Recall of Stressful Events in Fibromyalgia Syndrome

It has long been speculated that stressful events bear importance in the pathogenesis of the fibromyalgia syndrome [FMS]. The nature of the events have ranged from physical to psychological trauma (1–8), most dramatically in the form of motor vehicle accidents (3). One of the issues that has raised doubt about the strength of the evidence has been the fact that most of the reports have involved clinically symptomatic FMS patients recalling and associating past events with the onset of the current symptoms. One of the main reasons that it matters is that patients with compromised ability to work naturally raise the question regarding who should pay for that disability.

The first research article in this issue of the Journal of Musculoskeletal Pain [JMP] comes from Maranhão, Brazil (9). The authors asked the following question: Are FMS patients who identify a triggering event or situation as being responsible for the onset of their condition clinically different from FMS patients who do not acknowledge such a triggering event? They recruited local FMS patients but excluded those with a rheumatic disease and those with comorbid major depression. They then clinically compared those who identified a triggering event versus those with no apparent triggering event. Despite the relatively small sample sizes, their analysis disclosed significant clinical differences between the groups with respect to compromised quality of life and the prevalence of certain comorbidities. The authors discuss these findings by comparison with relevant prior medical literature.

The second research contribution comes from Saskatoon, Saskatchewan, Canada (10). A chronic pain center which offers an interdisciplinary treatment program had previously studied the outcomes of pain patients from beginning of their program to discharge [a period of six weeks] and found significant improvement on essentially all measures. The current study was an extension of the first but was designed to determine whether the improvements seen with the short-term interventions were robust to at least one year of follow-up and how they would compare with a comparison group. The comparison cohort consisted of patients who had the initial evaluation but did not participate in the interventional program. The findings are pretty clear but what they will mean for chronic pain treatment programs is less apparent. The authors discuss these issues.

The third research contribution comes from Herlev, Ballerup, and Aalborg, Denmark (11). The authors' objectives were to determine the relationships between the subjective severity of knee pain to the objective findings derived from selected laboratory measures and imaging tests. Subjective pain severity was measured using a visual analog scale. Laboratory tests included a serum bone turnover marker and a urinary marker of cartilage turnover. Magnetic resonance imaging of the medial tibio-femoral compartment was used to document cartilage volume, thickness, curvature, smoothness, and homogeneity. This article has a clear arthritis focus, so why is it being presented in the pages of JMP, whose focus is soft tissue pain [STP]? The answer is found in the limited value of most of the objective joint related measures to explain the subjective pain. Often knee pain in osteoarthritis patients is found to have its origin in the soft tissues rather than in the joint. Occasionally, skilled treatment of the peri-articular STP problem can reduce the severity of knee pain even in a patient with known osteoarthritis.

The answer may, in part, come from the fourth research contribution submitted from Hadera and Kefar Sava, Israel (12). The authors tested the relative value in the treatment of osteoarthritis knee pain derived from injecting glucocorticoid intra-articularly versus injecting glucocorticoid peri-articularly. The severity of the osteoarthritis ranged from Grade 1 to Grade 3–4. The pain measures came from the Western Ontario and McMaster Universities osteoarthritis index. With both injection methods, 80 mg of methylprednisolone acetate [2 cc] was administered with 3 cc of two percent lidocaine. No synovial fluid was aspirated. The peri-articular injections were given in the region of the collateral ligaments without entry of the joint capsule. The patients were randomized to treatment group and were followed for three months. The reader is encouraged to carefully assess the results and what the authors believe they mean. It is possible that skilled trigger point injection in the peri-articular soft tissues about the knee would have been even more effective.

The fifth research article comes from Stockton on Tees, Hartlepool, and Middlesbrough, England (13). The authors describe a retrospective clinical review and long-term follow-up of patients operated for the hip snapping syndrome. Patients with this condition experience a click in the hip area when the hip is adducted and flexed. The surgical procedure was performed only when conservative therapy was judged to have failed. The authors report the largest series of surgical interventions for this problem. It took 12 years to accumulate 25 operated cases because conservative therapy is usually sufficiently effective to avert surgery. The assessed outcome measures were obtained by patient self-report.

There is a Research Ideas paper (14) from Clemmens, North Carolina, in which the authors propose a mechanism by which fibromyalgia and vitamin D deficiency might be pathogenically related. The authors also propose a study that might help to clarify the questions raised by their essay. Readers with expertise in this area are encouraged to respond to the authors' hypothesis.

Please take note of the columns which provide reviews of papers in other medical journals since the previous issue of the JMP. The overall topics of these reviews are “Fibromyalgia Syndrome,” “Myofascial Pain Syndrome,” and “Other Soft Tissue Pain Syndromes.”

As always, readers of 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 keep the featured book after their evaluation report is completed. If you would be interested in being a book reviewer for the JMP, please communicate that to the editor.

Potential authors of contributions to the JMP should note that submissions and all communications between the authors and the JMP staff are to be accomplished online. Visit http://mc.manuscriptcentral.com/wjmp for more details. This web address may change soon, as the publisher launches its own manuscript management website.

The clear mandate of the IMS, for which the JMP is the official journal, is to perpetuate the international meeting that is currently held every three years. The next international meeting will be MYOPAIN 2013 and will be held in Seattle, Washington, USA. The IMS website www.myopain.com will offer details as they become available.

I. Jon Russell, MD, PhD

The Editor