Immunologic profile of patients with fibromyalgia.

Fibromyalgia is a musculoskeletal disorder characterized by generalized myalgias, arthralgias widespread tender points in discreet areas on examination. It is frequently accompanied by fatigue, stiffness, and a nonrestorative sleep pattern. These patients generally have a normal blood count and chemistry profile. There is a subset of people with fibromyalgia (FM) who test positive for the antinuclear antibody (ANA) and have constitutional symptoms that resemble those of patients with early lupus. We studied the immunologic profile of patients with FM who are ANA-positive (+). A retrospective review of patient records in a university-based rheumatology practice was conducted. In a group of 66 FM patients, 30% (20) were ANA+, with a 75% preponderance of the speckled pattern and 20% diffuse pattern. The remaining 5% were equally split between diffuse-speckled and speckled-nucleolar patterns. All had negative staining for extractable nuclear antibodies. The Smart Index (SI), a ratio of the sedimentation rate to one-half the patient's age, was developed to characterize each patient's inflammatory response. The FM patients who were ANA negative (-) had a mean SI of 0.55, whereas the FM patient's who were ANA+ had a SI of 1.07. These ANA+ patients represent a subgroup of patients who have FM with an inflammatory response profile larger than that of the ANA-patients.

Post-traumatic fibromyalgia. A long-term follow-up.

This report describes a follow-up study of 176 individuals seen between 1980 and 1990, in whom a diagnosis of post-traumatic fibromyalgia was made. Sixty-seven people completed a lengthy questionnaire and underwent a confirmatory physical examination using the American College of Rheumatology Criteria to confirm or deny the presence of fibromyalgia at the time of follow-up. A total of 60.7% noted the onset of symptoms after a motor vehicle accident, 12.5% after a work injury, 7.1% after surgery, 5.4% after a sports-related injury and 14.3% after other various traumatic events. Fifty-six of 67 individuals had 11 or more tenderpoints (average, 13.5), 3 had 10 tenderpoints, and 7 had fewer than 10 or no tenderpoints. Study subjects were asked to compare the use of the following for the first 2 yr after onset as well as the year preceding the current evaluation: biofeedback, medications, physical therapy, manipulation, massage therapy and tenderpoint injections. In addition, we asked detailed questions regarding symptoms commonly seen in association with fibromyalgia (fatigue, sleep disturbance, etc.). Symptoms of traumatically induced fibromyalgia are quite similar to spontaneous fibromyalgia. There was a dramatic reduction in the use of all forms of physical treatments. Fifty-four percent continued to use over-the-counter pain medications, and 39% were on antidepressants. Eighty-five percent of the patients continued to have significant symptoms and clinical evidence of fibromyalgia.

A profile of fibromyalgia in occupational environments.

The effect of the occupational environment on fibromyalgic patients has not been well studied. Individuals (321) from across the United States completed a questionnaire regarding effects of their current and past occupations on their fibromyalgia. Occupations with a high percentage of responders were general office workers (20%), health care providers (14%) and educators (11%). Of the respondents, 8% were unemployed. Activities reported to aggravate the symptoms of fibromyalgia were computer or typing (37%), prolonged sitting (37%), prolonged standing and walking (27%), stress (21%), heavy lifting and bending (19%) and repeated moving and lifting (18%). Activities that did not appear to exacerbate the symptoms of fibromyalgia included walking (19%), variable light sedentary work (15%), teaching (8%), light desk work (6%) and phone work (6%). Patients with fibromyalgia report that they do not tolerate prolonged, repetitive activities, maintaining any one position for sustained periods of time and jobs with high stress. Light sedentary occupations that allow varied tasks and changing positions appear to be tolerated the best.

Fibromyalgia syndrome. New associations.

Previous research has demonstrated a number of conditions, such as sleep disturbance, fatigue, depression, spastic colon and mitral valve prolapse, associated with fibromyalgia. The present report describes additional symptoms and medical conditions that appear to be associated with the syndrome based on a survey of 554 individuals with fibromyalgia compared with a group of 169 controls. Individuals with fibromyalgia self report a greater incidence of bursitis, chondromalacia, constipation, diarrhea, temporomandibular joint dysfunction, vertigo, sinus and thyroid problems. Symptomatic complaints found statistically more prevalent in fibromyalgia patients included concentration problems, sensory symptoms, swollen glands and tinnitus. Other associations occurring with significant increased frequency were chronic cough, coccygeal and pelvic pain, tachycardia and weakness. Our previous report on inheritance patterns in fibromyalgia was reaffirmed with 12% reporting symptomatic children and 25% reporting symptomatic parents. Of the respondents, 70% noted that their symptoms were aggravated by noise, lights, stress, posture and weather.

Wrist flexion as an adjunct to the diagnosis of carpal tunnel syndrome.

The effects of five minutes of wrist flexion on median motor and sensory evoked potential latencies in 87 individuals were studied. Nineteen subjects had carpal tunnel syndrome (CTS) as diagnosed by increased median nerve latencies across the wrist, and 68 had values in the normal range and were assigned to the control group. A slight prolongation of up to 0.5m sec of evoked potential latencies was observed in both groups after flexion, but the differences between the two groups were not significant to establish the value of adding wrist flexion to conventional screening methods.

Prevalence of mitral valve prolapse in primary fibromyalgia: a pilot investigation.

Fifty patients with primary fibromyalgia and a negative cardiovascular symptom history underwent echocardiography to determine the prevalence of mitral valve prolapse (MVP). The mean age of the population was 40 +/- 13 years (14 men, 36 women). Mitral valve prolapse was detected in 75%; 33% with myxomatous mitral valve leaflets. The prevalence of MVP in this population is significantly higher (p less than 0.0001) than in the general population. Primary fibromyalgia and MVP may be part of a more generalized connective tissue abnormality characterized by distinct genetically determined variants.

Familial occurrence of primary fibromyalgia.

Seventeen families of patients with primary fibromyalgia were studied for evidence of inherited primary fibromyalgia. Fifty parents and siblings were included in the analysis. Twenty-six (52%, mean age 33.5 years) had characteristic symptoms and findings of primary fibromyalgia. Eleven (22%, mean age 28 years) were asymptomatic but had clinical evidence of abnormal muscle consistency to palpation without tender or trigger points. One person had clinical evidence of lupus. Thirteen (26%) had no evidence of fibromyalgia or abnormal muscle consistency. The mode of inheritance was autosomal dominant. Identical twins are described who developed symptoms of primary fibromyalgia within six months of each other, as are two brothers who developed abnormal palpable muscle consistency years before acquiring the characteristic findings of the fibromyalgia syndrome. Primary fibromyalgia may be an inherited condition with a variable latent stage before clinical expression of the disease.

Chronic myofascial pain: management by low-output helium-neon laser therapy.

Therapeutic benefits of low-output helium-neon laser therapy have not been established, but laser therapy has been suggested as an effective means of treating many acute and chronic musculoskeletal pain syndromes. Although not released for general clinical use by the FA, the helium-neon laser has been promoted to physical therapists and athletic trainers as potentially useful for the treatment of pain syndromes. In particular, it has been proposed that it may be more effective than conventional measures such as medication and conventional physical therapy in the treatment of myofascial pain syndromes (fibrositis, fibromyalgia). The citations in the literature include only case reports. Sixty-two patients were treated by using acupuncture points. Two sessions of five treatments were given six weeks apart. A crossover double-blind technique was used in the treatments. The clinical responses were assessed using portions of the McGill Pain Questionnaire. No statistical difference between the treatment and the placebo groups could be determined.

Inversion devices: their role in producing lumbar distraction.

Twenty persons with chronic low back pain participated in a clinical study to evaluate the effects of gravity traction. Each subject was instructed in the use of three devices, two for inversion and one for upright suspension traction. Baseline pulse and rate blood pressure were recorded before and after traction. Periods of traction did not exceed 20 minutes. The order of use of the devices was randomized. Each participant was monitored for significant side effects and was questioned to determine which device was best tolerated, easiest to use, or caused changes in back symptoms. Lateral lumbar spine radiographs were taken with the subject in the standing position and after varying periods of inversion. Observations included the following: An average increase in blood pressure of 17.2 systolic (range 4-34) and 16.4 diastolic (range 2-50) while in the inverted position. An average decrease in heart rate of 16.4 beats per minute (range, 4-32). No significant physiologic changes of blood pressure or pulse were observed in patients using GLR suspension traction; distraction of the lower lumbar intervertebral spaces (range, 0.3 to 4.0 mm) with inverted traction in all cases; side effects including periorbital and pharyngeal petechiae (one patient), persistent headaches (three patients), persistent blurred vision (three patients), and contact lense discomfort (one patient); and improvement of low back symptoms in 13 of the 16 symptomatic patients. Although these devices make lumbar traction practical in a home setting, their use should be under medical supervision because of possible side effects.

Home cervical traction: evaluation of alternate equipment.

Overhead intermittent cervical traction is often utilized to control the symptoms of cervical radiculopathy associated with osteoarthritis. The long-term home use of presently available counterweight systems has often presented problems including: (1) lack of patient compliance, (2) difficulty with application by elderly or debilitated patients, (3) tensing of both the cervical paraspinalis and upper extremity muscles while maneuvering the counterweights, and (4) discomfort while using the device. A prototype home pneumatic traction device was developed, which has many of the advantages of the expensive hydraulic units in common use in physical therapy departments. The initial favorable responses of 17 patients led to the development of a prototype commercial unit in cooperation with the Jobst Company. Of 36 patients who used the pneumatic traction device at home, 29 (81%) preferred it to the conventional counterweight system. Typical reasons were that it was easier to use, more "workable" and provided a steadier pull with more gradual onset of traction. Disadvantages most commonly mentioned were minor air pressure loss in the hand pump model and the complexity of the unit. The most rational approach to the use of these new pneumatic devices would be to initiate a home traction program using conventional counterweight units and then to switch to the pneumatic unit for long-term patients or those who are unable to apply conventional traction systems unassisted.

Effect of tourniquet time on postoperative quadriceps function.

Postoperative weakness of quadriceps function following knee arthrotomy has often been attributed to pain inhibition or lack of motivation. However, the delayed recovery may be the result of a slowly resolving axonal compression syndrome caused by the pneumatic tourniquet. Forty-eight patients who underwent knee arthrotomy were evaluated including postoperative electromyographic testing and clinical follow-up. Thirty of these patients (62.5%) developed postoperative EMG changes. Abnormalities were noted in various muscle groups but most commonly involved the quadriceps alone or quadriceps and gastrocnemius. An effort was made in 20 patients to substantially decrease the duration of tourniquet compression by limiting tourniquet inflation to intracapsular portions of the procedures. Fewer EMG changes and more rapid clinical recovery were noted in patients with decreased tourniquet times, suggesting that it is beneficial to minimize the duration of tourniquet compression. In all patients who returned for serial testing, the EMG abnormalities eventually resolved.

Electromyographic changes in postmeniscectomy patients. Role of the pneumatic tourniquet.

Delayed rehabilitation in postmeniscectomy patients may be due to a slowly resolving axonal compression syndrome secondary to the use of the pneumatic tourniquet. Twenty-five patients who underwent meniscectomy were examined to determine whether the pneumatic tourniquet used during the procedure caused a neurological dificit detectable by electromyography (EMG). Of these, 18 had postsurgical EMG changes that eventually resolved. Analysis of the data suggests a relationship between the occurrence of EMG abnormalities, the duration of the tourniquet inflation during surgery, and patient's recovery time. Quadricep muscle weakness after knee surgery has generally been attributed to disuse atrophy. In an attempt to prevent this problem, patients participate in a quadriceps exercise program, if possible, before surgery, with continuation after surgery. The persistence of weakness has been believed to be secondary to inadequate exercise.

Durability of monopolar Teflon-coated electromyographic needles.

The results of a two-year study on durability and cause of failure of electromyographic monopolar electrodes are reported. The electrodes were obtained from the regular stock of three different manufacturing sources. Durability is defined on the basis of the number of patients that could be examined before failure. The range was 3 to 110 with the averages 19.7, 33.8, and 62.5 for the three different manufacturers. Common causes of electrode failure included: Teflon retraction, 40.6%; tip dullness or burrs, 34.8%; structural failure of wire or pin, 13.1%; electrical artifacts, 9.7%; and bending of needle shank, 5.7%. Variations in manufactures' tip contour and bevel correlated with tip durability.

Polyneuropathy due to n-hexane.

In 25 years, at least eight of 50 total exposed employees in a small plant developed a mild neuropathy. Studies of urine or blood for lead, arsenic, mercury, cadmium, thallium, and antimony revealed no sign of toxic agents, but the atmosphere in one room contained toxic levels of n-hexane. The sourse was the glue used in the plant. Serum cholinesterase levels were reduced, offering a possible laboratory tests to alert clinicians to the possibility of n-hexane exposure. All patients recovered completely. Mechanical and administrative adjustments should prevent such industrial accidents.

Subcutaneous electrical stimulation (acupuncture) in the clinical practice of physical medicine.

There has been a rapid growth in both interest and concern over the value of acupuncture in this country during the last three years. Initially it was regarded with doubt, then with overwhelming interest, but only recently have any research data appeared as to its true value and applicability to western medicine. An acupuncture research project was initiated in November 1972 by the author to assess the immediate and long-range benefits of acupuncture in a group of 179 patients with various neuromuscular-skeletal pain and mobility problems. A total of 1,112 treatments have been administered. A follow-up survey of these patients was completed in October 1974 with 126 (70%) of the patients responding to a subjective questionnaire. In 49% of the patients the initial response to acupuncture treatments was some reduction of symptoms and in a significant percentage there was persistence of beneficial response for greater than three months.

Acupuncture effect on neurosensory deafness.

Bilateral neurosensory deafness offers a unique opportunity to study the effects of acupuncture objectively. By treating only one ear, and using audiometric evaluation techniques instead of subjective evaluations of hearing, an analysis of any achieved improvement seemed feasible. Only patients with well documented bilateral nerve deafness were accepted into the program. A baseline audiogram with speech discrimination and puretone air and bone conduction thresholds was obtained prior to treatment. Thirty-eight patients underwent ten consecutive acupuncture treatments on one ear only, with the other ear serving as a control. After the course of acupuncture, the audiometrics were repeated by the same audiologist. There was no significant increase in hearing after acupuncture therapy.

Paraspinal electromyographic abnormalities as a predictor of occult metastatic carcinoma.

Profound membrane irritability localized primarily to the paraspinal muscles was the major electromyographic criterion proposed by LaBan and associates to predict the early presence and localization of spinal metastatic disease. A retrospective review was recently conducted to determine the accuracy of this interpretation and the effect of the electromyographic report on the attending physician's subsequent workup. In an analysis of 1800 electromyograms at Riverside Hospital, 91 cases were found which met the following criteria: (1) three or more paraspinal segments involved, (2) little or no membrane irritability in the anterior rami, and (3) no previous surgery on the paraspinal area. The proven discharge diagnoses were carcinoma in 24%, herniated nucleus pulposus in 28%, degenerative disc disease in 16%, diabetes mellitus in 9% and miscellaneous in 8%; in 15% no diagnosis could be made. We were unable to differentiate some cases of herniated nucleus pulposus from carcinoma using such criteria as profoundness of levels or number of spinal segments involved. There are partial explanations of why only paraspinal segments may be involved with profound changes in the diseases mentioned, but no explanation for the widespred involvement in localized disease such as a herniated disc. At our hospital it was interesting to note that internists infrequently order myelography or cerebrospinal fluid analysis while orthopedists, neurosurgeons and neurologists rarely order metastatic surveys.