Central sensitization in fibromyalgia?

A systematic review on structural and

functional brain MRI: A Summary
Rehabilitation sciences and physiotherapy researchers at several Belgium
universities worked together to explore the effects of pain sensitization of musculoskeletal
disorders like fibromyalgia (FM) on both the central brains structure and degree of
functionality. The disease is marked by both amplified pain sensitization (hyperalgesia) and
translation of non-painful stimulation into central nervous system (CNS) pain sensitization
(allodynia). FMs CNS hyperexcitability prompted the increased use of non-invasive
imaging procedures to map changes to the brain and elsewhere in response to the diseases
characteristic chronic pain effect. A non-invasive neuroimaging method includes voxel-
based morphometry, which changes in brain volume by using statistical tools for
comparison. Other techniques like functional magnetic resonance imaging (fMRI) and
resting-state functional magnetic resonance imaging (rs-fMRI) have also quantified
changes to the brain for such chronic pain patients.
Pain in Motion research group, University of Antwerp researchers, and Ghent
university parsed through articles pulled from medical electronic databases: PubMed and
Web of Science. NIHs controlled medical subject headings and evidence-based models
guided the use of specific search terms like FM for patient population; structural and
functional MRI for diagnostic instrument; central sensitization (among other variants) for
outcome measures. Two physiotherapists led the article review. Moreover, the Dutch
Cochrane Centres online checklist for research quality control was implemented to
evaluate the studies chance for bias in areas like patient group description, control group
description, selection bias, exposure, confounders, etc.
The search query yielded a narrowed dataset of 52 references and nine articles of
which only 22 studies were used for final qualitative analysis, which had full agreement by
both the article reviewers. Evidence tables were produced to compare each studies patient
group composition, control group composition, main findings, and ancillary remarks.
Unfortunately, some of the studies lacked pertinent information relating to age and gender
of the patient groups. In terms of their findings, some studies found no difference in global
gray matter density between patient and control groups; others established significant
brain volume and cortical thickness differences for fibromyalgia patients experiencing
prolonged chronic pain episodes.
According to the qualitative review, unchanged global gray matter volume; gray
matter atrophy in the anterior cingulate cortex, insula, thalamus, pons, left precuneus, etc.;
higher neuronal activity and more pain upon equal pressure stimulus; extended pain
perception upon nociceptive stimulation by injection; and temporal brain activation in FM
patients. Further evaluation is needed to examine larger populations of as well as
mechanisms behind the CS pain processing activity of FM patients.
Fibromyalgia: an update for oral health care providers? A Summary
Fibromyalgia (FM) patients experience chronic pain from a disorder once classified
as a musculoskeletal disease. As part of a large family of pain disorders, FM can present
symptoms globally in patients, and, as a result, dentists and other oral health care
providers can play a role in recognizing and diagnosing FM in their patients suffering from
chronic care. The potential for increased diagnostic help by dental professionals may prove
to be a healthcare management boon as fibromyalgia affects up to 5% of the U.S.
population, targeting females nine times higher than males.
Dental professionals ought to be versed in the FM classification criteria outlined by
the American College of Rheumatology (ACR). FM patients typically present with pain for
more than 3 months globally around their body in areas defined, but not limited to,
diagnostic tender points: medial fat pad of knee, muscle areas posterior to greater
trochanter, upper border of trapezius, muscle insertion area into occiput, etc. Specifically, if
upon external pressure or palpation, the patient experiences tenderness or signs of
allodynia, stipulations defined by ACR may be fulfilled in diagnosing FM. Unfortunately,
FMs etiology is not known. However, recent research has shown FM patients presenting
with neuroendocrine dysfunction in areas like the sympathoadrenal system and the HPA-
axis, as well as serotonin, norepinephrine, and adenosine triphosphate level abnormalities.
Furthermore, nearly 33% of FM patients exhibited lowered blood pressure and increased
syncope episodes; moreover, other FM patients presented with nighttime sympathetic
tone, which may be a response to decreased inhibitory neuronal pathways. Also, FM sera
exhibit abnormal quantities of growth hormone, tryptophan, serotonin, substance P,
cytokine, interleukin-6, etc. FM patients characterize their symptoms as diffuse, deep,
throbbing, or stabbing; other FM patients may experience sleep disturbances, dizziness,
fatigue, IBS, dysmenorrhea, stiffness, fever, swollen glands, dry eyes, non-restorative sleep,
chest pain mimicking angina pectoris, etc. Comorbidities include IBS, chronic fatigue
syndrome, temporomandibular disorder, chronic headaches, lower back pain, and
interstitial cystitis.
Upon assessing and c confirming these clinical signs, dental professionals need to
place a referral to a rheumatologist or a rehab physician for further management and
treatment. In terms of non-medical areas affected or related to the disease, dentists should
also be aware that many FM patients have a lower socioeconomic status and may hold
stigma upon disease diagnosis. For treatment options, tricyclic antidepressants, selective
serotonin reuptake inhibitors like fluoxetine; serotonin-norepinephrine reuptake
inhibitors like duloxetine; muscle relaxants like cyclobenzaprine; anticonvulsants like
pregabalin; analgesics like tramadol; cognitive behavior therapy; herbal supplements like
ginseng and melatonin; and transcranial direct current stimulation may be prescribed for
chronic care management.
Dentists need to be aware that FM primarily presents as the temporomandibular
disorders (TMD); headaches; and oral complaints. TMDs (excluding internal
temporomandibular joint derangements) like masticatory myalgia and joint pain may be
signs of FM. Distinguishing between trauma-related TMD and FM-related TMD must be
practiced by oral health care professionals. Treatment options for TMD in FM patients need
to be conservative as little research has been conducted in this area of chronic pain care.
Moreover, dentists should be aware of nonspecific headaches like migraines or tension-
type headaches. Onset of headaches, duration of headaches, consequential analgesic use,
etc. need to be explored with the patients. Furthermore, other oral complaints by patients
potentially with FM include xerostomia (dry mouth); glossodynia (oral burning); and
dysgeusia (taste distortion). A table of dental considerations outlines points dentists need
to cover in visits like preoperative considerations such as medical history, oral complaint
history, and orofacial pain and headache complaints. Intraoperative considerations include
TMD presentation. Postoperative points of considerations include persistence of jaw pain,
in which case opioid analgesics, macrolide antibiotics, and NSAIDs may need to be
prescribed depending on the primary line of medication (e.g. TCAs or SSRIs).