The Journal of rheumatology. Supplement
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Accumulating evidence suggests that fibromyalgia syndrome (FM) pain is maintained by tonic impulse input from deep tissues, such as muscle and joints, in combination with central sensitization mechanisms. This nociceptive input may originate in peripheral tissues (trauma and infection) resulting in hyperalgesia/allodynia and/or central sensitization. ⋯ Such alterations of relevant pain mechanisms may lead to longterm neuroplastic changes that exceed the antinociceptive capabilities of affected individuals, resulting in ever-increasing pain sensitivity and dysfunction. Future research needs to address the important role of abnormal nociception and/or antinociception for chronic pain in FM.
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The fibromyalgia syndrome (FM) seems an unlikely candidate for classification as a neuropathic pain. The disorder is diagnosed based on a compatible history and the presence of multiple areas of musculoskeletal tenderness. A consistent pathology in either the peripheral or central nervous system (CNS) has not been demonstrated in patients with FM, and they are not at higher risk for diseases of the CNS such as multiple sclerosis or of the peripheral nervous system such as peripheral neuropathy. ⋯ Requiring demonstrable pathology in the nervous system in the definition of neuropathic pain is the traditional approach. The expansion of the definition to require only enduring nervous system dysfunction is less palatable because it opens the classification to many disorders of uncertain etiology, including complex regional pain syndrome. As it is uncertain which of the many different chronic pain syndromes include an enduring component of central sensitization, restricting the term "neuropathic pain" to those disorders with a primary etiology clearly related to the peripheral or CNS is prudent and consistent with clinical practice.
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The appropriateness and utility of considering fibromyalgia syndrome (FM) and other syndromes without anatomically localized pathology of the nervous system as neuropathic pain syndromes is uncertain. In this afterword, a synthesis of the information presented in these proceedings and opinion as to how FM relates to classical neuropathic pain syndromes is provided.
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We live in a culture of evidence-based medicine. Many areas of medicine have embraced this culture. However, for unusual diseases, like the childhood arthritides, there is little evidence. ⋯ The best known are the Pediatric Rheumatology Collaborative Study Group in North America, and the Paediatric Rheumatology International Trials Organization in Europe, South America, and Asia. A new North American collaborative study group has formed--the Childhood Arthritis and Rheumatology Research Alliance (CARRA)--to undertake investigator-initiated clinical trials. These groups might potentially lead the way to a new evidence-based culture for childhood arthritis.
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Nonpharmacological treatments, including physiotherapy and occupational therapy, have assumed a complementary role to drug therapy in managing inflammatory arthritis. Clinicians and researchers are facing 3 major challenges concerning the use of these treatments. First, strong evidence is only present in a few nonpharmacological interventions, such as exercise, patient education, and low level laser in the treatment of rheumatoid arthritis. ⋯ Understanding the relationships among rehabilitation-related variables and disability; 3. Development and evaluation of innovative care models; and 4. Design and evaluation of knowledge transfer innovations.