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Massage Therapy in the Management of Fibromyalgia: A Pilot Study
Abstract
Objective: To study the clinical effectiveness of Swedish massage in fibromyalgia syndrome [FMS].
Methods: Swedish massage [SM] was compared with standard physician care [SC] without or with interim follow-up telephone calls [SCPC] in 37 subjects.
Results: Baseline Arthritis Impact Measurement Scales [AIMS] of physical activity, depression, anxiety, and pain for all patients indicated poor status. Baseline Quality of Well Being [QWB] scores showed impaired quality of life; the Rheumatology Attitudes Index [RAI] scores indicated helplessness. All but five subjects had a Center for Epidemiologic Studies Depression score above 15. At four weeks [7-SM/8-SC/9-SCPC], the SM group improved in RAI [P = 0.06] and AIMS mobility [P = 0.05]. At 28 weeks [4-SM/6-SC/6-SCPC], there were no significant intergroup differences. The 16 study completers had significantly lower baseline QWB scores [P = 0.025] than dropouts.
Conclusions: Although our study showed some effect of SM in FMS at four weeks, benefits were modest and not significant at later time-points, perhaps attributable to low subject retention. The subject warrants further exploration.
... Table 1 summarises the characteristics of the primary studies. There were 478 participants with fibromyalgia across the ten studies; 212 participants in eight studies were assigned to massage intervention (Brattberg, 1999;Alnigenis et al., 2001;Lund et al., 2006;Ekici et al., 2009;Castro-Sanchez et al., 2011a, 2011bLiptan et al., 2013;Yuan et al., 2013), and in the other two, the number of participants assigned to each group was not specified (Sunshine et al., 1996;Field et al., 2002). Sample sizes ranged from 12 to 94 participants, with a median of 39. ...
... Sunshine et al. (1996) did not specify the measures used to assess pain, fatigue, stiffness or sleep. (Brattberg, 1999;Alnigenis et al., 2001;Lund et al., 2006;Liptan et al., 2013;Yuan et al., 2013), and unclear in three (Sunshine et al., 1996;Field et al., 2002;Ekici et al., 2009). Because a study protocol was not available for comparison with the published report for the majority of the trials, it was not possible to assign a judgment of low or high risk of publication bias, with the exception of two trials that were considered low risk. ...
... No meta-analysis was performed, as all of the studies presented high risk of bias. Alnigenis et al. (2001) compared Swedish massage with standard care for pain, anxiety, depression and HRQoL, measured in short-term follow-up. No statistically significant differences were found between groups. ...
The systematic review aimed to evaluate the effectiveness of massage in fibromyalgia. An electronic search was conducted at MEDLINE, SCiELO, EMBASE, ISI, PEDro, SPORTDiscus, CINAHL, Cochrane CENTRAL and LILACS (Jan1990-May2013). Ten randomized and non-randomized controlled trials investigating the effects of massage alone on symptoms and health-related quality of life of adult patients with fibromyalgia were included. Two reviewers independently screened records, examined full-text reports for compliance with the eligibility criteria, and extracted data. Meta-analysis (pooled from 145 participants) shows that myofascial release had large, positive effects on pain and medium effects on anxiety and depression at the end of treatment, in contrast with placebo; effects on pain and depression were maintained in the medium and short term, respectively. Narrative analysis suggests that: myofascial release also improves fatigue, stiffness and quality of life; connective tissue massage improves depression and quality of life; manual lymphatic drainage is superior to connective tissue massage regarding stiffness, depression and quality of life; Shiatsu improves pain, pressure pain threshold, fatigue, sleep and quality of life; and Swedish massage does not improve outcomes. There is moderate evidence that myofascial release is beneficial for fibromyalgia symptoms. Limited evidence supports the application of connective tissue massage and Shiatsu. Manual lymphatic drainage may be superior to connective tissue massage, and Swedish massage may have no effects. Overall, most styles of massage therapy consistently improved the quality of life of fibromyalgia patients.
... 11 full-texts were excluded due to no random (n = 1), duplicate publications (n = 1), no diagnostic criteria of FM (n = 1), massage therapy plus other complementary and alternative treatments (n = 4), and other manual therapies (n = 4). In 9 eligible RCTs, 8 published in English [23][24][25][26][27][28][29][30] and 1 published in Chinese [31]. Six of them were included in meta-analyses [24,26,[28][29][30][31]. ...
... Risk of bias evaluation is reported in Figure 2. Four studies employed appropriate random sequence generation and allocation concealment [23,27,28,30], others were unclear due to not state the detailed randomized and allocated method [24][25][26]29,31]. The authors reported that they employed blinded assessors in 4 RCTs [23,26,28,29], while this parameter was unclear in four trials [24,27,30,31], one failed to do so [25]. ...
... Risk of bias evaluation is reported in Figure 2. Four studies employed appropriate random sequence generation and allocation concealment [23,27,28,30], others were unclear due to not state the detailed randomized and allocated method [24][25][26]29,31]. The authors reported that they employed blinded assessors in 4 RCTs [23,26,28,29], while this parameter was unclear in four trials [24,27,30,31], one failed to do so [25]. The risk of bias for reporting participant dropout or withdrawal was low risk in six RCTs [24,25,27,28,30,31], others were unclear [23,26,29]. ...
Although some studies evaluated the effectiveness of massage therapy for fibromyalgia (FM), the role of massage therapy in the management of FM remained controversial.
The purpose of this systematic review is to evaluate the evidence of massage therapy for patients with FM.
Electronic databases (up to June 2013) were searched to identify relevant studies. The main outcome measures were pain, anxiety, depression, and sleep disturbance. Two reviewers independently abstracted data and appraised risk of bias. The risk of bias of eligible studies was assessed based on Cochrane tools. Standardised mean difference (SMD) and 95% confidence intervals (CI) were calculated by more conservative random-effects model. And heterogeneity was assessed based on the I(2) statistic.
Nine randomized controlled trials involving 404 patients met the inclusion criteria. The meta-analyses showed that massage therapy with duration ≥5 weeks significantly improved pain (SMD, 0.62; 95% CI 0.05 to 1.20; p = 0.03), anxiety (SMD, 0.44; 95% CI 0.09 to 0.78; p = 0.01), and depression (SMD, 0.49; 95% CI 0.15 to 0.84; p = 0.005) in patients with FM, but not on sleep disturbance (SMD, 0.19; 95% CI -0.38 to 0.75; p = 0.52).
Massage therapy with duration ≥5 weeks had beneficial immediate effects on improving pain, anxiety, and depression in patients with FM. Massage therapy should be one of the viable complementary and alternative treatments for FM. However, given fewer eligible studies in subgroup meta-analyses and no evidence on follow-up effects, large-scale randomized controlled trials with long follow-up are warrant to confirm the current findings.
... 20 Manual therapy (movement, self-massage, and stretching) was compared to sham therapy (muscle relaxation). 21 Swedish massage was compared to standard physician care, 22 and connective tissue massage was compared to no intervention. 23 Neck/Shoulder Pain-2 Trials. ...
... Also, 11/19 had blinded outcome assessor(s); 9-13,15,17,20,24,25,27 1/19 had blinded subjects. 9 Furthermore, 4/19 studies had greater than 20% loss to follow-up; 13,16,22,26 and 7/19 trials included an intentionto-treat analysis. 9,12,[16][17][18]25,27 ...
... Alnigenis et al. 22 Brattberg 23 Field et al. 21 Hagen et al. 14 Poole et al. 18 Rowlands and Brantingham 26 Smith et al. 19 Included references categorized by the Modified Oxford Centre for Evidence-based Medicine Levels of Evidence in the order from highest to lowest levels A, B, and C. musculoskeletal disorders is scarce. ...
Chronic musculoskeletal pain contributes greatly to the community's disability and morbidity. Although many interventions are employed for treating chronic musculoskeletal pain, few have been proven in randomized controlled trials. Manual therapy is a widely used method for managing such conditions, but to date, its efficacy has not been established. This evidence-based review aims to assess the efficacy of manual therapy interventions for chronic musculoskeletal pain. MEDLINE, CINAHL, EBM Reviews (Cochrane DSR, ACP Journal Club, DARE, and CCTR), Ovid Healthstar, and PsycINFO databases were searched from 1961 to March 2009 using keywords of interest. Potential studies for inclusion were reviewed independently by two reviewers. Methodological quality was assessed based on the Physiotherapy Evidence Database scale. Trials were quantitatively categorized according to the Modified Oxford Centre for Evidence-based Medicine Levels of Evidence. Meta-analysis was not possible due to heterogeneity of outcome measures. Evidence supports some manual therapy techniques in chronic low back and knee pain.
... In another RCT [23], 37 women with FM were randomly assigned to one of three groups: MT (45 min of Swedish massage), standard care, and standard care with follow-up phone calls from a nurse. The MT group received 10 treatments over 24 weeks (at 0, 1, 2, 3, 4, 6, 8, 13, 20, and NS non-significant, MT massage therapy, PMR progressive muscle relaxation, NT no treatment, SC standard care, SCPC standard care followed by phone calls, CTM connective tissue massage, MLD manual lymphatic drainage * Compared to baseline measurements. ...
... For example, Sunshine et al. [7] found that MT leads to improvements in pain, stiffness, anxiety, depression, and quality of life of patients with FM compared with TENS. On the other hand, one study [23] found no benefits of MT for patients with FM, but this study was very small and of low methodological quality. To conclude the aforementioned, most evidence supports the assumption that MT is beneficial for patients with FM. ...
... First factor is the type of MT. Among reviewed studies, three applied Swedish massage [7,23,24], one used combination of Swedish massage and Shiatsu [8], one mechanical deep massage [18], two connective tissue massage [21,25], and two manual lymphatic drainage [17,25]. These massage methods are very different in depth of techniques, force used in their application, and what is more important, in a mechanism of influence. ...
Massage therapy is widely used by patients with fibromyalgia seeking symptom relief. We performed a review of all available studies with an emphasis on randomized controlled trials to determine whether massage therapy can be a viable treatment of fibromyalgia symptoms. Extensive narrative review. PubMed, PsychInfo, CINAHL, PEDro, ISI Web of Science, and Google Scholar databases (inception-December 2009) were searched for the key words "massage", "massotherapy", "self-massage", "soft tissue manipulation", "soft tissue mobilization", "complementary medicine", "fibromyalgia" "fibrositis", and "myofascial pain". No language restrictions were imposed. The reference lists of all articles retrieved in full were also searched. The effects of massage on fibromyalgia symptoms have been examined in two single-arm studies and six randomized controlled trials. All reviewed studies showed short-term benefits of massage, and only one single-arm study demonstrated long-term benefits. All reviewed studies had methodological problems. The existing literature provides modest support for use of massage therapy in treating fibromyalgia. Additional rigorous research is needed in order to establish massage therapy as a safe and effective intervention for fibromyalgia. In massage therapy of fibromyalgia, we suggest that massage will be painless, its intensity should be increased gradually from session to session, in accordance with patient's symptoms; and the sessions should be performed at least 1-2 times a week.
... Massage therapy with duration ≥5 weeks had benecial immediate effects on improving pain, anxiety, and depression in patients with bromyalgia [19]. While, another pilot study suggest modest benets to FM patients at four weeks which is not signicant at later time-points [20]. So, there are fewer and contraindicatory ndings about the benecial effect of massage therapy in bromyalgia. ...
Management of Fibromyalgia Syndrome
... One of the challenges in conducting a systematic review in the field of massage therapy is the lack of consistent terminology. Therefore, a standardised Alnigenis (2001) 38 Atkins (2013) 39 Buttagat (2011) 27 Buttagat (2012) 29 Buttagat (2012) 28 Cherkin (2001) 34 Cherkin (2011) 26 Field (2002) 36 Field (2004) 21 Field (2007) 40 Field (20 11) 22 Hasson (2004) 23 Hernandez-Reif (2001) 37 Irnich (2001) 24 Little (2008) 41 Lund (2006) 42 Mackawan (2007) 35 Melancon (2005) 25 Perlman (2006) 11 Perlman (2012) 30 Pope (1994) 31 Sherman (2009) 43 Stasinopoulos (2004) 44 Van den Dolder (2003) 32 Walach (2003) 45 Yang (2012) taxonomy for massage is warranted. This will enable researchers and massage therapists to more clearly communicate about the nature of massage treatment and its effectiveness. ...
Is massage therapy effective for people with musculoskeletal disorders compared to any other treatment or no treatment?
Systematic review of randomised clinical trials.
People with musculoskeletal disorders.
Massage therapy (manual manipulation of the soft tissues) as a stand-alone intervention.
The primary outcomes were pain and function.
The 26 eligible randomised trials involved 2565 participants. The mean sample size was 95 participants (range 16 to 579) per study; 10 studies were considered to be at low risk of bias. Overall, low-to-moderate-level evidence indicated that massage reduces pain in the short term compared to no treatment in people with shoulder pain and osteoarthritis of the knee, but not in those with low back pain or neck pain. Furthermore, low-to-moderate-level evidence indicated that massage improves function in the short term compared to no treatment in people with low back pain, knee arthritis or shoulder pain. Low-to-very-low-level evidence from single studies indicated no clear benefits of massage over acupuncture, joint mobilisation, manipulation or relaxation therapy in people with fibromyalgia, low back pain and general musculoskeletal pain.
Massage therapy, as a stand-alone treatment, reduces pain and improves function compared to no treatment in some musculoskeletal conditions. When massage is compared to another active treatment, no clear benefit was evident. [Bervoets DC, Luijsterburg PAJ, Alessie JJN, Buijs MJ, Verhagen AP (2015) Massage therapy has short-term benefits for people with common musculoskeletal disorders compared to no treatment: a systematic review.Journal of PhysiotherapyXX: XX-XX].
Copyright © 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
... Of the 29 included studies, 7 studies compared two different BAI (table 4) (Altan et al., 2009;Castel et al., 2007;Da Silva et al., 2007;Field et al., 2002Field et al., , 2003Haanen et al., 1991;Kendall et al., 2000) and in case of 4 studies it was impossible to extract data because of incomplete (Alnigenis et al., 2001;Horwitz et al., 2006;Weissbecker et al., 2002) or no useful data (Castro-Sanchez et al., 2011a). These 11 studies are not included in the meta-analysis, leaving 18 studies suitable for metaanalysis (Astin et al., 2003;Brattberg, 1999;Carson et al., 2010;Castro-Sanchez et al., 2011b, 2011cEkici et al., 2009;Field et al., 1997;Haak and Scott, 2008;Ho, 2012;Jones et al., 2012;Maddali Bongi et al., 2010;Mannerkorpi and Arndorw, 2004;Mataran-Penarrocha et al., 2011;Menzies et al., 2006;Schmidt et al., 2011;Sephton et al., 2007;Sunshine et al., 1996;Wang et al., 2010) (table 5). ...
... The treatments were given for five weeks and led to significant improvement in both groups, but the FIQ scores indicated that manual lymph drainage therapy was more effective. Other RCTs have achieved similar beneficial effects and improvements in symptoms (57,58), and only one randomised study of 37 FM patients found no positive effects of Swedish massage in comparison with no treatment group (59). ...
Fibromyalgia (FM) is currently classified as a chronic pain syndrome. Its main features are chronic widespread pain in the presence of tender points (TPs) upon physical examination, sleep disturbances and fatigue, although patients also report a variety of other complaints. Many therapies have been proposed over recent years with mixed results, including various pharmacological therapies for the treatment of symptoms; but there is still no effective drug treatment for the syndrome itself. Non-pharmacological therapies are an important part of the treatment, and there is evidence supporting a number of interventions, including aerobic exercise, strength and stretching training, cognitive-behavioural therapy, and patient education. Complementary and alternative medicine (CAM) techniques have not yet been fully acknowledged by scientific medicine because little is known about their mechanisms of action and usefulness. The aim of this wide-ranging review of the literature is to analyse the types of CAM techniques used to treat FM and their effectiveness, highlighting the disagreements among the authors of more specialised reviews.
... Of that 75%, three-fourths found it to be effective. In one study, women (n = 37; age range 21-65 years) who received Swedish massage for 24 weeks showed a trend toward improved mobility and reduced helplessness but no improvement in pain, depression, or well-being compared with a standard-care group and standard-care group with follow-up phone calls (Alnigenis, Bradley, Wallick, & Emsley, 2001). Also notable, that study had issues with attrition after the 4-week time point. ...
Little is known regarding treatment choices of youth diagnosed with juvenile-onset fibromyalgia (JFM) as they move into young adulthood. Additionally, there is little empirical evidence to guide youth with FM into appropriate treatment options, leading to a variety of therapies used to manage FM symptoms. The purpose of this descriptive study was to examine all therapies used by individuals with JFM as they entered young adulthood and the perceived effectiveness of these treatments. As part of a larger follow-up study, participants completed a web-based survey of all current and past treatments received for FM symptoms 2 years after their initial presentation and diagnosis at a pediatric rheumatology clinic. One hundred ten out of 118 eligible patients participated in the follow-up assessment as young adults (mean age 18.97 years; 93.6% female). A majority of participants reported use of conventional medications (e.g., antidepressants, anticonvulsants) and nondrug therapies (e.g., psychotherapy). Currently and within the past 2 years, antidepressant medications were the most commonly used to manage FM. Complementary treatments were used less often, with massage being the most popular choice. Although currently used treatments were reported as being effective, past treatments, especially medications, were viewed as being more variably effective. This is a potential reason why young adults with JFM might try more complementary and alternative approaches to managing their symptoms. More controlled studies are needed to investigate the effectiveness of these complementary methods to assist treatment providers in giving evidence-based treatment recommendations.
... Despite lack of strong evidence for the use of non-pharmacological interventions in FM [28], different modes of sensory stimulation like massage, relaxation therapies and acupuncture have gained increasing popularity. Massage has been reported to reduce pain, depression and anxiety in patients with FM [1] [5] [9]. Hypothetically , stimulation of mechanical receptors in the skin and deeper tissues during massage or psychologically induced interventions may alter the functions of limbic structures of the brain, leading to a reduction in pain and stress-like symptoms changes that possibly are reflected in reduced concentrations of Corticotropin Releasing Factor-Like Immunoreactivity, CRF-LI, in 24-h urine samples. ...
The purpose of this preliminary study was to evaluate the relationship between a possible biochemical marker of stress, 24-h urinary concentrations of Corticotropin Releasing Factor-Like Immunoreactivity (CRF-LI), and ratings of stress-related symptoms like depression and anxiety, as well as to evaluate pain and emotional reactions in patients with fibromyalgia (FM). Another purpose was to study the effects of massage and guided relaxation, with respect to change in the same variables. Urine sampling and ratings were performed before treatments, after and 1 month after completed treatments. Concentrations of CRF-LI was analysed with radioimmnoassay technique. For the assessment of depression, anxiety and pain the CPRS-A questionnaire was used and for rated pain and emotional reactions the NHP questionnaire was used. The 24-h urinary concentration of the CRF-LI was found to be related to depression, mood and inability to take initiative. After treatment the urinary CRF-LI concentrations and the rated levels of pain and emotional reactions were found to have decreased. In conclusion, the 24-h urinary CRF-LI concentration may be used as a biochemical marker of stress-related symptoms such as depression in patients with FM and possibly also other conditions characterized by chronic pain. Therapies such as massage and guided relaxation may be tried for the amelioration of pain and stress but further studies are required.
... For fibromyalgia, two studies conducted by the same group found massage to be superior to TENS [64] and PMR [65]. The two other fibromyalgia studies revealed greater pain reduction for massage versus no treatment by 6-month follow- up [66] and no benefits for massage compared with usual care (i.e., standard care provided by physicians including medications) [67]. For mixed chronic pain, one study found that massage led to less pain than usual care [68] but the other two studies reported no benefits of massage over relaxation (at 3-month follow-up) [69] or mediation and usual care (at 1-month follow-up) [70]. ...
Complementary and alternative medicine (CAM) is a group of diverse medical and healthcare systems, therapies, and products that are not presently considered part of conventional medicine. This article provides an up-to-date review of the efficacy of selected CAM modalities in the management of chronic pain. Findings are presented according to the classification system developed by the National Institutes of Health National Center for Complementary and Alternative Medicine (formerly Office of Alternative Medicine) and are grouped into four domains: biologically based medicine, energy medicine, manipulative and body-based medicine, and mind-body medicine. Homeopathy and acupuncture are discussed separately as "whole or professionalized CAM practices." Based on the guidelines of the Clinical Psychology Division of the American Psychological Association, findings indicate that some CAM modalities have a solid track record of efficacy, whereas others are promising but require additional research. The article concludes with recommendations to pain practitioners.
IntroductionFibromyalgia is a chronic disease of unknown origin characterized by widespread pain, fatigue, disordered sleep and joint stiffness among other symptoms.Objective
To compare outcomes of manual lymph drainage and myofascial therapy in patients with fibromyalgia.Methods
This was a systematic review. The databases PubMed/MEDLINE, CINAHL, SCOPUS, ScieLo, PEDro, Dialnet, Web of Science, and Elsevier were searched for articles in English or Spanish examining the efficacy of myofascial therapy and/or manual lymph drainage to treat fibromyalgia. Of 356 articles extracted, sixteen articles and one doctoral thesis fulfilled the criteria established for inclusion.ResultsThe methodological quality of the studies reported in the articles was good (PEDro score 7.49 ± 1.47). The studies included compared different treatments with lymph drainage and/or myofascial therapy. Outcomes indicated improved quality of life for both therapies in all the studies.Conclusions
Myofascial therapy and lymph drainage may be effective in patients with fibromyalgia. Further work is needed as the scientific evidence available is still insufficient.
Objective: The purpose of this study was to systematically review the literature for randomized trials of complementary and alternative medicine (CAM) interventions for fibromyalgia (FM). Methods: A comprehensive literature search was conducted. Databases included the Cochrane library, PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health, Natural Medicines Comprehensive Database Manual, Alternative and Natural Therapy Index System (MANTIS), Index for Chiropractic Literature, and Allied and Complementary Medicine (AMED). Inclusion criteria were (a) subjects were diagnosed with fibromyalgia and (b) the study design was a randomized controlled trial that compared a CAM therapy vs a control group. Studies were subgrouped by CAM treatment into 11 categories. Evidence tables and forest plots were organized to display quality ratings and effect sizes of each study. Results: The literature search yielded 1722 results; 102 abstracts were selected as potential articles for inclusion. Sixty studies met criteria and were rated by 2 reviewers; 18 were rated as good quality; 20, moderate; 18, low; and 4, very low. Synthesis of information for CAM categories represented by more than 5 studies revealed that balneotherapy and mindbody therapies were effective in treating FM pain. This study analyzed recent studies and focused exclusively on randomized controlled trials. Despite common use of manual therapies such as massage and manipulation to treat patients with FM, there is a paucity of quality clinical trials investigating these particular CAM categories. Conclusion: Most of these studies identified were preliminary or pilot studies, thus had small sample sizes and were likely underpowered. Two CAM categories showed the most promising findings, balneotherapy and mind-body therapies. Most of the other CAM categories showed a trend favoring the treatment group. It appears that several CAM therapies show some preliminary treatment effect for FM pain, but larger trials that are more adequately powered are needed. (J Manipulative Physiol Ther 2011;34:483-496) Key Indexing Terms: Fibromyalgia; Complementary and Alternative Medicine; Randomized Controlled Trials; Systematic Review
Hintergrund
Die planmäßige Aktualisierung der S3-Leitlinie zum Fibromyalgiesyndrom (FMS; AWMF-Registernummer 041/004) wurde ab März 2011 vorgenommen.
Material und Methoden
Die Leitlinie wurde unter Koordination der Deutschen Interdisziplinären Vereinigung für Schmerztherapie (DIVS) von 9 wissenschaftlichen Fachgesellschaften und 2 Patientenselbsthilfeorganisationen entwickelt. Acht Arbeitsgruppen mit insgesamt 50 Mitgliedern wurden ausgewogen in Bezug auf Geschlecht, medizinischen Versorgungsbereich, potenzielle Interessenkonflikte und hierarchische Position im medizinischen bzw. wissenschaftlichen System besetzt.
Die Literaturrecherche erfolgte über die Datenbanken Medline, PsycInfo, Scopus und Cochrane Library (bis Dezember 2010). Die Graduierung der Evidenzstärke erfolgte nach dem Schema des Oxford Center of Evidence Based Medicine. Die Formulierung und Graduierung der Empfehlungen erfolgte in einem mehrstufigen, formalisierten Konsensusverfahren. Die Leitlinie wurde von den Vorständen der beteiligten Fachgesellschaften begutachtet.
Ergebnisse und Schlussfolgerung
Ausdauer- und Krafttraining geringer bis mittlerer Intensität werden stark empfohlen. Chirotherapie, Lasertherapie, Magnetfeldtherapie, Massage und transkranielle Magnetstimulation werden nicht empfohlen.
SUMMARY Objectives: This paper focuses on nonpharmacologic approaches to fibromyalgia treatment. Descriptions of the most well researched strategies, such as exercise, cognitive-behavioral therapy, and multidisciplinary treatment using multiple treatment components, along with novel treatments for which evidence is beginning to emerge, are compared and evaluated. Findings: Evidence for the pain reduction benefits of moderate intensity exercise is strong. Both cognitive-behavioral therapy as a stand-alone treatment and multicomponent strategies that incorporate exercise and cognitive-behavioral or education strategies have significant benefits to patients mainly in enhanced self-efficacy and physical capacity and decreased pain. Novel therapies such as acupuncture, biofeedback, balneotherapy, therapeutic massage, movement therapy, vegetarian diets and supplements, and magnets all demonstrate therapeutic benefits in small clinical trials. There is some evidence that discernible characteristics may differentiate responders from nonresponders to many therapies. Conclusions: Overall, there is moderate to strong evidence of the effectiveness of some nonpharmacologic approaches to fibromyalgia treatment. Novel treatments from a wide group of practitioners and health perspectives are beginning to emerge as legitimate strategies. An individualized approach that incorporates patient's abilities, preferences, physical and psychological characteristics is critical to the success of treatment.
Background
A guideline for the treatment and diagnostic procedures for fibromyalgia syndrome (FMS) was developed in cooperation with 10 German medical and psychological associations and 2 patient self-help groups.
Methods
A systematic literature search including all controlled studies evaluating physiotherapy, exercise and strength training as well as physical therapies was performed in the Cochrane Collaboration Reviews (1993–12/2006), Medline (1980–12/2006), PsychInfo (1966–12/2006) and Scopus (1980–12/ 2006). Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. Grading of the strengths of recommendations was done according to the German program for disease management guidelines. Standardized procedures to reach a consensus on recommendations were used.
Results
Aerobic exercise training is strongly recommended (grade A) and the temporary use of whole body hyperthermia, balneotherapy and spa therapy is recommended (grade B).
Conclusion
The significance which can be assigned to most of the studies on the various procedures for therapy is restricted due to short study duration (mean 6–12 weeks) and small sample sizes.
The purpose of this study was to systematically review the literature for randomized trials of complementary and alternative medicine (CAM) interventions for fibromyalgia (FM).
A comprehensive literature search was conducted. Databases included the Cochrane library, PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health, Natural Medicines Comprehensive Database Manual, Alternative and Natural Therapy Index System (MANTIS), Index for Chiropractic Literature, and Allied and Complementary Medicine (AMED). Inclusion criteria were (a) subjects were diagnosed with fibromyalgia and (b) the study design was a randomized controlled trial that compared a CAM therapy vs a control group. Studies were subgrouped by CAM treatment into 11 categories. Evidence tables and forest plots were organized to display quality ratings and effect sizes of each study.
The literature search yielded 1,722 results; 102 abstracts were selected as potential articles for inclusion. Sixty studies met criteria and were rated by 2 reviewers; 18 were rated as good quality; 20, moderate; 18, low; and 4, very low. Synthesis of information for CAM categories represented by more than 5 studies revealed that balneotherapy and mind-body therapies were effective in treating FM pain. This study analyzed recent studies and focused exclusively on randomized controlled trials. Despite common use of manual therapies such as massage and manipulation to treat patients with FM, there is a paucity of quality clinical trials investigating these particular CAM categories.
Most of these studies identified were preliminary or pilot studies, thus had small sample sizes and were likely underpowered. Two CAM categories showed the most promising findings, balneotherapy and mind-body therapies. Most of the other CAM categories showed a trend favoring the treatment group. It appears that several CAM therapies show some preliminary treatment effect for FM pain, but larger trials that are more adequately powered are needed.
There have been several systematic reviews attempting to evaluate the efficacy of possible treatments for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and fibromyalgia (FM). However, information regarding the efficacy of complementary and alternative medicine (CAM) has not been comprehensively or systematically covered in these reviews, despite its frequent use in the patient community.
The purpose of this study was to systematically review and evaluate the current literature related to alternative and complementary treatments for ME/CFS and FM. It should be stressed that the treatments evaluated in this review do not reflect the clinical approach used by most practitioners to treat these illnesses, which include a mix of natural and unconventionally used medications and natural hormones tailored to each individual case. However, nearly all clinical research has focused on the utility of single CAM interventions, and thus is the primary focus of this review.
Several databases (e.g., PubMed, MEDLINE,((R)) PsychInfo) were systematically searched for randomized and nonrandomized controlled trials of alternative treatments and nonpharmacological supplements. Included studies were checked for references and several experts were contacted for referred articles. Two leading subspecialty journals were also searched by hand. Data were then extracted from included studies and quality assessments were conducted using the Jadad scale.
Upon completion of the literature search and the exclusion of studies not meeting criterion, a total of 70 controlled clinical trials were included in the review. Sixty (60) of the 70 studies found at least one positive effect of the intervention (86%), and 52 studies also found improvement in an illness-specific symptom (74%). The methodological quality of reporting was generally poor.
Several types of alternative medicine have some potential for future clinical research. However, due to methodological inconsistencies across studies and the small body of evidence, no firm conclusions can be made at this time. Regarding alternative treatments, acupuncture and several types of meditative practice show the most promise for future scientific investigation. Likewise, magnesium, l-carnitine, and S-adenosylmethionine are nonpharmacological supplements with the most potential for further research. Individualized treatment plans that involve several pharmacological agents and natural remedies appear promising as well.
Complementary medicine has become an important subject for rheumatologists, not least because many patients try complementary treatments. Recent clinical trials yield promising results. In particular, evidence suggests that several herbal medicines and dietary supplements can alleviate the pain of osteoarthritis and rheumatoid arthritis. Clearly, rigorous testing of complementary treatments is possible, and considering their popularity, should be encouraged. (C) 2003 Lippincott Williams Wilkins.
Complementary and alternative medicine (CAM) has gained increasing popularity, particularly among individuals with fibromyalgia syndrome (FMS) for which traditional medicine has generally been ineffective. A systematic review of randomized controlled trials (RCTs) and non-RCTs on CAM studies for FMS was conducted to evaluate the empirical evidence for their effectiveness. Few RCTs achieved high scores on the CONSORT, a standardized evaluation of the quality of methodology reporting. Acupuncture, some herbal and nutritional supplements (magnesium, SAMe) and massage therapy have the best evidence for effectiveness with FMS. Other CAM therapies have either been evaluated in only one RCT with positive results (Chlorella, biofeedback, relaxation), in multiple RCTs with mixed results (magnet therapies), or have positive results from studies with methodological flaws (homeopathy, botanical oils, balneotherapy, anthocyanidins, dietary modifications). Lastly, other CAM therapies have neither well-designed studies nor positive results and are not currently recommended for FMS treatment (chiropractic care).
Pain of long duration is a common suffering in modern man. One such pain condition is fibromyalgia syndrome (FMS). Opinions about what treatment regimen that are to be used in these patients are diverging, and many of the treatments suggested are not, or only poorly, scientifically investigated. The aim of this pilot investigation was to evaluate if FMS patients with signs and symptoms of temporomandibular disorders (TMDs) refractory to conservative TMD treatment would respond positively to tactile stimulation in respect of local and/or general symptoms. Ten female patients fulfilling the inclusion criteria received such treatment once a week during a 10-week period. At the end of treatment, a positive effect on both clinical signs and subjective symptoms of TMD, as well as on general body pain, was registered. Eight out of 10 patients also perceived an improved quality of their sleep. At follow-ups after 3 and 6 months some relapse of both signs and symptoms could be seen, but there was still an improvement compared to the initial degree of local and general complaints. At the 6-months follow-up, half of the patients also reported a lasting improvement of their sleep quality. One hypothetical explanation to the positive treatment effect experienced by the tactile stimulation might be the resulting improvement of the patients' quality of sleep leading to increased serotonin levels. The results of the present pilot study are so encouraging that they warrant an extended, controlled study.
Previous reviews of massage therapy for chronic, non-malignant pain have focused on discrete pain conditions. This article aims to provide a broad overview of the literature on the effectiveness of massage for a variety of chronic, non-malignant pain complaints to identify gaps in the research and to inform future clinical trials. Computerized databases were searched for relevant studies including prior reviews and primary trials of massage therapy for chronic, non-malignant pain. Existing research provides fairly robust support for the analgesic effects of massage for non-specific low back pain, but only moderate support for such effects on shoulder pain and headache pain. There is only modest, preliminary support for massage in the treatment of fibromyalgia, mixed chronic pain conditions, neck pain and carpal tunnel syndrome. Thus, research to date provides varying levels of evidence for the benefits of massage therapy for different chronic pain conditions. Future studies should employ rigorous study designs and include follow-up assessments for additional quantification of the longer-term effects of massage on chronic pain.
People with depressive disorders or subsyndromal symptoms of depression (SSD) often use complementary and alternative therapies, including massage therapy (MT). This systematic review evaluates the evidence, from randomised clinical trials (RCTs), for the effectiveness of multiple sessions of classical European (Swedish) MT for the treatment of depression.
Eligible RCTs were identified via eight electronic databases and manual searches of references. Two reviewers independently selected trials, assessed trial quality and extracted data.
Four RCTs met our inclusion criteria. Three of these RCTs compared MT with relaxation therapies, but provided insufficient data and analyses to contribute meaningfully to the evaluation of MT for depression. The fourth included RCT used MT as a control condition to evaluate a depression-specific acupuncture treatment. This trial provided limited evidence that, in the early stages of treatment, MT is less effective than acupuncture for treating depression, a treatment which itself is not accepted for this condition.
Despite previous research suggesting that MT may be an effective treatment for depression, there is currently a lack of evidence to support this assertion from RCTs that have selected participants for depression or SSD.
To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in greater than or equal to 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.
A Rheumatology Attitudes Index (RAI) has been modified from the Arthritis Helplessness Index to assess the psychological construct of learned helplessness. The validity of the RAI was established in comparisons to the Arthritis Helplessness Index. The external criterion validity of the RAI was established by identification of statistically significant correlations between RAI scores and physical measures of disease status, including joint count, grip strength, walking time, and button test, as well as with questionnaire self-report scores for difficulty, dissatisfaction and pain in activities of daily living (ADL). Any variation in RAI scores which could be explained by available disease status measures was explained entirely by ADL self-report scores, with no additional explanation by traditional physical measures. Responses to individual RAI statements were significantly correlated with either questionnaire or physical measures of disease status for only 6 of the 15 RAI statements.
Studied children with mild to moderate juvenile rheumatoid arthritis who were massaged by their parents 15 minutes a day for 30 days (and a control group engaged in relaxation therapy). The children's anxiety and stress hormone (cortisol) levels were immediately decreased by the massage, and over the 30-day period their pain decreased on self-reports, parent reports, and their physician's assessment of pain (both the incidence and severity) and pain-limiting activities.
Reports clarification of the original article by T. Field ( American Psychologist , 1998[Dec], Vol 53[12], 1270–1281). Some of the content of the article was published in "Touch Therapies," by Tiffany M. Field (in R. R. Hoffman, M. F. Sherrick, & J. S. Warm, Eds., Viewing Psychology as a Whole; The Integrative Science of William N. Dember, 1998, pp. 603–624, Washington, DC: American Psychological Association). There is also some overlap with a journal article: "Touch Therapy Effects on Development," by Tiffany M. Field ( International Journal of Behavioral Development, 1998, Vol. 22, No. 4, pp. 779–797). (The following abstract of this article originally appeared in record 1998-11439-002 .) Massage therapy is older than recorded time, and rubbing was the primary form of medicine until the pharmaceutical revolution of the 1940's. Popularized again as part of the alternative medicine movement, massage therapy has recently received empirical support for facilitating growth, reducing pain, increasing alertness, diminishing depression, and enhancing immune function. In this article studies are reviewed that document these effects, and models are proposed for potential underlying mechanisms.
Objective. To record the prevalence, extent, cost, and satisfaction with use of alternative medicine practices by patients with fibromyalgia syndrome (FMS), compared to control rheumatology patients. Methods. An interviewer-based questionnaire was administered to 221 consecutive rheumatology patients and 80 FMS patients. Results. Alternative medicine interventions were currently being used extensively by rheumatology patients overall, and by FMS patients in particular. All categories of alternative practices were used more often by FMS patients, compared to controls, including overall use 91% versus 63% (P = 0.0001), over-the-counter products 70% versus 54% (NS), spiritual practices 48% versus 37% (NS), and alternative practitioners 26% versus 12% (P = 0.003), respectively Two-thirds of patients using alternative medicine practices were concurrently using multiple interventions. Patient satisfaction ratings were highest for spiritual interventions. Conclusions, Alternative medicine practices were currently being used by almost all FMS patients. This observation might indicate that traditional medical therapies are inadequate in providing symptomatic relief to FMS patients.
Dr. Joseph L. Hollander's multiauthored text, extensively revised and enlarged since its last edition in 1960, retains its position as the only comprehensive American work covering the field of rheumatology. All of the sections of the book have been extensively revised, and several new chapters added. These major changes reflect the growth of knowledge in rheumatic diseases, both clinically and in areas of fundamental research.The chapters are written by men of experience in the field, and all of the contributions are so uniformly good that a reviewer hesitates to single out any for special comment. However, Dr. Leon Sokoloff's text and illustrations of his sections on the pathology of rheumatic diseases are extraordinary.All books of this sort, with many contributors, present the editors with problems of duplication and of omission. Dr. Hollander and his nine major section editors have, on the whole, admirably avoided these pitfalls. One amusing
Massage therapy is frequently employed for low back pain (LBP). The aim of this systematic review was to find the evidence for or against its efficacy in this indication. Four randomized clinical trials were located in which massage was tested as a monotherapy for LBP. All were burdened with major methodological flaws. One of these studies suggests that massage is superior to no treatment. Two trials imply that it is equally effective as spinal manipulation or transcutaneous electrical stimulation (TES). One study suggests that it is less effective than spinal manipulation. It is concluded that too few trials of massage therapy exist for a reliable evaluation of its efficacy. Massage seems to have some potential as a therapy for LBP. More investigations of this subject are urgently needed.
The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.
Thirty adult fibromyalgia syndrome subjects were randomly assigned to a massage therapy, a transcutaneous electrical stimulation (TENS), or a transcutaneous electrical stimulation no-current group (Sham TENS) for 30-minute treatment sessions two times per week for 5 weeks. The massage therapy subjects reported lower anxiety and depression, and their cortisol levels were lower immediately after the therapy sessions on the first and last days of the study. The TENS group showed similar changes, but only after therapy on the last day of the study. The massage therapy group improved on the dolorimeter measure of pain. They also reported less pain the last week, less stiffness and fatigue, and fewer nights of difficult sleeping. Thus, massage therapy was the most effective therapy with these fibromyalgia patients.
(C) Williams & Wilkins 1996. All Rights Reserved.
To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in ⩾ 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.
We administered a standardized history questionnaire and performed a tender point examination on 27 patients with debilitating fatigue of at least 6 months duration, seen in a primary care practice, as well as on 20 patients with fibromyalgia. Sixteen of the 27 patients with chronic fatigue met the full criteria for the working case definition of chronic fatigue syndrome (CFS). Eight patients with chronic fatigue denied having any current persistent, diffuse musculoskeletal pain, and their tender point scores were similar to those in 10 normal control subjects. In contrast, 19 patients with chronic fatigue (70%) had persistent, diffuse musculoskeletal pain. The results of their tender point examinations were similar to those of the patients with fibromyalgia. Thus, the majority of these patients with debilitating chronic fatigue, including those who met criteria for CFS, met the historical and tender point diagnostic criteria for fibromyalgia. The presence of current musculoskeletal pain will identify those CFS patients who have fibromyalgia.
Objective. To determine the prevalence and characteristics of fibromyalgia in the general population.
Methods. A random sample of 3,006 persons in Wichita, KS, were characterized according to the presence of no pain, non-widespread pain, and widespread pain. A subsample of 391 persons, including 193 with widespread pain, were examined and interviewed in detail.
Results. The prevalence of fibromyalgia was 2.0% (95% confidence interval [95% CI] 1.4, 2.7) for both sexes, 3.4% (95% CI 2.3, 4.6) for women, and 0.5% (95% CI 0.0, 1.0) for men. The prevalence of the syndrome increased with age, with highest values attained between 60 and 79 years (>7.0% in women). Demographic, psychological, dolorimetry, and symptom factors were associated with fibromyalgia.
Conclusion. Fibromyalgia is common in the population, and occurs often in older persons. Characteristic features of fibromyalgia–pain threshold and symptoms–are similar in community and clinic populations, but overall severity, pain, and functional disability are more severe in the clinic population.
1.1. Connective tissue massage produces relief of pain and increases microcirculation in a number of vascular beds.2.2. The concentration of plasma β-endorphins has been measured in 12 volunteers before and 5, 30 and 90 min after a 30-min session of connective tissue massage.3.3. There was a moderate mean increase of 16% in β-endorphin levels from 20.0 to 23.2 pg/0.1 ml (P = 0.025), lasting for about 1 hr with a maximum in the test 5 min after termination of the massage.4.4. It is assumed that the release of β-endorphins is linked with the pain relief and feeling of warmth and well-being associated with the treatment.
To assess functional ability in fibromyalgia patients, we examined 28 patients during the performance of five standardized work tasks (SWT), and compared their performance to 26 RA patients and 11 healthy community controls. Fibromyalgia patients performed 58.6% and RA patients 62.1% of the work done by normals. Work performance was strongly associated with pretest Stanford Health Assessment Disability Index (HAQ) scores (r = 0.705), but also with pain, global severity, and psychologic status in both RA and fibromyalgia groups. We also examined work status in 176 fibromyalgia patients. Sixty percent were employed, 9.6% considered themselves disabled, but only 6.2% received disability payments (none for the specific diagnosis of fibromyalgia). Thirty percent of patients had changed jobs because of this illness. Functional ability is impaired in fibromyalgia. SWT and the HAQ disability instrument may be effective in the clinical assessment of fibromyalgia.
Demographics and health service utilization were studied for 81 patients with fibrositis during 1985. Patients reported high levels of pain, mild disability, and moderate impairment of global health. Work disability was limited and only 6.3 percent described themselves as disabled. Employed patients were able to work full work weeks. Utilization of outpatient medical services was increased compared with that of control subjects and national averages during the study year, but was consistent with other rheumatic disorders such as osteoarthritis and low back pain. Medication usage was limited and seemed appropriate. Very high hospitalization rates were noted prior to diagnosis of fibrositis, both for musculoskeletal and non-musculoskeletal hospitalizations, but these rates dropped during the post-diagnosis study year.
The concept of validity as it applies to measures of health and health status is examined in the context of a set of standard, widely accepted definitions of validity. Criterion validity is shown to be irrelevant to health status measures because of the lack of a single specific, directly observable measure of health for use as a criterion. To overcome this problem, the Index of Well-being has been constructed to fulfill the definition of content validity by including all levels of function and symptom/problem complexes, a clearly defined relation to the death state, and consumer ratings of the relative desirability of the function levels. Data from a two-wave household interview survey provide convergent evidence of construct validity by demonstrating an expected positive correlation of the Index of Well-being with self-rated well-being and expected negative correlations with age, number of chronic medical conditions, number of reported symptoms or problems, number of physician contacts, and dysfunctional status. Discriminant evidence of construct validity is demonstrated by predicted differences in correlation between concurrent Index of Well-being scores and self-assessed overall health status, and between the Index of Well-being scores and self-rated well-being on different days. A simple method of estimating a currently usable comprehensive population index of health status, the Weighted Life Expectancy, is described.
We administered a standardized history questionnaire and performed a tender point examination on 27 patients with debilitating fatigue of at least 6 months duration, seen in a primary care practice, as well as on 20 patients with fibromyalgia. Sixteen of the 27 patients with chronic fatigue met the full criteria for the working case definition of chronic fatigue syndrome (CFS). Eight patients with chronic fatigue denied having any current persistent, diffuse musculoskeletal pain, and their tender point scores were similar to those in 10 normal control subjects. In contrast, 19 patients with chronic fatigue (70%) had persistent, diffuse musculoskeletal pain. The results of their tender point examinations were similar to those of the patients with fibromyalgia. Thus, the majority of these patients with debilitating chronic fatigue, including those who met criteria for CFS, met the historical and tender point diagnostic criteria for fibromyalgia. The presence of current musculoskeletal pain will identify those CFS patients who have fibromyalgia.
1. Connective tissue massage produces relief of pain and increases microcirculation in a number of vascular beds. 2. The concentration of plasma beta-endorphins has been measured in 12 volunteers before and 5, 30 and 90 min after a 30-min session of connective tissue massage. 3. There was a moderate mean increase of 16% in beta-endorphin levels from 20.0 to 23.2 pg/0.1 ml (P = 0.025), lasting for about 1 hr with a maximum in the test 5 min after termination of the massage. 4. It is assumed that the release of beta-endorphins is linked with the pain relief and feeling of warmth and well-being associated with the treatment.
Many qualified schools of massage where the nurse can be educated and certified to perform massage therapy are located throughout the United States and are listed in massage therapy journals. The rehabilitation nurse who provides massage therapy will gain personal satisfaction through knowing that the client will benefit from the therapy both physically and psychologically.
In a six-month, randomized, double-blind study at 14 centers, auranofin (3 mg twice daily) was compared with placebo in the treatment of patients with classic or definite rheumatoid arthritis. All patients had unremitting disease for at least the previous six months and at least three months of therapy with nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, oral steroids, and analgesics were allowed throughout the trial. Efficacy was analyzed in 154 patients who received auranofin and 149 who received placebo. To reflect an expanded view of outcome assessment, the measures used included some 20 nontraditional measures of functional performance, pain, global impression, and utility (worth or value) in addition to five standard clinical measures of rheumatoid synovitis (e.g., number of tender joints). The nontraditional measures were mainly in the form of structured questionnaires administered by trained interviewers. To minimize the statistical problem of multiple comparisons, most of the measures were grouped into four composites--clinical (standard measures), functional, global, and pain--and the treatment effect for each composite was tested at the 0.0125 level of significance. Auranofin was superior to placebo in the clinical (p = 0.003), functional (p = 0.001), and global (p = 0.007) composites and trended similarly in the pain composite (p = 0.021). Individual measures within the composites consistently favored auranofin. Other measures, not part of the composites, also favored auranofin, including a patient utility measure designed for this study, the PUMS (p = 0.002). Results confirm the hypothesis that the favorable effect of auranofin on clinical synovitis is accompanied by improvements across a range of outcomes relevant to the patient's quality of life.
The importance of measuring health outcomes such as functional status and quality of life has increased with the greater emphasis on efficiency and on judgements of clinical effectiveness of therapies for patients with chronic disease. One measure of health status, the quality of well-being (QWB), has received significant attention as a health policy model because it quantifies health on a scale ranging from "zero" (death) to "one" (optimal health). The scale is based on weights (values) that were derived by having several thousand individuals in the general population rate scenarios in which a patient is described in terms of mobility, physical activity, social activity, and major symptom or problem. The present study was undertaken to determine if a disease-specific population composed of patients with moderate and moderately severe rheumatoid arthritis who were participating in a national multicenter trial of a new oral therapeutic agent, would rank scenarios similarly to the general population sample. In this study, close agreement was found between the weights obtained from the general population sample and the weights obtained from the sample of rheumatoid arthritic patients (R = 0.937). The investigators believe that the study supports the use of the original general population weights and suggest that the index may be used for populations with a specific condition as well as for general populations.
A gate control system modulates sensory input from the skin before it evokes pain perception and response.
The Arthritis Impact Measurement Scales (AIMS) have been developed to assess the health status of arthritis patients. In this study, the self-administered AIMS questionnaire, which includes scales designed to measure the physical, psychologic, and social aspects of health status, was completed by 625 patients with various forms of arthritis. A comprehensive battery of analytic techniques was used to investigate the performance of these scales in this large sample. The results confirmed the reliability and validity of the AIMS instrument. They also showed that AIMS performs well in at least 4 major types of arthritis, in a range of sociodemographic groups, and across time. These findings emphasize the strengths of the AIMS approach and suggest that the instrument will prove useful as a tool to assess arthritis outcome in a wide variety of clinical settings.
To determine the prevalence and characteristics of fibromyalgia in the general population.
A random sample of 3,006 persons in Wichita, KS, were characterized according to the presence of no pain, non-widespread pain, and widespread pain. A subsample of 391 persons, including 193 with widespread pain, were examined and interviewed in detail.
The prevalence of fibromyalgia was 2.0% (95% confidence interval [95% CI] 1.4, 2.7) for both sexes, 3.4% (95% CI 2.3, 4.6) for women, and 0.5% (95% CI 0.0, 1.0) for men. The prevalence of the syndrome increased with age, with highest values attained between 60 and 79 years (> 7.0% in women). Demographic, psychological, dolorimetry, and symptom factors were associated with fibromyalgia.
Fibromyalgia is common in the population, and occurs often in older persons. Characteristic features of fibromyalgia--pain threshold and symptoms--are similar in community and clinic populations, but overall severity, pain, and functional disability are more severe in the clinic population.
Chronic fatigue syndrome (CFS), fibromyalgia (FM), and multiple chemical sensitivities (MCS) are conditions associated with fatigue and a variety of other symptoms that appear to share many clinical and demographic features. Our objectives were to describe the similarities and differences among patients with CFS, FM, and MCS. Additional objectives were to determine how frequently patients with MCS and FM met the criteria for CFS and if they differed in their health locus of control.
Demographic, clinical, and psychosocial measures were prospectively collected in 90 patients, 30 each with CFS, FM, and MCS. Patients were recruited from a university-based referral clinic devoted to the evaluation and treatment of chronic fatigue and three private practices. Variables included demographic features, symptoms characteristic of each condition, psychological complaints, a measure of health locus of control, and information on health care use.
Overall, the three patient groups were remarkably similar in demographic characteristics and the presence of specific symptoms. Patients with CFS and FM frequently reported symptoms compatible with MCS. Likewise, 70% of patients with FM and 30% of those with MCS met the criteria for CFS. Health care use was substantial among patients with CFS, FM, and MCS, with an average of 22.1, 39.7, and 23.3 visits, respectively, to a medical provider during the prior year. Health locus of control did not differ among the three populations.
In general, demographic and clinical factors and health locus of control do not clearly distinguish patients with CFS, FM, and MCS. Symptoms typical of each disorder are prevalent in the other two conditions.
To compare the frequency of lifetime psychiatric disorders among 3 groups of subjects: patients with fibromyalgia syndrome (FMS) from a tertiary care setting, community residents with FMS who had not sought medical care for their FMS symptoms ("FMS nonpatients"), and healthy controls.
We used the Computerized Diagnostic Interview Schedule to assess lifetime psychiatric diagnoses, as well as the Center for Epidemiological Studies Depression scale and the Trait Anxiety Inventory to assess current psychological distress, among 64 patients with FMS, 28 FMS nonpatients, and 23 healthy individuals.
Patients with FMS, relative to FMS nonpatients and healthy controls, were characterized by a significantly greater number of lifetime psychiatric diagnoses (P = 0.002). Nonpatients did not differ from controls in psychiatric diagnoses. Patients also exhibited higher psychological distress levels than nonpatients, and nonpatients showed greater distress than controls. Differences in psychological distress between patients and nonpatients were eliminated after controlling for pain threshold and fatigue ratings.
Psychiatric disorders are not intrinsically related to the FMS syndrome. Instead, multiple lifetime psychiatric diagnoses may contribute to the decision to seek medical care for FMS in tertiary care settings.
To record the prevalence, extent, cost, and satisfaction with use of alternative medicine practices by patients with fibromyalgia syndrome (FMS), compared to control rheumatology patients.
An interviewer-based questionnaire was administered to 221 consecutive rheumatology patients and 80 FMS patients.
Alternative medicine interventions were currently being used extensively by rheumatology patients overall, and by FMS patients in particular. All categories of alternative practices were used more often by FMS patients, compared to controls, including overall use 91% versus 63% (P = 0.0001), over-the-counter products 70% versus 54% (NS), spiritual practices 48% versus 37% (NS), and alternative practitioners 26% versus 12% (P = 0.003), respectively. Two-thirds of patients using alternative medicine practices were concurrently using multiple interventions. Patient satisfaction ratings were highest for spiritual interventions.
Alternative medicine practices were currently being used by almost all FMS patients. This observation might indicate that traditional medical therapies are inadequate in providing symptomatic relief to FMS patients.
To examine the frequency and predictors of reported complementary treatment use in a sample of 111 subjects with fibromyalgia (FM). The perspective was adopted that complementary treatment use represents a form of medical help-seeking that may be subject to a variety of biological, social, and psychological influences.
Patients with FM were recruited from community and university based clinics and support groups throughout the greater San Diego, California, area. Patients participated in a comprehensive evaluation of their pain, psychological functioning, and disability prior to their potential involvement in a clinical trial designed to help them copy with their condition. They were also administered a rheumatological evaluation to verify their FM and a 20 item questionnaire to assess their use of complementary treatment strategies specifically for coping with FM.
Ninety-eight percent of the sample reported the use of at least one strategy over the preceding 6 months. Exercise, bed rest, vitamins, heat treatment, and spirituality/praying were the most frequently used strategies by subjects on a daily basis. Multiple regression analysis revealed that lower age, higher pain, and higher disability were uniquely associated with higher complementary treatment use. The Pain Rating Index, a measure of the subjective severity of pain from the McGill Pain Questionnaire, proved highly significant in explaining the relationship between pain and questionnaire scores. Pain coping strategies and quality of social support did not predict complementary treatment use.
The findings suggest that poor clinical status is a major predictor of complementary treatment use in FM. However, longitudinal research is recommended to clarify the relationship between clinical status and help-seeking patterns in patients with FM over time.
Fibromyalgia is a noninflammatory rheumatic disorder characterized by chronic widespread musculoskeletal pain. Although many studies have described the pain and other clinical symptoms associated with this disorder, the primary mechanisms underlying the etiology of fibromyalgia remain elusive. This article reviews recent data supporting the links among each of three systems--the musculoskeletal system, the neuroendocrine system, and the central nervous system (CNS), all of which appear to play major roles in fibromyalgia pathophysiology--and pain in fibromyalgia, and concludes by presenting a model of the pathophysiology of abnormal pain perception in fibromyalgia which integrates the research findings described.
Massage therapy is older than recorded time, and rubbing was the primary form of medicine until the pharmaceutical revolution of the 1940s. Popularized again as part of the alternative medicine movement, massage therapy has recently received empirical support for facilitating growth, reducing pain, increasing alertness, diminishing depression, and enhancing immune function. In this article studies are reviewed that document these effects, and models are proposed for potential underlying mechanisms.
Massage therapy is frequently employed for low back pain (LBP). The aim of this systematic review was to find the evidence for or against its efficacy in this indication. Four randomized clinical trials were located in which massage was tested as a monotherapy for LBP. All were burdened with major methodological flaws. One of these studies suggests that massage is superior to no treatment. Two trials imply that it is equally effective as spinal manipulation or transcutaneous electrical stimulation (TES). One study suggests that it is less effective than spinal manipulation. It is concluded that too few trials of massage therapy exist for a reliable evaluation of its efficacy. Massage seems to have some potential as a therapy for LBP. More investigations of this subject are urgently needed.
Psychosocial distress and psychological abnormality occurs frequently in fibromyalgia patients. Patterns of decreased levels of education, and increased rates of divorce, obesity, and smoking have been noted in clinical and epidemiological studies. Links to physical and sexual abuse have been noted as well. Major depression as well as increased rates of depression, anxiety, and somatization are also commonly found in fibromyalgia.
Despite substantial interest and investigation during the past 10 years, fibromyalgia continues to provoke many controversies. The major issues discussed in this review include the diagnostic utility of fibromyalgia, psychiatric and central nervous system factors, therapy and outcome, and compensation and disability. It is important to recognize the psychosocial factors that distinguish patients with fibromyalgia from persons in the community who meet criteria for the syndrome but who do not seek medical care. Such factors may be among the most important in long-term treatment.
Chronic pain often differs from acute pain. The correlation between tissue pathology and the perceived severity of the chronic pain experience is poor or even absent. Furthermore, the sharp spatial localization of acute pain is not a feature of chronic pain; chronic pain is more diffuse and often spreads to areas beyond the original site. Of importance, chronic pain seldom responds to the therapeutic measures that are successful in treating acute pain. Physicians who are unaware of these differences may label the patient with chronic pain as being neurotic or even a malingerer. During the past decade, an exponential growth has occurred in the scientific underpinnings of chronic pain states. In particular, the concept of nonnociceptive pain has been refined at a physiologic, structural, and molecular level. This review focuses on this new body of knowledge, with particular reference to the chronic pain state termed "fibromyalgia."
Subjective:
Chronic widespread pain with multiple tender points (fibromyalgia syndrome) is a common clinical presentation. Criteria for inclusion of fibromyalgia patients into research studies have led to a medical model which integrates symptoms, signs, epidemiology, pathogenesis, responses to treatment, and prognosis. Controversy regarding fibromyalgia relates mostly to issues of compensation. THEORETICAL: The diagnosis of fibromyalgia has been challenged as an inappropriate extraction from an epidemiological continuum of subjective discomfort. There are many conditions in which normally distributed measures exhibit distinctly unique outcomes at their extremes.
Objective:
Since fibromyalgia patients exhibit lowered pain thresholds, the process of nociception was studied. Samples of fibromyalgia urine, blood, and spinal fluid disclosed abnormalities consistent with a biomedical model of failed neuroregulatory inhibition, altered nociception, central sensitization, and allodynia. All three views support fibromyalgia as a distinct clinical syndrome deserving of informed medical care and continued research to better understand chronic widespread pain.
Fibromyalgia syndrome was an attempt to create, for the purposes of investigation, a relatively homogeneous clinical entity out of the clinical phenomena of musculoskeletal pain and tenderness. The attempt has foundered, arising out of circular argument and violation of its own criteria, thus creating an over-inclusive and ultimately meaningless label. The epistemological errors include the failure to distinguish a clinical feature from a disease process, the use of syndromic description without a unifying concept and failure to agree on the importance and biological nature of tenderness itself.
Depression and anxiety are common in medical patients and are associated with diminished health status and increased health care utilization. This article presents a quantitative review and synthesis of studies correlating medical patients' treatment noncompliance with their anxiety and depression.
Research on patient adherence catalogued on MEDLINE and PsychLit from January 1, 1968, through March 31, 1998, was examined, and studies were included in this review if they measured patient compliance and depression or anxiety (with n>10); involved a medical regimen recommended by a nonpsychiatrist physician to a patient not being treated for anxiety, depression, or a psychiatric illness; and measured the relationship between patient compliance and patient anxiety and/or depression (or provided data to calculate it).
Twelve articles about depression and 13 about anxiety met the inclusion criteria. The associations between anxiety and noncompliance were variable, and their averages were small and nonsignificant. The relationship between depression and noncompliance, however, was substantial and significant, with an odds ratio of 3.03 (95% confidence interval, 1.96-4.89).
Compared with nondepressed patients, the odds are 3 times greater that depressed patients will be noncompliant with medical treatment recommendations. Recommendations for future research include attention to causal inferences and exploration of mechanisms to explain the effects. Evidence of strong covariation of depression and medical noncompliance suggests the importance of recognizing depression as a risk factor for poor outcomes among patients who might not be adhering to medical advice.
Further analysis of learned helplessness in rheumatoid arthritis using a " Rheumatology Attitudes Index Radloff LS: The CES-D scale: A self-report depression scale for recording the general population
- Callahan
- Brooks Rh Lf
Callahan LF, Brooks RH, Pincus T: Further analysis of learned helplessness in rheumatoid arthritis using a " Rheumatology Attitudes Index. " J Rheumatol 15: 418-426, 1988. 21. Radloff LS: The CES-D scale: A self-report depression scale for recording the general population. Applied Psychol Measurement 1: 385-401, 1977.
Arthritis and allied conditions. A Text-book of Rheumatology
- Bradley La Alarcon
Bradley LA, Alarcon GS: Fibromyalgia. Arthritis and allied conditions. A Text-book of Rheumatology. Edited by WJ Koopman. Williams and Wilkins, Baltimore, 1997, pp 1619-1640.
why such a controversy?
- D L Goldenberg
- Fibromyalgia
Weights for scoring the quality of well-being instrument among rheumatoid arthritis. A comparison to general population weights
- D J Balaban
- P C Sagi
- N I Goldfarb
- S Menler