Samantha J. McAllister

Beyond pain in fibromyalgia: insights into the symptom of fatigue.

Fatigue is a disabling, multifaceted symptom that is highly prevalent and stubbornly persistent. Although fatigue is a frequent complaint among patients with fibromyalgia, it has not received the same attention as pain. Reasons for this include lack of standardized nomenclature to communicate about fatigue, lack of evidence-based guidelines for fatigue assessment, and a deficiency in effective treatment strategies. Fatigue does not occur in isolation; rather, it is present concurrently in varying severity with other fibromyalgia symptoms such as chronic widespread pain, unrefreshing sleep, anxiety, depression, cognitive difficulties, and so on. Survey-based and preliminary mechanistic studies indicate that multiple symptoms feed into fatigue and it may be associated with a variety of physiological mechanisms. Therefore, fatigue assessment in clinical and research settings must consider this multi-dimensionality. While no clinical trial to date has specifically targeted fatigue, randomized controlled trials, systematic reviews, and meta-analyses indicate that treatment modalities studied in the context of other fibromyalgia symptoms could also improve fatigue. The Outcome Measures in Rheumatology (OMERACT) Fibromyalgia Working Group and the Patient Reported Outcomes Measurement Information System (PROMIS) have been instrumental in propelling the study of fatigue in fibromyalgia to the forefront. The ongoing efforts by PROMIS to develop a brief fibromyalgia-specific fatigue measure for use in clinical and research settings will help define fatigue, allow for better assessment, and advance our understanding of fatigue.

A cross-sectional assessment of the prevalence of multiple chronic conditions and medication use in a sample of community-dwelling adults with fibromyalgia in Olmsted County, Minnesota

Objectives The objective of this study was to evaluate the problem of multiple chronic conditions and polypharmacy in patients with fibromyalgia. Design Retrospective medical record review. Setting Olmsted County, Minnesota. Participants 1111 adults with fibromyalgia. Primary and secondary outcome measures Number and type of chronic medical and psychiatric conditions, medication use. Results Medical record review demonstrated that greater than 50% of the sample had seven or more chronic conditions. Chronic joint pain/degenerative arthritis was the most frequent comorbidity (88.7%), followed by depression (75.1%), migraines/chronic headaches (62.4%) and anxiety (56.5%). Approximately, 40% of patients were taking three or more medications for symptoms of fibromyalgia. Sleep aids were the most commonly prescribed medications in our sample (33.3%) followed by selective serotonin reuptake inhibitors (28.7%), opioids (22.4%) and serotonin norepinephrine reuptake inhibitors (21.0%). Conclusions The results of our study highlight the problem of multiple chronic conditions and high prevalence of polypharmacy in fibromyalgia. Clinicians who care for patients with fibromyalgia should take into consideration the presence of multiple chronic conditions when recommending medications.

A comparison of fibromyalgia symptoms in patients with Healthy versus Depressive, Low and Reactive affect balance styles

Abstract Background and aims Affect balance reflects relative levels of negative affect (NA) and positive affect (PA) and includes four styles: Healthy (low NA/high PA), Depressive (high NA/low PA), Reactive (high NA/high PA) and Low (low NA/low PA). These affect balance styles may have important associations with clinical outcomes in patients with fibromyalgia. Herein, we evaluated the severity of core fibromyalgia symptom domains as described by the Outcomes Research in Rheumatology-Fibromyalgia working group in the context of the four affect balance styles. Methods Data from 735 patients with fibromyalgia who completed the Brief Pain Inventory, Multidimensional Fatigue Inventory, Profile of Mood States, Medical Outcomes Sleep Scale, Multiple Ability Self-Report Questionnaire, Fibromyalgia Impact Questionnaire-Revised, Medical Outcomes Study Short Form-36, and Positive and Negative Affect Schedule were included in this analysis. Results The majority (51.8%) of patients in our sample had a Depressive affect balance style; compared to patients with a Healthy affect balance style, they scored significantly worse in all fibromyalgia symptom domains including pain, fatigue, sleep disturbance, dyscognition, depression, anxiety, stiffness, and functional status (P = <.001 to .004). Overall, patients with a Healthy affect balance style had the lowest level of symptoms, while symptom levels of those with Reactive and Low affect balance styles were distributed in between those of the Depressive and Healthy groups. Conclusions and implications The results of our cross-sectional study suggest that having a Healthy affect balance style is associated with better physical and psychological symptom profiles in fibromyalgia. Futures studies evaluating these associations longitudinally could provide rationale for evaluating the effect of psychological interventions on affect balance and clinical outcomes in fibromyalgia.

Psychological Resilience, Affective Mechanisms and Symptom Burden in a Tertiary-care Sample of Patients with Fibromyalgia.

Research demonstrates that patients with fibromyalgia who have higher positive and lower negative affect have lower symptom burden. Affect has been shown to be associated with resilience. This study examined the relationship between affect, resilience and fibromyalgia symptom burden in a clinical sample of patients with fibromyalgia. We hypothesized that (a) positive and negative affect would be associated with fibromyalgia symptom burden; (b) resilience would be associated with positive and negative affect; (c) resilience would be associated with fibromyalgia symptom burden; and (d) the connection between resilience and fibromyalgia symptom burden would be mediated by both positive and negative affect. A sample of 858 patients with fibromyalgia completed questionnaires. Mediation modelling revealed statistically significant direct effects of resilience on fibromyalgia symptom burden (β = -0.10, P < 0.001) and statistically significant indirect effects of resilience on fibromyalgia symptom burden through affect (β = -0.36, P < 0.001), suggesting that both resilience and affect influence fibromyalgia symptom burden. Our results suggest that improving affect through resiliency training could be studied as a modality for improving fibromyalgia symptom burden.

Effects of transdermal magnesium chloride on quality of life for patients with fibromyalgia: a feasibility study

BACKGROUND Fibromyalgia is a syndrome characterized by chronic pain, fatigue, depression, and sleep disturbances. Its primary cause is unclear. Several studies have reported decreased intracellular magnesium levels in patients with fibromyalgia and have found negative correlation between magnesium levels and fibromyalgia symptoms. OBJECTIVE To gather preliminary data on whether transdermal magnesium can improve quality of life for women who have fibromyalgia. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS This is a patient questionnaires and survey in a fibromyalgia clinic at a tertiary medical center. Forty female patients with the diagnosis of fibromyalgia were enrolled. Each participant was provided a spray bottle containing a transdermal magnesium chloride solution and asked to apply 4 sprays per limb twice daily for 4 weeks. Participants were asked to complete the Revised Fibromyalgia Impact Questionnaire, SF-36v2 Health Survey, and a quality-of-life analog scale at baseline, week 2, and week 4. MAIN OUTCOME MEASURE Questionnaire and survey scores, evaluated through intent-to-treat and per-protocol analyses. RESULTS Twenty-four patients completed the study (mean [SD] age, 57.2 [7.6] years; white, 95%; mean body mass index, 31.3 kg/m2). With intention-to-treat analysis, Revised Fibromyalgia Impact Questionnaire subscale and total scores were significantly improved at week 2 and week 4 (total score, P=0.001). Per-protocol analysis results were similar: all subscales of the Revised Fibromyalgia Impact Questionnaire were significantly improved at week 2 and week 4 (total score, P=0.001). CONCLUSION This pilot study suggests that transdermal magnesium chloride applied on upper and lower limbs may be beneficial to patients with fibromyalgia. TRIAL REGISTRATION ClinicalTrials.gov.ldentifier NCT01968772.

Intra- and Inter-Patient Symptom Variability in Fibromyalgia: Results of a 90-Day Assessment.

Symptoms of fibromyalgia (FM)--chronic widespread pain, fatigue, unrefreshing sleep, dyscognition etcetera--present with varying degrees of severity in different individuals; however, studies reporting daily estimates of variability of symptoms are sparse. Given the limited literature on the stability and variability of FM symptoms, the purpose of the present study was to determine the feasibility of daily visual analogue, self-report measures to assess daily variability and time trends in core FM symptoms. Ten female patients completed daily assessments of common FM symptoms (pain, fatigue, anxiety, depression, stress, cognitive dysfunction, unrefreshing sleep and lightheadedness) for approximately 90 days. The completion rate was excellent (89.6%). The results demonstrated that average symptom intensity differs markedly across the different symptoms that were measured. Unrefreshing sleep, fatigue and pain are clearly higher in intensity than other symptoms and are followed by memory problems, stress, anxiety and depression. There is also notable average intra-individual change across time (10-15 points on a 100-point scale). Average symptom intensity does not appear to be related to the amount of symptom change within individuals. The results of the present study confirm that intensive longitudinal study, using comprehensive symptom assessment in patients with FM, is both possible and informative, in the sense that a rich description of the daily experience of living with FM can be obtained. Future work, utilizing larger samples, will offer the opportunity to investigate better the causes, consequences and correlates of the daily ups and downs of key symptoms that compromise quality of life in patients with FM.

A report of the autonomic symptom profile in patients with fibromyalgia.

Autonomic dysregulation is thought to contribute to the pathophysiology and symptoms in patients with fibromyalgia (FM). The majority of studies in FM that have reported autonomic dysregulation have relied on heart rate variability measurement and report increased sympathetic and decreased parasympathetic tone, chronotropic incompetence, and impaired autonomic cardiovascular regulation with blunted sympathetic reactivity to acute stress. 1Y3 These results may have clinical implications as increased sympathetic tone contributes to symptoms such as muscle tension and pain, fatigue, heightened stress response, and unrefreshing sleep, all common patient-reported symptoms in FM. 1,3Y6 The Autonomic Symptom Profile (ASP) is a validated selfreport questionnaire that comprehensively assesses autonomic symptoms across 11 subscales and yields a Composite Autonomic Symptoms Scale (COMPASS) score. 7 The ASP is unique in comparison to other commonly utilized self-report measures in that it assesses both symptoms and functional status. For example, the secretomotor subscale of the ASP assesses secretomotor symptoms such as sweating with vigorous exercise, ability to tolerate heat, and mucosal secretory dysfunction including dry eyes and dry mouth. 8 Similarly, the pupillomotor subscale of the ASP assesses pupillomotor symptoms such as light sensitivity, visual blurring, and dysfunction pupillomotor including trouble focusing eyes and difficulty seeing at night. 8 The ASP also includes a sleep subscale that evaluates presence of sleep disorders such as narcolepsy, obstructive sleep apnea, and abnormal sleeping patterns in addition to assessment of sleep quality. This is relevant as sleep and autonomic function are interdependent by virtue of their common controls, regulatory neurochemicals, and functions, but also because unrefreshing sleep is a predominant complaint in patients with FM. 9,10 There is one previous report utilizing the ASP in patients with FM. In this study, the Spanish version of the ASP was administered to 20 patients with FM, and results were compared with those of 30 patients with rheumatoid arthritis and 30 control subjects. 11 Patients with FM had the highest COMPASS scores in comparison with patients with rheumatoid arthritis and control subjects. In addition, total COMPASS scores correlated with FIQ total scores, suggesting a potential association between FM severity and autonomic dysfunction. 11 Our objective was to assess autonomic symptoms utilizing the ASP and their correlation with the Fibromyalgia Impact QuestionnaireYRevised (FIQ-R) in a large sample of patients with FM. METHODS Participants