By Robert M. Bennett, MD, FRCP
Journal: J of Musculoskeletal Pain, Vol. 9 (4), 2001, pp. 99-123
Affiliation: Professor of Medicine, Chairman, Division of Arthritis and Rheumatic Diseases, Department of Medicine [L 329 A], Oregon Health Sciences University, Portland, OR 97201.
There has been a flurry of interesting papers over the last months that are relevant to understanding the etiology of fibromyalgia. The central theme of these papers is the diversity of nociceptive stimuli that can lead to central sensitization. The papers covered in this review include: defective muscle relaxation, extracapsular silicone, osteoarthritis, bladder irritation, irritable bowel syndrome, pelvic pathology, and enteroviral infections. A clinical article reported a 21 percent prevalence of widespread pain 115 percent meeting American College of Rheumatology criteria for fibromyalgia] in hospitalized Israeli patients. There were only a few relevant treatment articles, one notable report showed chronic noncancer pain patients preferred transdermal fentanyl over long acting oral morphine.
The Prevalence of Musculoskeletal Pain and Fibromyalgia in Patients Hospitalized on Internal Medicine Wards. Buskila D, Neumann L, Odes LR, Schleifer E, Depsames R, Abu-Shakra M. Semin Arthritis Rheum 30(6):411-417, 2001.
This study evaluated the prevalence of widespread and regional nonarticular pain in 524 hospitalized Israeli patients. Overall, 62 percent of hospitalized patients reported pain. Of these, 95 percent said they had chronic pain. Chronic widespread pain was reported by 21 percent of patients and 15 percent fulfilled 1990 American College of Rheumatology criteria of fibromyalgia [95 percent female]. Chronic regional pain was even more common, being reported by 36 percent of the patients. Patients with widespread chronic pain were more likely to: have sleep disturbances, headaches, fatigue, and use more drugs. Furthermore, they had, more office consults,with their family physician, the average number of visits being 6.2 per year.
This is an important study for all physicians. If one accepts contemporary ideas regarding fibromyalgia being a disorder of sensory processing in terms of central sensitization, this study provides evidence that a substantial subset of hospitalized patients will experience amplified sensations which will color their symptom reporting. Thus it would be important for attending physicians and others to identify such patients in order to optimize symptom relief. The identification of such patients is certainly not a current practice, as most physicians are blissfully unaware of the concept of central sensitization.
Chronic Illness-A Disruption in Life: Identity-Transformation Among Women with Chronic Fatigue Syndrome and Fibromyalgia. Asbring P. J Adv Nurs 34(3):312-319, 2001.
Thirteen Swedish women with fibromyalgia and 12 with chronic fatigue syndrome were interviewed to determine the nature of the existential crisis they have experienced and their success in adapting to their new identities. The main conclusions was that having fibromyalgia profoundly affected their personal identity, particularly in relation to work and social life. For most women, loss of identity was partial rather than total, and required varying degrees of personal change. Not all change of identity was deleterious, as some women experienced gains in terms of personal development and positive reassessments of their life’s worth.
For most of us, for most of our lives the expectation and reality has been recovery from illness. Patients with incurable chronic disorders often experience a personal crisis when they first realize the reality of having a given diagnosis. In my experience, this existential crisis usually lasts between one and three years. During this time it is difficult for the patient to make much progress until they have come to terms with accepting the given diagnosis. Patients differ widely in their ability to cope with the new reality, and may need help in improving coping strategies and maintaining a positive mindset. The observation that there may be some positive identity changes is an important concept that can be used to advantage in cognitive behavioral therapy.
Predicting Complaints of Impaired Cognitive Functioning in Patients with Chronic Pain. McCracken LM, Iverson GL. J Pain Symptom Manage 21(5):392-396, 2001.
Two hundred and seventy-five patients attending a university pain management center completed questionnaires relating to: cognitive functioning, pain severity and location, sleep quality, medication use, litigation status, anxiety, and depression. Overall, 54 percent of chronic pain patients complain of cognitive difficulties. The most common complaints are shown in the following table:
Frequencies of Cognitive Complaints [percent]
Forgetting a lot, recent things, appointments 23.4
Minor accidents 23.1
Not finishing things started 20.5
Not keeping attention on activity 18.7
Difficulty with concentration and thinking 17.2
Making mistakes 15.4
Difficulty reasoning and problem-solving 12.8
Reacting slowly 9.2
Behaving confused or disoriented 9.2
A correlation analysis showed the use of antidepressants, pain intensity, and the presence of pain related anxiety were most closely associated with total cognitive dysfunction. Age, pain duration, use of tranquilizers, and involvement in litigation were not significantly associated with cognitive complaints.
It is not clear how many of these chronic pain patients would have fulfilled the 1990 American College of Rheumatology criteria for a diagnosis of fibromyalgia. However, given the fact that cognitive dysfunction is commonly reported in fibromyalgia patients, it seems reasonable to assume that there are etiological factors that are common to all chronic pain states. It would have been interesting to determine whether depressed patients who were adequately treated with antidepressants have the same degree of cognitive dysfunction. Future studies should try to isolate the effects of reduced motivation and the distractions of psychological distress.
© 2001 by The Haworth Press, Inc. All rights reserved.