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The effects of sodium oxybate on clinical symptoms and sleep patterns in patients with fibromyalgia [In Process Citation]

J Rheumatol 2003 May;30(5):1070-4 (ISSN: 0315-162X) Scharf MB; Baumann M; Berkowitz DV Tri-State Sleep Disorders Center, Cincinnati, Ohio, USA.

OBJECTIVE: Fibromyalgia (FM) is associated with the sleep phenomenon of alpha intrusion, and with low growth hormone secretion. Sodium oxybate has been shown to increase both slow-wave sleep and growth hormone levels. This double blind, randomized, placebo controlled crossover trial was conducted to evaluate the effects of sodium oxybate on the subjective symptoms of pain, fatigue, and sleep quality and the objective polysomnographic (PSG) sleep variables of alpha intrusion, slow-wave (stage 3/4) sleep, and sleep efficiency in patients with FM. METHODS: Patients received either 6.0 g/day sodium oxybate or placebo for 1 month, with an intervening 2 week washout period. Efficacy measures included PSG evaluations, tender point index (TPI), and subjective measurements from daily diary entries. Safety measures included clinical laboratory values, vital signs, and adverse events.

RESULTS: Twenty-four female patients were included in the study; 18 completed the trial. TPI was decreased from baseline by 8.5, compared with an increase of 0.4 for placebo (p = 0.0079). Six of the 7 pain/fatigue scores (overall pain, pain at rest, pain during movement, end of day fatigue, overall fatigue, and morning fatigue) were relieved by 29% to 33% with sodium oxybate, compared with 6% to 10% relief with placebo (p < 0.005). Alpha intrusion, sleep latency, and rapid-eye-movement sleep were significantly decreased, while slow-wave (stage 3/4) sleep was significantly increased, compared with placebo (p < 0.005). Two of the 5 subjective sleep related variables were significantly different from placebo: morning alertness (improved by 18% with sodium oxybate, compared with 2% for placebo; p = 0.0033) and quality of sleep (improved by 33% and 10%, respectively; p = 0.0003). CONCLUSION: Sodium oxybate effectively reduced the symptoms of pain and fatigue in patients with FM, and dramatically reduced the sleep abnormalities (alpha intrusion and decreased slow-wave sleep) associated with the nonrestorative sleep characteristic of this disorder. Language: English MEDLINE Indexing Date: 200305

Read the full online article on medline here

Depression and Soft Tissue Pain
Journal: J of Musculoskeletal Pain, Vol. 11(1) 2003, pp. 1-3

http://www.haworthpress.com/store/product.asp?sku-J094

In this issue of the Journal of Musculoskeletal Pain [JMP], depression is implicated as an important comorbid factor in patients with soft tissue pain. According to Sorrell, Flanagan, and McCall (1,2), depressed United States patients with myofascial pain syndrome [MPS] were more resistant to treatment than were MPS patients who did not exhibit con- comitant depression. Similarly, Hagg, et al.. (3), found that depression bore an important influence on perceived quality of life among Swedish patients with surgical low back pain, among Swedish patients with fibromyalgia, and even among Swedish community non- patients with chronic low back pain. Indeed, this phenomenon is not limited to people with soft tissue pain conditions because depression is believed to be an important comorbid factor regarding disability among patients with osteoarthritis (4-6), patients with rheumatoid arthritis (7-10), and patients with systemic lupus (11,12) to name just a few painful disorders. The old arguments that depression is the cause of low back pain or of pain in patients with fibromyalgia are clearly lame from multiple unsupported parades, but it is fair to say that the resilience of the human spirit becomes less elastic in the presence of chronic pain.

It has been estimated that depression is present in about 10 percent of the general pop- ulation (13,14), in about 20 percent of all hospitalized patients, irrespective of the admitting diagnosis (13), and in about 40 percent of patients with chronic pain (15). The hypothesis that depression can cause rheumatoid pain or myofascial pain by altering pain perception was not supported by careful studies of these disorders (16,17), so it seems likely that concomitant depression, when it is present, can be one consequence of the chronic pain and other limitations imposed by these diseases. Of course, there is no reason that major depression could not present independently of the development of the painful condition. Since painful conditions and depression seem to be comorbid more frequently than would be predicted by chance alone, it would be nice be certain which should be viewed as the chicken and which the egg. Considering our current uncertainties, the better part of valor may be to recognize this association when it occurs and to do something about it.

The approach of Sorrell, Flanagan, and McCall (1,2) was to expectantly integrate psychological support with physical interventions to create a multidisciplinary treatment regimen for myofascial pain syndrome. Despite the apparent clinical value of that change, their failures were still notably among those patients with the longest durations of chronic pain and with comorbid depression.

On the other hand, Hagg et al. (3) point out that there were patients with long-term disability, due to marked physical limitations, who viewed their quality of life to be more favorable than the compromise in their function would project. In such cases, the authors proposed that community support had helped them adapt to "a lower level of physical activity" and had "allowed them to continue [their] personal development" under conditions that "minimize[d] detriments to social relationships" (3). The alternative is nourished by inadequate diagnosis, by delayed treatment, by innuendo that the patient is faking the symptoms for the purpose of secondary gain, and, occasionally, by 'cold medical and social shoulders.' People "with poorly defined and poorly acknowledged chronic pain accompanied by a lack of effective treatment" may be more at risk to experience a poor medical outcome, "extended stress responses, neuroendocrine dysregulation, and impaired medical and psychological functioning that [legitimately] leads to a generalized perception of poor quality of life" (3). Alas, hypotheses such as these are much more difficult to prove than they are to articulate. In the meantime, empathy requires some effort but is usually rewarded in kind.

Bunkan et al. (18) have offered a unique Norwegian attempt to apply psychometric theory and practice to the examination of skeletal muscles. This paper proposes to validate the palpable muscle consistency subscale of a Comprehensive Body Examination instrument (19) that may eventually be used as a validated out- come measure for research study.

Finally, the Research Ideas contribution by Lewis and Fontrier (20) suggests a possible mechanism for benefit from lithium therapy of patients with fibromyalgia.

When this editorial was originally written, it was still uncertain whether or not the new format for the Journal of Musculoskeletal Pain would become a reality with this issue. After 10 years of successful production of this journal in the smaller size, the pieces of the puzzle all came together this year to make the change. It was prompted by an earlier request from the Board of the International MYOPAIN Society but printing procedure at the publication site had, in the past, restricted the size. New equipment obtained by the publisher has made the change possible but adaptation to this format has somewhat delayed release of this first 2003 issue. In addition, the publisher had recently made color processing available to the Journal of Musculoskeletal Pain when that is needed for clarity of presentation. The Journal of Musculoskeletal Pain Editorial Staff, the Editorial Board, the Editorial Committee, and the International MYOPAIN Society Board and its officers would all like to express their appreciation to Mr. Bill Cohen, Publisher, and to the Staff at Haworth Press for their efforts toward making this new format a reality. Readers of the Journal of Musculoskeletal Pain are encouraged to write to the Editor and communicate their impressions regarding this new format.

Readers of the Journal of Musculoskeletal Pain are invited to submit original manuscripts for peer review, research ideas to promote investigation, and letters to keep us all on the narrow path toward truth. Letters may be sent bye-mail to the Editor at mailto:russel@uthscsa.edu , but be certain to indicate that your comments are for publication in the JMP. Letters sent by e-mail must be followed by mail [to the Editor] or by FAX [210-567-6669] submission of the same letter in hard copy along with a signed publication agreement.

I. Jon Russell, MD, PhD, The Editor

REFERENCES
1. Sorrell MR, Flanagan W: Treatment of chronic resistant myofascial pain using a multidisciplinary protocol [The Myofascial Pain Program]. J Musculoske Pain 11(1):5-9,2003. 2. Sorrell MR, Flanagan W, McCall JL: The effect of depression and anxiety on the success of multidisciplinary treatment of chronic resistant myofascial pain. J Musculoske Pain 11(1):17-20,2003. 3. Hiigg 0, Burckhardt C, Fritzell P, Nordwall A, and The Swedish Lumbar Spine Study Group: Quality of life in chronic low back pain: A comparison with fibromyalgia and the general population. J Musculoske Pain 11(1):31-38.2003. 4. Odding E,Valkenburg HA, Starn HJ, Hofman: Determinants of locomotor disability in people aged 55 years and over: the Rotterdam Study. European Journal of Epidemiology 17:1033-1041,2001. 5. Kominski GF, Simon PA, Ho A, Luck J, Lim YW, Fielding JE: Assessing the burden of disease and injury in Los Angeles County using disability-adjusted life years. Public Health Reports 117: 185-191,2002. 6. Wu LR, Parkerson GR, Jr., Doraiswamy PM: Health perception, pain, and disability as correlates of anxiety and depression symptoms in primary care patients. Journal of the American Board of Family Practice 15:183-190,2002. 7. Cathey MA, Wolfe F, Kleinheksel SM: Functional ability and work status in patients with fibromyalgia. Arthritis Care Res 1:85-98,1988. 8. Pincus T, Callahan LF, Bradley LA, Vaughn WK, Wolfe F: Elevated MMPI. scores for hypochondriasis, depression, and hysteria in patients with rheumatoid arthritis reflect disease rather than psychological status. Arthritis Rheum 29:1456-1466,1986. 9. Holm MB, Rogers JC, Kwoh CK: Predictors of functional disability in patients with rheumatoid arthritis. Arthritis Care & Research 11:346-355,1998. 10. Escalante A, del Rincon I., Mulrow CD: Symptoms of depression and psychological distress among Hispanics with rheumatoid arthritis. Arthritis Care & Research 13(3): 156-167,2000. 11. Segui J, Ramos-Casals M, Garcia-Carrasco M, de Flores T, Cervera R, Valdes M, Font J, Ingelmo M: Psychiatric and psychosocial disorders in patients with systemic lupus erythematosus: A longitudinal study of active and inactive stages of the disease. Lupus 9:584-588, 2000. 12. Ward MM, Lotstein DS, Bush TM, Lambert RE, van Vollenhoven R, Neuwelt CM: Psychosocial correlates of morbidity in women with systemic lupus erythematosus. Journal of Rheumatology 26:2 I 53-2158, 1999. 13. Nielsen ACI, Williams TA: Prevalence by self- report questionnaire and recognition by nonpsychiatric physicians. Arch Gen Psychiatry 37:999-1004, I 980. 14. Robins LN, Helzer IE, Weissman MM, Orvaschel H, Gruenberg E, Burke ID lr, Regier DA: Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 41:949-958,1984. 15. Ahles TA, Khan SA, Yunus MB, Spiegel DA, Masi AT: Psychiatric status of patients with primary fibromyalgia, patients with rheumatoid arthritis, and subjects without pain: A blind comparison of DSM-III diagnoses. American Journal of Psychiatry 148: 172 I -1726, 1991. 16. Dohrenwend BP, Raphael KG, Marbach 11, Gallagher RM: Why is depression comorbid with chronic myofascial face pain? A family study test of alternative hypotheses. Pain 83: 183-192, 1999. 17. Ward MM: Are patient self-report measures of arthritis activity confounded by mood? A longitudinal study of patients with rheumatoid arthritis. J Rheumatol 21:1046-1050,1994. 18. Bunkan BH, Opjordsrnoen S, Moen 0, Ljunggren AE, Friis S: Palpation of skeletal muscles: A psychometric evaluation of the muscular items of the Comprehensive Body Examination. J Musculoske Pain 11(1): 21-30,2003. 19. Bunkan BH: Kropp, respirasjon og kroppsbilde. [Body, respiration and body image]. Norwegian University Press, Oslo, 1996, 20. Lewis 1M, Fontrier 11I: Lithium and fibromyalgia. J Musculoske Pain 11(1):69-70,2003.

Bone mineral density in fibromyalgia patients-- correlation to disease activity.

Scand J Rheumatol. 2003;32(3):146-50.
Jensen B, Wittrup IH, Bliddal H, Danneskiold-Samsoe B, Faber J.
Parker Institute, Frederiksberg Hospital, Copenhagen, Denmark. Bjensen@aab11.dk
PMID: 12892250

OBJECTIVE: To compare bone mass (BMD) in women with fibromyalgia (FM) with healthy females, and to evaluate whether self-reported pain and lack of functional capacity correlate to reduced BMD in FM patients.

METHODS: Thirty-one FM patients (20 pre- and 11 postmenopausal) and fourty-one healthy women (30 pre- and 10 postmenopausal) were enrolled in the study. BMD of the lumbar spine and the femoral neck was measured by a DEXA (Norland) scanner. Self reported pain was measured on a Visual Analog Scale (VAS). The Activity of Daily Living (ADL) component of the Fibromyalgia Impact Questionnaire (FIQ-ADL) was used as measure for physical capacity.

RESULTS: BMD-lumbar spine and BMD-femoral neck did not differ significantly between FM patients and controls, though premenopausal FM patients tended to have lower BMD-femoral neck (p = 0.09). Self reported pain and FIQ-ADL among FM patients correlated with BMD-femoral neck (r(s) = -0.52, p = 0.003); (r(s) = -0.31, p = 0.09).

CONCLUSION: Premenopausal FM patients tended to have lower BMD of hip than controls. Self reported pain correlated negatively to BMD. Thus, the severity of FM might have a negative impact on bone mass.

A metabolic basis for fibromyalgia and its related disorders: the possible role of resistance to thyroid hormone.

Journal: Med Hypotheses. 2003 Aug;61(2):182-9.

Authors: Garrison RL [1], Breeding PC.
[1] Corresponding author. Correspondence to: R.L. Garrison, MD, 3306 Montavesta Drive, Apt D70, Lexington, KY 40502, USA. Phone: 1-859-420-0888; Fax: 1-859-268-0026
Received 4 April 2000; accepted 10 October 2000; available online 11 June 2003. NLM Citation: PMID: 12888300

It has long been recognized that the symptom complex of fibromyalgia can be seen with hypothyroidism. Hypothyroidism may been categorized, like diabetes, into type I (hormone deficient) and type II (hormone resistant).

Most cases of fibromyalgia fall into the latter category. The syndrome is reversible with treatment, and is usually of late onset. It is likely more often acquired than due to mutated receptors. Now that there is evidence to support the hypothesis that fibromyalgia may be due to thyroid hormone resistance, four major questions appear addressable.

First, can a simple biomarker be found to help diagnose it? Second, what other syndromes similar to Fibromyalgia may share a thyroid-resistant nature? Third, in non-genetic cases, how is resistance acquired? Fourth, what other methods of treatment become available through this new understanding?

Preliminary evidence suggests that serum hyaluronic acid is a simple, inexpensive, sensitive, and specific test that identifies fibromyalgia. Overlapping symptom complexes suggest that chronic fatigue syndrome, Gulf war syndrome, premenstrual syndrome, post traumatic stress disorder, breast implant silicone sensitivity syndrome, bipolar affective disorder, systemic candidiasis, myofascial pain syndrome, and idiopathic environmental intolerance are similar enough to fibromyalgia to merit investigation for possible thyroid resistance.

Acquired resistance may be due most often to a recently recognized chronic consumptive coagulopathy, which itself may be most often associated with chronic infections with mycoplasmids and related microbes or parasites. Other precipitants of thyroid resistance may use this or other paths as well.

In addition to experimentally proven treatment with supraphysiologic doses of thyroid hormone, the thyroid-resistant disorders might be treatable with anti-hypercoagulant, anti-infective, insulin-sensitizing, and hyaluronolytic strategies.

Mycoplasma blood infection in chronic fatigue and fibromyalgia syndromes.

Journal: Rheumatol Int. 2003 Jul 16 [Epub ahead of print].
Author: Endresen GK. Affiliation: Department of Rheumatology, The National Hospital, University of Oslo, Forskningsvn. 2-Block B, 0027, Oslo, Norway. Email: mailto:gerhard.endresen@rikshospitalet.no Received: 17 February 2003 Accepted: 13 May 2003 Published online: 16 July 2003 NLM Citation: PMID: 12879275

Chronic fatigue syndrome (CFS) and fibromyalgia syndrome (FMS) are characterised by a lack of consistent laboratory and clinical abnormalities. Although they are distinguishable as separate syndromes based on established criteria, a great number of patients are diagnosed with both.

In studies using polymerase chain reaction methods, mycoplasma blood infection has been detected in about 50% of patients with CFS and/or FMS, including patients with Gulf War illnesses and symptoms that overlap with one or both syndromes. Such infection is detected in only about 10% of healthy individuals, significantly less than in patients.

Most patients with CFS/FMS who have mycoplasma infection appear to recover and reach their pre-illness state after long-term antibiotic therapy with doxycycline, and the infection can not be detected after recovery. By means of causation and therapy, mycoplasma blood infection may permit a further subclassification of CFS and FMS.

It is not clear whether mycoplasmas are associated with CFS/FMS as causal agents, cofactors, or opportunistic infections in patients with immune disturbances. Whether mycoplasma infection can be detected in about 50% of all patient populations with CFS and/or FMS is yet to be determined.

[Note: The full text of this article is available at: http://www.springerlink.com/app/home/content.asp?wasp=524c86bqtp7jqkflkq5r&referrer=contribution&format=13&page=1 although you must be a registered user...registration is quick & simple]

Elements of fibromyalgia in an open population.

Rheumatology (Oxford) 2003 Mar 31; [epub ahead of print] Schochat T, Raspe H. Institute for Occupational, Social and Environmental Medicine, Medical University Ulm. PMID: 12730531

OBJECTIVE: To examine the nosological concept of fibromyalgia in the general population.

METHODS: A postal survey of rheumatic pain and non-specific bodily complaints was sent to all 3174 German female residents of Bad Sackingen, Germany, aged 35 to 74 yr. A stratified random sample of 653 subjects was further examined in a clinical survey.

RESULTS: On the population level the point prevalence of chronic widespread pain was 13.5%. In the clinical survey, tender point count was associated not only with the extent of rheumatic pain, but also independently with the extent of bodily complaints. Subjects with no history of rheumatic pain but with non-specific bodily complaints had as many positive tender points as subjects without bodily complaints but with a history of rheumatic pain. Subjects could be identified who met the tender point criterion of the ACR without a history of widespread pain. Multivariate analyses demonstrated that some symptoms carry a risk for positive tender points (low physical mobility, pain, bodily complaints) and some for chronic widespread pain (poor health status, catastrophizing, emotional reactions, low energy level, sleep disturbances) that are independent of each other and of age.

CONCLUSIONS: The results do not only question the relevance and specificity of a history of widespread pain in diagnosing fibromyalgia, but also the concept of fibromyalgia as a distinct rheumatological disorder. The results support the concept of fibromyalgia as part of a wider spectrum of dysfunctional syndromes.

Systemic lupus erythematosus in three ethnic groups: Prevalence and correlates of fibromyalgia.

Lupus 2003;12(4):274-9 Friedman AW, Tewi MB, Ahn C, McGwin G Jr, Fessler BJ, Bastian HM, Baethge BA, Reveille JD, Alarcon GS; LUMINA Study Group. University of Texas-Houston Health Science Center, Houston, TX 77030, USA. PMID: 12729050

The purpose of this study was to determine the prevalence and correlates of fibromyalgia (FM) in a prospective, multiethnic systemic lupus (SLE) cohort.

A total of 266 SLE patients with disease duration of < or = 5 years at study entry were evaluated longitudinally for the presence of FM (per ACR criteria). Sociodemographic factors, behavioral/psychological variables, clinical features, serologic factors (autoantibodies), and self-reported functioning (MOS SF-36) were ascertained in all patients. Subjects were evaluated at study entry and annually thereafter. The prevalence of FM was then calculated, as was the prevalence of FM-like manifestations (widespread pain with at least 6, but fewer than 11/18 tender points). Variables were evaluated for association with FM or FM-like manifestations by univariate and stepwise logistic regression analyses.

FM was present in 14 patients (5%; 9/92 Caucasians (C), 4/109 African Americans (AA), 1/65 Hispanics (H)) and FM/FM-like manifestations in 35 (13%; 16 C, 9 AA, 10 H). There was no difference noted between those with and without FM with respect to gender, education level, income below poverty level, disease activity or damage. By stepwise logistic regression analyses, the strongest association with both FM and FM/FM-like manifestations was a self-reported history of anxiety or affective disorder (P = 0.0237, OR = 4.6 and P = 0.0068, OR = 3.4, respectively). Caucasian ethnicity was strongly associated with FM (P = 0.0066, OR = 7.5) and African American ethnicity was negatively associated with FM/FM-like (P = 0.0204, OR = 0.3). Poorer self-reported physical functioning was associated with FM/FM-like (P = 0.0443, OR = 0.96).

FM and FM-like manifestations correlate best with the presence of Caucasian ethnicity, concomitant anxiety or affective disorder, and to a lesser extent with poorer self-reported physical functioning. African American ethnicity is negatively associated with the combination of FM and FM-like manifestations. Clinical measures of disease activity, disease damage, specific organ dysfunction, sociodemographic factors and serologic features are not correlated with FM in this early SLE cohort.

Central Nociceptive Hyperexcitability Important in Fibromyalgia

Laurie Barclay, MD

May 1, 2003 — Central nociceptive hyperexcitability may be important in fibromyalgia (FM), according to the results of a study published in the May issue of Arthritis & Rheumatism. The nociceptive flexion reflex may be helpful in discriminating which patients would benefit from central analgesia.

"Our results strongly, although indirectly, point to a state of central hyperexcitability of the body's central pain system in patients with FM," lead author J. A. Desmeules, MD, from Geneva University Hospital in Switzerland, says in a news release. Of 85 outpatients with FM attending a self-management program, 89% were women, all were middle-aged, and mean disease duration was eight years.

Compared with 40 healthy controls matched for age and sex, peripheral quantitative sensory testing in FM patients showed significantly altered cold and heat pain thresholds, with tolerance to cold pain 66% lower. Threshold for the spinal nociceptive flexion reflex was 50% lower than in controls.

Using a cutoff value of less than 27.6 mA for nociceptive flexion reflex, sensitivity was 73% and specificity was 80% for detecting central allodynia.

According to Dr. Desmeules, these findings suggest the benefits of treating FM with analgesics acting on the central nervous system. Antidepressants have been shown to reduce the pain sensitivity reflex of healthy volunteers after a single dose.

"The nociceptive flexion reflex can be used to assess central allodynia in patients with FM," the authors write, while recommending additional research. "It may also help discriminate patients who may benefit from use of centrally acting analgesics."

Arthritis Rheum. 2003;48:1420-1429 Reviewed by Gary D. Vogin, MD

GH Response to Exercise Impaired in Fibromyalgia

NEW YORK (MedscapeWire) May 06 — Growth hormone (GH) response to maximal exercise is impaired in patients with fibromyalgia, according to research reported in the May issue of Arthritis & Rheumatism. Normalization with pyridostigmine pretreatment suggests a defect in somatostatin tone, which may be related to the exhaustive stage of chronic stress. "The results of this study indicate that GH deficiency is probably more common in fibromyalgia patients than was originally reported," senior author Robert Bennett, MD, MRCP, from Oregon Health Sciences University in Portland, says in a news release. Fibromyalgia is thought to be a stress-related syndrome, linked to malfunctions of the hypothalamic, pituitary, and adrenal hormones, including GH. In this study, 20 women with fibromyalgia and a control group of 10 healthy women exercised to volitional exhaustion, reaching maximum respiratory and pulse rate on a treadmill. One month later, testing was repeated 1 hour after pretreatment with pyridostigmine, which inhibits somatostatin secretion. Without pyridostigmine pretreatment, 11 of the 20 patients with fibromyalgia had no exercise-induced increase in GH levels. After the administration of pyridostigmine, 19 of the 20 patients had a normal GH response to exercise. The overall increase in GH was 8 times higher than without pretreatment and was similar to that seen in controls. Pyridostigmine alone did not stimulate GH secretion in patients with fibromyalgia, nor did it affect GH levels in controls. Even those fibromyalgia patients with normal insulin-like growth factor 1 levels had an impaired GH response to exercise. "Recognition of defective GH secretion in fibromyalgia patients is of some practical relevance because GH replacement therapy was shown to benefit fibromyalgia patients in a 9-month placebo-controlled study," Bennett says.

Arthritis Rheum. 2002;46(5):1344-1350 Reviewed by Gary D. Vogin, MD

Collagen and muscle pathology in fibromyalgia patients

Rheumatology (Oxford). 2003 Jul 16 [Epub ahead of print]. Gronemann ST, Ribel-Madsen S, Bartels EM, Danneskiold-Samsoe B, Bliddal H. The Parker Institute, Department of Rheumatology, Frederiksberg Hospital, H:S University Hospital. PMID: 12867573

OBJECTIVE: To measure collagen concentration and search for muscle pathology in muscle non-tender-point areas from fibromyalgia (FM) patients.

METHODS: Muscle biopsies were obtained from m. vastus lateralis of 27 carefully selected, female fibromyalgia patients, and from eight age-matched female control subjects. Amino acids were determined by HPLC and electron microscopy was performed.

RESULTS: The FM patients had lower hydroxyproline and lower total concentration of the major amino acids of collagen than the controls. No significant difference was seen in the concentration of the major amino acids of myosin or of total protein. Electron microscopy showed no significant differences between FM patients and controls although atrophied muscle fibrils occurred in FM patients only, but frequencies were not significantly different.

CONCLUSION: Fibromyalgia patients had a significantly lower amount of intramuscular collagen. This may lower the threshold for muscle micro-injury and thereby result in non-specific signs of muscle pathology.

Nerve conduction tests in patients with fibromyalgia: comparison with normal controls

Rheumatol Int. 2003 Jul;23(4):166-70. Ersoz M. Ankara Physical Medicine and Rehabilitation Education and Research Hospital, Ministry of Health, Ankara, Turkey, mailto:mersoz@tr.net PMID: 12856141

The purpose of this study was to evaluate nerve conduction in fibromyalgia (FM) patients and normal subjects.Testing of F waves and motor, sensory, and mixed nerve conduction was performed in 33 consecutive female FM patients complaining of paresthesias in the extremities and in 17 age- and sex-matched healthy volunteers.

The nerve conduction results in FM patients were no different from those of normal subjects except for prolonged peroneal distal motor latency ( P=0.048) and decreased peroneal motor conduction velocity ( P=0.030). Five of the 33 patients (15%) showed abnormalities in peroneal nerve conduction, five (15%) had carpal tunnel syndrome (CTS), and overall nine (27%) had electrophysiologic findings of focal entrapment, which indicated that focal neuropathies were common in this patient group.

There was no evidence of generalized polyneuropathy in the FM patients.

Chronic widespread pain and fibromyalgia: what we know, and what we need to know.

Best Pract Res Clin Rheumatol. 2003 Aug;17(4):685-701. Clauw DJ, Crofford LJ. Division of Rheumatology, Department of Medicine, University of Michigan Medical School, 101 Simpson, 48109-0723, Ann Arbor, MI, USA PMID: 12849719

Fibromyalgia (FM) is currently defined as the presence of both chronic widespread pain (CWP) and the finding of 11/18 tender points on examination. Only about 20% of individuals in the population with CWP also have 11/18 tender points; these individuals are considerably more likely to be female, and have higher levels of psychological distress.

There is no clear clinical diagnosis for the other 80% of individuals with less than 11/18 tender points, but it is likely that these persons, like FM patients, also have pain that is 'central' (i.e. not due to inflammation or damage of structures) rather than peripheral in nature.

Research into FM has taught us a great deal about the confluence of neurobiological, psychological and behavioural factors that can cause chronic central pain. These conditions respond best to a combination of symptom-based pharmacological therapies, and non-pharmacological therapies such as exercise and cognitive behavioural therapy.

In contrast to drugs that work for peripheral pain due to damage or inflammation (e.g. NSAIDs, corticosteroids), neuroactive compounds [especially those that raise central levels of noradrenaline (norepinephrine) or serotonin] are most effective for treating central pain.

The effect of combined therapy (ultrasound and interferential current) on pain and sleep in fibromyalgia.

Pain. 2003 Aug;104(3):665-72.
Almeida TF, Roizenblatt S, Benedito-Silva AA, Tufik S. Department of Psychobiology, Universidade Federal de Sao Paulo, Rua Napoleao de Barros 925, Vila Clementino, 04024-002, Sao Paulo, SP, Brazil PMID: 12927639

Multidisciplinary treatment has proven to be the best therapeutic option to fibromyalgia (FM) and physiotherapy has an important role in this approach. Considering the controversial results of electrotherapy in this condition, the aim of this study was to assess the effects of combined therapy with pulsed ultrasound and interferential current (CTPI) on pain and sleep in FM.

Seventeen patients fulfilling FM criteria were divided into two groups, CTPI and SHAM, and submitted to pain and sleep evaluations. Pain was evaluated by body map (BM) of the painful areas; quantification of pain intensity by visual analog scale (VAS); tender point (TP) count and tenderness threshold (TT). Sleep was assessed by inventory and polysomnography (PSG). After 12 sessions of CTPI or SHAM procedure, patients were evaluated by the same initial protocol.

After treatment, CTPI group showed, before and after sleep, subjective improvement of pain in terms of number (BM) and intensity (VAS) of painful areas (P<0.001, both); as well as objective improvement, with decrease in TP count and increase in TT (P<0.001, both). Subjective sleep improvements observed after CTPI treatment included decrease in morning fatigue and in non-refreshing sleep complaint (P<0.001, both). Objectively, PSG in this group showed decrease in sleep latency (P<0.001) and in the percentage of stage 1 (P<0.001), increase in the percentage of slow wave sleep (P<0.001) and in sleep cycle count (P<0.001). Decrease in arousal index (P<0.001), number of sleep stage changes (P<0.05) and wake time after sleep onset (P<0.05), were also observed and no difference regarding pain or sleep parameters were verified after SHAM procedure.

This study shows that CTPI can be an effective therapeutic approach for pain and sleep manifestations in FM.

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