Dietary interventions in fibromyalgia: a systematic review

Online Questionnaire with Fibromyalgia Patients Shows Negative Correlations between Disease Severity and Adherence to Mediterranean Diet

Fibromyalgia (FM) is a multidimensional disorder in which intense chronic pain is accompanied by a variety of psychophysical symptoms that impose a burden on the patients' quality of life. Despite the efforts and the recent advancement in research, FM pathogenesis and effective treatment remain unknown. Recently, the possible role of dietary patterns and/or components has been gaining attention. The current study aimed to investigate a potential correlation between adherence to the Mediterranean diet (MedDiet) and FM severity in a sample of Italian FM patients. An online survey was designed, composed of customized questions and validated questionnaires with the aim of investigating the intensity and type of pain, the presence of other psychophysical symptoms, the overall impact of FM, general food and lifestyle habits, and adherence to the MedDiet. The collected responses were analyzed for descriptive statistics, linear regression, and propensity score analyses. The results show that, despite considerable use of pharmaceuticals and supplements, FM participants suffered from a high-severity grade disease. However, those with good adherence to the MedDiet experienced a lower pain intensity and overall FM impact. A propensity score analysis indicates a positive influence of the MedDiet against FM severity, thus unveiling the need for well-designed intervention studies to evaluate the therapeutic potential of different dietary patterns.

Nutrition and Chronobiology as Key Components of Multidisciplinary Therapeutic Interventions for Fibromyalgia and Associated Chronic Fatigue Syndrome: A Narrative and Critical Review

Fibromyalgia (FM) is often accompanied by chronic fatigue syndrome (CFS). It is a poorly understood disorder that mainly affects women and leads to chronic pain, fatigue, and insomnia, among other symptoms, which decrease quality of life. Due to the inefficiency of current pharmacological treatments, increasing interest is being directed towards non-pharmacological multicomponent therapies. However, nutrition and chronobiology are often overlooked when developing multicomponent therapies. This narrative and critical review explore the relevance of nutritional and chronobiological strategies in the therapeutic management of FM and the often-associated CFS. Reviewed literature offers scientific evidence for the association of dietary habits, nutrient levels, body composition, gut microbiota imbalance, chronobiological alterations, and their interrelation with the development and severity of symptoms. This review highlights the key role of nutrition and chronobiology as relevant and indispensable components in a multidisciplinary approach to FM and CFS.

Efficacy of a gluten-free diet in reducing the widespread pain index and symptom severity scale in patients affected by fibromyalgia

OBJECTIVE

Dietary interventions to improve fibromyalgia (FM) symptoms reported conflicting results. This study aimed to treat FM patients with a gluten-free diet (GFD), alternated with a non-restricted gluten-containing diet, followed by a rechallenge of the GFD.

METHODS

Twenty postmenopausal women with FM and no history of celiac disease participated. A GFD was assigned for 6 months. This was followed by 3 months of a non-restricted gluten-containing diet and then a new GFD for another 6 months. At each visit, the widespread pain index (WPI) and the symptom severity scale (SS) scores were evaluated.

RESULTS

The mean age of the patients enrolled was 53.9±10 years. None of the patients had a diagnosis of irritable bowel disease, although they reported vague gastrointestinal symptoms. After 6 months of a GFD, a statistically significant reduction was observed for the WPI (10.3±1.8 vs 7.7±1.4; p<0.0001) and the SS scale (6.4±1.8 vs 4.15±1.6; p=0.0002). The D percentage reduction of the WPI after 6 months of GFD was -24%±9%, while for the SS scale, it was -36%±21%. The following reintroduction of a gluten-containing diet brought about a statistically significant rise in the absolute SS scale and WPI, as well as a D modification of the WPI (21%±13%) and of the SS scale (74%±90%). The rechallenge of the GFD showed a significant improvement in absolute and D WPI (-24%±7%) and SS (-36%±11%). No modifications to the body mass index were found.

CONCLUSIONS

A GFD improved FM symptoms evaluated with WPI and SS. This was confirmed for the first time, also with a rechallenge of the GFD that followed a non-restricted gluten-containing diet.

Beyond Seasoning-The Role of Herbs and Spices in Rheumatic Diseases

Although we have witnessed remarkable progress in understanding the biological mechanisms that lead to the development of rheumatic diseases (RDs), remission is still not achieved in a substantial proportion of patients with the available pharmacological treatment. As a consequence, patients are increasingly looking for complementary adjuvant therapies, including dietary interventions. Herbs and spices have a long historical use, across various cultures worldwide, for both culinary and medicinal purposes. The interest in herbs and spices, beyond their seasoning properties, has dramatically grown in many immune-mediated diseases, including in RDs. Increasing evidence highlights their richness in bioactive molecules, such as sulfur-containing compounds, tannins, alkaloids, phenolic diterpenes, and vitamins, as well as their antioxidant, anti-inflammatory, antitumorigenic, and anticarcinogenic properties. Cinnamon, garlic, ginger, turmeric, and saffron are the most popular spices used in RDs and will be explored throughout this manuscript. With this paper, we intend to provide an updated review of the mechanisms whereby herbs and spices may be of interest in RDs, including through gut microbiota modulation, as well as summarize human studies investigating their effects in Rheumatoid Arthritis, Osteoarthritis, and Fibromyalgia.

Assessment of complementary and alternative medicine methods in the management of ankylosing spondylitis, rheumatoid arthritis, and fibromyalgia syndrome

A wide variety of musculoskeletal, arthritic, connective tissue, and vasculitic diseases fall under the umbrella of "rheumatic diseases". Ankylosing spondylitis, rheumatoid arthritis, and fibromyalgia syndrome are the three members of this disease group with relatively high prevalence. Pharmacological options are at the center of therapeutic algorithms in treating rheumatic diseases, particularly in reducing inflammation. Despite significant advances in pharmacological treatment in recent years, achieving complete treatment success in a group of patients is impossible. Therefore, patients with rheumatic diseases frequently utilize alternative treatment options, such as complementary and alternative medicine. Complementary and alternative medicine is a broad category of health practices not part of the leading health system. Patients with rheumatic diseases turn to complementary and alternative medicine for various reasons, including restricted access to some treatments due to high prices and rigorous regulations, worries about drug side effects, and symptoms that continue despite pharmacological treatment. In addition, because complementary and alternative medicine options are considered natural, they are frequently accepted as well tolerated and have few harmful effects. Ankylosing spondylitis, rheumatoid arthritis, and fibromyalgia syndrome are the primary foci of this comprehensive review. First, we attempted to summarize the non-traditional physical medicine and complementary and alternative medicine options that can be utilized to manage these diseases. Second, we addressed the link between exercise and inflammation in rheumatic diseases. We briefly discussed the possible benefits of exercise-based approaches. In addition, we highlighted the benefits of cooperation between rheumatology and physical medicine-rehabilitation clinics.

A Chinese version of the revised Fibromyalgia Impact Questionnaire: A validation study

OBJECTIVE

The revised Fibromyalgia Impact Questionnaire (FIQR) was developed to measure the quality of life of patients with fibromyalgia in randomized controlled trials and routine care. The purpose of this study was to translate and adapt the FIQR from English to Chinese, and to examine the validity and reliability of the Chinese version of the FIQR (CFIQR).

METHODS

Following the translation of the FIQR, fibromyalgia patients from 6 centers were recruited and completed the CFIQR, the validated Chinese version of the Medical Outcome Study Short Form 36 Health Survey (SF-36) and the Beck Depression Inventory (BDI). In this study, Cronbach's alpha coefficient, test-retest reliability and item total correlation were used for evaluating external and internal reliability; and criterion and structural validity were evaluated.

RESULTS

A total of 200 fibromyalgia patients completed the study. The internal consistency was excellent (Cronbach's alpha .90, .88, .88 and .93 for function, overall impact, symptoms scales and total score, respectively; item-total correlations from .25 to .83.) Test-retest reliability levels of the CFIQR total and subscale scores were strong correlation (intraclass correlation coefficient >0.75). Furthermore, there were significant correlations between the 3 subscale and the total score of the CFIQR and the SF-36, as well as the CFIQR and the BDI, by criterion validity (P < .01). Confirmatory factor analysis gave an acceptable value for structural validity according to the 3-factor structures of function, overall impact and symptoms.

CONCLUSIONS

The CFIQR is a valid and reliable instrument for both clinical practice and research purposes with Chinese speakers globally. [ClinicalTrials.gov: NCT03381131].

An anti-inflammatory and low fermentable oligo, di, and monosaccharides and polyols diet improved patient reported outcomes in fibromyalgia: A randomized controlled trial

Background

Fibromyalgia (FM) has been associated with dysbiosis and low-grade inflammation. Studies have reported that diet influences clinical features in FM.

Objective

To evaluate the effect of an anti-inflammatory and low fermentable oligo, di, and monosaccharides and polyols (FODMAP) diet on clinical outcomes of patients with FM.

Methods

This two arms Randomized Controlled Trial (NCT04007705) included 46 female patients with FM. The intervention group (n = 22) adopted an anti-inflammatory diet for 3 months, excluding gluten, dairy, added sugar, and ultra-processed foods, along with a low FODMAPs diet in the first month. The control group (n = 24) followed general healthy eating recommendations. Both diets were applied by a certified dietitian. Before and after the intervention, participants were assessed regarding pain, fatigue, gastrointestinal symptoms, quality of sleep, and quality of life, through the Revised Fibromyalgia Impact Questionnaire (FIQR), Visual Analogue Pain Scale (VAS), Visual Analog Scale from gastrointestinal symptoms (VAS GI), Brief Pain Inventory (BPI), Pittsburg Sleep Quality Index (PSQI), Fatigue Severity Survey (FSS), and The Short Form Health Survey (SF-36). A blood sample was collected and high-sensitive C-Reactive Protein and Erythrocyte Sedimentation Rate were quantified. Paired Samples t-test/Wilcoxon and independent samples t-test/Mann−Whitney were used to compare variables between groups.

Results

After intervention, there was an improvement in intervention group scores of FIQR (p = 0.001), VAS (p = 0.002), BPI (p = 0.011), FSS (p = 0.042), VAS_GI (p = 0.002), PSQI (p = 0.048), and SF36 (p = 0.045) compared to control group. Inflammatory biomarkers (hs-CRP, ESR) did not change in both groups. The intervention was beneficial in the intervention group, regardless of age, disease duration, body mass index variation, and body fat change between baseline and post-intervention.

Conclusion

An anti-inflammatory and low-FODMAP diet improved clinical features in patients with FM and may be useful as a complement to pharmacological therapy.

Clinical Trial Registration

[https://clinicaltrials.gov/ct2/show/NCT04007705], identifier [NCT04007705].

Efficacy of Acupuncture, Intravenous Lidocaine, and Diet in the Management of Patients with Fibromyalgia: A Systematic Review and Network Meta-Analysis

Introduction: This network meta-analysis aimed to assess the efficacy of acupuncture, intravenous lidocaine, and diet compared with other comparators such as physiotherapy and sham/placebo in fibromyalgia patients. Materials and Methods: We searched Embase, PubMed, Scopus, and Web of Science for relevant studies till September 2021. The included studies were randomized controlled clinical trials. For the network meta-analysis, we used the R software. Results: There were 23 included RCTs. The total sample size was 1409 patients. Compared with the sham/placebo group, the network analysis showed the highest improvement in the quality of life in the acupuncture group standardized mean difference (SMD) = −10.28, 95%-CI [−14.96; −5.59]), and then in the physiotherapy group (SMD = −7.48, 95%-CI [−14.72; −0.23]). For the pain, there was a significant reduction with acupuncture (SMD = −1.69, 95%-CI [−2.48; −0.89]), compared with sham/placebo. Regarding depression, it showed a significant reduction with acupuncture (SMD = −9.64, 95%-CI [−16.13; −3.14]) compared with sham/placebo. Finally, for stiffness, it showed no significant differences in the stiffness between acupuncture (SMD = −8.52, 95%-CI [−20.40; 3.36]), fluoxetine (SMD = −6.52, 95%-CI [−29.65; 16.61]), and physiotherapy (SMD = −4.64, 95%-CI [−22.83; 13.54]) compared with sham/placebo. Conclusions: The acupuncture showed a significant effect in the management of fibromyalgia patients. It reduced pain, depression, and enhanced the quality of life. While physiotherapy showed a significant improvement in the quality of life only. In contrast, intravenous lidocaine and diet showed no significant differences when compared with sham/placebo.

Dietary Supplements for Pain Relief in Patients with Fibromyalgia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Pain is the most frequently encountered symptom by patients with fibromyalgia (FM). Dietary supplements (DSs) in particular have a proven impact as a possible adjunctive therapy for symptom management in FM. However, there is currently no conclusive review outlining the evidence for DSs in pain management in FM. This study aims to assess currently available studies evaluating the use of DSs for pain relief in FM. Randomized controlled trials regarding the use of DSs on adult FM patients were included for evidence synthesis. Study results indicated that DSs significantly relieved pain in FM (SMD 1.23; 95% CI 0.02-2.43, P = 0.046) but did not improve quality of life (QoL) (SMD 0.73; 95% CI -0.07-1.53, P = 0.075) in the data. Adverse events of DSs varied from mild to severe, with the most common being gastrointestinal symptoms and androgenic side effects in 5.7% and 3.9% of patients, respectively. More well-designed RCTs are required in the future. The protocol for this review has been published on PROSPERO (CRD42020149941).

Scope of Use and Effectiveness of Dietary Interventions for Improving Health-Related Outcomes in Veterans: A Systematic Review

Military veterans often have numerous physical and mental health conditions and can face unique challenges to intervention and management. Dietary interventions can improve the outcomes in many health conditions. This study aimed to evaluate the scope of health conditions targeted with dietary interventions and the effectiveness of these interventions for improving health-related outcomes in veterans. A systematic literature review was performed following PRISMA guidelines to identify and evaluate studies related to veterans and dietary interventions. Five electronic databases were searched, identifying 2669 references. Following screening, 35 studies were evaluated, and 18 were related to a US national veteran weight-loss program. The included studies were critically appraised, and the findings were narratively synthesized. Study designs ranged from randomised controlled trials to cohort studies and were predominantly U.S. based. The intervention durations ranged from one to 24 months. The mean subject age ranged from 39.0 to 69.7 years, with often predominantly male participants, and the mean body mass index ranged from 26.4 to 42.9 kg/m². Most dietary interventions for veterans were implemented in populations with overweight/obesity or chronic disease and involved single dietary interventions or dietary components of holistic lifestyle interventions. The most common primary outcome of interest was weight loss. The success of dietary interventions was generally moderate, and barriers included poor compliance, mental health conditions and large drop-out rates. The findings from this review illustrate the need for further refinement of dietary and lifestyle interventions for the management of veterans with chronic health conditions.

Effect of ancient Khorasan wheat on gut microbiota, inflammation, and short-chain fatty acid production in patients with fibromyalgia

BACKGROUND

Fibromyalgia (FM) syndrome is mainly characterized by widespread pain, sleeping disorders, fatigue, and cognitive dysfunction. In many cases, gastrointestinal distress is also reported, suggesting the potential pathogenic role of the gut microbiota (GM). The GM is deeply influenced by several environmental factors, especially the diet, and recent findings highlighted significant symptom improvement in FM patients following various nutritional interventions such as vegetarian diet, low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols based diets, gluten-free diet, and especially an ancient grain supplementation. In particular, a recent study reported that a replacement diet with ancient Khorasan wheat led to an overall improvement in symptom severity of FM patients.

AIM

To examine the effects of ancient Khorasan wheat on the GM, inflammation, and short-chain fatty acid production in FM patients.

METHODS

After a 2-wk run-in period, 20 FM patients were enrolled in this randomized, double-blind crossover trial. In detail, they were assigned to consume either Khorasan or control wheat products for 8 wk and then, following an 8-wk washout period, crossed. Before and after treatments, GM characterization was performed by 16S rRNA sequencing while the fecal molecular inflammatory response and the short-chain fatty acids (SCFAs) were respectively determined with the Luminex MAGPIX detection system and a mass chromatography-mass spectrometry method.

RESULTS

The Khorasan wheat replacement diet, in comparison with the control wheat diet, had more positive effects on intestinal microbiota composition and on both the fecal immune and SCFAs profiles such as the significant increase of butyric acid levels (P = 0.054), candidatus Saccharibacteria (P = 9.95e-06) and Actinobacteria, and the reduction of Enterococcaceae (P = 4.97e-04). Moreover, the improvement of various FM symptoms along with the variation of some gut bacteria after the Khorasan wheat diet have been documented; in fact we reported positive correlations between Actinobacteria and both Tiredness Symptoms Scale (P < 0.001) and Functional Outcome of Sleep Questionnaire (P < 0.05) scores, between Verrucomicrobiae and both Widespread Pain Index (WPI) + Symptom Severity scale (SS) (P < 0.05) and WPI (P < 0.05) scores, between candidatus Saccharibacteria and SS score (P < 0.05), and between Bacteroidales and Sleep-Related and Safety Behaviour Questionnaire score (P < 0.05).

CONCLUSION

The replacement diet based on ancient Khorasan wheat results in beneficial GM compositional and functional modifications that positively correlate with an improvement of FM symptomatology.

The Critical Role of Nutrition Care to Improve Pain Management: A Global Call to Action for Physical Therapist Practice

Physical therapists have unique education in the comprehensive biopsychosocial assessment and treatment of chronic pain and its mechanisms. Recently, physical therapists have raised awareness regarding the impact of nutrition on promoting health and managing noncommunicable diseases. Robust evidence supports the implementation of nutrition in physical therapist education and practice. Of particular interest for the physical therapist are investigations that use dietary interventions for the treatment of chronic pain. Yet physical therapists have received little guidance regarding their role in nutrition care for pain management and may pass on opportunities to counsel their patients on the connection between nutrition and pain. Therefore, a clinical paradigm shift and unified voice within the profession is called on to encourage physical therapists to develop tailored multimodal lifestyle interventions that include nutrition care for the management of chronic pain. This Perspective describes evidence supporting the implementation of nutrition care in physical therapist practice, supports the role of nutritional pain management for physical therapists, and encourages the use of nutrition care for primary, secondary, tertiary, prevention, health promotion, and wellness related to chronic pain. To achieve these aims, this Perspective offers suggestions for how physical therapists can (1) enhance clinical decision making; (2) expand professional, jurisdictional, and personal scope of practice; (3) evolve entry-level education; and (4) stimulate new investigations in nutrition care and pain science research. In doing so, physical therapists can assert their role throughout the pain management continuum, champion innovative research initiatives, and enhance public health by reducing the impact of chronic pain.

IMPACT

The nutrition care process for pain management is defined as the basic duty to provide adequate and appropriate nutrition education and counseling to people living with pain. Including the nutrition care process as part of a multimodal approach to pain management provides an opportunity for physical therapists to assert their role throughout the pain management continuum. This includes championing innovative research initiatives and enhancing public health by reducing the impact of chronic pain for over 50 million Americans.

Dietary Intake Is Unlikely to Explain Symptom Severity and Syndrome-Specific Microbiome Alterations in a Cohort of Women with Fibromyalgia

BACKGROUND

Significant alterations were recently identified in the composition and putative function of the gut microbiome in women with fibromyalgia. As diet can influence the composition of the gut microbiome, differences in nutritional intake could, in theory, account for some of these specific fibromyalgia microbiome alterations. The current study aims to compare the diet of women with fibromyalgia to that of controls in order to explore possible associations between the intake of certain nutrients, symptom severity and gut microbiome composition.

METHODS

The study population was comprised of 56 women with fibromyalgia and 68 controls. Dietary intake was assessed using the NIH Automated Self-Administered 24 h recall, following dietitian's instructions and the completion of a three-day dietary recall. The gut microbiome was assessed by 16S ribosomal RNA gene sequencing of stool samples.

RESULTS

Most demographic and anthropometric characteristics were comparable between groups. The average energy and macronutrient intake (total and relative) and overall diet quality score were not different between patients and controls, nor were the main vitamins, minerals, fatty acids, alcohol, caffeine, sugar or fiber intakes. The daily intake of micronutrients and normalized macronutrients in women with fibromyalgia was largely not correlated with disease-specific measures, including pain intensity, fatigue, cognitive symptoms and quality of sleep, or with the relative quantity of almost any of the gut microbiome bacterial taxa differentially abundant in fibromyalgia.

CONCLUSION

These data demonstrate that dietary intakes, as evaluated by self-reported questionnaires, probably cannot explain the syndrome-specific differences in gut microbiome or the clinical phenotype of fibromyalgia.

Fibromyalgia syndrome: epidemiology, diagnosis and treatment

Fibromyalgia syndrome (FMS) profoundly impacts patients' quality of life with its symptoms and clinical signs. Fibromyalgia syndrome impairs daily living activities, reduces work efficiency and raises health-related costs. Although the prevalence rates vary depending on geographical location and diagnostic criteria, it is a common disorder worldwide. Females have a higher prevalence of fibromyalgia syndrome, with varied rates, and there is an increase in prevalence rates with age. Although its etiopathogenesis has not been fully elucidated, various hypotheses have been proposed that central sensitization is at the core of the process. Fibromyalgia syndrome diagnostic approaches have advanced significantly over time, moving away from pain assessments alone and emphasizing multiple clinical signs of FMS. This condition has raised physicians' and researchers' awareness of non-pain symptoms. Considering the complicated etiopathogenesis of fibromyalgia syndrome, diverse pathways connected with symptoms, and multiple clinical presentations, it becomes clear that drug and non-drug treatments should be chosen in combination.

Use of Dietary Supplements and Perceived Knowledge among Adults Living with Fibromyalgia in Norway: A Cross-Sectional Study

Fibromyalgia syndrome (FMS) is a complex medical condition characterized by widespread musculoskeletal pain. To date, no gold standard treatment has been developed, and persons with FMS often seek alternative methods to control their symptoms, such as dietary supplements (DS). This study aimed to describe the use of DS in persons living with FMS and examine the associations between the use of DS and its potential predictors. We recruited a convenience sample of 504 participants (≥18 years) living with FMS. The main outcome variables included estimated expenditure on DS in the last 12 months in Norwegian kroner (NOK) and the differences between the groups of users and non-users of DS. Of the 504 participants, 430 reported having used DS, and the mean amount of money spent in the previous year was determined to be NOK 2300. The most common DS reported were vitamin D, magnesium, and omega-3 fatty acids. The predictors of being a DS user were high education, high self-reported knowledge of DS but low overall knowledge of health claims. Users of DS marketed for muscles/joints appear to spend more money on DS. The increasing availability of DS and aggressive advertising in the media through health claims stipulate the need for interventions that lead to informed decisions about DS.

Diet and Chronic Non-Cancer Pain: The State of the Art and Future Directions

Nutrition plays an important role in pain management. Healthy eating patterns are associated with reduced systemic inflammation, as well as lower risk and severity of chronic non-cancer pain and associated comorbidities. The role of nutrition in chronic non-cancer pain management is an emerging field with increasing interest from clinicians and patients. Evidence from a number of recent systematic reviews shows that optimising diet quality and incorporating foods containing anti-inflammatory nutrients such as fruits, vegetables, long chain and monounsaturated fats, antioxidants, and fibre leads to reduction in pain severity and interference. This review describes the current state of the art and highlights why nutrition is critical within a person-centred approach to pain management. Recommendations are made to guide clinicians and highlight areas for future research.

Diagnostic Challenges and Management of Fibromyalgia

The World Health Organization regards chronic pain to be a public health concern. In clinical medicine, fibromyalgia (FM) is the most prevalent chronic widespread pain disease. In terms of impairment, consumption of health and social resources, and impact on primary and speciality care systems, it has reached worrisome proportions. This disease is frequently managed by primary care providers. Because of its intricacy, fibromyalgia diagnosis and treatment can be difficult. Fibromyalgia is a controversial condition. It might appear ill-defined in comparison to other pain conditions, with no clear knowledge of pathophysiology and hence no particular targeted therapy. This invariably sparks debates and challenges. There is no obvious cut-off point that distinguishes FM from non-FM. The diagnosis of fibromyalgia has been complicated by several factors, including patients' health-seeking behaviour, symptom identification, and physician labelling of the disease. Fibromyalgia is currently considered a centralized pain condition, according to research that has improved our understanding of its etiopathology. A multidisciplinary strategy combining pharmacological and non-pharmacological therapies based on a biopsychosocial paradigm can result in effective therapy. Cultural and psychosocial variables appear to be a recent development in fibromyalgia, and they appear to have a larger influence on physician diagnosis than severe symptom levels in FM patients. Although physicians rely on FM criteria as the only way to classify FM patients in research and clinical settings, some crucial elements of the diagnostic challenge of fibromyalgia remain unsolved - invalidation, psychosocial variables, and diverse illness manifestation are some examples. Beyond the existing constructional scores, physicians' judgment gained in real communicative contexts with patients, appears to be the only dependable route for a more accurate diagnosis for fibromyalgia. We have performed an exhaustive review of the literature using the keywords "Fibromyalgia", "challenges" and "diagnosis" in PubMed and Google Scholar indexes up to September 2021. This article aims to examine the causes, diagnosis, and current treatment protocols of FM, as well as discuss some continuing debates and diagnostic challenges which physicians face in accurately diagnosing fibromyalgia.

Fibromyalgia in Older Individuals

Fibromyalgia (FM) is a condition of chronic widespread pain (CWP) that can occur throughout the life cycle and is likely underrecognized in older patients. FM is associated with considerable suffering and reduction in quality of life and may occur as a unique condition, but in older patients is most likely to be associated with another medical illness. Understood mechanistically to be a sensitization of the nervous system, recently identified as nociplastic pain, FM is accepted as a valid medical illness that requires a positive diagnosis and directed treatments. The cornerstone of treatments for FM are nonpharmacologic interventions, with the understanding that medications provide only modest benefit for most patients, and with particular concern about adverse effects in older patients. If FM is not recognized, treatments may be misdirected to the other medical condition, with failure to address FM symptoms, leading to overall poor outcome. In contrast, new complaints in older patients should not immediately be attributed to FM, and physicians should be vigilant to ensure that onset of a new illness is not ignored. As FM is most often a lifelong condition, patients should be encouraged to identify their own personal strategies that can attenuate symptoms, especially when symptoms flare. Continued life participation should be the outcome goal.

A preliminary investigation of nutritional intake and supplement use in Australians with myalgic encephalomyelitis/chronic fatigue syndrome and the implications on health-related quality of life

Background

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex, multisystem illness without a currently recognized pharmacological treatment. Dietary supplementation and modification have been posited as potential management strategies; however, their efficacy is controversial.

Objective

This study aimed to assess the nutritional intake and supplement use of Australian ME/CFS patients and the perceived effect on health-related quality of life (HRQoL) for the first time in an Australian patient population.

Design

Between February 2019 and January 2020, ME/CFS patients across Australia volunteered in this cross-sectional study in response to online advertisements. Eligible respondents were invited to complete three online self-administered questionnaires investigating their supplement use, nutritional intake, and HRQoL. The study participants’ supplement use and nutritional intake were summarized and compared with the population data returned from the Australian Health Survey (2011–2012). Multiple linear regression analysis was also performed to determine the effect of participants’ supplement use and nutrient intake on HRQoL.

Results

Twenty-four eligible ME/CFS patients (54.2% meeting the International Consensus Criteria, 79.2% female, mean age = 43.4 ± 10.5 years) completed the online questionnaires. Supplement use was highly prevalent among the study sample (87.5%) and considerably more common when compared with population data (31.9%). Daily total fats and caffeine intakes were significantly higher among ME/CFS patients when compared with the Australian population (P = 0.009 and P = 0.033, respectively), whereas daily intakes of total carbohydrates and alcohol were significantly lower (both P < 0.001). No consistent trends between nutrition and supplement use with patients’ HRQoL could be identified.

Conclusions

The daily diet and supplement use of ME/CFS patients appear to vary considerably from those of the general Australian population. Although the role of nutritional intake and supplement use on ME/CFS patients’ HRQoL remains unclear, dietary changes and the use of supplements appear to be of value to ME/CFS patients.

An Omega-3-rich Anti-inflammatory Diet Improved Widespread Allodynia and Worsened Metabolic Outcomes in Adult Mice Exposed to Neonatal Maternal Separation

Inflammation plays a key role in the progression and maintenance of chronic pain, which impacts the lives of millions of Americans. Despite growing evidence that chronic pain can be improved by treating underlying inflammation, successful treatments are lacking and pharmaceutical interventions are limited due to drug side effects. Here we are testing whether a 'healthy human' diet (HHD), with or without anti-inflammatory components (HHAID), improves pain-like behaviors in a preclinical model of chronic widespread hypersensitivity induced by neonatal maternal separation (NMS). The HHD and HHAID are isocaloric and macronutrient-matched, have a low glycemic index, and fat content (35 kcal%) that is high in omega-3 fatty acids, while only the HHAID includes a combination of key anti-inflammatory compounds, at clinically relevant doses. Mice on these diets were compared to mice on a control diet with a macronutrient composition commonly used in rodents (20% protein, 70% carbohydrate, 10% fat). Our results demonstrate a benefit of the HHAID on pain-like behaviors in both male and female mice, despite increased caloric intake, adiposity, and weight gain. In female mice, HHAID specifically increased measures of metabolic syndrome and inflammation compared to the HHD and control diet groups. Male mice were susceptible to worsening metabolic measures on both the HHAID and HHD. This work highlights important sexual dimorphic outcomes related to early life stress exposure and dietary interventions, as well as a potential disconnect between improvements in pain-like behaviors and metabolic measures.

Nociplastic pain: towards an understanding of prevalent pain conditions

Nociplastic pain is the semantic term suggested by the international community of pain researchers to describe a third category of pain that is mechanistically distinct from nociceptive pain, which is caused by ongoing inflammation and damage of tissues, and neuropathic pain, which is caused by nerve damage. The mechanisms that underlie this type of pain are not entirely understood, but it is thought that augmented CNS pain and sensory processing and altered pain modulation play prominent roles. The symptoms observed in nociplastic pain include multifocal pain that is more widespread or intense, or both, than would be expected given the amount of identifiable tissue or nerve damage, as well as other CNS-derived symptoms, such as fatigue, sleep, memory, and mood problems. This type of pain can occur in isolation, as often occurs in conditions such as fibromyalgia or tension-type headache, or as part of a mixed-pain state in combination with ongoing nociceptive or neuropathic pain, as might occur in chronic low back pain. It is important to recognise this type of pain, since it will respond to different therapies than nociceptive pain, with a decreased responsiveness to peripherally directed therapies such as anti-inflammatory drugs and opioids, surgery, or injections.

Vegetarian and Vegan Diet in Fibromyalgia: A Systematic Review

Fibromyalgia (FM) is a chronic non-degenerative disease characterized by the presence of multiple symptoms such as chronic pain, which negatively influence the quality of life of sufferers, most of whom are women. Currently, there is no effective treatment to limit the impact of these symptoms. The aim of this research is to review the scientific evidence on the effect of following a vegetarian or vegan diet on fibromyalgia patients. A systematic review included the original articles that answered the research question. These articles were in 2021 in the PubMed, Web of Science and Scopus databases. The research used the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. No time restriction was applied, and grey literature was not included. The evaluation of the methodological quality of the articles was carried out using the following different scales: STROBE (strengthening the reporting of observational studies in epidemiology), PEDro (Physiotherapy Evidence Database), and MMAT (Mixed Methods Appraisal Tool) scales. A total of 88 studies were analyzed, of which 6 investigations were included in this systematic review (n = 4 clinical trials and n = 2 cohort studies). These investigations show significant improvements in biochemical parameters, quality of life, quality of sleep, pain at rest and general health status when following mainly plant-based dietary patterns. In conclusion, these findings are promising but interpretation of the findings is limited due to the methodological quality of the studies. Well-designed clinical trials are needed to consolidate these dietary recommendations in FM patients.

Vegetarian Diet: An Overview through the Perspective of Quality of Life Domains

Vegetarianism has gained more visibility in recent years. Despite the well-described effects of a vegetarian diet on health, its influence on the quality of life of the individuals who follow it still needs to be properly investigated. Quality of life relates to a subjective perception of well-being and functionality, and encompasses four main life domains: physical, psychological, social, and environmental. The adoption of a vegetarian diet, despite being a dietary pattern, could potentially influence and be influenced by all of these domains, either positively or negatively. This review aims to present an overview of the background, conceptualization, features, and potential effects of vegetarianism in all quality of life domains. The choice of adopting a vegetarian diet could have positive outcomes, such as better physical health, positive feelings related to the adoption of a morally correct attitude, an increased sense of belonging (to a vegetarian community), and lower environmental impact. Other factors, however, could have a negative impact on the quality of life of those choosing to abstain from meats or other animal products, especially when they go beyond one's control. These include the environment, the social/cultural group in which a person is inserted, gender-based differences, economic aspects, and a limited access to a wide variety of plant-based foods. It is important to understand all the effects of adopting a vegetarian diet-beyond its nutritional aspects. Not only do studies in this area provide more consistent data, but they may also contribute to mitigating all factors that might prevent individuals from adopting a vegetarian diet, or that may have a negative impact on the quality of life of those who already follow it.

A study protocol for a randomized controlled trial of an anti-inflammatory nutritional intervention in patients with fibromyalgia

Background

This study aims to analyze the effects of a potentially anti-inflammatory nutritional intervention in disease assessment parameters, inflammatory markers, and quality of life of fibromyalgia (FM) patients.

Methods

A sample of 100 female patients diagnosed with FM, followed up at Portuguese Institute of Rheumatology (IPR) in Lisbon, is being randomly allocated in two groups. Patients in the intervention group are adopting an anti-inflammatory diet, characterized by the exemption of the intake of foods containing gluten, dairy, sugar, and ultra-processed foods, during 3 months. During the first month, a low fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) diet is implemented, along with the anti-inflammatory diet, followed by the reintroduction of all fruits and vegetables over a consecutive period of 2 months. Patients in the control group are adopting a diet based on general recommendations for healthy eating. The outcomes are pain, fatigue, quality of sleep, quality of life, gastrointestinal symptoms, and inflammation. Before and after the 3 months intervention, and also 1 month after beginning the intervention, the following questionnaires are applied: Revised Fibromyalgia Impact Questionnaire, visual analog pain scale, Brief Pain Inventory,visual analog scale from a list of common gastrointestinal and extraintestinal symptoms in FM, Short Form 36, Fatigue Severity Survey, and Pittsburg Sleep Quality Index. Ultra-sensitive serum C-reactive protein, eritrocyte sedimentation rate, and interleukin-8 are determined. Age, physical activity, anthropometric parameters, and body composition are being collected. Student’s t test will assess the association between the disease evaluation parameters, the inflammatory markers, and the dietary interventions.

Discussion

The results of this study are expected to determine whether a change in patient nutrition helps to alleviate symptoms, which would optimize medical intervention.

Trial registration

www.ClinicalTrials.gov NCT04007705. Registered on July 5, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05146-3.

A systematic review of the association between fibromyalgia and functional gastrointestinal disorders

BACKGROUND

Fibromyalgia and functional gastrointestinal disorders (FGID) including irritable bowel syndrome (IBS) are common conditions presenting in clinical settings and are more prevalent in women. While the relationship between IBS and fibromyalgia has been demonstrated, a review of the prevalence of the broader group of FGID in adults with fibromyalgia has not been undertaken. The aim of this review was to systematically review the published literature, identifying the comorbidity of FGID in people with fibromyalgia, and to discuss the clinical implications, limitations of current research and areas of interest for future research.

METHODS

Medline, Embase, CINAHL and Web of Science were searched during June 2019. Results were screened for original research articles meeting established criteria for identification of FGID in adults diagnosed with fibromyalgia.

RESULTS

A total of 14 studies involving 1340 adults with fibromyalgia, 363 healthy controls and 441 adults with other pathologies were included in this review. Only 1 of the 14 studies included surveyed the full range of FGID . Functional gut disorders were matched to Rome II criteria for reporting and comparison. In addition to increased abdominal pain and functional bloating or gas, IBS of mixed-pattern and constipation-types appear to be more prevalent than diarrhoea-predominant IBS in adults with fibromyalgia.

CONCLUSION

This review confirms previous reports that IBS is common in people living with fibromyalgia and suggests that IBS-mixed and constipation types predominate. An association with a range of FGID other than IBS is suggested, but data are limited. Research exploring the association between fibromyalgia and functional gastrointestinal dysfunction beyond IBS are warranted.

Effectiveness of a Khorasan Wheat-Based Replacement on Pain Symptoms and Quality of Life in Patients with Fibromyalgia

OBJECTIVE

To investigate the effects of a replacement diet with Khorasan wheat products in patients with fibromyalgia, in comparison with a similar replacement diet with control products made from organic semi-whole-grain modern wheat.

DESIGN

Randomized, double-blinded crossover trial.

SETTING

Outpatient clinic.

SUBJECTS

Twenty subjects (19 female and one male, mean age = 48.9 ± 12.3 years) with fibromyalgia.

METHODS

Participants were randomly assigned to consume either Khorasan or control wheat products (pasta, bread, crackers, biscuits) for eight weeks and then crossed. Validated self-administered questionnaires were collected from each subject at the beginning and end of each intervention period.

RESULTS

A general linear model for repeated measurement, adjusted for potential confounders, showed that the overall score reported from each questionnaire improved after both intervention and control periods, but the effect was more evident after the intervention with Khorasan. In particular, a statistically significant difference in Widespread Pain Index (WPI) + Severity Scale (SS) and Functional Outcome of Sleep Questionnaire (FOSQ) was observed, which decreased significantly by 21.5% and 11.7% respectively, only after the Khorasan period, while no statistically significant variations were reported after the control period. Similarly, FM Impact Questionnaire scores decreased significantly only after the Khorasan period, with a reduction that was significantly different between the intervention and control periods (-22.5% vs -0.3%, P = 0.037). The improvement was even greater in people with higher symptom severity.

CONCLUSIONS

A dietary intervention with Khorasan wheat products seems to benefit patients with fibromyalgia, especially those with greater symptom severity.

Dietary Interventions in the Management of Fibromyalgia: A Systematic Review and Best-Evidence Synthesis

Fibromyalgia syndrome (FMS) is characterised by chronic widespread pain alongside fatigue, poor sleep quality and numerous comorbidities. It is estimated to have a worldwide prevalence of 1.78%, with a predominance in females. Treatment interventions for fibromyalgia have limited success, leading to many patients seeking alternative forms of treatment, including modifications to their diet and lifestyle. The effectiveness of dietary changes in fibromyalgia has not been widely researched or evaluated. This systematic review identified twenty-two studies, including 18 randomised control trials (RCTs) and four cohort studies which were eligible for inclusion. In total these studies investigated 17 different nutritional interventions. Significant improvements in reported pain were observed for those following a vegan diet, as well as with the low fermentable oligo di-mono-saccharides and polyols (FODMAP) diets. Supplementation with Chlorella green algae, coenzyme Q10, acetyl-l-carnitine or a combination of vitamin C and E significantly improved measures of pain. Interpretation of these studies was limited due to the frequent poor quality of the study design, the wide heterogeneity between studies, the small sample size and a high degree of bias. Therefore, there is insufficient evidence to recommend any one particular nutritional intervention for the management of fibromyalgia and further research is needed.

Dietary Patterns and Interventions to Alleviate Chronic Pain

Pain is one of the main problems for modern society and medicine, being the most common symptom described by almost all patients. When pain becomes chronic, the life of the patients is dramatically affected, being associated with significant emotional distress and/or functional disability. A complex biopsychosocial evaluation is necessary to better understand chronic pain, where good results can be obtained through interconnected biological, psychological, and social factors. The aim of this study was to find the most relevant articles existent in the PubMed database, one of the most comprehensive databases for medical literature, comprising dietary patterns to alleviate chronic pain. Through a combined search using the keywords “chronic pain” and “diet” limited to the last 10 years we obtained 272 results containing the types of diets used for chronic pain published in the PubMed database. Besides classical and alternative methods of treatment described in literature, it was observed that different diets are also a valid solution, due to many components with antioxidant and anti-inflammatory qualities capable to influence chronic pain and to improve the quality of life. Thirty-eight clinical studies and randomized controlled trials are analyzed, in an attempt to characterize present-day dietary patterns and interventions to alleviate chronic pain.

Comparative study of the effectiveness of a low-pressure hyperbaric oxygen treatment and physical exercise in women with fibromyalgia: randomized clinical trial

Background

Fibromyalgia (FM) is characterized by chronic pain and fatigue, among other manifestations, thus advising interventions that do not aggravate these symptoms. The main purpose of this study is to analyse the effect of low-pressure hyperbaric oxygen therapy (HBOT) on induced fatigue, pain, endurance and functional capacity, physical performance and cortical excitability when compared with a physical exercise program in women with FM.

Methods

A total of 49 women with FM took part in this randomized controlled trial. They were randomly allocated to three groups: physical exercise group (PEG, n = 16), low-pressure hyperbaric oxygen therapy group (HBG, n = 17) and control group (CG, n = 16). Induced fatigue, perceived pain, pressure pain threshold, endurance and functional capacity, physical performance and cortical excitability were assessed. To analyse the effect of the interventions, two assessments, that is, pre and post intervention, were carried out. Analyses of the data were performed using two-way mixed multivariate analysis of variance.

Results

The perceived pain and induced fatigue significantly improved only in the HBG (p < 0.05) as opposed to PEG and CG. Pressure pain threshold, endurance and functional capacity, and physical performance significantly improved for both interventions (p < 0.05). The cortical excitability (measured with the resting motor threshold) did not improve in any of the treatments (p > 0.05).

Conclusions

Low-pressure HBOT and physical exercise improve pressure pain threshold, endurance and functional capacity, as well as physical performance. Induced fatigue and perceived pain at rest significantly improved only with low-pressure HBOT.

Trial registration

ClinicalTrials.gov identifier NCT03801109.

Fibromyalgia

Fibromyalgia is characterized by chronic, widespread musculoskeletal pain and associated fatigue, sleep disturbances, and other cognitive and somatic symptoms. For many patients, these symptoms persist for years and lead to frequent health care use; for some, fibromyalgia and its symptoms can be debilitating. Although many treatments are available, management remains challenging. This article highlights the clinical features of fibromyalgia, discusses diagnostic criteria and their evolution, and reviews treatment options.