Fibromyalgia Subsets

Fibromyalgia Subsets
Devin J. Starlanyl 6/04

Fibromyalgia (FM) is not homogenous. As I. Jon Russell, MD, PhD, editor of Journal of Musculoskeletal Pain, said to me, "Fibromyalgia is not an 'it'. It's a 'they'." Research shows that this is true ^{(1, 2, 3, 4, 5, 6)}. I believe that the key to treating FM, like CMPD, is to identify and control the initiating and perpetuating factors as much as possible. I also believe that identifying subsets are a key to this process.

Years ago, my friend J. B. Eisinger, French clinician and researcher, contacted me with an exciting proposal. He planned to organize a team to define meaningful clinical subsets of FM. These subsets would be categorized by perpetuating factors, cause (initiating factors), and symptoms (presenting factors). Patients would be coded as to age, gender, duration and seriousness of symptoms. For research purposes, after tabulating the coding, the names could then be omitted, keeping the patients anonymous. I was asked to be part of the team. The result was a medical journal article that would be especially valuable for FM researchers ⁽⁷⁾. The protocol was published in French. Using the translated format of the protocol for anonymous clinical study for researchers, I have modified it into a protocol for identification of FM subsets for clinicians, with Dr. Eisinger's approval. I hope clinicians will find it helpful. Devin J. Starlanyl

Bibliography

1.	Walen HR, Cronan TA, Server ER et al. 2002. Subgroups of fibromyalgia patients: evidence for heterogeneity and an examination of differential effects following a community-based intervention. J Musculoskel Pain 10(3):9-32.
2.	Bennett RM. 2002. Adult growth hormone deficiency in patients with fibromyalgia. Curr Rheumatol Rep 4(4):306-12.
3.	Smith JD, Terpening CM, Schmidt SO et al. 2001. Relief of fibromyalgia symptoms following discontinuation of dietary excitotoxins. Ann Pharmacother 35(6):702-706.
4.	Giesecke T, Williams DA, Harris RE et al. 2003. Subgrouping of fibromyalgia patients on the basis of pressure-pain thresholds and psychological factors. Arthritis Rheum 48 (10):2916-2922.
5.	Gursoy S. 2002. Absence of association of the serotonin transporter gene polymorphism with the mentally healthy subset of fibromyalgia patients. Clin Rheumatol 21(3):194-195.
6.	Stratz T, Schochat T, Farber L, Schweiger C, Muller W. Are there subgroups in fibromyalgia? J Musculoskel Pain3 (suppl 1) : 15 [Abstract].
7.	Eisinger, J, D Starlanyl, F Blotman, L Bueno, E Houvenagle, R Juvin, P Kaminsky, K Lawson, X Le Loet, J Lowe, P Manesse, K Mechtouof, N Memran, W Muller, M Nicollet, JC Perragut, A Plantamura, JP Poinsignon, E Reig, R Ruiz Lopez, KL Schmitt, P Sichere, J Teitelbaum, R Treves, H Zakarian. 2000. [Protocole d'informations anonyme sur les fibromyalgiques.] Medicine du sud-est Lyon Mediterranee Medical. 1: 9-11. [French]

Protocol for Identification of Fibromyalgia Subsets

1.	General Information
	Patient Name _______________________________		Date ______________
	This form was filled out by: _______________________________________
	o the patient alone	o assisted by a doctor
	The diagnosis was made by: ______________________________________

o a generalist

o a rheumatologist

o another specialist

	Type of pain:
	o diffuse	o persistent	o enigmatic	Number of Tender points = _____

2.	General Coding
	o Male	o Female	Age = ______

	Exercise/Diet
	Excessive consumption of caffeine, alcohol, carbohydrates, tobacco?
	Family clustering (members of family with FMS or FMS-like symptoms)?

Physical Activity:
o None	o 1 Hour a Day		o 2 Hours	o 2 Hours and Sport	o Athlete
Duration and severity (social, professional and on life quality repercussion):
1 - Less than 5 years		1 - Moderate (normal activity)		1 - Life quality = good
2 - More than 5 years		2 - Severe (frequent sick leave)		2 - life quality = moderate
3 - More than 10 years		3 - Very severe (one year sick leave)		3 - life quality = bad
4 - More than 15 years		4 - disabling (compulsory help)		4 - life quality = very bad

Symptoms, Perpetuating Factors and Possible Etiologies:

Allergies (asthma, vasomotor rhinitis; urticaria, ocular, chronic sinusitis)

Bruxism, Temporomandibular Dysfunction

Circulatory Dysfunction (Raynaud's Syndrome, migraine)

Digestion (GERDS, IBS)

Endocrinology/Metabolism (malnutrition, obesity, insulin resistance, Metabolic Syndrome)

Fatigue (distinct physical fatigue, mental fatigue/loss of memory and/or focus, CFIDS)

Gynecology (Premenstrual Syndrome, untreated menopause, vaginismus, vulvar pain)

Hypothyroidism: Treated with T4 (equilibrated/not) or other hormones (equilibrated/not)

Infections (chronic bacterial, fungal, viral, protozoal)

Juvenile (symptoms appeared at puberty; prepuberty)

Cancer (treated/not treated with recent chemotherapy, other treatment)

Systemic lupus erythematosis, polyarthritis rheumatica, osteoarthritis

Medicamentosus (Possible onset due to beta blockers, other medications, toxins, pollutants)

Neurological (carpal tunnel, MS, NMH)

Ocular (cataract, glaucoma, Sicca Syndrome)

Psychiatric (depression intrinsic/secondary, anxiety, panic attacks, PTSD, ADHD, OC)

Quantification of Pain (spontaneous, moderate, major, hyperalgesia, allodynia)

Regional pain (myofascial trigger points latent/active, local/regional, multiple regions; chronic myofascial pain/lasting trigger points in at least three quadrants with spinal involvement, myofascial nerve/lymph/blood vessel entrapment)

Sleep disorders (severe insomnia, sleep apnea central/congestive, narcolepsy, PLMS, RLS

Trauma (spinal, peripheral)

Urological (irritable bladder, voiding dysfunction)

Dysautonomia (orthostatic hypotention, tachychardia, palpitations)

Other causes:

Other symptoms:

Co-existing conditions: (diabetes, hypertension)

Other treatments and medications linked with FM (analgesics, antidepressants...)

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