FMS Community Newsletter #30
Tuesday, October 29, 2002


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FMS Community Newsletter 30
Tuesday, October 29, 2002
1963 subscribers and 30 new subscribers. Welcome!
Featured link: Preventing and reducing stress

This week's feature article at the website of the CFIDS/Fibromyalgia
Self-Help program is titled "Reducing and Preventing Stress." It offers
descriptions of the many stress reduction techniques used by students in
our program, and also their strategies for avoiding stress. The article
is the fifth in the series "What Works for Managing CFIDS and

Check it out:
AOL users: <a href="">Read it here</a>
This week's news:
1) Research into medicinal use of marijuana in the UK
2) Nerves exposed: Man with CFS shares his knowledge
3) Tricyclic antidepressants and fibromyalgia: what is the mechanism of
4) The psychopharmacology of fibromyalgia: a drug development
5) Tips for getting a proper diagnosis of an autoimmune disease
6) Subjective quality of life, health, I-ADL ability and adaptation
strategies in fibromyalgia
7) Effects of a multiprofessional rehabilitation programme for patients
with fibromyalgia syndrome.
8) Patient satisfaction in the rehabilitation of fibromyalgia inpatients

9) Subgroups of Fibromyalgia Patients: Evidence for Heterogeneity and an
Examination of Differential Effects Following a Community-Based
10)Pain: The Fifth Vital Sign
1) Research into medicinal use of marijuana in the UK

In the November issue of FaMily magazine we print an article on the
medicinal use of cannabis for fibromyalgia sufferers written by a
spokesman for GW Pharmaceuticals - the leading UK company involved in
this research.

To read the article visit
2) Nerves exposed: Man with CFS shares his knowledge

It is common for people who suffer from a disease or disorder -- or who
have a child who suffers from that disease or disorder -- to become
knowledgeable about [it]. But Douglas Linsday has become more than
knowledgeable. In fact, he will be going to Hilton Head, S.C. this week
to present a paper at the International Symposium on the Autonomic
Nervous System.

Check it out:



AOL users: <a


0Debilitating%20disease%20launches%20local%20man">Read it here</a>
3) Tricyclic antidepressants and fibromyalgia: what is the mechanism of

Expert Opin Investig Drugs 2002 Oct;11(10):1437-45

Lawson K.

Biomedical Research Centre and Division of Biomedical Sciences,
Hallam University, School of Science and Mathematics, City Campus,
Sheffield, S1 1WB, UK.

PMID: 12387704

Fibromyalgia is a chronic pain disorder of which other clinical
such as persistent fatigue and disordered sleep, may be a secondary
consequence. The initial pharmacological approach to treating the
is the management of the pain. Tricyclic antidepressants are the most
effective drugs in use so far, especially when administered in
with other therapies (e.g., selective serotonin re-uptake inhibitors),
which suggests modulation of the neurotransmitters serotonin and

The effectiveness of amitriptyline and related tricyclic
however, is consistent with the involvement of mechanisms, such as
potassium channel modulation and NMDA receptor antagonism, in addition
or in place of the modulation of monoamine neurotransmitters.
of the importance of each of the pharmacological properties of
amitriptyline and related molecules in the management of fibromyalgia
provide clues for the rational design of new drugs.
4) The psychopharmacology of fibromyalgia: a drug development

Psychopharmacol Bull 2002 Winter;36(1):165-213

Kranzler JD, Gendreau JF, Rao SG.

Cypress Bioscience, Inc., 4350 Executive Drive, Suite 325, San Diego, CA
92121, USA.

PMID: 12397854

The fibromyalgia syndrome (FMS) is the most frequent cause of chronic
widespread pain. In this review, we summarize the state of the art on
syndrome and its pathophysiology, with an emphasis on identifying bases
the development of novel therapies.

Toward this end, the anatomy and physiology of pain pathways are
summarized, followed by a review of the altered biology of pain
neurotransmitter function, and neuroendocrine systems in FMS.

The categories of drugs currently employed to treat the disorder are
detailed, along with a critical review of the literature supporting such
use. Throughout the article, FMS is compared with and related to both
depressive disorder and neuropathic pain, conditions that may share some
common biological processes with FMS but for which new drug discovery
efforts are significantly more active due to the more established nature
these diagnoses.
5) Tips for getting a proper diagnosis of an autoimmune disease

For people with autoimmune diseases, getting a proper diagnosis can be
of the most difficult challenges they face. The American Autoimmune
Diseases Association (AARDA) conducted a survey of autoimmune disease
patients and found that the majority of those eventually diagnosed with
serious autoimmune diseases had significant problems in getting a
6) Subjective quality of life, health, I-ADL ability and adaptation
in fibromyalgia.

Clin Rehabil 2002 Sep;16(6):675-83

Lindberg L, Iwarsson S.

Division of Occupational Therapy, Tomelilla Health Care Centre, Sweden.

PMID: 12392344

OBJECTIVES: To describe subjective quality of life and health,
self-perceived instrumental activities of daily living (I-ADL) ability
adaptation strategies, and to explore possible relationships between
variables in fibromyalgia patients.

DESIGN: Two instruments were used with fibromyalgia patients: the
Fibrositis Impact Questionnaire and 'Living with fibromyalgia -
to chronic disease and handicap', and correlative analyses were

SUBJECTS: A sample of 34 patients undergoing rehabilitation (in a

RESULTS: The majority of the patients used many adaptation strategies,
demonstrating some significant relationships with perceived I-ADL
and subjective quality of life and health. Different symptoms correlated
highly significantly with self-perceived ability in I-ADL.

CONCLUSION: The significant relationships between adaptation strategies
I-ADL ability and health demonstrated deserve clinical awareness and
further research efforts.
7) Effects of a multiprofessional rehabilitation programme for patients
with fibromyalgia syndrome.

J Rehabil Med 2002 May;34(3):119-27

Gustafsson M, Ekholm J, Broman L.

Department of Rehabilitation Medicine, Karolinska Institutet, Stockholm,

The present study sought to evaluate the efficacy of a 12-week
multidisciplinary rehabilitation programme mainly emphasizing
for patients with either fibromyalgia syndrome or chronic, widespread

Forty-three non-randomized female patients with fibromyalgia syndrome or
chronic, widespread pain were assigned to the programme or served as
waiting-list controls. The outcome was assessed with the Body Awareness
Scale-Health, the Multidimensional Pain Inventory, the Quality of Life
the Visual Analogue Scale and a pain drawing. Both groups were
after 3 and 6 months, the treatment group also after 1 year.

The treatment group improved in quality of movement and in vegetative
disturbances according to the Body Awareness Scale-Health after the
programme. At the 3-month and 1-year follow-ups the improvements were
sustained. The control group showed deterioration after 3 and 6 months
three of the main scales of the Body Awareness Scale-Health.

This clinical trial of a rehabilitation programme, proved beneficial for
improving quality of movement and reducing the experience of vegetative

PMID: 12395939
8) Patient satisfaction in the rehabilitation of fibromyalgia inpatients

[Article in German]

Z Rheumatol 2002 Oct;61(5):560-7

Wild J, Muller W.

Rheumaklinik Bad Sackingen GmbH und Hochrhein-Institut fur
Rehabilitationsforschung e.V. Bergseestrasse 61 79713 Bad Sackingen,

PMID: 12399884

The treatment of fibromyalgia syndrome is still unsatisfactory,
because it is in most cases impossible to achieve complete relief from
pain. With regard to this issue, we investigated the satisfaction of
in-patients for fibromyalgia with their therapeutic regimen.

The survey comprised 96 patients (91 females, 5 males) who had
in an interdisciplinary group treatment program of in-patient. We used
own custom-designed scoring system to assess the patients' satisfaction.
The patients were asked to rate the therapeutic measures as well as the
groups of people involved in the treatment on a scale from 1 to 10 (very
bad to very good).

The results revealed that patients were highly satisfied with the
therapeutic measures that had been taken. Every mean score was greater
seven. Psychological care, coaching patients to cope better with their
illness, and instruction in relaxation techniques received especially

An analysis of the factors yielded four factors that contribute to
satisfaction: 1) general medical regimen, 2) special massage methods, 3)
physician and psychologist, 4) relaxation techniques. An
approach in treating fibromyalgia has proved useful.
9) Subgroups of Fibromyalgia Patients: Evidence for Heterogeneity and an
Examination of Differential Effects Following a Community-Based

Journal: J of Musculoskeletal Pain, Vol. 10(3) 2002, pp. 9-32

Heather R. Walen, PhD; Terry A. Cronan, PhD.; Eva R. Serber, BA; Erik
Groessl, PhD; Karen Oliver, BA, PhD Candidate

Affiliations: Heather R. Walen, PhD, is Project Director, Terry A.
PhD, is Professor, and Eva R. Serber, BA, is Graduate Student, San Diego
State University; Karen Oliver, BA, is PhD Candidate, San Diego State
University/University of California, San Diego, Joint Doctoral Program
Clinical Psychology; Project USE, San Diego, CA.

Erik Groessl, PhD, is Project Director, University of California, San
Diego, Health Outcomes Assessment Project, 8950 Villa La Jolla Drive,
2143, La Jolla, CA 92037.

Address correspondence to: Dr. Terry A. Cronan, Project USE, 6505
Road, San Diego, CA 92116.

The authors thank the people at Kaiser Permanente for their cooperation
assistance in conducting this study, and all the research assistants and
participants who made this study possible. They also thank W.A. Hillix
comments on earlier drafts.

Preparation for this article was supported by NIH grant AR-44020 and P60
Submitted: March 15,2001.
Revision accepted: October 29,2001.

Objectives: The present study had three purposes:

1. to use cluster analysis to determine whether the same three clusters
pain patients [adaptive copers, dysfunctional, and interpersonally
distressed] identified in the literature would emerge, using different
measures that assess similar constructs in a sample of fibromyalgia

2. to validate the classification, using variables associated with FMS,
not used in the cluster analysis; and

3. to determine whether the clusters would respond differently to a
year-long community-based intervention focused on social support and

Methods: Participants were 600 members of a large health maintenance
organization, primarily Caucasian [85 percent] and female [95 percent],
with an average age of 53.9 [SO = 11.4]. Participants were part of a
study examining the effects of social support and education on FMS
and health care use.

Results: Cluster analysis revealed three clusters that were congruent
past research; follow-up analyses validated the uniqueness of each
There was no evidence that the intervention differentially affected the
clusters. There were a number of cluster by time interaction effects,
suggesting that both the dysfunctional and interpersonally distressed
groups improved in symptoms [e.g., pain, depression] over time,
of intervention group.

Conclusions: People with FMS may fall into distinct subgroups; however,
utility of dividing participants into these groups in planning
interventions remains unclear. Results emphasize the need to take into
account the fluctuating nature of the syndrome, as well as the
phenomenon of regression toward the mean, when examining treatment
KEYWORDS. Fibromyalgia, pain, clusters, intervention


Fibromyalgia syndrome [FMS] is a chronic, often debilitating, condition
that is resistant to treatment. Its diagnosis relies on a patient's
of chronic pain, having pain in 11 of 18 tender points, and ruling out
diseases with similar symptoms (1,2). While its most prominent feature
widespread muscular pain, other symptoms include fatigue, sleep
disturbances, morning stiffness, headaches, depression, and irritable
syndrome (1).

The multifaceted expression of FMS, along with unpredictable treatment
outcomes, has led a number of researchers to propose that FMS may not be
single disease, and/or that subgroups of FMS patients may be
(3-6). This suggests that treatment efficacy may depend on identifiable
patient characteristics.

Past research has classified chronic pain patients into meaningful
(5,7-9). However, these studies were subject to two main criticisms:
used an a priori method of classification based on the assumption that
those with elevated scores on a select number of subscales were similar
other ways, and they were primarily psychological in nature, ignoring
possible heterogeneity in variables assessing physical health domains.

In an attempt to respond to these criticisms, Turk and Rudy (10) used a
measure that contains both psychological and physical variables [the
Haven-Yale Multidimensional Pain Inventory: MPI], in conjunction with an
empirical statistical procedure. Cluster analyses were used to minimize
within-group differences and maximize between-group differences (11).
Studies using this procedure identified three clusters: "dysfunctional,"
characterized by high levels of pain, disability, and psychological
distress; "interpersonally distressed," characterized by interpersonal
difficulties and low levels of social support; and "adaptive copers,"
characterized by low distress and disability and high levels of
self-efficacy. While a fourth cluster ["impaired"] emerged when medical
data were added to the analyses, this profile has not been replicated on
other samples or by other researchers (12). The first three clusters
been derived and replicated on general chronic pain patients (10,13) and
those with temporomandibular disorders (14).

Using the same clustering techniques, but using separate measures of
disability, and depressive symptoms, rather than the MPI,
et al. (4) identified two clusters among 118 FMS patients: high and low
functioning. In these studies, the clusters were found to differ on
meaningful variables [e.g., measures of helplessness, coping, stress,
mood], adding to the validity of the classification (4,10).

Research identifying meaningful subgroups has led to speculation that
groups may be differentially affected by treatment; however, few studies
have examined such effects (15-17). Neither McGill (15) nor Moore et al.
(16) found treatment effects dependent on clusters de- rived from the
Minnesota Multiphasic Personality Inventory [MMPI]; however, Turk et al.
(17) did detect treatment differences by cluster.

They classified a small group [N = 48] of FMS patients who participated
an interdisciplinary treatment program. The intervention consisted of
half-day sessions consisting of education, exercise, and
cognitive-behavioral therapy over a one-month period. They found that
cluster types differed in outcomes. The most important difference was
those classified as "dysfunctional" benefited more from the
reporting lower levels of depression and perceived disability at the
assessment than the "interpersonally distressed" and "adaptive copers."
Thus, this study supported the hypothesis that some patients may derive
more benefits from an intervention than others, based on pre-existing
differences, but this study did not include a control group.

Based on intervention research with osteoarthritis patients, we designed
and implemented a year-long intervention examining the effects of social
support and education on FMS symptoms and health care use (18). Patients
were randomly assigned to a social support, a combination of social
and education, or to a no-treatment control group. The results indicated
that there were no differential changes in the groups for health status
[including measures of FMS symptoms], or health care costs. However,
symptoms and psychological well-being improved during the study for all
groups, including the control groups (18). Because of the lack of
effects, we wanted to examine whether differences would be revealed by
examining clusters of patients.

Past studies examining subgroups of pain patients have had limitations
small sample sizes, typically averaging 100 patients or less, and few
monitored changes over time or as the result of treatment (15-17). The
present study used a large sample of FMS patients [N = 600] and had
purposes: 1. to use cluster analyses to determine whether the same three
clusters identified in the literature using the MMPI and MPI could be
derived from different measures assessing similar constructs; 2. to
validate the classification by examining whether there were differences
among the clusters using variables associated with FMS, but not used in
cluster analyses; and 3. to determine whether the groups differed on
outcomes following a year-long community-based intervention focused on
social support and education. We expected that we would replicate the
subgroups established in the literature and that these subgroups would
differ on external variables. Further, we expected that the
and interpersonally distressed clusters taking part in an intervention
providing social support, or social support plus education, would show
greater gains than the cluster that was coping adaptively at the
assessment, or those assigned to the control group. Such a finding would
have clinical implications, suggesting that classifying patients into
subgroups and tailoring interventions might produce more favorable
than generic treatment programs.

2002 by The Haworth Press, Inc. All rights reserved.

Copies of the complete article are available for a fee from The Haworth
Document Delivery Service: 1-800-HAWORTH.
E-mail address:
AOL users: <a
href="">Read it

[Note: It is also possible that your local library can help you obtain a
copy of this article via one of its interlibrary loan agreements.]
10) Pain: The Fifth Vital Sign

from Medscape General Medicine [TM]
Reviewed by: Roman D. Jovey, MD

by Marni Jackson
Crown Publishers
Copyright 2002
366 pages
ISBN 0-609-60375-2
$23.95 hardcover

Pain. We all experience it sooner or later. And although most of us
rather not, feeling pain is necessary for our survival. Those humans who
inherit a very rare genetic trait associated with pain insensitivity
tend to
die at a young age because, without the ability to hurt, they cannot
the early symptoms of injury or illness. This type of pain, called acute
pain, is part of our early defense system and helps to ensure our
In fact, the sensation of pain is so important that our brain and
system have evolved a complex and redundant series of signalling
and pathways to ensure that if one pathway is somehow damaged, we will
be able to feel the hurt.

There is another category of pain, however, called chronic pain. As far
we know, this type of pain does not serve any known purpose; it has
its usefulness. Think of it as the signalling system stuck in the "on"
position. This type of pain can be caused by an obvious source of
damage to the body, such as in rheumatoid arthritis. The nerves
can be damaged, such as with shingles or carpal tunnel syndrome.
the most frustrating problems for both patient and physician are those
involving a more mysterious dysfunction in the pain sensing or
interpretation centers of the spinal cord and brain. Fibromyalgia and
chronic migraine fall into this category.

In her book, Pain: The Fifth Vital Sign, journalist and writer Marni
has produced a well-researched, eloquent look at the science, the
and the meaning of pain. She does a notable job of making a complex
understandable, by the frequent use of metaphors and by the telling of
stories involving real people suffering from this affliction. This
sharing her own experiences of pain due to recurrent migraines and

Doctors are now practicing in an era of "evidence-based" medicine. If
can't prove something, based on a randomized, double-blind,
placebo-controlled trial, then it must not be true. Taken to excess,
view discounts individual clinical experiences. In her research and
of some of the history of pain medicine, Jackson found "nuggets of
observational knowledge from the pioneers of pain." Observations that
clinicians made more than a century ago are being rediscovered and

Throughout the book, Jackson attempts to pull together information from
history, science, philosophy, culture, religion, and from the patients
pain specialists she interviews, in a search for the meaning of pain. In
doing so, she helps the reader to understand the difference between pain

The author writes about the "Myth of Two Pains" -- physical vs mental --
that has plagued us for centuries and continues to adversely affect our
treatment of patients suffering from chronic pain. She notes the
19th-century view that: "pain wasn't legitimate unless it could be
to, probed and measured; otherwise it was 'hysteria,' 'neurasthenia,' or
simply madness."

On the other hand, Jackson also discusses why pain is not simply about
altered neurochemistry. She writes about the need to acknowledge
psychosociospiritual contributors in a patient with pain, without
the victim" or dismissing the problem as "all in the head." She touches
the intriguing idea that our early life experiences of suffering, such
childhood traumas, can hardwire our "pain thermostats" to be more
to pain later in life.

Jackson discovers firsthand and writes about the roots of doctors'
irrational and unreasonable fear of using opioids to treat pain of all
types. She explores some of the historical context of this opiophobia by
looking at the availability of these drugs and use (and abuse) over the
centuries. She puts a current perspective on this issue by exploring how
current restrictive laws and regulations adversely affect how doctors
prescribe opioids to treat pain today. She attempts to balance the
story by describing the real-life struggles of a teen with heroin

The criticisms I have of this book are minor. In her discussion of
headache, Jackson calls serotonin a hormone and outlines a model of the
pathophysiology of migraine that is now somewhat dated. She also offers
reader some specific treatment advice and names specific medications
than outlining categories of treatment and advising the reader to
these options with his or her doctor.

Jackson also engages in a bit of doctor bashing by recycling the
of the detached, unfeeling doctor ("coldness becomes part of their
profession.") while extolling the caring, hands-on approach of nurses.
has been my observation over 20 years of medical practice that as fiscal
pressure mounts in the healthcare system, and nurses are given more
to care for, more reports to fill out, and fewer resources, they now
much less time to "lay hands on their patients and make small talk."
Finally, Jackson does push the envelope somewhat when she suggests that
pain of our direct ancestors may affect our own response to pain.

With these and a few other very minor exceptions, this is a well-written
interesting book for anyone trying to learn about the mystery of pain.
patients in pain or for those who care about them, this book offers
increased understanding regarding the nature of the problem and a range
possible solutions. For healthcare professionals, Jackson challenges us
"think outside the box" in our ideas about pain and pain treatment and,
importantly, to listen to the patient.

Roman D. Jovey, MD, is a complex pain consultant at Credit Valley
Mississauga, Ontario, Canada.

Medscape General Medicine 4(3), 2002. 2002 Medscape

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