Rodrigo Pegado de Abreu Freitas

Influence of cortisol and DHEA-S on pain and other symptoms in post menopausal women with fibromyalgia

OBJECTIVE This study aims to assess cortisol and dehydroepiandrosterone sulfate (DHEA-S) levels in post-menopausal women with FMS and correlate it with pain threshold and tolerance, depression and quality of life. METHODS We conducted a cross sectional observational study of 17 women with FMS (FMS group), and 19 healthy volunteers (CT group). Algometry, the Beck Depression Index (BDI) and Fibromyalgia Impact Questionnaire (FIQ) were used. Blood samples were collected in the morning (8:00-9:30 am) to determine cortisol and DHEA-S plasmatic levels by chemiluminescence. RESULTS Significant differences between groups were recorded for pain threshold and tolerance (p< 0.0001), BDI (p< 0.0001) and all FIQ parameters (p< 0.0001). No significant differences in cortisol levels were found between the two groups (p=0.325). In the FMS group, a tangential effect was observed for DHEA-S (p=0.094) and positive correlations were found between DHEA-S, pain threshold (p=0.017) and pain tolerance (p=0.044). No correlation was observed between cortisol and DHEA-S levels and the variables of depression and quality of life for either group. CONCLUSIONS There seems to be an influence of the decreased levels of DHEA-S and increased pain sensitivity in post-menopausal women with FMS.

Is there a difference in the electromyographic activity of the pelvic floor muscles across the phases of the menstrual cycle

[Purpose] To evaluate the electrical activity of the pelvic floor muscle in women during the follicular, ovulatory, and luteal phases of the menstrual cycle and its correlation with estradiol and total testosterone levels. [Subjects and Methods] This cross-sectional study involved 30 women with ovulatory menstrual cycles. Total testosterone and estradiol levels were measured and the muscle tone and maximum voluntary contraction of the pelvic floor muscles were evaluated using surface electromyography. [Results] Muscle tone was significantly lower during the follicular (21.1±3.3 μV) and ovulatory (27.1±5.9 μV) phases than the luteal phase (30.4±4.1 μV). The maximum voluntary contraction was not different across phases. The estradiol level on the 7th day of the menstrual cycle showed a strong positive correlation with muscle tone and maximum voluntary contraction, and the testosterone level was positively correlated with muscle tone on the 21st day. [Conclusion] Women have better muscle tone during the luteal phase. The muscle tone and maximum voluntary contraction were strongly correlated with the estradiol level on the 7th day, and the muscle tone was correlated with the testosterone level on the 21st day of the menstrual cycle. These findings suggest that hormonal fluctuations during the menstrual cycle alter pelvic floor muscle activity.

Transcutaneous electrical nerve stimulation (TENS) and exercise: strategy in fibromyalgia treatment.

We read with great interest the recent manuscript by Mutlu et al. [1] entitled ‘‘Efficacy of supervised exercise combined with transcutaneous electrical nerve stimulation in women with fibromyalgia: a prospective controlled study.’’ The authors investigate the results of a supervised exercise with transcutaneous electrical nerve stimulation (TENS) in an exercise-controlled study in women with fibromyalgia. The study showed that monitored exercise program was successful to decrease myalgic pain, improve functional capacity and quality of life of women with fibromyalgia, and that combined use of TENS and exercise can promote rapid relief of myalgic pain in the treatment for fibromyalgia. The importance of this type of study is unquestionable, since fibromyalgia covers a considerable part of the worldwide population [2, 3], and we are still in the ongoing study of the establishment of strategies to increase patients’ adherence to exercise. The exercise is a low-cost intervention that can promote health benefits in several ways and can relieve symptoms of fibromyalgia [4]. However, we believe that the use of gate control theory through TENS possibly had an effect on reducing pain due to completion of exercise, since this population is more susceptible to manifestations of muscle fatigue that may increase his pain and interfere with adherence to exercise, especially in the early stages of a physical training. Nevertheless, there are numerous evidences that pain in fibromyalgia has no peripheral sensory or muscular origin [5, 6]. Authors [6] describe that such responses suggest that these individuals have a fundamental problem with pain or sensory processing rather than an abnormality confined to the region of the body where pain is experienced. Many patients course with a set of symptoms that focus the presence of the central nervous system as a protagonist, and it is probable that the neurobiological changes found in the syndrome have its etiology in this system [3, 4]. Therefore, if the pain from fibromyalgia is possibly caused by central sensory disturbances, how the TENS could act on this system? Transcutaneous electrical nerve stimulation is, in fact, a form of noninvasive electrical stimulation able to control the pain; however, the mechanisms of action depend on the manipulable parameters, specifically the frequency and intensity of the pulses of current [7]. TENS in the parameters used in the study would act in a more peripheral level through the theory of ascending spinal locks initially proposed by Melzack and Wall [8] and thus has a more immediate effect (during application) and less permanent. This questioning is reinforced, mainly because of the fact that TENS has been used in different period (morning) of the execution of the exercise (afternoon). Mutlu et al. [1] present an immediate effect with the conventional TENS, which did not last throughout the exercise sessions. We believe that TENS in your BURST mode (pulse trains of high frequency modulated to low frequency) would be more appropriate since the mechanism of action involves the release of endogenous opioids [9, 10] and thus involves the central nervous system components whose effects would be more durable and suitable for chronic pain typical of fibromyalgia. This in turn could determine a lower frequency of use of equipment that unlike the one used in the study (daily use) could only happen on days the exercise takes place once the effects are more permanent. We focus that the TENS possibly decreases persistence of nociceptive inputs in peripheral tissue and the arrival of S. C. Andrade R. P. A. Freitas (&) W. H. de Brito Vieira Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil e-mail: rodrigopegado@gmail.com

Agreement in cardiovascular risk rating based on anthropometric parameters.

Objective To investigate the agreement in evaluation of risk of developing cardiovascular diseases based on anthropometric parameters in young adults. Methods The study included 406 students, measuring weight, height, and waist and neck circumferences. Waist-to-height ratio and the conicity index. The kappa coefficient was used to assess agreement in risk classification for cardiovascular diseases. The positive and negative specific agreement values were calculated as well. The Pearson chi-square (χ2) test was used to assess associations between categorical variables (p<0.05). Results The majority of the parameters assessed (44%) showed slight (k=0.21 to 0.40) and/or poor agreement (k<0.20), with low values of negative specific agreement. The best agreement was observed between waist circumference and waist-to-height ratio both for the general population (k=0.88) and between sexes (k=0.93 to 0.86). There was a significant association (p<0.001) between the risk of cardiovascular diseases and females when using waist circumference and conicity index, and with males when using neck circumference. This resulted in a wide variation in the prevalence of cardiovascular disease risk (5.5%-36.5%), depending on the parameter and the sex that was assessed. Conclusion The results indicate variability in agreement in assessing risk for cardiovascular diseases, based on anthropometric parameters, and which also seems to be influenced by sex. Further studies in the Brazilian population are required to better understand this issue.

Evaluation of the relationship between the pelvic floor muscles and insulin resistance.

Purpose The aim of this study was to evaluate the pelvic floor muscles (PFMs) in women with insulin resistance (IR) using surface electromyography and to associate the results with insulin levels. Patients and methods Through an analytical, cross-sectional study, 86 women were evaluated and divided into two groups: a control group (n=35) and an IR group (n=51). Data were collected through detailed history-taking, physical examination, and biochemical analysis. Fasting insulin levels were used for diagnosing IR. Electromyography of the PFMs was used for analyzing the tone and maximal voluntary contraction (MVC). The measures of central tendency and linear regression models were used. Results The average age was 25.3±4.5 years in the IR group and 27.2±4.4 years in the control group. The mean weight was 75.6±17.6 kg and 51.8±4.9 kg in the IR and control groups, respectively. Fasting insulin levels were 19.7±6.6 µIU/mL in the IR group and 5.4±1.8 µIU/mL in the control group (P<0.010). There were significant differences between the groups with regard to PFM tone (IR: 13.4±3.4 µV; control: 25.1±3.3 µV; P<0.001) and MVC (IR: 47.6±4.5 µV; control: 64.3±5.0 µV; P<0.001). Multiple linear regression analysis using the insulin levels as dependent variable showed a significant association for MVC (P=0.047), weight (P=0.017), and waist circumference (P=0.000). Conclusion Compared with the control group, the IR group showed lower electromyographic activity of the PFMs, and there was an association between insulin levels and electromyographic activity.

ESTIMATION OF BODY MASS INDEX FROM SELF-REPORTED MEASURES: WHAT IS THE VALIDITY?

The aim of this study was to evaluate the use of self-reported measures for calculating body mass index (BMI) and nutritional status. A cross-sectional quantitative study was conducted on 1,000 students. Body weight and height were measured by a trained evaluator and were obtained by self-report of the participants. There was a trend towards underestimation of body weight by 0.3 kg and overestimation of height by 1.0 cm, which resulted in lower self-reported BMI compared to measured BMI (p <0.001; r = 0.34). Analysis of agreement with measured BMI showed very high reliability of self-reported BMI. The evaluation of nutritional status based on measured BMI resulted in an increase in the percentage of eutrophic individuals (+2.3%) and a decrease in obese individuals (-3.2%). This decrease was greater among men (-6.1%). A change in nutritional status classification occurred in 14.5% of the participants when evaluated by self-reported BMI. In conclusion, there is good agreement between self-reported and measured BMI, but the results suggest caution in the use of self-reported BMI alone or as a continuous variable. Categorized information seems to be more appropriate for the classification of nutritional status.

Impacts of social support on symptoms in Brazilian women with fibromyalgia.

We aimed to assess the impact of social support on symptoms in Brazilian women with FM. An observational, descriptive study enrolling 66 women who met the 1990 American College of Rheumatology (ACR) criteria. Social support was measured by the Social Support Survey (MOS-SSS), functionality was evaluated using the Fibromyalgia Impact Questionnaire (FIQ), depression was assessed using the Beck Depression Inventory (BDI), anxiety was measured using the Hamilton Anxiety Scale (HAS), affectivity was measured by Positive and Negative Affect Schedule (PANAS), and algometry was carried out to record pressure pain threshold (PPth) and tolerance (PPTo) at 18 points recommended by the ACR. Patients were divided into normal (NSS) or poor social support (PSS) groups with PSS defined as having a MOS-SSS score below the 25th percentile of the entire sample. Mann-Whitney or Unpaired t-test were used to compare intergroup variables and Fishers for categorical variables. Analysis of covariance and Pearson correlation test were used. No differences in sociodemographic variables between PSS and NSS were found. Differences between NSS and PSS groups were observed for all four subcategories of social support and MOS-SSS total score. Significant differences between NSS and PSS on depression (p=0.007), negative affect (p=0.025) and PPTh (p=0.016) were found. Affectionate subcategory showed positive correlation between pain and positive affect in PSS. Positive social interaction subcategory showed a negative correlation between FIQ and depression state. Therefore social support appears to contribute to ameliorate mental and physical health in FM.

Pain and associated symptoms: comparison between fibromyalgia and temporomandibular disorder

BACKGROUND AND OBJECTIVES: Fibromyalgia has multivariate symptoms, also affecting temporomandibular region. This study aimed at comparing facial signs and symptoms of females with fibromyalgia and females with temporomandibular disorder. METHODS: This is a crossover study with 61 females divided in two groups: fibromyalgia group (31) and temporomandibular disorder group (30). Evaluated variables in all patients were: pain intensity in temporomandibular joint by means of visual analog scale, report of pain or discomfort during daily activities (mouth opening/closing, during meals, when talking), presence of joint noises (clicking and popping), dizziness, tinnitus, headache and mouth opening capacity. Variables were compared by unpaired t and Chi-square tests. RESULTS: Facial pain was reported by 100% of studied patients with no difference in intensity among fibromyalgia and temporomandibular disorder groups (p=0.2170). Fibromyalgia group has reported more pain during daily life activities as compared to temporomandibular disorder group (p<0.0001). With regard to joint noises, there has been more right temporomandibular joint clicking (p=0.006) in the temporomandibular disorder group. Fibromyalgia group patients have higher percentage of signs and symptoms associated to temporomandibular disorder, such as dizziness, tinnitus and headache (p<0.000). CONCLUSION: Fibromyalgia patients have clinical signs and symptoms similar to those found in temporomandibular disorder patients, being pain, discomfort during daily activities, tinnitus, hum and headache more exacerbated in the fibromyalgia group.

Relationship between pelvic floor muscle and hormone levels in polycystic ovary syndrome.

To evaluate the electrical activity of the pelvic floor muscles (PFM) in women with polycystic ovary syndrome.

Vascular physiotherapy: a strategy for treatment of chronic venous disease

The study was carried out at Universidade Federal do Rio Grande do Norte (UFRN), Natal, RN, Brazil. We read with great interest the recent manuscript by Leal et al.1 entitled “Vascular physiotherapy in treatment of chronic venous disease”. The authors investigate the results of a supervised rehabilitation protocol including warm-up, training and relaxation. The training protocol consisted of vascular kinesiotherapy using manual lymph drainage and resistance and aerobic exercises. The importance of this type of study is unquestionable since chronic venous disease (CVD) affects a considerable proportion of the worldwide population and can involve chronic wounds and disability.2 This is an initial treatment for CVD and its aim is to reduce symptoms and help prevent the development of secondary complications and disease progression.3 However, another preliminary therapeutic option for all CEAP clinical classes of CVD is continuous compression therapy.3 In this case, the objective is to administer graded external compression to the leg, opposing the hydrostatic forces of venous hypertension.3 A number of compression garments are available including elastic compression stockings, multilayer elastic wraps, dressings, elastic and nonelastic bandages and nonelastic garments.3 The American College of Phlebology strongly recommends compression therapy as an effective method for the management of symptoms related to CVD.4 These recommendations apply to most patients in most circumstances without reservations.3,4 It is clear that the results of the treatment protocol applied by Leal et al.1 were good, but they could have been enhanced by addition of elastic compression stockings or nonelastic bandages worn during the exercise protocol and afterwards.5 Treatment with 30 to 40 mm Hg compression stockings results in significant improvement in pain, swelling, skin pigmentation, activity, and well-being if compliance of 70% to 80% is achieved.5 Compression stockings have been shown to reduce the residual volume fraction, which is an indicator of improved calf muscle pump function, and they also reduce reflux in vein segments.5 Another important question is standardization of exercises prescribed for CVD. Structured exercise improves calf muscle pump function in chronic venous insufficiency and the efficacy of physical conditioning has been convincingly demonstrated in patients with chronic venous disease, but none of the practice guidelines for treatment of chronic venous disease describe the aerobic or strength training used in detail.5-7 Perhaps this is the reason Leal et al.1 did not provide details of the aerobic and resistance exercises prescribed. If the objective of physical treatment is to improve calf muscle pump function, we suggest following the American College of Sports Medicine’s guidelines for exercise prescription.7 These recommendations may also be applied to adults with certain chronic diseases or disabilities, when appropriately evaluated and advised by a health professional. In conclusion, the vascular physiotherapy protocol for treatment of chronic venous disease conducted by Leal et al.1 achieved important results and could be enhanced with compression garments. The protocol with resistance and aerobic exercises could have been explained in greater detail in order that it could be reproduced by other health professionals.