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Introduction
Fibromyalgia (FM) is a process ofwidespread pain, with norecognizable cause, at least 11points painful to pressure, of the 18regions explored in musculo-tendinous.Wolfe F y cols. The American Colege of Rheumatology 1990. Criteria for the Classification ofFibromyalgia. Repost of the Multicenter Criteria Committee. Arthritis Rheum. 1990; 33:160‐172.
Introduction
Fibrositis (Gowers, 1904)
Psychogenic rheumatism (Boland,1947)
Myofascial syndrome (Travell,1952)Gowers WR. Lumbago‐its lessons and analogues. Br Med J. 1904; 117‐121.Boland EW. Psychogenic Rheumatism. The musculoskeletal expression of psychoneurosis. Ann Rheum Dis. 1947; 6: 195‐203.Travell J. Referred pain of skeletal muscle. NY State J Med. 1952; 55: 331‐339.
.
Introduction
Muscular rheumatism (Hench, 1976)
Diagnostic criteria (Wolfe y cols., 1990).Hench PK. Nonarticular rheumatism, Twenty‐second rheumatism review: review of the American and English literature for the years 1973 and
1974. Arthritis Rheum. 1976; 19 Supl: 1081‐1089.Wolfe F y cols. The American Colege of Rheumatology 1990. Criteria for the Classification of Fibromyalgia. Repost of the Multicenter Criteria
Committee. Arthritis Rheum. 1990; 33:160‐172.
.
Fibro – my – algia(Soft tissue) (muscle) ‐ (pain)
Introduction
.
.
The prevalence of FM in the Spanish populationolder than 20 years is estimated at 2.4%. Average age of onset of the FM band between 40 and 49 years. Mainly in women.
Valverde F, Juan A, Ribas B, Benito Urbina JC, Carmona L and working EPISE 2000. Prevalence of fibromyalgia in the Spanish population. Study EPISE 2000. Rev Esp Reumatol. 2000, 27: 157.
CLINICAL MANIFESTARIONS.
PAIN FATIGUE
Authonomic sympoms
Introduction
Main symptoms of fibromyalgiaSymtoms %Pain 100Fatigue 75‐90Sleep disorders 56‐72 / 75‐90Rigidity 75‐85Psycological features 30‐70Irritable bowel 34‐60Headache 44‐58
DIAGNOSIS
• Purely clinical.•• Currently, there are no specific
tests for the diagnosis of FM.
• Criteria of the American College ofRheumatology(ACR,1990)
.
Diagnosis.
History of widespread pain over 3 months
+11 or more sensible trigger points
FMACR 1990
Wolfe F et al. Arthritis Rheum. 1990,33:160-172
IntroductionTriggers Points
Occipitals Inserciones de los músculos occipitales
Low Cervicals bajos
Front of the space inter ‐
5 to C7 transverse
Trapezes Midpoint of the upper edge
Supraespinatus The origin on the spine of the scapula near the medial
2º costal rib In the 2nd sternal juanction condra
Epicondyle 2 cm. distal epicondyle
buttocks Upper outer quadrant
Trochanteric Trochanteric prominence
knees Fat pad in half near the joint line
Study Population
• 93 participants
• Women
• Aged between 30 and 60 years
• Diagnosis of FM according to criteria set by ACR, 1990
Sociodemographic Characteristics
Age Groups n Mean SD30‐39 11 35,45 3,1140‐49 41 44,93 2,7150‐59 41 54,2 3,09
30‐39
40‐49
50‐59
Distribution of the sample by age group
Sociodemographic Characteristics
Age Groups n Mean SD30‐39 11 35,45 3,1140‐49 41 44,93 2,7150‐59 41 54,2 3,09
30‐39
40‐49
50‐59
Distribution of the sample by age group
Employment Status
Self‐employed20%
Hired26%
Jobless9%
Disability20%
Housewife10%
Others15%
Total GroupSelf‐employed
9%
Hired18%
Jobless37%Disability
9%
Housewife9%
Others18%
30‐39 Age Group
Self‐employed22%
Hired27%
Jobless5%
Disability22%
Housewife10%
Others14%
40‐49 Age GroupSelf‐employed
22%
Hired27%
Jobless5%
Disability22%
Housewife10%
Others14%
50‐59 Age Group
Familial History
2%
79%
19% UnknowledgeNoYes 0
510152025303540%
Hypothermic
OVERWEIGHT
Stature LOW HEIGHT
Body Mass Index
12%
34%
30%
13%
11%OneTwoThreeFourFive
Comorbility
Two : Dermatitis+Allergies 20,68% Three: CV disorders+Migraine+Hyperch 26,08% Allergies+Migraine 10,34% CV disorders+Allergies+Migraine 17,39%
Comorbility
63%
37%
Hipercholesterolemia
43%
57%
Cardiovascular diseases
84%
16%
Hypothyrodism
46%54%
Migraine
56%
44%
Dermatitis
51%49%
Respiratory Allergies
Neuro-cardiovascular-endocrine-hypersensible comorbility YES NO
Visual Analogue Scale (VAS)
Without pain Mild pain Moderate pain Intense pain
5 5,5 6 6,5 7
30‐39 Age group (n=11)
40‐49 Age group (n=41)
50‐59 Age group (n=41)
VAS
SD 1,69
SD 1,79
SD 2,33
Pain Visual Analogue ScalePain VAS
R L L R
123
4
5
67
8
9
67
8
9
123
4
5
0.67±0.301.07±0.51
1.15±0.66
1.26±0.62
0.95±0.461.34±0.461.12±0.49
1.47±0.83
1.49±0.80
0.98±0.431.38±0.701.11±0.32
1.39±0.75
1.43±0.71
0.65±0.321.02±0.46
1.11±0.55
1.18±0.55
1. Occipital; 2. Cervical; 3. Trapezium; 4. Gluteus; 5. Trochanter; 6. Scalene;7. Costal 2nd; 8. Epicondyle; 9. Knee
1. Scalene 0.67±0.302. Occipital 0.95±0.463. Costal 2nd 1.07±0.514. Trapezium 1.12±0.495. Epicondyle 1.15±0.666. Knee 1.26±0.627. Cervical 1.34±0.778. Gluteus 1.47±0.839. Trochanter 1.49±0.80
FibromyalgiaControl Group
1. Scalene 1.48±0.722. Occipital 2.66±1.043. Costal 2nd 3.20±2.104. Trapezium 3.56±1.845. Epicondyle 4.20±2.286. Cervical 4.21±2.187. Knee 4.39±2.198. Trochanter 4.49±2.129. Gluteus 4.58±2.51
Introduction
The major cognitive complaints,described by patients with FM are:
Memory lossDifficulty remembering names / wordsLack of concentration
Grace GM, Nielson WR, Hopkins M, Berg MA. Concentration and Memory Deficits in Patients with Fibromyalgia Syndrome. J Clin ExpNeuropsychol. 1999; 21 (4): 477‐487.Glass JM, Park DC. Cognitive dysfunction in fibromyalgia. Curr Rheumatol Rep. 2001; 3 (2): 123‐127.
IntroductionFibrom
ialgia. A
lteracion
es cognitivas
Cognitive impairment is anycognitive complaints withoutevidence of dementia orconfusion syndrome
Patients with FM complaint normally .cognitive relate
IntroducciónSeveral authors have sought to deepentheir knowledge of cognitive impairment inpatients with FM:Grace et al., 1999Park et al., 2001
Surh,2003
Grace GM, Nielson WR, Hopkins M, Berg MA. Concentration and Memory Deficits in Patients with Fibromyalgia Syndrome. J Clin ExpNeuropsychol. 1999; 21 (4): 477‐487.Park Dc, Glass JM, Minear M, Crofford LJ. Cognitive Function in Fibromyalgia patients. Arthritis Rheum. 2001; 44 (9): 2125‐2133.Surh J. Neuropsychological impairment in fibromyalgia: Relation to depression, fatigue and pain. J Psychosom Res. 2003; 55: 321‐329.
Introduction The personality of patients with FM has
been the subject of several studies
Malt EA, Olafsson S, Lund A, Urson H. Factors explaining variance in perceived pain in women with fibromyalgia. BMC Musculoskelet Disord.2002; 3: 12.Wolfe F, Anderson J, Harkness RM, Bennett R, Caro X, Goldenberg D et al. Health status and disease severity in fibromyalgia: results of a six‐center longitudinal study. Arthritis Rheum. 1997; 40: 1571‐1579.
Generally considered that hispersonality is marked by ahigh degree of neuroticism
Introduction
The Model of the Five Factors (MCF)is a model for interpretation of thecharacter that looks the same as thecomposition of five factors or
dimensions.
Neuroticism, Extraversion, Openness, Responsibility andKindness
(Costa and McCrae, 1999)
Costa PT, McCrae RR. Manual técnico del NEO‐PI‐R. Madrid: TEA; 1999.
Description of cognitive performance and personality traits of patients with
fibromyalgia and their relationship to the perception of pain, depressive symptoms
and disease impact
Hipothesis1. Cognitive performance of patients with FM displayed
alterations in some areas of higher brain function, asmeasured by validated scales, and adapting to ourenvironment.
2. Cognitive impairment present in patients with FM do not fallwithin the concept of mild cognitive impairment (MCI)
3. The cognitive changes do not involve a direct effect on theimpact of FM because they do not occur consistently orprogressive within the context of the illness.
4. The personality profile of patients with FM shows cleartraits of neuroticism. This trait of neuroticism has animportant impact on depressive symptoms that a highpercentage of these patients manifest
.
Objetives
Fibromyalgia and cognitive performance
To describe the cognitive
performance of patients with FM
using internationally validated instruments
for this purpose.
To identify cognitive impairment present in patients with FM and compared with those
described in MCI.
To assess the relationship between cognitive impairment present in patients with FM and the
perception of pain, depressive symptoms and disease impact
Objetives
Fibromyalgia and personality traits
Assessing personality traits of patients with FM and the relationship between these traits and depressive symptoms in these subjects.
Material & methodsPhase 1:
Design and Planning
Fase 2:PreparaciónPhase 2:
Preparationn
Phase 3:Data
Phase 4:Analysis of data
Steps
Steps
Pasos
•September-December 2006 Call through media Recruiting potential participants
•January-March 2007 Developing research protocol and procedures manual Design semi-structured interview> cambiar Proponer una traducción mejor
• Julio‐noviembre 2007
•From December 2007
Referral of the research protocol to the Center for Study of Bioethics at the UIC, for approval.
Approved June 5, 2006
Material & methods
POPULATION
Vallès Oriental
FEMALES30‐60 YEAR OLDFM
Females betweeen 30‐60 years
2006
84.534 inhabitants
EPISER 2000Prevalence in Spain
4,2%
Estimated population of FM
3.550
Material & methods
CRITERIA
•FEMALE•Between 30‐59
• Have physical and mental conditions to answer tests
• informed consentACT CRITERIA
• Not meeting inclusion criteria
• In a position to issue disability Recognition
• Severe psychiatric disorders
• Submit other neurological disease
INCLUSION EXCLUSION
Material & methods
181 recruited patients
94selected subjects
73 started the study
Personneal interviewcriteria
87 Without inclusion criteria
12 did not agree to participate 9 no study carried out for work
38 no established clinical diagnosis of FM 16 with severe psychiatric disorder 7 males 3 disease neurological 13 Status of litigation 6> 60 years 4 <30 years
Material & MethodsInstrumen
tos de
evaluación
Semistructured interview
Visual analogue scale (VAS)
Questionnaire impact of FM (FIQ
)Battery of neuropsychological tests
Personality Inventory NEO-FFI
Material & methods
Semistructured interview
CLINICAL DATA
SOCIAL AND DEMOGRAPHIC DATA
Material & methdsInstrumen
tos de
evaluación
Visual analogue Scale (VAS)
0 1 2 3 4 5 6 7 8 9 10
Material y métodoInstrumen
tos de
evaluación
Cuestionario de impacto de la FM (FIQ)1. ¿Ha sido usted capaz de...
Siempre La mayoría de las veces En ocasiones Nuncaa. ¿Hacer la compra?b. ¿Hacer la colada conlavadora?
c. ¿Preparar la comida? d. ¿Lavar a mano los platos
y los cacharros de cocina?e. ¿Pasar la fregona, la mopa
o la aspiradora?f. ¿Hacer las camas? g. ¿Caminar varias manzanas? h. ¿Visitar amigos/familiares? i. ¿Subir escaleras? j. ¿Utilizar transporte público?
00
00
0
00000
11
11
1
11111
22
22
2
22222
33
33
3
33333
Material y métodoInstrumen
tos de
evaluación
2. ¿Cuántos días de la última semana se sintió bien?0 1 2 3 4 5 6 7
3. ¿Cuántos días de la última semana no pudo hacer su trabajo habitual, incluido el doméstico, por causa de la fibromialgia?
0 1 2 3 4 5 6 7Redondee con un círculo el número que mejor indique cómo se sintió en general durante la última semana:4. En su trabajo habitual, incluido el doméstico, ¿hasta qué punto el dolor y otros síntomas de la fibromialgia dificultaron su capacidad para trabajar?
0 1 2 3 4 5 6 7 8 9 105. ¿Cómo ha sido de fuerte el dolor?
0 1 2 3 4 5 6 7 8 9 10
Material y métodoInstrumen
tos de
evaluación
6. ¿Cómo se ha encontrado de cansada?0 1 2 3 4 5 6 7 8 9 10
7. ¿Cómo se ha sentido al levantarse por las mañanas?0 1 2 3 4 5 6 7 8 9 10
8. ¿Cómo se ha notado de rígida o agarrotada?0 1 2 3 4 5 6 7 8 9 10
9. ¿Cómo se ha notado de nerviosa, tensa o angustiada?0 1 2 3 4 5 6 7 8 9 10
10. ¿Cómo se ha sentido de deprimida o triste?0 1 2 3 4 5 6 7 8 9 10
Material & Methods
Neuropsicological BatteryYield overall cognitive Mini-mental state examination from
Lobo
MemoryMemory Impairment ScreenAuditory Verbal Learning Test from Rey
Lenguage Semantic Verbal Fluency Test
Atention Trail Making Test (form A)
Hability, visual & space Clock Drawing Test
Depresive symptoms Hamilton Test
Material & methodsInstrumen
tos de
evaluación
Inventory assessment of personality, NEO-FFI
A Strongly Disagree B Disagree C Neutral D according E Strongly agree
• It consists of 60 items to 5 dimensions of personality:
• Neuroticism (N), Extraversion , n (E), Openness (O), Agreeableness (A) and Responsibility (R)
•Running Time: 10-15 minutes
Material & Methods
Recruitment of potential participants
Selection of subjects
Step 1
Step 2
Pasos
•Call through media Regional press Granollers TV
•Personal interview Checking compliance criteria Information and sign informed consent
Data Collection Step 3
•FPhase 1: demographic and clinical data
•Phase 2: Neuropsychological assessment and personality traits
Statistical analysis Data Step 4
•Descriptive statistical analysis Correlational analysis SPSS version 17 for windows
ResultsPAIN N= 54
Pain visual analogue scale (EVA)
6,09 ± 1,66DE
ResultsCLINICALAL DATA N= 54
Pain visual analogue scale (VAS)
mild moderate severe
0,005,0010,0015,0020,0025,0030,0035,0040,0045,00
0 1 2 3 4 5 6 7 8 9 10
%
7,41%
38,89%
14, 81%18,52%
14,81%
5,56%
92,59% moderate‐sevee
ResultadosDatos clínicos N= 54
Manifestaciones cognitivas referidas
0102030405060708090100
Pérdida de memoria Dificultad de concentración
85,1994,44
14,815,56
SI NO
Resultados
Datos evaluación neuropsicológica N= 54
0
2
4
6
8
10
12
14
16
24 25 26 27 28 29 30
42
1012
7
15
4
Nº Sujetos
Puntuación global
normal
48,15%
27,43 ± 1,67
MMST‐30 from Lobo
bordeline
51,85%
Results
N= 54
MMST 30 from LoboDominios cognitivos Range Mín. Max. Mean ± SD
TIME 0 ‐ 5 3 5 4,87 ± 0,39
SPACE 0 ‐ 5 4 5 4,94 ± 0,23
MEMORY (FIXATION) 0 ‐ 3 0 3 2,94 ± 0,41
ATENTION 0 ‐ 5 0 5 4,59 ± 0,98
DIFFERED MEMORY 0 ‐ 3 0 3 2,06 ± 0,98
LANGUAGE 0 ‐ 9 6 9 8,02 ± 0,74
Distribution of the sample of patientswith FM (n=54)according to semantic verbal fluency (sVFT).
Porcentual distribution of patients according to depresive symtoms
attending to global examination by Hamilton
Average scores, standard deviation (SD) and range obtained for the sample of FM patients in neuropsychological tests (n = 54)
Test Range Mín. Max. Mean ± sTMEC-30 0 – 30 24 30 27,43 ± 1,67
TAVR
1ª evocación 0 – 15 1 8 5,24 ± 1,64
2ª evocación 0 – 15 4 13 7,93 ± 2,20
3ª evocación 0 – 15 3 15 9,39 ± 2,72
4ª evocación 0 – 15 3 15 10,48 ± 2,51
5ª evocación 0 – 15 6 15 11,67 ± 2,29
6ª evocación 0 – 15 4 15 10,46 ± 3,04
Aprendizaje 2 11 6,57 ± 1,91
Retención 1 10 5,15 ± 2,41
MIS 0 – 8 6 8 7,83 ± 0,47
TFVs 10 28 17,5± 4,66
TMT-A
Errores - 0 4 0,28 ± 0,79
Segundos - 23 190 62,39 ± 31,04
TDR 0 – 10 3 10 8,32 ± 1,65
HAD 0 – 52 10 37 23,85 ± 6,04
Distribution of patients by degree of impact of disease on the basis of the
overall score for them in the FIQ.
Average scores obtained by patients on the subscales of the FIQ.
Discussion
Some studies showed that in FM exist cognitivedisorders (85.19% memory lapses, concentrationproblems, 94.44%).
In MMST, 51.9% between 24 and 27 and 48.1% and 28and 30 in the remaining group (48,1 %)
Mean Value= 27, 43±1,67SD.
Grace y cols., 1999; Glass y cols., 2005 evidencian una sobrevaloración de los déficitscognitivos.
Castel y cols., 2008, refuerzan dicha evidencia señalando que la percepción de falloscognitivos vendría condicionada en gran parte por la depresión y no por los déficitsobjetivados.
Discussion
The patients studied had poorer performance in verballearning ability or extent of short-term memory thanexpected in healthy subjects matched for age and sex.
E‐1 (TAVR)= 5, 24±1,64DT.
Grace y cols., 1999; Park y cols., 2001; Dick y cols., 2002; Munguía‐Izquierdo y cols., 2008;Castel y cols., 2008.
Discussion
The processing speed and memoryretention or delayed recall of the patientsstudied is similar to that shown by healthysubjects matched for age and sex
Grace y cols., 1999; Park y cols., 2001; Leavitt y Katz, 2008 Côté y Moldofsky, 1997; Alanoglu y cols., 2005
Grace y cols., 1999; Park y cols., 2001; Glass y cols., 2005
DiscussionFibrom
ialgia y fluidez v
erbal
The results obtained by patients in SFVT studyshow a decline in verbal fluency.
Mean Value (SFVT)= 17, 50±4,66DT.
LandrØ y cols., 1997; Park y cols., 2001.
Discussion
The patients reveal a measure of selective attention below normative values in
healthy population. Mean Value (TMT‐A)= 62, 39±31,04DT.
Grace y cols., 1999; Dick y cols., 2002; Leavitt y Katz, 2006; Munguía‐Izquierdo y cols.,2008; Verdejo‐García y cols., 2009; Pericot‐Nierga y cols., 2009.
Walitt y cols., 2008.
DiscussionThe cognitive impairment found in the patientsstudied can not be framed within the concept ofMCI in response to the diagnostic criteria set bythe IPA-WHO (Levy et al., 1994).
Criterios diagnósticos deterioro cognitivo leve (DCL)
1. Quejas subjetivas de memoria formuladas por las personas ypreferentemente corroboradas por algún familiar o informante.2. Objetivación de un deterioro de la memoria a través de pruebasneuropsicológicas específicas.3. Conservación de cierta normalidad en el resto de las funcionescognitivas.4. Desempeño normal de las actividades de la vida diaria o mínimaafectación en las actividades instrumentales.5. Ausencia de criterios diagnósticos de demencia.
+6. No existe explicación evidente, médica, neurológica ni psiquiátrica que pueda explicar el trastorno. (Chertkow, 2002).
1. No restricción de edades.2. Decremento de la capacidad cognitiva afirmada por el pacientey/o un informador.3. Decremento gradual y de duración mínima de 6 meses.4. Cualquiera de los siguientes ámbitos puede estar afectado: a)memoria y aprendizaje, b) atención y concentración, c) pensamiento,d) lenguaje, e) función visuuoespacial.5. Disminución de las puntuaciones de evaluación del estado mentalo de los test neuropsicologicos una DE por debajo del valor del grupocontrol.6. El trastorno no tiene suficiente intensidad para establecer eldiagnóstico de demencia, ni existe delirium.7. No existen procesos cerebrales, sistémicos o psiquiátricos quepuedan explicar el cuadro.
Pericot-Nierga y cols., 2009.Maletic y cols., 2009.
Discusión
The studied patients showed systemicmanifestations of pain, fatigue and depressivesymptoms with cognitive impairment, whosecharacteristics conform to the concept of “mildcognitive disorder"(MCD) proposed by WHO, 1992.
World Health Organization (WHO). The ICD‐10 classification of mental and behavioral disorders (F00‐F99). Géneve: WHO; 1992. p. 311‐388.
Mild cognitive disorder (MCD). WHO, 1992.
• Presencia de alteraciones de la memoria, el aprendizaje y la concentración demostrables mediante tests neuropsicológicos.• A menudo la fatiga acompaña a las alteraciones cognitivas.• Las alteraciones cognitivas pueden ser atribuibles a lesión o enfermedad cerebral o enfermedad sistémica que se conozca pueda ocasionardisfunción.• Excluido diagnóstico de demencia, síndrome amnésico, síndrome postencefálico o conmoción cerebral.
DiscussionFibrom
ialgia y alte
racion
es cognitivas
Cognitive impairment evidenced in the patientsstudied bear no relation to either perceived painintensity, or with depressive symptoms, nor withthe impact of the disease.
Suhr, 2003; Castell y cols., 2008.Grace y cols., 1999; Park y cols., 2001; Munguía‐Izquierdo y cols., 2008; Verdejo‐García ycols., 2009.
Grace y cols., 1999; Park y cols., 2001; Dick y cols., 2002; Sephton y cols., 2003; Thieme ycols., 2004.LandrØ y cols., 1997; Suhr, 2003; Castel y cols., 2008
Discussion
In relation to personality traits of the patientsstudied the results show a high degree ofneuroticism, low extraversion, openness andaccountability.
Rook y cols., 1981; Epstein y cols., 1999; Malt y cols., 2002; Zautra y cols., 2005; Besteiro ycols., 2008.
Zautra y cols., 2005; Ayats y cols., 2006; Besteiro y cols., 2008.
Martínez y cols., 1995.
Ayats y cols., 2006.
ConclusionsPain
Fatigue
Cognitive disorders
Depresive symtoms
Sleep disorders