Dyscognition in the Fibromyalgia Syndrome

One of the very disturbing clinical complaints of fibromyalgia syndrome [FMS] patients is dyscognition (1). Their problem with cognition tends to be more complicated than forgetting where the car keys were placed or why this particular room was entered when it was (2). Typically, the patient will complain of fuzzy thinking, so the phenomenon has been termed fibrofog (3). Physicians have been frustrated by the long list of written questions and concerns presented by the FMS patients at clinical visits. They say that the list was needed because they feared that they would forget to ask something important. It turns out that they actually remember their questions pretty well, so this phenomenon has been referred to as cognitive insecurity (4). Many views and many terms do not shed much light on the magnitude of this problem, on its cause or on approaches that should be taken to help patients with it. One could wonder if the problem with cognitive dysfunction in FMS is related to poor sleep (5), to chronic pain (6–8), to distraction by anxiety/depression (6,9), to the loss of cortical gray matter (10,11), to premature aging (12), to the use of medications that alter central nervous system function (13–15), or to an idiosyncratic need for operant conditioning (16). An additional question would be whether subgroups of FMS patients differ substantially from other FMS subgroups with regard to basis for their cognitive concerns (12,17).

The lead research article for this issue of the Journal of Musculoskeletal Pain comes from Ann Arbor, Michigan, USA (18). It involves academic investigators who have an established track record of interest in FMS and in the influence of cognitive dysfunction upon its overall clinical impact (12,19,20). Their objectives in the current study were to seek evidence for different types of dyscognition and to identify any associations between each dyscognition type and other recognized clinical manifestations of FMS. A validated, self-report instrument called Multiple Abilities Self-Report Questionnaire was used to identify different types of dyscognition. This instrument classifies dyscognition into the following five cognitive domains: 1. language ability, 2. visual–perceptual ability, 3. verbal memory, 4. visual memory, and 5. attention/concentration. The resultant data on the different domains of dyscognition were then compared with subjective reports of pain, fatigue, sleep problems, mood, and illness burden. The study involved 96 female volunteers composed of 72 FMS patients and 24 healthy normal controls with similar between-group educational attainments. The reader will want to examine the authors' data carefully and consider their conclusions. It seems clear that dyscognition in FMS is not an “it” but rather a “they.” While it is well known that associations between measured clinical manifestations do not establish a cause-and-effect relationship, it is reasonable to predict that understanding the driving influences on the dyscognition of FMS may help clinicians to more strategically focus their therapeutic interventions. In addition, this information may eventually guide in the development of new strategic therapies. It seems quite likely that more study of this concept will be prompted by the findings of this report.

The second research contribution comes from academic clinicians in Madrid and Alcorón, Spain (21). The principal objectives of their study were to use data from the 2006 Spanish National Health Survey to first characterize moderately severe musculoskeletal pain in the population of that country according to socio-demographics and health-related variables; secondarily, to determine the prevalence of psychological distress among individuals with and without musculoskeletal pain; and finally, to analyze the association between psychological distress and disabling musculoskeletal pain. In their manuscript, the authors repeatedly use the term “invalidating musculoskeletal pain” which is said to occur in 6.4 percent in the Spanish adult population. Since their word “invalidating” has the English Language meaning of causing to be incorrect or non-valid [invalidate], it bears clarification to the current setting. It seems that the authors are referring to the state of disability from the musculoskeletal pain [i.e. the state of being an invalid]. The authors state this as follows: “We classified as cases [invalidating musculoskeletal pain sufferers] those subjects who suffered from self-reported musculoskeletal pain [bone, spine, or joint pain] in the preceding two weeks that reduced or limited their main working activity or free time activity by at least half.” From a database of 29,478 records, the authors selected 1331 subjects with and 1331 without musculoskeletal pain matched by age, gender, and province of residence. Subjects with depression, anxiety, or other mental problems were excluded. Their findings indicate the relative frequency of psychological distress among the study populations and some of the consequences of that distress in affected individuals.

People all over the world spend approximately one-third of their life [six to eight hours of every 24-hour period] sleeping with their heads resting on their pillow. The quality of that sleeping function can have dramatic effects on how the individual feels during the waking hours. It thus stands to reason that the pillow should be chosen well. The third research study report comes from academic investigators in Queensland and South Australia, Australia (22,23). Their contributions come in the form of two studies reported together in two overlapping papers. A third study is described but the data for that study were not provided. The studies were apparently conducted by the investigators in the country of South Africa. Study subjects who slept on their side were recruited to report the type of pillow they usually used and their satisfaction with that pillow. Using that information as background, the investigators provided experimental pillows to see what the responses of the subjects would be to the new appliances. Among the symptoms evaluated were the development of cervicothoracic pain and daytime tiredness. A final study documented the anatomy of the cervicothoracic spine while lying on different types of pillows but the results of that study are not provided. There is a lot of information in the provided tables. Figure 1 of paper number 1 provides an outline guide to the series of studies.

The fourth research study report comes from Seoul, Korea, in collaboration with investigators located in Durham, North Carolina, USA (24). The report deals with an attempt to avoid adverse effects and limitations to local stellate ganglionic block which is usually performed at the C6 level by conducting the procedure differently and at the C7 level. The study compared the outcomes from an oblique approach to the ganglion with those experienced using a classical anterior approach to the ganglion at the C7 level. Sixty-eight patients with sudden sensorineural hearing loss [an indication for stellate ganglionic block] were studied in the two different methodological groups. The authors concluded with a preference for one of the experimental methods based on a difference in the resultant incidence of hoarseness.

Readers of the JMP are again provided columns with summaries of the important developments in soft tissue pain published in other medical journals. These features not only provide a comprehensive review of what is new in the field, but also allow readers to benefit from illuminating commentary by experts from two continents.

Notice the interesting Letter to the Editor (25) from Sevilla, Spain, and comment (26) from Toulon, France. There is also a book review from Addison, Texas.

As always, readers of the JMP are invited to submit original manuscripts for blinded peer review, case reports of general interest, research ideas to promote further investigation, and letters to keep us all informed. The JMP editorial office frequently receives relevant books to be evaluated by and for the benefit of our readers. Book reviewers are allowed to keep the featured book after the evaluation report is completed. If you would be interested in being a book reviewer for the JMP, please communicate that to the editor. There is always a need for reviewers of scientific manuscripts. Submissions to the JMP and all communications between the authors, reviewers, and the JMP staff are accomplished online. Please visit http://mc.manuscriptcentral.com/wjmp for more details.

The following paragraphs represent SECOND NOTICE for the International MYOPAIN Society: This journal is the print media voice of the International MYOPAIN Society [IMS]. A clear mandate of the IMS is to perpetuate the international meeting that has traditionally been held alternately in Europe or the United States every three years since 1989. The most recent International MYOPAIN Meeting was held in Toledo, Spain on October 3–7, 2010. The manuscripts from the invited speakers at that meeting were published in the JMP 18(3,4) as a combined special symposium issue. Those IMS members who were unable to attend the meeting and attendees who wish to jog their memories regarding some aspects of a given presentation can refer to their copy of that issue. Members of the IMS can view the current and past issues online.

The next International MYOPAIN meeting is scheduled for 2013 in Seattle, Washington, USA. That city is renowned for its beautiful coastal scenery and its unique fish market. The IMS website www.myopain.com will offer details as they become available.

Some important decisions were made by the IMS Board during the meeting in Toledo. After the Seattle meeting, the frequency of IMS international meetings will increase to every two years and will involve Asian-Pacific countries, as well as Europe and the United States. In that light, the 2015 meeting will be held in Sydney, Australia. The IMS Board has also approved the establishment of regional associations under the umbrella of the IMS. Groups anywhere in the world wishing to begin organization in that way should submit a plan to the IMS Board of Directors. Finally, Barbara Runnels, who has been administrator of the IMS since its inception in 1995, wishes to retire and has asked the IMS Board to find a replacement. The Board has accepted her resignation with the provision that she continue for one year as advisor to new staffing. The Board is currently seeking a person or company to provide the needed administrative services. Time will tell how these innovations will play out. If readers have strong opinions regarding these IMS Board decisions, they are encouraged to send their comments to the JMP in the form of Letters to the Editor.