Getting Women with Fibromyalgia Moving

What is fibromyalgia and what exactly what does exercise have to do with the treatment and long-term outcome of the condition?  A recent study published in Medicine & Science in Sports & Exercise is helpful in understanding the relationship between fibromyalgia and exercise and how clinicians (and patients) might find better strategies for treatment.

Fibromyalgia is a clinically defined pain syndrome estimated to affect about 5 per cent of the general population with criteria for diagnosis defined by the American College of Rheumatology to include:

• Pain in all four quadrants of the body
• Pain along the spine
• Presence of 11 of 18 specific tender points

The 18 specific tender points (or trigger points) are outlined in the accompanying public domain figure from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and Wikipedia.

Women have higher prevalence rates for fibromyalgia.  The reason for this gender discrepancy in unknown as is the cause of the disorder.   Patients meeting criteria for this medical pain disorder commonly have significant cognitive and emotional symptoms as well.   Endorsement rates for problems with cognitive impairment (poor concentration, memory problems, psychomotor speed problems and diminished attention span) are common in fibromyalgia.  Additionally, rates of anxiety and mood symptoms and disorders appear high.  The cause for this association is also unknown.

Like many pain syndromes, exercise seems to be helpful in the long-term management of fibromyalgia.  Although a natural response to pain is to reduce activity, this physical withdrawal can be counterproductive to a good long-term outcome.  It is important for women with fibromyalgia and their physicians to assess and monitor response to exercise as a key component to treatment.

McLoughlin and a research team from the University of Iowa and the University of Wisconsin studied the relationship between self-reported exercise and actual exercise in a group of women with fibromyalgia and a group of women without fibromyalgia.  They utilized an accelerometer that was worn on the hip for 7 days to compare actual activity levels to what the women were reporting.   The key findings from the study were:

• Fibromyalgia subjects reported less physical activity (confirmed by accelerometer data) than controls
• Both those with fibromyalgia and controls reported higher levels of activity than could be validated by accelerometer data
• Self-report activity levels were poorly correlated with accelerometer activity in fibromyalgia but not controls
• High depression scores in fibromyalgia correlated with lower physical activity

For clinicians, the take home message here is you can’t rely only on your fibromyalgia patient’s self-report of exercise.  I think we will be seeing more use of devices such as accelerometers in clinical practice to get a more objective measure of physical activity.  Similar movement measurement capabilities (like those found in accelerometers) are available in the iPhone and iPod Touch.  Such tools may also be used to monitor change in activity with a new intervention, i.e. attending Jazzercise on a regular basis.  Targeting depression treatment in women with fibromyalgia may be one method to improve the chances of getting activity levels up.

The need for implementing activity programs is not limited to the medical illness of fibromyalgia.  Similar programs in obesity, heart disease, diabetes and lung disease are needed.  Collecting activity levels in these and other medical conditions may give clinicians additional insight into the effects of inactivity on disease progression.

Getting activity levels up in fibromyalgia can lead to significant improvement.  A recent trial of exercise in fibromyalgia by Fontaine and colleagues found regular activity reduced pain and reduced functional impairment.  This intervention paired education with a pedometer data that would be monitored by the research team.  When accountability is incorporated in exercise trials, compliance and benefits go up.

MCLOUGHLIN, M., COLBERT, L., STEGNER, A., & COOK, D. (2011). Are Women with Fibromyalgia Less Physically Active than Healthy Women? Medicine & Science in Sports & Exercise, 43 (5), 905-912 DOI: 10.1249/MSS.0b013e3181fca1ea

Fontaine KR, Conn L, & Clauw DJ (2010). Effects of lifestyle physical activity on perceived symptoms and physical function in adults with fibromyalgia: results of a randomized trial. Arthritis research & therapy, 12 (2) PMID: 20353551

Common Neuropsychiatric Problems in Epilepsy

Epilepsy represents a complex neuropsychiatric condition with significant public health impact.  The prevalence estimates of active epilepsy range from about 1 to 4% of the general population.  Like other medical conditions, epilepsy appears to increase the risk for a variety of secondary (or cormorbidity problems).  Understanding these related risks can aid patients, families and clinicians in understanding symptoms, common presentation conundrums and best treatment approaches. A recent epidemiology survey published by Ottman and colleagues of a large sample of the general population in the U.S. provides insight into the range and relative risk for variety of disorders in those with epilepsy.  The key elements of this survey include the following key design items:

• Data part of Epilepsy Comorbidity and Health (EPIC) Survey
• Mail survey to random households in the United States
• Case definition of epilepsy a yes response to the following question: “Have you ever been told you have a seizure disorder or epilepsy?”.
• Those who reported being diagnosed with epilepsy (2.0% of those surveyed) were compared to those without a self-reported diagnosis
• Surveyed other neuropsychiatric, pain and other medical conditions included: anxiety disorder, depression, bipolar affective disorder, ADHD, sleep disorder/apnea, tremor/movement disorder, migraine, fibromyalgia, chronic pain, neuropathic pain, asthma, diabetes, high blood pressure
• Risk ratios controlled for a variety of potential confounding variables including: sex, age, income, population density,census region, prior head injury, and prior stroke

The comorbid conditions with the highest relative risks (that were statistically significant) are shown in the accompanying summary figure.   A prevalence ratio of 2.0 would mean those with epilepsy are twice as likely to have the diagnosis compared to controls without epilepsy. ADHD, bipolar disorder, movement disorder/tremor and fibromyalgia led the rank list of diagnoses.  A significant number of the disorders showed statistically significant associations between a risk of 1.0 to 2.0.   The only disorders that showed no link to a diagnosis of epilepsy were diabetes and high blood pressure.

The primary weaknesses of these types of studies is reliance on self-report diagnosis by a the respondents.  One way to exam the validity of diagnoses is to conduct more detailed direct interviews and examinations of a subset of study participants.  Also the rates of self-reported diagnoses can be compared to known direct interview studies.  Here are the rates of self-reported neuropsychiatric diagnoses in those without epilepsy in the current study: depression 25.6%, anxiety 13.9%, bipolar disorder 6.8%, ADHD 5.5%.   The bipolar disorder self-report rates seem unexpectedly high and the implications for the validity of this study is unclear.

The authors note their study demonstrating a lifetime self-report prevalence rate of 2.0% is consistent with previous other population-based surveys.  Neuropsychiatric comorbidities were common in those reporting epilepsy ranging from a low of 8.7% for neuropathic pain to 32.5% for depression.  The authors note this study will aid those caring for epilepsy and help target comprehensive assessment and managment.

Ottman R, Lipton RB, Ettinger AB, Cramer JA, Reed ML, Morrison A, & Wan GJ (2011). Comorbidities of epilepsy: Results from the Epilepsy Comorbidities and Health (EPIC) Survey. Epilepsia PMID: 21269285