FIBROMYALGIA, CHRONIC FATIGUE SYNDROME AND RELATED CENTRAL SENSITIVITY SYNDROMES (CSS) A PRIMARY CARE T OOLKIT COMPLEX CHRONIC DISEASES PROGRAM BC WOMEN’S HOSPITAL Ric Arseneau, MD FRCPC MA(Ed) MBA FACP CGP Clinical Professor Division of General Internal Medicine St. Paul's Hospital & BC Women’s Hospital Director of Program Planning Complex Chronic Diseases Program University of British Columbia No Conflicts of Interest to Declare MEDICALLY UNEXPLAINED PHYSICAL SYMPTOMS (MUPS) IS IT REAL ? Psychological / Psychiatric Not real Nothing you can do Frustrating / unsatisfying Free-association exercise with housestaff IS IT RARE ? 5 OVERLAPPING GROUPS Fatigue Pain Brain Fog Sleep Unexplained Problems Symptoms Gut CNS Autonomic Pain Research and Treatment Volume 2012, Article ID 584573, 8 pages doi:10.1155/2012/584573 Review Article The Prevalence of Fibromyalgia in Other Chronic Pain Conditions Pain Research and Treatment 3 Pain ResearchMuhammad and Treatment B. Yunus 3 Table 1: Prevalence of fibromyalgia syndrome (FMS) in other central sensitivity syndromes (CSS) conditions. Table 1: Prevalence of fibromyalgia syndrome (FMS) in other central sensitivity syndromes (CSS) conditions. CSS condition ∗ % prevalence of FMS (mean) % prevalence of FMS (range) Reference no. Irritable bowelCSS syndrome condition∗ 40.7% prevalence 20.0–65.0 of FMS (mean) [9, 11–14] % prevalence of FMS (range) Reference no. Section of Rheumatology, Department of Medicine, University of Illinois College of Medicine at Peoria, One Illini Drive, TemporomandibulardisorderIrritablePeoria, bowel IL 61605, syndrome USA 23.7 13.0–52.0 40.7 [9, 15–19] 20.0–65.0 [9, 11–14] Headaches(all) 26.3 10.0–40.0 [9, 20–23] Tension-typeTemporomandibulardisorder headacheCorrespondence should be addressed 29.7 to Muhammad B. Yunus, [email protected] 23.0–36.4 23.7 [9, 23] 13.0–52.0 [9, 15–19] MigraineHeadaches(all)Received 3 May 2011; Accepted 15 16.0 August 2011 10.0–22.0 26.3 [21, 22] 10.0–40.0 [9, 20–23] Mixed¶ 38.2 36.4–40.0 [20, 23] InterstitialcystitisTension-typeAcademic Editor: Mary-Ann headache Fitzcharles 15.4 12.0–22.4 29.7 [9, 24–27] 23.0–36.4 [9, 23] Chronic fatigue syndromeCopyright © 2012 Muhammad B. 55.2 Yunus. This is an open access article distributed 15.6–80 under the Creative Commons [9, 28, 29 Attribution] Vulvar vestibular syndromeMigraineLicense, which permits unrestricted 23.4 use, distribution, and reproduction in 15.6–31.2 any medium, 16.0 provided the original [30 work, 31] is properly 10.0–22.0 [21, 22] cited. Gulf War syndromeMixed¶ 17.6 2.0–33.838.2 [32–34] 36.4–40.0 [20, 23] ∗ Prevalence of FMS in otherCentral CSS conditions sensitivity with syndromes a single study (CSS) has includebeen discussed fibromyalgia in the text. syndrome (FMS), irritable bowel syndrome, temporomandibular ¶Mixture of tension-typeInterstitialcystitis headachedisorder, and restless migraine. legs syndrome, chronic fatigue syndrome, and other similar chronic 15.4 painful conditions that are based on central 12.0–22.4 [9, 24–27] sensitization (CS). CSS are mutually associated. In this paper, prevalence of FMS among other members of CSS has been described. ChronicAn important fatigue recent syndrome recognition is an increased prevalence of FMS in other chronic 55.2 pain conditions with structural pathology, for 15.6–80 [9, 28, 29] although they are presentexample, to a rheumatoid lesser extent arthritis, in other systemic members lupus, ankylosingthat is, spondylitis, increased osteoarthritis, prevalence of diabetes FMS compared mellitus, and with inflammatory study or bowel of CSS as a manifestationVulvardisease. vestibular of DiagnosisCS [6]. and syndrome proper management of FMSpopulation among these controls, diseases are it of seems 23.4 crucial proper importance to conclude so that unwarranted that true use of 15.6–31.2 [30, 31] It was notGulf until 1990s Warsuch whenmedications syndrome the presence as corticosteroids of FMS can in many be avoided,associations since FMS often of occurs FMSwith when 17.6the RA or diseases SLE is relatively discussed mild. exist. 2.0–33.8 [32–34] chronic diseases with structural pathology was generally recognized among∗ Prevalence the researchers. of FMS in Now, other it CSS is known conditions6. Pathophysiological with a single study Mechanisms has been discussed of Disease in the text. that FMS is significantly associated with RA [10, 38–41], ¶Mixture of tension-type headache and migraine. systemic lupus1. Introduction: (SLE) [42–48], ankylosing Historical spondylitis Overview (AS) and the AssociationsCathey were with the first FMS: to recognize Central the Sensitization association of FMS with [49, 50], osteoarthritisImportance (OA) [51 of], Nomenclatures diabetes mellitus [52, 53], Is Centralrheumatoid arthritis (RA) [10]. Although they were called endometriosis [54], hypothyroidism [55], and inflammatory “secondary fibrositis,” these were cases of concomitant FMS bowel diseaseThe [56 fact, 57 that](Table fibromyalgia 2). syndrome (FMS) is associated6.1. with CS andwith CSS typical Conditions. symptomsCentral and multiple and common tender points to CSS (TP) in diseases are CS. The pathophysiology of CS has been CS aloneseveralalthough (without similar FM) conditions they has been are without reported present structural in juvenile to pathology a lesser was extentassociation in other with RA. members The diagnosis of FMSthat in the pre-1990 is, increased prevalence of FMS compared with study or first reported in a controlled study in 1981 [1], followingdiscussed elsewhere [6, 8, 75]andisbeyondthescopeofthis chronic arthritis [59], OA [60–65], endometriosis [66], ACR criteria era was made on the characteristic symptoms of whichof CSS a conceptual as a manifestation model was proposed with of CS a Venn [essay.6 dia-]. TobeFMS sure, as well the mechanismsas many tender involved points [ in10 CS]. arepopulation multiple controls, it seems proper to conclude that true carpal tunnel syndrome [67–69], chronic pancreatitis [70, gram, showing the mutual overlaps in these syndromesand [2]. complexWhat’s [75]. Some in a name? of these Asked mechanisms Shakespeare involve rhetorically tem- in 71], and Parkinson’s disease [72–74]. It is likely that CS associations of FMS with the diseases discussed exist. Since then,It was a large not number until of studies 1990s have when confirmed theporal these presence summationRomeo and of(windup), Juliet. FMS My long-term own in manyanswer potentiation is “A lot.” A name (LTP), should is the harbinger of future development of FMS, as may associations, compared with both healthy controls as wellheterosynaptic as be meaningful, potentiation, tell the a dysfunctional gist of the topic, descending and must notpain distort be demonstratedchronic in future diseases studies. It is with as if “fibro, structural fibro pathology was generally diseases with structural (the so-called “organic”) pathologyinhibition,the and underlying an activation truth, recognizing of the descending that scientific facilitatory truth is not everywhere and not a place for the (rational) eyes to hide.” (DWSP)recognized [3, 4]. (Although among there the are structural researchers. changes,pathwaycarved [75 Now,]. It in rockis also it and evident does is change known that over input time. in In one this set discourse, of I An interesting question is, and data have not emerged yet e.g., decreased hippocampus and gray matter volumenociceptive in shall fibers use the amplifies terms syndrome, subsequent illness, response condition,6. to other andPathophysiological disease Mechanisms of Disease to answer it,that are other FMS members is of significantly the CSS family, such associated as with RA [10, 38–41], some CSS conditions, these changes seem to resultnonstimulated from synonymously. noceptive Further, or nonnociceptive since the term fibromyalgia fibers (het- implies IBS and myogenicprolonged TMD central also associated sensitization with (CS) these and chronic will be discussed Associations with FMS: Central Sensitization systemic lupus (SLE) [42–48], ankylosingerosynapticnothing potentiation). more spondylitis than Such pain as phenomena has (AS) been discussed explain by diff Fitzcharlesuse diseases withat structural the end.) pathology? These overlapping conditions are collectively and Yunus in this issue of the journal, I prefer the term distribution of pain as well as allodynia. FMS hasknown been as reported central sensitivity also in syndromes Sjogren’s (CSS)syndrome, [5–8], since CS “fibromyalgia syndrome” since FMS is so muchIs more Central than [49, 50], osteoarthritis (OA) [51], diabetesAfter many years mellitus of research [52 in, animal53], models, human hepatitis C, HIV,is the and common other binding infections, gluefor between example, them. Lyme The term CSS pain with a large number of other distressing symptoms. volunteers, and chronic pain conditions, several facts have disease. Truewasendometriosis to first the coinedtitle of in this 2000 essay, [5 []andhasbeenreviewed[54 however,], hypothyroidism only those 5–8]. We [55],Elsewhere, and inflammatory I have argued that differentiation between emerged. While a noxious stimulus at some point6.1. in the CS and CSS Conditions. Central and common to CSS diseases that[ usually6]andothers[ cause9 pain] have have described been described mutual associations in this among illness and disease is artificial and contrary to patient bowel disease [56, 57](Table 2). past might have initiated increased neuronal sensitivity, no paper. the CSS conditions. interest and hampers proper management ofdiseases CSS