Fibromyalgia syndrome: definition and diagnostic aspects.

Ever since it was first defined, fibromyalgia (FM) has been considered one of the most controversial diagnoses in the field of rheumatology, to the point that not everybody accepts its existence as an independent entity. The sensitivity and specificity of the proposed diagnostic criteria are still debated by various specialists (not only rheumatologists), whose main criticism of the 1990 American College of Rheumatology criteria is that they identify subsets of particular patients that do not reflect everyday clinical reality. Furthermore, the symptoms characterising FM overlap with those of many other conditions classified in a different manner. Over the last few years, this has led to FM being considered less as a clinical entity and more as a possible manifestation of alterations in the psychoneuroendocrine system (the spectrum of affective disorders) or the stress reaction system (dysfunctional symptoms). More recently, doubts have been raised about even these classifications; and it now seems more appropriate to include FM among the central sensitisation syndromes, which identify the main pathogenetic mechanism as the cause of skeletal and extra-skeletal symptoms of FM and other previously defined "dysfunctional" syndromes.

Etiopathogenetic mechanisms of fibromyalgia syndrome.

Fibromyalgia syndrome (FMS) is a common chronic condition of widespread pain with causal mechanisms that are largely unknown. It is characterized by moderate to severe musculoskeletal pain and allodynia, but its pathogenesis appears confined to the nociceptive structures of the central nervous system. FMS is often triggered by negative environmental influences, especially if they occur in childhood. In a fetus, these environmental triggers may influence the development of the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal axis (HPA). Increasing evidence supports the comorbidity of psychological conditions including depression, panic disorders, anxiety, and post-traumatic stress disorder (PTSD). Recent evidence suggests that genetic factors may play a role in the pathogenesis of FMS. Central sensitization has long been associated with FMS pain. It describes enhanced excitability of dorsal horn neurons, which leads to transmission of altered nociceptive information to the brain. Understanding of pathogenetic pathways in FMS has advanced beyond observing patient responses to neurophysiologically targeted therapies and basic research.

Non pharmacological treatments in fibromyalgia.

Fibromyalgia is a complex syndrome associated with significant impairment in quality of life and function and with substantial financial costs. Once the diagnosis is made, providers should aim to increase patients' function and minimize pain. Fibromyalgia patients frequently use alternative therapies, strongly indicating both their dissatisfaction with and the substantial ineffectiveness of traditional medical therapy, especially pharmacological treatments. At present, pharmacological treatments for fibromyalgia have a rather discouraging cost/benefit ratio in terms of poor symptom control and high incidence of side effects. The interdisciplinary treatment programs have been shown to improve subjective pain with greater success than monotherapy. Physical therapies, rehabilitation and alternative therapies are generally perceived to be more "natural," to have fewer adverse effects, and in some way, to be more effective. In this review, physical exercise and multimodal cognitive behavioural therapy are presented as the more accepted and beneficial forms of nonpharmacological therapy.

Fibromyalgia syndrome: preventive, social and economic aspects.

There many open questions concerning the concept of primary prevention in FM. Diagnostic or classification criteria are not universally accepted, and this leads to difficulties in establishing the onset and duration of the disease. In the case of FM, primary prevention may consist of the immediate care of acute pain or treatment for affective disturbances as we do not have any specific laboratory or instrumental tests to determine risk factors of the disease. The goal of secondary prevention is early detection of the disease when patients are largely asymptomatic and intervention improves outcome. Screening allows for identification of an unrecognized disease or risk factor, which, for potential FM patients, includes analysis of tender points, Fibromyalgia Impact Questionnaire (FIQ), pain location and intensity, and fatigue and sleep complaints. Tertiary prevention inhibits further deterioration or reduces complications after the disease has developed. In FM the aim of treatment is to decrease pain and increase function via multimodal therapeutic strategies, which, in most cases, includes pharmacological and non-pharmacological interventions. Patients with FM are high consumers of health care services, and FM is associated with significant productivity-related costs. The degree of disability and the number of comorbidities are strongly associated with costs. An earlier diagnosis of FM can reduce referral costs and investigations, thus, leading to a net savings for the health care sector. However, every social assessment is closely related to the socio-economic level of the general population and to the legislation of the country in which the FM patient resides.

Symptoms and signs in fibromyalgia syndrome.

Fibromyalgia syndrome (FM) is a common chronic pain condition that affects at least 2% of the adult population. Chronic widespread pain is the defining feature of FM, but patients may also exhibit a range of other symptoms, including sleep disturbance, fatigue, irritable bowel syndrome, headaches, and mood disorders. The etiology of FM is not completely understood and the syndrome is influenced by factors such as stress, medical illness, and a variety of pain conditions. Establishing diagnosis may be difficult because of the multifaceted nature of the syndrome and overlap with other chronically painful conditions. A unifying hypothesis is that FM results from sensitization of the central nervous system; this new concept could justify the variety of characteristics of the syndrome. FM symptoms can be musculoskeletal, non-musculoskeletal, or a combination of both; and many patients will also experience a host of associated symptoms or conditions. The ACR classification criteria focus only on pain and disregard other important symptoms; but three key features, pain, fatigue and sleep disturbance, are present in virtually every patient with FM. Several other associated syndromes, including circulatory, nervous, digestive, urinary and reproductive systems are probably a part of the so called central sensitivity or sensitization syndrome. A minority subgroup of patients (30-40%) has a significant psychological disturbance. Psychological factors are an important determinant of any type of pain, and psychological comorbidity is frequent in FM. Psychiatric disorders most commonly described are mood disorders, but psychiatric illness is not a necessary factor in the etiopathogenesis of FM.

Fibromyalgia syndrome: the pharmacological treatment options.

Pharmacological treatment has been gradually enriched by a variety of compounds; however, no single drug is capable of fully managing the constellation of fibromyalgia (FM) symptoms. Currently, it is not possible to draw definite conclusions concerning the best pharmacological approach to managing FM because results of randomized clinical trials present methodological limitations and therapeutic programs are too heterogeneous for adequate comparison. However, a variety of pharmacological treatments including antidepressants, nonsteroidal anti-inflammatory drugs (NSAIDS), opioids, sedatives, muscle relaxants and antiepileptics have been used to treat FM with varying results. In this review, we will evaluate those pharmacological therapies that have produced the most significant clinical results in treating FM patients. The nature of FM suggests that an individualized, multimodal approach that includes both pharmacologic and nonpharmacologic therapies seems to be the most appropriate treatment strategy to date.

The evaluation of the fibromyalgia patients.

Fibromyalgia (FM) is a rheumatic disease characterized by musculoskeletal pain, chronic diffuse tension and/or stiffness in joints and muscles, easy fatigue, sleep and emotional disturbances, and pressure pain sensitivity in at least 11 of 18 tender points. At present, there are no instrumental tests or specific diagnostic markers for FM; in fact, many of the existing indicators are significant for research purposes only. Many differential diagnoses may be excluded by an extensive clinical examination and patient history. Considering overlap of FM with other medical conditions, the treating physicians should be vigilant: chest-X-rays and abdominal ultrasonography are the first steps of general evaluation for all the patients with suspected FM. Functional neuroimaging methods have revealed a large number of supraspinal effects in FM, a disorder mediated by mechanisms that are essentially unknown. Many treatments are used in FM patients, but evaluating their therapeutic effects in FM is difficult because the syndrome is so multifaceted. To address the identification of core outcome domains, the Initiative on IMMPACT and OMERACT workshop convened a meeting to develop consensus recommendations for chronic pain clinical trials.

Myofascial pain mimicking radicular syndromes.

Myofascial pain is very often underscored and misunderstood in clinical practice. In many cases the localization of myofascial pain may resemble other diseases, such as radicular syndromes (e.g., low back pain from herniated disc) and even diseases of internal organs (e.g., angina pectoris, bowel diseases or gynaecological disturbances). In pain clinics one can routinely see patients with myofascial painful disorders showing a radicular topography and normal CT and MRI: as a consequence, when vertebral abnormalities are present on CT or MRI, it should be checked whether the cause of pain is radicular, myofascial, or both. On the other hand, the conventional approach to painful disorders may lead to errors and wrong diagnosis, depending on several factors: a) pain is often considered a symptom of an organic disease; b) the diagnosis is usually directed towards the structural cause of pain only; c) the functional components of the suffering patient are underscored; d) the site of pain may introduce some bias. When the latter is concerned, it is usually admitted that a neck pain may depend on muscle contraction (e.g. torticollis), while such a cause is less commonly admitted for leg, where the attention is first directed towards the sciatic nerve; myofascial origin of pain is even less considered in abdominal or pelvic painful disorders, where patients with no structural detectable diseases are often considered as neurotic and referred to the psychiatrist. The reason for this topographical dependence of diagnosis lies in the conventional attitude to focus on the most relevant and frequent organic diseases, thus introducing a bias with relevant epistemological implications.

Postoperative pain treated by intravenous L-tryptophan: a double-blind study versus placebo in cholecystectomized patients.

The effectiveness of intravenous administration (i.v.) of L-tryptophan, which is the precursor of cerebral serotonin, was verified in the treatment of postoperative pain. The study was carried out on 45 female patients, aged between 34 and 61 years, undergoing cholecystectomy who were randomly divided into three groups. Group 1 (age: 50.33 +/- 8.64 years) received 100 ml of 5% mannitol solution i.v.; group 2 (age: 49.80 +/- 11.11 years) 100 ml of a mannitol solution containing 7.5 mg/kg L-tryptophan; and group 3 (age: 53.46 +/- 9.60 years) 100 ml of a mannitol solution containing 15 mg/kg L-tryptophan. Vital capacity (preoperative VC) was measured before surgery. Anesthesia used was isoflurane. Narcotics or neuroleptics were not used. Pain was assessed before treatment (T-0 min), at the end of administration (T-30) and at T-60, 120, 180, 240, 300 and 360 min by the following variables: respiratory rate (RR), heart rate (HR), mean arterial pressure (MAP), Scott-Huskisson test (VAS), pain vital capacity (PVC), analgesic vital capacity (AVC), and respiratory restoration factor (RRF) calculated from Bromage's formula (RRF = (AVC - PVC/preoperative VC - PVC) X 100). As regards variables RR, HR, MAP and VAS, differences between the values from T-30 to T-360 and the value at T-0 were calculated. Means and S.E.M. were calculated on the obtained values and on RRF values for each group. The significance of the differences between groups was calculated using Student's t test and Bonferroni's test. Results show a significant decrease of pain in groups 2 and 3 treated with L-tryptophan, in comparison with group 1 (controls). No significant difference was observed between the treated groups, although more lasting pain relief was observed in group 3 in comparison with group 2. Intravenous L-tryptophan showed its effectiveness in the treatment of postoperative pain even when used alone. Its use may be considered for patients with renal failure, in order to strengthen pharmacological analgesia or to prevent postoperative pain by its intraoperative administration.

Diode laser in cervical myofascial pain: a double-blind study versus placebo.

We present a double-blind trial in which a pulsed infrared beam was compared with a placebo in the treatment of myofascial pain in the cervical region. The patients were submitted to 12 sessions on alternate days to a total energy dose of 5 J each. At each session, the four most painful muscular trigger points and five bilateral homometameric acupuncture points were irradiated. Those in the placebo group submitted to the same number of sessions following an identical procedure, the only difference being that the laser apparatus was nonoperational. Pain was monitored using the Italian version of the McGill pain questionnaire and the Scott-Huskisson visual analogue scale. The results show a pain attenuation in the treated group and a statistically significant difference between the two groups of patients, both at the end of therapy and at the 3-month follow-up examination.

The effects of parachlorophenylalanine and naloxone on acupuncture and electroacupuncture modulation of capsaicin-induced neurogenic edema in the rat hind paw. A controlled blind study.

OBJECTIVE: The aim of this work was to study the effect of pre-treatment with parachlorophenylalanine (PCPA) and posttreatment with naloxone on the modulating action on neurogenic inflammation of manual acupuncture and low intensity (5 mAmp), low frequency (5 Hz) electroacupuncture (EA). METHODS: Edema was induced by the subcutaneous administration of 50 micrograms capsaicin in rat paws. Pre-treatment with intraperitoneal PCPA was given for 3 days: 200 mg/Kg on the first day and 100 mg/Kg on the second and third days. Naloxone (1 mg/Kg) was administered at the end of the stimulation. RESULTS: The results show that naloxone and PCPA reduce the anti-edema effect of both manual acupuncture and EA. Combined administration of the two drugs completely eliminated the effect of manual acupuncture, and decreased but did not abolish the effect of electroacupuncture. CONCLUSION: These results indicate that both the opioid and the serotonergic inhibitory control systems are involved in the modulating action of acupunctural stimulation on neurogenic inflammation.

[3H]imipramine binding sites are decreased in platelets of chronic pain patients.

Tritiated imipramine binding to whole platelets was measured in 16 chronic pain patients not suffering from major depression and in a control group. Maximum binding was significantly lower in chronic pain patients than in the control group, whereas the binding affinity was not significantly different.

Biochemical and morphological changes in Escherichia coli irradiated by coherent and non-coherent 632.8 nm light.

Irradiation of Escherichia coli cells with either coherent or non-coherent 632.8 nm light (4 J cm-2) causes a transient acceleration of cell proliferation, which is maximal about 60 min after the end of the phototreatment. The stimulatory effect is dose dependent and is especially evident in the case of defective E. coli strains which are in the logarithmic phase of growth, while it becomes less important when cells are exposed to non-coherent 600-700 nm light. Stimulated cells exhibit biochemical and morphological changes, such as an intensified synthesis of cytoplasmic membrane proteins, increased cell volume and ribosomal content, which are suggestive of an enhanced cell metabolism.

Variables of stimulation and placebo in acupuncture reflexotherapy.

Placebo can be defined as "the idea of recovery." It represents the natural impulse toward recovery that is catalyzed by treatment or even simply by the idea of treatment. Therefore, placebo is not an "active" treatment; it is used in scientific research to discriminate between the actual effect of a drug or therapeutic technique and the result of chance or the will to recover. Even though it is only an idea, placebo can cause improvement and recovery in approximately 30% of the subjects treated with any therapeutic program and for very different pathologies. Acute pathologies are more sensitive to placebo than chronic ones; functional disorders respond better than organic alterations, and so on. The main controversial issues in the methodology of acupuncture research are: placebo, double-blinding, and the intensity of stimulation of needles. The most used placebo method is sham acupuncture, which is the insertion of the needles outside acupuncture points. It is argued that this methodologically incorrect choice leads to studying the importance of the acupuncture point, rather than that of acupuncture as a transdermic stimulation technique.

[Acupuncture (dry needle) versus neural therapy (local anesthesia) in the treatment of benign back pain. Immediate and long-term results]. / Agopuntura (ago a secco) versus neuralterapia (anestetico locale) nella terapia delle lombalgie benigne. Risultati immediati e a distanza.

AIM: A retrospective study of benign low back pain, comparing the early and long-term results obtained by means of acupuncture and Huneke's neural-therapy is presented. METHODS: Two groups, (dry needling group and neural-therapy group) consisting of 104 and 152 patients respectively, were compared for age, pain duration, treatment length, number of sessions and initial intensity of the pain. RESULTS: The age and pain duration resulted significantly higher in the neural-therapy group; the percentage of subjective improvement proved to be greater for neural-therapy, even if not in a statistically significant manner, both immediately after therapy (70.4% and 74.8%) and at all the time intervals studied (every 3 months until 4 years, when possible). Similar results have been obtained both in acute cases (pain duration shorter than 6 weeks) and in chronic ones (pain lasting at least 6 months). CONCLUSION: In conclusion, this study shows a slight, but not statistically significant, preference for neural-therapy, subjectively considered by the patient more effective than acupuncture in 49 out of 51 comparisons carried out.

[Correlation between the number of sessions and therapeutical effect in patients suffering from low back pain treated with acupuncture: a randomized controlled blind study]. / Correlazione fra numero di sedute ed effetto terapeutico nel trattamento di pazienti affetti da dolore lombare sottoposti ad agopuntura. Studio randomizzato e controllato in cieco.

AIM: The aim of this study is to verify the therapeutical effect of acupuncture reflexotherapy in low back pain treatment and to test if the number of sessions could influence the results at the end of therapy. METHODS: Thirty-one patients, suffering from low back pain, were randomly divided into 2 groups: the first group (16 patients, 5 males and 11 females, mean age 57.17 +/- 13.06 years) received 5 weekly somatic acupuncture sessions; the second group (15 patients, 4 males and 11 females, mean age 49.36 +/- 11.98 years) underwent 10 weekly somatic acupuncture sessions. The acupoints used were the same in both groups. Pain was monitored by a daily self rating chart. Pain was recorded using a card filled in by the patient, every day. At the end of therapy, a remaining pain scored between 0% and 50% of original pain was considered a good result; unsatisfactory result was a pain between 51% and 80%; poor result a score of 81% or more of original pain. RESULTS: In the first group, 11 patients (68.75%) obtained a good result, 1 patient (6.25%) an unsatisfactory result and 4 patients (25%) a poor result. The remaining pain was 65.5% of the original pain (unsatisfactory result). In the second second group, 13 patients (86.66%) obtained a good result and 2 patients (13.33%) a poor result. The remaining pain was 43.9% of the original pain (good result). CONCLUSION: Ten sessions of acupuncture seem to gain a better therapeutical effect than 5 in the treatment of chronic low back pain.

[Proposed method for double-blind study of reflexotherapy phenomena]. / Proposta di un metodo per lo studio dei fenomeni riflessoterapici in "doppio cieco".

The Authors report their experience with the placebo, an essential step in the clinical study of reflexotherapy. They assert that also in this branch of medicine it is possible to carry out a "double blind" clinical experimentation by means of placebo, that is, an essential condition in order to develop a scientific assessment of both the limits and the potentialities of reflexotherapy.

Cerebral tryptophan metabolism in humans in relation to malignant pain.

The authors investigated the cerebral metabolism of tryptophan in patients suffering from malignant pain by means of CSF dosage of tryptophan (Trp), 5-hydroxytryptophan (5-HTP), serotonin (5-HT) and 5-hydroxyindoleacetic acid (5-HIAA). The level of 5-HIAA in patients with pain was 66.48 +/- 13.67 ng/ml, while in those without pain was 25.05 +/- 13.25 ng/ml; the difference was statistically significant, p = 0.001. Trp, 5-HTP and 5-HT levels did not register significant differences in the two groups of patients, although a tendency to lower values was seen in patients with pain, supporting the hypothesis of increased turnover of this metabolic pathway in cancer patients. A statistically significant inverse correlation was also found between cerebral Trp levels and pain levels measured on the Scott-Huskisson visual analogue scale. The data obtained confirm the importance of the cerebral serotoninergic pathway in pain modulation and the interest which CSF analysis may have for the assessment of patients suffering from pain.

Comparison study between acupuncture and pentazocine analgesic and respiratory post-operative effects.

The authors studied the effects of acupuncture and pentazocine on post-operative respiratory function and pain management on patients hysterectomized by means of a subumbilical midline incision. The acupunctural technique consisted of GB-26, St-36, Sp-6 and auricular Shen-Men bilateral electrostimulation for 40 minutes. The analgesic effect of acupuncture was equivalent to that of 30 mg pentazocine, yet the most important effect of acupuncture consisted in a net increase of vital capacity during the period of acupuncture analgesia that lasted for 3-4 hr after stimulation; contrariwise, pentazocine did not cause any vital capacity increment and vital capacity remained at the levels observed prior to narcotic administration.

Effects of deep vs. superficial stimulation of acupuncture on capsaicin-induced edema. A blind controlled study in rats.

The modality of needle stimulation in acupuncture is part of the concept of the ìintensityî of the stimulation, a variable indicating the ìdosageî of the treatment administered. In this study we intend to compare the effect of superficial and deep needle insertion in the leg ipsilateral or contralateral to the paw treated with capsaicin. Testing was carried out on 100 male Sprague-Dawley rats weighing 120-140 g, divided into 5 groups according to the treatment received. Group 1 [20 animals] was kept as control; Group 2 [20] received ipsilateral deep acupuncture stimulation; Group 3 [20] received ipsilateral superficial acupuncture stimulation; Group 4 [20] received contralateral deep acupuncture stimulation; Group 5 [20] received superficial contralateral acupuncture stimulation. Results show that both acupuncture modalities are efficient when administered ipsilaterally to the paw where capsaicin is injected, while contralaterally only deep stimulation shows a certain efficiency. It is possible to conclude that deep insertion has a greater efficiency, probably because it affects a greater number of receptors; stimulation is therefore of an intensity greater than that seen in superficial insertion.