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Clinical Characteristics of Korean Patients with Fibromyalgia

Seong-Ho Kim*

Inje University College of Medicine, Busan, Korea

*Corresponding Author:
Seong-Ho Kim
Department of Internal Medicine
Inje University College of Medicine
Busan, Korea
Tel: 82-10-9100-3092
E-mail: [email protected]

Received date: October 02, 2015; Accepted date: November 03, 2015; Published date: November 07, 2015

Citation: Kim SH (2015) Clinical Characteristics of Korean Patients with Fibromyalgia. Fibrom open 1:101. doi:10.4172/FOA.1000101

Copyright: © 2015 Kim SH. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Objective: Fibromyalgia syndrome (FS) involves chronic pain accompanied by alteration of cognitive functions, mainly memory and attention. Despite vigilance is a pre-requisite for appropriate performance in most cognitive tasks, it has not been assessed directly in fibromyalgia. The current research aimed to study vigilance in this illness and to explore the potential role of other common symptoms of the syndrome such as pain, sleep quality, anxiety and depression in vigilance performance.

Methods: The Psychomotor Vigilance Task (PVT) was used to assess the vigilance level in a group of fibromyalgia female patients (n=28) compared to a group of healthy women (n=18) matched in age and education level.

Results: The fibromyalgia group reported higher levels of anxiety, depression, negative mood and pain, poorer sleep quality, and lower levels of alertness than the control group. In the PVT, the fibromyalgia group showed slower responses in the PVT as compared to the control group. Fibromyalgia patients further showed high individual differences in vigilance, with a subgroup of them having similar performance in the PVT than the control group. Performance in the PVT showed no relationship with subjective measures.

Conclusion: These findings provided direct support to a vigilance deficit in fibromyalgia as a group. However, there are individual differences suggesting that not all the patients with fibromyalgia necessarily experience vigilance detriment. Since the vigilance state can determine basic functions such as memory and attention, these individual differences should be considered when assessing other cognitive domains in fibromyalgia.

Keywords

Fibromyalgia; Korea; Characteristics

Introduction

Fibromyalgia (FM) is a common condition afflicting 2% of the population [1]. It is characterized by chronic widespread pain with increased sensitivity to pressure elicited pain. The American College of Rheumatology [ACR] classification criteria in 1990 stipulated the presence of chronic widespread pain for at least 3 months and the presence of at least 11 out of 18 tender points [2]. Aside from pain, common problems of FM are morning stiffness, fatigue, nonrestorative sleep, pain, concentration, and memory [3].

Epidemiological studies report a FM prevalence of between 2 and 7% in most nations, with a female to male ratio of approximately 9:1 [3]. The prevalence of FM was 2.2% in Korean and was significantly higher in female and aged individuals [4]. It is increasingly evident that FM represents a significant challenge in view of its high prevalence, frequent comorbidities, and frustration with current treatment modalities.

Although fibromyalgia (FM) has been known to present a variety of clinical symptoms, a detailed investigation on this topic has not been performed in Korean patients. We tried to identify various FM-related symptoms and compare the clinical features of patients with primary FM and those of patients with secondary FM.

Materials and Methods

Study population

Total 336 patients with FM were consecutively recruited from out patient rheumatic clinics of 10 medical centers participated in national survey on clinical characteristics of Korean patients with FM from June 2008 to March 2009 in Korea. All of them at the time of initial diagnosis met classification criteria for FM proposed by ACR in 1990 [2]. The protocol of this study was approved by Institutional Review Board at each medical center. Total participants gave informed consent for this research.

Data collection

Demographics of enrolled patients including age, gender, height, weight, symptom duration, disease duration after diagnosis, education, employment status, marital status, annual income and insurance were preliminary assessed. In addition, alcohol intake was identified such as current alcoholic and non-alcoholic at the time of enrollment in this study. Smoking status was also classified into current smoker and nonsmoker. At the assessment of medical history, we surveyed accompanying diseases in the participants such as diabetes mellitus, hypertension, hepatitis, thyroid disease, affective disorder and other rheumatic disease.

At the assessment of symptoms and signs, we surveyed past and current symptoms and signs in the participants such as generalized weakness, unrefreshing sleep, fatigue, stiffness, paresthesia, swelling, febrile sense, tension headache, subjective cognitive dysfunction, dry eye, dry mouth, swollen glands, vasomotor rhinitis, dizziness and vestibular complaints, syncope and neutrally mediated hypotension, temporomandibular joint syndrome, non-cardiac chest pain, costochondritis, dyspnea, esophageal dysmotility, dyspepsia, irritable bowel syndrome, irritable bladder and female urethral syndrome, vulvodynia and vagismus, skin redness, restless leg syndrome and reflex sympathetic dystrophy. The glossary of symptom and sign is defined in Table 1.

Term Description
Stiffness Morning stiffness
Swelling Feeling of swollen hands and feet
Cognitive dysfunction Subjective memory and concentration difficulties
Dry eye Positive response to at least one of 3 questions:
Have you had daily, persistent, troublesome dry eyes for > 3 months?
Do you have a recurrent sensation of sand or gravel in the eyes?
Do you use tear substitutes > 3 times a day?
Dry mouth Positive response to at least one of 2 questions?
Have you had a daily feeling of dry mouth for > 3 months?
Do you frequently drink liquids to aid in swallowing dry food?
Swollen glands Recurrent or persistently swollen salivary gland as an adult
Vasomotor rhinitis Rhinorrhea, nasal congestion, itching, and sneezing that is not attributable to allergy or infection and is thought to be a hypersensitive reaction to various potentially irritating stimuli (as strong odors, air pollution, or sudden temperature changes).
Temporomandibular joint syndrome Pain, muscle tenderness, clicking in the joint, and limitation or alteration of mandibular movement.
Costochondritis Local pain and tenderness of costochondral junction (chest around the sternum)
Esophagealdysmotility Subjective symptom of heartburn, not noted by barium or manometric studies
Irritable bowel syndrome The Rome criteria
Irritable bladder, female urethral syndrome Subjective symptom of urinary frequency, urgency, burning, and more with a lack of objective findings.
Restless leg syndrome International Restless Legs Syndrome Study Group Diagnostic Criteria (1995)
Reflex sympathetic dystrophy/CRPS International Association for the Study of Pain Diagnostic Criteria (1994)

Table 1: Glossary of signs and symptoms.

We also surveyed stressors capable of triggering FM in the participants such as peripheral pain syndrome, infection, physical trauma, psychological stress/distress, hormonal alteration, drugs, vaccines and catastrophic events. In addition, we surveyed current medications in the participants such as selective serotonin reuptake inhibitor (SSRI), serotonin norepinephrine reuptake inhibitor (SNRI), pregabalin, gabapentin, tricyclic antidepressant (TCA), muscle relaxant, nonsteroidal anti-inflammatory drugs (NSAID), tramadol, acetaminophen, sedative-hypnotics and benzodiazepine etc.

Identification of tender points was assessed through direct palpation at 18 specific sites with a force amount of 4.0 kg according to the standardized manual tender point survey [5]. First, the presence of a tender point at specific sites was identified. Second, the intensity of each tender point was graded as follows: 0, no tenderness; 1, light tenderness (confirming answer when asked); 2, moderate tenderness (spontaneous verbal response); and 3, severe tenderness (moving away). The summation of these points was regarded as the score of total tender points. The Korean version of the fibromyalgia impact questionnaire (FIQ) was used to assess the functional abilities in patients with FMS on a scale of 0 to 100 for each subject [6]. Brief fatigue inventory (BFI) was used for the measure of fatigue severity in FMS patients [7]. The severity of depression was measured by brief depression inventory (BDI) [8,9]. The 36-item Medical Outcomes Study Short-Form Health Survey (SF-36) was evaluated for quality of life in FMS and consisted of eight items including physical health (physical functioning, role-physical, bodily pain, general health) and mental health (vitality, social functioning, role-emotional, mental health) [10]. The state-trait anxiety inventory (STAI)-1 and STAI-2 were developed as methods for evaluation of the degree of anxiety [11]. The state anxiety and trait anxiety were identified using these two methods. Self efficacy scale was assessed in our study [12]. Social family support and social friend support were also assessed in this study [13].

Statistical analysis

Data were described as the mean ± standard deviation or number with percent (%) of cases. For the comparison of clinical characteristics between primary and secondary FM, Chi-square test was used for the comparison of categorical variables and Mann-Whitney U test was applied in the assessment of the differences of sequential variables. A p value <0.05 was considered statistically significant. Statistical analysis was performed using the Statistical Package for the Social Sciences, version 13.0 (SPSS Inc., Chicago, IL, USA).

Results

General characteristics of enrolled subjects

Generalized demographic and clinical characteristics are identified in Table 2. The majority (89.6%) of participants were women (n=301), and the average age was 47.9 years. On average, participants were diagnosed with FM approximately two years prior to recruitment and participation in this study. Mean duration of education was approximately 11.0 years, which was comparable with a high school degree. The study population having an occupation of physical labor was 32.9% (n=107). Current alcohol consumers were estimated at 22.0% (n=74) of the study population. The prevalence of accompanying affective disorders such as depression or anxiety was estimated as approximately 26.5%. Approximately 26.2% of the patients had underlying rheumatic diseases including Behcet’s disease, osteoarthritis, rheumatoid arthritis, Sjögren syndrome, systemic lupus erythematosus, or other rheumatic disorders.

Characteristics Values
Age (years) 47.9 ± 10.9
Sex (women) 301/336 (89.6)
Symptom duration (years) 8.3 ± 8.1
Disease duration (years) 2.0 ± 3.0
Education (years) 11.0 ± 4.0
Periods of education (years)  
0 – 6 54/280 (19.3)
7 – 9 54/280 (19.3)
10 – 12 99/280 (35.4)
> 12 73/280 (26.1)
Annual income (US $/year) 27,455.6 ± 26,792.7
Current smoking (n = 336) 33/336 (9.8)
Female/Male (n, % of each gender) 22 (7.3)/ 11 (31.4)
Current employment* (n = 325) 107/325 (32.9)
Marital status* (n = 334)  
Single 30/334 (9.0)
Married 273/334 (81.7)
Divorced 18/334 (5.4)
Separated 4/334 (1.2)
Widowed 9/334 (2.7)
Current alcohol intake status 74/336 (22.0)
Non-current alcoholic 262/336 (78.0)
Current alcoholic
Diabetes mellitus
Hypertension
Hepatitis B or C
Thyroid disease
74/336 (22.0)
20/336 (6.0)
59/335 (17.6)
14/336 (4.2)
28/336 (8.3)
Affective disorders† 89/336 (26.5)
Rheumatic diseases‡ 88/336 (26.2)
None 248/336 (73.8)
Behcet’s disease 12/336 (3.6)
Osteoarthritis 32/336 (9.5)
Rheumatoid arthritis 26/336 (7.7)
Sjögren’s syndrome 5/336 (1.5)
Systemic lupus erythematosus 9/336 (2.7)
Others (gout, spondyloarthropathy) 4/33.6 (1.2)

Table 2: Demographics, social and medical characteristics in enrolled patients (n=336).

Current and past accompanying symptoms and signs

The following symptoms were exhibited by more than two-thirds of FM patients, in order of frequency: fatigue, unrefreshing sleep, generalized weakness, stiffness, tension headache, swelling, febrile sense, and dizziness (Table 3).

  Past (%) Current (%) Total (%)
Fatigue 300/336 (89.3) 302/336 (89.9) 324/336 (96.4)
Unrefreshing sleep 286/336 (85.1) 282/336 (83.9) 312/336 (92.9)
Generalized weakness 279/336 (83.0) 273/336 (81.3) 303/336 (90.2)
Stiffness 258/336 (76.8) 267/336 (79.5) 289/336 (86.0)
Tension headache 244/336 (72.6) 215/336 (64.0) 271/336 (80.7)
Swelling 215/334 (64.4) 194/336 (57.7) 243/334 (72.8)
Febrile sense 189/335 (56.4) 203/335 (60.6) 234/335 (69.9)
Dizziness, vestibular complaints 207/336 (61.6) 183/335 (54.6) 234/335 (69.9)
Dry mouth 168/335 (50.1) 201/335 (60.0) 215/334 (64.4)
Subjective cognitive dysfunction 148/335 (44.2) 202/335 (60.3) 209/335 (62.4)
Dry eye 175/336 (52.1) 188/336 (56.0) 205/336 (61.0)
Dyspepsia 177/335 (52.8) 163/336 (48.5) 195/335 (58.2)
Paresthesia 159/334 (47.6) 168/333 (50.5) 184/333 (55.3)
Non-cardiac chest pain 142/336 (42.3) 120/334 (35.9) 165/334 (49.4)
Dyspnea 127/336 (37.8) 103/335 (30.7) 150/335 (44.8)
Restless leg syndrome 129/335 (38.5) 134/335 (40.0) 149/335 (44.5)
Irritable bladder, female urethral syndrome 128/334 (38.3) 121/332 (36.4) 146/332 (44.0)
Esophagealdysmotility 125/335 (37.3) 111/335 (33.1) 139/335 (41.5)
Irritable bowel syndrome 120/336 (35.7) 111/336 (33.0) 136/336 (40.5)
Temporomadibular joint syndrome 101/335 (30.1) 102/335 (30.4) 124/334 (37.1)
Skin redness 96/334 (28.7) 94/334 (28.1) 114/334 (34.1)
Vasomotor rhinitis 97/336 (28.9) 90/334 (26.9) 109/334 (32.6)
Costochondritis 90/335 (26.9) 85/336 (25.3) 104/335 (31.0)
Syncope, neurally mediated hypotension 79/336 (23.5) 35/334 (10.5) 87/334 (26.0)
Swollen glands 73/336 (21.7) 64/335 (19.0) 82/335 (24.5)
Vulvodynia, vagismus 55/300 (18.3) 40/300 (13.3) 63/300 (21.0)
Reflex sympathetic dystrophy 49/335 (14.6) 30/335 (9.0) 52/335 (15.5)

Table 3: Current and past accompanying symptoms and signs in the 336 patients with fibromyalgia.

Stressors that triggered fibromyalgia symptoms

Stressors that triggered FM symptoms were found in 58.6% of the patients and can be listed in the following order: psychological distress, peripheral pain syndrome, catastrophic events, physical trauma, hormonal alteration, infections, and drugs (Table 4).

Variables Number (%)
Psychological stress/distress (e.g., conflict with in-laws) 83/336 (24.7)
Peripheral pain syndrome (e.g., osteoarthritis) 64/336 (19.0)
Catastrophic events (e.g., childbirth) 21/336 (6.3)
Physical trauma (e.g., motor vehicle accident) 19/336 (5.7)
Hormonal alteration (e.g., menopause) 4/336 (1.2)
Infections 3/336 (0.9)
Drugs 3/336 (0.9)
Non-available 139/336 (41.4)

Table 4: Stressors that triggered fibromyalgia symptoms.

Comparison of clinical characteristics between primary and secondary fibromyalgia

Compared to patients with primary FM, patients with secondary FM were significantly older, less educated, more Medical Aid beneficiaries, had more dizziness, received more NSAIDs and analgesics, and had higher levels of trait anxiety (p<0.05, p<0.05, p=0.001, p<0.05, p<0.01, p<0.01, and p<0.05, respectively) (Table 5).

  Primary (N=248) Secondary (N=88) P value
Age 47.4 (40.6, 53.4) 48.1 (43.5, 60.1) 0.038
Women (%) 223/248 (89.9) 78/88 (88.6) 0.690
Symptom duration, years 6.00 (3.00, 10.00) 5.00 (2.00, 10.00) 0.638
Disease duration, years 0.50 (0.08, 3.00) 1.00 (0.07, 3.00) 0.460
Education, years 12.00 (9.00, 14.00) 12.00 (6.00, 12.00) 0.017
Employment (%) 80/238 (33.6) 27/87 (31.0) 0.691
Marital status, married (%) 206/246 (83.7) 67/88 (76.1) 0.147
Insurance, insured/beneficiary 227/16 71/17 0.001
Alcohol, no/past/current 164/25/59 67/6/15 0.219
Smoking, never/ex-smoker/smoker 206/28/14 82/5/1 0.055
Diabetes mellitus (%) 15/248 (6.0) 5/88 (5.7) 1.000
Hypertension (%) 39/247 (15.8) 20/88 (22.7) 0.146
Hepatitis B or C (%) 11/248 (4.4) 3/88 (3.4) 1.000
Thyroid disease (%) 24/248 (9.7) 4/88 (4.5) 0.178
Affective disorder (%) 80/238 (33.6) 27/87 (31.0) 0.691
Clinical features (%)      
Fatigue 240/248 (96.8) 84/88 (95.5) 0.521
Unrefreshing sleep 230/248 (92.7) 82/88 (93.2) 1.000
Generalized weakness 225/248 (90.7) 78/88 (88.6) 0.539
Stiffness 212/248 (85.5) 77/88 (87.5) 0.723
Tension headache 204/248 (82.3) 67/88 (76.1) 0.213
Swelling 176/248 (71.0) 67/86 (77.9) 0.261
Febrile sense 172/248 (69.4) 62/87 (71.3) 0.787
Dizziness, vestibular complaints 165/247 (66.8) 69/88 (78.4) 0.043
Dry mouth 160/246 (65.0) 55/88 (62.5) 0.698
Subjective cognitive dysfunction 151/248 (60.9) 58/87 (66.7) 0.370
Dry eye 147/248 (59.3) 58/88 (65.9) 0.310
Dyspepsia 143/248 (57.7) 52/87 (59.8) 0.801
Paresthesia 132/246 (53.7) 52/87 (59.8) 0.380
Non-cardiac chest pain 126/247 (51.0) 39/87 (44.8) 0.383
Dyspnea 108/247 (43.7) 42/88 (47.7) 0.535
Restless leg syndrome 111/248 (44.8) 38/87 (43.7) 0.901
Irritable bladder, female urethral syndrome 105/244 (43.0) 41/88 (46.6) 0.617
Esophagealdysmotility 103/247 (41.7) 36/88 (40.9) 1.000
Irritable bowel syndrome 96/248 (38.7) 40/88 (45.5) 0.312
Temporomadibular joint syndrome 92/247 (37.2) 32/87 (36.8) 1.000
Skin redness 77/246 (31.3) 37/88 (42.0) 0.088
Vasomotor rhinitis 77/246 (31.3) 32/88 (36.4) 0.427
Costochondritis 75/247 (30.4) 29/88 (33.0) 0.688
Syncope, neurally mediated hypotension 60/246 (24.4) 27/88 (30.7) 0.260
Swollen glands 61/247 (24.7) 21/88 (23.9) 1.000
Vulvodynia, vagismus 41/222 (18.5) 22/78 (28.2) 0.077
Reflex sympathetic dystrophy 43/247 (17.4) 9/88 (10.2) 0.125
Medications (%)      
Selective serotonin reuptake inhibitor 70/241 (29.0) 24/87 (27.6) 0.890
Serotonin norepinephrine reuptake inhibitor 47/241 (19.5) 12/87 (13.8) 0.259
Pregabalin 54/241 (22.4) 16/87 (18.4) 0.542
Gabapentin 10/241 (4.1) 3/87 (3.4) 1.000
Tricyclic antidepressant 93/239 (38.9) 42/85 (49.4) 0.097
Muscle relaxant 63/241 (26.1) 21/87 (24.1) 0.776
Non-steroidal anti-inflammatory drugs 119/241 (49.4) 58/87 (66.7) 0.006
Tramadol 98/241 (40.7) 37/87 (42.5) 0.800
Acetaminophen 3/241 (1.2) 7/87 (8.0) 0.004
Sedative-hypnotics 34/241 (14.1) 17/87 (19.5) 0.232
Benzodiazepine 47/241 (19.5) 12/87 (13.8) 0.259
Tender point number 14.0 (12.0, 18.0) 14.0 (11.0, 18.0) 0.394
Tender point count 27.0 (16.3, 36.0) 26.0 (15.0, 33.8) 0.280
Fibromyalgia Impact Questionnaire 61.6 (48.8, 74.3) 59.1 (41.2, 71.7) 0.261
Brief Fatigue Inventory 6.3 (5.0, 7.9) 6.7 (4.6, 8.0) 0.684
SF-36      
 Physical Functioning 37.0 (29.7, 42.3) 34.9 (27.6, 42.3) 0.367
 Role-Physical 34.8 (27.5, 42.2) 34.8 (27.5, 42.2) 0.834
 Bodily Pain 33.4 (29.2, 37.6) 33.4 (29.2, 41.4) 0.469
 General Health 29.3 (25.8, 35.3) 28.2 (23.4, 37.3) 0.853
 Vitality 30.2 (24.0, 39.6) 33.4 (24.0, 42.7) 0.101
 Social Functioning 35.0 (29.6, 45.9) 37.8 (29.6, 45.9) 0.887
Role-Emotional 32.6 (20.9, 44.2) 32.6 (21.9, 44.2) 0.342
 Mental Health 33.1 (24.7, 41.6) 33.1 (24.7, 43.7) 0.750
Physical Component Summary 36.0 (31.0, 40.6) 35.9 (30.4, 41.0) 0.616
Mental Component Summary 33.4 (24.4, 41.6) 34.0 (27.3, 41.3) 0.425
Beck Depression Inventory 18.0 (11.0, 25.0) 18.0 (10.3, 27.0) 0.862
State-Trait Anxiety Inventory I 48.0 (40.0, 57.0) 48.5 (41.8, 59.3) 0.491
State-Trait Anxiety Inventory II 50.0 (42.5, 57.0) 54.0 (45.3, 61.8) 0.032
Self efficacy 740.0 (550.0, 930.0) 700.0 (520.0, 875.0) 0.234
Social support family 39.0 (34.0, 45.0) 37.5 (34.0, 43.0) 0.397
Social support friend 36.0 (34.0, 42.0) 36.0 (33.0, 43.0) 0.651

Table 5: Comparison of clinical characteristics between primary and secondary fibromyalgia.

Comparison of clinical characteristics among patients with fibromyalgia in Korea and other countries

The frequencies of the various subjective symptoms in the present study and other Caucasian and Asian published series of FM patients were shown in Table 6 and 7. Korean patients with FM had fewer symptoms related to cognitive dysfunction and vulvodynia than Western (especially, German) patients (Table 6). Korean patients with FM had more symptoms related to restless leg syndrome, temporomadibular joint syndrome and skin redness than Western (especially, USA) patients (Table 6). Unrefreshing sleep, fatigue, stiffness, headache, and subjective swelling were more frequently found in Korean patients than in Caucasian and other Asian patients (Table 7).

  NFA cases (%) DFV cases (%) Korean cases (%) P value
(vs NFA)
P value
(vs DFV)
Fatigue 1028/2569 (40.0) 689/695 (99.1) 324/336 (96.4) <0.0001 0.0048
Unrefreshing sleep   679/692 (98.1) 312/336 (92.9)   0.0001
Generalized weakness   672/693 (97.0) 303/336 (90.2)   <0.0001
Stiffness   680/697 (97.6) 289/336(86.0)   <0.0001
Tension headache 1207/2569 (47.0) 634/693 (91.5) 271/336 (80.7) <0.0001 <0.0001
Swelling   623/687 (90.7) 243/334 (72.8)   <0.0001
Febrile sense   559/685 (81.6) 234/335 (69.9)   <0.0001
Dizziness, vestibular complaints 1156/2569 (45.0) 642/695 (92.4) 234/335 (69.9) <0.0001 <0.0001
Dry mouth   614/694 (88.5) 215/334 (64.4)   <0.0001
Subjective cognitive dysfunction   667/691 (96.5) 209/335 (62.4)   <0.0001
Dry eye   575/685 (83.9) 205/336 (61.0)   <0.0001
Dyspepsia 1028/2569 (40.0) 505/689 (73.3) 195/335 (58.2) <0.0001 <0.0001
Paresthesia 1130/2569 (44.0) 621/694 (89.5) 184/333 (55.3) 0.0001 <0.0001
Non-cardiac chest pain   544/689 (79.0) 165/334 (49.4)   <0.0001
Dyspnea     150/335 (44.8)    
Restless leg syndrome 822/2569 (32.0)   149/335 (44.5) <0.0001  
Irritable bladder, female urethral syndrome 668/2569 (26.0) 457/689 (66.3) 146/332 (44.0) <0.0001 <0.0001
Esophagealdysmotility     139/335 (41.5)    
Irritable bowel syndrome 1130/2569 (44.0) 485/680 (71.3) 136/336 (40.5) 0.2468 <0.0001
Temporomadibular joint syndrome 745/2569 (29.0)   124/334 (37.1) 0.0029  
Skin redness 642/2569 (25.0)   114/334 (34.1) 0.0005  
Vasomotor rhinitis 951/2569 (37.0)   109/334 (32.6) 0.1308  
Costochondritis     104/335 (31.0)    
Syncope, neurally mediated hypotension     87/334 (26.0)    
Swollen glands     82/335 (24.5)    
Vulvodynia   532/656 (81.1) 63/300 (21.0)   <0.0001
Reflex sympathetic dystrophy     52/335 (15.5)    
Lower back pain 1619/2569 (63.0) 692/695 (99.6)      
Arthritis 1182/2569 (46.0)        
Muscle spasm 1182/2569 (46.0) 458/683 (67.1)      
Tingling 1182/2569 (46.0) 621/694 (89.5)      
Tinnitus 771/2569 (30.0) 575/694 (82.9)      
Depression 1028/2569 (40.0) 596/690 (86.4)      
Anxiety 976/2569 (38.0) 606/696 (87.1)      

Table 6: Comparison of FM symptoms in NFA and DFV cases with those in Korean cases.

  Caucasian cases (%) Asian cases (%) Korean cases (%) P value
(vs Caucasian)
P value (vs Asian)
Widespread pain 700/777 (90.1) 72/80 (90.0) 336/336 (100.0) <0.0001 <0.0001
Unrefreshing sleep 625/879 (71.1) 54/80 (67.5) 312/336 (92.9) <0.0001 <0.0001
Fatigue 684/777 (88.0) 69/80 (86.3) 324/336 (96.4) <0.0001 0.0017
Stiffness 182/241 (75.5) 37/50 (74.0) 289/336 (86.0) 0.0031 0.0482
Anxiety 507/777 (65.3) 48/80 (60.0)      
Headache 513/879 (58.4) 49/80 (61.3) 271/336 (80.7) <0.0001 0.0002
IBS 376/879 (42.8) 34/80 (42.5) 136/335 (40.5) 0.3777 0.7155
Subjective swelling 471/879 (53.6) 12/30 (40.0) 243/334 (72.8) <0.0001 0.0003
Numbness, paresthesia 419/856 (48.9) 52/80 (65.0) 184/333 (55.3) 0.0729 0.1346
Mental stress 416/649 (64.1) 13/30 (43.3)      
Depression 251/649 (38.7) 11/30 (36.7) 89/335 (26.6) 0.0002 0.3379
Dysmenorrhea 45/113 (39.8) 15/30 (50.0)      
Raynaud-like sx 21/55 (38.2) 13/50 (26.0)      
Often feeling cold 43/55 (78.2)        
Nausea 25/55 (45.5)        
Vertigo 26/55 (47.3)   234/335 (69.9) 0.0014  
Subjective feeling of muscle tension 42/55 (76.4)        
Siccasx   36/50 (72.0) 215/334 (64.4)   0.3434

Table 7: Comparison of FM symptoms in Caucasian and Asian cases with those in Korean cases.

Discussion

The results of this study are from 336 patients and from 10 medical centers all over the country. This is the first report of clinical characteristics of Korean patients with FM. Although chronic widespread pain was the dominant symptom, patients with FM also experienced multiple symptoms in addition to pain. The most commonly reported symptoms were fatigue, unrefreshing sleep, generalized weakness, stiffness, tension headache, swelling, febrile sense, and dizziness. The range of FM symptoms in the Korean population are similar to the Western population [3,14,15]. The economic impact of FM on employment was also notable, with current employment 32.9% which was corroborated by others (22~67%, average 40%) [14]. It took an average of 2 years before receiving a diagnosis of FM. The diagnosis of FM is delayed. Patients wait a significant period of time before presenting to a physician, adding to the prolonged time to diagnosis. Helping clinicians to diagnose patients with FM should benefit both patients and funders of healthcare.

Commonly used medications for FM, as reported by the clinicians, were NSAID, TCA, tramadol, SSRI, and muscle relaxant in descending order of frequency. Pregabalin, SNRI, benzodiazepine, sedativehypnotics, and gabapentin etc were used above this. Pregabalin prescription rate was relatively low because in that time (early phase of patients enrollment) there was no approval to prescription of pregabalin for FM by Korea Food and Drug Administration.

The frequencies of the various subjective symptoms in the present study and other Caucasian and Asian published series of FM patients [16-25] seem fairly identical as shown in Table 6 and 7. However, the frequencies of the various subjective symptoms in USA (National Fibromyalgia Association, NFA) study [3] were much less than ours (Table 6). The surveyed NFA population was self-selected as people with FM who had Internet access and was familiar with the NFA website. Approximately 70% of the respondents mentioned that they obtained information about FM from the website. It is possible that those familiar with NFA differ in important ways from people with FM in general. They were not personally interviewed or formally diagnosed. Thus an unknown proportion of those responding may not have met 1990 ACR classification criteria for a diagnosis of FM [2]. In addition, only some 60 percent of them took medications, which suggest they had less severe symptoms than our patients. Our all patients, on the other hand, met 1990 ACR classification criteria for a diagnosis of FM [2], which means their symptoms were severe and frequently appeared.

Furthermore, the frequencies of the various symptoms in German (German Fibromyalgia Association, GFA) study [25] were much more than ours (Table 6). The terminology of symptoms in GFA study is more of a ordinary person’s expression than a medical term. In addition, that terminology was not defined in that study. On the other hand, the symptoms and sign were defined by glossary before study enrollment and patients were personally interviewed in our study. It might be the reason why the frequencies of the symptoms in GFA study were different from ours.

The other Caucasian studies were tried in USA (16-19), Sweden (20), Denmark [21] and Israel [22] etc. Asian studies were tried in Japan [23] and Bangladesh [24]. Variation of the prevalence of the each symptom may depend on different classification criteria, different definitions of the symptoms and sign, actual patient differences or various biases in the studies. In particular, a large variation is seen for the percentage of patients complaining of unrefreshing sleep, fatigue, stiffness, headache, and subjective swelling, with the highest frequencies obtained in this study (Table 7). The frequencies of the various subjective symptoms in our study and German study were much more than USA (Table 6). That is the most likely explanation why pregabalin and SNRI (e.g., milnacipran) were not usual prescription for FM in 2 countries on that time (from 2007 till 2008).

Several limitations of this study should be considered. First, although the study was open to women and men, the majority of people enrolled in the study were women. Although the majority of people diagnosed with FM are women, future studies should include men in order to assess any variance in symptoms experienced by men or any differences in the way that FM impacts the lives of men. Second, patients were recruited by the investigators and were required to be able to participate in this study and therefore may not be representative of all Korean patients with FM. Finally, while the size of the groups allowed for an intensive survey and tender point examination, confirmatory information with a larger population of patients is needed. However, the strengths of this study may be summarized as follows. First, the symptoms and sign were defined by glossary before study enrollment. Similar studies of clinical feature used the terminology on symptoms and sign without definite glossary. Second is a comparison between Korea and other countries. Several differences were found between the Korean and the other countries patients with FM in the clinical features. Further study will be needed to clarify whether these differences arise from racial factor(s).

We found that the range of FM symptoms in the Korean population are similar to the Western population. A comprehensive assessment of the multiple symptoms domains associated with FM and the impact of FM on multidimensional aspects of function should be a routine part of the care of FM patients.

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Review summary

  1. Daniel Miller
    Posted on Aug 30 2016 at 11:58 am
    The article shows the clinical characteristics of Korean patients with fibromyalgia. The interesting finding is that the author has tried to compare the clinical characteristics of Korean patients with those of Western population. This article is the first report of the clinical fibromyalgia (FM) characteristics in a relative large Korean population. A variety of the parameters specifying FM, such as typical symptoms, stressors, tender points, fatigue, are summarized and compared with those in western countries. Overall, this article has significant value for further investigation of FM diseases in a large scope, particularly in Korean.
 

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