DoD Comprehensive Clinical Evaluation Program (CCEP), which ran for 1 year between 1994 and 1995 in an attempt to provide evaluation and treatment for all Gulf War veterans who believed they were suffering a medical condition related to their deployment. Deployed veterans who participated in the CCEP had more than 26 times the risk of being hospitalized for fibromyalgia than did nonparticipants. By comparison, the authors found that for the 3-year period prior to the CCEP, the rate of hospitalization for fibromyalgia was similar between Gulf War veterans and their nondeployed contemporaries (RR 0.92, 95% CI 0.74-1.13). The Smith et al. study has the advantage of a large, population-based sample and good statistical power for the detection of an effect. Its major limitations are the inclusion of only active-duty personnel, changes in hospitalization rates for fibromyalgia in association with the practices of the CCEP, and the fact that few cases of fibromyalgia are severe enough to warrant hospitalization. The findings on fibromyalgia are summarized in Table 4-12.

Secondary Studies

The Iowa study (Iowa Persian Gulf Study Group, 1997) surveyed 1896 deployed and 1799 nondeployed Iowa veterans. No physical examinations were conducted; fibromyalgia was assessed from the symptom criteria described by Wolfe and colleagues (Wolfe et al., 1995). Symptoms of fibromyalgia were present in 18.2% and 23.8% of deployed regular military and National Guard veterans, respectively, and 9.2% and 13.2% of nondeployed regular military and National Guard veterans, respectively, with an adjusted prevalence difference of 9.3% (95% CI 7.3-11.2). Steele (2000) conducted a similar telephone interview study among 1545 deployed and 435 nondeployed Kansas Gulf War veterans. Of the deployed and nondeployed veterans, 2% (n = 24) and less than 0.5% (n = 2), respectively, reported having received a physician’s diagnosis of fibromyalgia with new onset between 1990 and 1998 (adjusted OR 3.69, 95% CI 0.86-15.84).

A survey of the entire cohort of Canadian Gulf War deployed veterans (Goss Gilroy, 1998) found that they were more likely than nondeployed veterans—group-matched to cases on sex, age, and regular versus reserve status—to report symptoms of fibromyalgia (16% vs 10%; adjusted OR 1.81, 95% CI 1.55-2.13).

Bourdette et al. (2001) studied 244 Oregon and Washington Gulf War veterans who had unexplained illness after clinical evaluation to exclude “explainable” illness. Of these veterans, 50 (20.8%) fulfilled the ACR criteria for fibromyalgia. The study’s main limitations are its lack of a nondeployed comparison group and lack of clarity about the nature of the clinical examination for fibromyalgia.

Updated and Supplemental Literature

Primary Studies

The Update committee identified only one new primary paper that looked specifically at CWP in deployed and nondeployed Gulf War veterans. A random sample of a population-based cohort of regular military and National Guard and reserve veterans (Iowa Persian Gulf Study Group, 1997), 1896 deployed and 1799 nondeployed, who listed Iowa as their home state at the time of enlistment were surveyed in 1995-1996. Veterans were identified through the DMDC. The study was conducted through structured telephone interviews to determine the prevalence of CWP on the basis of responses to the SF-36. Gulf War veterans reported significantly more bodily pain than did nondeployed veterans (p < 0.01). In a follow-up study of a subset of this

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