ww w . r e u m a t o l o g i a . c o m . b r
REVISTA
BRASILEIRA
DE
REUMATOLOGIA
Review
article
Prevalence
of
fibromyalgia:
literature
review
update
Amelia
Pasqual
Marques,
Adriana
de
Sousa
do
Espírito
Santo,
Ana
Assumpc¸ão
Berssaneti,
Luciana
Akemi
Matsutani,
Susan
Lee
King
Yuan
∗UniversidadedeSãoPaulo(USP),FaculdadedeMedicina,DepartamentodeFisioterapia,FonoaudiologiaeTerapiaOcupacional,São Paulo,SP,Brazil
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t
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e
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f
o
Articlehistory:
Received29March2016 Accepted25October2016 Availableonline8February2017
Keywords:
Fibromyalgia Prevalence Review
Rheumaticdiseases Chronicpain
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Thepresentstudyaimedtoupdatetheliteraturereviewontheprevalenceoffibromyalgia publishedin2006.Abibliographicalsurveywascarriedoutfrom2005to2014intheMEDLINE, WebofScience,Embase,LILACSandSciELOdatabasesand3274recordswereidentified. Fiveresearchersselectedthestudies,followingtheinclusioncriteria:studiesthatobtained theprevalenceoffibromyalgia.Fibromyalgiastudiesinassociateddiseaseswereexcluded. Whenscreeningbytitleandabstract,2073irrelevantarticleswereexcluded.Thefulltextsof 210articleswereevaluatedforeligibilityandthisreviewincluded39studies,describedin41 articles.Theselectedstudiesweregroupedintofourcategories:(A)prevalenceof fibromyal-giainthegeneralpopulation;(B)prevalenceoffibromyalgiainwomen;(C)prevalenceof fibromyalgiainruralandurbanareas;(D)prevalenceoffibromyalgiainspecialpopulations. Theliteratureshowsvaluesoffibromyalgiaprevalenceinthegeneralpopulationbetween 0.2and6.6%,inwomenbetween2.4and6.8%,inurbanareasbetween0.7and11.4%,in ruralareasbetween0.1and5.2%,andinspecialpopulationsvaluesbetween0.6and15%. Thisliteraturereviewupdateshowsasignificantincreaseinfibromyalgiaprevalence stud-iesintheworld.Thenew2010AmericanCollegeofRheumatologycriteriahavenotbeen widelyusedyetandtheCOPCORD(Community-orientedprogramforcontrolofRheumatic Diseases)methodologyhasincreasedthequalityofstudiesontheprevalenceofrheumatic diseasesingeneral.
©2017ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗ Correspondingauthor.
E-mail:[email protected](S.L.Yuan).
http://dx.doi.org/10.1016/j.rbre.2017.01.005
A
prevalência
de
fibromialgia:
atualizac¸ão
da
revisão
de
literatura
Palavras-chave:
Fibromialgia Prevalência Revisão
Doenc¸asreumáticas Dorcrônica
r
e
s
u
m
o
Opresenteestudotevecomoobjetivoatualizararevisãodeliteraturasobreaprevalênciada fibromialgiapublicadaem2006.Foirealizadolevantamentobibliográficodoperíodode2005 a2014nasbasesdedadosMEDLINE,WebofScience,Embase,LILACSeSciELO, identificando-se3274registros.Cincopesquisadoresselecionaramosestudos,deacordocomoscritérios deinclusão:estudosqueobtiveramaprevalênciadafibromialgia.Foramexcluídos estu-dosdafibromialgiaemdoenc¸as.Natriagempelotítuloeresumo, foramexcluídos2073 artigosirrelevantes.Foramavaliadosquantoàelegibilidadeostextoscompletosde210 arti-gos,incluindo-senestarevisão39estudos,descritosem41artigos.Osestudosselecionados foramagrupadosemquatro categorias:a)prevalênciadafibromialgianapopulac¸ãoem geral;b)prevalênciadafibromialgiaemmulheres;c)prevalênciadafibromialgiaemáreas ruraiseurbanas;d)prevalênciadafibromialgiaempopulac¸õesespeciais.Aliteraturaaponta valoresdeprevalênciadafibromialgianapopulac¸ãoemgeralentre0,2e6,6%,emmulheres valoresentre2,4e6,8%,nasáreasurbanasentre0,7e11,4%,nasruraisentre0,1e5,2%, eem populac¸õesespeciaisvaloresentre0,6e15%.Estaatualizac¸ãoderevisãode liter-aturamostraumaumentoexpressivodeestudosdeprevalênciadafibromialgiaaoredor domundo.OsnovoscritériosdoColégioAmericanodeReumatologiade2010foramainda poucoutilizadoseametodologiaCOPCORD(ProgramaOrientadoparaaComunidadepara ControledeDoenc¸asReumáticas)aumentouaqualidadedosestudosdeprevalênciade doenc¸asreumáticasemgeral.
©2017ElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCC BY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Fibromyalgia(FM)isachronicpainsyndromewithacomplex, multifactorial and not completely known etiopathogenesis that affects mainly women, being characterized by gener-alized musculoskeletal pain and palpation-specific tender points,oftenassociatedwithsleepdisorders,fatigue,somatic andcognitivesymptoms,aswellaspsychicdisorders.1,2
WepublishedourfirstliteraturereviewonFMprevalence in2006,intheBrazilianJournalofRheumatology.3Duringthe
periodof1990–2005, theFMprevalencefoundinthe popu-lationrangedbetween0.7and4.4%,beingmoreprevalentin womenthan inmen.Itwaspossibletoconstructfive cate-goriesaccordingtostudysimilaritypatterns:prevalenceofFM inadultpopulations;prevalenceofFMinwomen;prevalence ofFMinchildrenandadolescents;prevalenceofFMinspecific populationsand;prevalenceofchronicanddiffusepaininthe population,accordingtotheAmericanCollegeof Rheumato-logy(ACR)criteriaof1990.4Weobservedthatmoreprevalence
studieswerenecessary.
Afteralmostadecade,itisnecessarytoupdatethe litera-turereviewonFMprevalence,aimingtoknowthenewstudies onthistopic,especiallyafterthepublicationin2010ofthenew ACRfibromyalgiadiagnosticcriteria.2
Methods
Thisliteraturereviewupdatewascarriedout withan elec-tronicsearchintheMEDLINE,LILACS,Embase,WebofScience
andSciELOdatabases,from2005to2014.Thekeywordsused were “fibromyalgia” and “prevalence” and the correspond-ingwordsinPortuguese,“fibromialgia”and“prevalência”.A searchwasalsocarriedoutbasedonthelistofpublications availableonthewebsiteoftheCommunity-OrientedProgram forControlofRheumaticDiseases’(COPCORD),aninitiativeof theInternationalLeagueofRheumatologyAssociations.
Atotalof3274articleswerefound,and992wereexcluded, astheywereduplicates.Fivephysicaltherapistswithclinical and research experience infibromyalgia selectedthe stud-iesaccordingtotheinclusioncriteria:cross-sectionalstudies that obtainedthe prevalenceoffibromyalgiainthegeneral populationandinspecificpopulations,forinstance,women, children, adolescents and the elderly. Theexclusion crite-rionwasstudiesthatobtainedtheprevalenceoffibromyalgia associatedwithotherdiseases.Whenscreeningbytitleand abstract,2073articleswereexcludedfromthisreview.Thefull textsof210articleswereassessedforeligibility.Attheend, 39studies,described in41articles(Fig.1),wereincludedin thisreview.
Eachresearchercarried out the selectionprocess ofthe studiesindividuallyandtwomeetingswereheld:oneafterthe screeningandanotherafterapplyingtheeligibilitycriteriato jointlydefinethearticlestobeincluded.
Records after removal of duplicates (n=2282) Records identified at the electronic search (n=3273)
Additional records identified from other sources (n=1)
Full-text articles evaluated regarding eligibility (n=210)
Full-text articles included (n=41)
Studies included in the qualitative synthesis (n=39)
Records excluded after screening (n=2073)
Unavailable full-text articles (n=3)
Excluded articles (n=166) SciELO (n=33)
WOS (n=1036) LILACS (n=45)
Embase (n=1189) MEDLINE (n=970)
Fig.1–Flowchartoftheselectionoffibromyalgiaprevalencestudies.
(ofoverall FMprevalence,partialandstratified);Discussion (limitations);Contact(email).
Results
and
discussion
Inthisupdatedsearch,therewasasignificantincreaseinFM prevalencestudies,asweobtainedmorethantwicethe num-berofstudiesincludedinthefirstreview.3Onlyfourrecent
studies used the new 2010 ACR diagnostic criteria and/or itsmodifiedversionforepidemiologicalstudies.5–8Intwelve
studies, the method used was based on the standardized
high-qualityprotocolanddesignrecommendedbyCOPCORD (Fig.2).9–20
The selected articles were carefully grouped into four categories: (A) prevalence of FM in the general popula-tion; (B) prevalenceofFMin women; (C)prevalenceofFM in rural and urban areas; (D) prevalence of FM in special populations.
Prevalenceoffibromyalgiainthegeneralpopulation
InthecategoryPrevalenceofFibromyalgiaintheGeneral Pop-ulation,19articleswerefound.Ofthese,tworeportedonthe prevalenceinNorthAmerica,oneinCentralAmerica,twoin
BRA: 2.0%
VEN: 0.2%
CUB: 0.2% MEX: 0.7–0.8%
SPA: 2.3–2.4% FRA: 1.4–5.4%
SCO: 1.2–5.4% HOL: 1.3%
GER: 0.5–5.8% ITA: 2.2–6.6%
TUR: 8.8%
LEB : 1.0%
IND: 0.05%
MAL: 0.9% CHI: 0.8%
JAP: 2.1% IRA: 2.3%
USA: 1.1–6.4% POR: 3.6%
Table1–Prevalenceoffibromyalgiainthegeneralpopulation.
Reference Country Sample FMdiagnosticcriteria Prevalence
Salaffi(2005)21 Italy n=3664
>18years
ACR1990 2.22%
Scudds(2006)22 China n=1467
18–65years
ACR1990 0.82%
Veerapen(2007)14 Malaysia n=2594
>15years
Unspecified Overall:0.92%
F:0.8%/M:0.08%
Loza(2008)23 Spain n=2192
>20years
ACR1990 2.4%
Reyes-Llerena(2009)13 Cuba n=3155 Unspecified 0.22%
Branco(2010)24,25 France,Italy,Germany,
SpainandPortugal
n=4517 >15years
LFESSQ-4andLFESSQ-6 LFESSQ-4:4.7%
LFESSQ-6:2.9%
Creavin(2010)26 Netherlands n=2447
>18years
Self-report 1.3%
Sauer(2010)27 Germany n=1.646.284 CID-10:M79.7indatabases Overall:0.45%
F:0.4%/M:0.05% Peláez-Ballestas
(2011)12,28
Mexico n=19,213
>18years
ACR1990 Overall:0.68%
F:1%/M:0.34%
Perrot(2011)29 France n=3326
>18years
LFESSQandACR1990 1.6%
Chaaya(2012)9 Lebanon n=3530
15–90years
ACR1990 Overall:1%
F:2%/M:0%
Goren(2012)30 Brazil n=12,000
>18years
Self-report 2%
Jones(2013)5 Scotland n=1604
>25years
ACR1990,ACR2010and modifiedACR2010
ACR1990:1.7%/ACR2010:1.2% ACR2010mod:5.4%
Sandoughi(2013)11 Iran n=2700
>15years
Unspecified Overall:2.31%
F:3.66%/M:0.9%
Vincent(2013)7 USA n=2994
>21years
ModifiedACR2010 6.4%
Wolfe(2013)8 Germany n=2515
≥15years
ModifiedACR2010 2.1%
Granados(2014)10 Venezuela n=3973
>18years
ACR1990 0.2%
Nakamura(2014)6 Japan n=20,407
>20years
ACR2010 2.1%
FM,fibromyalgia;ACR,AmericanCollegeofRheumatology;LFESSQ,TheLondonFibromyalgiaEpidemiologyStudyScreeningQuestionnaire;F, female;M,male.
SouthAmerica,eightinEuropeandfiveinAsia.Thelowest overallprevalencewas0.2%inVenezuela,10andthehighest
was6.4%intheUnitedStates.7Thehighestprevalencevalues
werefoundintwoarticlesthatusedthemodifiedACR crite-riaof2010:6.4%inaprevalencestudyinaspecificregionof theUnitedStates7and5.4%inastudyinScotland.5Overall,
excludingthesestudies,prevalencerangedfrom0.2%to4.7% (Table1).
Prevalenceoffibromyalgiainwomen
FMiscommonlymoreprevalentamongwomen.31The
preva-lence of FM in studies carried out in the adult female populationrangedbetween2.4%and6.8%.Fourstudieswere found,halfofthemfromTurkey32,33andtheotherhalffrom
Norway.34,35 BotharticlesontheTurkishpopulationstudied
samplesofwomenfromthesamecity ofTrabzon.Thetwo articlesontheNorwegianpopulationarebasedondatafroma largehealthcarestudycarriedoutintheNord-Trøndelag dis-trict,withseveralcharacteristicsofwomenresiding inthat district,inadditiontoFM.Possibly,forthisreason,the preva-lencevalueswereclose(2.4%and2.6%).
Themethodologicaldifferenceofthestudieswasthe cri-terionusedtoidentifyFM.IntheNorwegianstudies,women wereaskedwhethertheyhadeverbeendiagnosedwithFM. InTurkey,womenwereevaluatedbyaresearcherphysician followingthe 1990ACRcriteria atthetime ofthe research (Table2).
Prevalenceoffibromyalgiainurbanandruralareas
Sincetheacknowledgmentofthefibromyalgiasyndrometo thepresentday,oneofthequestionsofthescientific commu-nityistheunderstandingoffactorsthatareimplicatedinits onset.36Socio-economic-culturalfactorsarebelievedtohave
aninfluenceonitsprevalence.37Inthisrespect,someauthors
havechosenadivisionregardingwherepeoplelive:urbanand ruralareas.
Amongthenineselectedstudies,sixshowed geographi-calproximity(Iran,15,18Turkey,38India,16Bangladesh17,39),and
fiveofthemusedtheCOPCORDmethodology.15–19
Table2–Prevalenceoffibromyalgiainwomen.
Reference Country Sample FMdiagnosticcriteria Prevalence
Topbas(2005)32 Turkey n=1930
20–64years
ACR1990 3.6%
Cakirbay(2006)33 Turkey n=1045
18–55years
ACR1990 6.8%
Mork(2010)34 Norway n=15,990
>20years
Self-reportofmedicaldiagnosis 2.4%
MorkeNilsen(2012)35 Norway n=12,350
>20years
Self-reportofmedicaldiagnosis 2.6%
FM,fibromyalgia;ACR,AmericanCollegeofRheumatology.
beatendencyfortheruralareatopresentahigherprevalence thantheurbanarea,especiallyinstudiesthatevaluatedboth regions.
Prevalenceoffibromyalgiainspecialpopulations
Table4showsthestudiesonfibromyalgiaprevalenceinspecial populations.Workersfromsevendifferenthealthinstitutions wereinvitedtoparticipateintheTodastudy,butthesampling
processwasnotclearlydescribed.Sevenwomenandonlyone manmettheFMclassificationcriterion.42
Eiygor et al. invited all 322 medical students from the School ofMedicine of Ege University to participate in the study,ofwhich11refusedtoparticipateand5wereexcluded. SixsubjectsmettheFMclassificationcriteria,withaslightly higherprevalenceinwomenthanmen.43
Assumpc¸ãoetal.recruitedbytelephonesubjectsfromalist of2269registeredusersofbasichealthunitsthathadacontact
Table3–Fibromyalgiaprevalencestudiesinurbanandruralareas.
Reference Country Samplecharacteristics FMdiagnosticcriteria Prevalence
Urban×rural
Mas(2008)40 Spain Both n=2192
>20years
ACR1990 Rural:4.1%
Urban:1.7% Overall:2.37%
Turhanoglu(2008)38 Turkey Both n=600
>20years F:51%
ACR1990 Rural:5.2%
Urban:11.4% Overall:8.8% F:12.5%/M:5.1% JoshieChopra
(2009)16
India Both n=8145
>16years F:50.8%
ACR1990 Rural:3.77%
Urban:1.2% Overall:0.05% Rodriguez-Amado
(2011)19
Mexico Both n∼5000
>18years
ACR1990 Rural:1.3%
Urban:0.7% Overall:0.8%
Haq(2005)17 Bangladesh Both n=2601rural+1307urban
slum+1252emergingurban >15years
F:98%rural,85%urbanslum and82%emergingurban
ACR,yearnot described
Rural:4.4%(F:7.5%/M: 1.2%)
Urbanslum:3.2%(F: 5.3%/M:1.4%) Emergingurban:3.3% (F:5.8%/M:3.3%) Alvarez-Nemegyei
(2005)41
Mexico Rural n=761
>18years F:49.8%
ACR1990 Rural:1.3%
Davatchi(2008)14 Iran Urban n=10,291
>15years F:52.6%
Notdescribed Urban:0.69%
Davatchi(2009)15 Iran Rural n=1565
>15years F:55.1%
ACR1990 Rural:0.06%
Masudul-Hassan (2012)28
Bangladesh Rural n=5217
F:52%
ACR,yearnot described
Rural:3.95%
Table4–Prevalenceoffibromyalgiainspecialpopulations.
Reference Country Sample FMdiagnosticcriteria Prevalence
Type Characteristics
Toda(2007)41 Japan Healthcareworkers n=539
F:63.6%
ACR1990 Overall:1.48%
F:2.04%/M:0.51%
Eyigor(2008)16 Turkey Medicalstudents n=306
F:62.4%
ACR1990 Overall:2%
F:2.1%/M:1.7%
Assumpc¸ão(2009)4 Brazil Lowsocioeconomic
level
n=768 35–60years F:77%
ACR1990 4.4%
Buskila(2009)7 Israel Serioustraincrash
survivors
n=53
≥18years
ACR1990 15%
Davatchi(2009)15 Iran Caucasiansand
Turks
n=7445
Caucasians+2846 Turks
≥15years
Notdescribed Caucasians:0.6%
Turks:0.7%
Santos(2010)38 Brazil Elderly n=361
≥65years
F:64%
ACR1990 5.5%
Cobankara(2011)11 Turkey Textileworkers n=655
F:81.2%
ACR1990 Overall:7.3%
F:9%/M:0.8%
Kim(2012)24 SouthKorea Primarycarecenter
users
n=1077 18–80years F:52.1%
Clinicaldiagnosisor ACR1990
ACR1990:1.7%(F: 2.9%/M:0%).
Clinical:2.3%(F:3.9%/M: 0.6%).
FM,fibromyalgia;ACR,AmericanCollegeofRheumatology;F,female;M,male.
telephonenumberinthecityofEmbudasArtes,stateofSao Paulo,Brazil.Ofthenon-probabilisticsampleof768contacted individuals,only304agreedtotheclinicalexamination.Based onaBayesiananalysis,a4.4%FMprevalencewasestimated usingthelargersample.44
In2008,Buskilaetal.sentmailinvitationsto153survivors ofthe2005traindisasterinIsrael,ofwhich115respondedand only53agreedtoparticipateinthestudy.Eightwomenmet theFMclassificationcriteria.45
Davatchietal.carriedoutthestudyin22districtsofTehran, followingthe COPCORD projectmethods. Of 10,291people interviewed,71.4% wereCaucasians and 23.1% were Turks. Therewasnostatisticallysignificantdifferencebetweenthe ethnicgroupsregardingtheprevalenceofFM.20
Basedonasamplecalculation, Santoset al.invited400 individuals(9 refusedto participateand 30 were excluded) fromasampleof2072subjectsfromthecross-sectionalstudy “SaoPauloAging&HealthStudy”,carriedoutwithallelderly residentsof66censussectorswiththelowestHuman Devel-opmentIndexesofthedistrictofButantã.Twentywomenmet theclassificationcriteriaintheFMprevalencestudy.46
Inapopulationof16,383textileworkersintheindustrial regionofthecityofDenizli,Cobankaraetal.neededtorecruit 585subjects,accordingtothesamplecalculation.Oftentextile mills,theyrandomlyselectedfourwith655workers,ofwhich nonerefusedtoparticipateinthestudy.Forty-eightsubjects withFMwerediagnosed,withtheprevalencebeinghigherin womenthaninmen.47
Kimet al.recruited all1158individuals who visitedthe FamilyMedicineCenteratKangbukSamsungHospitalfrom ApriltoMay2010.Thirty-fivesubjectsrefusedtoparticipate, while46wereexcluded,astheyrespondedinadequatelytothe evaluationquestionnaires.The1990ACRclassificationcriteria
weremetby18women,whileagreaternumberof25subjects (22womenand3men)were obtainedbasedontheclinical diagnosis.48
Theresultsofstudiesinwhichthesamplingprocedureor thecriteriausedforFMdiagnosiswerenotadequateshould beanalyzedwithcaution.Therateofrespondentsand non-respondents shouldbe described and bewithinacceptable valuestoconfirmthevalidityoftheprevalencedata.49
Practicalimplications
This reviewcan contributetothe implementation of diag-nosticguidelinesandrecommendationsforthetreatmentof fibromyalgia,updatinghealthprofessionals,aswellas stimu-latingfutureprevalencestudies.
Studylimitations
Thelimitations foundwere:inclusion ofarticleswrittenin PortugueseandEnglishonlyand,despiteattemptstocontact theauthors,threeoftheselectedarticlescouldnotbeincluded becausethefulltextcouldnotbefound.
Conclusion
COPCORDmethodologyincreasedthequalityofstudiesonthe prevalenceofrheumaticdiseasesingeneral.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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