Friday, February 15, 2013

Fibromyalgia at the ACR 2012 in Washington

Fibromyalgia has been an important issue for me at the ACR 2012 in Washington. As there have been 65 abstracts on fibromyalgia, I have to select a few.

Robert S. Katz and colleagues looked at: "Events That Trigger the Onset of the Fibromyalgia Syndrome (FMS)" [Abstract No. 867]. Robert S. Katz is well know in the world of fibromyalgia. Conclusion: "Surgery, severe illness, and accidents precipitated the onset of fibromyalgia in some patients. ... Fibromyalgia symptoms usually began with neck or back pain. Some of the FMS patients experienced symptoms consistent with hypervigilance and post-traumatic stress disorder." The findings aren't so new, but the abstracts illustrates that all kinds of trauma may trigger fibromyalgia.

Dennis C. Ang and collegues were interested in: "Cognitive Behavioral Therapy and Milnacipran in Combination Appears to Be More Efficacious Than Either Therapy Alone" [Abstract No. 952]. Conclusion: "Based on the observed effect sizes, our preliminary data justifies pursuing a larger definitive trial to test the superiority of combination therapy vs. monotherapy.Additionally, a direct comparison of CBT vs. drug monotherapy is warranted to inform future health care decisions." This is due to the fact, that in result the following appeared: "Compared to drug alone, CBT alone was marginally efficacious in improving SF-36 physical function." The problem of this study may be found in the decription of methods: "Subjects also received 8 sessions of telephone-delivered CBT or educational instructions, but only from baseline to week 9." This isn't enough to lead to behavioral changes. But it shows that educational efforts are positive and should be pursued.

Robert S. Katz and colleagues presented another interesting study: "How FMS Patients Become Workaholics" [Abstract No. 1565]. Conclusion: "Pain, fatigue and cognitive dysfunction seriously limited the ability of fibromyalgia patients to work. Patients who were able to continue working utilized tactics including not giving up, staying busy, maintaining a positive attitude, exercise, eating well, getting enough sleep and other strategies. Those who are disabled generally felt they were incapable of successfully using those strategies." I see lots of patients with fibromyalgia who go after the all or nothing principle. This point of view leads to looking at incapabilities rather than looking at chances how to reduce self overload and strain.

Oh, I just happen to notice, I've chosen another study of Robert S. Katz and colleagues. They looked at hypervigilance: "Hypervigiliance in Fibromyalgia" [Abstract No. 1858]. Conclusion: "Results suggest that FMS patients are more aware of social and environmental stressors and more likely to be hypervigilant. They have trouble sleeping and are more easily startled. They are less likely to trust their surroundings. Hypervigilance might confer a survival advantage in threatening circumstances, but the hyper-reactivity associated with the condition could also be associated with the central sensitization of pain and dysesthesias, insomnia and other symptoms associated with FMS." Yes! It's easy to observe this hypervigilance in patients with fibromyalgia starting to learn progressive muscle relaxation after Jacobson. But one can train patients to become less hypervigilant. OK, that's hard work, but very rewarding.

Neda Faregha and colleagues presented an abstracts on: "Emotional Pain and Catastrophizing Influence Quality of Life in Fibromyalgia" [Abstract No. 1865]. Conclusion: "Higher scores on emotional pain and catastrophizing were predictors of poor quality of life, whereas sensory scores better predicted function. Emotional pain, especially when associated with high levels of catastrophization has important negative effects on well-being for FM patients. Psychological interventions targeting these aspects may offer additional benefits to the standard pharmacological management of pain." Another study that directs us to use cognitive behavioral therapy in treating fibromyalgia adequately.

Terry H. Oh and colleagues looked at: "Association of Opioid Use with Symptom Severity and Quality of Life in Patients with Fibromyalgia" [Abstract No. 1866]. Conclusion: "The frequency of opioid use was 24 % in patients with fibromyalgia seen in the FTP at a tertiary medical center. Our results demonstrate that opioid use is associated with adverse social factors and worse symptom severity and physical health in patients with fibromyalgia. To better deal with this problem in clinical practice, factors that predispose to opiod use in patients with fibromyalgia need to be further investigated." Then do this reseaqrch, but lets already start not treating fibromyalgia with opioids. There's no evidence showing a benefit, but strong evidence for opioids leading to central pain sensitization.

Winnie K. Pang and colleagues presented a spirited study: "Financial Conflicts of Interest and Industry Sponsorship Are Associated with Positive Outcomes in Fibromyalgia Randomized Controlled Trials" [Abstract No. 1870]. Conclusion: "Industry sponsorship and FCOIs [financial conflicts of interest] are common in published fibromyalgia drug therapy RCTs and are more likely to be associated with positive outcomes. The small number of eligible trials precluded adjustment for potential confounders to assess whether these represent independent association with study outcome." Positive results are published, to only a lesser effect negative results are published. And marketing does the rest. I won't say that drugs have no place in treating fibromyalgia, but the importance of drugs is much lower than the current practice of prescriptions.

Emma K. Guymer and colleagues (includes Geoffrey O. Littlejohn, whom I konow from my research time in Victoria) looked at: "Increased Psychosocial Stress Is a Major Component of Fibromyalgia Triggers" [Abstract No. 1881]. Conclusion: "Most patients report a specific trigger for their fibromyalgia. The majority of these involved increased levels of psychosocial stress, including those with injury or illness. Patients with an increased psychosocial stress component to their trigger had less severe clinical features if they regularly exercised." Another study, which stresses the combination of exercise and cognitive behavioral therapy (coping with psychosocial stress).

Frederick Wolfe and colleagues presented a study on a cohort of 2,322 fibromyalgia patients: "Rate and Predictors of Work Disability in Fibromyalgia" [Abstract No. 2642]. Conclusion: "The receipt of a SSD [Social Security disability] award is common in fibromyalgia, with an annual incidence of 3.4% (3.0, 3.9%). Although many variables were predictive of SSD in univariate models, only self-report of functional status and current unemployment and/or self-reported disability predicted future SSD. One explanation for the few predictors is that BMI, smoking, education and symptoms contribute to functional status, which then dominates all other predictors." Ann B. I. Bremander and collegues showed [Abstract No. 95], that smoking is associated with worse and more widespread pain, worse disease activity, function, fatigue and health related quality of life in patients with axial spondyloarthritis. Same applies to psoriatic arthritis [Abstract No. 1828]. There's still much to be found in smoking and rheumatology, but also fibromyalgia patients might benefit from stopping to smoke, though this still needs a study for effect size.

There have been lots of new studies on fibromyalgia at the ACR 2012, let's see, what the next meetings around the world will bring to us!

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