Healing Choices, P.C.

The American College of Rheumatology 1990
Criteria For the Classification of
Fibromyalgia

Report of the Multicenter Criteria Committee

Frederick Wolfe, Hugh A. Smythe, Muhammad B. Yunus, Robert M. Bennett, Claire Bombardier, Don. L. Goldenberg, Peter Tugwell, Stephen M. Campbell, Micha Abeles, Patricia Clark, Adel G. Fam, Stephen J. Farber, Justus J. Fiechtner, C. Michael Franklin, Robert A. Gatter, Daniel Hamaty, James Lessard, Alan S. Lichtbroun, Alfonse T. Masi, Glenn A. McCain, W. John Reynolds, Thomas J. Romano, L Jon Russell, and Robert P. Sheon

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.

The effectiveness of multidisciplinary rehabilitation in the treatment of fibromyalgia: a randomized controlled trial.

College of Medicine , University of Saskatchewan , Saskatoon , Canada .

OBJECTIVES: To assess the effectiveness of multidisciplinary rehabilitation in the treatment of fibromyalgia in comparison to standard medical care. METHODS: Seventy-nine men and women were randomly assigned to one of two groups. The intervention group consisted of a rheumatologist and physical therapist intake and discharge, 18 group supervised exercise therapy sessions, 2 group pain and stress management lectures, 1 group education lecture, 1 group dietary lecture, and 2 massage therapy sessions. The control group consisted of standard medical care with the patients' family physician. Outcome measures included self-perceived health status, pain-related disability, average pain intensity, depressed mood, days in pain, hours in pain, prescription and nonprescription medication usage, and work status. Outcomes were measured at the end of the 6-week intervention and at 15-month follow-up. RESULTS: Thirty-five out of 43 patients from the intervention group and 36 out of 36 patients from the control group completed the study. There were no statistically significant differences between the 2 groups prior to intervention. Intention-to-treat analysis revealed that the intervention group, in comparison to the control group, experienced statistically significant changes at intervention completion in self-perceived health status, average pain intensity, pain related disability, depressed mood, days in pain, and hours in pain, but no significant differences in nonprescription drug use, prescription drug use, or work status. At 15 months, all health outcomes retained their significance except health status. Nonprescription and prescription drug use demonstrated significant reductions at 15 months. Binary logistic regression indicated that long-term changes in Pain Disability Index were influenced by long-term exercise adherence and income status. CONCLUSIONS: Positive health-related outcomes in this mostly unresponsive condition can be obtained with a low-cost, group multidisciplinary intervention in a community-based, nonclinical setting.

Six-month and one-year follow-up of 23 weeks of aerobic exercise for individuals with fibromyalgia.

University Health Network and University of Toronto , Toronto , Ontario , Canada .

OBJECTIVE: To measure mood and physical function of individuals with fibromyalgia, 6 and 12 months following 23 weeks of supervised aerobic exercise. METHODS: This is a follow-up report of individuals who were previously enrolled in 23 weeks of land-based and water-based aerobic exercise classes. Outcomes included the 6-minute walk test, Beck Depression Inventory (BDI), State-Trait Anxiety Inventory, Arthritis Self-Efficacy Scale (ASES), Fibromyalgia Impact Questionnaire (FIQ), tender point count, patient global assessment score, and exercise compliance. Outcomes were measured at the start and end of the exercise classes and 6 and 12 months later. RESULTS: Analyses were conducted on 29 (intent-to-treat) or 18 (efficacy) subjects. Six-minute walk distances and BDI total scores were improved at follow-up (all analyses). BDI cognitive/affective scores were improved at the end of 23 weeks of exercise (both analyses) and at the 12-month follow-up (efficacy analysis only). BDI somatic scores were improved at 6-month (both analyses) and 12-month follow-up (intent-to-treat only). FIQ and ASES function were improved at all follow-up points. ASES pain was improved in efficacy analyses only (all follow-up points). Tender points were unchanged after 23 weeks of exercise and at follow-up. Exercise duration at follow-up (total minutes of aerobic plus anaerobic exercise in the preceding week) was related to gains in physical function (6- and 12-month follow-up) and mood (6-month follow-up). CONCLUSION: Exercise can improve physical function, mood, symptom severity, and aspects of self efficacy for at least 12 months. Exercising at follow-up was related to improvements in physical function and perhaps mood.

Recognition of Environmental / Food
Sensitivities Could Have a Significant Impact

After 6 months the treatment group experienced

50% less pain
70% less depression
30% less stiffness

The control group reported an increase in pain and depression.

Pain treatment with acupuncture for patients with fibromyalgia.

Division of Physical Medicine, Department of Orthopedics and Traumatology, University of Sao Paulo School of Medicine, Ave. Giovanni Gronchi, 1106 San Paulo, Brazil. ucklrsu@ucl.ac.uk

Fibromyalgia is a chronic, painful musculoskeletal syndrome of unknown etiopathogenesis. In addition to medicamentous and physical and psycho logic therapies, several other adjunct therapies have been used as alternatives in the attempt to obtain analgesia and decrease the symptoms that are characteristic of this problem. This article presents a literary review on the use of acupuncture as an adjunct or chief treatment for patients with fibromyalgia, comparing it with an ongoing clinical experience that has been carried out at Hospital das Clinicas in the city of Sao Paulo . The results were found by applying traditional acupuncture, which demonstrated positive rates in the Visual Analogue Scale, myalgic index, number of tender points, and improvement in quality of life based on the SF-36 questionnaire.

The role of acupuncture in pain management.

Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA. jaudette@partners.org

This article reviews the theories and applications of acupuncture to musculoskeletal pain management. First, Chinese theories of acupuncture are discussed briefly. Next, current understanding of nociception and central pain modulation is discussed in detail, followed by discussion of the physiologic effect of acupuncture analgesia. Other theories of acupuncture analgesia are presented based on neuromodulation of the central nervous system. Finally, the efficacy of acupuncture for many musculoskeletal pain syndromes, including spine-related pain, soft tissue pain, neuropathic pain, arthritis of the knee, and upper extremity tendonitis, is reviewed. The article concludes with a discussion of methodologic issues related to conducting randomized, placebo-controlled trials of acupuncture and goals for future research in this area of pain management.

Influence of social support and emotional context on pain processing and magnetic brain responses in fibromyalgia.

Montoya P, Larbig W, Braun C, Preissl H, Birbaumer N.

University of the Balearic Islands, Palma, Spain pedro.montoya@uib.es

OBJECTIVE: To examine the effects of social support provided by the presence of patient's significant other on pain ratings, pain thresholds, and brain activity associated with tactile stimulation in 18 fibromyalgia (FM) patients and 18 migraine patients (controls), and to assess the influence of emotional context on thermal pain perception and processing of non-pain-related information. METHODS: Thermal pain thresholds and somatosensory brain magnetic responses elicited by tactile stimulation at the elbow (a painful tender point in the FM group) and at the finger (nonpainful site) were evaluated under 2 experimental conditions of social support: patient alone and patient's significant other present. Brain activity was recorded using a 151-channel whole-head magnetoencephalography system. Additionally, the emotional context during presentation of tactile stimuli was manipulated by presenting aversive, pain-related pictures and neutral pictures and asking the patients to imagine that they were experiencing the situations depicted. RESULTS: Thermal pain thresholds indicated greater sensitivity in FM patients than in migraine patients, as well as enhanced sensitivity at the elbow than at the fingers. Specifically, in FM patients, there were significant reductions in pain sensitivity and subjective pain ratings when patients were stimulated at the painful tender point in the presence of their significant others as compared with the ratings when the patients were alone. Brain activity elicited by elbow stimulation was also significantly reduced in FM patients when a significant other was present as compared with the activity when the patient was alone. These effects were not observed in the migraine patients. CONCLUSION: When the significant other was present, FM patients reported less pain and thermal pain sensitivity and showed diminished brain activity elicited upon tactile stimulation of a tender point compared with these levels when the patients were alone. These findings are consistent with the hypothesis that social support through the presence of a significant other can influence pain processing at the subjective-behavioral level as well as the central nervous system level.

Common Conditions

Healing Choices, P.C. is an interdisciplinary specialty medical practice founded by Keith W.L. Rafal, M.D, MPH. The practice supports an integrative rehabilitation approach to patient care and is dedicated in partnership with patients to create opportunities in health and healing that serves to bridge conventional and alternative medicine.

The practice specializes in the consultation and treatment of a variety of chronic medical conditions. Keith W.L. Rafal, MD, MPH has been the Medical Director of a large regional interdisciplinary practice for patients who have been diagnosed with Fibromyalgia, and Myofascial Pain Syndrome. We have access to a dedicated team of physical and occupational therapist and a therapeutic pool program Through an interdisciplinary approach we also successfully treat other conditions such as chronic low back pain, neck pain, carpal tunnel syndrome, chronic headaches, Irritable Bowel Syndrome, arthritis, strokes, and women's health concerns. Healing Choices empowers patients to make the necessary changes in their lives that will facilitate healing.