Primary and Secondary Fibromyalgia Are The Same: The Universality of Polysymptomatic Distress

Whole-Body Photobiomodulation Therapy Propels the Fibromyalgia Patient into the Recomposition Phase: A Reflexive Thematic Analysis

BACKGROUND

Recent evidence has identified great promise for the novel whole-body photobiomodulation therapy (PBMT) for individuals with fibromyalgia (FM). However, currently no evidence has documented the experiences of participants. The objective of this study was to qualitatively assess treatment experience and response in a group of participants with FM undergoing a course of whole-body PBMT.

METHODS

An interpretive hermeneutic phenomenological study situated within the worldview of pragmatism was undertaken. A convenience sample of individuals with FM were included if they had undertaken a novel 6-week trial of PBMT. Individuals undertook semi-structured interviews exploring treatment experience and multidimensional treatment responses during Week 3 and Week 6.

RESULTS

Sixteen trial participants (47.3 ± 10.9 years) took part in this study. The analysis produced three overarching themes that were previously identified from a baseline study (namely, 'Body Structure & Function', 'Activities & Participation', and 'Environment') with an additional five sub-themes that highlighted the intervention experience. Subsequently, four important processes were observed and identified: increased motivation; feeling proud; improved confidence; feeling like 'old self'. This ultimately culminated in the identification of a positive spiral, which we have termed 'recomposition'.

CONCLUSIONS

We believe our study is the first in the field of chronic pain management to utilise qualitative methodology to directly assess the acceptability and efficacy of a specific medical intervention in a clinical trial, and the first study to qualitatively assess whole-body PBMT experience. The findings are compelling and warrant further work to support the introduction of this device into the National Health Service (NHS).

Racial Disparities in Pain Among Women with Fibromyalgia: Secondary Data Analysis of Severity, Interference with Function, and Response to Guided Imagery

Background: Fibromyalgia syndrome (FMS) is characterized by widespread persistent musculoskeletal pain. Mostly prevalent among White women, little is known about FMS in other population cohorts. This study examined secondary data of a racially diverse sample of women with FMS that were collected as part of a randomized controlled clinical trial that examined the effect of a complementary therapy intervention over the course of a 10-week guided imagery intervention to identify demographic, social, or economic differences in self-reported pain. Materials and Methods: The Brief Pain Inventory (BPI), which measures pain severity and interference, was administered to 72 women (21 Black and 51 Whites) at baseline, 6 and 10 weeks. Student's t tests and time series regression models examined racial difference in pain dimensions and treatment response. Regression models accounted for age, race, income, duration of symptoms, treatment group, pain at baseline, smoking, alcohol use, comorbid conditions, and time. Results: Black women experienced significantly higher pain severity (β = 5.52, standard deviation [SD] = 2.13) and interference (β = 5.54, SD = 2.74) than Whites (severity β = 4.56, SD = 2.08; interference β = 4.72, SD = 2.76) (interference: t = 1.92, p = 0.05; severity: t = 2.95, p = 0.00). Disparities persisted over time. Controlling for differences in age, income, and previous pain levels, Black women had 0.26 (standard error [SE] = 0.065) higher pain severity and 0.36 (SE = 0.078) higher interference than Whites. Low-income earners also experienced 2.02 (SE = 0.38) and 2.19 (SE = 0.46) higher pain severity and interference, respectively, than other earners. Results were robust to inclusion of comorbidities. Conclusions: Black women and low-income earners experienced significantly higher levels of pain severity and interference and a lower dose response to the intervention. Differentials were robust to inclusion of demographic, health, and behavioral characteristics. Findings suggest that external factors may contribute to pain perception among women with FMS.

Fibromyalgia and mental health in rheumatoid arthritis: a cross-sectional prevalence study from the COVID-19 pandemic

OBJECTIVES

This study evaluated the prevalence of fibromyalgia (FM), anxiety and depression in patients with rheumatoid arthritis (RA) and their effects on the clinical parameters of RA during the COVID-19 pandemic.

DESIGN

Cross-sectional, outpatient clinic, observational, non-interventional.

SETTING

Single-centre, tertiary care, multispecialty, service and research hospital, north-central India.

PARTICIPANTS

Adult patients with RA, controls.

RESULTS

This cross-sectional study included 200 patients with RA diagnosed with the American College of Rheumatology/European League Against Rheumatism 2010 (ACR) criteria and 200 controls. FM was diagnosed using the revised 2016 ACR FM Criteria. Disease activity, quality of life and functional disability in patients with RA were assessed using multiple Disease Activity Scores. The presence of depression and anxiety was determined using the Hospital Anxiety and Depression Scale. FM was present in 31% of patients with RA compared with 4% of controls in our study. Patients with RA with FM were older, predominantly females with longer disease duration, and more likely to be on steroids. Patients with RA with FM had a higher disease activity, and none of our RA with FM patients were in remission. The multivariable analysis found FM to be an independent predictor of the Simplified Disease Activity Index for RA. Patients with RA with FM had worse functional ability and poorer quality of life. The prevalence of anxiety and depression was 12.5% and 30%, significantly higher in RA with FM patients.

CONCLUSION

During the COVID-19 pandemic, around one-third of our study patients had FM and depression, significantly higher than pre-COVID-19 times. Thus, mental health assessment should be incorporated into the routine management of patients with RA.

Association of COMT Val158Met Polymorphism with Fibromyalgia in Khartoum State, Sudan

Fibromyalgia (FM) is a disorder characterized by chronic musculoskeletal pain, fatigue, and cognitive problems. Neurotransmitters, mainly catecholamines, appear to be involved in regulating the etiology of FM. Catechol-O-methyltransferase (COMT) is involved in catabolizing catecholamines such as norepinephrine. The most common variant studied in the COMT gene is the valine (Val) to methionine (Met) substitution at codon 158. This is the first study in Sudan addressing FM cases and genetic susceptibility to the disease. We aimed in this study to investigate the frequency of COMT Val 158 Met polymorphism among patients with FM, rheumatoid arthritis, and in healthy individuals. Genomic DNA from forty female volunteers was analyzed: twenty were from primary and secondary FM patients, ten were from rheumatoid arthritis patients, and ten were from healthy control. FM patients' age was ranging from 25 years to 55 with a mean of 41.14 ± 8.90. The mean age of the rheumatoid arthritis patients and healthy individuals was 31.3 ± 7.5 and 38.6 ± 11.2, respectively. Samples were genotyped for COMT single nucleotide polymorphism rs4680 (Val158Met), using the amplification-refractory mutation system (ARMS-PCR). Genotyping data have been analyzed using the Chi-square and Fisher exact test. The most common genotype among the study participants was the heterozygous Val/Met found in all participants. It was the only genotype found in the healthy participants. The genotype Met/Met was found only in FM patients. The genotype Val/Val was found only in rheumatoid patients. Analyses have shown no association between the Met/Met genotype and FM, and this could be due to a small sample size. In a larger sample size, a significant association could be found as this genotype was shown only by FM patients. Moreover, the Val/Val genotype, which is shown only among rheumatoid patients, might protect them from developing FM symptoms.

Looking at fibromyalgia differently - An observational study of the meaning and consequences of fibromyalgia as a dimensional disorder

OBJECTIVE

Despite data showing that fibromyalgia can be represented as a dimensional disorder, almost all assessments treat fibromyalgia as a dichotomous categorial disorder; and research shows that agreement between community diagnosis of fibromyalgia and fibromyalgia criteria is poor. We investigated the validity of FM as a discrete disorder by exploring the relationships of categorical fibromyalgia, the polysymptomatic distress (PSD) scale, and clinical variables.

METHODS

In a databank of 33,972 rheumatic disease patients, we studied the categorical diagnosis of fibromyalgia, the PSD scale separately and divided into severity groups, measures of widespread pain, as well as somatic syndrome questionnaires like the Patient Health Questionnaire-15 (PHQ-15), and clinical pain, global, HAQ disability and quality of life scales (EQ-5D).

RESULTS

Clinical and demographic variables became more abnormal with increasing PSD score groups, indicating substantial increase in symptoms and pain. The changes across PSD categories were linear and large. When we compared FM- (PSD 8-11) with FM+ (PSD 12-18) patients we found considerable overlap in scores for pain, HAQ disability, patient global, PHQ-15, psychological status, and other variables. Somatic symptom scores were highly correlated with PSD (r=0.718). There was no evidence of a differential pain effect that was present in FM+ but not FM- subjects.

CONCLUSION

Fibromyalgia is more accurately considered a dimensional than a dichotomous disorder. There is vast variability among fibromyalgia positive and negative cases that is governed by the strong and linear relationships between the dimensional PSD scale and clinical variables. The PSD scale provides measurements of the fibromyalgia dimension that support and enlighten categorical fibromyalgia and are an effective tool to measure clinical status and changes. Whatever the mechanism of the pain and symptom increase in fibromyalgia, it appears to operate over the entire fibromyalgia symptom dimension, not just in those with categorical fibromyalgia.

The impact of nociplastic pain features on the response to physical therapy in patients with primary myofascial pain

BACKGROUND

Myofascial pain is a common, but poorly understood multifactorial condition.

OBJECTIVE

This study analyzed how the degree of central sensitization (nociplastic pain) can impact the response to physical therapy for patients with myofascial pain.

METHODS

This prospective, observational cohort study compared pain phenotyping and functional measures in 30 participants with non-acute neck/shoulder girdle primary myofascial pain following 3-months of physical therapy. The Fibromyalgia Survey Questionnaire Score served as a surrogate of central sensitization.

RESULTS

All participants demonstrated some benefit from physical therapy; however, those with moderate levels of nociplastic pain features were less likely to have clinically significant improvements on the Neck Disability Index, PEG score, or pain catastrophizing measures. Those with higher levels of nociplastic pain had a similar chance of showing improvement as those with lower levels, except regarding catastrophizing. Significant improvements were independent of the type or amount of therapy received.

CONCLUSION

The degree of nociplastic pain in patients with myofascial pain appears to be inversely related to improvements from a peripherally based treatment. This is not to say that individuals with moderate to higher levels of nociplastic pain do not benefit from physical therapy, but they proportionally benefit less.

Subcategories of Fibromyalgia: A New Concept

Fibromyalgia has previously been categorized as primary, secondary, and juvenile fibromyalgia. However, these definitions do not adequately explain the etiopathology of disease, nor do they help direct new specific therapies. Herein, we review the previously known categorizations of fibromyalgia. Based on common patient characteristics and previously studied pathophysiologies, we propose new subcategorizations of fibromyalgia that we have self-narrated, including hormonal fibromyalgia, neuroendocrine fibromyalgia, psychologic fibromyalgia, inflammatory fibromyalgia, and lastly, neuropathic fibromyalgia. Future research needs to be done to verify, add to, and fully describe these self-narrated categories of fibromyalgia that we have proposed.

The risk factors for self-reported fibromyalgia with and without multiple somatic symptoms: The Lifelines cohort study

OBJECTIVE

The numerous risk factors for fibromyalgia reflect its heterogeneous nature. This study assessed whether the predictors of fibromyalgia onset vary according to number of prior somatic symptoms.

METHODS

The prospective, population-based Lifelines cohort study included 138,617 adults without fibromyalgia or marked muscle pain. At baseline socio-demographic status, physical and psychiatric disorders, psycho-social and behavioural variables were assessed as potential predictors. At follow-up (mean 2.4 years later) new onsets of fibromyalgia were recorded by self-report. The predictors of new onsets of self-reported fibromyalgia were assessed using logistic regression with interaction terms between key variables and number of somatic symptoms.

RESULTS

At follow-up 679 (0.5%) participants reported new onset fibromyalgia. The strongest predictors were: female sex, rheumatoid and osteo-arthritis, IBS, impaired sleep, migraine, few years of education and impairment by bodily pain. Interaction terms with somatic symptoms were significant for years of education, low income, rheumatoid arthritis and no. of analgesics; these were predictors only for fibromyalgia with few somatic symptoms. Participants with multiple somatic symptoms had a higher number of predictors than those with few somatic symptoms.

CONCLUSION

This study suggests that people developing self-reported fibromyalgia with multiple pre-existing somatic symptoms have a high risk factor load reflecting risk factors for both fibromyalgia and multiple somatic symptoms. Self-reported fibromyalgia with few somatic symptoms has fewer predictors which may be specific to fibromyalgia. Future research could usefully study whether different pathophysiological mechanisms occur when fibromyalgia is preceded by high or low number of somatic symptoms.

Association among Disorders of Gut-Brain Interaction (DGBI) and Fibromyalgia: A Prospective Study

The disorders of gut-brain interaction (DGBI) have been associated with Fibromyalgia (FM). However, there are no data about the relationship between FM and DGBI using Rome IV criteria. This study aimed to evaluate the prevalence of FM in patients with Irritable Bowel Syndrome (IBS) and/or Functional Dyspepsia (FD) and the prevalence of IBS and FD in FM patients using Rome IV criteria. DGBI patients and FM patients were recruited from two outpatient clinics devoted to DGBI and FM. All patients underwent a standardized gastrointestinal (GI) symptoms questionnaire. FM symptoms in DGBI patients were assessed through Fibromyalgia Rapid Screening Tool (FiRST) and Fibromyalgia Impact Questionnaire. Thereafter, the rheumatologists evaluated them. 49.0% of FM patients fulfilled the diagnostic criteria for IBS, 81.6% for FD with an overlap for both IBS/FD in 44.9%. IBS-C was the most prevalent IBS-subtype in DGBI patients, whereas IBS-M was the most prevalent in FM patients (p = 0.01). 45.3% of DGBI patients reported pathological FiRST scores. DGBI patients with FM showed the highest score at the standardized GI questionnaire followed by FM patients with DGBI and DGBI without FM. In conclusion DGBI are common in FM patients and vice versa. The presence of FD is extremely frequent in FM patients. A multidisciplinary approach should be routinely used for the management of these patients.

Subjective Cognitive Dysfunction in Patients With and Without Fibromyalgia: Prevalence, Predictors, Correlates, and Consequences

BACKGROUND

Subjective cognitive dysfunction (SCD) is common in fibromyalgia (FM), where it has been called 'fibrofog.' But its predictors and correlates are not well understood, including the extent to which SCD is present in fibromyalgia and non-fibromyalgia clinical populations. In addition, there are no studies available concerning SCD and fibromyalgia in the general population. We investigated these issues in a longitudinal rheumatic disease research databank and two cross-sectional general population studies.

METHODS

11,150 unselected patients with rheumatoid arthritis completed an assessment of FM and cognitive severity (CS) status using the full 0-3 fibromyalgia 2016 criteria assessment. In addition, CS was dummy coded as present/absent (CS+). Assessments of SCD and fibromyalgia prevalence were available in two German general population studies.

RESULTS

Fibromyalgia was present (FM+) in 2,493 (21.7%) of clinical subjects and absent (FM-) in 9,017 (78.3%) by FM 2016 criteria. Cognitive severity was present in 1,304 (52.3%) of those with fibromyalgia and 1,009 (11.2%) of non-fibromyalgia subjects (FM-). In two general population studies, 42.0% to 52.3% of those with fibromyalgia were CS+ as were 1.4% to 5.5% of FM- subjects. Patients with CS+ had more abnormal scores for every measure of rheumatoid arthritis (RA) severity, fibromyalgia severity, and general health. The presence of CS+ was strongly related to somatic and non-somatic symptoms scores and less strongly to pain variables. The best predictor of CS+ in the clinic and the general population was the symptom severity scale (SSS), a criterion of fibromyalgia.

CONCLUSIONS

Persons with SCD have high counts of somatic and psychological symptoms. Subjective cognitive dysfunction is best predicted by a simple symptoms score, and not by pain extent scores. Although SCD is called fibrofog in patients with FM, 43.6% of CS+ cases occurred in FM- subjects. Fibromyalgia and CS are correlated but appear to be different parts of a symptom severity continuum. 'Fibrofog' as a phenomenon linked only to fibromyalgia is a misnomer because it can be identified in many non-fibromyalgia patients as well.

The Evolution of Fibromyalgia, Its Concepts, and Criteria

Fibromyalgia developed in the 1950s from a substrate of difficult to explain regional and widespread pain mixed with symptoms of psychosocial distress. Controversies regarding psychological issues were common. Multiple criteria arose to define the disorder, but each identified a different set of patients. The identification of widespread pain as a criterion changed the nature of the disorder by effectively eliminating regional pain as a component condition. The easy-to-measure and relatively reliable widespread pain criterion then came to define the disorder. In the primary care community, diagnostic criteria were largely ignored, and a substantial fraction of diagnosed patients with lower pain scores, particularly women and those with high non-pain symptom scores, were diagnosed. Non-pain symptoms were added back to the fibromyalgia definition and criteria in 2010. Recognition grew that fibromyalgia fit the description of a functional somatic disorder. The idea of fibromyalgia as a primary pain disorder with a neurobiological basis contended with fibromyalgia as a broader biopsychosocial disorder. It is increasingly recognized that fibromyalgia represents a dimensional, non-binary condition and that features of fibromyalgia extend to persons who do not satisfy the criteria. Severity assessments are now available but rarely used. The course of fibromyalgia is not well studied, and improvement and remission criteria have not been successfully defined. The future of fibromyalgia as a discrete disorder remains uncertain as features of fibromyalgia are increasingly observed in patients with multiple different medical conditions.

Cross-cultural adaptation and validation of the German Central Sensitization Inventory (CSI-GE)

BACKGROUND

The Central Sensitization Inventory (CSI) is a screening tool designed to detect symptoms related to Central Sensitization (CS) and Central Sensitivity Syndromes (CSS) by measuring the degree of related phenomena. The objective of this study was to create a German, culturally-adapted version of the CSI and to test its psychometric properties.

METHODS

A German version of the CSI (CSI-GE) was developed, culturally-adapted, and pretested for comprehensibility. The psychometric properties of the resulting version were validated in a clinical study with chronic pain and pain-free control subjects. To assess retest reliability, the CSI-GE was administered twice to a subgroup of patients. Structural validity was tested using factor analyses. To investigate construct validity a hypotheses testing approach was used, including (1) correlations between the CSI-GE and several other well-established questionnaires as well as (2) an investigation of the CSI-GE discriminative power between different subgroups of participants believed to have different degrees of CS.

RESULTS

The CSI-GE showed excellent reliability, including high test-retest characteristics. Factor analyses confirmed a bi-factor dimensionality as has been determined previously. Analysing construct validity 6 out of 11 hypotheses (55%) were met. CSI-GE scores differentiated between subgroups according to expectations. Correlations between CSI-GE scores and other questionnaires suggested that none of the correlated constructs was identical, but there was overlap with other questionnaires based on symptom load. Several correlations did not fit with our current understanding of CS.

CONCLUSION

The CSI-GE appears to be a reliable tool for measuring CS/CSS-related symptomatology. Whether this implies that the CSI-GE measures the degree of CS within an individual subject remains unknown. The resulting score should be interpreted cautiously until further clarification of the construct.

Fibromyalgia influences health-related quality of life and disease activity in psoriatic arthritis

Fibromyalgia syndrome (FMS) is common in patients of psoriatic arthritis (PsA), but the magnitude of its impact is uncertain. This cross-sectional study evaluated the impact of FMS on health-related quality of life (HRQoL) and disease activity in PsA. Adults classified with PsA (CASPAR criteria) at the rheumatology and dermatology outpatient clinics of PGIMER, Chandigarh, India between January 2014 and June 2015 were recruited. All patients were assessed for FMS using the 2010 ACR criteria. Health-related quality of life was assessed using PROMIS-HAQ, HAQ-pain, HAQ-health and revised fibromyalgia impact questionnaire (FIQR). Disease activity measures (SJC, TJC, BASDAI, enthesitis, dactylitis, PASI) and PROMIS-HAQ were correlated with measures of FMS [FIQR, symptom severity scale (SSS) score and widespread pain index (WPI)]. Multivariate regression analyses were used to identify predictors of PROMIS-HAQ and FMS. Out of 106 PsA patients screened, 102 [50 (49%) females; mean age 43.8 (12.4) years] were included. 19 (18.3%) had FMS. Patients of PsA with FMS had significantly (p < 0.05) higher TJC (14 vs 7), SJC (10 vs 5), BASDAI (6.1 vs 4.1) and enthesitis (53 vs 33%), but no difference in dactylitis, severity of skin disease and disease duration. A significant positive correlation of measures of FMS (FIQR, SSS and WPI) with SJC, TJC and BASDAI was noted. PROMIS-HAQ, HAQ-pain and HAQ-health were significantly worse (p < 0.001) in patients of PsA with coexisting FMS. Presence of FMS was found to be an independent predictor of worse PROMIS-HAQ. Female gender and higher TJC independently predicted presence of FMS. To conclude, FMS is an important contributor towards poor HRQoL in patients of PsA and is associated with higher values of joint disease activity measures.

Why It Hurts: The Mechanisms of Pain in Rheumatoid Arthritis

Pain is a near-universal feature of rheumatoid arthritis, but peripheral joint inflammation may not suffice to explain the etiology of pain in all patients with rheumatoid arthritis. Inflammation in rheumatoid arthritis releases several algogens that may generate pain. Also, central nervous system processes may play a crucial role in the regulation and perpetuation of pain. Several methods for assessing pain in rheumatoid arthritis exist, and recently the role of assessing therapeutics in treating specific etiologies of pain has gained interest.

Medical cannabis for the treatment of fibromyalgia syndrome: a retrospective, open-label case series

BACKGROUND

The use of cannabis for treating fibromyalgia syndrome (FMS) has not been comprehensively investigated. Thus, we have assessed the efficacy and adverse events (AEs) of short- and long-term medical cannabis (MC) treatment for FMS.

METHODS

Data were obtained from medical reports archived in the pain clinic of Ponderano (Italy; retrospective study). FMS patients, who were resistant to conventional therapy, received licensed MC with various Δ-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) content, as powdered whole flowers (decoction or vaporization) or oil extracts. Demographic and clinical parameters, including Numerical Rating Scale (NRS), Oswestry Disability Index (ODI), Hospital Anxiety and Depression Scale, Widespread Pain Index (WPI), Severity Score (SyS), and side effects, were obtained after 1, 3, and 12 months. Data were analyzed with Wilcoxon signed-rank tests for paired data.

RESULTS

Thirty-eight patients were included. Thirty, 18, and 12 patients continued therapy for 1, 3, and 12 months, respectively. Significant improvements (p < 0.01) were observed in NRS, ODI, WPI, and SyS at 1 month; in NRS, ODI, and WPI at 3 months; and in NRS, ODI, and SyS at 12 months. Therapy was interrupted by 17 patients (48.6%) owing to nonserious AEs according to the FDA. The most common side effects were mental confusion (37%), dizziness (14%), nausea/vomiting (14%), and restlessness/irritation (14%). The median daily dose of milled flowers administered as THC-dominant MC and hybrid MC (with similar THC/CBD ratio) was 200 mg/day and 400 mg/day, respectively. After 3 months of titration, the median content of THC administered with THC-dominant MC cultivars was 46.2 mg, and of THC + CBD administered as a hybrid MC cultivar, was 23.6 mg + 38 mg. At 3 months, median THC content administered in the oil extract of the THC-dominant MC cultivars was 9.7 mg, while that of THC + CBD administered in the oil extract of the hybrid MC cultivars was 1.8 mg + 2 mg.

CONCLUSIONS

MC may represent an alternative treatment for patients with FMS who are unresponsive to conventional therapy. However, its application may be limited by the incidence of nonserious AEs.

Fibromyalgia: Recent Advances in Diagnosis, Classification, Pharmacotherapy and Alternative Remedies

Fibromyalgia (FM) is a syndrome that does not present a well-defined underlying organic disease. FM is a condition which has been associated with diseases such as infections, diabetes, psychiatric or neurological disorders, rheumatic pathologies, and is a disorder that rather than diagnosis of exclusion requires positive diagnosis. A multidimensional approach is required for the management of FM, including pain management, pharmacological therapies, behavioral therapy, patient education, and exercise. The purpose of this review is to summarize the recent advances in classification criteria and diagnostic criteria for FM as well as to explore pharmacotherapy and the use of alternative therapies including the use of plant bioactive molecules.

All-cause and cause-specific mortality in persons with fibromyalgia and widespread pain: An observational study in 35,248 persons with rheumatoid arthritis, non-inflammatory rheumatic disorders and clinical fibromyalgia

PURPOSE

Studies of the relation of fibromyalgia (FM) and widespread pain (WSP) to mortality have differed as to the presence or absence of an association and the extent of cause-specific mortality. However, no studies have investigated which definitions of FM and WSP associate with mortality, nor of FM mortality in other diseases. We investigated these issues and the meaning of mortality in patients with FM.

METHODS

We used Cox regression to study 35,248 rheumatic disease patients with up to 16 years of mortality follow-up in all patients and separately in those with diagnoses of rheumatoid arthritis (RA) (N = 26,458), non-inflammatory rheumatic disorders (NIRMD) (N = 5,167) and clinically diagnosed FM (N = 3,659). We applied 2016 FM criteria and other FM and WSP criteria to models adjusted for age and sex as well as to models that included a full range of covariates, including comorbid disease and functional status. We estimated the degree of explained of variance (R2) as a measure of predictive ability.

RESULTS

We found positive associations between al`l definitions of FM and WSP and all-cause mortality, with relative risks (RR)s ranging from 1.19 (95%CI 1.15-1.24) for American College of Rheumatology (ACR) 1990 WSP to 1.38 (1.31-1.46) in age and sex adjusted revised 2016 criteria (FM 2016). However, in full covariate models the FM 2016 RR reduced further to 1.15 (1.09-1.22). The association with mortality was noted with RA (1.52 (1.43-1.61)), NIRMD (1.43 (1.24-1.66)) and clinical FM (1.41 (1.14-1.75) - where 37% of FM diagnosed patients did not satisfy FM 2016 criteria. In the all-patient analyses, the age and sex explained variation (R2) was 0.255, increasing to 0.264 (4.4%) when FM 2016 criteria were added, and to 0.378 in a full covariate model. Death causes related to FM 2016 status included accidents, 1.45 (1.11-1.91); diabetes 1.78 (1.16-2,71); suicide, 3.01 (1.55-5.84) and hypertensive related disorders, 3.01 (1.55-5.84). Cancer deaths were less common 0.77 (0.68-0.88).

CONCLUSIONS

FM is weakly associated with mortality within all criteria definitions of FM and WSP examined (3.4% of explained variance), and across all diseases (RA, NIRMD, clinical FM) equally. Clinical and criteria-defined FM had different mortality outcomes. We found no evidence for a positive association of cancer and FM or WSP.

Fibromyalgia Assessment Screening Tool: Clues to Fibromyalgia on a Multidimensional Health Assessment Questionnaire for Routine Care

OBJECTIVE

To develop feasible indices as clues to comorbid fibromyalgia (FM) in routine care of patients with various rheumatic diseases based only on self-report multidimensional Health Assessment Questionnaire (MDHAQ) scores, which are informative in all rheumatic diagnoses studied.

METHODS

All patients with all diagnoses complete an MDHAQ at each visit; the 2011 FM criteria questionnaire was added to the standard MDHAQ between February 2013 and August 2016. The proportion of patients who met 2011 FM criteria or had a clinical diagnosis of FM was calculated. Individual candidate MDHAQ measures were compared to 2011 FM criteria using receiver-operating characteristic (ROC) curves; cutpoints to recognize FM were selected from the area under the curve (AUC) for optimal tradeoff between sensitivity and specificity. Cumulative indices of 3 or 4 MDHAQ measures were analyzed as fibromyalgia assessment screening tools (FAST).

RESULTS

In 148 patients, the highest AUC in ROC analyses versus 2011 FM criteria were seen for MDHAQ symptom checklist, self-report painful joint count, pain visual analog scale (VAS), and fatigue VAS. The optimal cutpoints were ≥ 16/60 for symptom checklist, ≥ 16/48 for self-report painful joint count, and ≥ 6/10 for both pain and fatigue VAS. Cumulative FAST indices of 2/3 or 3/4 MDHAQ measures correctly classified 89.4-91.7% of patients who met 2011 FM criteria.

CONCLUSION

FAST3 and FAST4 cumulative indices from only MDHAQ scores correctly identify most patients who meet 2011 FM criteria. FAST indices can assist clinicians in routine care as clues to FM with a general rheumatology rather than FM-specific questionnaire.

Performance of 2016 revised fibromyalgia diagnostic criteria in patients with rheumatoid arthritis

Fibromyalgia (FM) is a common comorbidity in rheumatoid arthritis (RA). Recently, there were several updates for the American College of Rheumatology (ACR) FM criteria. To assess the performance of the 2016 revised ACR FM criteria in patients with RA in comparison to 1990 criteria and to study the relation to composite disease measures. This study included 130 adult RA patients fulfilling the 2010 ACR/EULAR classification criteria for RA. Patients were evaluated according to 2016 and 1990 ACR criteria for FM. Kappa agreement between the two criteria was determined. Spearman's correlation between the polysymptomatic distress scale (PSD) and selected variables including disease activity score-28 with erythrocyte sedimentation rate (DAS-28 ESR), clinical disease activity index (CDAI), patient global assessment (PGA), and visual analogue scale (VAS) for pain was evaluated. Of the 130 RA patients, 52 patients (40%) satisfied the 2016 criteria and 40 (31.5%) the 1990 criteria. The Kappa agreement between the two criteria was 0.733. RA patients with FM had higher DAS28-ESR, CDAI, PGA, and VAS compared with those without FM. A significant positive correlation was found between the polysymptomatic Distress scale (PSD) and DAS28-ESR, CDAI, and PGA (r_s 0.481, 0.516, 0.511, respectively, P < 0.001). FM coexists in a substantial number of RA patients according to the 2016 revised criteria and associated with high composite disease activity measures. Therefore, assessment of FM should be considered in RA patients with persistently high disease activity.

The Relation of Physical Comorbidity and Multimorbidity to Fibromyalgia, Widespread Pain, and Fibromyalgia-related Variables

OBJECTIVE

To investigate the relation of physical (non-psychological) comorbidity and multimorbidity to quantitative measures of fibromyalgia (FM) and musculoskeletal pain.

METHODS

We studied 12,215 patients in a research databank with quantitative measures of FM-related variables (FMV) that included binary determinations of FM and widespread pain (WSP), and constituent variables of FM diagnosis that included the WSP index (WPI), the symptom severity score (SSS), and the polysymptomatic distress scale (PSD). We assessed self-reported comorbid conditions and covariates that included age, sex, body mass index, hypertension, smoking history, and total household income. We used nearest-neighbor matching and regression adjustment treatment effects models to measure the effect of comorbidities on FMV.

RESULTS

We found a positive association between FMV and the probability of having each comorbid condition. Patients with ≥ 1 comorbidities had PSD, WPI, and SSS increases of 3.0 (95% CI 2.7-3.3), 1.8 (95% CI 1.6-2.0), and 1.2 (95% CI 1.1-1.3) units, respectively, and an increase in FM prevalence from 20.4% to 32.6%. As the number of comorbid conditions present increased from 1 to 4 or more, PSD, WPI, SSS, and FM percent increased stepwise. For patients with ≥ 4 conditions, the predicted prevalence of FM was 55.2%.

CONCLUSION

FM and FMV are associated with an increase in the number of comorbidities, and the association can be measured quantitatively. However, the association of WSP and FM may be an effect of definitions of WSP and FM, because comorbidity increases are also present with subsyndromal levels of both conditions.

Pain and affective distress in arthritis: relationship to immunity and inflammation

INTRODUCTION

Most arthritides are associated with pain and psychological distress (clinically significant depression and anxiety). Pain and depression are mutually exacerbating; both may continue even when joint involvement appears well controlled. Area covered: There is strong evidence that arthritis-related stress impacts the central nervous system and, together with peripheral inflammatory changes, can cause central sensitization that can lead to chronic pain and worsening of affective distress. Cytokines and chemokines participate both in joint inflammation and in central sensitization. We review evidence of these relationships in five arthritides, namely rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, gout, and in osteoarthritis of the hips and knees. Central sensitization in these conditions results in long-lasting pain and psychological distress. Expert commentary: Chronic pain and depression are important but often neglected in the clinical assessment and treatment of arthritis. The potential role of biologic cytokines and Janus kinase inhibitors in dealing with these symptoms needs further study.

Fibromyalgia and small fiber neuropathy: the plot thickens!

Several groups of investigators have described the presence of small fiber neuropathy in fibromyalgia patients. This writing discusses how this new finding could renovate fibromyalgia concept, diagnosis, and treatment. Predominant rheumatology thinking proposes fibromyalgia as a "centralized pain syndrome." An alternative hypothesis views fibromyalgia as a stress-related dysautonomia with neuropathic pain features. Dorsal root ganglia may be the key autonomic-nociceptive short-circuit sites. The recent recognition of small fiber neuropathy in a large subgroup of fibromyalgia patients reinforces the dysautonomia-neuropathic hypothesis and validates fibromyalgia pain. These new findings support fibromyalgia as a primarily neurological entity, nevertheless, rheumatologist will likely remain the best equipped specialist to diagnose fibromyalgia and differentiate it from other multi-symptomatic rheumatic syndromes. Skin biopsy and corneal confocal microscopy will probably become useful fibromyalgia diagnostic tests. Dorsal root ganglia sodium channel blockers are potential fibromyalgia analgesic medications. Subgroups of young girls with "autoimmune neuropathic fibromyalgia" may respond to immunoglobulin therapy. Multimodal intervention directed to regain autonomic nervous system resilience will likely remain the cornerstone for fibromyalgia therapy.

Fibromyalgia diagnosis and biased assessment: Sex, prevalence and bias

Purpose

Multiple clinical and epidemiological studies have provided estimates of fibromyalgia prevalence and sex ratio, but different criteria sets and methodology, as well as bias, have led to widely varying (0.4%->11%) estimates of prevalence and female predominance (>90% to <61%). In general, studies have failed to distinguish Criteria based fibromyalgia (CritFM) from Clinical fibromyalgia (ClinFM). In the current study we compare CritFM with ClinFM to investigate gender and other biases in the diagnosis of fibromyalgia.

Methods

We used a rheumatic disease databank and 2016 fibromyalgia criteria to study prevalence and sex ratios in a selection biased sample of 1761 referred and diagnosed fibromyalgia patients and in an unbiased sample of 4342 patients with no diagnosis with respect to fibromyalgia. We compared diagnostic and clinical variables according to gender, and we reanalyzed a German population study (GPS) (n = 2435) using revised 2016 criteria for fibromyalgia.

Results

In the selection-biased sample of referred patients with fibromyalgia, more than 90% were women. However, when an unselected sample of rheumatoid arthritis (RA) patients was studied for the presence of fibromyalgia, women represented 58.7% of fibromyalgia cases. Women had slightly more symptoms than men, including generalized pain (36.8% vs. 32.4%), count of 37 symptoms (4.7 vs. 3.7) and mean polysymptomatic distress scores (10.2 vs. 8.2). We also found a linear relation between the probability of being females and fibromyalgia and fibromyalgia severity. Women in the GPS represented 59.2% of cases.

Discussion

The perception of fibromyalgia as almost exclusively (≥90%) a women’s disorder is not supported by data in unbiased studies. Using validated self-report criteria and unbiased selection, the female proportion of fibromyalgia cases was ≤60% in the unbiased studies, and the observed CritFM prevalence of fibromyalgia in the GPS was ~2%. ClinFM is the public face of fibromyalgia, but is severely affected by selection and confirmation bias in the clinic and publications, underestimating men with fibromyalgia and overestimating women. We recommend the use of 2016 fibromyalgia criteria for clinical diagnosis and epidemiology because of its updated scoring and generalized pain requirement. Fibromyalgia and generalized pain positivity, widespread pain (WPI), symptom severity scale (SSS) and polysymptomatic distress (PSD) scale should always be reported.