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Fibromyalgia

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Prevalence and treatment outcome of primary and secondary fibromyalgia in patients with spinal pain.

Author

Borenstein D

Address

Division of Rheumatology, George Washington University Medical Center, Washington, D.C., USA.

Source

Spine, 20: 7, 1995 Apr 1, 796-800

Abstract

STUDY DESIGN. This was a prospective cohort study. OBJECTIVES. To determine the prevalence of primary and secondary fibromylagia and response to therapy in patients with spinal pain over a 12-month period. SUMMARY OF BACKGROUND DATA. Fibromyalgia is a syndrome characterized by generalized pain and widespread tenderness on palpation in specific areas of the musculoskeletal system, including the cervical and lumbosacral spine. Primary fibromylagia is idiopathic, whereas secondary fibromyalgia occurs in association with underlying disorders such as ankylosing spondylitis, trauma, or surgery. The frequency of fibromyalgia in patients with spinal pain has not been determined. METHODS. One-hundred-twenty-five consecutive patients referred to a rheumatologist in a spine center for evaluation of back pain over a 4-month period were evaluated for fibromylagia. Diagnosis at the time of referral and referring physician were recorded. Fifteen patients, six with primary fibromyalgia and nine with secondary fibromyalgia, were identified and followed for 12 months. Standardized therapy was offered to all patients with fibromyalgia. Patients with secondary fibromyalgia also received therapy for their underlying condition. RESULTS. At 12 months, the six patients with primary fibromyalgia had an improvement in symptoms. The treatment outcome for the nine patients with secondary fibromyalgia was less successful. CONCLUSIONS. Fibromyalgia is a disorder that occurs in a small proportion of patients with back pain. Fibromyalgia is not frequently recognized by referring physicians. In the authors' limited experience, patients with primary fibromyalgia appear to improve with conservative care. They have been less successful with those diagnosed as having secondary fibromyalgia.

Fibromylagia Abstracts Presented at the Annual Meeting American College of Rheumatology
and Association of Rheumatology Health Professionals October 18-22, 1996 - Orlando, Florida

386
FIBROMYALGIA IN SLE M. Petri, J. Steckroth, Johns Hopkins University, Baltimore, MD.
Past studies have suggested that fibrornyalgia (FM) is much more common in SLE than in the general population. We determined the prevalence of FM in a large cohort of SLE patients (pts) and associations with other clinical and laboratory variables. Patients/Methods: 169 SLE pts (93% female, 55% Afro-American, mean age 39.1 plus or minus 13.1 years) were examined for FM, defined using ACR criteria, by one observer. Clinical and laboratory variables were ascertained from a cumulative cohort database. Results: 29.6% had I I or more tender points (TP). The mean # of TP was 4.6 ± 5.8. Tender points increased with age (p= 0.002). Race and gender were not associated with the number of TP. Non-high school graduates had more TP (p = 0.03) as did pts with disability (p = 0.06). The following clinical variables were associated with TP. lack of livedo reticularis (p = 0.08), depression (p = 0.03), lack of anemia (p = 0.01), Sjogren's (p = 0.048), mouth ulcers (p = 0.07), and pancreatitis (p = 0.03). The following laboratoryvariables were associated with the number of TP: normal anti-DNA (p 0.08), normal C3 (p = 0.08), normal C4 (p = 0.006), normal ESR (p = 0.08). FM TP were not associated with myositis or prednisone use, but there was a borderline association with hydroxychloroquine use (p = 0.08).

Conclusion: Fibromyalgia in SLE is extremely common. It is strongly associated with the LACK of serologic or laboratory abnormalities. It does not appear to represent a subdinlical myositis or drug myopathy, although the borderline association with hydroxychloroquine use deserves further study.

387
A RANDOMIZED, CONTROLLED TRIAL OF EXERCISE AND EDUCATION IN FIBROMYALGIA. Susan Gowans, Susan Voss, Amy deHueck, and Mary Richardson, Physiotherapy and Occupational Therapy Departments, The Toronto Hospital, 200 Elizabeth Street, Toronto, Ontario, Canada, M5G 2C4 & The Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada.

Fibromyalgia affects 2 to 4% of the population and is associated with significant disability. Although exercise is the leading nonpharmacological treatment for fibromyalgia, evidence for the efficacy of exercise in this population is limited. This study evaluates the effect of an exercise and educational program for fibromyalgia, with 41 patients who met the American College of Rheumatology (1990) criteria for fibromyalgia. The 6 week program consisted of moderately-intense aquafit classes (30 min, 2 times/week) and multidisciplinary group education (2 times/week). The study was divided into 2 phases. In phase 1, subjects were randomly assigned to the fibromyalgia program (n=20) or became wafting list controls for 6 weeks (n=21). Subjects were assessed at baseline and 6 weeks. In phase 2, waiting list controls entered the 6 week program and were assessed post program. In addition, all subjects were assessed 3 or 6 months post program. Outcome was assessed with a 6 minute walk test, the Fibromyalgia Impact Questionnaire (FIQ), the Arthritis Self-Efficacy Scale and a questionnaire on knowledge of fibromyalgia management. The program produced immediate improvements (p < .05) in 6 min walk distance(326 m vs 412 m), knowledge, well-being (a FIQ subscale) and fatigue (another FIQ subscale). These measures were unchanged in waiting list controls. Immediate gains in 6 min walk distance, and well being were maintained at 3 or 6 month follow-up. Thus, short-term exercise and educational programs can improve physical function and a variety of psychometric measures in fibromyalgia. Further studies are in progress to determine the effect of exercise alone on physical function and mood.

394

COSTS INCURRED IN WOMEN WITH FIBROMYALGIA SYNDROME (FMS). Mary Ann Fitzcharles, Helen Assimakopoulos, Hanna Zowall, John M. Esdai1e. and Ann E. Clarke, McGill University, Montreal, Quebec, Canada H3A IA 1.

Background: FMS, one of the commonest reasons for consultation to a rheumatologist, may affect up to 2% of the population. The direct, i.e. all resources consumed in patient care, and indirect costs, i.e. wages loss due to lack of work force participation because of morbidity, have never been evaluated.

Aim: To determine the direct and indirect costs incurred by 82 consecutive FMS patients.

Patients & Methods: Patients reported their health services utilization and employment history over the preceding 6 months. Ambulatory costs included health care providers, diagnostic/laboratory procedures, and emergency room visits and were calculated using fully allocated costs, i.e. a method by which the resources of overhead hospital departments are assigned to the service centre. Indirect costs represent lost income for wage earners and domestic labour wages on days non-wage earners were unable to attend to household responsibilities.

Results: The mean total annual cost per patient, expressed in 1994 dollars, was $6098. Mean annual direct cost was $1435 ($1168 for health care providers, $173 for diagnostic/laboratory procedures, and $94 for emergency room visits). Mean annual indirect cost was $4663. On average, FMS patients made 18 visits to a physician annually, exceeding the known average by 3-fold. Patients had few hospitalizations (2) and outpatient surgeries (6).

Conclusiona The direct and indirect costs of FMS are substantial for both the individual and society.

653

THE ASSOCIATION OF SOFT TISSUE RHEUMATISM AND HYPERMOBILITY - A NEW CONCEPT. N. Hudson, M.-A.Fltzcharles, M. Cohen, M. Starr and J.M. Esdaile. McGill University, Montreal, Canada.

Background : Soft tissue rheumatism (STR - tendinitis, bursitis, fasciitis and fibromyalgia) accounts for 30% of referrals to rheumatologists. The estimated prevalence of generalised hypermobility in the adult population is 5-15%.

Objective :This study was designed to examine mobility status and physical activity level in patients with STR.

Methods : All consecutive rheumatology clinic attendees with a primary diagnosis of STR were screened for (i) mobility status and (ii) history of rheumatic complaints and current physical activity level; each done by an observer blind to the clinical diagnosis. Generalised hypermobility was defined according to the Beighton and Bulbena criteria.

Results : Of 82 patients up to age 70 with STR, 29 (35%) met criteria for generalised hypermobility. Hypermobile patients (n=29) were younger (44 yrs vs 52 yrs; p=0.006) than non-hypermobiles (n=53), and more were females (93% vs 85%; p= n.s.)

Hypermobile compared to non-hypermobile individuals reported significantly more previous episodes of STR (90% vs 51%, p < 0.01), and more recurrent episodes of STR at a single site (69% vs 38%, p<0.001)- Although we were unable to show any differenoe in the time spent doing physical activity between the two groups, the hypermobile patients were doing significantly more repetitive activities. When specific anatomic sites of STR were analysed, small joints (elbows, hands and feet) currently affected with STR were more likely to show localised hypermobility than if those joints were asymptomatic.

Conclusion : These findings suggest that hypermobility may be a factor in the development of STR. Repetitive activity may be a contributing factor towards STR in some hypermobile individuals.

1110

The London Fibromyalgia Epidemiology Study: The Prevalence of Fibromyalgia (FMS) in London, Ontario. K. White, M. Speechley, M. Harth,T. Ostbve UWO, London, Ontario N6A 5A5

Objective: To estimate the prevalence of FMS among non institutionalized adult males (M) and females (F) in London.

Methods: A random-digit dialing telephone survey was undertaken to screen for chronic widespread pain and fatigue over the previous 3 months, randomly interviewing 1 adult per household, using a prevalidated screening instrument. Subjects with chronic widespread pain were examined by a rheumatologist at University Hospital to confirm or exclude FMS using the 1990 A.C.R. criteria. Results: We contacted 4674 eligible adults; 3395 (72.6%) agreed to be interviewed. Recalling the previous 3 months, 34.8% reported some musculoskeletal pain lasting at least I week, 6.5% chronic widespread pain, 54.5% frequent fatigue, and 21.5% frequent fatigue that significantly limited activities. Of 221 with widespread chronic pain, 176 (79.6%) agreed to be examined. FMS was confirmed in 100 (86 F), who had a mean age of 47.8 years (C.I. 45.0, 50.6). The age-adjusted overall point prevalence of FMS was 4.2% in F and 1.1% In M, for a F:M prevalence ratio of 3.8:1. In both sexes, prevalence steadily increased with age until age 64, peaking at 8.9% in F age 50-64, and at 2.1% in M age 50-64. In both sexes, prevalence decreased sharply after age 64; no M cases over age 64 were identified.

PREVALENCE OF FMS (with 95% confidence intervals [CI])

Age Males Females Combined
8-34 1.1% (0.8, 1.5) 1.5% (1.3, 1.8) 1.3% (1.2, 1.5)
35-49 1.1% (0.6, 1.7) 5.4% (5.1, 5.7) 3.7% (3.5, 3.9)
50-64 2.1% (1.3, 3.4) 8.9% (8.3, 9.5) 6.3% (5.9, 6.7)
65+ 0.0% (0.0, 2.0) 3.6% (3.1, 4.2) 2.6% (2.2, 3.0)
TOTAL 1.1% (0.9, 1.2) 4.2% (4.1, 4.3) 2.7% (2.6, 2.8)

VERY HIGH RATES OF SERVICE UTILIZATION IN FIBROMYALGIA PRE AND
POST DIAGNOSIS. F Wolfe, RM Bennett, X Caro, DL Goldenberg, IJ Russell & MB Yunus. Wichita, Portland, Los Angeles, Boston, San Antonio and Peoria, USA.

It is suspected that utilization of services (UOS) may be increased in fibromyalgia (FIB), be that utilization may fall post diagnosis. Yet almost no data are available. Over a 7 year period we monitored UOS for 1190 fibromyalgia patients from 7 centers by a mailed questionnaire administered at 6 month intervals. Participant number varied by center, and data were inversely weighted by center N so that each center contributed equally to the study results. Data are average utilization over the study period, and reflect utilization after diagnosis by the rheumatology center.

Patients averaged 11.4 outpatient medical visits per year of which 1.9 were to rheumatologists. In addition, there were 2.9 non-traditional medical visits, 1.5 imaging procedures, 3 laboratory tests, and 0.35 hospitalizations per year. 23.2% of hospitalizations were for pain and neuro-musculo-skeletal reasons. The next common causes were GU (11.3%). GI (11.2%), CV (8.6%) and depression (5%). At the Wichita center where a comparison rheumatic disease population was available (N=9,822) lifetime rates of surgical procedures were increased compared to RD controls: odds ratios & 95% CI for back or neck surgery 2.9 (2.3, 3.7), appendectomy 2.7 (1.6, 4.5), carpal tunnel 2.6 (1.5, 4.5), bladder 1.9 (1.5. 2.6), abdominal 1.7 (1.6, 1.9), and tonsillectomy (1.3 (I.2, 1.5).

At study end. 57.8% were taking NSAIDS, 19.2% ASA. and 28.9% acetaminophen. .4% were on narcotics, but for an average of 1.1 months out of the last 6 months. GI medications were used by 22%, tri-cyclics by 35.9%, S2 blockers by 12.8%. Reported lifetime comorbid conditions included depression 55.9%, GI disease 55.9%, GU 53.7%, severe allergies 48.8%, hypertension 39.0%. These data indicate very high rates of current and lifetime utilization of services by fibromyalgia patients, and that utilization continues after diagnosis.. The broad UOS suggest a somatization disorder component and increased rates for childhood tonsillectomy may reflect learned behaviors.

151
PATIENTS WITH CHRONIC FATIGUE SYNDROME (CFS) AND SILICONE-ASSOCIATED ILLNESS (SAI) ARE SIMILARLY DISABLED : Henry Y. Chow, Joseph M. Cash, Leonard H. Calabrese, William S. Wilke
We prospectively studied two patient populations: 80 patients who met criteria for chronic fatigue syndrome (CFS) and 76 patients with silicone associated illness (SAI). All patients were evaluated using identical instruments by the authors and were found to be very similar with regard to the frequency of symptoms of CFS, symptoms of fibromyalgia syndrome, mean depressive symptoms and laboratory measures (Arthritis Rheum 38:S264, 1995). Here we evaluated and compared disability between these patient populations.

Methods: Patients were asked to complete a self-administered 100 point descriptive disability scale and the visual analogue subscales of the Fibromyalgia Impact Questionnaire (FIQ) (J Rheumatol 18:728-233, 1991).

Results: No statistical differences were discovered when the data were analyzed using the T-test method. Both populations scored disability levels which correspond to moderate symptoms at rest with activity level reduced to 50-90%of expected.

In addition, no between group differences were seen when the visual analogue subscales of the FIQ were compared. Both groups were similar with regard to the degree of fatigue, pain, tiredness, morning fatigue, stiffness, nervousness and depression, in agreement with our previous findings. Conclusion: In addition to the marked clinical similarities previously demonstrated, patients with CFS and SAI share equal levels of self-perceived disability.

380
DECREASED OLFACTORY PERFORMANCE IN PATIENTS WITH FIBROMYALGIA IN THE PRESENCE OF AN INCREASED ESTIMATION OF SUBJECTIVE SENSIBILITY.

Jorg Wendler, Thomas Hummel, Oliver Kramer, Hans-Georg Kraetchamp, Joachim R. Kalden, Gerd Kobal, Dept of Medicine 111, 213ept. of Pharmacology, University of Erlangen-Nurmberg, 91054 Erlangen, Germany.

Beside pain and increased sensibility to pain stimuli many patients with fibromyalgia (FM) complain of hypersensibility of other sensory systems like phonophobia, photophobia, or olfactory hypersensibility. Thus, olfactory performance of 17 FM patients was tested and compared with age and sex matched healthy controls. Before testing all subjects were asked to rate their own olfactory capability on a 3-point wale (1=1ess than average, 2=normal, 3=above average). Subsequently, a total of three psychophysical tests was performed, namely tests for odor threshold (n-butanol), odor discrimination (16 pairs of odorants), and odor identification (16 common odorants). In addition. subjects rated both intensity and hedonic tone of 5 selected odorants.

FM patients rated their own offactory capabilities slightly higher than healthy controls (FM patients: M=2.59, SD=0.62; controls: M=2.27, SD=059). On average FM patients estimated the selected 5 odorants to be more intense than healthy controls. However, these changes did not reach the level of statistical significance. In contrast to the subjective judgement of olfactory sensitivity, in the odor identification task FM patients performed significantly worse compared to healthy controls (p=0.05). This was accompanied by both an increase of mean thresholds for n-butanol and a decrease of mean odor discrimination. These changes were not related to clinical symptoms of FM (duration of disease, rating of severity of symptoms) as indicated by non-significant coefficients of correlations. Regarding the pathogenesis of FM these results support the hypothesis that a disturbed perception of sensory input leads to various sensory hypersensibilities.

381
DEVELOPMENT OF A LABORATORY MARKER FOR FIBROMYALGIA. Oscar S. Gluck and John R.P. Tesser, Arizona Rheumatology Center, Phoenix, AZ 85015; Scott A. Tenenbaum, Janet Rice, David M. Sander, Douglas R. Plymale and Robert F. Garry, Tulane University School of Medicine., New Orleans, LA 70112; Russell B. Wilson, Autoimmune Technologies, LLC, New Odeans, LA 70112.

In a previous blinded single-center clinical trial, 68% of silicone breast implant (SBI) exposed Individuals experiencing advanced signs and symptoms of non-classical autoimmune disease were reactive on an assay that detects serum antibodies to polymeric substances, the Anti-Polymer Antibody (APA) test. 43% of SBI exposed individuals experiencing moderate disease were seroreactive on the APA test, and only 3% of individuals experiencing limited symptoms were seroreactive. Because of the similarity of symptoms between symptomatic SBI patients and fibromyalgia patients, fibromyalgia patients were tested for APA seroreactivity. Sera from patients meeting the ACR criteria for fibromyalgia (n=48). osteoarthritis patients (n=16), and rheumatoid arthritis patients (n=14) were blinded and then submitted for analysis. Patients with silicone implants of any kind and patients with other autoimmune conditions such as lupus and scleroderma were excluded from the study. Following analysis, seroreactivity was found to be significantly higher in fibromyalgia patients (48%) as compared with osteoarthritis patients (19%; P < 0.025) or rheumatoid arthritis patients (7%; < 0.005). These results clearly suggest that serum antibodies to polymeric substances as detected by the APA test may be a useful marker In the diagnosis of fibromyalgia and other related conditions. This study will serve as the pilot for a multi-center study.

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