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Background As with fibromyalgia, several musculoskeletal disorders are characterized by chronic pain, raising a clinical question – do the instruments used to assess fibromyalgia symptoms according to ACR criteria (ACR criteria) generate similar scores in other chronic musculoskeletal pain? Objective To compare the symptoms among fibromyalgia and other chronic musculoskeletal pain. Additionally, we also compared the most researched outcomes in fibromyalgia (i.e., present pain at rest and after movement; fatigue; pain severity and impact; function, global impact, and fibromyalgia symptom). Methods A cross-sectional study. Participants over 18 years old were included if they presented report of chronic musculoskeletal pain (≥ 3 months) and after that, they were divided into two groups (fibromyalgia and chronic pain). They answered the Fibromyalgia Impact Questionnaire-Revised (FIQ-R), Brief Pain Inventory (BPI), Numerical Pain Rating Scale (NPRS) for pain and fatigue, WPI, and SSS. Results A total of 166 participants were included in this study into two independent groups (chronic pain, n = 83; fibromyalgia, n = 83). We observed significant differences (p < 0.05) and large effect sizes (Cohen’s d, ≥ 0.7) in clinical outcomes comparisons between groups (i.e., widespread pain; symptom severity; present pain at rest and after movement; fatigue; pain severity and impact; function, global impact, and fibromyalgia symptoms). Conclusion Fibromyalgia patients (2016 ACR criteria) compared to other chronic musculoskeletal pain patients have higher levels of pain (at rest or after movement) and fatigue, greater impairment in both functionality and global impact, and worse symptoms. Therefore, the WPI and SSS instruments should be used exclusively to assess fibromyalgia symptoms. Keywords Chronic Pain, Diagnostic Services, Rheumatology, Primary Health Care *Correspondence: Mariana Arias Avila firstname.lastname@example.org Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. 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BMC Musculoskeletal Disorders (2023) 24:467 Page 2 of 6 Introduction information regarding fibromyalgia / chronic pain after Fibromyalgia (or fibromyalgia syndrome) is a chronic the end of their participation (Supplementary material 1). condition characterized by widespread pain and com- plex symptomatology , such as fatigue , sleep dis- Participants and study size turbances , mood disorders , and symptoms not Considering the primary outcome of our study (com- explained by structural changes . Its prevalence varies parisons between groups), we performed the sample cal- from 2 to 6% in the world population and is more iden- culation a priori using the t-test two tails (independent tified in women aged between 20 and 55 years [ 2]. The groups) through G*Power (version 126.96.36.199). We used the literature recommends that the diagnosis of fibromyalgia effect size of 0.44 [ 12, 13], alpha of 0.05, power of 0.80, should be based on the guidelines of the American Col- and critical f of 1.97. As such, the total sample size was lege of Rheumatology (ACR) . However, taking into estimated at 166 participants divided into 2 independent account that it is a disease characterized (in part) by groups  (fibromyalgia, n = 83; chronic pain, n = 83). chronic musculoskeletal pain, nothing prevents us from Participants over 18 years old that could read and write using the same ACR criteria to evaluate other musculo- in Brazilian Portuguese were included if they presented skeletal diseases, as the fibromyalgia assessment/diag - report of chronic musculoskeletal pain (≥ 3 months) and nosis (2016 ACR criteria) uses generic instruments such after that, they were divided into two groups (fibromyal - as the Widespread Pain Index (WPI) and the Symptom gia and chronic pain). For the fibromyalgia group, people Severity Scale (SSS) . should have the fibromyalgia diagnosis (participants were However, although WPI and SSS instruments perform considered as with fibromyalgia if they fulfilled the ACR generic assessments of chronic musculoskeletal pain 2016 fibromyalgia diagnostic criteria [ 6], including the (on axial region and/or upper and lower limbs) , it is WPI ≥ 7 and the SSS ≥ 5 or WPI = 4–6 and SSS ≥ 9). For necessary to verify whether there is a difference among the chronic pain group, participants should have a his- the clinical outcomes’ specificities (e.g., function, global tory of chronic pain (≥ 3 months) but no fibromyalgia impact, symptoms, pain severity/impact, and fatigue) (i.e., arthritis, osteoarthritis, low back pain, neck pain, when comparing patients with fibromyalgia to patients and so on). Namely, participants with chronic pain whose with other chronic musculoskeletal pain. Therefore, the symptoms do not meet the ACR 2016 fibromyalgia diag - hypothesis of this study was that patients with fibromy - nostic criteria. Complete database is available at the algia have a worse clinical outcome compared to other link < https://docs.google.com/spreadsheets/d/1Yxno- chronic musculoskeletal pain. f1JH0bUEbD44ZfxBx8ILqcjg58Z/edit?usp sharing&oui u Th s, the objective of this study was to compare (via d 104821689851272179944&rtpof true&sd true>. = = = WPI and the SSS) the symptoms among fibromyalgia Participants were excluded from the analysis if they had and other chronic musculoskeletal pain. Additionally, we a history of tumors, traumas, acute infections, self-report also compared the most researched outcomes in fibro - of severe psychiatric illnesses (including severe depres- myalgia (i.e., present pain at rest and after movement [7, sion, bipolarity, and schizophrenia), presence of severe 8]; fatigue [7, 8]; pain severity and impact ; function, comorbidities in the heart, liver, and/or kidney, presence global impact, and fibromyalgia symptom [ 10]). of neoplasia, systemic autoimmune or inflammatory con - comitant diseases, hypothyroidism, pregnancy and/or Methods breastfeeding, and presence of therapeutic intervention Study design and ethical considerations in the last six months. A cross-sectional study performed according to the STROBE Guidelines . The protocol has been Assessment tools approved by the ethics committee of Universidade Fed- Participants answered Fibromyalgia Impact Question- eral de São Carlos, in Brazil (report number 4.193.940). naire-Revised (FIQ-R) , Brief Pain Inventory (BPI) This study was disclosed in social media from November , and Numerical Pain Rating Scale (NPRS) [7, 8] for 2020 to August 2021. pain and fatigue. All participants rated their pain (in two We disclosed in social media (Instagram® and Face- different situations: at rest, and after body movement) book®) and through messaging applications (WhatsApp®). and fatigue from 0 (if they did not present pain/fatigue) All people who manifested interest in taking part in the to 10 (if they presented the worst imaginable pain or study were contacted and checked for eligibility criteria. fatigue). All those who were included in the study received an FIQ-R assesses the impact of fibromyalgia on life in online form (via GoogleForms®) and agreed to take part relation to functional capacity, professional status, psy- in the study by clicking on the “I agree to take part in the chological disorders, and physical symptoms . Its present study” after reading the informed online consent Brazilian version has excellent test-retest reliability form. All participants received an online booklet with (ICC = 0.75) and comprises 21 items that investigate three Pontes-Silva et al. BMC Musculoskeletal Disorders (2023) 24:467 Page 3 of 6 domains: function (9 items, 30 points), global impact (2 all questions about pain/fatigue, zero means no pain/ items, 20 points), and symptoms (10 items, 50 points) fatigue and 10 was the worst pain/fatigue imaginable. In [10, 15]. Scores range from 0 to 100, with the latter being chronic pain conditions, NPRS had a moderate to high meaningful of a worst condition. The minimal important test-retest reliability (0.67 to 0.96) . clinical difference for the FIQ-R is 27 points [ 16]. We also use BPI, a self-report instrument validated for Statistical analysis the Brazilian population . BPI assesses pain severity The distribution of variables was verified using Kol - and impact on a person’s life with 15 items that assess mogorov-Smirnov test. We set the significance level at presence, severity, location, functional impact, used ther- 5% for all statistical tests, which in turn were processed apeutic strategies, and treatment efficacy on an 11-point using the Statistical Package for the Social Sciences soft- scale ranging from zero (no pain/no interference) to 10 ware, version 17.0 (Chicago, IL, USA). The compari - (as bad as it can be). High scores indicate worse pain sons between variables were performed via independent severity and impact. Its Brazilian version presented a T-test and presented as: mean, standard deviation (SD), two-dimensional structure (pain severity and interfer- mean difference (MD) with confidence interval (95% CI), ence) and excellent internal consistency (α = 0.87–0.91) and effect size [ 20], calculated using Cohen’s d according . to classification values: 0.2 = small, 0.5 = moderate, and We assess pain intensity using the NPRS, a self-report ≥ 0.7 large . instrument validated for the Brazilian population . NPRS is a single-item instrument that was used for pain Results and fatigue intensity. We evaluated pain in two different Three hundred and ninety-six women volunteered. After situations: at rest – “Currently and at the moment when the screening, according to the eligibility criteria men- you are sitting/lying on the couch watching your favor- tioned in the methods, a total of 166 participants were ite TV show, do you feel pain?”; after body movement – included in this study into two independent groups “Currently and when you walked from the supermarket (Chronic Pain [CP], n = 83; Fibromyalgia [FM], n = 83). parking lot to the grocery store or crossed the street to We observed significant differences (p < 0.05) and large work, do you feel pain?” . For fatigue, we asked “Dur- effect sizes (Cohen’s d, ≥ 0.7) in clinical outcomes com- ing the answer to this questionnaire, which number best parisons shown in Tables 1 and 2 (i.e., widespread pain corresponds to your state of fatigue/body tiredness?“. In [WPI]; symptom severity [SSS]; present pain at rest, after movement, and fatigue [NPRS]; pain severity and impact [BPI]; function, global impact, and fibromyalgia Table 1 Participants’ characteristics – values presented in mean symptoms [FIQ-R]). Prevalence of WPI is similar in both (SD). groups. However, the number of regions affected by pain Variables Chronic Fibromyal- p is significantly different between them (Table 1). pain group gia group (n = 83) (n = 83) Our study shows large effect sizes, indicating the clini - Age (years) 43.1 (13.0) 38.7 (10.1) 0.011* cal relevance of the comparisons of the present study. Body mass (kg) 71.7 (13.5) 73.5 (15.5) 0.085 Clinical relevance (also known as clinical significance) Stature (m) 1.62 (0.0) 1.64 (0.0) 0.766 indicates that the results of a study are meaningful or not Body mass index (Kg/m ) 27.3 (5.2) 27.2 (5.3) 0.795 for several stakeholders . The clinical relevance facili - Widespread Pain Index (score) 4.8 (2.7) 13.3 (3.6) < 0.001* tates the understanding and interpretation of results for Symptom Severity Scale (score) 5.9 (2.9) 9.2 (1.9) < 0.001* professionals. Currently, the assessment of this approach Numerical Pain Rating Scale has become a popular method to assist the transfer of (score) knowledge into clinical practice. Present pain at rest 5.0 (2.5) 6.6 (1.8) 0.007* Pain after movement 5.4 (2.7) 7.5 (2.2) 0.017* Discussion Present fatigue 5.2 (3.3) 7.9 (1.8) < 0.001* Main results synthesis Brief Pain Inventory (score) The objective of this study was to compare (via WPI and Pain severity 5.2 (2.2) 6.8 (1.6) < 0.001* the SSS) the symptoms among fibromyalgia and other Pain impact 5.5 (2.7) 7.4 (2.0) 0.001* chronic musculoskeletal pain. Additionally, we also com- FIQ-R (score) pared the most researched outcomes in fibromyalgia (i.e., Function (0–30) 11.9 (8.6) 21.5 (5.9) < 0.001* present pain at rest and after movement [7, 8]; fatigue [7, Global impact (0–20) 9.5 (6.3) 16.3 (3.8) < 0.001* 8]; pain severity and impact ; function, global impact, Symptoms (0–50) 25.8 (12.3) 37.6 (6.9) < 0.001* and fibromyalgia symptom [ 10]). Our results showed that Total score (0-100) 47.4 (25.5) 75.5 (14.6) < 0.001* patients with fibromyalgia have higher levels of wide - BPI: Brief Pain Inventory; FIQ-R: Fibromyalgia Impact Questionnaire-Revised. * Significant difference (independent t-test, p < 0.05) spread pain and symptom severity than patients with Pontes-Silva et al. BMC Musculoskeletal Disorders (2023) 24:467 Page 4 of 6 Table 2 Comparison of Pain and FIQ-R between groups : (A) Widespread pain, defined as pain in at least 4 Variables Group Mean Mean CI 95% d of 5 body’s regions; (B) Symptoms have been present at (n = 166/2) (SD) Difference a similar level for at least three months; (C) Widespread a # NPRS Chronic Pain 5.0 (2.5) -1.62 -2.30, 0.7 pain index ≥ 7 and symptom severity scale score ≥ 5 (or -0.95 Widespread pain index of 4–6 and symptom severity Fibromyalgia 6.6 (1.8) scale score ≥ 9); (D) A diagnosis of fibromyalgia is valid b # NPRS Chronic Pain 5.4 (2.7) -2.12 -2.87, 0.8 irrespective of other diagnoses . -1.36 Although this initiative is relevant to health sciences, it Fibromyalgia 7.5 (2.2) c # is possible to note that patients continue to be assessed NPRS Chronic Pain 5.2 (3.3) -2.66 -3.49, 1.0 -1.82 via the biomedical model . Perhaps, that happening Fibromyalgia 7.9 (1.8) because The prevalence of fibromyalgia appears to differ Brief Pain according to the diagnostic criteria used . The 1990 Inventory criteria have been considered stricter than the 2010 cri- Pain severity Chronic Pain 5.2 (2.2) -1.50* -2.18, 0.8 teria, such that only more severely affected patients are -0.99 identified [ 29]. Studies recruiting fibromyalgia patients Fibromyalgia 6.8 (1.6) according to the 1990 ACR criteria reported higher mean Pain impact Chronic Pain 5.5 (2.7) -1.95* -2.68, 0.8 WPI and SSS scores than studies in which patients were -1.22 recruited using the 2010 ACR criteria [29, 30]. However, Fibromyalgia 7.4 (2.0) most recent studies as well as international recommenda- FIQ-R # tions guide the use of the 2016 ACR criteria . Function Chronic Pain 11.9 -9.57* -11.86, 1.3 (8.6) 7.29 Fibromyalgia 21.5 Ours and the literature’s results (5.9) Chronic musculoskeletal pain is one of the main reasons Global Chronic Pain 9.5 (6.3) -6.77* -8.38, 1.3 for referrals to health professionals . It can be caused impact -5.15 by a wide variety of inflammatory [ 32] and noninflam - Fibromyalgia 16.3 matory conditions , including arthritis , hyper- (3.8) mobility , low back pain , neck pain , growing Symptoms Chronic Pain 25.8 -11.80* -14.87, 1.1 pains , and complex regional pain syndrome . (12.3) -8.73 Some patients with fibromyalgia have these symptoms Fibromyalgia 37.6 associated with the disease, thus, hindering the diagnos- (6.9) tic accuracy of fibromyalgia [ 28]. As such, some authors Total score Chronic Pain 47.4 -28.15* -34.53, 1.3 (25.5) 21.77 have used the WPI in the evaluation of other disorders, Fibromyalgia 75.5 e.g., temporomandibular disorders , psoriatic arthri- (14.6) tis , musculoskeletal surgery , and headache . CI: Confidence Interval; d: effect size (Cohen’s d); FIQ-R: Fibromyalgia Impact Our results indicate that the WPI, as well as the SSS, Questionnaire-Revised; NPRS: Numerical Pain Rating Scale ( present pain b c at rest, pain after movement, present fatigue); SD: Standard Deviation. * should be used exclusively on fibromyalgia evaluation. In Significant difference (independent t-test, p < 0.05). Significant effect size addition, the scores of the instruments most used in stud- (Cohen’s d, large effect, ≥ 0.8) ies on fibromyalgia (FIQ-R, BPI, and NPRS), observed in our study, reinforced that the severity of symptoms is other chronic musculoskeletal pain. Namely, the instru- greater in fibromyalgia patients. However, although our ments used to assess fibromyalgia symptoms according results support the use of SSS in patients with fibromyal - to ACR criteria (WPI + SSS) generate significantly dif - gia, we highlighted that Elkana et al.  found that the ferent scores in other chronic musculoskeletal pain (the SSS has an insignificant relationship between the subjec - same happens with the other outcomes analyzed). There - tive appraisal of cognitive impairment and the objective fore, reinforcements that these instruments (WPI + SSS) cognitive scores on computerized subtests. Therefore, we should be used only in patients with fibromyalgia. suggest novel studies in this area. Fibromyalgia diagnosis: challenges and perspectives Strengths and clinical applicability Since the last century, studies on fibromyalgia have eval - Although patients with fibromyalgia have chronic mus - uated patients using biomedical models [23, 24]. This culoskeletal pain in different parts of the body (spine, evaluation model was strengthened 1990’s year when knee, and so on ), it does not mean that patients who the ACR established classification criteria for fibromyal - have other chronic musculoskeletal pain, but no fibro - gia . Then, other updates appeared (2010 and 2011) myalgia, may be evaluated using the same instruments whose combined review resulted in the 2016 criteria Pontes-Silva et al. BMC Musculoskeletal Disorders (2023) 24:467 Page 5 of 6 Acknowledgements proposed by the ACR to assess fibromyalgia symptoms We thank all the participants who kindly volunteered for this research. (WPI and SSS) . Authors’ contributions As clinical applicability to evidence-based practice, AP-S designed the study; APDS and MAA collected the data; AP-S, AVDF, APDS, we suggest to the health professionals, first of all, screen MCS, JMDS, and MAA analyzed and interpreted of the data; All authors wrote the initial draft; All authors read and approved the final manuscript. fibromyalgia using specific instruments (e.g., the fibro - myalgia rapid screening tool ). In the same way, other Funding chronic musculoskeletal pain must be evaluated by spe- The study was partially supported by Coordination of Improvement of Higher Education Personnel - Brazil (CAPES) – Finance Code 001 and National Council cific instruments (respecting the cross-cultural adapta - for Scientific and Technological Development (CNPq). Role of funding sources: tion ), because there are questionnaires, scales, and The funders had no role in study design, data collection, and analysis, decision specific tests for low back pain [ 43], knee pain , neck to publish, or preparation of the manuscript. pain , temporomandibular disorders , and other Data availability musculoskeletal diseases. Therefore, the WPI and SSS The data and materials in this paper are available from the corresponding apply to the individuals which ACR has suggested: fibro - author on request. myalgia patients [1, 6, 47]. Declarations Limitations and prospects for novel studies Ethics approval and consent to participate Although this was the first study to compare fibromyal - This study was approved by the Research Ethics Committee of the gia symptoms, according to ACR criteria (WPI + SSS), to Universidade Federal de São Carlos (report number 4.193.940), whose guidelines have been in accordance with the Declarations of Helsinki. All scores in other chronic musculoskeletal pain, our study respondents participated in this study freely and signed an informed consent has limitations that must be addressed. Although par- form. ticipants reported pain and global symptoms lasting > 3 Consent for publication months, we do not know the pain duration total values Not applicable. in the groups, the prevalence of headache, cramps in the lower abdomen, and depression during the previous six Competing interests Almir Vieira Dibai-Filho and André Pontes-Silva are BMC Musculoskeletal months. We also do not know if the investigated instru- Disorders’ Editors and Reviewers. All other authors do not have any Competing ments (WPI + SSS) are sufficient to assess fibromyalgia interests. symptoms or whether they should be associated with Author details computerized tests. Besides, medication use was not Study Group on Chronic Pain (NEDoC), Laboratory of Research controlled in that study, and we did not use a polysymp- on Electrophysical Agents (LAREF), Physical Therapy Department, tomatic distress scale— we suggest novel studies to inves- Universidade Federal de São Carlos, Rodovia Washington Luís, Km 235, São Carlos, São Paulo 13565-905, Brazil tigate these limitations. Postgraduate Program in Physical Education, Department of Physical Education, Universidade Federal do Maranhão, São Luís, MA, Brazil Conclusion Postgraduate Program in Rehabilitation Sciences. Physical Therapy Department, Universidade Federal do Rio Grande do Norte, Natal, RN, Fibromyalgia patients (2016 ACR criteria) compared to Brazil other chronic musculoskeletal pain patients have higher Laboratory of Research on Neuroscience (LAPENE), Physical Therapy levels of pain (at rest or after movement) and fatigue, Department, Graduate Program in Health Science, Graduate Program in Physiological Science, Universidade Federal de Sergipe, Aracaju, Sergipe, greater impairment in functionality and global impact, Brazil and worse symptoms. Therefore, WPI and SSS instru - ments should be used exclusively to assess fibromyalgia Received: 3 March 2023 / Accepted: 25 May 2023 symptoms. List of abbreviations ACR American College of Rheumatology BPI Brief Pain Inventory FIQ-R Fibromyalgia Impact Questionnaire-Revised References MD Mean Difference 1. Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Flub E, et al. 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BMC Musculoskeletal Disorders – Springer Journals
Published: Jun 7, 2023
Keywords: Chronic Pain; Diagnostic Services; Rheumatology; Primary Health Care
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