Sandra Cristina de Andrade

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

Benefícios da talassoterapia e balneoterapia na fibromialgia

Talassoterapia e balneoterapia sao modalidades terapeuticas utilizadas ha varios anos em outras regioes do mundo na prevencao e no tratamento de diversas enfermidades, incluindo doencas reumaticas. No entanto, so recentemente tem sido descritas na literatura em fibromialgia (FM), contribuindo para a reducao da dor e de outros sintomas da doenca e melhorando a qualidade de vida dos pacientes. Nesta revisao sao relatados os principais estudos que avaliam a talassoterapia e/ou a balneoterapia como abordagem terapeutica na FM, abordando aspectos a serem investigados no intuito de estabelecer o valor dessa forma de tratamento. Os autores ainda destacam a necessidade da realizacao de estudos no Brasil, utilizando principalmente a talassoterapia, uma vez que o baixo custo, aliado ao facil acesso de boa parte das pessoas ao litoral, podem beneficiar pacientes com FM.

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.

Pressure pain endurance in women with fibromyalgia

BACKGROUND AND OBJECTIVES:Fibromyalgia syndrome is a chronic condition causing spontaneous widespread pain associated with hypersensitivity. This study aimed at investigating the pressure pain endurance in women with fibromyalgia syndrome to determine the range of painful stimulation that an individual with fibromyalgia syndrome can resist acceptably.METHODS:We conducted an observational, descriptive, crosssectional study with 60 subjects (51.23±8 years), who met the American College of Rheumatology/1990 (ACR) criteria for fibromyalgia syndrome, and 42 healthy volunteers (48.33±9 years) as the control group. Algometry was performed to record pressure pain detection threshold and pressure pain tolerance, and fibromyalgia impact questionnaire was used to determine the impact of fibromyalgia syndrome. Pressure pain endurance was calculated as the arithmetic difference between pressure pain tolerance and pressure pain detection threshold.RESULTS:A significant difference in fibromyalgia impact questionnaire (p<0.0001), pressure pain detection threshold, and pressure pain tolerance (p<0.0001) was found between both groups. Furthermore, a significant difference in pressure pain endurance (p<0.0001) for each of the 18 points identified by ACR was noted between both groups, with the highest range of physical stimulation observed in the control group. A correlation between pressure pain endurance and pressure pain detection threshold (r=0.8334; p<0.0001) and pressure pain tolerance (r=0.8387; p< 0.0001) was observed in the fibromyalgia syndrome group.CONCLUSION:Pressure pain endurance of the fibromyalgia syndrome group was extremely lower, when compared with that of healthy controls, and may be used as an additional component to measure the disturbance in pain perception and to determine the range of painful stimulation that an individual with fibromyalgia syndrome can acceptably resist.