UPDATED March2015 See BLOCKQUOTE HERE (SCROLL DOWN) on free use of Medscape; all other links are free as-is.
Grateful thanks to Darwinian Detritus for link-testing and proofreading. NOTE: The sole purpose of this overall report is EDUCATION on FM diagnosis, symptoms, care, self-care, treatments, related issues, & recent research, on the principle that ongoing in-depth patient education helps equip them and their clinicians for optimal partnership toward better outcomes and quality of life.
[#1] Fibromyalgia (FM) 1955 to 1995 to 2014, Daniel J. Clauw's 2014JAMA. 2014 Apr 16;311(15):1547-55. doi: 10.1001/jama.2014.3266. clinical and evidence REVIEW of 59 years of FM scholarship —fulltext purchasable but not freely available; see free Medscape reportage: [#2] Effective Treatment for FM May Now Be Possible— differs most from his 1995 [3] Fibromyalgia: More Than Just a Musculoskeletal Disease“ FREE FULL TEXT HERE on epidemiology:
After osteoarthritis, FM is the most common "rheumatic" disorder, [with] prevalence from 2% to 8% [and] female:male ratio of 2:1 ... [it] can develop at any age, including in [#4] childhood —[5] youth, and [6] elders—, [and all] countries, cultures and ethnic groups —e.g., [7] Morocco, [8] Japan, [9] Brazil—; there is no evidence [of] higher prevalence in industrialized countries and cultures.
1995 objective clinical features held true with some additions (per the new gender ratio, the pain-marking body diagram is changed from female to male), verified as significantly beyond normal incidence by brain-imaging, genetics, and other research: the "cardinal" widespread, migratory, diffuse and multifocal pain and tenderness, and
sleep disruption...[stiff soft-tissues]...migraine and [other] headaches...severe and debilitating fatigue...[exertion intolerance]... paresthesias... ocular and vestibular malfunction... sensitivity to pressure[/touch/irritation], bright light...noise... short-term memory and concentration difficulties..."allergic" symptoms ... adverse reactions to drugs and environmental stimuli (many patients meet criteria for "multiple chemical hyper- sensitivity") ... cardiac, pulmonary, gastrointestinal, esophageal, [reproductive]/genito-urinary, biochemical, hormonal and neuro-transmitter abnormalities... history of [prolonged/repeated injury/trauma]...
which he shows as typical of the global sensory hyper-responsiveness characterizing Central (nervous system) Sensitivity Disorders (#33, 34 below) and is not somatization neuroticism. In 1995, Clauw advised that
an effective management plan...can have a considerable positive impact...[although] it may take several months until benefit is seen... physician and patient must discuss symptoms...in depth...that there is no known cure and [it's] likely to be chronic with a fluctuating course. [Encourage patients] to take an active role... A passive [role] is rarely successful in this disorder... stress should be minimized... patients [should not try] to subsist on less sleep than their body{sic} requires... time-based pacing [to not do] so much on a "good" day that they [are worse] for several days thereafter... pleasant activities that can act as distractors from pain... [low-impact low-intensity] exercise is vital [and] can be [begun] with...a physical therapist [proceeding to independence]... Injections of tender points with a topical{sic} anesthetic... biofeedback,(#71 below) acupuncture, massage therapy ...may all be of benefit...
but clinicians and insurance continued emphasizing [#10] pharmaceutical treatment, largely anti-cholinergic in impact, familiar from female "mood" and "psychogenic pain" treatment and the sex-bias stigma of whining-complainers-about-nothing that trivializes patients as human beings and increases risk for dangerous health issues going dismissed as FM symptoms until too late to salvage life ... or save it.
So, Are We There Yet?
If Clauw's 2014 review seems no radical advance, that may be due in part to a tone apparently pitched to engage physicians such as his grand rounds conferee who asked, "How should physicians manage a clinic visit...to avoid feeling...manipulated by the patient?"
That's just one factor that makes May Be/maybe the operative expression. To skip discussion for now, scroll down 4 or 5 screen's-worth to citation #13 (and a generously free-access link in it to the Canadian Medical Association Journal's "Fibromyalgia: Evolving Concepts Over The Past 2 Decades", 6 May 2013), #15, #99, #173, etc. (All links should open parallel browser tabs so back-arrowing is unnecessary.)
Or, to continue discussion here: ...being retrospective, the 2014 review emphasizes past care approaches which patients diagnosed a while ago likely have already undergone. Drugs remain the mode. Clauw notes that:
...Twin studies suggest that approximately 50% of the risk of developing FM and related conditions is genetic and 50% is environmental ... Genes associated with increased or decreased frequency of chronic pain states or pain sensitivity regulate the breakdown or binding of pain sensitivity-modulating neurotransmitters and others of inflammatory pathways. [Differing] pain sensitivity between individuals may result ... explaining why [any given drugs] either help many co-occurring symptoms...in a given individual...or do not help at all...
but also says, "Successful treatment may require concomitant use of several drug classes". The 2012 grand rounds conference of his 2014 Review is based on the FM case study of a 64-year-old nurse with 20 years of chronic pain. Her prescription history, including for her co-morbidities, is staggering merely to read let alone imagining to endure:
...gabapentin, venlafaxine, pregabalin and hydrocodone/acetaminophen most of which [gave her] significant adverse effects... cyclobenzaprine ... amlodipine, hydrochlorothiazide, levothyroxine, moexipril, pantoprazole, pravastatin... [She has] experienced loss of energy, weight gain, ...headaches, insomnia... depressed mood... pain, and fatigue [limiting] her physical activity to not more than a few contiguous hours. [She] asks if there is a treatment regimen that will allow her to be more functional while avoiding adverse effects.
Clauw's response to her —and to the manipulated-feeling colleague— at first looks promising:
If clinicians treat FM or other chronic pain conditions with drugs alone, they will fail. This is akin to treating diabetes with insulin or drugs alone, without corresponding attempt to modify diet or weight. ...patients with chronic pain hurt, motivating them to be more adherent to nondrug therapies. Be on the offensive. Be persistent in encouraging your patients about exercise, and trying web-based ... therapies [(cognitive behavioral therapy, exercise games, his Univ of Michigan FibroGuide)]. Do not be defensive and think every time these patients come in...a different drug is the only available approach. If practitioners use nondrug therapies more aggressively and fewer opioids, NSAID drugs, and [surgeries], and more centrally acting analgesics, FM is easier to manage. emphasis added --ed.
Drugs again. And for whom do they make FM "easier"? Is a sedated and sedate patient a problem solved?
The good-behavior notion of health —condemning assertive patient speech or action as insult or a sign of disease itself, and infantilizing such patients to rationalize ‘treating’ them like rebellious children, medicating them for it “for their own good”— is historically pernicious especially with "women's complaints“, characterizing them as silly, selfish, immature, unreal, objectionable, and their ailments “all in their minds.” The still-common trashcan diagnoses are a legacy of eras intolerant of health issues more common in females than males. Those diagnoses tend to operate as pejorative medical "reassurance" about devalidated patients, to family members, bosses, and others may who prefer that patients meet their demands and not “indulge” in illness, insinuating that there's no "significant" physical trouble. Thus, the patient whom medical treatment makes behave as other people want them to —or less in ways others dislike— is easily thought "cured". Or at least less trouble to everyone else, which may be what matters to them most. Intractable illness is, after all, stressful to everyone involved.
Genetics and ethnicity aside where drug metabolism is concerned (e.g., #61, 79, 108, 148, 178a), male patients tend to respond more safely to drugs than women do. With men now 1/3 of FM patients —a whole new market for BigPharma— will the drug emphasis in FM treatment be strengthened, with renewed hazards to women and new ones for men? Among the typical FM guinea-pig series of one shot-in-the-dark drug after another, many adverse effects (some of them permanent) are described in published research, and the drug package inserts often state that they can induce fatigue; lethargy; weight gain; muscle weakness; exertion intolerance, and impaired memory, concentration, and executive function —remarkably like the profile of the illness itself, for some of which the blame is often put on patients themselves. Clauw remarks that
...the same neurotransmitters that control pain and sensory sensitivity also control sleep, mood, memory, and alertness...
and just what that control will do to those capacities is not greatly within human control. In fact, the extent to which FM symptoms are iatrogenic {medically caused} sequelae {consequences} of treatment meted out before and after FM diagnosis to patients struggling year after year to sustain employability, family, household, and functionality, is an area of research essentially nonexistent to date (cf.#19, 69, 162, 172...).
If we really don't have control, what do we have?
“Education,” the American College of Obstetricians and Gynecologists says [#11] “Doctors have a responsibility to enhance the health literacy of their patients,“ defining that literacy as
...the degree to which individuals have the capacity to obtain, process, and understand basic health information … needed to make appropriate health decisions.
...recognizing, for example, that a cold requires less information for decision-making than does "walking pneumonia".
More conservatively than in 1995, however, Clauw now advises clinicians to educate patients about the "non-progressive nature of the illness" ▬ progressive meaning it gets worse over time with increasing irreparable damage, non- progressive meaning it won't/there isn't. Yet realistically, this cannot be predicted because FM rarely arises in isolation. There's no way to know ■ whether it has reached its worst level by date of diagnosis ■ whether FM impact will be aggravated by degradation of persistent injuries and/or co-morbidities unquestionably known to progress ■ whether the educational physician is well-versed on autonomic dysfunction (e.g., #24, especially cardiac abnormality in FM) and other fatigue and exertion intolerance factors that deplete personal capacity for good self-care and lead to further deterioration ■ extent to which polypharmacy or drug/chemical hypersensitivity add impact ■ whether the patient has the securely middle-class resources (e.g, leisure and finances) for optimal self-care and "lifestyle" modifications. (Does the third world have "lifestyles"? Do impoverished individuals anywhere?) ▬
......and about the importance of playing an active role in their own care [particularly through] stress reduction, sleep, and exercise...
in which, again, availability of real-world resources are basic, notably whether physicians accept and promote the patient’s “active” role beyond those quoted few areas.
Is such limited “education” adequate for appropriate health decisions by FM patients? Clinicians themselves are faced with evolving concepts of "stress", "rest", "exercise", "therapy" etc., which, humanly and professionally, they tend to resist. Patients have to be equipped for that — example: another of Clauw's conferees asks, "Will injury occur if...patients push themselves to continue exercising even while in pain?" as if that physician thinks heavy fatigue causing poor attention to hazards is not a key injury factor even among professional athletes, and as if exertion intolerance isn’t a factor in all debilitating illnesses. Clauw replies that activity and exercise are beneficial in chronic pain conditions, "focusing first on increasing daily 'activity' before actually starting exercise" and that patients only must not do too much too soon leading to "worsened pain". The conferee recognized no other risks except worse pain (cf. #9 above), yet Clauw gives no reminders of other risks.
Which Patients Merit Fully Effective Treatment?
Having said:
FM can be diagnosed and treated in the primary care setting. Referral to specialists should be necessary only [when] diagnosis is uncertain (e.g., to a rheumatologist or neurologist, depending on symptoms) or for patients refractory to therapy...
(patient rather than disease being “refractory” is a common medical shorthand that perpetuates patient-blame - cf.#64) the 2014 review somewhat contradictorily calls upon
...treatment teams...even if...only virtual, [including] clinicians with expertise in patient education ... exercise therapy (e.g., physical or occupational therapists), and cognitive behavioral therapy.
How does a physical therapist virtually teach, coach and monitor low-intensity low-impact graded exercise or give TENS treatments —per the 2014 "Non-pharmacological" section— or deliver any care service beyond online education, web-based cognitive behavioral therapy or exercise games?
And the catch-22: few U.S. health plans cover such full-scope care (let alone what's accessible anywhere else). Must patients pay out-of-pocket or forego care that actually makes a difference? In the US, disability-based skilled services from Medicare might comprise full-scope, but Clauw's conferees worry that putting patients on disability is “reward” for illness. They call it
secondary gain resulting from ... financial support as an alternative to work
to which Clauw's 2014 patriarchal and condemnatory answer is:
There will always be individuals who fake or magnify symptoms to benefit financially, but this is...a minority... More problematic is non-volitional worsening...when patients with pain enter the disability and compensations systems. As eloquently noted by Hadler,The Object Lesson of Fibromyalgia, Spine 1996;21(20):2397-2400 "If you have to prove that you're sick, you can't get well." I think chronic pain patients are very deserving of disability but find that they almost always clinically worsen when they get involved in disability or litigation. The...system [creates] frustration, anxiety, isolation, and inactivity, all of which are counterproductive to rehabilitation approaches that benefit chronic pain patients...
As dumbed-down and privilege-oriented as the 2014 review seems —not least in suggesting that work-for-a-living patients struggling with symptoms no one takes seriously still seek medical help... yet magically need no respite (with income to pay the costs) in which to relearn/re-engineer daily life (cf 26a)— it does bring rehabilitation into the FM discussion at last! ...although problematically categorizing tai chi, yoga, etc as complementary/alternative therapy (not as rehabilitative occupational therapy: cf. #53, 95, 151, 167) along with tender-point injections, massage therapy (#128, 164), etc., even acupuncture from which the case study patient herself was surprised to benefit, i.e., not placebo effect, although that effect is nevertheless cited:
Some evidence suggests that these treatments give patients a greater sense of control over their illness... a choice of therapies may improve the likelihood for a placebo response by activating the body's [innate] therapeutic mechanisms. Despite the absence of high-quality evidence regarding their efficacy, alternative therapies may be useful as long as they do not cause harm since options for treating FM are limited.
...limited indeed, so long as low-cost options ▬such as diet, self-applied over-the-counter topical/transdermal analgesics (e.g., arnica gel, Aspercreme), affordable groups/classes (tai chi, etc)▬ which promote the active role and the patient’s independence in self-care go under-researched for lack of profitability, thence dismissed in medical journals as placebos.
In sum, the fact that Clauw saw necessary to review 59 years of evidence, itself underlines that: [a] advance is slow; [b] error frequency is high in trial&error research, from formal controlled studies to physician commands upon patients, and everything in between, putting subjects/patients on trial as well as through them (and/or hell, depending which side of the needle you're on); and [c] misconceptions stubbornly abound, to the detriment of all.
Thus, when hide-bound clinicians are the only healthcare available, "May Be Treatable" translates to hoping that modestly useful methods of past decades might help patients not previously subjected to them.
Whether the work of Clauw (1995, 2014, all between, and onward - #99), Yunus, Moldofsky, Goldenberg, Buskila, et al (mostly men) can change clinician grasp and attitude depends on whether clinicians use the research only to confirm their treatment preferences by relying just on information with which they agree, or whether they're open to a wider vision, without prejudices, in order to advocate and facilitate in the patients' best interests. And that depends on how extensively other approaches are researched and those articles published. Clauw's 1995 and 2014 reviews contain more than can be covered in a discussion shorter than either of those medical journal articles themselves. They might or might not be worth patients' copying at college or university libraries that subscribe to the publications, or asking for from cooperative clinicians or public library I.L.L., although the 2014 full page "...Treatment Guidelines" are summarized fairly well by Clauw himself in #99 below.
At least FM study's frame of reference is starting to grow beyond easy prejudices as knowledge develops of its complexity and recognition of its disastrous potential for patients anywhere in the world in hardship or violent conditions that decrease capacity to secure the necessities of life. If this is mostly because men are now understood to be 1/3 instead of 1/10 of the patient group, we must make the best of it. The articles independently collected below, across a wider spectrum of treatment concepts —ranging from informative to tentative to controversial to appalling— show how clinicians and researchers currently discuss FM and related topics among themselves. Where they've commented at Medscape articles can be very illuminating, e.g., a doctor said at an early 2014 article, "Then treat the depression and the illness goes away." If that were true, FM would have been cured half a century ago.
Introductory Articles
Robert M. Bennett et alii's 2007 [#12] Internet Survey of 2,596 People with FM details the daily western-patient FM experience, much of which goes unasked, dismissed, or trivialized by healthcare professionals. Dr. Bennett —MD, Professor of Medicine and head of the FM Research Group at Oregon Health & Science University, Portland— weighs in again in [#13] FM Guidelines Trigger Changes for Family Practitioners:
The reality is that most rheumatologists do not want to be involved in the routine care of FM and prefer to focus on patients with rheumatoid arthritis and other autoimmune disorders.
Not surprising. FM is widely agreed not really a rheumatic nor rheumatoid nor autoimmune nor arthritic nor inflammatory disease in classic sense, rather exhibiting similarities to them all, yet in some views, involving neurogenic inflammation of soft/fibrous tissues, even as specialized as in the iris of the eye, and possibly even mechanoreceptors {#120}.) Historically, the most examined symptom —chronic musculoskeletal pain— has been a focus of the arthritis-and-rheumatology field: at the NlH the National Institute of Arthritis, Musculoskeletal & Skin Diseases/NIAMS has had major responsibility for FM study, if with (to be devoutly hoped) interdisciplinary collaboration across every boundary between specialties as the facts increasingly dictate, notably recently, neurology ([#14] Many FM Patients Have Small-Fiber Polyneuropathy) and even in 1995, Clauw listed conditions known to resemble or be associated with/co-morbid with FM, the presence or absence of which would be significant in treatment decisions:
■ RHEUMATIC ■ Early rheumatoid arthritis ■ Polymalgia rheumatica ■ Systemic Lupus erythematosus ■ Sjogren's syndrome ■ Polymyositis/dermatomyositis ■ Scleroderman ■ ENDOCRINE/METABOLIC ■ Hypothyroidism ■ Hyperparathyroidism ■ Hypoparathydroidism ■ Hypercalcemia ■ Alcohokic or metabolic myopathy ■ Hypokalemia ■ Osteomalacia ■ Paget's disease ■ NEOPLASTIC ■ Carcinomatosis ■ Multiple myeloma ■ Lymphoma ■ INFECTIOUS ■ Human immunodeficiency virus ■ Viral hepatitis ■ Parasitic infections ■ Subacute bacterial endocarditis ■
The 1990 American College of Rheumatology paired tender-point Diagnostic Criteria (described by Clauw as "research classification criteria...never meant for use in clinical practice") were little to work with, and difficult as to skill. [15] FM: New Criteria Improve Diagnosis summarizes changes the criteria have undergone in the U.S. alone. Their evolution comes at a price: 5 different sets sowing confusion and the first 4 technically challenging. FM organizations say patients diagnosed today have already spent several years and thousands of dollars at 3 to 5 clinician practices trying to learn what's going wrong with their health. 15 years ago, it was 9 clinicians plus years. In view of common mis-diagnoses during that trek and drugs accordingly prescribed, on-or-off-label, the mis-medication impact multiplies devastation upon daily life and health besides effects of unmanaged disease.
The Rest of the List, Alphabetical by Title
In recognition of the large patient subset for whom conventional treatments fail (or worse), this compilation emphasizes other information. However, inclusion here does not indicate certainty of usefulness, nor validate approach, nor that the total represents the full range of scholarship on FM or related topics (articles with a bearing on issues common to FM are included even if not mentioning FM at all). Inclusion only means the refractory fibromyalgic editor of this collection found the material informative, educational, intrigueing, surprising or valuable — for reasons positive OR negative. The list is alphabetical to avoid conclusions drawn based on order; thus, articles a different compiler might group by topic (with repetitive results, since many articles touch on multiple topic concerns) are scattered throughout this list. Numbering is for easy reference in discussion here or elsewhere. The ▼ symbol indicates that a blockquoted exerpt (not necessarily conclusion or summary) follows a citation-link, or that a tightly-related citation follows as an exception to alphabetical order (indicated by ▲ ). Exerpted articles are not necessarily of greater importance than articles for which a citation-link alone is given. Most linked pages provide additional links to similar articles. Read critically for best results.
[16] 1-week multidisciplinary FM program is logistically feasible & has potential for clinical efficacy.
[17] Altered Pain Perception May Underlie Some Dry Eye Disease
[18] American Bellies Are Getting Bigger: You Won't Believe Why
[18a] American College of Rheumatology FM webpages
[19] ▼"Antidepressant-Induced liver toxicity has been underestimated in the scientific literature."
[20] ▲ SSRIs (selective serotonin reuptake inhibitors) & Hypnotics Increase Fracture Risk
[20a] Are Doctors Arrogant?
[21] Association between alcohol consumption & symptom severity & quality of life in patients with FM, Arthritis Research and Therapy, March 2013.
[22] ▼ Atomoxetine May Improve Driving Skills in Adults With ADHD
[22a] ▲ brand name: Strattera (Wikipedia)
[23] Attention fatigue, directed (Wikipedia)
[24] ▼ Autonomic Dysfunction in Women With FM 2012 (abnormalities of heart function)
...While the etiology of FM is not fully understood, data have suggested that FM may stem from dysfunction of the autonomic nervous system [which] has been reported at rest, and after a physiological stressor such as exercise [but] few studies have examined the responses during exercise. ...In a recent issue of Arthritis Research & Therapy, Ribeiro and colleagues … present data further supporting the theory that women with FM suffer from autonomic dysfunction in response to, and during recovery from, acute exercise [which may] increase the risk for [premature cardiovascular disease], cardiovascular events and mortality ... Ribeiro et al examined cardiovascular responses during and after a maximal treadmill test in women with FM and healthy controls. Chronotropic incompetence —the inability to increase heart rate with increasing exercise intensities— was used as a measure of cardiac autonomic response during the exercise bout, [and] heart rate recovery taken at 1 and 2 minutes post-exercise was used to assess recovery from the acute aerobic exercise bout. The major findings of this study were relatively novel. ...women with FM had a lower oxygen consumption (VO2max) than healthy controls [as reported previously but also] that chronotropic reserve was significantly lower in women with FM than healthy controls. Furthermore, 57.1% of these women presented chronotropic incompetence compared to none of the healthy controls. Lastly, there was a significant reduction in heart rate recovery at 1 minute and 2 minutes after the exercise bout in these women compared to healthy controls, suggesting inability of the parasympathetic system to recover. Ribeiro and colleagues … noted that [FM] patients had lower heart rates and lower levels of circulating catecholamines at the same absolute workload compared to healthy controls. Other studies have demonstrated altered muscle function during aerobic exercise in women with FM, which may be related to autonomic dysfunction… [and] that autonomic modulation is altered in women with FM during recovery from an acute bout of resistance exercise... as well as during recovery from isometric handgrip... ...it appears that autonomic modulation is impaired after exercise — either aerobic exercise or resistance exercise — regardless of the method utilized to investigate it. Martinez-Lavin and Hermosillo... have suggested that autonomic dysfunction may explain many FM symptoms such as insomnia, irritable bowel syndrome, anxiety, orthostatic intolerance, and fatigue, as well as pain. Furthermore, data suggest that women with FM experience hyperactivity of the sympathetic system at rest, and hypoactivity of the sympathetic nervous system during a stressor, such as exercise, standing or cold exposure... emphasis added.
[25] ▲ ▼Autonomic cardiovascular control and responses to experimental pain stimulation in FM syndrome
Objective: This study involves a comprehensive investigation of autonomic cardiovascular regulation in FM at rest and during painful stimulation and its association with pain indices. Methods: In 35 patients and 29 healthy controls, electrocardiography, impedance cardiography, and finger continuous blood pressure measurements were conducted. For the purpose of experimental pain induction, a cold pressor test was applied. Results: FM patients showed lower pain threshold and tolerance, as well as higher ratings of pain intensity and unpleasantness on visual analogue scales. Resting stroke volume, myocardial contractility, R-R interval, heart rate variability, and sensitivity of the cardiac baroreflex were reduced in the patients, and increases in stroke volume and myocardial contractility during cold pressor stimulation were less pronounced. In the whole sample as well as in the FM group, baroreflex sensitivity was inversely associated with subjective pain intensity, and a higher number of baroreflex operations per unit of time predicted higher pain tolerance. Conclusions: The data suggest impaired autonomic cardiovascular regulation in FM in terms of reduced sympathetic and parasympathetic influences, as well as blunted sympathetic reactivity to acute stress. The association between baroreflex function and pain experience reflects the pain inhibition mediated by the baroreceptor system. Given the reduced baroreflex sensitivity in FM, one may assume deficient ascending pain inhibition arising from the cardiovascular system, which may contribute to the exaggerated pain sensitivity of FM.
[26] Back to School & Chronic Fatigue Syndrome: CDC Expert Commentary Dec 2012.
[26a] Becoming the Patient: Not as Easy as It Looks A remarkably advanced physician puts himself on a diabetic self-care/self-regulation regimen (complete with simulated insulin pump) to experience the learning-curve demand and taskload [of chronically ill patients]. He finds it steep going, even without having the actual disease impact as the basic burden. Printer-friendly (see near the top right corner below the title/author/date lines).
[27] Benzodiazepine Use and Risk of Alzheimer's Disease: Case-Control Study
[28] Brain Clears Toxins During Sleep
[29] ▼ Caffeine Enhances Memory Consolidation in humans
...For [this] study, ([28a] preview published online January 12, 2014) in the journal Nature Neuroscience, 160 healthy volunteers were shown 200 pictures of different everyday items and asked questions about them. They were then given a pill containing 200 mg caffeine or a placebo. The next day, the participants were given a surprise memory test. They were shown another set of pictures, some the same as before, some new items, and some similar but slightly different. Those individuals who had taken the caffeine were better able to discriminate the new items and were more likely to detect that the similar items were different from those viewed the day before...
[29a] ▼ Can Alcohol Consumption Be an Alternative Treatment for FM?
...Several observational studies have examined associations between alcohol consumption and chronic pain conditions... Kim and colleagues are the first to examine [alcohol consumption in the light of] FM symptom severity and quality of life. Among the 946 adult FM patients (94% women, mean age 49 years old) reporting low or moderate alcohol consumption (≤3 or >3 to 7 drinks per week), there was lower FM symptom severity and better quality-of-life scores compared with those who reported no alcohol consumption (non-drinkers)... [and those who reported being heavy drinkers (>7 drinks per week) fared worse]... Because alcohol consumption consists of complex behaviors that intersect with many social, economic, psychological, and demographic factors, disentangling this complex web of relationships is a challenge. Interestingly, after exploring possible mechanisms for their findings, Kim and colleagues speculated that alcohol consumption may attenuate FM symptoms and improve quality of life by mediating psychological benefits and stress relief or by promoting factors associated with social integration. Another possible mechanism proposed is central nervous mediation via the modulating gamma-aminobutyric acid (GABA) system. Several neurotransmitters (including GABA) in the ascending and descending pain pathways have been implicated in FM... Thus, behavioral and pharmacological therapies that modulate or mimic the effects of GABA production can be promising for FM treatment. This initial exploration...has posed a number of questions that need to be answered by future [research] with stronger study designs...
[30] Canadian Pain Society 2012 Guidelines for the Diagnosis & Management of FM syndrome 52 pps. Clauw draws extensively on this in his 2014 Review recommendations.
[31] Care for Obese Women Should Be Nonjudgmental
[32] CDC/Centers for Disease Control: fibromyalgia
[33] ▼ Central nervous system reorganization in a variety of chronic pain states: a review.
...recent advances in neuroimaging and neurophysiology are rapidly expanding our understanding of [nonspecific low back pain, FM, complex regional pain, post-amputation phantom pain, and chronic pain after spinal cord injury] syndromes. It is now clear that substantial functional and structural changes, or plasticity, in the central nervous system (CNS) are associated with many chronic pain syndromes. A group of cortical and subcortical brain regions, often referred to as the "pain matrix," often show abnormalities on functional imaging studies in persons with chronic pain, even with different pain locations and etiologies. Changes in the motor and sensory homunculus also are seen. Some of these CNS changes return to a normal state with resolution of the pain...The purpose of this article is to review recent advances in [understanding these] CNS changes associated with chronic pain in a number of clinical entities encountered in the field of physical medicine and rehabilitation...
[34] ▼ Central sensitivity syndromes: a new paradigm & group nosology
[35] ▲ Fibromyalgia Central Sensitization Disorder by Muhammad Yunus.
[36] ▼ Characteristic electron microscopic findings in the skin of patients with FM—preliminary study (Neuro-anatomy)
[In this] blinded study...Skin biopsy samples were obtained from 13 FM patients and 5 control subjects... Biopsies were read by an individual without knowledge of participant status. 5 skin biopsies from healthy controls showed relatively even distribution of variegated sized unmyelinated axons sheathed well by complicatedly folded Schwann cell membranes. In tissues from 9/13 this may mean 9 out of the 13 --ed. FM patients, unmyelinated Schwann cells were noted to be ballooned...this finding was not noted in any controls... Axons in most patients trended towards being localized in the periphery of the unmyelinated Schwann cell sheaths... Particularly, peripheral localization of axon in the unmyelinated Schwann cell sheath had a strong relationship with ballooning of Schwann cell..., simplified folding of Schwann cell sheath..., and smaller axon. Myelinated nerve fibers were unremarkable. The EM findings seen in the skin of FMS patients show unusual patterns of unmyelinated nerve fibers as well as associated Schwann cells. If these findings are replicated in a larger study, these abnormalities may contribute to, or be due to, the lower pain threshold seen in FMS patients.
[37] ▼ Chemical Intolerance Common in Primary Care Patients
A new study has found that chemical intolerance is prevalent among primary care patients, yet is rarely diagnosed. The study...notes that routine use of a simple questionnaire may help identify these patients more effectively. Using the Quick Environmental Exposure and Sensitivity Inventory (QEESI) screening tool, David Katerndahl, MD...Univ of Texas Health Science Ctr, San Antonio, and colleagues identified 20.3% of 400 adult patients screened who met the criteria for chemical intolerance. These patients often met the screening criteria for other disorders as well...
[38] ▲ Chemical Intolerance in Primary Care Settings: Prevalence, Comorbidity, & Outcomes
...Chemical intolerance occurs in 1 of 5 primary care patients yet is rarely diagnosed by busy practitioners. Psychiatric comorbidities contribute to functional limitations and increased health care use. Chemical intolerance offers an etiologic explanation. Symptoms may resolve or improve with avoidance of salient chemical, dietary (including caffeine and alcohol), and drug triggers. Given greater medication intolerances in chemical intolerance, primary care clinicians could use the QEESI to identify patients for appropriate triage to comprehensive nonpharmacologic care... Key Words: chemical intolerance, idiopathic environmental intolerance, multiple chemical sensitivity, psychiatric comorbidity, functional impairments, health care utilization, practice-based research
[39] ▲ A Question for Women's Health: Chemicals in Feminine Hygiene Products and Personal Lubricants "...A recent report by the nonprofit Women's Voices for the Earth (WVE) points out that feminine hygiene products may use ingredients that are known or suspected endocrine-disrupting chemicals (EDCs), carcinogens, or allergens."
[39a] Childhood Trauma Heightens Disease Risk Into Adulthood
[40] cholinesterase inhibitors (e.g., Aricept and memantine] in mild cognitive impairment patients showed no significant impact on cognition and higher risk for side effects compared with placebo.
[41] Chronic Opioid Use in FM Syndrome: A Clinical Review
[42] Chronic Pain, Obesity, & Physical Function & Disability in Older Adults.
[43] Chronic Widespread Pain, Including FM: A Pathway for Care Developed by the British Pain Society
[44] Classifying FM patients according to severity: the combined index of severity in FM
[45] ▲ A confirmatory study of the Combined Index of Severity of FM (ICAF*): factorial structure, reliability and sensitivity to change.
[46] ▲ Development of a self-reporting tool to obtain a combined index of severity of FM.
[47] Clinical Trial Completion & Reporting [are] Inadequate
[48] ▼ [Cognitive & executive function symptoms {are} independent of depression in FM]
A new study confirms that people with FM can experience objective impairments in cognitive and executive function (EF) independent of depression.... FM patients "often complain about ... 'Fibro-fog', a cluster of cognitive disorders not always reflected in poor test-based performance, but which strongly interferes with work and daily life," lead author Valentina Tesio, PhD [Department of Clinical and Oncological Psychology, Città della Salute e della Scienza Hospital of Turin, and the Department of Neuroscience, University of Turin, Italy] and colleagues write in an article [48a] published online July 21 [2014] in Arthritis Care and Research, [but] this has proven difficult to study, in part because "EF represent a multifaceted construct, composed of separable factors... Considering EF as a whole would therefore not allow identification of subtle differences in cognitive complaints.
Therefore, in 90-minute testing of patients and matched healthy controls, using standard tests ▬the Hospital Anxiety and Depression Scale, the Digit Scan-Backward test, the Rey Auditory Verbal Learning Test, the FACT-Cog 2 (Functional Assessment of Cancer Therapy-Cognition Scale, useful with patients other than those with cancer because "it does not contain specific references to cancer or cancer treatment"), the Trail Making Test, the 1-Back test (reaction time measured in milliseconds, along with accuracy), and the FM Impact Scale▬ to examine the relationship between self-evaluation and objective measures of pain, anxiety, depression, memory, working memory, and four interrelated components of EF: shifting, the ability to shift attention between tasks; inhibition, the ability to suppress automatic or routine responses; updating, replacing old, outdated information with newer, more relevant information; and access, the ability to access long-term memories, also needed for verbal fluency.
"[the] data indicate that the long-term and working memory, shifting of attention and updating executive functions of FM patients are impaired compared to [healthy controls]," the authors conclude. "These impairments are reflected in subjective complaints independently of depressive symptoms." They recommend inclusion of a self-report questionnaire to assess cognitive impairment, in the initial clinical evaluation of patients with FM.
[49] [Cognitive impairment in patients suffering from FM. An underestimated problem].(Article in German, Abstract in English)
[50] Cognitive Risks of Anticholinergics in the Elderly
[51] ▼ Comorbid somatic symptoms & functional status in patients with FM & chronic fatigue syndrome: sensory amplification as a common mechanism.
OBJECTIVE: Authors investigated a potential shared pathologic mechanism: a generalized perceptual abnormality where there is heightened responsiveness to varied sensory stimulation, including pain... CONCLUSION: Sensory amplification may be an underlying pathophysiologic mechanism in these disorders that is relatively independent of depression and depressive symptoms. emphasis added
[52] Co-Morbidities to Look for In FM (titled in some sources "Prevalence of FM in Vasovagal Syncope")
[53] ▼ Complementary & Alternative Medicine for Rheumatic Diseases Acupuncture, Yoga, Tai Chi, Massage Therapy...
...This review provides an overview of mind–body therapies that have been used to treat the symptoms of several musculoskeletal conditions and rheumatic diseases. Pain in OA, FM and rheumatoid arthritis arises from a complex interplay between psychological, structural and biologic aspects of each disorder. Many patients with these chronic illnesses experience high levels of pain and psychological distress that are incompletely relieved by current pharmacologic or physical interventions. Mind–body therapies, an essential component of CAM, may be particularly applicable for promoting overall quality of life for patients with these chronic rheumatic conditions. Over the past two decades, clinical trials and observational studies have provided encouraging evidence that mind–body interventions can confer benefits to these groups. However, more prospective trials are needed. In particular, more robust assessment of methodologically rigorous protocols is required to determine which patients are most likely to respond and for how long, how effective these therapies are compared with pharmacologic interventions and whether or not they can be used to delay surgery or prevent disability.
[53a] Contact Dermatitis from Mercapto Compounds "widely used in natural and synthetic rubber, in the mining industry, and in a variety of nonrubber products" including in medical and dental procedures, hospitals, clinics, homes, and workplaces.
[54] Controlled Emotions, Inflammation, & Disease Intense self-regulation of negative emotions by 157 healthy adult volunteers, as measured by greater brain activity registered in fMRI, raised levels of pro-inflammatory chemicals in arteries.
[55] ▼ Confirmation: Low-Dose Naltrexone Eases FM Pain
[55a] ▲ Opioid Formulations With Sequestered Naltrexone: A Perspective Review
[56] Controlled Processes & Automaticity in Memory Functioning in FM Patients: Relation With Emotional Stress & Hypervigilance Abstract.
Evidence exists that chronic pain partially consumes the limited attentional resources, with the consequence that controlled processes sustaining cognitive tasks are affected and that automatic processes are preserved. FM is consistently rated as more severe than other chronic painful conditions. It is assumed here that FM is more attention-demanding, leading to a more pronounced decrease of the controlled processes in comparison with other chronic painful conditions. In this perspective, Study 1 compares FM patients, patients with localized pain and healthy subjects in a procedure separately estimating the within-task contributions of controlled and automatic processes in a cued recall task. As predicted, controlled processes are more strongly affected in FM patients related to the group with localized pain. Unexpectedly, contribution of automatic processes is increased in FM. Study 2 replicates these results and reveals that memory functioning in FM patients is related to their painful condition as a whole rather than to any particular patient’s characteristics.
[57] ▼ Controlled trial of hypnotherapy in the treatment of refractory FM - Full text pdf - 4 pps.
In a controlled [1991] study, 40 patients with refractory FM were randomly allocated to treatment with either hypnotherapy (HT) or physical therapy (PT) for 12 weeks with followup at 24 weeks. Compared with the patients in the PT group, the patients in the HT group showed a significantly better outcome with respect to their pain experience, fatigue on awakening, sleep pattern and global assessment at 12 and 24 weeks, but this was not reflected in an improvement of the total myalgic score measured by a dolorimeter. At baseline most patients in both groups had strong feelings of somatic and psychic discomfort as measured by the Hopkins Symptom Checklist. These feelings showed a significant decrease in patients treated by HT compared with PT, but they remained abnormally strong in many cases. We conclude that HT may be useful in relieving symptoms in patients with refractory FM.
[58] Creatine Overview (of disease research, other uses, dietary sources, supplement forms, precautions, possible interactions, possible adverse effects. Univ of Maryland Med Ctr.
[59] ▲ Creatine Supplements to Improve Strength in FM (a.k.a. "Improving Strength in FM" in other publications).
[60] ▲ An open-label study adding creatine monohydrate to ongoing medical regimens in patients with the FM syndrome.
...After 8 weeks of...creatine, we witnessed a significant improvement in parameters reflecting severity of FM, quality of life and sleep, disability, and pain. These results deteriorated 4 weeks after stopping creatine therapy. The findings of this study are preliminary and limited due to the small sample and relatively high rate of dropouts. emphasis added.
[60a] ▼ A cross-sectional study of self-reported chemical-related sensitivity is associated with gene variants of drug-metabolizing enzymes. Abstract AND Full-text pdf. Northern Germany, pub'd in Environmental Health, 2007.
...individuals with self-reported chemical-related sensitivity were more frequent carriers of genetic variants of GSTM1, GSTT1 and NAT2. We believe that our results reflect the gene-environment associations of increased chemical-related sensitivity in individuals suffering from diseases like Multiple Chemical Sensitivity, Idiopathic Environmental Intolerance, or Chronic Fatigue Syndrome, but have to be reproduced in further studies to prove our observations.
[61] CYP2D6*4 Polymorphism, Tramadol Treatment and Its Clinical Impact in Patients With Postherpetic Neuralgia polymorphism
[62] Designing & Delivering a Hypnotherapy Service for Irritable Bowel Syndrome in Primary Care in England.
[63] Dietary aspects in fibromyalgia patients: results of a survey on food awareness, allergies, and nutritional supplementation.
[63a] Dietary Supplements: Physician Knowledge & Adverse Event Reporting
[64] A disorder of sympathomimetic amines leading to increased vascular permeability may be the etiologic factor in various treatment-REFRACTORY health problems in women.
[65] ▼ Distraction as a key determinant of impaired memory in patients with FM
...METHODS: Thirty-five patients with FM and 35 controls, matched for age and sex, and presenting with complaints of memory loss, completed cognitive measures with and without stimulus competition. ...CONCLUSION: The findings validate the perception of failing memory in patients with FM and are the first psychometric based evidence to our knowledge of short-term memory problems in FM linked to interference from a source of distraction. Adding a source of distraction caused the majority of FM patients to retain new information poorly, and may be integral to an understanding of FM memory problems. Much needs to be learned about why new information is disproportionately lost by FM populations when a source of distraction enters the experiential field.
[66] ▼ Does Eye Color Predict Response to Pain?
[67] Dorsal root ganglia, sodium channels, & FM sympathetic pain.
[68] Drug Class Review: Drugs for Fibromyalgia: Final Original Report [Internet] 2011
[69] DRUG-INDUCED NEUROLOGIC CONDITIONS including cognitive impairment, insomnia, movement disorders, etc.
[70] ▼ Economic Implications of Potential Drug–Drug Interactions in Chronic Pain Patients Full text.
Abstract: ...Chronic pain patients may be subject to polypharmacy because of long-term pharmacological pain treatment and additional comorbidities... these interactions can have unintended and severe consequences... Utilizing medical and prescription claims databases, five studies were conducted to assess the health care utilization of and associated financial payments for patients [greater than] 18 years with chronic noncancer pain... The studies reported that drug–drug exposures are prevalent, costly and can occur in any age group and that physicians should consider ways to limit their patients' exposure to potential drug–drug interactions.
[71] EEG Biofeedback Treatment Improves Certain Attention and Somatic Symptoms in FM: A Pilot Study. (Full text pdf.)
[72] Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function & mortality: a systematic review.
[73] ▼ Effect of HMB supplementation on body composition, fitness, hormonal profile & muscle damage indices. Journal of Pediatric Endocrinology & Metabolism, Hebrew Univ of Jerusalem.
[73a] ▲ Efficacy of β-hydroxy-β-methylbutyrate supplementation in elderly & clinical populations
[73b] ▲ Elderly Persons With ICU-Acquired Weakness: Potential Role for β-Hydroxy-β-Methylbutyrate (HMB) Supplementation?
[74] ▼ Effects of Class IV laser therapy on FM impact & function in women with FM.
...evidence that LHT may be a beneficial modality for women...in order to improve pain and upper body range of motion, ultimately reducing the impact of FM.
[75] Effects of Gut-directed Hypnotherapy on IBS in Different Clinical Settings
[76] Eleven Tips for Better Opioid Prescribing
[77] ▼ Empowering Processes & Outcomes of Participation in Online Support Groups for Patients With Breast Cancer, Arthritis, or FM
... we explored if, and in which ways, patients feel empowered by participation [and] which empowering and disempowering processes occur ... [by interviewing] 32 participants of online support groups. This analysis revealed the following empowering processes: exchanging information, encountering emotional support, finding recognition, sharing experiences, helping others, and amusement. Disempowering processes were mentioned far less often. Empowering outcomes mentioned were being better informed; feeling confident in the relationship with their physician, their treatment, and their social environment; improved acceptance of the disease; increased optimism and control; enhanced self-esteem and social well-being; and collective action. This article demonstrates that participation in online support groups can make a valuable contribution to the emergence of empowered patients.
[78] Environmental Working Group dot Org - articles on neuro-endocrine disruptor chemicals
[79] ▼ ER Trips for Kids' Pain & Coughs Often End With Codeine
...Depending on ethnicity, up to a third of people are known to metabolize codeine much faster than usual, which could lead to an overdose. ... Dr. Alan Woolf of Boston Children's Hospital, who co-wrote a commentary on the new study, added that [other patients] may not break the drug down enough for it to be effective...
[80] Europe PubMed Central searchterm "fibromyalgia"
[80a] Evaluation of gastric emptying rate in patients with fibromyalgia: a case control study. Mod Rheumatol 2011 Apr;21(2):174-7 Erdogan S (Department of Nuclear Medicine, Adnan Menderes University Medical School, Aydın, Turkey), Gurer G, Afsin H, Kucukzeybek Y.
[81] Even a Little Physical Activity May Prevent Depression
[82] ▼ [Exercise as pain therapy for FM] "Aerobic Exercise 'Most Effective Weapon..." (Why is the woman shown as the FM patient wearing no clothes?)
..."There is no magic drug against FM and, in my opinion, there will never be. ...Drugs may help, but patients don't like them," said investigator Winfried Häuser, MD, from Technische Universität München in Germany... "Studies may show an effect of drugs, but the effects of drugs are lost once the patient is not taking them," he explained. "In contrast, we see sustained but declining effects of aerobic exercise and multicomponent therapy [e.g. psychotherapy and exercise] in FM at 1 or 2 years. Cognitive behavioral therapies do have some effect on pain and disability, but these may be small."
TREAT THE INDIVIDUAL, NOT THE AVERAGE
"Results of trials are averages and not representative of individual patient experiences... said Dr. Häuser. "Some patients obtain little or no relief and others obtain very good relief of pain; the average represents only a tiny minority of patients. The same is true for psychological therapies." Treatment decisions should take tolerability, safety, cost, and the patient's willingness {sic} to continue therapy into account, he explained. And treatment should provide substantial pain relief. "If we really want to know what works in clinical practice, we have to go beyond randomized controlled trials that exclude a lot of patients seen in real-world clinical practice. We need to look at databanks and consumer reports," he said. For example, the National Data Bank on Rheumatic Disease contains data on 3123 adults with FM who were followed for 11 years. Overall, no improvement was seen for fatigue or functional status, and the improvement for pain was small (0.2 on a 10-point scale). And a cross-sectional survey Dr. Häuser was involved in revealed some important findings on the most beneficial therapies for FM ([83a] Patient-related predictors of treatment satisfaction of patients with FM syndrome: results of a cross-sectional survey). ...When patients were asked to list the top 10 most beneficial therapies for FM, no drugs were mentioned, Dr. Häuser reported. When they were asked to list what they considered to be the 10 most harmful therapies, they named only approved drugs.
[83] [EXERCISE (low-intensity low-impact graded exercise)] CFS/ME - Dr. Nancy Klimas (youtube) Acknowledgment to the kosak who provided this lead - my apologies that I don't have that person's name. [84] ▼ Eye Movement Therapy Offers Faster Recovery From PTSD Eye movement desensitization and reprocessing (EMDR) therapy [85] ▲ Brief eclectic psychotherapy v. eye movement desensitisation and reprocessing therapy for post-traumatic stress disorder: randomised controlled trial
Background:Trauma-focused cognitive–behavioural therapy (CBT) [i.e., "Brief eclectic psychotherapy"] and eye movement desensitisation and reprocessing therapy (EMDR) are efficacious treatments for post-traumatic stress disorder (PTSD), but few studies have directly compared them using well-powered designs and few have investigated response patterns...(trial registration: ISRCTN64872147)... Method: [140] out-patients with PTSD were randomly assigned to brief eclectic psychotherapy... or EMDR...and assessed at all sessions on self-reported PTSD (Impact of Event Scale – Revised). Other outcomes were clinician-rated PTSD, anxiety and depression. Results:Both treatments were equally effective in reducing PTSD symptom severity, but the response pattern indicated that EMDR led to a significantly sharper decline in PTSD symptoms than brief eclectic psychotherapy, with similar drop-out rates (EMDR: n = 20 (29%), brief eclectic psychotherapy: n = 25 (36%)). Other outcome measures confirmed this pattern of results. Conclusions: Although both treatments are effective, EMDR results in a faster recovery compared with the more gradual improvement with brief eclectic psychotherapy.
[86] ▼ Fatigue-Busting Programs Work Even in Advanced Cancer: Monitoring Symptoms Is Key In a small Dutch study of advanced-cancer patients receiving usual care vs those receiving patient-tailored treatment, fatigue in 1/3 of the individually-tailored group was significantly alleviated by treating a range of physical distress symptoms per the eclectic and inter-disciplinary international NCCN palliative care guideline. A similar-size U.S. patient-query study by Mayo Clinic researchers found that few were receiving guideline-congruent fatigue treatment, and "...almost a third reported napping during the day, which can actually worsen fatigue". Lead author Andrea Cheville, MD, a physiatrist, said in a press statement:
Fatigue is not merely a quality of life issue...[it] is also associated with reduced survival..." emphasis added
[87] ▼ FDA Approves Contrave [combination of bupropion (a.k.a. Wellbutrin, Zyban) and naltrexone [88] ▲ Low Dose Naltrexone [89] Fibromyalgia Medscape slideshow. (Why is a woman nude in this?) [90] ▼ FM: a disorder of the brain?
This article presents evidence that FM patients have alterations in CNS anatomy, physiology, and chemistry... There is substantial psychophysical evidence that FM patients perceive pain and other noxious stimuli differently than healthy individuals and that normal pain modulatory systems, such as diffuse noxious inhibitory control mechanisms, are compromised in FM. Furthermore, functional brain imaging studies revealing enhanced pain-related activations corroborate the patients' reports of increased pain. Neurotransmitter studies show that FM patients have abnormalities in dopaminergic, opioidergic, and serotoninergic systems. Finally, studies of brain anatomy show structural differences between the brains of FM patients and healthy individuals. The cerebral alterations offer a compelling explanation for the multiple symptoms of FM, including widespread pain and affective disturbances. The frequent comorbidity of FM with stress-related disorders, such as chronic fatigue, posttraumatic stress disorder, irritable bowel syndrome, and depression, as well as the similarity of many central nervous system abnormalities, suggests at least a partial common substrate for these disorders. Despite the numerous cerebral alterations, FM might not be a primary disorder of the brain but may be a consequence of early life stress or prolonged or severe stress, affecting brain modulatory circuitry...in genetically susceptible individuals...
[91] FM & executive function Google Scholar search [92] FM Brain Misreads Pleasure/Pain Signals USEFUL ARTICLE, STUPID MISTAKEN TITLE [93] FM, chronic fatigue, and adult attention deficit hyperactivity disorder...: a case study.
Adult attention deficit hyperactivity disorder (ADHD) may share common features with FM and chronic fatigue syndrome (CFS). In an outpatient psychiatric clinic (in Michigan), a number of adult patients who presented primarily with symptoms of ADHD, predominately inattentive type, also reported unexplained fatigue, widespread musculoskeletal pain or a pre-existing diagnosis of CFS or FMS. As expected, ADHD pharmacotherapy usually attenuated the core ADHD symptoms of inattention, distractibility, hyperactivity, and impulsivity. Less expected was the observation that some patients also reported amelioration of pain and fatigue symptoms. The utility of ADHD medications in FMS and CFS states may be their innate arousal and enhanced filtering properties. This model supposes that FMS and CFS are central processing problems rather than peripheral disorders of muscles and joints.
[94] ▼ FM: Disease Synopsis, Medication Cost Effectiveness and Economic Burden
...A single FM patient can cost society tens of thousands of dollars each year, with the overall expense increasing alongside disease severity. Indirect costs account for the majority of total expenditures and involve losses in productivity, reduced work hours, absenteeism, disability, unemployment, early retirement, informal care and other out-of-pocket costs. Health care utilization increases in concert with the severity of illness...
[95] FM: Does CAM Work? [96] Fibromyalgia Network (No longer in print, may have an internet presence.) Nov 2012 eNews • August 2012 eNews • June 2012 eNews [97] FM Patients Hypersensitive to Non-pain Sensations [98] FM Symptoms Respond to Parathyroidectomy, in Some [98a] Fibromyalgia Symptom Reduction by Online Behavioral Self-monitoring, Longitudinal Single Subject Analysis and Automated Delivery of Individualized Guidance. [99] FM: THE LATEST IN DIAGNOSIS & CARE - DANIEL J. CLAUW et al. SEPTEMBER 17, 2014 3rd section "The Latest in Management." (Note 2nd Section Title, "Who Manages FM Patients?") [100] ▼ FM Underdiagnosed [especially in men], Report Mayo Clinic Experts
The first population study to compare the prevalence of diagnosed FM to the general population prevalence of people reporting symptoms that met the...2010 ACR diagnostic criteria indicates that FM may be more common than previously thought and that most FM cases are not being diagnosed, especially in men. The researchers, led by Ann Vincent, MD, medical director of the Mayo Clinic's Fibromyalgia and Chronic Fatigue Clinic, Rochester, Minnesota, [reported] that FM prevalence [by symptomology] was 6.4% in the general population of Olmstead County but...diagnosed FM was only 1.1%...FM prevalence in men was 4.88%...in the general population but only 0.15%...diagnosed cases [and prevalence] in women was 7.71%...in the general population survey [with] 2.00%...diagnosed cases. ...The researchers used data from the Olmsted County, Minnesota, Rochester Epidemiology Project to identify 3410 potential patients with FM, to estimate the prevalence of diagnosed FM in clinical practice. They also conducted a random survey of adults in Olmsted County to estimate the percentage who met the FM research survey criteria. Of the 830 participants who responded to the survey, 44, or 5.3%, met the criteria for FM, but only 12 had been diagnosed with FM. ...Dr. Vincent told Medscape Medical News, "This is an epidemiology study, so clinical implications are an extrapolation. However, having said that, the...rate at which FM was being diagnosed in the community [was] lower than previous estimates... Other published literature supports our observation that FM is not always recognized or diagnosed correctly when a patient is evaluated." ...The researchers were surprised by two [findings]:... that FM prevalence was somewhat higher in younger age groups [in contrast] to the trend of increasing prevalence of diagnosed FM with older age...and that FM prevalence in women was not significantly higher than in men... With regard to prevalence in men, Dr. Vincent said, "The old ACR criteria had some inherent issues (since women are biologically more sensitive to pain, they will have more tender points)... The hope of the new criteria was to comprehensively assess presence of FM based on all its key symptoms by patient report [and this would account for previous] reported gender discrepancy. Our results suggest that this is correct: Men do report symptoms of FM. Whether they getting diagnosed is another question."
[101] ▼ FIQR Revised Fibromyalgia Impact Questionnaire ©2014 MAPI Research Trust [101a] ▲ FIRST FIbromyalgia Rapid Screening Tool ©2010 MAPI Research Trust [102] The First Israeli Fibromyalgia Congress, February 2013. [103] ▼ Gender Based Violence Section: "Health Consequences" includes FM. (See also relevant citations in this diary and this one.) [104] ▼ Gene expression alterations at baseline and following moderate exercise in patients with Chronic Fatigue Syndrome and FM.
...Forty-eight patients with CFS only, or CFS with comorbid FM, 18 patients with FM that did not meet criteria for CFS, and 49 healthy controls underwent moderate exercise (25 min at 70% maximum age-predicted heart rate). ...At least two subgroups of patients with CFS can be identified by gene expression changes following exercise. The larger subgroup showed increases in mRNA for sensory and adrenergic receptors and a cytokine. The smaller subgroup, contain[ing] most of the patients with CFS with orthostatic intolerance, showed no post-exercise increases in any gene and was defined by decreases in mRNA for α-2A. FM-only patients can be identified by baseline increases in three genes. Postexercise increases for four genes meet published criteria as an objective biomarker for CFS and could be useful in guiding treatment selection for different subgroups.
[104a] ...Ginseng Effective for ...Fatigue[?] Contains links to U.S. Pharmacopieal Convention Verified Dietary Supplements and USPC participating manufacturers [105] "The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain" Diane E. Hoffmann and Anita J. Tarzian, The Journal of Law, Medicine & Ethics March 2001, Volume 28, Issue Supplement s4, Pages 4–114, cited in NYT article The Gender Gap in Pain [treatment] [106] High frequency of childhood ADHD history in women with FM March 2001, first published online OCT 2008. [107] Hospital Room Lighting May Worsen Patients' Mood, Pain (compare lighting in the home, workplace, school, etc.) [107a] How Can I Deal With 'Difficult' Patients and Families? [108] ▼ How Common Are Drug & Gene Interactions? Prevalence in a Sample of 1143 Patients With CYP2C9, CYP2C19 & CYP2D6 Genotyping Executive Summary.
BACKGROUND: Adverse drug reactions (ADRs) are a major preventable public health problem. Better identification of ADRs can save money and lives. Drug–drug interactions (DDIs) are recognized as a major cause of ADRs. ...in addition...CYP genotyping now allows drug–gene interactions (DGIs) and drug–drug–gene interactions (DDGIs) to be identified as a potential source of ADRs as well. RESULTS: 1053 major or substantial interactions in 501 individuals. DGIs represented 14.7%, DDGIs 19.2% and DDIs 66.1% of major [and] substantial interactions. DGIs represented 13.9%, DDGIs 21.5% and DDIs 64.6% of major interactions. CONCLUSION: Identification of DGIs and DDGIs increased the number of potential clinically significant interactions by approximately 50% as compared with DDIs alone. This increased the number of individuals identified with potential clinically significant ADRs.
[109] Identifying treatment responders & predictors of improvement after cognitive-behavioral therapy for juvenile FM [109a] Imaging Reveals Neural Patterns of Pain, Addiction [110] Improper Use of Prescription Drugs Costs $200 Billion a Year, Report Finds [111] In Kids With Chronic Pain, Function Improves Faster Than Pain With Psychological Treatment [112] ▼ Intensive Pain Rehab Improves Kids' Mental Health
Intensive interdisciplinary pain rehabilitation tailored to the needs of children with chronic pain helps them to improve their psychological function both during and after their rehab. "Pediatric pain rehabilitation is really focused on returning kids to functioning and helping them learn to be able to work through pain, but one of the side effects of that is that kids start to make improvements in their depression, in their anxiety, in those psychological factors that have come about as a result of pain taking them out of life..."
[113] Interactive Technology for Symptom Monitoring in Patients With FM [114] Interdisciplinary FM Treatment Benefits [are] Sustained [114a] Internet-delivered acceptance and values-based exposure treatment for FM: a pilot study. [115] Intranasal Ketamine Delivers Rapid Antidepressant Effect [115a] Is magnesium citrate treatment effective on pain, clinical parameters and functional status in patients with FM? [116] Juvenile FM & Improved Recognition by Pediatric Primary Care Providers [117] ▼ Juvenile Primary FM
Juvenile primary FM syndrome (JPFS) is a musculoskeletal pain syndrome...in the child and adolescent...characterized by multiple discrete tender points (TPs), fatigue, and sleep disturbance...joint stiffness, skin tenderness, postexertional pain, sleep disturbance, irritable bowel symptoms, poor memory, tension headaches, dizziness, fluid retention, paraesthesias, restless legs, bruising, and Raynaud phenomenon... The pain experienced is modulated by factors such as activity, anxiety, stress, and weather changes. Chronic musculoskeletal pain affects quality of life, whereas fatigability influences motor response and ability to complete activities of daily living within an expedient time frame ... ...FMS is a physiologic entity rather than a psychiatric disorder. [Mohammad B.] Yunus proposes a class of disorders called central sensitivity syndromes (CSSs), which result from changes in the central nervous system (CNS)... Neurochemical pathology of the CNS (spinal cord and brain) causes areas of the body to become sensitized, so that pain is experienced from even mild touch or pressure. Proposed members of the CSS family include the following...: Fibromyalgia syndrome Chronic fatigue syndrome Irritable bowel syndrome T-T headache (tension type) Migraine Temporomandibular disorders Myofascial pain syndrome Female urethral syndrome/interstitial cystitis Multiple chemical sensitivity syndrome Restless leg syndrome Periodic limb movements in sleep (PLMS) Primary dysmenorrhea Posttraumatic stress disorder The underlying concept of the CSSs is that the 13 disorders have some similar clinical features and a common pathophysiologic component of central sensitization (CS)... Yunus disputes the idea that the pain experienced by people with CSSs is merely psychiatric, psychosocial, or psychological in nature. Although depression and stress may contribute to the symptoms of CSS, they are still based on objective changes in the CNS...
[118] [Kappa opiod research] Google Scholar search for articles on kappa-receptor opioids, studied since at least 1996 as more effective for women with fewer side effects than the conventional Mu_opioid_receptors [119] ▼ Kommunikationspraeferenzen...(Communication preferences in patients with FM: descriptive results and patient characteristics as predictors) (Full text in English here - 27 pps.) Abstract:
BACKGROUND: Communication with patients with FM is often considered difficult. The primary objective of this explorative study was to describe the communication preferences of FM patients in comparison with other chronic diseases... METHODS:...256 FM patients were asked to fill out the KOPRA [(Kommunikationspraeferenzen...) communication preferences of patients with chronic illness] questionnaire at the beginning of their rehabilitation, answering questions about their communication preferences. The KOPRA's descriptive parameters were calculated and compared with other diagnosis groups. In order to include as many influencing factors as possible, data on patient-related sociodemographic, medical, pain impact and psychologic variables were gathered.... RESULTS:FM patients consider an open and patient-centered communication style to be especially important. Emotionally supportive communication and communication about personal circumstances are important for FM patients, but the preferences of individual patients vary widely. FM patients reveal higher values in all the sub-dimensions of communication preferences compared with patients with low back pain or chronic ischemic heart disease. Only a few variables appear to predict patient communication preferences... CONCLUSION:Health care providers who communicate with FM patients should employ an open and patient-centered communication style, and affective communication components should be adapted to accommodate each patient.
[120] ▼ Lamellar corpuscle (Anatomical illustration included.)
Lamellar corpuscles, or Pacinian corpuscles, are one of the four major types of mechanoreceptor. They are nerve endings ...responsible for sensitivity to vibration and pressure... and possibly very low frequency sounds...The Lamellar corpuscle is [egg-shaped] and approximately 1 mm in length. The entire corpuscle is wrapped by a layer of connective tissue. It has 20 to 60 concentric lamellae [rings within rings within rings] composed of fibrous connective tissue and fibroblasts [which play "a critical role in wound healing [and] make collagens, glycosaminoglycans, reticular and elastic fibers, glycoproteins {Integral membrane proteins}...and cytokine TSLP. Fibroblasts are the most common cells of connective tissue in animals...sculpt the "bulk" of an organism."), separated by gelatinous material. The lamellae are very thin, flat, modified Schwann cells. In the center of the corpuscle is the inner bulb, a fluid-filled cavity with a single afferent unmyelinated nerve ending...Lamellar corpuscles sense stimuli due to the deformation of their rings of lamellae, which press on the top of the sensory neuron and causes it to bend...making it "leak" [positive sodium] ions. If this...reaches a certain threshold, nerve impulses... are formed...[which are] transferred along the axon [by] sodium channels and sodium/potassium pumps in the axon membrane. Once the top of the neuron is depolarized, it will depolarize the first [myelinated] node... as it is a rapidly adapting fibre, this does not carry on indefinitely, and the signal propagation ceases. This is a graded response, meaning that the greater the deformation, the greater the generator potential ... a bigger or faster deformation induces a higher impulse frequency. Action potentials are formed when the skin [for example] is rapidly distorted but not when pressure is continuous. The frequencies of the impulses decrease quickly and soon stop due to the layers of connective tissue that cover the nerve ending. This adaptation is useful, as it stops the nervous system from being overloaded... such as the pressure exerted by clothing....See also Pacinian neuroma...any swelling of a nerve, even in the absence of abnormal cell growth. In particular, traumatic neuroma results from trauma to a nerve... Neuromas can be painful, or sometimes, as in the case of acoustic neuromas, they can give rise to other symptoms... emphasis added
[121] Language Impairment in FM & Chronic Fatigue Syndrome [122] Laser Therapy May Improve Outcomes in FM [123] Little Evidence That Cholinesterase Inhibitors Prevent Progression of Mild Cognitive Impairment to Dementia, but They Are Associated With Adverse Effects [124] Long-term Success of GUT-directed Group Hypnosis for Patients With Refractory Irritable Bowel Syndrome: A Randomized Controlled Trial [125] The Low FODMAP Diet Improves Gastrointestinal Symptoms in Patients With Irritable Bowel Syndrome: A Prospective Study [126] ▼ Low-level laser therapy (LLLT) to treat FM.
...The aim of this study was to evaluate the effects of LLLT in patients with FM. A placebo-controlled...clinical trial was carried out with 20 patients divided randomly into either an LLLT group (n = 10) or a placebo group (n = 10). The LLLT group was treated with [the laser on 18 tender points] 3 times a week over 4 weeks. Before and after treatment, patients were evaluated with the FM Impact Questionnaire (FIQ), McGill Pain Questionnaire, and visual analog scale (VAS). ...After LLLT or sham treatment, the number of tender points was significantly reduced in both groups... However, all other FM symptoms showed significant improvements after LLLT compared to placebo... LLLT...should be further investigated as a therapeutic tool for management in FM.
[127] Low-dose naltrexone for the treatment of FM: findings of a small, randomized, double-blind, placebo-controlled, counter-balanced, crossover trial assessing daily pain levels. [128] Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. [128a] Mitochondrial Myopathy Presenting as FM: A Case Report [129] Myalgic Encephalomyelitis Internat'l Consensus Criteria - 2012 (Chronic Fatigue Syndrome) [130] National Fibromyalgia and Chronic Pain Association website abstracts: Widespread pain and FM in a bi-racial cohort of young women (2007) • The incidence of FM and its associated comorbidities: a population-based retrospective cohort study based on International Classification of Diseases, 9th Revision codes (2006) • FM syndrome in an Amish community: a controlled study to determine disease and symptom prevalence (2003) • ...the prevalence of FM syndrome in London, Ontario (Canada) (1999) • A population study of the incidence of FM among women aged 26-55 yr (1997) • The prevalence and characteristics of FM in the general population (1995) • Prevalence of primary and secondary fibrositis (1983) • Biology and therapy of FM; Genetic aspects of FM syndrome (2006) • PAGINA EN ESPANOL
[131] ▼ Neurobiology of depression, FM & neuropathic pain
This article synthesizes recent data suggesting that the high rates of comorbidity observed between major depression, FM and neuropathic pain likely result from the fact that these disorders share multiple biological and environmental underpinnings. This perspective suggests that these biologically complex conditions result from similar genetic vulnerabilities interacting with environmental adversity. Shared genetic determinants include poorly functional alleles regulating monoaminergic, glutamatergic, neurotrophic, opioid and inflammatory cytokine signaling. Chief among environmental risk factors are psychosocial stress and illness, both of which promote, in vulnerable individuals, relative resistance to glucocorticoids, increased sympathetic/decreased parasympathetic activity and increased production and release of proinflamnmatory mediators. Dysregulation of stress/inflammatory pathways promotes alterations in brain circuitry that modulates mood, pain and the stress response. Over time, these functional changes likely promote disruptions in neurotrophic support and disturbances of glia-neuronal communication. These changes, in turn, have been associated with the related processes of central sensitization in pain disorders and “kindling” in depression, both of which may account for the progressive and self-perpetuating nature of these disorders, especially when inadequately treated.
[132] New Diagnostic Criteria Pinpoints{sic} FM Medscape Education 2014. [133] Neuronal & immunological basis of action of antidepressants in chronic pain - clinical & experimental studies. [134] U.S. National Institute of Arthritis & Musculoskeletal & Skin Diseases FM Questions & Answers [135] ▼ Nine Things Chronic Pain Specialists Want Hospitalists to Know
... 3. Sometimes stopping pills, rather than adding them, can cure pain: Many chronic pain patients accumulate a patchwork of pills (e.g. benzodiazepines, opioids, muscle relaxants, and antidepressants). Many interpret noxious symptoms associated with the drug burden as "uncontrolled pain." Two conditions that might afflict the pain sufferer who takes multiple medications are opioid-induced hyperalgesia (OIH) and medication-overuse headaches (MOH). They are uncommon but should be on a hospitalist's differential for difficult-to-control chronic pain. Opioids commonly are implicated in causing MOH, a chronic headache occurring at least 15 days a month, four hours a day if untreated, and for at least three consecutive months. OIH is a nociceptive sensitization caused by opioids that can occur suddenly or insidiously. ...5. A little local anesthetic (and some steroid) goes a long way: ...hospitalists should be able to train and be credentialed to offer such procedures as trigger-point injections, joint injections (knees, shoulders), or even a peripheral nerve injection (e.g. lateral femoral cutaneous nerve or ilioinguinal nerve injection). Some hospitalists might even want to learn ultrasound-guided sacroiliac joint injections for chronic unexplained back pain. Offering an indicated and effective injection is a good nonopioid option. And local anesthetic injections can help hospitalists establish an elusive diagnosis. For example, many patients spend years getting worked up for head and neck pain when dry-needling with a small volume (1 cc) of local anesthetic into a neck muscle trigger point can break their pain generator, eliminating their pain.
[136] Noise sensitivity & multiple chemical sensitivity scales: Properties in a population based epidemiological study. [137] ▼ Noninvasive Optical Characterization of Muscle Blood Flow, Oxygenation & Metabolism in Women With FM Development and initial trial use of a novel near-infrared hybrid spectroscopic device technologically related to finger-clip O2 meters used in medical offices and hospitals to monitor percentage of optimum oxygen in the patient's bloodstream. The researchers recruited 14 postmenopausal women diagnosed with FM and 23 healthy postmenopausal women with whom to compare results, used a blood-pressure-like cuff on their arms as an ischemic device, and gave them leg-muscle work, after which the new device measured oxygenation in arm and leg bloodflow. Their findings seem to be that fibromyalgic bloodflow carries less oxygen, fibromyalgic muscles can only use a smaller proportion of what oxygen there is, and re-oxygenation of blood takes longer, compared to the healthy group.
Although the specific pathogenic mechanisms of FM remain unclear, studies have suggested that the muscle pain and fatigue of FM may be associated with mitochondrial dysfunction...lower capillary density...reduced capillary permeability...or impaired vasodilatory capacity... Those impairments may consequently affect muscle tissue microcirculation and oxygen metabolism. However, previous studies investigating peripheral/muscle blood flow or oxygen consumption in populations with FM have reported conflicting results... Some studies have found reduced skin/muscle blood flow or oxygen consumption in people with FM... whereas others reported that muscle blood flow or oxygen metabolism was not significantly altered... It has also been reported that subjects with FM have prolonged oxygen level (oxy- and deoxyhemoglobin concentrations) recovery times following muscle ischemia... or aerobic exercise... Near-infrared diffuse optical spectroscopy (NIRS) offers a noninvasive, rapid, portable, and low-cost alternative for monitoring tissue blood oxygenation and oxygen consumption in microvasculature, although it does not directly measure tissue blood flow. Near-infrared light probes tissue millimeters to centimeters below the skin surface, allowing for measurement of oxy- and deoxyhemoglobin concentrations and, total hemoglobin concentration and blood oxygen saturation ... NIRS has been broadly used for noninvasive assessment of tissue oxygenation in clinic... NIRS has also been used in studies of FM... and Chronic Fatigue Syndrome...to evaluate tissue hemodynamic responses following muscle ischemia and aerobic exercise.
[138] ▼ Objective evidence that small-fiber polyneuropathy underlies some illnesses currently labeled as FM. [139] ▲ Small fiber peripheral neuropathy [140] Osteopathic Medicine Meshes With New Health Care [141] ▼ Pain Is Associated With Short Leukocyte Telomere Length in Women With FM
...Telomere length, considered a measure of biological aging, is linked to morbidity and mortality. Psychosocial factors associated with shortened telomeres are also common in chronic pain; yet, little is known about telomere length in pain populations. Leukocyte telomere length was evaluated in 66 women with FM and 22 healthy female controls. Participants completed questionnaires and a subgroup of FM patients underwent quantitative sensory testing (QST; n = 12) and neuroimaging (n = 12). Telomere length was measured using the quantitative polymerase chain reaction method. Although patients had shorter telomere length than controls, the difference was not statistically significant. However, higher levels of pain within FM were associated with shorter telomere length (P = .039). When pain and depression were combined, patients categorized as high-pain/high-depression had an age-adjusted telomere length 265 base pairs shorter than those with low-pain/low-depression (P = .043), a difference consistent with approximately 6 years of chronological aging. In the subset tested, telomere length was also related to pain threshold and pain sensitivity, as well as gray matter volume, such that patients with shorter telomeres were more sensitive to evoked pain and had less gray matter in brain regions associated with pain processing (eg, primary somatosensory cortex). These preliminary data support a relationship between pain and telomere length. ...Our findings support a link between premature cellular aging and chronic pain. These preliminary data imply that chronic pain is a more serious condition than has typically been recognized in terms of bodily aging. emphasis added. Key words: Pain; fibromyalgia; telomere; premature aging; neuroimaging
[142] Pain, Not Chronic Disease, Is Associated With the Recurrence of Depressive & Anxiety Disorders [143] [Young] Pain Patients at Cognitive Risk From Anticholinergic Burden [144] Pain Sensitivity [may be] Related to Brain Structure Link included to interesting abstract of this research with "116 healthy volunteers (62 women, 54 men)" and especially the final sentences of the abstract seem to hint that fibrofog is a way the brain filters out/copes with chronic pain and the piled-on physical and neuro-psychological distresses of FM, hopefully an area of inquiry researchers will investigate, though nothing actually to do with this article:
These structural variations occurred in areas associated with the default mode network, attentional direction and shifting, as well as somatosensory processing. These findings underscore the potential importance of processes related to default mode thought and attention in shaping individual differences in pain sensitivity and indicate that pain sensitivity can potentially be predicted on the basis of brain structure. ...[Senior author, Robert Coghill, PhD, Wake Forest Baptist Medical Center, explained that] Pain competes with other thoughts. "These areas are part of the default mode network, a set of connected brain regions that are associated with the free-flowing thoughts that people have while they are daydreaming. We believe default-mode activity may compete with brain activity that generates an experience of pain, such that individuals with high default-mode activity would have reduced sensitivity to pain." [In the illustration provided courtesy of Wake Forest Baptist Medical Center,]... areas marked with arrows are involved in self-directed thought and attention. Patients most sensitive to pain have less grey matter in these areas than those who are least sensitive. "There is a competition going on in your head between pain or other things you are thinking about," he added. "This can be something of a double-edged sword. In acute pain, you need to know that it is there. For example, if you touch something hot, you need to feel pain so that you remove your hand. But in the case of chronic pain, attention to the pain may make it worse." The default mode network also plays an important role in attention, and individuals who can best keep their attention focused may also be best at keeping pain under control, he said. "If you are preoccupied with something else, then that thought pattern can overrule other things." Dr. Coghill notes that these results are in line with a previous Canadian study showing that individuals who stay on task do not have pain interfere so much.
[144] Patient Health Questionnaire 15 as a generic measure of severity in FM: surveys with patients of three different settings. [146] Patients: 'Difficult,' 'Tough' or Just Misunderstood? [147] Persistent Organic Pollutants [148] Pharmacogenetics of Antidepressant Drugs [148a] 'Polyherbacy' a Common Challenge in Pain Patients [149] Predicting FM, a narrative review... [149a] Psychotropic-Related Hip Fractures: Meta-Analysis of First-Generation & Second-Generation Antidepressant & Antipsychotic Drugs [150] The Quick Environmental Exposure & Sensitivity Inventory [151] A Randomized Controlled Trial of Qigong Exercise on Fatigue Symptoms, Functioning, & Telomerase Activity in Persons with Chronic Fatigue or Chronic Fatigue Syndrome Full text (may be printable). [152] ▼ Record Number of Med Students, but More Needed to Help Physician Shortage October 2013
...the U.S still faces an impending physician shortage if Congress does not raise caps on residency funding [said Darrell Kirch, MD, President and Chief Executive Officer, Association of American Medical Colleges] "Medical schools have done their part to expand enrollment...and new medical schools have opened, making room for more students [with] first-time enrollees in US medical schools at an all-time high of 20,055. So the students have stepped up and done their part. The medical schools have responded quickly and with clarity. Now Congress needs to do its part and lift this 16-year-old ban on the number of training positions," Dr. Kirch said.
[152a] Reference Practice Essentials: Fibromyalgia [153] Rehabilitation & FM [154] Relationship Between Behavioural Coping Strategies & Acceptance in Patients With FM - Elucidating Targets of Intervention [155] ▼ Relationships among rhinitis, FM, & chronic fatigue 2010
New information about the pathophysiology of idiopathic nonallergic rhinopathy indicates a high prevalence in chronic fatigue syndrome (CFS). This article shows the relevance of CFS and allied disorders to allergy practice. CFS has significant overlap with...FM, autonomic dysfunction (irritable bowel syndrome and migraines), sensory hypersensitivity (dyspnea; congestion; rhinorrhea; and appreciation of visceral nociception in the esophagus, gastrointestinal tract, bladder, and other organs), and central nervous system maladaptations (central sensitization) recorded by functional magnetic resonance imaging (fMRI). Neurological dysfunction may account for the overlap of CFS with idiopathic nonallergic rhinopathy. Scientific advances are in fMRI, nociceptive sensor expression [etc.,] and potentially...provide additional insights to novel pathophysiological mechanisms of the “functional” complaints of these patients that are mistakenly interpreted as allergic syndromes. As allergists, we must accept the clinical challenges posed by these complex patients and provide proper diagnoses, assurance, and optimum care even though current treatment algorithms are lacking.
See also other articles here related to autonomic dysfunction, and Fibromyalgia and Nondipper Circadian Blood Pressure Variability (an autonomic nervous system malfunction) [156] Repetitive Transcranial Magnetic Stimulation Benefits Quality of Life in FM "but did not have any effect on pain". [157] Rheumatologists are NOT the doctors to deal with FM March 2005. [158] duplicate citation deleted [159] Sex & gender differences in pain & inflammation: a rapidly maturing field Full text 2006. [160] Sleep Disorders News & Perspectives (incl'g sleep meds hazards & benefits) [161] ▼ Small Benefit of SNRIs for FM Pain
Compared with placebo, the selective serotonin and noradrenaline reuptake inhibitors (SNRIs) duloxetine (Cymbalta) and milnacipran (Savella) are slightly more likely to reduce pain in patients with [FM, but] they're not substantially superior in terms of reducing fatigue and sleep problems or in improving quality of life, and they appear to cause more adverse effects. If patients do get pain relief from one of the SNRIs, it's likely to be only slight, and it's not clear how long that relief might last, said study author Brian T. Walitt, MD, associate professor, medicine, Georgetown University, Washington, DC. Dr. Walitt stressed that FM encompasses more than just pain. "And considering that these drugs don't really do much for any other aspect of a patient's life, the value of these medications seems small at best..."
[162] ▼ Societal & patient burden of FM syndrome.
...FM is an under-diagnosed disorder of unknown aetiology, characterized by chronic widespread muscular pain, often accompanied by somatic and psychological symptoms. Several studies have described the impact of FM on patients' functionality, disability and quality of life. Other studies have reported on the burden to patients, healthcare payers and society. This review brings the existing evidence together and concludes that the patient burden of FM is very high in comparison with many other conditions. The burden to healthcare payers and society is important as well, and can be mostly explained by factors not directly related to the treatment of FM. Data suggest that the cost before diagnosis may even be higher than the cost after diagnosis. It is very likely that the combination of symptoms not only complicates the recognition and treatment of FM, but also magnifies the burden of FM. Despite the complex and controversial construct of this syndrome, the results in terms of patient, healthcare payer and societal burden are quite consistent. emphasis added.
[163] (Stigma and prejudice as searchterms with FM searched in PubMed) search terms "fibromyalgia" + "prejudice" and fibromyalgia + stigma
[164] Study works out kinks in understanding of massage
[165] Substance P Function and Substance P ... pain
[166] Sympathetic Nervous System Dysfunction in FM, Chronic Fatigue Syndrome, Irritable Bowel Syndrome, & Interstitial Cystitis: A Review of Case-Control Studies
[167] Tai Chi May Be Useful to Treat FM
[168] ▼ Telomeres & Early-Life Stress: An Overview
...there has been increasing recognition in the general medical literature that sequelae ...of adverse early-life experiences... might encompass more pervasive alterations in health status and physiology. Recent findings in telomere biology have suggested a new avenue for exploring the adverse health effects of childhood maltreatment. Telomere length in proliferative tissues declines with cell replication and the effect can be accelerated by such factors as inflammation, oxidative stress, radiation, and toxins. Reduced telomere length, as a proxy for cellular aging, has been associated with numerous chronic somatic diseases that are generally considered to be diseases of aging, such as diabetes, cancer, and heart disease [in addition to] several psychiatric conditions, particularly depression, ...a focus in psychiatry, with a historic neurobiological emphasis on physiological systems that are demonstrably stress-responsive, such as the hypothalamic-pituitary-adrenal axis and neuroimmune function. ...Now, emerging work suggests a robust, and perhaps dose-dependent, relationship with early-life stress. These findings present new opportunities to reconceptualize the complex relationships between experience, physical and psychiatric disease, and aging. emphasis added.
[169] Ten Drugs Cause Majority of ER Visits in Adults for Adverse Psych Med Effects
[170] Ten Kinds of Drugs That May Cause Memory Loss
[171] ...Thermoregulation and Pain Modulation in Fibromyalgia (Body temperature dysregulation.)
[172] Toxic & Drug-induced Peripheral Neuropathies: Updates on Causes, Mechanisms & Management
[173] ▼ Treatment of FM Syndrome: Recommendations of Recent Evidence-Based Interdisciplinary Guidelines with Special Emphasis on Complementary & Alternative Therapies. ABSTRACT:
[Authorship]J. Ablin...Tel Aviv Sourasky Medical Center, 64239 Tel Aviv, Israel • Fitzcharles MA...McGill University Health Centre, Canada • Buskila D...H. Soroka Medical Center, Beer Sheva, Israel • Shir Y...McGill University Health Centre, Canada • Sommer C...Universitätsklinikum Würzburg, Germany • Häuser W...Klinikum Saarbrücken, Saarbrücken, Germany & Technische Universität München, Würzburg, Germany • Objective. Current evidence indicates that there is no single ideal treatment for FM. First choice treatment options remain debatable, especially concerning the importance of complementary and alternative medicine (CAM) treatments. Methods. Three evidence-based interdisciplinary guidelines on FM in Canada, Germany, and Israel were compared for their first choice and CAM recommendations. Results. All three guidelines emphasized a patient-tailored approach according to key symptoms. Aerobic exercise, cognitive behavioral therapy, and multicomponent therapy were first choice treatments. The guidelines differed in the grade of recommendation for drug treatment. Anticonvulsants (gabapentin, pregabalin) and serotonin noradrenaline reuptake inhibitors (duloxetine, milnacipran) were strongly recommended by Canadian and Israeli guidelines. These drugs received only a weak recommendation by German guidelines. In consideration of CAM treatments, acupuncture, hypnosis/ guided imagery, and Tai Chi were recommended by German and Israeli guidelines. Canadian guidelines did not recommend any CAM therapy...
[174] Treatment Preferences for CAM in Children with Chronic Pain
[175] Toward a 'Where' & 'How' Understanding of Dopamine Dysfunction in Disorders of Attention
[176] Understanding the Relationship Between Stress, Distress & Healthy Lifestyle Behaviour: A Qualitative Study of Patients & General Practitioners Full text.
[177] Understanding why cognitive-behavioral therapy is an effective treatment for adolescents with juvenile FM
[178] Use of lisdexamfetamine dimesylate in treatment of executive functioning deficits & chronic fatigue syndrome: A double blind, placebo-controlled study (An ADHD drug.)
[178a] Utilization of Pharmacogenomics & Therapeutic Drug Monitoring for Opioid Pain Management
[179] Validation of the modified 2010 American College of Rheumatology diagnostic criteria for FM in a Spanish population.
[180] ▼ Why Are So Many Patients Noncompliant? A fair clinician viewpoint. However, the FDA maintains the [181] MedWatch Online Voluntary (Adverse Medical Product Event) Reporting Form not only for "health professionals" but also for "consumers/patients", clear evidence that physicians cannot always be relied upon to relay these reports.
[182] ▲ ▼ Compliance (medicine)
In medicine, compliance (also adherence, capacitance or Concordance) describes the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication or drug compliance, but it can also apply to other situations such as medical device use, self care, self-directed exercises, or therapy sessions. Both the patient and the health-care provider affect compliance, and a positive physician-patient relationship is the most important factor in improving compliance...although the high cost of prescription medication also plays a major role... Compliance is commonly confused with concordance. Concordance is the process by which a patient and clinician make decisions together about treatment... ...Major barriers to compliance are thought to include the complexity of modern medication regimens, poor "health literacy" and lack of comprehension of treatment benefits, the occurrence of undiscussed side effects, the cost of prescription medicine, and poor communication or lack of trust between...patient and... health-care provider... Efforts to improve compliance have been aimed at simplifying medication packaging, providing effective medication reminders, improving patient education, and limiting the number of medications prescribed simultaneously.
[183] Women with fibromyalgia have lower levels of calcium, magnesium, iron and manganese in hair mineral analysis.
[184] Yoga in the Management of Overweight & Obesity. Full text. "...yoga appears promising as a way to assist with behavioral change, weight loss, and maintenance."
and
[185] ... a Trees-Flowers Anti-Insomnia Help-Thing