Example 1: scientific literature review “Classification, Epidemiology and Natural History of Fibromyalgia”

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Classification, Epidemiology and Natural History of Fibromyalgia”

Musculoskeletal (MSK) pain is common worldwide. In economically developed countries such as the USA, between 14 and 26% of the adult population suffers from chronic pain or arthritis,i, approximately 11% report chronic, widespread painii and MSK disorders account for 15% of work loss daysiii. The figures are similar elsewhere. In Canada, 15% of adults report chronic MSK painiv, 7% reported chronic, widespread painv and 5% report physical disabilities secondary to MSK illness.vi In Europe, the prevalence of chronic widespread MSK pain varies between 11 and 17%vii,, and MSK disorders account for between 14 and 17% of work loss days.viii In economically developing countries, the prevalence of MSK pain may be even higher, effecting 24-31% of adults in Indonesiaix and 36% of respondents in Thailand.x

Fibromyalgia Syndrome (FMS), also known as fibrositis, is a common form of non-articular rheumatism that is associated with chronic generalized MSK pain, fatigue, and a long list of other complaints.xi Clinic studies have found FM to be common in countries worldwide, including economically developing countries such as Mexico,xii Polandxiii and Pakistan.xiv The primary objective of this article is to review the classification, epidemiology and natural history of FM.

The Classification of Fibromyalgia

Controversies in Classification

Medicine has recognized muscular and other soft tissue pain as clinical problems for several centuries.xv, Gowers coined the term “Fibrositis” in 1904 for a painful condition of muscles, which he believed to be due to inflammation.xvi Although clinical states of regional, and generalized muscular pain attracted the interest of some physicians, no consistent pathological changes could be detected, certainly none that strongly suggested inflammation. “Fibrositis” had become an almost forgotten entity until Smythe and Moldofsky started publishing their studies.xvii The term “fibrositis” was subsequently changed to that of “fibromyalgia” (FM) or “fibromyalgia syndrome” (FMS) as it became clear that inflammation in either muscle or fibrous tissue was not part of this condition.xviii

At first FM seemed to meet with a friendly reception. Physicians were pleased to find that they could now label the many patients with generalized pain, fatigue, and sleep disorders that they were seeing in their practices. This honeymoon period did not last very long. The last ten years especially have seen increasingly hostile criticism of FM. The condition affects many patients, and a veritable epidemic was said to have occurred; moreover, many of the sufferers seemed unable to work and requested disability payments.xix FM was perceived by some as one of several functional somatic syndromes with patients mistakenly attributing abnormalities of function to a physical rather than psychological condition.xx There are also those who think that FM does not exist.xxi Some of the criticism probably reflects a sense of frustration with the slow progress made in the understanding and treatment of this condition, the absence of specific abnormalities, and the difficulties in assessing disability claims made by the patients.xxii
Frustrations aside, there are nevertheless some strong criticisms, which have to be addressed. Three of these are especially important [see Table 1]:

  1. is it appropriate to consider FM as an entity that deserves specific recognition and is distinct from chronic widespread pain, (CWP)?

  2. the definition of FM by a committee of the American College of Rheumatology (ACR) (4) involved tautological reasoning, and no gold standards were used;xxiii

  3. both the historical criteria (pain) and the physical signs (report of pain on pressure of tender points) are entirely subjective and patient-dependent without any hard evidence of underlying abnormalities. What objective changes, if any, are there to support the existence of FM?

A distinct entity or part of a spectrum?
Generalized musculoskeletal pain, which accounts for the great majority of cases of

i Lawrence RC, Hochberg MC, Kelsey JL, et al. Estimates of prevalence of selected arthritic and musculoskeletal diseases in the United States. J. Rheumatol, 1989;16:427-441.

, Magni G, Marchetti M, Moreschi C, et al. Chronic musculoskeletal pain and depressive symptoms in the National Health and Nutrition Examination. I. Epidemiologic follow-up study. Pain 1993;53:163-8.

ii Wolfe F, Ross K, Anderson J et al: The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum 1995;38:19-28.

iii Felts W, Yelin E: The economic impact of the rheumatic diseases in the United States. J Rheumatol, 1989; 16: 867-884.

iv Lee P, Helewa A, Smythe H et al: Epidemiology of musculoskeletal disorders (complaints) and related disability in Canada. J Rheumatol 1985;12:1169-73.

v White KP. Speechley M, Harth M, Ostbye T: The London Fibromyalgia Epidemiology Study: The prevalence of fibromyalgia syndrome in London, Ontario J Rheumatol 1999;26:1570-6.

vi Reynolds DL, Chambers LW, Badley EM, Bennett KJ, Goldsmith CH, Jamieson E, Torrance GW, Tugwell P: Physical Disability among Canadians Reporting Musculoskeletal Diseases. J Rheumatol 1992;19 (7):1020-1030.

vii Andersson HI, Ejlertsson G, Leden I, Rosenberg C: Chronic pain in a geographically defined general population: studies of differences in age, gender, social class, and pain localization. Clin J Pain 1993;9:174-82.

, Hagen JB, Kvien TK, Bjorndal A. Musculoskeletal pain and quality of life in patients with non-inflammatory joint pain compared to rheumatoid arthritis: a population study. J Rheumatol 1997;24:1703-9.

, Croft P, Rigby AS, Boswell R et al: The prevalence of chronic widespread pain in the general population. J Rheumatol 1993;20:710-3.

viii Wood PHN, Badley EM: Rheumatic Disorders. In: Miller DL, Farmer RDT, eds. Epidemiology of Diseases. Oxford: Blackwell Scientific Publications, 1982: 333-346.

ix Darmawan J, Valkenburg HA, Muirden KD, Wigley RD: Epidemiology of rheumatic diseases in rural and urban populations in Indonesia: a World Health Organization international league against rheumatism COPCORD Study, Stage I, Phase 2. Annals Rheum Dis 1992;51:525-8.

x Chaiamnuay P, Darmawan J, Muirden KD, Assawatanabodee P. Epidemiology of rheumatic disease in Thailand: a WHO-ILAR COPCORD study. Community Oriented Programme for the Control of Rheumatic Disease. J Rheumatol 1998;25:1382-7.

xi Wolfe F: The Clinical Syndrome of Fibrositis. Amer J Med, 1986;81 (3A):7-14.

xii Alarcon-Segovia D, Ramos-Niembro F, Gonzales-Amaro RF: One thousand private rheumatology patients in Mexico City [letter]. Arthritis Rheum, 1983; 26: 688-689.

xiii The Epidemiology of Fibromyalgia: Workshop of the Standing Committee on Epidemiology European League Against Rheumatism (EULAR), Bad Sackingen, 19-21 November 1992. Brit J Rheumatol, 1994; 33: 783-786.

xiv Farooqi A, Gibson T: Prevalence of the major rheumatic disorders in the adult population of north Pakistan. Br J Rheumatol 1998;37:491-5.

xv Simons DG. Muscle pain syndrome – part I. Am J Phys Med 1975;54:289-311.

, Reynolds MD. The development of the concept of fibrositis. J. Hist Med Allied Sci. 1983;38:5-35.

xvi Simons DG. Muscle pain syndrome – part I. Am J Phys Med 1975;54:289-311.

xvii Smythe HA, Moldofsky H. Two contributions to the understanding of “fibrositis syndrome”. Bull Rheum Dis 1977;28:928-31.

xviii Wolfe F, Smythe HA, Yunus MB et al. The American College of Rheumatology criteria for the classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33:160-72.

xix Wolfe, F. The fibromyalgia problem. J Rheumatol 1997;24-1247-9.

xxBarsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med 1999;130:910-921.

xxi Hadler NM. Fibromyalgia: la maladie est morte. Vive le malade! J Rheumatol 1997;24:1250-1.

xxii Carette J. Fibromyalgia 20 years later: what have we really accomplished? J Rheumatol 1995;22:590-4.

xxiii Cohen ML. Is fibromyalgia a distinct clinical entity? The disapproving rheumatologist’s evidence. Bailliere J Best Pract Res Clin Rheumatol 199;13:379-89

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