Introduction
Fibromyalgia (FM) is defined as a “syndrome of central sensitisation
with dysfunction of the neuronal circuits involved in the perception,
transmission and processing of nociceptive afferents, with pain
predominantly expressed in the musculoskeletal
system”1. It is an incurable syndrome of unknown
origin with signs and symptoms often similar and overlapping with those
of other syndromes. This condition, unfortunately with high frequency,
delays its diagnosis. The pathogenetic mechanism underlying the clinical
picture is alteration of the nociceptive system.
Several hypotheses have been
proposed concerning the pathogenesis of FM and the management of FM
patients requires a multidisciplinary approach.
Accumulating evidence suggests that hyperbaric oxygen therapy (HBOT) is
a non-invasive modality with lasting efficacy to treat
FM2. HBOT is defined by the Undersea and Hyperbaric
Medical Society (UHMS) as a treatment in which a patient intermittently
breathes 100% oxygen while the treatment chamber is pressurised to
above sea level pressure (1 atmosphere absolute, 1 ATA = 760
mmHg)3. HBOT is able to induce many interesting
effects on plasma oxygen concentration. Based on Henry’s Law, increased
pressure will cause more gas to go into solution, and therefore,more
oxygen will be transported in the plasma. As a result a lot of oxygen
becomes available for the microcirculation, resulting in significant
improvement of all metabolic parameters, which have also been shown in
several works to influence neurological functions4. We
report about a case of woman affected by FM and treated with HBOT as
adjuvant, experimental and non conventional therapy.
Case
Presentation
In January 2021 a 54-year-old Caucasian woman with a negative medical
past history reported pain in her left arm 24 hours after receiving the
first dose of the Pfizer SARS-Covid 19 vaccine. Localised pain in the
injection zone (the triceps muscle of the left arm) was accompanied by
the onset of high fever (40°C), intense headache with vomiting and
abdominal pain. After 48 hours there was defervescence with return to
normo-thermia but progressive appearance of fatigue. Subsequently
patient report a relief of pain in the left arm with progressive
development of constant, severe and persistent pain in occipital and
back neck area, low back and legs with a marked sense of heaviness in
the lower limbs. The patient also complained of progressive difficulty
in walking, for which the use of nordic walking sticks was necessary.
Furthermore, she reported stiffening of the facial muscles with pain
defined as intense, mental fogginess, severe short-term memory
involvement and progressive depression, symptoms that had undoubtedly
caused a significant impairment in her quality of life.
The patient underwent routine blood sample tests (blood count, ESR, PCR,
protein electrophoresis, AST, ALT, gamma GT), as well as more specific
immuno-enzymatic tests (serum kappa and lambda chains, IgG, IgA, IgM,
anti-nuclear antibodies, ENA, ANA with subclasses). The exams showed no
values outside the standard range. Only a slight increase in ESR and a
reduction in 25-OH-vitamin D levels was shown. The patient also
performed total body CTs, spine MRI, femoral and lumbar bone
densitometry from which no structural morphological alteration was
highlighted except for an initial picture of osteoporosis. The exclusion
of inflammatory disease, although some rheumatic diseases could coexist,
suggested a possible diagnosis of FM and thus rheumatologists have
sought its diagnostic criteria5. The persistence of
pain was well over 3 months (the patient reported the onset of symptoms
about 18 months ago).
The following questionnaires were administered: Widespread Pain Index
(WPI), Symptom Severity Scale (SSS), Revised Fibromyalgia Impact
Questionnaire (FIQR), Pittsburgh Sleep Quality Index (PHQI), Generalized
Anxiety Disorder Screener (GAD-7), Functional Assessment of Chronic
Illness Therapy Fatigue (FACIT-F). The scores reported from each
individual questionnaires carried out before the start of HBOT were as
follows: WPI=18, SSS=10, FIQR=96,
PHQI=17, GAD-7=14, FACIT=12.
Thus she started a multidisciplinary therapeutic course based on
antalgic therapy, physiotherapy, psychological support, relaxation
techniques and healthy nutrition.
Among the various therapies, HBOT was indicated as an experimental
non-conventional treatment. The patient underwent forty sessions of HBOT
at 2.4 ATA (absolute atmospheres), total oxygen time 60 minutes per
session, once a day, five times a week, performed at the multi-place
chamber (Sistemi Iperbarici Integrati-Camera Iperbarica Mod 2000) of the
Hyperbaric Medicine Centre of ARNAS Ospedale Civico Di Cristina
Benfratelli, Palermo, Italy. Therapy started in the first week of
September and ended in mid-November 2022. Throughout each session, the
patient showed stable vital parameters (blood pressure, heart rate,
oxygen saturation and body temperature). Blood tests, markers of
flogosis and haematochemical examinations carried out at mid term and at
the end showed no change in values outside the normal range.
The patient underwent 40 sessions of HBOT. The clinical improvement
achieved was evident and affected all symptom areas reported before
treatment. In particular, there was a complete recovery of mobility with
the avoidance of walking sticks, an increase in muscular strength
evidenced by the ability to climb several flights of stairs and to walk
long distances independently. The patient reported a drastic reduction
in pain symptoms evident from the moment she woke up in the morning, a
significant improvement in sleep quality, previously reported as light,
non-restorative and with multiple breaks. The highly debilitating sense
of fatigue was reported after treatment as markedly reduced and in any
case easily manageable. In addition, a significant change in cognitive
abilities was reported, with disappearance of mental fogginess and
recovery of short-term memory. In summary, there was a significant
improvement in quality of life with the disappearance of the depression
into which the patient had plunged, a condition confirmed by
psychological advice at the end of the hyperbaric treatment. The scores
reported by each individual test at the end of HBOT are shown below:
WPI=6, SSS=3, FIQR=13, PHQI=2, GAD-7=3, FACIT=42.