Showing posts with label fibromyalgia. Show all posts
Showing posts with label fibromyalgia. Show all posts

Tuesday, October 24, 2017

October Series From HCV Advocate - HCV and Peripheral Neuropathy

New Online: HCV-related diseases

In October, HCV Advocate launched a series of patient-friendly articles about the Extrahepatic Manifestations of Hepatitis C, written by Alan Franciscus.

Browse through topics provided below, make sure not to miss new articles published later this month, sign up here to receive updates, follow HCV Advocate on Twitter or connect on Facebook. Find out what's new, here!

Begin with HCV Advocates Extrahepatic Manifestation Glossary and Fact Sheets.

October Blog Special
Extrahepatic Manifestations of Hepatitis C—Peripheral Neuropathy | Alan Franciscus
October 24, 2017
In the past, peripheral neuropathy was believed to be confined to people only infected with hepatitis C-related cryoglobulinemia, but now it is known that peripheral neuropathy may occur even in the absence of cryoglobulinemia.
Continue reading (LINK)

Tuesday, July 30, 2013

Study finds evidence of nerve damage in around half of fibromyalgia patients

Study finds evidence of nerve damage in around half of fibromyalgia patients

Small study could lead to identification of treatable diseases for some with chronic pain syndrome

About half of a small group of patients with fibromyalgia – a common syndrome that causes chronic pain and other symptoms – was found to have damage to nerve fibers in their skin and other evidence of a disease called small-fiber polyneuropathy (SFPN).

Unlike fibromyalgia, which has had no known causes and few effective treatments, SFPN has a clear pathology and is known to be caused by specific medical conditions, some of which can be treated and sometimes cured. The study from Massachusetts General Hospital (MGH) researchers will appear in the journal Pain and has been released online.

"This provides some of the first objective evidence of a mechanism behind some cases of fibromyalgia, and identifying an underlying cause is the first step towards finding better treatments," says Anne Louise Oaklander, MD, PhD, director of the Nerve Injury Unit in the MGH Department of Neurology and corresponding author of the Pain paper.

The term fibromyalgia describes a set of symptoms – including chronic widespread pain, increased sensitivity to pressure, and fatigue – that is believed to affect 1 to 5 percent of individuals in Western countries, more frequently women. While a diagnosis of fibromyalgia has been recognized by the National Institutes of Health and the American College of Rheumatology, its biologic basis has remained unknown. Fibromyalgia shares many symptoms with SFPN, a recognized cause of chronic widespread pain for which there are accepted, objective tests.

Designed to investigate possible connections between the two conditions, the current study enrolled 27 adult patients with fibromyalgia diagnoses and 30 healthy volunteers. Participants went through a battery of tests used to diagnose SFPN, including assessments of neuropathy based on a physical examination and responses to a questionnaire, skin biopsies to evaluate the number of nerve fibers in their lower legs, and tests of autonomic functions such as heart rate, blood pressure and sweating.

The questionnaires, exam assessments, and skin biopsies all found significant levels of neuropathy in the fibromyalgia patients but not in the control group. Of the 27 fibromyalgia patients, 13 had a marked reduction in nerve fiber density, abnormal autonomic function tests or both, indicating the presence of SFPN. Participants who met criteria for SFPN also underwent blood tests for known causes of the disorder, and while none of them had results suggestive of diabetes, a common cause of SFPN, two were found to have hepatitis C virus infection, which can be successfully treated, and more than half had evidence of some type of immune system dysfunction.

"Until now, there has been no good idea about what causes fibromyalgia, but now we have evidence for some but not all patients. Fibromyalgia is too complex for a 'one size fits all' explanation," says Oaklander, an associate professor of Neurology at Harvard Medical School. "The next step of independent confirmation of our findings from other laboratories is already happening, and we also need to follow those patients who didn't meet SFPN criteria to see if we can find other causes. Helping any of these people receive definitive diagnoses and better treatment would be a great accomplishment."

Source: Massachusetts General Hospital

Posted July 23 - Faster, simpler diagnosis for fibromyalgia may be on the horizon

Tuesday, July 23, 2013

Faster, simpler diagnosis for fibromyalgia may be on the horizon

Faster, simpler diagnosis for fibromyalgia may be on the horizon

Pilot study intended to lead to test for use by primary care physicians

COLUMBUS, Ohio – Researchers have developed a reliable way to use a finger-stick blood sample to detect fibromyalgia syndrome, a complicated pain disorder that often is difficult to diagnose.

If it were someday made available to primary care physicians, the test could knock up to five years off of the wait for a diagnosis, researchers predict.

In a pilot study, the scientists used a high-powered and specialized microscope to detect the presence of small molecules in blood-spot samples from patients known to have fibromyalgia.

By "training" the equipment to recognize that molecular pattern, the researchers then showed that the microscope could tell the difference between fibromyalgia and two types of arthritis that share some of the same symptoms.

Though more analysis is needed to identify exactly which molecules are related to development of the disorder itself, the researchers say their pilot data are promising.

"We've got really good evidence of a test that could be an important aid in the diagnosis of fibromyalgia patients," said Tony Buffington, professor of veterinary clinical sciences at The Ohio State University and senior author of the study. "We would like this to lead to an objective test for primary care doctors to use, which could produce a diagnosis as much as five years before it usually occurs."

Patients with fibromyalgia are often desperate by the time they receive treatment because of the lengthy process required to make a diagnosis. The main symptoms, persistent pain and fatigue, mimic many other conditions, so physicians tend to rule out other potential causes before diagnosing fibromyalgia. Additional symptoms include disrupted sleep and memory or thought problems. An estimated 5 million American adults have the disorder, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

"The importance of producing a faster diagnosis cannot be overstated, because patients experience tremendous stress during the diagnostic process. Just getting the diagnosis actually makes patients feel better and lowers costs because of reductions in anxiety," said Kevin Hackshaw, associate professor of medicine, division of rheumatology and immunology, at Ohio State's Wexner Medical Center and lead author of the study.

The study is published in the Aug. 21, 2013, issue of the journal Analyst.

The technology used in this work is infrared microspectroscopy, which identifies the biochemical content of a blood sample based on where peaks of molecules appear in the infrared spectrum. The technology offers hints at the molecules present in the samples based on how molecular bonds vibrate when they are struck by light.

The spectroscopy works on dried blood, so just a few drops from a finger stick produce enough blood to run this test.

Researchers first obtained blood samples from patients diagnosed with fibromyalgia (14), rheumatoid arthritis (15) and osteoarthritis (12). These other conditions were chosen for comparison because they produce similar symptoms as fibromyalgia, but are easier to diagnose.

The scientists analyzed each sample with the infrared microspectroscopy to identify the molecular patterns associated with each disease. This functioned as a "training" phase of the study.

When the researchers then entered blinded blood samples into the same machinery, each condition was accurately identified based on its molecular patterns.

"It separated them completely, with no misclassifications," Buffington said. "That's very important. It never mistook a patient with fibromyalgia for a patient with arthritis. Clearly we need more numbers, but this showed the technique is quite effective."

The researchers also analyzed some of the potential chemicals that could someday function as biomarkers in the fibromyalgia blood samples, but further studies are needed to identify the molecules responsible for the spectral patterns, he said.

Though an infrared microscope can be expensive, Buffington said the testing could be affordable if a central lab existed to run the samples. That the method can use dried blood samples makes this concept feasible because dried blood can be legally sent via U.S. mail, he noted.

Why is a veterinarian pursuing this type of research? Buffington is a renowned expert on domestic cats, including a painful bladder disorder they suffer called interstitial cystitis (IC). This syndrome also occurs in humans.

It turns out that the origins of IC, like such human disorders as irritable bowel syndrome and fibromyalgia, cannot be traced to the specific area of the anatomy most affected by the syndrome. These disorders are categorized as medically unexplained or functional syndromes, and Buffington has explored the possibility that a common link exists among these types of diseases, and that they might have origins in the central nervous system.

Buffington has filed two invention disclosures with the university, and Ohio State has filed multiple patent applications for the testing method, in the United States and internationally. In November, Ohio State was issued U.S. Patent 8,309,931 on a rapid diagnostic method for functional syndromes in humans and cats.


Additional co-authors include Luis Rodriguez-Saona and Marçal Plans of the Department of Food Science and Technology at Ohio State, and Lauren Bell of Metabolon Inc., based in Durham, N.C.

Contact: Tony Buffington, (614) 292-7987;

Written by Emily Caldwell, (614) 292-8310;

Tuesday, October 9, 2012

The Hepatitis-Fibromyalgia Connection

The Hepatitis-Fibromyalgia Connection

Fibromyalgia and chronic hepatitis C infection share many clinical features.
Fibromyalgia and chronic hepatitis C infection share many clinical features including prominent somatic complaints such as musculoskeletal pain and fatigue. In fact, some medical experts believe that the symptoms and presenting patterns in common between hepatitis C and fibromyalgia are not coincidental. There is the possibility that hepatitis C may be a trigger of fibromyalgia.

There is a growing body of evidence supporting a link between cytokines and somatic complaints. There have been reports of alterations of cytokines in fibromyalgia, including increased serum levels of interleukin (IL)-2, IL-2 receptor, IL-8, IL-1 receptor antagonist, and increased IL-1 and IL-6 produced in patients with fibromyalgia for longer than 2 years, to name but a few.

Alterations in the cytokines of fibromyalgia and chronic hepatitis C infection can produce hyperalgesia and other neurologically-mediated complaints, as the cytokine receptors can be found on brain cells and opiate receptors on blood cells.

Many individuals with other liver diseases do not suffer the pain seen in hepatitis C. And there is a high prevalence of fibromyalgia in hepatitis C patients; this is important for clinicians to appreciate, as the recognition of fibromyalgia in patient with hepatitis C will prevent assumptions of pain being due to liver disease—and perhaps allow for a more focused and correct treatment approach.

In recent years there has been a significant effort to educate the public on viral hepatitis, such as hepatitis B and C, to encourage testing and educate regarding prevention and treatment. It is always important to consider these infections when patients experience fatigue and/or pain for seemingly no reason.

Hepatitis B is usually spread when blood, semen, or another body fluid from a person infected with the hepatitis B virus enters the body of someone who is not infected. This can happen through sexual contact with an infected person or sharing needles, syringes, or other drug-injection equipment. Hepatitis B can also be passed from an infected mother to her baby at birth.

Hepatitis C is usually spread when blood from a person infected with the hepatitis C virus enters the body of someone who is not infected. Today, most people become infected with the hepatitis C virus by sharing needles or other equipment to inject drugs. Before 1992, when widespread screening of the blood supply began in the United States, hepatitis C was also commonly spread through blood transfusions and organ transplants.

Ask your doctor about hepatitis B and C testing should you feel there are unexplained symptoms you might be experiencing. You risk a needle stick, but you gain piece of mind.

Monday, June 25, 2012

Herbal cannabis use in fibromyalgia: Associated w-negative psychosocial parameters

Published in Arthritis Care & Research

Herbal Cannabis Use In Fibromyalgia Patients

Cannabinoids were used by 13% of patients referred with a diagnosis of FM. The association of herbal cannabis use with negative psychosocial parameters raises questions regarding the motive for this self-medication practice.

Patients with chronic pain, including fibromyalgia (FM), may seek treatments outside mainstream medicine. Medicinal cannabinoids are popularly advocated for pain relief but with limited evidence for efficacy in FM. The extent of use of cannabinoids in FM is unknown.

We have documented the self-reported prevalence of cannabinoid use in 457 patients carrying the diagnosis of FM and referred to a tertiary care pain centre. We validated the diagnosis of FM and examined the associations of cannabinoid use in these patients.

Cannabinoids were being used by 13% of all patients, 8% of whom used herbal cannabis (marijuana), 24% used prescription cannabinoids and 3% used both herbal cannabis and prescription cannabinoids. One third of all males used cannabinoids. Current unstable mental illness (36% vs. 23%; p=.2), opioid drug-seeking behaviour (17% vs. 4%; p=.1), and male gender (26% vs. 7%; p=.2) were all associated with herbal cannabis use. There was a trend for cannabinoid users to be unemployed and receiving disability payments.

The diagnosis of FM was validated in 32 patients, with 155 assigned another primary diagnosis. When the FM group was analyzed separately, significant associations were lost, but trends remained.

Cannabinoids were used by 13% of patients referred with a diagnosis of FM. The association of herbal cannabis use with negative psychosocial parameters raises questions regarding the motive for this self-medication practice.

Although cannabinoids may offer some therapeutic effect, caution regarding any recommendation should be exercised pending clarification of general health and psychosocial problems, especially for those self-medicating.  

Wednesday, May 2, 2012

The risk factors for fibromylagia syndrome (FBS) among Hepatitis C patients

The risk factors for fibromylagia syndrome (FBS) among Hepatitis C patients

Reference: Mohammad, A., et al., Prevalence of fibromyalgia among patients with chronic hepatitis C infection: relationship to viral characteristics and quality of life. J Clin Gastroenterol, 2012. 46(5): p. 407-12.

A study out of Ireland on the risk factors for fibromylagia syndrome (FBS) among chronic Hepatitis C patients. 

Brief Summary: Many patients with chronic Hepatitis C can manifest many different types of symptoms such as fatigue, myalgia, and fibromylagia syndrome (FBS). FBS is a medical disorder characterized with widespread muscle, tissue or joint pain. The main objective of this study was to identify the observational factors which are associated with patients who have FBS vs. no-FBS in chronic Hepatitis C patients. A total of 185 Hepatitis C patients were recruuited and a wide variety of observatioal factors were collected and recorded such as gender, age, pain intensity, functional impairment, etc. 

Results: The authors found the following factors to be risk factors for FBS among the patients with chronic Hepatitis C patients: age 45 years or more, female sex, living alone, history of depression, acquisition of HCV through blood transfusion, and presence of HCV genotype 1.

Implications for Practice: Chronic Hepatitis C Patients who show the corresponding risk factors may have a higher liklihood of having FBS. 

Discussion: As the authors mentioned, the pathogenesis of FBS is not completely understood. Thus, observational studies like this which identify risk factors can be used to further elucidate the cause of FBS. I obviously have not had the opportunity to read up on past papers related to this subject, but just from the author’s discussion section, it would seem as if there is a strong interaction between several variables – both environmental and genetic which can cause FBS. There are just so many follow-up studies that could be done on a project such as this.

Commentary on Statistics and Study Design: I have some constructive suggestions for the authros related to the statistics and study design of the investigation. The main objective of the investigation was to identify risk factors for patients who either have FBS or do not have FBS. Since the main desire was to identify independent risk factors, conducting a univariate logistic regression model fulfills this need. However, it would also be helpful to identify risk factors in a dependent fashion. In order to do this, the author’s could have constructed a multi-variate logisticregression model with the outcome variable (as before) being whether the patient had FBS or not, and then the predictor variables would have been all the risk factors. By doing this, the investigator could determine whether a given risk factor (or variable) is statistically associated with the outcome variable while controlling for (or ‘keeping constant’) all other variables in the investigation. This could help the investigator in narrowing down the risk factors which are most associataed with the outcome variable, and this is information which could be very useful. For instance, gender was found to be independantly associated with the outcome variable (FBS vs. no-FBS) in the univariate analysis. However, gender may not be associated with the outcome variable while controlling for – say – blood transfusion. In other words, blood transfusion has a much stronger association with the outcome variable than gender, and this would be useful to know. In this instance, gender is not really associated with the outcome variable – it may only been because more males than females happened to have FBS in the recruitment than males. So, the author’s could have done a multi-variate analysis and only reported those risk factors which were associated with the outcome variable in a dependant fashion. In short, whenever there are multiple predictor variables in a problem, you always want to run a multi-variate regression problem (for the reasons just stated) instead of a univariate approach. Also, by using a multi-variate regression problem, one could have tested the effect of various interactions among the different variables (ask me if you don’t know what this is).

Also, the author’s identified 4 different genotypes among the HC patients. However, in the final analysis, the investigators only made a comparative difference between genotype 1 vs. every other genotypes. It may have been helpful to do a comparative analysis between all the genotypes simultaneously (ex. genotypes 2 vs. 3, 2 vs. 4, 1 vs. 4), and there are statistical techniques to do this. It seems as if there were plenty of data samples for genotypes 2 through 4 to do this. Using the multi-variate regression idea, the investigator could have coded the genotypes variable as a qualitiatve class variable, and this would have allowed the comparison of all 4 groups against themselves (again, ask if you don’t know how to do this). This could have been really interesting to look at.

A big thanks for our friends from Ireland for running this study.

Sunday, December 11, 2011

Dec 2011-Improving the Recognition and Diagnosis of Fibromyalgia

Improving the Recognition and Diagnosis of Fibromyalgia

December 2011, 86 (12)

Lesley M. Arnold, MD⇓, Daniel J. Clauw, MD, Bill H. McCarberg, MD, and for the FibroCollaborative
+ Author Affiliations

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From the Department of Psychiatry and Behavioral Neuroscience and the Women's Health Research Program, University of Cincinnati College of Medicine, Cincinnati, OH (L.M.A.); Department of Anesthesiology, Medicine, and Psychiatry, University of Michigan, Ann Arbor (D.J.C.); and Chronic Pain Management Program, Kaiser Permanente, Escondido, CA (B.H.M.). A list of the additional members of the FibroCollaborative appears on page 464
↵ Individual reprints of this article are not available. Address correspondence to Lesley M. Arnold, MD, 222 Piedmont Ave, Suite 8200, Cincinnati, OH 45219 (

Source Mayo

Fibromyalgia (FM) is a chronic widespread pain disorder often seen in primary care practices. Advances in the understanding of FM pathophysiology and clinical presentation have improved the recognition and diagnosis of FM in clinical practice. Fibromyalgia is a clinical diagnosis based on signs and symptoms and is appropriate for primary care practitioners to make. The hallmark symptoms used to identify FM are chronic widespread pain, fatigue, and sleep disturbances. Awareness of common mimics of FM and comorbid disorders will increase confidence in establishing a diagnosis of FM.

Fibromyalgia (FM), a chronic widespread pain disorder, is estimated to affect more than 5 million Americans (2%-5% of the adult population).1-3 It is second only to osteoarthritis as the most common disorder seen in rheumatology practices.4 In recent years, increasingly more patients with FM are presenting to primary care clinicians for initial diagnosis and ongoing care.

Fibromyalgia is a persistent and potentially debilitating disorder that can have a devastating effect on quality of life, impairing the patient's ability to work and participate in everyday activities, as well as affecting relationships with family, friends, and employers.5 It imposes heavy economic burdens on society as well as on the patient.6,7

Recent research suggests that the chronic widespread pain that is the hallmark symptom of FM is neurogenic in origin.8 Fibromyalgia is associated with a central amplification of pain perception characterized by allodynia (ie, a heightened sensitivity to stimuli that are not normally painful) and hyperalgesia (ie, an increased response to painful stimuli). Neuroimaging studies have also shown that FM is associated with aberrant processing of painful stimuli in the central nervous system.9,10

Accurate diagnosis is the critical first step to more effective care and better outcomes for patients with FM. Developed by the FibroCollaborative, a diverse group of leading experts on FM, this review aims to discuss the current understanding of FM symptomatology and diagnostic approaches. Methods for recognizing patients who may have FM on the basis of presentation of symptoms and associated disorders are described, as well as important steps in the differential diagnosis, including the role of the physical examination, laboratory testing, and referrals to specialists to identify both disorders that can mimic FM and those that frequently coexist with FM.


Despite improved understanding of its pathologic processes, FM remains undiagnosed in as many as 3 out of 4 people with the condition (Data on file. Decision Resources report 2009. Pfizer, New York, NY). Diagnosis time averages 5 years,11 resulting in delayed treatment and potentially suboptimal medical care. Women currently account for 80% to 90% of cases diagnosed using the American College of Rheumatology (ACR) 1990 criteria for FM (prevalence, 3.4% in women vs 0.5% in men).1 Women are more sensitive to painful stimuli than men and therefore have a greater response than men to the diagnostic tender point examination that is included in the ACR criteria (tenderness on digital palpation at predesignated sites). As a result, men with chronic widespread pain rarely meet ACR criteria for FM, despite having a similar underlying pathologic process.12


Establishing the diagnosis of FM is an essential component of successful management.4 Many patients with FM have been living with chronic pain and other troubling and disabling symptoms for extended periods. Primary care practices undoubtedly see more patients with FM than is currently appreciated. When such patients are finally recognized and a diagnosis is confirmed, both clinician and patient clear a major hurdle to more effective management of the disorder.

Research shows that the diagnosis of FM has no negative effect on clinical outcomes. Indeed, patients newly diagnosed as having FM report improved satisfaction with health and fewer long-term symptoms.13 In addition, several studies have indicated that the utilization of medical resources and the associated costs decline after a diagnosis of FM.14,15 Patients with FM appreciate sincere efforts to help them and can be gratifying to treat.

The diagnostic evaluation of FM can take time, but this should not be a barrier in primary care practices. If a diagnosis of FM is suspected, a trial of treatment can begin while the evaluation for possible other coexisting disorders continues. Subsequent visits during initial diagnosis and management actually reassure the patient with FM that they are receiving appropriate care and validation, which can be very therapeutic.

Fibromyalgia is a clinical diagnosis based on the disorder's unique clinical characteristics and not solely a diagnosis of exclusion. Like other pain states (eg, migraine), FM is commonly diagnosed in the primary care setting on the basis of characteristic symptoms.

A focused history and physical examination are the cornerstones of FM recognition. No laboratory or radiologic testing is required to diagnose FM. Such tests are necessary only if clinically indicated to evaluate other potential diagnoses, including conditions that may be comorbid with FM. Routine laboratory tests may help guide the assessment, especially if they have not been performed at some point in the patient's work-up. Specialist referral is usually not necessary to confirm the diagnosis. The goal is to identify FM and initiate treatment as early as possible, even if further evaluation is needed to identify and confirm possible comorbid conditions that may also require management.

Patient HistoryCore Symptoms of FM.
The core symptoms of FM can be visualized as a triad that includes chronic widespread pain (in the right and left side of the body, above and below the waist, and in the axial skeleton) of long duration (≥3 months) as the primary, hallmark symptom, with fatigue16 and sleep disturbance (including nonrestorative sleep [ie, feeling unrefreshed after a night's sleep])5,16 as 2 other commonly associated symptoms. These 3 symptoms occur in most patients with FM. Presentation of chronic widespread pain for years, especially in the presence of fatigue and sleep disturbance, should raise suspicion for FM. For many patients, the fatigue commonly associated with FM is the most troublesome symptom and the one that leads them to seek medical attention.

Other key associated symptoms include tenderness, stiffness, mood disturbances (eg, depression and/or anxiety), and cognitive difficulties (eg, trouble concentrating, forgetfulness, and disorganized thinking).17-20 Fibromyalgia symptoms can wax and wane, varying in intensity from day to day and by physical location. Patients with FM frequently report impairment in multiple areas of function, especially physical function.5 Overall, patients with FM are a heterogeneous population. The impact of FM spans the continuum from patients who are mildly to moderately affected by FM symptoms to those who are more severely affected and have markedly impaired function and quality of life.

Fibromyalgia should be considered in all patients with multiple regions of chronic pain (at a single point in time or during the course of their lifetime), especially if they report multiple somatic symptoms. Generally, the index of suspicion for FM should increase the longer the chronic widespread pain and other symptoms have been present, the more variable the symptoms seem, and the more body systems that are involved.

Comorbid Disorders.
The presence of common comorbid disorders can also raise suspicion for FM, and it is important for the clinician to ask about chronic widespread pain when presented with these associated conditions. Examples of common comorbid disorders include mood or anxiety disorders, which can precede the development of FM. The lifetime (both current and past) prevalence of these disorders with FM is high, with any lifetime anxiety disorder reported in 35% to 62% of patients, lifetime major depressive disorder in 58% to 86% of patients, and lifetime bipolar disorder in up to 11% of patients.21,22 The high frequency with which FM and mood and anxiety disorders occur together is most likely explained by pathophysiologic abnormalities common to both mood and anxiety disorders and FM, rather than by FM causing the mood and anxiety disorders or the mood and anxiety disorders causing FM.23 Although psychiatric disorders often occur together with FM, they should not be confused with FM or viewed as being the same disorder.22 As comorbid conditions, mood and anxiety disorders need to be treated together with FM, sometimes with different interventions. Treatment aimed at mood alone may result in suboptimal outcomes for the management of all of the symptoms of FM.24

Other common comorbid disorders in patients with FM include the following regional pain syndromes that may share certain pathophysiologic features with FM: irritable bowel syndrome, tension-type headache/migraine, interstitial cystitis or painful bladder syndrome, chronic prostatitis or prostadynia, temporomandibular disorder, chronic pelvic pain, and vulvodynia.24,25 Patients may focus on local areas of pain and describe one particularly bothersome area; others may hesitate to mention all of their pain symptoms, especially if some of their pain has been dismissed or discounted previously. Therefore, it is important for clinicians to determine whether pain is limited to 1 or more regions of the body or whether the pain is more widespread.

Fibromyalgia Risk Factors.
The patient's history may reveal risk factors for FM, such as familial predisposition. Relatives of people with FM are at a higher risk. In a recent family study, first-degree relatives of patients with FM were 8 times more likely to have FM than relatives of the control group of patients with rheumatoid arthritis (RA).26 Environmental factors, including physical trauma or injury, infections (eg, Lyme disease and hepatitis C), and other stressors (eg, work, family, life-changing events, and abuse history), pose additional risk.27 Finally, sex is a risk factor. Women are diagnosed as having FM approximately 7 times more often than men; however, the source of at least some of this disparity appears to be an artifact of requiring a certain degree of tenderness to diagnose FM using ACR criteria.28

Medical History Tools.
Tools are available to facilitate a focused medical history in the time-constrained primary care setting. The use of a body pain diagram during the initial examination can assist patients in documenting the presence of widespread pain and establish a baseline for monitoring treatment response. Patient screening can begin in the office waiting area using brochures that include a body pain diagram and a simple questionnaire, with questions such as the following: Have you had pain in your muscles or joints that has lasted 3 months or more? Do you have pain all over? Do you become fatigued during the day so that you have to stop normal activities? Do you wake up in the morning and feel more tired than when you went to bed?

Physical Examination
The physical examination of a patient with suspected FM should focus on identifying associated or comorbid disorders as warranted by symptoms, signs, and the medical history because these may require separate management. Joints should be examined for swelling, tenderness, range of motion, and crepitus, and patients should be evaluated for peripheral pain generators (eg, RA, osteoarthritis, tendonitis, adhesive capsulitis) as well as focal and/or objective weakness. If the history is suggestive, signs of connective tissue disease should be assessed and a neurologic examination conducted. It is important to note that the presence of a second disorder (even a painful one) does not necessarily exclude a diagnosis of FM, which can occur together with other painful conditions.29 In general, the physical examination findings are normal in FM except for diffuse tenderness,30 evaluated by counting tender points or by digital palpation of several regions of the body. The physical examination (regardless of whether tender points are counted) remains key in the evaluation of patients to assess the tenderness (allodynia and hyperalgesia) associated with FM as well as to aid in the differential diagnosis.

The ACR criteria for FM (Figure 1) include a history of widespread pain lasting 3 months or longer.31 Widespread pain is defined as pain above and below the waist and on both sides of the body. In addition, axial skeletal pain (in the cervical spine, anterior chest, thoracic spine, or lower back) must be present. According to the ACR, a patient must have pain on digital palpation at 11 of 18 predesignated sites, commonly referred to as tender points, to be diagnosed as having FM. Approximately 4 kg of pressure must be applied to a site, and the patient must indicate that the site is painful.32 In practical terms, the pressure to assess tenderness with digital examination is the pressure needed to see your own nail bed blanch.

The ACR criteria have a sensitivity of 88.4% and a specificity of 81.1%.31 Many health care professionals find the manual tender point examination useful for confirming the presence of widespread tenderness and increasing confidence in the diagnosis.33 These criteria were originally designed to standardize patient classification in clinical trials rather than to diagnose FM in routine clinical practice.12 Nevertheless, the tender point examination has been used in hundreds of studies and is recognized by the ACR for the diagnosis of FM.

As a possible alternative to the ACR criteria for use in clinical settings, Wolfe et al34 recently proposed clinical diagnostic criteria for FM that do not rely on counting tender points. The proposed criteria take into account not only pain but also other FM-related symptoms and are intended to assess the severity of those symptoms (Table 1).34 To administer the Widespread Pain Index and Symptom Severity scale, the physician asks the patient to report the location of any pain during the past week at 19 sites, including areas of the shoulders, arms, hips, legs, jaws, chest, abdomen, back, and neck.
The Symptom Severity scale focuses on 3 physical symptoms, as well as somatic symptoms in general. Fatigue, waking unrefreshed, and cognitive symptoms are rated on the basis of the level of severity during the previous week. Table 1 summarizes typical somatic symptoms that might be considered.34 Research to determine the clinical usefulness of these proposed criteria is ongoing. Studies of other approaches to the identification of patients with FM in primary care settings are also under way. Many clinicians also use the previously described core symptoms to identify patients with FM.

Once FM is diagnosed, treatment should begin even if further evaluation for comorbid conditions is ongoing. Identification of disorders that coexist with FM may help to reveal contributing factors that may need to be addressed in the comprehensive management plan.


Current medications should be identified and medication-related pain such as statin-induced muscle pain or opioid-induced hyperalgesia ruled out. Identification of disorders that can mimic FM (eg, hypothyroidism and inflammatory rheumatic diseases) or that are frequent comorbid conditions in patients with FM (eg, RA, osteoarthritis, systemic lupus erythematosus, spinal stenosis, neuropathies, sleep disorders such as sleep apnea, and mood and anxiety disorders) is essential so that appropriate treatments can be initiated.35 The presence of a second disorder does not exclude a diagnosis of FM; both disorders will need management.

Laboratory Testing

Extensive laboratory testing is not generally necessary to diagnose FM.35 A diagnosis of FM can be established on the basis of the history and physical examination findings with selective use of laboratory testing.

Although not required to establish the diagnosis of FM, routine laboratory testing (if not already performed within the past 6-12 months) is frequently obtained to evaluate other possible causes of symptoms or signs. These tests include measurement of erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) levels, a complete blood cell count, a comprehensive metabolic panel, and a thyroid function test. Routine testing for rheumatoid factor or antinuclear antibodies is not recommended to diagnose FM unless the patient has signs or symptoms suggesting an autoimmune disorder, or if initial inflammatory indices (ie, ESR and/or CRP level) are abnormal (recognizing that some patients with RA or systemic lupus erythematosus may have normal ESR and/or CRP values). Depending on symptoms (eg, duration of pain and acute vs chronic), medical history, and physical examination findings, other tests, such as measurement of ferritin, vitamin B12, and vitamin D levels and determination of iron-binding capacity and percentage of saturation, may be indicated.35

Further Investigation/Specialist Referral

A diagnosis of FM can be established appropriately in the primary care setting, but specialist referral may be indicated. The patient should be referred for specialist evaluation if uncertainty remains about the diagnosis because of unusual symptoms or signs, disease course, laboratory findings, or other concerns. Referral should also occur when the patient has abnormal laboratory results that suggest another condition requiring specialty care. It may also be necessary for the treatment of comorbid conditions, including mood/anxiety and sleep disorders. Figure 2 and Table 2 summarize the approach to the diagnosis of FM.

Questions About Fibromyalgia

  1. Which one of the following triad of symptoms is the most typical presentation of fibromyalgia (FM)?

    1. Pain, anorexia, and elevated creatine phosphokinase levels

    2. Pain, mild dysphasia, and ataxia

    3. Pain, disturbed sleep, and fatigue

    4. Pain, paresthesia, and depression

    5. Pain, swollen joints, and elevated erythrocyte sedimentation rate

  2. Which one of the following best describes the pathophysiology of FM pain?

    1. Aberrant processing of painful stimuli in the central nervous system

    2. Diffuse chronic inflammation of muscle tissue

    3. Degeneration of muscle fibrous tissue

    4. Neuronal damage by vitamin B12 deficiency

    5. Excessive production of neurotransmitters in muscle tissue

  3. Which one of the following is not a risk factor for FM?

    1. Family history of FM

    2. Family history of rheumatoid arthritis

    3. History of trauma or injury

    4. History of abuse

    5. Sex

  4. Which one of the following laboratory tests is required for FM diagnosis?

    1. Rheumatoid factor

    2. Erythrocyte sedimentation rate

    3. C-reactive protein level

    4. Iron-binding capacity

    5. No laboratory tests are required to establish the diagnosis of FM

  5. Which one of the following presentations should raise a high index of suspicion for FM?

    1. Chronic pain at a specific site

    2. Swelling of multiple joints

    3. A 1-week history of pain in multiple sites

    4. Chronic widespread pain lasting 2 years

    5. Symptoms of depression

Correct answers: 1. c, 2. a, 3. b, 4. e, 5. d


Editorial support was provided by Dr Gayle Scott, PharmD, of UBC Scientific Solutions and funded by Pfizer.

  • Dr Arnold has received grants/research support from Eli Lilly and Company, Pfizer, Cypress Biosciences, Wyeth Pharmaceuticals, Boehringer Ingelheim, Allergan, and Forest Laboratories. She is a consultant for Eli Lilly and Company, Pfizer, Cypress Biosciences, Wyeth Pharmaceuticals, Boehringer Ingelheim, Forest Laboratories, Allergan, Takeda, UCB, Theravance, AstraZeneca, and sanofi-aventis. Dr Clauw has received grants/research support from Pfizer and Forest Laboratories. He is a consultant for Pfizer, Eli Lilly and Company, Forest Laboratories, Cypress Biosciences, Pierre Fabre Pharmaceuticals, UCB, and AstraZeneca. Dr Clauw is a member of the advisory boards for Pfizer, Eli Lilly and Company, Forest Laboratories, Cypress Biosciences, Pierre Fabre Pharmaceuticals, UCB, and AstraZeneca. Dr McCarberg has received honoraria from Cephalon, Eli Lilly and Company, Endo Pharmaceuticals, Forest Laboratories, Merck & Co., Pfizer, and Purdue Pharma. The FibroCollaborative group was sponsored by Pfizer.

  • Additional Members of the FibroCollaborative. Kenneth Barrow, PA-C, MHS, Independence Back Institute, Wilmington, NC; Lucinda Bateman, MD, Fatigue Consultation Clinic Inc, Salt Lake City, UT; Larry Culpepper, MD, MPH, Boston University, Boston, MA; Cassandra Curtis, MD, American Health Network, Greenfield, IN; Yvonne D'Arcy, MS, CRNP, CNS, Suburban Hospital-Johns Hopkins Medicine, Bethesda, MD; L. Jean Dunegan, MD, JD, Hillsdale Community Health Center, Brighton, MI; Kevin B. Gebke, MD, Indiana University, Indianapolis; Robert Gerwin, MD, Pain and Rehabilitation Medicine, Bethesda, MD; Don L. Goldenberg, MD, Newton-Wellesley Hospital, Newton, MA; James I. Hudson, MD, ScD, Harvard University, Belmont, MA; Rakesh Jain, MD, MPH, Clinical Research Center, Lake Jackson, TX; Arnold L. Katz, MD, Overland Park Regional Medical Center, Overland Park, KS; Andrew G. Kowal, MD, Tufts University, Burlington, MA; Charles Lapp, MD, Duke University, Charlotte, NC; Philip J. Mease, MD, Swedish Medical Center, Seattle, WA; Danielle Petersel, MD, Pfizer Inc, New York, NY; I. Jon Russell, MD, PhD, University of Texas, San Antonio; Stephen M. Stahl, MD, PhD, University of California, San Diego; Dennis C. Turk, PhD, University of Washington, Seattle; and Alvin F. Wells, MD, PhD, Rheumatology & Immunotherapy Center, Oak Creek, WI.A question-and-answer section appears at the end of this article.

Wednesday, December 29, 2010

Mindfulness therapy no help in fibromyalgia trial

NEW YORK (Reuters Health) - A program aimed at easing stress with meditation and yoga may not be much help for people with the chronic-pain condition fibromyalgia, a recent study suggests.

The study, published in the journal Pain, looked at the effects of so-called mindfulness-based stress reduction -- a technique developed by researchers at the University of Massachusetts in 1979 that combines mindfulness meditation and gentle yoga postures.

The technique is now available throughout the world -- in the form of an eight-week program of classes -- to help people manage general stress or health problems, including chronic pain.

For the new study, researchers led by Dr. Stefan Schmidt, of the University Medical Center in Freiburg, Germany, tested the program's effects among 177 women with fibromyalgia.

They found that women assigned to the mindfulness program showed no greater gains in health-related quality of life than those assigned to a waiting list for treatment.

That meant no significant improvements in either physical symptoms or emotional well-being.

"I'm surprised it didn't work better than it did," Dr. Alex Zautra, a professor in psychology at Arizona State University in Tempe, told Reuters Health. Zautra, who was not involved in the study, said he would have expected better results since people with fibromyalgia would seem to be good candidates for the mind-body therapy.

Fibromyalgia is a syndrome marked by widespread pain -- including discomfort at specific "tender points" in the body -- along with symptoms like fatigue, irritable bowel and sleep problems. It is estimated to affect up to 5 million U.S. adults, most commonly middle-aged women.

The precise cause of fibromyalgia is unknown. There are no physical markers, like inflammation or tissue damage in the painful areas -- but some researchers believe the disorder involves problems in how the brain processes pain signals.

Standard treatments include painkillers, antidepressants, cognitive-behavioral therapy and exercise therapy. However, many people with fibromyalgia find that their symptoms persist despite treatment.

One reason, some researchers suspect, may be because standard treatments do not specifically address the role psychological stress and emotions can play in triggering pain.

Studies have found that people with fibromyalgia have higher-than-average rates of stressful life events, like childhood abuse and marital problems. There's also evidence suggesting they are less aware of their own emotions and have more difficulty holding on to positive feelings compared to people without fibromyalgia.

The idea behind mindfulness practices, Zautra said, is that people become more aware of how they are feeling, emotionally and physically, from moment to moment. Then they can start to see how their emotions affect their perceptions of their physical symptoms.

But maybe the problem, Zautra said, is that "awareness by itself is not enough for patients with fibromyalgia."

That is, people with the disorder may need extra help in learning how to manage the emotions that come up when they meditate or practice mindfulness-based yoga.

Another recent study of the "mind-body" approach to fibromyalgia suggested that patients can benefit from addressing their emotions. In that study of 45 women with fibromyalgia, about half of those who underwent a therapy called "affective self-awareness" reported a significant improvement in their pain over six months.

Affective self-awareness -- a newer therapy that is not widely available -- tries to get people to "directly engage" their emotions with the help of various techniques. Mindfulness meditation and "expressive" writing are two of them.

Zautra and his colleagues are in the middle of a clinical trial testing their own mindfulness-based program against standard cognitive-behavioral therapy and general health education for people with fibromyalgia.

So the "jury is still out," Zautra said, as to whether some fibromyalgia patients can benefit from mindfulness practices.

In the meantime, if someone with the disorder wants to try a mindfulness meditation class, "this study doesn't tell them not to," Zautra said.

"But don't expect it to cure your pain," he added. "This study raises questions about when and for whom (mindfulness techniques) may be helpful."

The current findings are based on 177 women with fibromyalgia who were randomly assigned to one of three groups: one that went through the eight-week mindfulness-based stress reduction program; an "active" control group that received relaxation training and learned gentle stretching exercises; and a second control group where patients were put on a waiting list for treatment.

All of the women completed a standard questionnaire to rate their health-related quality of life at the beginning of the study, directly after the therapy program ended, and again two months later.

Overall, Schmidt's team found, the entire study group showed a small improvement in quality of life over time. But there were no significant differences between the three groups.

According to Zautra, one possibility is that only certain subsets of fibromyalgia patients stand to benefit from this or other mindfulness-based therapies.

In one of his own studies, Zautra said, people with rheumatoid arthritis who also had a history of depression benefited more from mindfulness meditation than arthritis patients who had never battled depression.

It's possible -- though not proven -- that the same pattern could hold true for fibromyalgia patients, he noted.

SOURCE: Pain, online December 13, 2010

Monday, November 8, 2010

Fibromyalgia can be experienced concurrently with hepatitis B and C

Presented below is a collection of studies and abstracts from 2009-2010; which lends merit to the connection between the hepatitis c virus and fibromyalgia.

The association between chronic hepatitis C virus infection and fibromyalgia still remains controversial. Studies have shown that Hepatitis C can be associated with arthritis ; it can also cause arthralgias, which is joint pain without swelling. There are also many other illnesses which can be associated with so-called secondary fibromyalgia.

The fact remains in rare cases several forms of arthritis have been linked to HCV infection. One of the most commonly types of arthritis associated with hepatitis C is rheumatoid arthritis (RA). The relationship between RA and the hepatitis c virus results in antibodies starting to attack normal body tissue, although some physicians feel it may be more closely related to liver damage and share the argument the condition usually affects people with cirrhosis.
Treating arthritis with some anti-inflammatory drugs can suppress the immune system and may lead to increased viral replication of the virus. The other concern is many of the drugs used to treat RA are metabolised by the liver; if the liver is damaged toxins may build up. However evidence shows that treating HCV with antiviral medications which reduces the viral load can decrease arthritic symptoms.
From Fibromyalgia Frontiers • 2010 (Volume 18, Number 1
2010 Fibromyalgia Pathophysiology and Treatment
There is a strong association between fibromyalgia and many diseases rheumatologists treat (RA, osteoarthritis, Sjogrens syndrome, lupus and certain infections Hepatitis C and lyme disease.
Fibromyalgia Searching for an Answer /2010

From an article in LHT

The Mysterious Condition of Fibromyalgia

It sneaks in unannounced and makes itself completely at home. It affects every aspect of life, turning days into challenges. This unwelcome arrival frequently manages to hide so it is almost invisible, yet it shows little sign of leaving. This is fibromyalgia (FM), often referred to as “fibro,” and it affects millions of Americans every year. The vast majority of those afflicted, an estimated 95 percent, are women.
Ask some physicians to explain fibromyalgia, and they will tell you it is a condition that exists in the minds of hysterical females; others will claim it is an unidentified health problem that requires additional sleep and an occasional pain reliever. A growing number of medical professionals, however, will tell you what the American College of Rheumatology (ACR) determined in 1990. They would confirm it is an actual medical syndrome that affects all four body quadrants, causes widespread pain for at least three months, and involves at least 11 “tender points” among 18 sites on the body.
The sites are overly sensitive to stimuli that typically would not cause pain. Fibromyalgia is a real condition creating real problems for people of all ages and ethnic backgrounds and can be experienced concurrently with hepatitis B and C. Viral infections often appear in the medical backgrounds of those suffering from fibromyalgia. It is not known how the occurrence of a viral disease, such as hepatitis, is specifically linked to the condition.
Studies have explored various potential triggers of the syndrome, including trauma, stress and hepatitis infections. For example, research findings published in a 2005 study suggested having chronic hepatitis B appeared to increase the risk of FM and its associated symptoms. According to the ACR, the American Medical Association, the National Institutes of Health, the Food and Drug Administration (FDA), and the American Pain Society, this condition is real. So why does it take an average of five years for a patient to get an accurate diagnosis? Unfortunately, as powerful as fibromyalgia can be, it is just as elusive.
It does not show up on a blood test or X-ray. It doesn’t have a defining hallmark of symptoms but has generalized ones that can fit the parameters of other conditions. “Fibromyalgia has no specific physical abnormalities to see, just elevated tenderness,” explains Dr. Philip Mease, director of Rheumatology Research at the Swedish Medical Center in Seattle, Washington. Dr. Jacob Teitelbaum, medical director of Fibromyalgia and Fatigue Centers and author of “From Fatigued to Fantastic,” adds that there is no fancy test for the condition. “Doctors will say it doesn’t exist,” he notes. “If your physician tells you this, just say ‘goodbye,’ and walk out the door. You don’t want a doctor you have to educate.”
Head to Toe The name fibromyalgia means pain in the muscle fibers. From mild annoyances to completely debilitating, the pain element only paints a limited picture of this pervasive condition. There are numerous other common complaints associated with fibro. (See Common Complaints.) A thorough medical history is the best way to discover most of these issues, although some doctors will order thyroid panels and complete blood counts to look for abnormal numbers. Dr. Eric Braverman, director of the Place for Achieving Total Health, has been working with fibro patients for more than 20 years.
“Technology has come a long way, so we have more effective ways of finding and treating fibro,” he says. “There have been more cases of fibromyalgia in recent years because of lack of health care in the U.S. Many people are finding they can’t visit their doctors as often so it goes untreated.” Any combination of these symptoms can play havoc with a person’s life, not only physically, but also emotionally, socially and mentally. As Teitelbaum describes it, “Imagine you’re a busy mother of several children and suddenly you experience brain fog, so people see you as dumb.
You gain the typical 32.5 pounds, your libido drops the typical 73 percent, you have no energy and you feel like you have a toothache throughout your entire body. Your medical tests come back normal—so now your friends, family and doctors think you’re crazy.” Braverman agrees. “Physically, the pain can be excruciating and force a person to the confinement of their beds. Mentally, fibro has been proven to cause depression due to the pain and anguish that people experience. Socially, it definitely has an effect. Many people find that they cannot go out as much as before, to run errands, go to dinner, or attend social gatherings. It is an all-encompassing disease.” Searching for an Answer Scott, a former education student and now author of a children’s book called “Johnny the Phoenix” knows this feeling. He was diagnosed with the condition in 2006, after searching for an answer for two years.
Constant headaches had resulted in four sinus surgeries and a battery of neurological tests. Nothing helped. Then a friend handed him a book about fibromyalgia. After a sleep study that showed apnea, he went to a new doctor and was diagnosed immediately. A husband and father, Scott’s days often depend on the weather. “I find that barometric pressure has a large impact, as well as extreme heat and cold,” he says. “I get as much sleep as possible, usually over nine hours. I look ahead to what needs to be done, and I try to use no more than 90 percent of the energy that I have available. It is a very frustrating disease, because there is no way to plan for good or bad days.” Today, Scott is on disability because it is impossible for him to work. “If you find that you have severe fibro as I do, fight for your disability,” he advises. “Sit down and take stock of what you have left. For me, it is my ability to tell stories, so I write. Just because you have fibromyalgia doesn’t mean that your life has ended. It simply means you need to go to your back-up abilities.”
To Make Matters Worse Just as the condition does not have a definitive test, it does not have a distinct cause or treatment either.
Over 150 clinical trials are being conducted at any one time trying to determine the answers. So far, researchers have proposed that fibromyalgia may be an abnormality in brain chemicals. An imbalance in neurotransmitters, such as norepinephrine, serotonin and dopamine, directly affects how pain is experienced and how it is blocked. “A person with fibro is like a house with a thermostat that is off kilter,” explains Mease. “There is an alteration in sensory processing in the individual. There is an excess of sensory input and a deficiency in the body’s ability to inhibit or block it. Too much comes in and not enough protects it.” Teitelbaum compares it to an energy crisis. “With fibro, the body blows a fuse,” he explains. “And that fuse is the hypothalamus.” Other theories are that fibro is a genetic condition (it tends to run in families) or that it comes along as a “fellow traveler” as Mease calls it, with other infectious or autoimmune diseases, such as hepatitis. Regardless of the cause, what many patients want most, once they have their diagnosis, is help.
Unfortunately, treatment is as complex an issue as the condition itself. Patients may take a variety of medications designed to battle specific symptoms, including pills to combat pain, diarrhea, and depression. They may need pills to increase energy or sleep at night. Prescription costs easily run into the hundreds or even thousands of dollars. The FDA has approved several drugs for the condition including milnacipran (Savella®), duloxetine (Cymbalta®) and pregabalin (Lyrica®). As with most medications, however, there are side effects to consider. Other possible treatments include massage, acupuncture, chiropractic care and heat applications.
Some fibro patients also have had trigger point (spots that are tender to palpation) injections in which an anesthetic is injected into the muscle, which is then gently stretched. The problem with this method is that the injections are usually quite painful, and it can take days for the patient to feel relief. Teitelbaum recommends treatment through what he calls the SHINE Protocol. “Ninety-one percent of fibro patients show improvement after following these steps,” he says. In the protocol, “S” stands for sleep.

“It’s essential that the body gets at least eight hours of sleep, even if it means helping it by using herbs, medication or other techniques,” explains Teitelbaum. “H” stands for hormonal support, as in taking supplements to support the thyroid and adrenal glands. “I” stands for infection because fibro patients often deal with a variety of infections. “N” stands for nutritional support, indicating the importance of a healthy diet, and “E” stands for exercising as able. While exercise typically helps, it is hard to do when dealing with intense exhaustion and muscles that are already complaining.

Cutting off Sleeves Lee’s life hasn’t been easy for some time. After a full life as an educator and syndicated newspaper columnist, he began to experience health problems. In 1990, he was diagnosed with multiple sclerosis. Later, he developed several types of arthritis. Everything got worse in 1995 when a speeding semi-truck loaded with a payload of stone broadsided him, burying him under 75 tons of rubble. “The police thought I was dead,” he admits. He almost was. It took six hours to extricate him. He spent a month in intensive care and six months in the hospital. When he appeared in the courtroom, he was still in a wheelchair and hooked up to an IV. “I was so out of it, I had no idea what was even going on. I got absolutely nothing.” It wasn’t until 2004 that Lee was diagnosed with fibro. Amazingly, after all his health problems, it is fibro that has had the most profound effect on his life. “This pain supersedes everything else,” he states. “There are spots on my arms that hurt so much I have had to cut off all the sleeves on my shirts. I can’t stand the touch of the fabric.”
Not much makes Lee feel better. He uses a massage pad in his chair but says he has to put several towels or blankets between the rollers and his skin or he can’t stand the pressure.
Each month Lee’s medications cost $3,000. After being unemployed for more than 14 years, this is money he simply does not have so he stopped taking most of the medication. “Each night I plan to do things the next day, but then it gets here, and I just can’t shake the exhaustion,” he explains. “I try to go out, but I can’t . . . often for days or even weeks on end. Fibromyalgia saps all my energy.” Lee lives alone and depends on his friends and daughter to stop by and help with chores. He spends a great deal of time in bed. “Mentally, there is so much I want to do,” he says, “but physically, it isn’t possible.”
Fibromyalgia is an unwelcome visitor that creeps in the body. It brings pain, fatigue, fog, and insomnia. Noticing it doesn’t take long; identifying it can take what seems like forever. Treatment is often a hit and miss process. Eviction is rarely possible, but sometimes, with a skillful doctor and appropriate treatments, a truce can reached.


*Excerpt : In addition to the genetic associations, various external stimuli such as infection, trauma and stress may contribute to development of the syndrome (see Table 3). Bennett and colleagues provided an Internet survey of 2,596 people with FM.[32] Approximately 21% of responders indicated that they could not identify any triggering events of their illness. Over 73% of those who indicated some triggering event made attributions to emotional trauma or chronic stress. The next most common attribution was acute illness (26.7%), followed by physical stressors (surgery, motor vehicle collisions, and other injuries). Various infectious agents have been linked to the development of FM as well as to that of the closely related chronic fatigue syndrome.

Viral agents, including hepatitis C and HIV, have been associated with FM on epidemiological and clinical grounds.[33,34] In particular cases, such as Lyme disease and HIV, obvious overlap of clinical manifestations can be described; nonetheless, evidence of the utility of antibiotic or antiviral treatment in FM or chronic fatigue syndrome is lacking.[35]
Various forms of physical trauma have been implicated as triggering events in the pathogenesis of FM. Increased rates of FM have been demonstrated among patients undergoing cervical trauma during motor vehicle accidents.[36] Most recently, Wynne-Jones and colleagues found a 7.8% frequency of widespread pain within 12 months among a cohort of patients who underwent a motor vehicle collision.[37] Emotional trauma and stress have also been implicated as triggers of FM. Post-traumatic stress disorder may precipitate the development of FM, and both conditions share similar pathogenic mechanisms.[38]

Clin Rheumatol. 2010 Dec;29(12):1373-80. Epub 2010 Apr 22.

Prevalence of rheumatologic manifestations of chronic hepatitis C virus infection among Egyptians/2010

Mohammed RH, Elmakhzangy HI, Gamal A, Mekky F, El Kassas M, Mohammed N, Hamid MA, Esmat G.Department of Rheumatology and Rehabilitation, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt,
Chronic hepatitis C virus (HCV) viremia has been known to provoke a plethora of autoimmune syndromes referred to as extrahepatic manifestations of chronic HCV infection. Aim of the current study was to assess the prevalence of rheumatologic manifestations among Egyptians with hepatitis C infection and its' association with cryoglobulin profile.

The current research represents a cross-sectional study where patients with chronic HCV infection attending the outpatient clinic of the National Hepatology and Tropical Medicine Research Institute over a period of 1 year were interviewed.

Patients with decompensated liver disease, on interferon therapy, having end-stage renal disease or coexisting viral infection like hepatitis B surface antibody positive patients were all excluded from the research. Laboratory investigations as well as serological assay including cryoglobulin profile, rheumatoid factor, antinuclear antibody, HCV-PCR were performed.

Three hundred and six patients having chronic HCV infection were interviewed in this research.

The overall estimated prevalence of rheumatologic manifestations in the current research was 16.39%

chronic fatigue syndrome 9.5%,
sicca symptoms 8.8%
arthralgia 6.5%
fibromyalgia 1.9%
myalgia 1.3%, arthritis 0.7%
cryoglobulinemic vasculitis 0.7%
autoimmune hemolytic anemia 0.7%
thrombocytopenia 0.7%.

Xerophthalmia was significantly present in male population (p = 0.04), whereas fibromyalgia, cryoglobulinemic vasculitis, arthritis, and autoimmune hemolytic anemia were significantly present in female population under study (p less then 0.05).

In chronic HCV genotype 4 infection, the prevalence of rheumatologic manifestations was 16.3% with chronic fatigue syndrome and sicca sysmptoms being the most common with no significant correlation to the degree of elevation of liver disease or viral load.
PMID: 20411290 [PubMed - in process]

Current Opinion in Rheumatology:
January 2010 - Volume 22 - Issue 1 - p 91-96
doi: 10.1097/BOR.0b013e328333ba5d
Systemic disorders with rheumatic manifestations:

Edited by Jonathan Kay

Rheumatic manifestations of hepatitis/2010
Vassilopoulos, Dimitrios; Manolakopoulos, Spilios


Purpose of the review: Rheumatic manifestations are commonly encountered in patients with hepatitis B virus (HBV) or C (HCV) infection. In this review the most common clinical rheumatic manifestations of HBV or HCV infection and their management will be critically presented with a special emphasis on the efficacy and safety of the new biologic agents.

Recent findings: Recent significant advances in the antiviral therapy of chronic hepatitis B and C as well as the emergence of new biologic therapies (anti-TNF agents, rituximab) for the treatment of rheumatic diseases have changed significantly the therapeutic approach for patients with rheumatic disorders in the setting of hepatitis B or C. For patients with hepatitis B, prophylactic antiviral therapy with oral antiviral agents (nucleoside or nucleotide analogues) is recommended for all cases in which immunosuppressive therapies are administered, whereas for severe hepatitis C-associated mixed cryoglobulinemia, a number of recent studies have shown the short-term safety and efficacy of rituximab.

Summary: Rheumatologists in collaboration with hepatologists have today an array of efficacious therapeutic options to explore for patients presenting with rheumatic disorders in the setting of a co-existent HBV or HCV infection. Appropriate pretreatment screening and close monitoring are essential for these difficult-to-treat patients.

Understanding fibromyalgia/2009

Rev Salud Publica (Bogota). 2009 Aug;11(4):662-74.

Restrepo-Medrano JC, Ronda-Pérez E, Vives-Cases C, Gil-González D.
Facultad de Enfermería, Universidad de Antioquia.


This study was aimed at describing the main features of articles published in scientific journals between 1992 and 2007 addressing the analysis of the etiological factors associated with this condition.


This consisted of a systematic review of scientific articles regarding this association using the following health and social science databases: Medline, Cinhal, Web of Science, Lilacs, Sociological Abstracts, Embase, Psycoinfo and ISI web of Knowledge.


21 articles were obtained during the study period, distributed as follows: 7 theoretical reviews (33.3 %), 6 cross-sectional studies (28.5 %), 4 cohort studies, (19.0 %) 2 case-control studies (9.5 %) and 1 systematic review (4.7 %). Of these, 7 (33.3 %) considered the following to risk factors to be associated with the emergence of other factors such as silicone implants, socio-demographic and hormonal factors: 3 on stress (14.3 %), 4 on hepatitis C (19.0 %), 3 on traumatic antecedents (14.3 %) and 4 on occupation (19.0 %). The most productive time was 2000-2004. There was broad thematic dispersion in the published journals.


Available empirical evidence about risk factors related to fibromyalgia is still scarce and scattered. Future studies should focus on generating more knowledge about the risk factors studied so as to help improve fibromyalgia care, diagnosis and treatment.
PMID: 20169222 [PubMed - indexed for MEDLINE]Free Article


Study Highlights New Way to Diagnose Fibromyalgia
And It Doesn’t Include a Tender Point Exam

Researchers found that testing for fibromyalgia using a widespread pain index and a measurement of the number and severity of symptoms leads to a more accurate fibromyalgia diagnosis than the commonly used tender point examination.
Researchers sought to develop updated criteria for diagnosing fibromyalgia that does not warrant a tender point examination, and their findings were published in the May 2010 issue of Arthritis Care & Research.
To create the new diagnostic criteria, the researchers developed a widespread pain index (WPI). The WPI is a 19-item checklist that tracks where a patient feels pain. Additionally, the researchers created a symptom severity scale to measure the amount and intensity of the patient’s symptoms.

The researchers hoped that by understanding the painful areas, in addition to the number and severity of the symptoms, they would create a more comprehensive diagnostic method that can detect fibromyalgia more accurately than the tender point exam that’s traditionally used.
To test the new criteria, the researchers conducted a multi-center study of 829 people who had fibromyalgia and a control group of people who had other pain disorders. The researchers found that the combination of the pain index, number of symptoms, and severity of symptoms provided the most accurate fibromyalgia diagnosis.
The researchers reported that the new criteria will correctly diagnose more than 88% of people with fibromyalgia—and that’s without a tender point examination.

Getting a solid fibromyalgia diagnosis is still a fairly new concept, as much of the medical community had once dismissed the disorder as merely a figment of the imagination. But the new diagnostic criteria, which have the support of the American College of Rheumatology, help legitimatize fibromyalgia.

If you would like to learn more about the updated fibromyalgia diagnosis criteria, read the study abstract here.
A new study found that there are significant benefits of Tai Chi for individuals with all types of arthritis, including fibromyalgia, rheumatoid arthritis and ...
The Hepatitis C Connection/2009
*Excerpt: Although not yet confirmed, many experts believe that Hepatitis C may act as a trigger to the onset of fibromyalgia. The documented links between the two conditions include: · Symptom Specificity – Fibromyalgia and chronic Hepatitis C infection share many clinical features including musculoskeletal pain and fatigue. While the two conditions do not always accompany each other, some symptoms may be unique when a person has both fibromyalgia and Hepatitis C. One study found that people dually diagnosed with fibromyalgia and Hepatitis C exhibit symptoms such as inflammation around a joint, bursa and/or tendon, and vasculitis (blood or lymph vessel inflammation) that are not seen in Hepatitis C negative people with fibromyalgia.
· Immune Proteins – Cytokines are proteins that regulate immune response. Interleukins are a specific type of cytokine that cause a person to feel pain. Several interleukins have been found to be dramatically elevated in fibromyalgia patients. Harvard researchers found those same interleukins increased in production when exposed to the Hepatitis C virus.· Hepatitis C and Pain – Many people infected with Hepatitis C virus infection complain of myalgias, arthritis and widespread pain. When compared to other liver diseases, the frequency of musculoskeletal pain clearly favors Hepatitis C. The frequencies of musculoskeletal pain for the following isolated conditions are as follows: Alcoholic liver disease = 48 percent, Hepatitis B = 59 percent and Hepatitis C = 91 percent. As fibromyalgia’s most prominent symptom, it is not surprising that musculoskeletal pain may represent the link to Hepatitis C.