Treatment and Assessment of Fibromyalgia

At St. Joseph's Care Group (SJCG) rheumatologist and chronic pain physician will determine if a client is eligible to participate in the study using the inclusion/exclusion criteria (outlined in the attached grant proposal). Physician would then ask if the client would be open to discussing their possible involvement in a research study. If so, a member of the research team other than physicians will visit with the client at the Chronic Pain Management program at SJCG to discuss the project and complete the informed consent process if the client would like to participate.

Following informed consent, the participant would be assigned to one of two groups following a restricted randomization procedure. This will be completed using open-source minimization software called Qminim. The process of minimization ensures group sizes are equal and eliminates potential bias that may be introduced which is important for clinical research of small sizes. Group 1 will receive Radial Shockwave Therapy (RSWT) while group 2 will be the placebo group. Once participants in the placebo group have completed the study, RSWT will be offered, although it will not be included in the data analysis. Participants will be grouped for minimization based on sex and age in the following ranges: 18-30, 31-45, 46-60 years. All participant information/group assignment will be coded to maintain confidentiality. Group assignment will be unknown to the participant until they complete the study (or withdraw from the study).

The following initial assessments will occur prior to receiving the RSWT or placebo: At SJCG: participants will undergo quantitative sensory testing for allodynia and hyperalgesia by one of the physicians. At Lakehead University School of Kinesiology: participants will have basic demographic information such as height, weight and age, measured and recorded on a data abstraction form by a member of the research team. The participant will also be asked to consider the most painful spot within each of the 3 most painful regions in his/her body. Participants will mark on a 100 millimeter VAS scale at the point that corresponds to the pain intensity for each region. The amount of pain will be estimated by measuring in millimeters the distance from the "no pain" marker to the mark provided by the participant for each question. This will be recorded on the data abstraction form. Pressure pain threshold will next be measured on the most painful spot within each of the 3 most painful regions using a Baseline© Pressure Tolerance Meter (60 lbs). Pressure will be applied perpendicular to the tissue in the three most painful regions as indicated by the participant. The participant will be asked to report when the pressure applied to the region became painful and the amount of pressure shall be recorded in pounds on the data abstraction form. A 30 second rest shall be allowed for recovery and the same technique shall be applied to the other painful locations. The specific location of the painful region shall be marked and documented by a trained member of the research team. Next, participants will be asked to complete the Beighton Scoring Screen for hypermobility, Beck's Depression Scale, and Pain Catastrophizing Scale questionnaires. All scores will be recorded on the data abstraction form. At Lakehead University (NOSM rooms 1002A, C, D E, F or School of Kinesiology SB-1028): participants will be scheduled to have a blood sample drawn by a registered phlebotomist. Specialized vacutainers will be used to isolate Peripheral Blood Mononuclear Cells (PBMCs) which will be later used in cytokine protein analysis. All blood taken will be labeled with a participant code to maintain confidentiality, and stored at NOSM.

At TBRHSC: 15 randomly selected participants from each group will undergo whole brain functional MRI (fMRI) imaging by a member of the research team at TBRHSC. The scans will include a resting state fMRI, an 8 minute scan during alternating 30 second on, 30 second off evoked pressure pain stimulus, a T1 high resolution anatomical image, and a diffusion tensor image. Please see the attached grant proposal for details regarding this imaging method.

Once the initial measures are completed, participants will be scheduled to begin the allocated treatment based on group assignment. Group 1 will receive RSWT to the most painful spot within each of the 3 most painful regions, while group 2 (placebo) will receive a similar treatment but a soft rubber cap will be applied to the applicator, leaving air between the transmitter and the cap and the participant's skin. Treatments will be spaced one week apart over a 5 week period of time and will occur at Lakehead University's School of Kinesiology, room SB-1028.

Upon completion of the treatments, participants will complete the same measures/questionnaires that were performed at the beginning of the study. Also, one vial of blood will be taken again and if the participant was in the fMRI group, they will repeat the same imaging sessions detailed above.

At the conclusion of the study, participants will be invited to participate in a focus group lead by another research team member during which qualitative feedback regarding the study will be discussed. This is a patient-centred approach that will help the investigators engage the fibromyalgia community and allow this input to guide future study design.

It is anticipated that 50 participants will be enrolled in the study. The main analysis will be a comparison of the pre- and post-outcomes, meaning that this is a repeated measures study design. This design has the advantage of minimizing the effect of inter-subject variability. A power analysis was performed a priori and it was determined that this sample size is sufficient; minimum detectable differences of 10% and standard deviation of ±15% resulting in a power of 0.892.