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Ramírez Medina CR, Feng M, Huang YT, Jenkins DA, Jani M. Machine learning identifies risk factors associated with long-term opioid use in fibromyalgia patients newly initiated on an opioid. RMD Open 2024; 10:e004232. [PMID: 38772680 DOI: 10.1136/rmdopen-2024-004232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 04/29/2024] [Indexed: 05/23/2024] Open
Abstract
OBJECTIVES Fibromyalgia is frequently treated with opioids due to limited therapeutic options. Long-term opioid use is associated with several adverse outcomes. Identifying factors associated with long-term opioid use is the first step in developing targeted interventions. The aim of this study was to evaluate risk factors in fibromyalgia patients newly initiated on opioids using machine learning. METHODS A retrospective cohort study was conducted using a nationally representative primary care dataset from the UK, from the Clinical Research Practice Datalink. Fibromyalgia patients without prior cancer who were new opioid users were included. Logistic regression, a random forest model and Boruta feature selection were used to identify risk factors related to long-term opioid use. Adjusted ORs (aORs) and feature importance scores were calculated to gauge the strength of these associations. RESULTS In this study, 28 552 fibromyalgia patients initiating opioids were identified of which 7369 patients (26%) had long-term opioid use. High initial opioid dose (aOR: 31.96, mean decrease accuracy (MDA) 135), history of self-harm (aOR: 2.01, MDA 44), obesity (aOR: 2.43, MDA 36), high deprivation (aOR: 2.00, MDA 31) and substance use disorder (aOR: 2.08, MDA 25) were the factors most strongly associated with long-term use. CONCLUSIONS High dose of initial opioid prescription, a history of self-harm, obesity, high deprivation, substance use disorder and age were associated with long-term opioid use. This study underscores the importance of recognising these individual risk factors in fibromyalgia patients to better navigate the complexities of opioid use and facilitate patient-centred care.
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Affiliation(s)
- Carlos Raúl Ramírez Medina
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Mengyu Feng
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - Yun-Ting Huang
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
| | - David A Jenkins
- Division of Informatics, Imaging and Data Science, The University of Manchester, Manchester, UK
| | - Meghna Jani
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Department of Rheumatology, Salford Royal Hospital, Northern Care Alliance, Salford, UK
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The Use of the Coenzyme Q 10 as a Food Supplement in the Management of Fibromyalgia: A Critical Review. Antioxidants (Basel) 2022; 11:antiox11101969. [PMID: 36290691 PMCID: PMC9598746 DOI: 10.3390/antiox11101969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
The coenzyme Q10 is a naturally occurring benzoquinone derivative widely prescribed as a food supplement for different physical conditions and pathologies. This review aims to sum up the key structural and functional characteristics of Q10, taking stock of its use in people affected by fibromyalgia. A thorough survey has been conducted, using Pubmed, Scifinder, and ClinicalTrials.gov as the reference research applications and registry database, respectively. Original articles, reviews, and editorials published within the last 15 years, as well as open clinical investigations in the field, if any, were analyzed to point out the lights and shadows of this kind of supplementation as they emerge from the literature.
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Varallo G, Suso-Ribera C, Ghiggia A, Veneruso M, Cattivelli R, Guerrini Usubini A, Franceschini C, Musetti A, Plazzi G, Fontana JM, Capodaglio P, Castelnuovo G. Catastrophizing, Kinesiophobia, and Acceptance as Mediators of the Relationship Between Perceived Pain Severity, Self-Reported and Performance-Based Physical Function in Women with Fibromyalgia and Obesity. J Pain Res 2022; 15:3017-3029. [PMID: 36186755 PMCID: PMC9525026 DOI: 10.2147/jpr.s370718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/18/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Individuals with fibromyalgia and obesity experience significant impairment in physical functioning. Pain catastrophizing, kinesiophobia, and pain acceptance have all been identified as important factors associated with the level of disability. The objective of this study was to evaluate the role of pain catastrophizing, kinesiophobia, and pain acceptance as mediators of the association between perceived pain severity and physical functioning in individuals with fibromyalgia and obesity. Patients and Methods In this cross-sectional study, 165 women with fibromyalgia and obesity completed self-report questionnaires of perceived pain severity (ie, Numeric Pain Rating Scale), pain catastrophizing (ie, Pain Catastrophizing Scale), kinesiophobia (ie Tampa Scale of Kinesiophobia), pain acceptance (ie, Chronic Pain Acceptance Questionnaire), and perceived physical functioning (ie, Physical Functioning subscale of the Fibromyalgia Impact Questionnaire). In addition, a performance-based test (ie, 6-minute walking test) was conducted to assess objective physical functioning. Two multiple mediation analyses were performed. Results Pain acceptance and kinesiophobia mediated the relationship between pain severity and self-reported physical functioning. Pain catastrophizing and kinesiophobia mediated the relationship between pain severity and performance-based functioning. Conclusion Pain acceptance, kinesiophobia, and pain catastrophizing should be addressed in rehabilitative intervention to improve physical functioning. Interestingly, the subjective and objective aspects of physical functioning are influenced by different factors. Therefore, interventions for women with fibromyalgia and obesity should focus on factors related to both subjective and performance-based physical functioning.
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Affiliation(s)
- Giorgia Varallo
- Department of Medicine and Surgery, University of Parma, Parma, 43121, Italy
| | - Carlos Suso-Ribera
- Department of Basic and Clinical Psychology and Psychobiology, Jaume I University, Castellon de la Plana, 12071, Spain
| | - Ada Ghiggia
- Department of Life Sciences, University of Trieste, Trieste, 34127, Italy
| | - Marco Veneruso
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | | | - Anna Guerrini Usubini
- Department of Psychology, Catholic University of Milan, Milan, 20123, Italy
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, 28824, Italy
| | | | - Alessandro Musetti
- Department of Humanities, Social Sciences and Cultural Industries, University of Parma, Parma, 43125, Italy
| | - Giuseppe Plazzi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, 41125, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna (ISNB), Bologna, 40139, Italy
| | - Jacopo Maria Fontana
- Istituto Auxologico Italiano IRCCS, Orthopaedic Rehabilitation Unit and Research Laboratory in Biomechanics and Rehabilitation, San Giuseppe Hospital, Verbania, 28824, Italy
- Correspondence: Jacopo Maria Fontana, San Giuseppe Hospital, Strada Cadorna 90, Verbania, 28824, Italy, Tel +39 0323 514 331, Email
| | - Paolo Capodaglio
- Istituto Auxologico Italiano IRCCS, Orthopaedic Rehabilitation Unit and Research Laboratory in Biomechanics and Rehabilitation, San Giuseppe Hospital, Verbania, 28824, Italy
- Department of Surgical Sciences, Physical and Rehabilitation Medicine, University of Turin, Turin, 10121, Italy
| | - Gianluca Castelnuovo
- Department of Psychology, Catholic University of Milan, Milan, 20123, Italy
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, 28824, Italy
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Is Whole-Body Cryostimulation an Effective Add-On Treatment in Individuals with Fibromyalgia and Obesity? A Randomized Controlled Clinical Trial. J Clin Med 2022; 11:jcm11154324. [PMID: 35893415 PMCID: PMC9332222 DOI: 10.3390/jcm11154324] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 12/10/2022] Open
Abstract
Pain severity, depression, and sleep disturbances are key targets for FM rehabilitation. Recent evidence suggests that whole-body cryostimulation (WBC) might be an effective add-on treatment in the management of FM. The purpose of this study was to evaluate the effects of an add-on WBC intervention to a multidisciplinary rehabilitation program on pain intensity, depressive symptoms, disease impact, sleep quality, and performance-based physical functioning in a sample of FM patients with obesity. We performed a randomized controlled trial with 43 patients with FM and obesity undergoing a multidisciplinary rehabilitation program with and without the addition of ten 2-min WBC sessions at −110 °C over two weeks. According to our results, the implementation of ten sessions of WBC over two weeks produced additional benefits. Indeed, both groups reported positive changes after the rehabilitation; however, the group that underwent WBC intervention had greater improvements in the severity of pain, depressive symptoms, disease impact, and quality of sleep. On the contrary, with respect to performance-based physical functioning, we found no significant between-group differences. Our findings suggest that WBC could be a promising add-on treatment to improve key aspects of FM, such as pain, depressive symptoms, disease impact and poor sleep quality.
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Cardenas-Rojas A, Castelo-Branco L, Pacheco-Barrios K, Shaikh ES, Uygur-Kucukseymen E, Giannoni-Luza S, Vasconcelos Felippe L, Gonzalez-Mego P, Luna-Cuadros MA, Gianlorenco ACL, Teixeira PE, Caumo W, Fregni F. Recruitment characteristics and non-adherence associated factors of fibromyalgia patients in a randomized clinical trial: A retrospective survival analysis. Contemp Clin Trials Commun 2021; 24:100860. [PMID: 34849424 PMCID: PMC8609141 DOI: 10.1016/j.conctc.2021.100860] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 10/08/2021] [Accepted: 11/09/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Fibromyalgia is a complex pain condition that affects mostly women. Given the disease's lack of understanding, patients report poor adherence to medication and mistrust of medical services. This study aims to describe the recruitment characteristics and non-adherence associated factors of fibromyalgia patients to an RCT. METHODS We performed a retrospective longitudinal analysis with data from our ongoing RCT. We investigated characteristics of subjects recruited, consented, and randomized. Adherence was studied using survival analysis techniques, and its associated factors were identified using Cox proportional hazards regression model. RESULTS 524 subjects were contacted, 269 were eligible, 61 consented and 40 subjects were randomized. Thirty-eight percent were non-adherent to the protocol with a median of visits of five. The recruitment survey reported that 90% would likely participate in RCTs, 52% had previous participation, and 19% were aware of RCTs by their physicians. Some barriers were investigator-related (staff's friendliness and receiving the results of their trial participation) and center-related (privacy-confidentiality issues and the institution's reputation), without difference between adherent and non-adherent participants. We report significant factors for non-adherence as VAS anxiety score of 5 or more (5.3 HR, p = 0.01), Body Mass Index (BMI) (0.91 HR, p = 0.041) and Quality of Life (QoL) - Personal development subdomain (0.89 HR, p = 0.046). CONCLUSION Recruitment and adherence of fibromyalgia patients is a challenge; however, they seem eager to participate in RCTs. We recommend creating a comfortable, friendly and trusting environment to increase the recruitment rate. Higher anxiety, lower BMI and lower quality of life were associated with a higher attrition rate.
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Affiliation(s)
- Alejandra Cardenas-Rojas
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Luis Castelo-Branco
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Universidad San Ignacio de Loyola, Vicerrectorado de Investigación, Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Lima, Peru
| | - Emad Salman Shaikh
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elif Uygur-Kucukseymen
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefano Giannoni-Luza
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Luna Vasconcelos Felippe
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Paola Gonzalez-Mego
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Maria Alejandra Luna-Cuadros
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Carolyna Lepesteur Gianlorenco
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Therapy, Federal University of Sao Carlos, Brazil
| | - Paulo E.P. Teixeira
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- MGH Institute of Health Professions, USA
| | - Wolnei Caumo
- Pain and Palliative Care Service at Clinical Hospital of Porto Alegre (HCPA), Federal University of Rio Grande do Sul, Brazil
| | - Felipe Fregni
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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The Role of Pain Catastrophizing and Pain Acceptance in Performance-Based and Self-Reported Physical Functioning in Individuals with Fibromyalgia and Obesity. J Pers Med 2021; 11:jpm11080810. [PMID: 34442454 PMCID: PMC8401554 DOI: 10.3390/jpm11080810] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 12/11/2022] Open
Abstract
Impaired physical functioning is one of the most critical consequences associated with fibromyalgia, especially when there is comorbid obesity. Psychological factors are known to contribute to perceived (i.e., subjective) physical functioning. However, physical function is a multidimensional concept encompassing both subjective and objective functioning. The contribution of psychological factors to performance-based (i.e., objective) functioning is unclear. This study aims to investigate the contribution of pain catastrophizing and pain acceptance to both self-reported and performance-based physical functioning. In this cross-sectional study, 160 participants completed self-report measures of pain catastrophizing, pain acceptance, and pain severity. A self-report measure and a performance-based test were used to assess physical functioning. Higher pain catastrophizing and lower pain acceptance were associated with poorer physical functioning at both self-reported and performance-based levels. Our results are consistent with previous evidence on the association between pain catastrophizing and pain acceptance with self-reported physical functioning. This study contributes to the current literature by providing novel insights into the role of psychological factors in performance-based physical functioning. Multidisciplinary interventions that address pain catastrophizing and pain acceptance are recommended and might be effective to improve both perceived and performance-based functioning in women with FM and obesity.
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Rodríguez-Roca B, Urcola-Pardo F, Anguas-Gracia A, Subirón-Valera AB, Gasch-Gallén Á, Antón-Solanas I, Gascón-Catalán AM. Impact of Reducing Sitting Time in Women with Fibromyalgia and Obesity: A Randomized Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126237. [PMID: 34207661 PMCID: PMC8296136 DOI: 10.3390/ijerph18126237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sitting time has negative effects on health, increasing the risk of obesity, osteoporosis, diabetes, and cancer. Thus, primary health care education interventions aimed to reduce sitting time and sedentary behavior could have beneficial effects on people's health and wellbeing. The purpose of this study was to assess the effectiveness of an intervention based on reducing sitting time to decrease cardiometabolic risk on a sample of women diagnosed with fibromyalgia and moderate obesity. METHODS Randomized controlled trial to evaluate the effectiveness of an intervention to decrease cardiometabolic risk in 84 participants. Sedentary behavior was monitored using an accelerometer before and at 3-month follow-up. RESULTS Compared with the control group, body mass index decreased, and the number of steps taken increased, in the intervention group 3 months after the intervention. No significant differences were found in the rest of the variables measured. CONCLUSION The intervention group decreased sitting time after the intervention. Group activities and support from primary care may be useful to improve treatment adherence. RCT registration: NCT01729936.
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Affiliation(s)
- Beatriz Rodríguez-Roca
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain; (B.R.-R.); (F.U.-P.); (A.A.-G.); (A.B.S.-V.); (A.M.G.-C.)
| | - Fernando Urcola-Pardo
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain; (B.R.-R.); (F.U.-P.); (A.A.-G.); (A.B.S.-V.); (A.M.G.-C.)
- Research Group Water and Environmental Health (B43_20R), University Institute of Research in Environmental Science of Aragón, University of Zaragoza, 50009 Zaragoza, Spain
| | - Ana Anguas-Gracia
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain; (B.R.-R.); (F.U.-P.); (A.A.-G.); (A.B.S.-V.); (A.M.G.-C.)
- Research Group Water and Environmental Health (B43_20R), University Institute of Research in Environmental Science of Aragón, University of Zaragoza, 50009 Zaragoza, Spain
- Research Group Safety and Care (GIISA0021), Institute of Research of Aragón, 50009 Zaragoza, Spain
| | - Ana Belén Subirón-Valera
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain; (B.R.-R.); (F.U.-P.); (A.A.-G.); (A.B.S.-V.); (A.M.G.-C.)
- Research Group Water and Environmental Health (B43_20R), University Institute of Research in Environmental Science of Aragón, University of Zaragoza, 50009 Zaragoza, Spain
- Research Group Sector III Healthcare (GIIS081), Institute of Research of Aragón, 50009 Zaragoza, Spain
| | - Ángel Gasch-Gallén
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain; (B.R.-R.); (F.U.-P.); (A.A.-G.); (A.B.S.-V.); (A.M.G.-C.)
- Research Group Nursing Research in Primary Care in Aragón (GENIAPA) (GIIS094), Institute of Research of Aragón, 50009 Zaragoza, Spain
- Correspondence: (Á.G.-G.); (I.A.-S.)
| | - Isabel Antón-Solanas
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain; (B.R.-R.); (F.U.-P.); (A.A.-G.); (A.B.S.-V.); (A.M.G.-C.)
- Research Group Nursing Research in Primary Care in Aragón (GENIAPA) (GIIS094), Institute of Research of Aragón, 50009 Zaragoza, Spain
- Correspondence: (Á.G.-G.); (I.A.-S.)
| | - Ana M. Gascón-Catalán
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain; (B.R.-R.); (F.U.-P.); (A.A.-G.); (A.B.S.-V.); (A.M.G.-C.)
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Fibromyalgia and obesity: A comprehensive systematic review and meta-analysis. Semin Arthritis Rheum 2021; 51:409-424. [PMID: 33676126 DOI: 10.1016/j.semarthrit.2021.02.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/30/2021] [Accepted: 02/15/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Obesity has been associated with several complications, including musculoskeletal disorders. Aim of the present systematic review was to identify all available evidence on the relationship between fibromyalgia (FM) and obesity, including epidemiological association, impact of obesity on FM severity and effect of weight loss strategies on FM symptoms. METHODS MedLine, Cochrane Central Register of Controlled Trials and Web of Science databases were searched up to September 2020 to identify eligible articles. Data from studies reporting the prevalence of obesity in FM patients were pooled using a random-effects model. RESULTS After removal of duplicate records, 393 studies proceeded to review. A total of 41 articles were deemed eligible for inclusion in final synthesis. Quality assessment revealed that the overall risk of bias was high. The overall prevalence of obesity in FM was 35.7% (95% CI: 31.8 - 39.9%), with higher figures reported for USA. The majority of studies included demonstrated that obesity is associated with different domains of the disorder, including composite measures of activity, pain severity, tender point count, stiffness, fatigue, physical functioning/disability, sleep, cognitive dysfunction, and quality of life; the strength of correlation was weak on average. Inconsistent data were available regarding the correlation with depression and anxiety. Only few studies addressed the effect of therapeutic weight loss in FM, either by bariatric surgery, diet/exercise combination or behavioral weight loss, providing preliminary evidence for a potential benefit of weight loss in ameliorating FM symptoms. CONCLUSIONS Available data support a potential interplay between obesity and FM-related symptoms. Weight management should be encouraged in patients with FM.
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Dong HJ, Larsson B, Rivano Fischer M, Gerdle B. Facing obesity in pain rehabilitation clinics: Profiles of physical activity in patients with chronic pain and obesity-A study from the Swedish Quality Registry for Pain Rehabilitation (SQRP). PLoS One 2020; 15:e0239818. [PMID: 32986777 PMCID: PMC7521725 DOI: 10.1371/journal.pone.0239818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 09/14/2020] [Indexed: 11/19/2022] Open
Abstract
Background The obesity epidemic has influenced pain rehabilitation clinics. To date, little is known about baseline level of physical activity (PA) in patients referred to pain rehabilitation clinics. We aimed to investigate the PA levels of patients referred to pain rehabilitation clinics and to evaluate the effect of excess weight on PA level. Methods and findings Data were obtained from the Swedish Quality Registry for Pain Rehabilitation between 2016 and 2017. These data included PA time (everyday PA and physical exercise per week), Body Mass Index (BMI), sociodemographic factors, chronic pain and psychological aspects (e.g., pain intensity, depressive and anxiety symptoms and insomnia problems). Insufficient PA was defined as less than 150 minutes per week. We performed logistic regressions as well as orthogonal partial least square regression to estimate the effects of excess weight on PA. Over one-fourth of the patients were classified as obese (BMI ≥30 kg/m2, 871/3110, 25.3%) and nearly one-third of these patients were classified as severely obese (BMI ≥35 kg/m2, 242/871, 27.8%). Time estimations for physical exercise varied among the BMI groups, but patients in the higher BMI category were more likely to spend less time on everyday PA. Compared to normal weight, mild obesity [odds ratio (OR) 0.65, 95% confidence interval (CI) 0.53–0.81] and severe obesity (OR 0.56, 95% CI 0.42–0.74) were associated with less PA. Mild obese patients had an elevated risk of 65% and severe obese patients had an elevated risk of 96% for insufficient PA. Increased pain intensity was positively related to insufficient PA (OR 1.17, 95% CI 1.06–1.29) among the obese patients. Conclusion Having low PA is very common for patients referred to pain rehabilitation clinics, especially for those with comorbid obesity. As a first step to increase PA, obese patients need to be encouraged to increase the intensity and amount of less painful daily PA.
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Affiliation(s)
- Huan-Ji Dong
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- * E-mail:
| | - Britt Larsson
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Marcelo Rivano Fischer
- Department of Health Sciences, Research Group Rehabilitation Medicine, Lund University, Lund, Sweden
- Department of Neurosurgery and Pain Rehabilitation, Skane University Hospital, Lund, Sweden
| | - Björn Gerdle
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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10
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Correa-Rodríguez M, Mansouri-Yachou JE, Casas-Barragán A, Molina F, Rueda-Medina B, Aguilar-Ferrandiz ME. The Association of Body Mass Index and Body Composition with Pain, Disease Activity, Fatigue, Sleep and Anxiety in Women with Fibromyalgia. Nutrients 2019; 11:E1193. [PMID: 31137906 PMCID: PMC6566359 DOI: 10.3390/nu11051193] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/14/2019] [Accepted: 05/22/2019] [Indexed: 12/26/2022] Open
Abstract
The link between fibromyalgia syndrome (FMS) and obesity has not been thoroughly investigated. The purpose of this study was to examine the relationships among body mass index (BMI) and body composition parameters, including fat mass, fat mass percentage, and visceral fat, as well as FMS features, such as tender point count (TPC), pain, disease activity, fatigue, sleep quality, and anxiety, in a population of FMS women and healthy controls. A total of seventy-three women with FMS and seventy-three healthy controls, matched on weight, were included in this cross-sectional study. We used a body composition analyzer to measure fat mass, fat mass percentage, and visceral fat. Tender point count (TPC) was measured by algometry pressure. The disease severity was measured with the Fibromyalgia Impact Questionnaire (FIQ-R) and self-reported global pain was evaluated with the visual analog scale (VAS). To measure the quality of sleep, fatigue, and anxiety we used the Pittsburgh Sleep Quality Questionnaire (PSQI), the Spanish version of the multidimensional fatigue inventory (MFI), and the Beck Anxiety Inventory (BAI), respectively. Of the women in this study, 38.4% and 31.5% were overweight and obese, respectively. Significant differences in FIQ-R.1 (16.82 ± 6.86 vs. 20.66 ± 4.71, p = 0.030), FIQ-R.3 (35.20 ± 89.02 vs. 40.33 ± 5.60, p = 0.033), and FIQ-R total score (63.87 ± 19.12 vs. 75.94 ± 12.25, p = 0.017) among normal-weight and overweight FMS were observed. Linear analysis regression revealed significant associations between FIQ-R.2 (β(95% CI)= 0.336, (0.027, 0.645), p = 0.034), FIQ-R.3 (β(95% CI)= 0.235, (0.017, 0.453), p = 0.035), and FIQ-R total score (β(95% CI)= 0.110, (0.010, 0.209), p = 0.032) and BMI in FMS women after adjusting for age and menopause status. Associations between sleep latency and fat mass percentage in FMS women (β(95% CI)= 1.910, (0.078, 3.742), p = 0.041) and sleep quality and visceral fat in healthy women (β(95% CI)= 2.614, (2.192, 3.036), p = 0.008) adjusted for covariates were also reported. The higher BMI values are associated with poor FIQ-R scores and overweight and obese women with FMS have higher symptom severity. The promotion of an optimal BMI might contribute to ameliorate some of the FMS symptoms.
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Affiliation(s)
- María Correa-Rodríguez
- Department of Nursing, Faculty of Health Sciences, University of Granada (UGR), Instituto de Investigación Biosanitaria Granada (IBS Granada), 18016 Granada, Spain.
| | - Jamal El Mansouri-Yachou
- Department of Physical Therapy, Faculty of Health Science, PhD student of the Biomedicine program of the University of Granada (UGR), 18016 Granada, Spain.
| | - Antonio Casas-Barragán
- Department of Physical Therapy, Faculty of Health Science, PhD student of the Biomedicine program of the University of Granada (UGR), 18016 Granada, Spain.
| | - Francisco Molina
- Department of Health Science, University of Jaén, Paraje Las Lagunillas s/n, 23071 Jaén, Spain.
| | - Blanca Rueda-Medina
- Department of Nursing, Faculty of Health Sciences, University of Granada (UGR), Instituto de Investigación Biosanitaria Granada (IBS Granada), 18016 Granada, Spain.
| | - María Encarnación Aguilar-Ferrandiz
- Department of Physical Therapy, Faculty of Health Science, University of Granada (UGR), Instituto de Investigación Biosanitaria Granada (IBS. Granada), 18016 Granada, Spain.
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11
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Koçyiğit BF, Okyay RA. The relationship between body mass index and pain, disease activity, depression and anxiety in women with fibromyalgia. PeerJ 2018; 6:e4917. [PMID: 29868295 PMCID: PMC5978395 DOI: 10.7717/peerj.4917] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/16/2018] [Indexed: 12/16/2022] Open
Abstract
Background Obesity is a possible factor which affects severity of symptoms and disease activity in fibromyalgia syndrome (FMS). The aim of our study was to determine the association between body mass index (BMI) and pain, tender point count (TPC), disease activity, anxiety and depression in patients with FMS. Methods This was a descriptive study. A total of 124 female FMS patients between 18 and 55 years of age were enrolled. FMS patients were evaluated with visual analog scale (VAS), fibromyalgia impact questionnaire (FIQ), Hamilton anxiety scale (HAM-A) and Hamilton depression scale (HAM-D). Patients were divided into three groups according to BMI levels: normal weight, overweight and obese. Normal weight was defined as BMI 18.5-24.9, overweight as BMI 25.0-29.9 and obesity as BMI ≥ 30. We assessed the BMI status and its association with symptom severity in patients with FMS. Results Significant differences were detected in VAS, TPC, FIQ and HAM-D among the groups (p < 0.05). There were no significant differences between the groups in HAM-A (p = 0.328). The highest scores were found in the obese group. Significant positive correlations were determined between BMI levels and VAS, TPC, FIQ and HAM-D (r = 0.277, p = 0.002; r = 0.384, p < 0.001; r = 0.292, p = 0.001; r = 0.357, p < 0.001). Discussion Obese female FMS patients had higher levels of pain, TPC, disease activity and depression. BMI was significantly and positively correlated with clinical manifestations of FMS. Therefore, FMS treatment programs should include weight loss strategies.
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Affiliation(s)
- Burhan Fatih Koçyiğit
- Department of Physical Medicine and Rehabilitation, Kahramanmaras Sütcü Imam University, Kahramanmaras, Turkey
| | - Ramazan Azim Okyay
- Department of Public Health, Kahramanmaras Sütcü Imam University, Kahramanmaras, Turkey
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12
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Alciati A, Atzeni F, Grassi M, Caldirola D, Sarzi-Puttini P, Angst J, Perna G. Features of mood associated with high body weight in females with fibromyalgia. Compr Psychiatry 2018; 80:57-64. [PMID: 29035730 DOI: 10.1016/j.comppsych.2017.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 07/27/2017] [Accepted: 08/29/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Fibromyalgia (FM) is a common syndrome whose main characteristic is chronic widespread musculoskeletal pain, the severity of which is frequently worsened by concomitant obesity. Major depression (MD), particularly as part of a bipolar spectrum disorder (BSD), is associated with both obesity and FM. OBJECTIVE To evaluate the relationship between lifetime MD, hypomanic symptoms and the body mass index (BMI) in patients with FM. METHOD Of the 115 patients originally screened, 87 women with FM finally entered the study. Forty-nine patients (57%) had a lifetime diagnosis of MD, assessed by a structured clinical interview based on DSM-IV criteria, and four of them (4.6%) had a current MD episode. Lifetime hypomanic symptoms were measured by means of the self-rated Hypomania Checklist. According to the international criteria for BMI, FM patients were classified as under/normal-weight (61%), overweight (30%) and obese (9%). RESULTS 62 patients (71.2%) with FM had a bipolar spectrum disorder (BSD). Thirty (48.3%) of them met criteria for bipolar II disorder, 32 (51,6%) for bipolar disorder NOS (18 FM patients with MD associated to sub-syndromal hypomanic syndrome and 14 with hypomanic syndrome without MD). No patient had a bipolar I disorder. Only one patient met the criteria for a major depressive disorder (MDD). There was no significant difference in mean BMI between the patients with and without a lifetime diagnosis of MD, but there was a positive association between the level of hypomanic symptoms and BMI values (p<0.009). When hypomania was considered categorically as hypomanic syndrome there was no significant effect on BMI. CONCLUSIONS Our finding adds to previous evidence indicating that hypomanic symptoms are a central feature of FM. In the case of the early identification of high-level hypomanic symptoms, body weight should be closely monitored in order to prevent obesity and its detrimental impact on females with FM.
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Affiliation(s)
- Alessandra Alciati
- Department of Clinical Neurosciences, Villa San Benedetto Menni Hospital, Hermanas Hospitalarias, FoRiPsi, Albese con Cassano, Como, Italy.
| | | | - Massimiliano Grassi
- Department of Clinical Neurosciences, Villa San Benedetto Menni Hospital, Hermanas Hospitalarias, FoRiPsi, Albese con Cassano, Como, Italy
| | - Daniela Caldirola
- Department of Clinical Neurosciences, Villa San Benedetto Menni Hospital, Hermanas Hospitalarias, FoRiPsi, Albese con Cassano, Como, Italy
| | | | - Jules Angst
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Switzerland
| | - Giampaolo Perna
- Department of Clinical Neurosciences, Villa San Benedetto Menni Hospital, Hermanas Hospitalarias, FoRiPsi, Albese con Cassano, Como, Italy; Research Institute of Mental Health and Neuroscience, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, University of Maastricht, Maastricht, Netherlands; Department of Psychiatry and Behavioral Sciences, Leonard Miller School of Medicine, University of Miami, Miami, USA
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13
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Kaleth AS, Slaven JE, Ang DC. Obesity Moderates the Effects of Motivational Interviewing Treatment Outcomes in Fibromyalgia. Clin J Pain 2018; 34:76-81. [PMID: 28272119 PMCID: PMC5831245 DOI: 10.1097/ajp.0000000000000500] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Obesity is a common comorbid condition among patients with fibromyalgia (FM). Our objective was to assess if obesity moderates the treatment benefits of exercise-based motivational interviewing (MI) for FM. MATERIALS AND METHODS This is a secondary data analysis of a completed clinical trial of 198 FM patients who were randomized to receive either MI or attention control (AC). Using body mass index (BMI) to divide participants into obese (BMI≥30 kg/m) and nonobese (BMI<30 kg m) groups, mixed linear models were used to determine interaction between treatment arms and obesity status with regards to the primary outcome of global FM symptom severity (Fibromyalgia Impact Questionnaire, FIQ). Secondary measures included pain intensity (Brief Pain Inventory), 6-Minute Walk Test, and self-reported physical activity (Community Health Activities Model Program for Seniors). RESULTS Of the 198 participants, 91 (46%) were nonobese and 107 (54%) were obese. On global FM symptom severity (FIQ), the interaction between treatment arms and obesity status was significant (P=0.02). In the nonobese group, MI was associated with a greater improvement in FIQ than AC. In the obese group, MI participants reported less improvement in FIQ compared with AC. The interaction analysis was also significant for Brief Pain Inventory pain intensity (P=0.01), but not for the walk test and self-reported physical activity. DISCUSSION This is the first study to show that obesity negatively affects the treatment efficacy of MI in patients with FM. Our findings suggest that exercise-based MI may be more effective if initiated after weight loss is achieved.
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Affiliation(s)
| | - James E Slaven
- Department of Biostatistics, Indiana University, Indianapolis, IN
| | - Dennis C Ang
- Department of Medicine, Division of Rheumatology, Wake Forest University School of Medicine, Winston-Salem, NC
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14
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Gist AC, Guymer EK, Eades LE, Leech M, Littlejohn GO. Fibromyalgia remains a significant burden in rheumatoid arthritis patients in Australia. Int J Rheum Dis 2017; 21:639-646. [PMID: 28296177 DOI: 10.1111/1756-185x.13055] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
AIM High rates of fibromyalgia (FM) are reported in rheumatoid arthritis (RA) patients. Advances in RA management have occurred, but information regarding current significance of FM in RA is limited. This investigation estimated the prevalence and health effects of concomitant FM in Australian RA patients. METHODS Participants were recruited from Australian rheumatology clinics. Subjects were assessed using the 1990 and 2011 American College of Rheumatology (ACR) FM criteria and the polysymptomatic distress score (PDS) was calculated. A medical history and a clinical examination were recorded. RA Disease Activity Score of 28 joints - erythrocyte sedimentation rate (DAS-28 ESR), and the Short Form-36 survey (SF-36) were completed. RESULTS Of 117 RA patients, 33.3% (n = 39) met 1990 ACR FM criteria and 41.9% (n = 49) met 2011 ACR FM criteria. RA patients with comorbid FM had worse outcomes across all domains of health as defined by the SF-36 (P < 0.05). There was correlation between both physical and mental health outcomes and the PDS (P < 0.001). RA patients with FM on average took 1.18 extra ongoing prescribed medications (P < 0.05), despite comparable RA disease activity (DAS-28: 3.09 vs. 3.27, P = NS). Comorbid central sensitivity conditions were more common in patients with FM (P < 0.001). CONCLUSION FM continues to demonstrate a high prevalence in a population of RA patients. RA patients with FM have more symptoms of other chronic sensitivity syndromes in addition to FM. They have a lower quality of life outcome and higher medication use. This has important clinical implications in terms of diagnosis, response to therapy, prescribing choices and clinical outcomes.
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Affiliation(s)
- Anthea C Gist
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Emma K Guymer
- Department of Rheumatology, Health and Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Laura E Eades
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michelle Leech
- Department of Rheumatology, Health and Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Geoffrey O Littlejohn
- Department of Rheumatology, Health and Department of Medicine, Monash University, Melbourne, Victoria, Australia
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Vincent A, Whipple MO, Low PA, Joyner M, Hoskin TL. Patients With Fibromyalgia Have Significant Autonomic Symptoms But Modest Autonomic Dysfunction. PM R 2016; 8:425-35. [PMID: 26314231 PMCID: PMC4766072 DOI: 10.1016/j.pmrj.2015.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/10/2015] [Accepted: 08/14/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND Research suggests that disordered autonomic function may be one contributor to deconditioning reported in fibromyalgia; however, no study to date has assessed these variables simultaneously with comprehensive measures. OBJECTIVE To characterize physical fitness and autonomic function with the use of clinically validated measures and subjective questionnaires between patients with fibromyalgia and healthy controls. DESIGN Cross-sectional, observational, controlled study. SETTING Community sample of patients with fibromyalgia and healthy controls. PARTICIPANTS Thirty patients with fibromyalgia and 30 pain and fatigue-free controls. METHODS Participants completed a battery of self-report questionnaires and physiological measures, including clinically validated measures of physical fitness and autonomic function. MAIN OUTCOME MEASUREMENTS Six-Minute Walk Test total distance, maximal oxygen consumption as assessed by cardiopulmonary exercise testing, total steps using activity monitor, Composite Autonomic Scoring Scale as assessed by Autonomic Reflex Screen, total metabolic equivalents per week using the International Physical Activity Questionnaire, and self-reported autonomic symptoms via the 31-item Composite Autonomic Symptom Score questionnaire. RESULTS Autonomic function, as assessed by self-report, was significantly different between patients and controls (P < .0001); in contrast, the only difference between patients and controls on the Autonomic Reflex Screen was in the adrenergic domain (P = .022), and these abnormalities were mild. Self-reported physical activity was not significantly different between patients and controls (P = .99), but levels of moderate and vigorous physical activity as measured by actigraphy were significantly lower in patients (P = .012 and P = .047, respectively). Exercise capacity (6-Minute Walk) was poorer in patients (P = .0006), but there was no significant difference in maximal volume of oxygen consumption (P = .07). CONCLUSIONS Patients with fibromyalgia report more severe symptoms across all domains, including physical activity and autonomic symptoms, compared with controls, but the objective assessments only showed modest differences. Our results suggest that patients with widespread subjective impairment of function have only modest objective measures of autonomic dysfunction. We recommend that the primary treatment goal should be focused on restoration of function, which may also ameliorate symptoms.
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Affiliation(s)
- Ann Vincent
- Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905(∗).
| | | | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN(‡)
| | - Michael Joyner
- Department of Anesthesiology, Mayo Clinic, Rochester, MN(§)
| | - Tanya L Hoskin
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN(‖)
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17
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Dursun H, Onrat E, Ercan E, Demirdal US, Avsar A, Dundar U, Solak O, Toktas H. Heart rate turbulence analysis in female patients with fibromyalgia. Clinics (Sao Paulo) 2015; 70:296-300. [PMID: 26017798 PMCID: PMC4418374 DOI: 10.6061/clinics/2015(04)13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 02/03/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Fibromyalgia is characterized by diffuse musculoskeletal pain and discomfort. There are several reports regarding autonomic nervous system dysfunction in patients with fibromyalgia. Heart rate turbulence is expressed as ventriculophasic sinus arrhythmia and has been considered to reflect cardiac autonomic activity. Heart rate turbulence has been shown to be an independent and powerful predictor of sudden cardiac death in various cardiac abnormalities. The aim of this study is to determine whether heart rate turbulence is changed in female patients with fibromyalgia compared with healthy controls. METHODS Thirty-seven female patients (mean age, 40±11 years) with fibromyalgia, and 35 age- and sex-matched healthy female control subjects (mean age, 42±9 years) were included. Twenty-four hours of ambulatory electrocardiography recordings were collected for all subjects, and turbulence onset and turbulence slope values were automatically calculated. RESULTS The baseline clinical characteristics of the two groups were similar. There were no significant differences in turbulence onset and turbulence slope measures between patients and control subjects (turbulence onset: -1.648±1.568% vs. -1.582±1.436%, p ϝ 0.853; turbulence slope: 12.933±5.693 ms/RR vs. 13.639±2.505 ms/RR, p ϝ 0.508). Although body mass index was negatively correlated with turbulence slope (r ϝ -0.258, p ϝ 0.046), no significant correlation was found between body mass index and turbulence onset (r ϝ 0.228, p ϝ 0.054). CONCLUSION To the best of our knowledge, this is the first study to evaluate heart rate turbulence in patients with fibromyalgia. It appears that heart rate turbulence parameters reflecting cardiac autonomic activity are not changed in female patients with fibromyalgia.
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Affiliation(s)
- Huseyin Dursun
- Dokuz Eylul University, Faculty of Medicine, Department of Cardiology, Izmir, Turkey
- E-mail:
| | - Ersel Onrat
- Afyon Kocatepe University, Faculty of Medicine, Department of Cardiology, Afyonkarahisar, Turkey
| | - Emine Ercan
- Afyon Kocatepe University, Faculty of Medicine, Department of Cardiology, Afyonkarahisar, Turkey
| | - Umit Secil Demirdal
- Katip Celebi University, Department of Physical Medicine and Rehabilitation, Izmir, Turkey
| | - Alaettin Avsar
- Afyon Kocatepe University, Faculty of Medicine, Department of Cardiology, Afyonkarahisar, Turkey
| | - Umit Dundar
- Afyon Kocatepe University, Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Afyonkarahisar, Turkey
| | - Ozlem Solak
- Afyon Kocatepe University, Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Afyonkarahisar, Turkey
| | - Hasan Toktas
- Afyon Kocatepe University, Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Afyonkarahisar, Turkey
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