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