Fibromyalgia: England

Sim J, Adams N. · Primary Care Sciences Research Centre, Keele University, Staffordshire, UK. · Baillieres Best Pract Res Clin Rheumatol. · Pubmed #10562382 No free full text.

Abstract: There is little empirical evidence for the effectiveness of physical and other non-pharmacological approaches to the management of fibromyalgia. Although a number of studies have been conducted into such approaches, many of these are uncontrolled, and relatively few randomized controlled trials of appropriate size and methodological rigour have been carried out. This chapter provides an overview of the evidence available under the following headings: exercise, EMG biofeedback training, electrotherapy and acupuncture, patient education and self-management programmes, multimodal treatment approaches, and other interventions. It is hard to reach firm conclusions from the literature, owing to the variety of interventions that have been evaluated and the varying methodological quality of the studies concerned. Nonetheless, in terms of specific interventions, exercise therapy has received a moderate degree of support from the literature, and has been subjected to more randomized studies than any other intervention. In contrast, there is little or no evidence available for most types of electrotherapy. In terms of overall management strategies, a multimodal programme of management, including physical, psychological and educational components and delivered in a multidisciplinary setting, has gained some support from descriptive and experimental studies, and accords with current understanding of the aetiology and clinical features of fibromyalgia. There is a clear need for further systematic evaluation of the effectiveness of non-pharmacological treatment approaches in fibromyalgia.

Wessely S, Hotopf M. · Academic Department of Psychological Medicine, Guy's, King's and St Thomas' School of Medicine, London, UK. · Baillieres Best Pract Res Clin Rheumatol. · Pubmed #10562373 No free full text.

Abstract: Most medical specialities have defined medically unexplained syndromes such as fibromyalgia, to categorize patients with prominent but unexplained symptoms. Other such syndromes include irritable bowel syndrome, chronic fatigue syndrome and atypical chest pain. In this chapter we present evidence to suggest that fibromyalgia is not a unique clinical entity, but shares much with these other syndromes. We use historical, clinical and epidemiological evidence to illustrate this idea. The historical data emphasize the essentially arbitrary way in which fibromyalgia developed. The clinical evidence shows the considerable overlap between patients with fibromyalgia and those with other unexplained syndromes. From an epidemiological perspective we emphasize the strong associations between symptoms such as myalgia and fatigue. We conclude by suggesting that fibromyalgia is one of many medically unexplained syndromes which have more similarities than differences between them.

Macfarlane GJ. · Unit of Chronic Disease/Epidemiology, School of Epidemiology and Health Sciences, University of Manchester, UK. · Baillieres Best Pract Res Clin Rheumatol. · Pubmed #10562370 No free full text.

Abstract: Generalized pain, which is one component of the fibromyalgia syndrome, is a common and disabling problem in the general population. Pain at individual sites, such as the lower back and shoulder, has traditionally been considered distinct from generalized pain and studied separately. This chapter considers first the basic definition and distribution of widespread pain in the population, and second examines the evidence as to whether widespread and regional pain are truly or usefully distinguished.

Sim J, Reid N. · Department of Physiotherapy Studies, Keele University, Staffordshire, United Kingdom. · Phys Ther. · Pubmed #10029058 links to  free full text

Abstract: This article examines the role of the confidence interval (CI) in statistical inference and its advantages over conventional hypothesis testing, particularly when data are applied in the context of clinical practice. A CI provides a range of population values with which a sample statistic is consistent at a given level of confidence (usually 95%). Conventional hypothesis testing serves to either reject or retain a null hypothesis. A CI, while also functioning as a hypothesis test, provides additional information on the variability of an observed sample statistic (ie, its precision) and on its probable relationship to the value of this statistic in the population from which the sample was drawn (ie, its accuracy). Thus, the CI focuses attention on the magnitude and the probability of a treatment or other effect. It thereby assists in determining the clinical usefulness and importance of, as well as the statistical significance of, findings. The CI is appropriate for both parametric and nonparametric analyses and for both individual studies and aggregated data in meta-analyses. It is recommended that, when inferential statistical analysis is performed, CIs should accompany point estimates and conventional hypothesis tests wherever possible.

Peters S, Stanley I, Rose M, Kaney S, Salmon P. · Department of Psychiatry, University of Liverpool, UK. · Fam Pract. · Pubmed #12429672 links to  free full text

Abstract: BACKGROUND: The management of persistent, unexplained physical symptoms is challenging and often unsatisfactory for patients and doctors. Aerobic exercise training has benefited patients referred to secondary care with symptoms of chronic fatigue and fibromyalgia. It is not known if this approach is either possible or beneficial for patients with the broader range of persistent, unexplained symptoms found in primary care. OBJECTIVES: To examine the feasibility and effects of aerobic exercise training in primary care patients with unexplained physical symptoms persisting more than 12 months. METHODS: Randomized comparison (n = 228) of aerobic exercise with stretching as control among patients recruited from primary care. Training comprised 20, one-hour, sessions led by NHS physiotherapists. Adherence to training was recorded along with two groups of outcome measures: (i) documented symptoms and health care use, monitored from six months before to six months after training; and (ii) self-reported measures including emotional state and perceived disability, assessed before, during and six months after training. RESULTS: Exercise training proved feasible: more than 70% of referred patients attended for assessment and were randomized to aerobic or control exercise; 78% of eligible patients attended the first session; and median attendance was 11 sessions for both programmes. Primary care consultations and prescriptions were significantly reduced in the 6 months after training; extent of reduction was related to attendance at training sessions, irrespective of type. Whilst self-reported measures improved similarly during both training programmes, improvements were unrelated to level of attendance. CONCLUSION: For primary care patients with persistent, unexplained physical symptoms willing to be involved in exercise training, aerobic exercise offers no benefits over non-aerobic exercise. Whilst the observed reduction in primary health care use following exercise training is potentially of practical importance in a group of patients characterized by high consultation rates, improvement in patients' subjective state was not clearly attributable to exercise training.

Moore RA, Straube S, Wiffen PJ, Derry S, McQuay HJ. · Pain Research and Nuffield Department of Anaesthetics, University of Oxford, West Wing (Level 6), John Radcliffe Hospital, Oxford, Oxfordshire, UK, OX3 9DU. · Cochrane Database Syst Rev. · Pubmed #19588419 No free full text.

Abstract: BACKGROUND: Antiepileptic drugs have been used in pain management since the 1960s. Pregabalin is a recently developed antiepileptic drug also used in management of chronic neuropathic pain conditions. OBJECTIVES: To assess analgesic efficacy and associated adverse events of pregabalin in acute and chronic pain. SEARCH STRATEGY: We searched MEDLINE, EMBASE, and CENTRAL to May 2009 for randomised controlled trials (RCTs). Additional studies were identified from the reference lists of retrieved papers and on-line clinical trial databases. SELECTION CRITERIA: Randomised, double blind trials reporting on the analgesic effect of pregabalin, with subjective pain assessment by the patient as either the primary or a secondary outcome. DATA COLLECTION AND ANALYSIS: Two independent review authors extracted data and assessed trial quality. Numbers-needed-to-treat-to-benefit (NNTs) were calculated, where possible, from dichotomous data for effectiveness, adverse events and study withdrawals. MAIN RESULTS: There was no clear evidence of beneficial effects of pregabalin in established acute postoperative pain. No studies evaluated pregabalin in chronic nociceptive pain, like arthritis.Pregabalin at doses of 300 mg, 450 mg, and 600 mg daily was effective in patients with postherpetic neuralgia, painful diabetic neuropathy, central neuropathic pain, and fibromyalgia (19 studies, 7003 participants). Pregabalin at 150 mg daily was generally ineffective. Efficacy was demonstrated for dichotomous outcomes equating to moderate or substantial pain relief, alongside lower rates for lack of efficacy discontinuations with increasing dose. The best (lowest) NNT for each condition for at least 50% pain relief over baseline (substantial benefit) for 600 mg pregabalin daily compared with placebo were 3.9 (95% confidence interval 3.1 to 5.1) for postherpetic neuralgia, 5.0 (4.0 to 6.6) for painful diabetic neuropathy, 5.6 (3.5 to 14) for central neuropathic pain, and 11 (7.1 to 21) for fibromyalgia.With 600 mg pregabalin daily somnolence typically occurred in 15% to 25% and dizziness occurred in 27% to 46%. Treatment was discontinued due to adverse events in 18 to 28%. The proportion of participants reporting at least one adverse event was not affected by dose, nor was the number with a serious adverse event, which was not more than with placebo.Higher rates of substantial benefit were found in postherpetic neuralgia and painful diabetic neuropathy than in central neuropathic pain and fibromyalgia. For moderate and substantial benefit on any outcome NNTs for the former were generally six and below for 300 mg and 600 mg daily; for fibromyalgia NNTs were much higher, and generally seven and above. AUTHORS' CONCLUSIONS: Pregabalin has proven efficacy in neuropathic pain conditions and fibromyalgia. A minority of patients will have substantial benefit with pregabalin, and more will have moderate benefit. Many will have no or trivial benefit, or will discontinue because of adverse events. Individualisation of treatment is needed to maximise pain relief and minimise adverse events. There is no evidence to support the use of pregabalin in acute pain scenarios.

Oliver JE, Silman AJ. · Arthritis Research Campaign, Copeman House, St Mary's Court, St Mary's Gate, Chesterfield, Derbyshire S41 7TD, UK. · Arthritis Res Ther. · Pubmed #19490599 links to  free full text

Abstract: This article will review how epidemiological studies have advanced our knowledge of both genetic and environmental risk factors for rheumatic diseases over the past decade. The major rheumatic diseases, including rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, systemic lupus erythematosus, scleroderma, osteoarthritis, gout, and fibromyalgia, and chronic widespread pain, will be covered. Advances discussed will include how a number of large prospective studies have improved our knowledge of risk factors, including diet, obesity, hormones, and smoking. The change from small-scale association studies to genome-wide association studies using gene chips to reveal new genetic risk factors will also be reviewed.

Relton C, Smith C, Raw J, Walters C, Adebajo AO, Thomas KJ, Young TA. · School of Health and Related Research, University of Sheffield, Sheffield, UK; School of Healthcare, University of Leeds, Leeds, UK. · Homeopathy. · Pubmed #19358959 No free full text.

Abstract: OBJECTIVES: To assess the feasibility of a Randomised Controlled Trial (RCT) design of usual care compared with usual care plus adjunctive care by a homeopath for patients with Fibromyalgia syndrome (FMS). METHODS: In a pragmatic parallel group RCT design, adults with a diagnosis of FMS (ACR criteria) were randomly allocated to usual care or usual care plus adjunctive care by a homeopath. Adjunctive care consisted of five in depth interviews and individualised homeopathic medicines. The primary outcome measure was the difference in Fibromyalgia Impact Questionnaire (FIQ) total score at 22 weeks. RESULTS: 47 patients were recruited. Drop out rate in the usual care group was higher than the homeopath care group (8/24 vs 3/23). Adjusted for baseline, there was a significantly greater mean reduction in the FIQ total score (function) in the homeopath care group than the usual care group (-7.62 vs 3.63). There were significantly greater reductions in the homeopath care group in the McGill pain score, FIQ fatigue and tiredness upon waking scores. We found a small effect on pain score (0.21, 95% CI -1.42 to 1.84); but a large effect on function (0.81, 95% CI -8.17 to 9.79). There were no reported adverse events. CONCLUSIONS: Given the acceptability of the treatment and the clinically relevant effect on function, there is a need for a definitive study to assess the clinical and cost effectiveness of adjunctive healthcare by a homeopath for patients with FMS.

Lawson K. · Biomedical Research Centre, Sheffield Hallam University, Faculty of Health and Wellbeing, Sheffield, UK. · Neuropsychiatr Dis Treat. · Pubmed #19337451 links to  free full text

Abstract: Fibromyalgia (FM) is a common, complex, and difficult to treat chronic widespread pain disorder, which usually requires a multidisciplinary approach using both pharmacological and non-pharmacological (education and exercise) interventions. It is a condition of heightened generalized sensitization to sensory input presenting as a complex of symptoms including pain, sleep dysfunction, and fatigue, where the pathophysiology could include dysfunction of the central nervous system pain modulatory systems, dysfunction of the neuroendocrine system, and dysautonomia. A cyclic model of the pathophysiological processes is compatible with the interrelationship of primary symptoms and the array of postulated triggers associated with FM. Many of the molecular targets of current and emerging drugs used to treat FM have been focused to the management of discrete symptoms rather than the condition. Recently, drugs (eg, pregabalin, duloxetine, milnacipran, sodium oxybate) have been identified that demonstrate a multidimensional efficacy in this condition. Although the complexity of FM suggests that monotherapy, non-pharmacological or pharmacological, will not adequately address the condition, the outcomes from recent clinical trials are providing important clues for treatment guidelines, improved diagnosis, and condition-focused therapies.

Nicholl BI, Macfarlane GJ, Davies KA, Morriss R, Dickens C, McBeth J. · Arthritis Research Campaign Epidemiology Unit, School of Translational Medicine, University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, UK. · Pain. · Pubmed #19059720 links to  free full text

Abstract: Chronic widespread pain (CWP) is associated with poor health-related quality of life (HRQoL). It is unclear whether pain itself is the cause of poor HRQoL or other factors play a role. We hypothesised that new onset of CWP was associated with poor physical and mental HRQoL but that psychosocial risk markers for CWP onset would explain this relationship. A prospective population-based survey measured pain and psychosocial status at baseline. Subjects free of CWP at baseline were followed up 15 months later, when pain status, threatening life events and HRQoL (SF-12) were assessed. The risk associated with the new onset of CWP and reporting poor SF12-MCS and SF12-PCS was quantified using multinomial logistic regression (relative risk ratios (RRRs) with 95% confidence intervals (95% CI)), adjusted for age and gender. 3000 subjects (77%) free of CWP at baseline participated at follow-up. 2650 subjects (88%) provided full SF-12 and pain data and formed the cohort for this analysis. 9.4% of subjects (n=248) reported new CWP. New CWP was associated with an increased risk of having the poorest SF12-MCS (RRR=2.3; 95% CI 1.6-3.2) and SF12-PCS (RRR=8.0; 95% CI 5.4-11.8) scores. After adjusting for baseline psychosocial status, the relationship between CWP onset and SF12-MCS was attenuated (RRR=1.2; 95% CI 0.8-1.8), although the association with SF12-PCS remained (RRR=4.8% CI 3.1-7.47). New onset of CWP is associated with poor mental and physical HRQoL. However, the relationship with mental HRQoL is explained by psychosocial risk markers.

McBeth J, Symmons DP, Silman AJ, Allison T, Webb R, Brammah T, Macfarlane GJ. · Arthritis Research Campaign Epidemiology Unit, Epidemiology Research Group, Research School of Translational Medicine, University of Manchester, Manchester, UK. · Rheumatology (Oxford). · Pubmed #19056799 links to  free full text

Abstract: OBJECTIVES: To test the hypothesis that individuals with regional and widespread pain disorders have an increased risk of mortality. METHODS: We conducted a prospective cohort study of 4515 adults. Subjects were an age- and sex-stratified sample who had participated in a population study of pain occurrence during 1996. Based on those reports subjects were classified as having no pain, regional pain or widespread pain. All subjects were identified on the National Health Service Central Register and followed up until April 2005, a total of 8.2 yrs, at which time information was obtained on vital status, and if applicable, date and cause of death. The relationship between pain status and subsequent death is expressed as mortality rate ratios with 95% CIs, adjusted for age, gender, ethnicity and practice. RESULTS: A total of 35.2% reported regional pain and 16.9% satisfied criteria for widespread pain. In comparison with those without pain, there was a 20% and 30% increased risk of dying over the follow-up period among subjects with regional and widespread pain, respectively. The specific causes of death in excess were cancer and cardiovascular disease. In addition, the mortality risk from both cancer and cardiovascular deaths was found to increase as the number of pain sites that subjects reported increased. CONCLUSIONS: This study supports a previous observation that persons with regional and widespread pain are at an increased risk of cancer death. Possible mechanisms should be explored.

Exley C, Swarbrick L, Gherardi RK, Authier FJ. · Birchall Centre for Inorganic Chemistry and Materials Science, Keele University, Staffordshire ST5 5BG, UK. · Med Hypotheses. · Pubmed #19004564 No free full text.

Abstract: Macrophagic myofasciitis and chronic fatigue syndrome are severely disabling conditions which may be caused by adverse reactions to aluminium-containing adjuvants in vaccines. While a little is known of disease aetiology both conditions are characterised by an aberrant immune response, have a number of prominent symptoms in common and are coincident in many individuals. Herein, we have described a case of vaccine-associated chronic fatigue syndrome and macrophagic myofasciitis in an individual demonstrating aluminium overload. This is the first report linking the latter with either of these two conditions and the possibility is considered that the coincident aluminium overload contributed significantly to the severity of these conditions in this individual. This case has highlighted potential dangers associated with aluminium-containing adjuvants and we have elucidated a possible mechanism whereby vaccination involving aluminium-containing adjuvants could trigger the cascade of immunological events which are associated with autoimmune conditions including chronic fatigue syndrome and macrophagic myofasciitis.

Davies KA, Macfarlane GJ, Nicholl BI, Dickens C, Morriss R, Ray D, McBeth J. · Arthritis Research Campaign Epidemiology Unit, Stopford Building, University of Manchester, Oxford Road, Manchester M13 9PT, UK. · Rheumatology (Oxford). · Pubmed #18842606 links to  free full text

Abstract: OBJECTIVES: Poor sleep is associated with chronic widespread pain (CWP). Conversely, good-quality sleep may play a role in the resolution of pain symptoms. Sleep is a multidimensional construct, comprising a number of diverse components. The aims of the current study were to examine the hypotheses that: (i) good sleep quality would predict the resolution of CWP, (ii) restorative sleep would predict the resolution of CWP and (iii) that these relationships would be independent of confounding psychological factors. METHODS: Subjects in a population-based prospective study completed a pain questionnaire at baseline from which subjects with CWP were identified. Baseline sleep was measured using the Estimation of Sleep Problems Scale which measures sleep onset, maintenance, early wakening and restorative sleep. The questionnaire also contained scales examining psychosocial status. Subjects were followed up 15 months later and pain status was assessed. RESULTS: A total of 1061 subjects reported CWP at baseline of whom 679 (75% of eligible subjects) responded at follow-up. Of those, a total of 300 (44%) no longer satisfied criteria for CWP. Univariate analysis revealed that three of the four sleep components were associated with the resolution of CWP: rapid sleep onset, odds ratio (OR) = 1.7, 95% CI 1.2, 2.5; absence of early wakening, OR = 1.6, 95% CI 1.1, 2.4; and restorative sleep, OR = 2.7, 95% CI 1.5, 4.8. After adjusting for the effect of psychosocial factors, which may have confounded the relationship, only restorative sleep (OR = 2.0, 95% CI 1.02, 3.8) was associated. CONCLUSIONS: Self-reported restorative sleep was independently associated with the resolution of CWP and return to musculoskeletal health.

Ryan S, Hill J, Thwaites C, Dawes P. · Haywood Hospital, Stoke-on-Trent. · Nurs Stand. · Pubmed #18828292 No free full text.

Abstract: AIMS: The primary aim of this study was to investigate whether a questionnaire developed for patients with rheumatoid arthritis (RA) could also be used with patients who have fibromyalgia. A secondary aim was to assess the impact of fibromyalgia on sexuality. METHOD: In the first of two phases the face and content validity of a sexuality questionnaire already being used in patients with RA were assessed in a qualitative, audio-taped, interview study of five patients with fibromyalgia. The second phase consisted of a self-report questionnaire distributed to 60 patients with fibromyalgia. FINDINGS: The interview data confirmed that the content of the RA sexuality questionnaire was relevant to patients with fibromyalgia. A total of 43 (72%) questionnaires were returned and, of these, 41 (95%) were usable. Patients reported that fibromyalgia had altered their sexual relationship. They cited pain, stiffness, fatigue, reduced sexual drive and the impact of drug therapy as the main reasons. CONCLUSION: The symptoms associated with fibromyalgia had a negative effect on sexual enjoyment. The questionnaire appears to be useful in addressing sexuality in patients with fibromyalgia.

Thompson EA, Mathie RT, Baitson ES, Barron SJ, Berkovitz SR, Brands M, Fisher P, Kirby TM, Leckridge RW, Mercer SW, Nielsen HJ, Ratsey DH, Reilly D, Roniger H, Whitmarsh TE. · Bristol Homeopathic Hospital, Bristol, UK. · Homeopathy. · Pubmed #18657769 No free full text.

Abstract: INTRODUCTION: We report findings from a pilot data collection study within a programme of quality assurance, improvement and development across all five homeopathic hospitals in the UK National Health Service (NHS). AIMS: (1) To pilot the collection of clinical data in the homeopathic hospital outpatient setting, recording patient-reported outcome since first appointment; (2) to sample the range of medical complaints that secondary-care doctors treat using homeopathy, and thus identify the nature and complexity of complaints most frequently treated nationally; (3) to present a cross section of outcome scores by appointment number, including that for the most frequently treated medical complaints; (4) to explore approaches to standard setting for homeopathic practice outcome in patients treated at the homeopathic hospitals. METHODS: A total of 51 medical practitioners took part in data collection over a 4-week period. Consecutive patient appointments were recorded under the headings: (1) date of first appointment in the current series; (2) appointment number; (3) age of patient; (4) sex of patient; (5) main medical complaint being treated; (6) whether other main medical complaint(s); (7) patient-reported change in health, using Outcome Related to Impact on Daily Living (ORIDL) and its derivative, the ORIDL Profile Score (ORIDL-PS; range, -4 to +4, where a score <or=-2 or >or=+2 indicates an effect on the quality of a patient's daily life); (8) receipt of other complementary medicine for their main medical complaint. RESULTS: The distribution of patient age was bimodal: main peak, 49 years; secondary peak, 6 years. Male:female ratio was 1:3.5. Data were recorded on a total of 1797 individual patients: 195 first appointments, 1602 follow-ups (FUs). Size of clinical service and proportion of patients who attended more than six visits varied between hospitals. A total of 235 different medical complaints were reported. The 30 most commonly treated complaints were (in decreasing order of frequency): eczema; chronic fatigue syndrome (CFS); menopausal disorder; osteoarthritis; depression; breast cancer; rheumatoid arthritis; asthma; anxiety; irritable bowel syndrome; multiple sclerosis; psoriasis; allergy (unspecified); fibromyalgia; migraine; premenstrual syndrome; chronic rhinitis; headache; vitiligo; seasonal allergic rhinitis; chronic intractable pain; insomnia; ulcerative colitis; acne; psoriatic arthropathy; urticaria; ovarian cancer; attention-deficit hyperactivity disorder (ADHD); epilepsy; sinusitis. The proportion of patients with important co-morbidity was higher in those seen after visit 6 (56.9%) compared with those seen up to and including that point (40.7%; P<0.001). The proportion of FU patients reporting ORIDL-PS>or=+2 (improvement affecting daily living) increased overall with appointment number: 34.5% of patients at visit 2 and 59.3% of patients at visit 6, for example. Amongst the four most frequently treated complaints, the proportion of patients that reported ORIDL-PS>or=+2 at visit numbers greater than 6 varied between 59.3% (CFS) and 73.3% (menopausal disorder). CONCLUSIONS: We have successfully piloted a process of national clinical data collection using patient-reported outcome in homeopathic hospital outpatients, identifying a wide range and complexity of medical complaints treated in that setting. After a series of homeopathy appointments, a high proportion of patients, often representing "effectiveness gaps" for conventional medical treatment, reported improvement in health affecting their daily living. These pilot findings are informing our developing programme of standard setting for homeopathic care in the hospital outpatient context.

Derbyshire SW, Whalley MG, Oakley DA. · School of Psychology, University of Birmingham, Edgbaston, Birmingham B152TT, UK. · Eur J Pain. · Pubmed #18653363 No free full text.

Abstract: The neuropsychological status of pain conditions such as fibromyalgia, commonly categorized as 'psychosomatic' or 'functional' disorders, remains controversial. Activation of brain structures dependent upon subjective alterations of fibromyalgia pain experience could provide an insight into the underlying neuropsychological processes. Suggestion following a hypnotic induction can readily modulate the subjective experience of pain. It is unclear whether suggestion without hypnosis is equally effective. To explore these and related questions, suggestions following a hypnotic induction and the same suggestions without a hypnotic induction were used during functional magnetic resonance imaging to increase and decrease the subjective experience of fibromyalgia pain. Suggestion in both conditions resulted in significant changes in reported pain experience, although patients claimed significantly more control over their pain and reported greater pain reduction when hypnotised. Activation of the midbrain, cerebellum, thalamus, and midcingulate, primary and secondary sensory, inferior parietal, insula and prefrontal cortices correlated with reported changes in pain with hypnotic and non-hypnotic suggestion. These activations were of greater magnitude, however, when suggestions followed a hypnotic induction in the cerebellum, anterior midcingulate cortex, anterior and posterior insula and the inferior parietal cortex. Our results thus provide evidence for the greater efficacy of suggestion following a hypnotic induction. They also indicate direct involvement of a network of areas widely associated with the pain 'neuromatrix' in fibromyalgia pain experience. These findings extend beyond the general proposal of a neural network for pain by providing direct evidence that regions involved in pain experience are actively involved in the generation of fibromyalgia pain.

Mouyis M, Ostor AJ, Crisp AJ, Ginawi A, Halsall DJ, Shenker N, Poole KE. · Box 157, Department of Medicine, Division of Bone Research, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK. · Rheumatology (Oxford). · Pubmed #18499714 links to  free full text

Abstract: OBJECTIVES: A role for vitamin D in the pathogenesis of autoimmune and inflammatory diseases is emerging. We undertook an audit of 25-hydroxyvitamin D (25OHD) investigation and treatment in rheumatology outpatients. METHODS: Serum 25OHD requests were matched to electronic medical records from rheumatology and metabolic bone clinics (April 2006-March 2007). Data were analysed separately for two groups, 'Documented osteoporosis/osteopaenia' (Group 1) and 'General rheumatology outpatients' (Group 2, sub-divided by diagnosis). Hypovitaminosis D was defined by 25OHD levels <50 nmol/l. Values were compared with healthy adults to calculate geometric z-scores. RESULTS: A total of 263 patients were included (Group 1, n = 122; Group 2, n = 141) with an overall median 25OHD of 44 nmol/l.The 25OHD level among general rheumatology patients (median 39 nmol/l, mean z score -1.2, was statistically significantly lower than among osteoporotic/osteopaenic patients (median 49 nmol/l, mean z score of -0.9, p < 0.05 for the difference). 25OHD was lower in inflammatory arthritis and chronic pain/fibromyalgia than in other groups. Prescribing was recorded in 100 in Group 1 (of whom 95% were prescribed calcium/800 IU cholecalciferol) and 83 in Group 2 (91% calcium/800 IU). Only 31% of the patients with 25OHD <50 nmol/l would have been identified using general guidelines for screening patients at 'high risk' of hypovitaminosis D. CONCLUSIONS: Improved guidelines for managing hypovitaminosis D in rheumatology patients are needed. We found a high prevalence of hypovitaminosis D among secondary care patients in rheumatology and widespread supplementation with 800 IU cholecalciferol. Substantially reduced levels of serum 25OHD were identified among patients with inflammatory arthritis and chronic pain.

Miller A, Doll H, David J, Wass J. · Department of Rheumatology, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, UK. · Eur J Endocrinol. · Pubmed #18426816 links to  free full text

Abstract: OBJECTIVE: To provide rheumatological assessment of patients with long-standing acromegaly and investigate the impact of musculoskeletal disease on quality of life. DESIGN: Cross-sectional observational study. METHODS: Fifty-eight patients diagnosed with acromegaly at least 5 years previously were interviewed and examined by a rheumatologist. Each patient completed the short form-36 (SF-36), arthritis impact measurement scales 2 (AIMS2) and acromegaly quality of life questionnaires (AcroQol). RESULTS: Fifty-two out of 58 (90%) reported musculoskeletal pain, with 29 (50%) reporting neck pain. Hip osteoarthritis was present in 49 (84%) and knee osteoarthritis in 20 (34%). Half the patients (52%) reported sleep disturbance, but only 2 (3.5%) had fibromyalgia. Ten (17.2%) had previously undergone carpal tunnel decompression. Fifty-one (88%) patients had consulted their general practioner and 31 (54%) complementary therapists. SF-36, AIMS2 and AcroQol scores were lower in patients with musculoskeletal pain. CONCLUSIONS: This study of musculoskeletal problems in patients with acromegaly reports systematic rheumatological examination, use of medical services and quality of life scores. Musculoskeletal problems should be routinely addressed in acromegaly by both endocrinologist and rheumatologist and a multidisciplinary approach taken to management.

Sim J, Madden S. · Primary Care Musculoskeletal Research Centre, Keele University, Keele, Staffordshire ST5 5BG, United Kingdom. · Soc Sci Med. · Pubmed #18423826 No free full text.

Abstract: There is growing interest in synthesizing qualitative research. Despite certain philosophical and methodological difficulties, such syntheses are potentially useful in enriching the insights of empirical qualitative work in a particular area. This paper reports an interpretive review of research into the subjective experience of fibromyalgia syndrome (FMS), utilizing principles of metasynthesis. Twenty-three separate studies were identified. Each study was evaluated using methodological criteria to provide a context for interpretation of substantive findings. Principal findings were extracted and synthesized under four broad categories: experience of symptoms, search for diagnosis, legitimacy, and coping. Our findings re-emphasised the point that pain in FMS is ambiguous and invisible, raising questions of credibility and legitimacy. People with a diagnosis of FMS appear to frame the experience of symptoms within the biomedical model, where FMS is viewed as an organic entity potentially identifiable through biomedical tests. The subjective meaning and perceived legitimacy of the diagnostic label appear to be important factors in the subjective experience of FMS. Coping strategies adopted can be subsumed under Mannerkorpi, K., Kroksmark, T., Ekdahl, C. [1999. How patients with fibromyalgia experience their symptoms in everyday life. Physiotherapy Research International, 4(2), 110-122.] notions of 'struggling', 'adapting', 'in despair' and 'giving up'. Most studies had at least one identified methodological shortcoming, though it is not straightforward to identify the significance of such shortcomings. We conclude that there is scope for further research into the subjective experience of FMS, and into the methodology of metasynthesis, especially in relation to methodological appraisal.

Duncan B, White A, Rahman A. · Pain Management Centre, The National Hospital for Neurology & Neurosurgery University College, London Hospitals, UK. · Acupunct Med. · Pubmed #18160924 No free full text.

Abstract: AIMS: Fibromyalgia is a common cause of chronic widespread pain. The benefit of medication is often limited by its side effects, and the improvements obtained with exercise and education are inconsistent. Many patients seek acupuncture treatment, which is reported to be helpful in some cases. This study aimed to explore the acceptability and benefits of acupuncture offered in the setting of a tertiary referral clinic. METHODS: An open, uncontrolled observational study was conducted among patients who met the usual fibromyalgia criteria and who had a pain score of at least 30 on a 100mm Visual Analogue Scale (VAS). Patients were allowed to continue other treatments but not to introduce new ones. Acupuncture was given using a Western approach according to a protocol developed by consensus. Patients were offered eight treatments in eight weeks. Outcome measures included VAS of pain intensity and Fibromyalgia Impact Questionnaire (range 0 - 100), and were taken before and after treatment, and at 14, 20 and 34 weeks from enrolment. RESULTS: Twenty four eligible patients were enrolled in a 12 month period. Baseline mean pain VAS score for these 24 patients was 74 (SD 18) and mean Fibromyalgia Impact Questionnaire score 78 (SD 12.4). Only 14 patients completed the course of treatment within about 10 weeks. Compliance was poor in the remaining patients because of difficulty attending clinic, and in two cases because of exacerbation of pain. Completion of outcome measures was variable and therefore the analysis of data is limited. Five patients scored at least 20% reduction in Fibromyalgia Impact Questionnaire score which is a clinically relevant improvement. Two of these scored at least 50% reduction. CONCLUSION: Acupuncture appears to offer symptomatic improvement to some patients with fibromyalgia in a tertiary clinic who have failed to respond to other treatments. In view of its safety, further acupuncture research is justified in this population.

Ismail K, Kent K, Sherwood R, Hull L, Seed P, David AS, Wessely S. · Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, UK. · Psychol Med. · Pubmed #17892626 No free full text.

Abstract: BACKGROUND: The aim was to determine the prevalence of chronic fatigue syndrome (CFS), chronic fatigue and fibromyalgia in UK military personnel after the Gulf War 1990-1991. METHOD: A two-phase cohort study was used. Three randomly selected subsamples identified from a population-based cross-sectional postal survey of over 10,000 current and ex-service UK military personnel (Gulf veterans were those deployed to the Gulf War 1990-1991; non-Gulf veterans were Bosnia peacekeepers 1992-1997 and those on active duty during the Gulf War 1990-1991 but not deployed) were recruited. Their disability status was assessed using the Short Form 36 physical functioning scale; Gulf veterans who reported physical disability (n=111) were compared with non-Gulf (n=133) veterans who reported similar levels of physical disability. Screening for known medical and psychiatric conditions was conducted to exclude medical explanations for disability and symptomatic distress. Standardised criteria for CFS, chronic fatigue and fibromyalgia were used. RESULTS: Disabled Gulf veterans were more likely to be overweight, have elevated gamma-glutamyl transferase levels and screen positive for hypertension. There were no other clinically significant differences in clinical markers for medically explainable conditions. Disabled Gulf veterans were more likely than similarly disabled Bosnia and Era veterans (adjusted odds ratio 7.8, 95% confidence interval 2.5-24.5) to meet the criteria for CFS. Rates for other medically unexplained conditions were not significantly increased. CONCLUSIONS: Symptoms in keeping with CFS account for a significant part of the symptomatic distress in Gulf veterans.

McCabe CS, Cohen H, Blake DR. · The Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath BA1 1RL, UK. · Rheumatology (Oxford). · Pubmed #17767000 links to  free full text

Abstract: OBJECTIVES: Conflict between sensory-motor central nervous processing generates somaesthetic disturbances, including pain, in healthy volunteers (HVs). Such conflict has been proposed as a potential cause of pain that occurs in the absence of injury or when the pain response is disproportionate to the injury. Fibromyalgia (FMS) exemplifies the former state. We hypothesized that the artificial generation of such conflict would exacerbate somaesthetic perceptions including pain in FMS greater than in HVs. METHODS: Twenty-nine adults with FMS took part in an established task that generates varied degrees of sensory-motor conflict during congruent/incongruent limb movements. A qualitative methodology recorded any changes in sensory experience. Data generated were compared with age and gender-matched HV data. RESULTS: Twenty-six subjects (89.7%) with FMS reported changes in sensory perception at some stage in the protocol in addition to, or worse than, baseline compared with 14 (48%) of HVs. All stages of the protocol generated a higher frequency of report in the FMS population than that of the maximum report in the HVs population. New perceptions included disorientation, pain, perceived changes in temperature, limb weight or body image. CONCLUSIONS: Our findings support the hypothesis that motor-sensory conflict can exacerbate pain and sensory perceptions in those with FMS to a greater extent than in HVs.

Theadom A, Cropley M. · Department of Primary Care and Public Health, Brighton and Sussex Medical School, Falmer, Brighton, UK. · Sleep Med. · Pubmed #17681881 No free full text.

Abstract: OBJECTIVE: To explore sleep-related dysfunctional beliefs, stress levels and sleep quality in patients with fibromyalgia in comparison to healthy controls. METHODS: One hundred sixty-six participants (83 patients with fibromyalgia and 83 healthy controls) completed self-report measures exploring beliefs and attitudes about sleep, perceived stress, sleep quality and levels of pain and fatigue. RESULTS: Relative to healthy controls, patients with fibromyalgia revealed significantly higher levels of dysfunctional beliefs and attitudes about sleep and perceived stress. High dysfunctional beliefs were significantly associated with poorer sleep quality and high perceived stress was significantly related to higher sleep disturbances and daytime dysfunction. CONCLUSIONS: Beliefs about sleep and perceived stress play a significant role in the sleep quality of patients with fibromyalgia. Interventions to improve sleep quality for people with fibromyalgia need to identify and address dysfunctional beliefs about sleep and incorporate stress management approaches.

Dunckley P, Aziz Q, Wise RG, Brooks J, Tracey I, Chang L. · Department of Physiology, Anatomy and Genetics, Oxford, UK. · Neurogastroenterol Motil. · Pubmed #17593138 No free full text.

Abstract: A better understanding of the cortical processes underlying attentional modulation of visceral and somatic pain in health are essential for interpretation of future imaging studies of hypervigilance towards bodily sensations which is considered to be an aetiologically important factor in the heightened pain reported by patients with irritable bowel syndrome and fibromyalgia. Twelve healthy subjects were recruited for this study. Simultaneous trains of electrical pulses (delivered to either the rectum or lower abdomen) and auditory tones lasting 6 s were delivered to the subjects during a whole-brain functional scan acquisition. Subjects were instructed to attend to the auditory tones (distracter task) or electrical pulses (pain task). Pain intensity ratings were significantly lower during the distraction task compared with the pain task (P < 0.01) in both sensory modalities. The left primary somatosensory cortex increased in activity with increasing pain report, during attention to visceral pain. Bilateral anterior insula (aIns) cortex activity increased with increasing somatic pain report independent of the direction of attention. Conversely, the primary and secondary auditory cortices significantly increased in activation with decreased pain report. These results suggest that pain intensity perception during attentional modulation is reflected in the primary somatosensory cortex (visceral pain) and aIns cortex activity (somatic pain).

Palmer B, Macfarlane G, Afzal C, Esmail A, Silman A, Lunt M. · ARC Epidemiology Unit, Manchester University Medical School, Oxford Road, Manchester M13 9PT, UK. · Rheumatology (Oxford). · Pubmed #17401133 links to  free full text

Abstract: BACKGROUND: Musculoskeletal pain is reported more commonly by South Asians in the UK than by white Europeans. This may result from a variety of factors, including cultural differences, and thus we investigated the extent to which differences in the prevalence of pain within the South Asian population could be explained by differences in acculturation (the extent to which immigrants take on the culture of their host population). METHODS: Nine hundred and thirty-three Europeans and 1914 South Asian (1165 Indian, 401 Pakistani and 348 Bangladeshi) subjects were recruited from the age-sex registers of 13 general practices in areas with high densities of South Asian populations (Bolton, Oldham, Ashton-under-Lyne and Birmingham). A 28-item acculturation scale was developed, based, on aspects including use of language, clothing style, and use of own-culture media. Principle component analysis generated a score (range 0-100), which was validated against constructs expected to relate to acculturation, such as years of full time education and time spent in the UK. The presence of widespread pain was assessed by the answer to the question 'Have you suffered from pain all over the body in the past month?' RESULTS: Widespread pain was more common in all three South Asian ethnic groups than in the white Europeans [odds ratio (OR) = 3.7, 95% confidence interval (CI) 2.9-4.9], with this increase ranging from 2.7 to 5.8 in the different South Asian subgroups. There was a similar increase in consultation rates for pain. Within the South Asians, pooling all three groups, there was a strong negative association between acculturation score and widespread pain, which remained after adjusting for age and sex: [OR (95% CI) per standard deviation decrease in acculturation score -1.2 (1.0-1.3)]. Adjusting for acculturation accounted for some, but not all, of the differences between the ethnic groups in the prevalence of widespread pain: OR 2.0 (95% CI 1.4-3.0). CONCLUSIONS: Widespread pain is more commonly reported in South Asians though there are interesting differences within the South Asian community. Lower acculturation has a strong influence on the reporting of pain, but cannot explain all of the difference between South Asian and European populations.