact de la Fibromyalgie (QIF), the French version of the FIQ. We administered the QIF to 102 women with fibromyalgia (FM): 71 women who consulted once, and 31 women who were follow for 3 visits (D0, M1, and M3). The patients were also asked to answer 4 other questionnaires: the McGill Pain Questionnaire, the Medical Outcome Study Short Form-36 (SF-36), the short form of the Arthritis Impact Measurement Scale 2 (AIMS2), and the General Health Questionnaire (GHQ) (for psychiatric assessment). To ensure test-retest reliability, the patients were asked to complete the QIF 7 days after the first visit and to send it back to the investigators by mail. During each visit, all patients were asked about pain intensity. A tender point count was obtained by thumb palpation and the tenderness threshold of each specific point was assessed by a 4-point scale score to determine the global tender point index. RESULTS: No major cultural adaptation was needed to obtain the French version of the FIQ. Test-retest reliability coefficients (intraclass correlation coefficient) for each question ranged from 0.04 to 0.84. Two items from the QIF (number of days when the patient felt good and visual analog scale stiffness) did not reach significant levels of test-retest reliability. Internal validity was good. The QIF score correlated well with the SF-36 and AIMS2 scores. The psychological aspects of the QIF were well correlated with those of GHQ-28. None of the items from the McGill Pain Questionnaire was correlated with QIF items. Similarly the clinical data concerning pain assessment were not correlated with QIF items. CONCLUSIONS: QIF is a valid instrument for measuring functional disability and health status in French women with FM. Some of the items were of a limited reliability, perhaps due to the variability of the multiple aspects of this syndrome.