Musculo-Skeletal Disorders - Fibromyalgia

by Kyle J. Norton

Fibromyalgia, according to the American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia in the newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites(a) as a result in responding to pressure. I. Symptoms Symptoms of Fibromyalgia may be depending to the patient gender In a study in a community and a clinic sample, researchers at the College of Medicine at Peoria, University of Illinois, showed that women experienced significantly more common fatigue, morning fatigue, hurt all over, total number of symptoms, and irritable bowel syndrome. Women had significantly more tender points. Pain severity, global severity and physical functioning were not significantly different between the sexes, nor were psychologic factors, eg, anxiety, stress, and depression. Gender differences have also been observed in other related syndromes, eg, chronic fatigue syndrome, irritable bowel syndrome, and headaches(1). Other study suggested that gender differences have also been reported in other related syndromes such as tension headache, migraine, irritable bowel syndrome, chronic fatigue syndrome, and temporomandibular disorder(2). Other symptoms may include widespread musculoskeletal pain, multiple "tender points", fatigue, sleep disturbance, stiffness and other symptoms such as headache, dizziness, trouble with concentration, irritable bowel syndrome, urinary urgency, depression(3). According to the American College of Rheumatolog Disordered sleep is such a prominent symptom in fibromyalgia, ithers include symptoms such as waking unrefreshed, fatigue, tiredness, and insomnia in the 2010 diagnostic criteria for fibromyalgia(4). II. Causes and Risk factors A. Causes 1. Oxidative stress There are some evidences demonstrating that oxidative stress is associated to clinical symptoms in FM of fibromyalgia(5).

2. Chronic stress The relationship between stress, depression and functionality seems to be part of a complex mechanism, which might affect the quality of life of patients with FM(6). 3. Alpha1-Antitrypsin (AAT) There is a a possible relationship between AAT deficiency (AAT-D) and fibromyalgia (FM)(7). 4. Inflammatory rheumatic disorders There is evidence to suggest that fibromyalgia occurs much more frequently than expected in individuals with inflammatory rheumatic disorders(8). 5. Sleep disturbance There is a reciprocal relationship exists between pain and sleep, and that intervention targeted primarily at insomnia may improve pain(9). 6. Etc.

B. Risk factors 1. Gender If you are women, you are at higher risk than men to develop Fibromyalgia(10) 2. Family history In the study to investigate whether Fibromyalgia (FM) patients differ from their first-degree relatives with and without FM regarding the four personality traits, based on Cloninger's TPQ questionnaire, found that relatives with FM display personality resemblance to FM patients especially in the personality trait harm avoidance. It appears that there are factors in this personality trait that are hereditary and that may contribute to the development of FM(11). 3. Environmental susceptibility may be the possible causes of Fibromyalgia(12). 4. Other illness

There is a believe that certain illness are associated to the increased risk of Fibromyalgia, such as diseases if infection. 5. Etc. III. Complications 1. Negative impact in relationships In a study was designed to survey a large community sample of adults with fibromyalgia about the impact on the spouse/partner, children and close friends, found that in addition to physical impairments that are well documented among individuals with fibromyalgia, fibromyalgia can result in a substantial negative impact on important relationships with family and close friends(13). 2. Psychological problem According to the study by Monash University and Monash Medical Centre in comparison between FM patients and healthy individuals found significant differences in control (Perceived Control of Internal States Scale and Mastery Scale), pain, perceived stress, fatigue, confusion, and mood disturbance (all P < 0.001). There were significant associations found between both high and low levels of control on stress, mood, pain, and fatigue (P < 0.001-0.05). Strong negative correlations were present between internal control and perceived stress (P < 0.0005)(14). 3. Pain disability, depression, and pressure sensitivity differences in genders In the study to determine the differences in pain, disability, depression, and pressure sensitivity between men and women with fibromyalgia syndrome (FMS), and to analyze the relationship between pain and pressure sensitivity in FMS, found that w determine the differences in pain, disability, depression, and pressure sensitivity between men and women with fibromyalgia syndrome (FMS), and to analyze the relationship between pain and pressure sensitivity in FMS(15). 4. Impaired functionality, and impact on the quality of life In the study to compare depressive symptoms and stress perception between women with and without FM, in addition to investigate the relationship between those characteristics and the functionality and the impact on the quality of life of those patients, showed that in the FM group, a positive

correlation was observed between the depressive symptoms and perceived stress (r = 0.54, P < 0.05), pain (r = 0.58, P < 0.01), impaired functionality (r = 0.56, P < 0.01), and impact on the quality of life (r = 0.46, P < 0.05). In this group there was also correlation between perceived stress and impaired functionality (r = 0.50;P < 0.05). Pain showed no relationship with perceived stress(16). 5. Fall risk There were significant relationships between fall risk and NRS scores (r= 0.565), and FIQ fatigue subscores (r=0.560) (both p<0.05). Worse postural performance and fall risk found in the fibromyalgia patients compared to controls were related with the sleep quality in the last 24 h and level of fatigue, according to the study by Pamukkale University Medical School(17). 6. Postural control deficits In the study to determine whether FM patients, compared to age-matched healthy controls (HCs), have differences in dynamic posturography, including sensory, motor, and limits of stability, found that that middle-aged FM patients have consistent objective sensory deficits on dynamic posturography, despite having a normal clinical neurological examination. Further study is needed to determine prospective fall rates and the significance of lower-extremity MTPs. The development of interventions to improve balance and reduce falls in FM patients may need to combine balance training with exercise and cognitive training(18). 7. Infections, neoplastic and cardiovascular disease and mortality In the study to determine whether fibromyalgia (FM) is associated with an increase in comorbidity (infections, neoplastic and cardiovascular disease) as well as with an increase in mortality, showed that despite the high comorbidity and medical resource use in FM, there is no evidence that this entity is associated with an increase in comborbidity due to cardiovascular disease or infections. The association between FM and HIV and hepatitis C virus infections suggests a possible relationship between FM and chronic viral infection. Patients with chronic generalized pain may have an increased risk of developing cancer. FM may also carry an increased risk of accidental death and death from cancer(19).

8. Etc. IV. Diagnosis In the narrative review of the literature, consensus documents by the American College of Rheumatology (ACR), evidence-based interdisciplinary German guidelines on the diagnosis and management of FMS by Klinikum Saarbrcken Internal Medicine 1 Winterberg 1 D-66119 Saarbrcken, the recommendations of a stepwise diagnostic work-up of patients with chronic widespread pain (CWP) in primary care include: Complete medical history including medication, complete medical examination, basic laboratory tests to screen for inflammatory or endocrinology diseases, referral to specialists only in case of suspected somatic diseases, assessment of limitations of daily functioning, screening for other functional somatic symptoms and mental disorders, and referring to mental health specialists in case of mental disorder(20). Other study suggested of 4 phased diagnosis. In phase one, physicians undertook a selfassessment of their practice. Phase two of the study involved diagnosis and treatment of a virtual case vignette. The third phase consisted of analysis of the data from phase two and providing feedback from an expert rheumatologist, and the fourth phase was to complete patient report forms for five patients in their practice(21). Here we quote the text from the study of The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgiaand Measurement of Symptom Severity by FREDERICK WOLFE,1 DANIEL J. CLAUW,2 MARY-ANN FITZCHARLES,3 DON L. GOLDENBERG,4 ROBERT S. KATZ,5 PHILIP MEASE,6 ANTHONY S. RUSSELL,7 I. JON RUSSELL,8 JOHN B. WINFIELD,9 AND MUHAMMAD B. YUNUS10 Objective. To develop simple, practical criteria for clinical diagnosis of fibromyalgia that are suitable for use in primary and specialty care and that do not require a tender point examination, and to provide a severity scale for characteristic fibromyalgia symptoms. Methods. We performed a multicenter study of 829 previously diagnosed fibromyalgia patients and controls using physician physical and interview examinations, including a widespread pain index (WPI), a measure of the number of painful body regions. Random forest and recursive partitioning analyses were used to guide the development of a case definition of fibromyalgia, to develop criteria, and to construct a symptom severity (SS) scale. Results. Approximately 25% of fibromyalgia patients did not satisfy the

American College of Rheumatology (ACR) 1990 classification criteria at the time of the study. The most important diagnostic variables were WPI and categorical scales for cognitive symptoms, unrefreshed sleep, fatigue, and number of somatic symptoms. The categorical scales were summed to create an SS scale. We combined the SS scale and the WPI to recommend a new case definition of fibromyalgia: (WPI >7 AND SS >5) OR (WPI 36 AND SS >9). Conclusion. This simple clinical case definition of fibromyalgia correctly classifies 88.1% of cases classified by the ACR classification criteria, and does not require a physical or tender point examination. The SS scale enables assessment of fibromyalgia symptom severity in persons with current or previous fibromyalgia, and in those to whom the criteria have not been applied. It will be especially useful in the longitudinal evaluation of patients with marked symptom variability. Please note: This criteria set has been approved by the American College of Rheumatology (ACR) Board of Directors as Provisional.This signifies that the criteria set has been quantitatively validated using patient data, but it has not undergone validationbased on an external data set. All ACR-approved criteria sets are expected to undergo intermittent updates.As disclosed in the manuscript, these criteria were developed with support from the study sponsor, Lilly Research Laboratories.The study sponsor placed no restrictions, offered no input or guidance on the conduct of the study, did not participatein the design of the study, see the results of the study, or review the manuscript or submitted abstracts prior to thesubmission of the paper. The recipient of the grant was Arthritis Research Center Foundation, Inc. The authors receivedno compensation. The ACR found the criteria to be methodologically rigorous and clinically meaningful.ACR is an independent professional, medical and scientific society which does not guarantee, warrant or endorse anycommercial product or service. The ACR received no compensation for its approval of these criteria(22). V. Preventions 1. Vitamin D Vitamin D deficiency is associated with anxiety and depression in fibromyalgia. In a study of Seventy-five Caucasian patients who fulfilled the ACR criteria for fibromyalgia had serum vitamin D levels measured and completed the Fibromyalgia Impact Questionnaire (FIQ) and Hospital Anxiety and Depression showed that Vitamin D deficiency is common in fibromyalgia and occurs more frequently in patients with anxiety and

depression. The nature and direction of the causal relationship remains unclear, but there are definite implications for long-term bone health(23). 2. Omega 3 fatty acid In the study to investigate and report on patients with neuropathic pain who responded to treatment with omega-3 fatty acids, five patients with different underlying diagnoses including cervical radiculopathy, thoracic outlet syndrome, fibromyalgia, carpal tunnel syndrome, burn injury were treated with high oral doses of omega 3 fish oil (varying from 2400-7200 mg/day of EPA-DHA), found thatthese patients had clinically significant pain reduction, improved function as documented with both subjective and objective outcome measures up to as much as 19 months after treatment initiation. No serious adverse effects were reported(24). 3. Caffeine In a study of forty-three of fifty-eight (74.1%) female patients with fibromyalgia completed an eight-week treatment period testing the combination of carisoprodol, paracetamol (acetaminophen) and caffeine versus placebo, found that the combination of carisoprodol and paracetamol (acetaminophen) and caffeine are effective in the treatment of fibromyalgia(25). 4. Coenzyme Q10 CoQ10 treatment restored mitochondrial dysfunction and the mtDNA copy number, decreased oxidative stress, and increased mitochondrial biogenesis. Our results suggest that CoQ10 could be an alternative therapeutic approach for FM(26). 5. Etc. VI. Treatments A. In conventional medicine perspective FMS usually involves females, and in these patients it often makes its first appearance during menopause. But it is often diagnosed both in young as well as elderly individuals. The management of pediatric FMS is centered on the issues of education, behavioral and cognitive change (with a strong emphasis on physical exercise), and a relatively minor role for pharmacological treatment with medications such as muscle relaxants, analgesics and tricyclic agents(27). A.1. Non medication

1. Psychological control According to the study by Monash University and Monash Medical Centre suggested that FM patients use significantly different control styles compared with healthy individuals. Levels and type of psychological control buffer mood, stress, fatigue, and pain in FM. Control appears to be an important "up-stream" process in FM mechanisms and is amenable to intervention(28). 2. Cognitive-behavioral and operant-behavioral therapy In the study to focus on the evaluation of the effects of operant behavioural (OBT) and cognitive behavioural (CBT) treatments for fibromyalgia syndrome (FMS), found that focused on the evaluation of the effects of operant behavioural (OBT) and cognitive behavioural (CBT) treatments for fibromyalgia syndrome (FMS)(29). 3. Exercise In the reviewing the available evidence addressing the effects of exercise on central pain modulation in patients with chronic pain showed that a dysfunctional response of patients with chronic pain and aberrations in central pain modulation to exercise has been shown, indicating that exercise therapy should be individually tailored with emphasis on prevention of symptom flares(30). 4. Physical therapy Based on anecdotal evidence or small observational studies physiotherapy may reduce overloading of the muscle system, improve postural fatigue and positioning, and condition weak muscles. Modalities and whole body cryotherapy may reduce localized as well as generalized pain in short term. Trigger point injection may reduce pain originating from concomitant trigger points in selected FM patient. Massage may reduce muscle tension and may be prescribed as a adjunct with other therapeutic interventions. Acupuncture may reduce pain and increase pain threshold. Biofeedback may positively influence subjective and objective disease measures. TENS may reduce localized musculoskeletal pain in fibromyalgia(31) 5. Ozone therapy In the study to determine the efficacy of ozone therapy in patients with fibromyalgia received 24 sessions of ozone therapy during a 12-week period, found that Significant improvement was also seen both in depression scores and in the Physical Summary Score of the SF-12. Transient meteorism after

ozone therapy sessions was the most frequently reported side-effect(32). B. Medications The aim of medicine is to relieve the symptoms of the disease In anarrative review from meta-analyses and systematic reviews published since 2005. For a few medications, findings from multiple recent trials are synthesized if a systematic review had not yet been published. Classes of medications are first reviewed, followed by an overview of four common pain disorders: neuropathic pain, low back pain, fibromyalgia and osteoarthritis, showed that stepped care approach based upon existing evidence includes (1) simple analgesics (acetaminophen or nonsteroidal anti-inflammatory drugs); (2) tricyclic antidepressants (if neuropathic, back or fibromyalgia pain) or tramadol; (3) gabapentin, duloxetine or pregabalin if neuropathic pain; (4) cyclobenzaprine, pregabalin, duloxetine, or milnacipran for fibromyalgia; (5) topical analgesics (capsaicin, lidocaine, salicylates) if localized neuropathic or arthritic pain; and (6) opioids(33). B. Alternative treatments Several types of alternative medicine have some potential for future clinical research. However, due to methodological inconsistencies across studies and the small body of evidence, no firm conclusions can be made at this time. Regarding alternative treatments, acupuncture and several types of meditative practice show the most promise for future scientific investigation. Likewise, magnesium, l-carnitine, and S-adenosylmethionine are nonpharmacological supplements with the most potential for further research. Individualized treatment plans that involve several pharmacological agents and natural remedies appear promising as well.(34) In other studies to valuate complementary or alternative medical (CAM) therapies for efficacy and some adverse events fibromyalgia (FM), researchers found that there is no permanent cure for FM; therefore, adequate symptom control should be goal of treatment. Clinicians can choose from a variety of pharmacologic and nonpharmacologic modalities. Unfortunately, controlled studies of most current treatments have failed to demonstrate sustained, clinically significant responses. Complementary or alternative medical (CAM) has gained increasing popularity, particularly among individuals with FM for which traditional medicine has generally been ineffective. Some herbal and nutritional supplements (magnesium, Sadenosylmethionine) and massage therapy have the best evidence for effectiveness with FM. Other CAM therapies such as chlorella,

biofeedback, relaxation have either been evaluated in only one randomised controlled trials (RCT) with positive results, in multiple RCTs with mixed results (magnet therapies) or have positive results from studies with methodological flaws (homeopathy, botanical oils, balneotherapy, anthocyanidins and dietary modifications)(34a). B.1. In Herbal medicine perspective In the measurement of the prevalence of NHP use among adults in Canada, identify the most commonly used agents, and determine the socioeconomic, demographic, and health-related correlates of use, showed that Glucosamine, echinacea, and garlic were the most frequently used products. Women reported NHP use more frequently than men (11.5% vs. 7.1%). As compared to young adults, NHP use was about 50% higher in middle-aged and older Canadians. There were no associations with either income or education level. Several disease states were associated with a high prevalence of NHP use: respondents with fibromyalgia (23.3%), inflammatory bowel disease (17.4%), and urinary incontinence (16.8%) were most likely to be NHP users(35). 1. Ginkgo biloba In an open, uncontrolled study was undertaken to measure the subjective effects of coenzyme Q10 combined with a Ginkgo biloba extract in volunteer subjects with clinically diagnosed fibromyalgia syndrome, researchers found that a progressive improvement in the quality-of-life scores was observed over the study period and at the end, the scores showed a significant difference from those at the start. This was matched by an improvement in self-rating with 64% claiming to be better and only 9% claiming to feel worse. Adverse effects were minor(36). 2. Harpagophytum procumbens (Devil's claw), Salix alba (White willow bark), and Capsicum frutescens (Cayenne) In a systematic review of randomized controlled trials to determine the effectiveness of herbal medicine compared with placebo, no intervention, or "standard/accepted/conventional treatments" for nonspecific low back pain, found that Harpagophytum procumbens (Devil's claw), Salix alba (White willow bark), and Capsicum frutescens (Cayenne) seem to reduce pain more than placebo. Additional trials testing these herbal medicines against standard treatments will clarify their equivalence in terms of efficacy(37). 3. Cayenne is also known as Cayenne Pepper, a red, hot chili pepper,

belonging to Capsicum annuum, the family Solanaceae, native to subtropical and tropical regions. It has been used in traditional medicine to increases metabolism, enhance circulatory system and stomach and the intestinal tract, adjust blood pressure, lower LDL cholesterol and triglycerides, treat frostbite, muscles, arthritis, rheumatism, low back pain, strains, sprains, bruises and neuralgia, etc. the non-pungent pepper CH-19 Sweet and of hot red pepper activates the sympathetic nervous system (SNS) and enhances thermogenesis as effectively as hot red pepper, ant that the heat loss effect due to CH-19 Sweet is weaker than that due to hot red pepper. Furthermore, we found that intake of CH-19 Sweet does not affect systolic BP or HR, while hot red pepper transiently elevates them, according to the study of "Effects of CH19 Sweet, a non-pungent cultivar of red pepper, on sympathetic nervous activity, body temperature, heart rate, and blood pressure in humans" by Hachiya S, Kawabata F, Ohnuki K, Inoue N, Yoneda H, Yazawa S, Fushiki T(38). C.1. In traditional Chinese medicine perspective 1. Acupuncture In a study to test the hypothesis that acupuncture improves symptoms of fibromyalgia, researchers at the Department of Anesthesiology, Mayo Clinic College of Medicine, showed that acupuncture significantly improved symptoms of fibromyalgia. Symptomatic improvement was not restricted to pain relief and was most significant for fatigue and anxiety(39). 2. Combination of acupuncture and cupping therapy A combination of acupuncture and cupping therapy was better than conventional medications for reducing pain (MD, -1.66; 95% CI, -2.14 to -1.19; p < 0.00001; I(2) = 0%), and for improving depression scores with related to FM (MD, -4.92; 95% CI, -6.49 to -3.34; p < 0.00001; I(2) = 32%). Other individual trials demonstrated positive effects of Chinese herbal medicine on pain reduction compared with conventional medications. There were no serious adverse effects reported that were related to TCM therapies in these trials, according to the study by The Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine(40). 2. Chinese herbal formulas In a study of differentiation of Two TCM practitioners conducted baseline TCM diagnostic examinations on 56 women with FM, found that three

primary TCM diagnoses were found in the population: Qi and Blood Deficiency (46.4%, CI 33.0% to 60.36%), Qi and Blood Stagnation (26.8%, CI 15.8% to 40.3%), and Liver Qi Stagnation (19.6%, CI 10.2% to 32.4%). Other study showed that syndromes were found to be important in FS include : 1) liver-Qi-stagnation 2) Yin and blood deficiency of the liver, 3) Yang-weakness of the spleen and kidney, 4) Yin-weakness of the kidney(41). Dr. Shen in the article of Chinese Herbs & Chinese Medicine for Fibromyalgia, suggested the below formula to relieve pain bai shao - 20%, qin jiao - 10%, du huo - 10%, yan hu sou - 10%, yu jin 10%, tao ren - 10%, hong hua - 10%, mu dan pi - 10%, da zao - 5%, gan cao - 5%, Basic Pain Formula; Take 3-4 grams (scoops), 3 times a day mixed with liquid or food. Preferably on an empty stomach. (Should not be taken by pregnant women)(42) Exercises To Completely Cure Fibromyalgia! An All Natural Method That Permanently Eliminates Fibromyalgia For common types of diseases of Ages of 50+, please visit http://medicaladvisorjournals.blogspot.ca/p/better-of-living-health-50over.html For other health article, visit http://medicaladvisorjournals.blogspot.ca Sources (a) http://www.ncbi.nlm.nih.gov/pubmed/2306288 (1) http://www.ncbi.nlm.nih.gov/pubmed/11286669 (2) http://www.ncbi.nlm.nih.gov/pubmed/11974674 (3) http://www.ncbi.nlm.nih.gov/pubmed/15074033 (4) http://www.ncbi.nlm.nih.gov/pubmed/21594765 (5) http://www.ncbi.nlm.nih.gov/pubmed/22532869 (6) http://www.ncbi.nlm.nih.gov/pubmed/22641587 (7) http://www.ncbi.nlm.nih.gov/pubmed/15694694 (8) http://www.ncbi.nlm.nih.gov/pubmed/19078011 (9) http://www.ncbi.nlm.nih.gov/pubmed/20047347 (10) http://www.ncbi.nlm.nih.gov/pubmed/15074033 (11) http://www.ncbi.nlm.nih.gov/pubmed/21122266

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