Showing papers on "Fibromyalgia published in 2013"

Small fibre pathology in patients with fibromyalgia syndrome

Abstract: Fibromyalgia syndrome is a clinically well-characterized chronic pain condition of high socio-economic impact Although the pathophysiology is still unclear, there is increasing evidence for nervous system dysfunction in patients with fibromyalgia syndrome In this case-control study we investigated function and morphology of small nerve fibres in 25 patients with fibromyalgia syndrome Patients underwent comprehensive neurological and neurophysiological assessment We examined small fibre function by quantitative sensory testing and pain-related evoked potentials, and quantified intraepidermal nerve fibre density and regenerating intraepidermal nerve fibres in skin punch biopsies of the lower leg and upper thigh The results were compared with data from 10 patients with monopolar depression without pain and with healthy control subjects matched for age and gender Neurological and standard neurophysiological examination was normal in all patients, excluding large fibre polyneuropathy Patients with fibromyalgia syndrome had increased scores in neuropathic pain questionnaires compared with patients with depression and with control subjects (P < 0001 each) Compared with control subjects, patients with fibromyalgia syndrome but not patients with depression had impaired small fibre function with increased cold and warm detection thresholds in quantitative sensory testing (P < 0001) Investigation of pain-related evoked potentials revealed increased N1 latencies upon stimulation at the feet (P < 0001) and reduced amplitudes of pain-related evoked potentials upon stimulation of face, hands and feet (P < 0001) in patients with fibromyalgia syndrome compared to patients with depression and to control subjects, indicating abnormalities of small fibres or their central afferents In skin biopsies total (P < 0001) and regenerating intraepidermal nerve fibres (P < 001) at the lower leg and upper thigh were reduced in patients with fibromyalgia syndrome compared with control subjects Accordingly, a reduction in dermal unmyelinated nerve fibre bundles was found in skin samples of patients with fibromyalgia syndrome compared with patients with depression and with healthy control subjects, whereas myelinated nerve fibres were spared All three methods used support the concept of impaired small fibre function in patients with fibromyalgia syndrome, pointing towards a neuropathic nature of pain in fibromyalgia syndrome

Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polysymptomatic distress: results from a survey of the general population.

Abstract: Objective To evaluate fibromyalgia in the general population with emphasis on prevalence, dimensionality, and somatic symptom severity. Methods We studied 2,445 subjects randomly selected from the German general population in 2012 using the American College of Rheumatology 2010 preliminary diagnostic criteria for fibromyalgia, as modified for survey research, and the polysymptomatic distress scale (PSD). Anxiety, depression, and somatic symptom severity were assessed with the Patient Health Questionnaire (PHQ) series, and measures of symptoms and quality of life were assessed with the European Organization for Research and Treatment of Cancer questionnaire. Results The prevalence of fibromyalgia was 2.1% (95% confidence interval [95% CI] 1.6, 2.7), with 2.4% (95% CI 1.5, 3.2) in women and 1.8% (95% CI 1.1, 2.6) in men, but the difference was not statistically significant. Prevalence rose with age. Fibromyalgia subjects had markedly abnormal scores for all covariates. We found smooth, nondisordered relationships between PSD and all predictors, providing additional evidence against the hypothesis that fibromyalgia is a discrete disorder and in support of a dimensional or spectrum disorder. There was a strong correlation (r = 0.790) between the PSD and the PHQ somatic symptom severity scale; 38.5% of persons with fibromyalgia satisfied the proposed Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for a physical symptom disorder. Conclusion The modified 2010 diagnostic criteria do not result in high levels of fibromyalgia. PSD and fibromyalgia are strongly related to somatic symptom severity. There is evidence in support of fibromyalgia as a dimensional or continuum disorder. This has important ramifications for neurobiologic and epidemiology research, and for clinical diagnosis, treatment, and ascertainment of disability.

2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome: Executive Summary

Abstract: BACKGROUND: Recent neurophysiological evidence attests to the validity of fibromyalgia (FM), a chronic pain condition that affects >2% of the population.

Prevalence of Fibromyalgia: A Population‐Based Study in Olmsted County, Minnesota, Utilizing the Rochester Epidemiology Project

Abstract: Fibromyalgia (FM) is a complex illness to diagnose and treat, with symptoms that may be part of, or overlap with other diseases or syndromes. It is also a costly public health problem. Medical costs related to health care utilization and pain-related medications for patients with FM are substantially higher than those for patients without FM (1–4). Therefore, evaluating the prevalence of FM has both clinical and economic relevance. Recognition of FM may not always be straightforward, because FM symptoms may be part of or overlap with other diseases or syndromes. Using the original 1990 American College of Rheumatology (ACR) criteria, Wolfe et al estimated that the prevalence of FM in the US general population is 2% (3.4% in women vs 0.5% in men) (5). Similarly, White et al (6), reporting on the London Fibromyalgia Epidemiology Study in Ontario, Canada, estimated the prevalence of FM at 3.3% (4.9% in women vs 1.6% in men), and Branco et al (7) reported on a multinational study of the prevalence of FM in 5 European countries, estimating it at 4.7%. A separate study, using a method similar to that of the ACR diagnostic criteria estimated the prevalence in Germany at 3.8%, with similar rates in men and women, (8). These differing estimates may reflect differences in study populations, study designs, and measurements. In 2010, the ACR published diagnostic criteria for FM that encompass the chronic widespread pain, fatigue, unrefreshing sleep, cognition, and somatic symptoms considered the hallmarks of this condition (9). These criteria were later modified to allow their use in epidemiologic and survey studies, without the requirement for an examiner to perform a tender point examination (10). The modification involved asking patients to report both pain and tenderness for the widespread pain index, in comparison to the ACR 2010 diagnostic criteria that only asked health care providers to determine areas of pain. Additionally, 3 representative items substituted for the comprehensive list of somatic symptoms that composed the ACR 2010 symptom severity score: 1) the presence or absence of headaches; 2) pain or cramps in the lower abdomen; and 3) depression in the past 6 months. Similar to the 2010 clinical criteria for FM, the modified criteria included a widespread pain index score of ≥7 and a symptom severity score of ≥5. Alternatively, participants are defined as having FM if the widespread pain index is 3 to 6 or the symptom severity score is ≥9. Additionally, symptoms must have been present at a similar level for at least 3 months. Routine use of these criteria in epidemiologic research may improve comparability of FM prevalence in different populations. Our primary objective in this study was to estimate the prevalence of FM in a defined population in 2 different ways. To accomplish this objective, we first estimated the prevalence of diagnosed FM in clinical practice in Olmsted County, Minnesota, using community medical records. We then surveyed a random sample of the population of Olmsted County using the modified 2010 ACR criteria to estimate the percentage of responders who fulfilled criteria.

Antiepileptic drugs for neuropathic pain and fibromyalgia ‐ an overview of Cochrane reviews

Abstract: Background Antiepileptic drugs have been used for treating different types of neuropathic pain, and sometimes fibromyalgia. Our understanding of quality standards in chronic pain trials has improved to include new sources of potential bias. Individual Cochrane reviews using these new standards have assessed individual antiepileptic drugs. An early review from this group, originally published in 1998, was titled 'Anticonvulsants for acute and chronic pain'. This overview now covers the neuropathic pain aspect of that original review, which was withdrawn in 2009. Objectives To provide an overview of the relative analgesic efficacy of antiepileptic drugs that have been compared with placebo in neuropathic pain and fibromyalgia, and to report on adverse events associated with their use. Methods We included reviews published in theCochrane Database of Systematic Reviews up to August 2013 (Issue 7). We extracted information from each review on measures of efficacy and harm, and methodological details concerning the number of participants, the duration of studies, and the imputation methods used, in order to judge potential biases in available data. We analysed efficacy data for each painful condition in three tiers, according to outcome and freedom from known sources of bias. The first tier met current best standards - at least 50% pain intensity reduction over baseline (or its equivalent), without the use of last observation carried forward (LOCF) for dropouts, an intention-to-treat (ITT) analysis, in parallel group studies with at least 200 participants lasting eight weeks or more. The second tier used data from at least 200 participants where one or more of the above conditions were not met. The third tier of evidence related to data from fewer than 200 participants, or with several important methodological problems that limited interpretation. Main results No studies reported top tier results. For gabapentin and pregabalin only we found reasonably good second tier evidence for efficacy in painful diabetic neuropathy and postherpetic neuralgia. In addition, for pregabalin, we found evidence of efficacy in central neuropathic pain and fibromyalgia. Point estimates of numbers needed to treat for an additional beneficial effect (NNTs) were in the range of 4 to 10 for the important outcome of pain intensity reduction over baseline of 50% or more. For other antiepileptic drugs there was no evidence (clonazepam, phenytoin), so little evidence that no sensible judgement could be made about efficacy (valproic acid), low quality evidence likely to be subject to a number of biases overestimating efficacy (carbamazepine), or reasonable quality evidence indicating little or no effect (lamotrigine, oxcarbazepine, topiramate). Lacosamide recorded such a trivial statistical superiority over placebo that it was unreliable to conclude that it had any efficacy where there was possible substantial bias. Any benefits of treatment came with a high risk of adverse events and withdrawal because of adverse events, but serious adverse events were not significantly raised, except with oxcarbazepine. Authors' conclusions Clinical trial evidence supported the use of only gabapentin and pregabalin in some neuropathic pain conditions (painful diabetic neuropathy, postherpetic neuralgia, and central neuropathic pain) and fibromyalgia. Only a minority of people achieved acceptably good pain relief with either drug, but it is known that quality of life and function improved markedly with the outcome of at least 50% pain intensity reduction. For other antiepileptic drugs there was no evidence, insufficient evidence, or evidence of a lack of effect; this included carbamazepine. Evidence from clinical practice and experience is that some patients can achieve good results with antiepileptics other than gabapentin or pregabalin. There is no firm evidence to answer the important pragmatic questions about which patients should have which drug, and in which order the drugs should be used. There is a clinical effectiveness research agenda to provide evidence about strategies rather than interventions, to produce the overall best results in a population, in the shortest time, and at the lowest cost to healthcare providers.

Objective evidence that small-fiber polyneuropathy underlies some illnesses currently labeled as fibromyalgia

Abstract: Fibromyalgia is a common, disabling syndrome that includes chronic widespread pain plus diverse additional symptoms. No specific objective abnormalities have been identified, which precludes definitive testing, disease-modifying treatments, and identification of causes. In contrast, small-fiber polyneuropathy (SFPN), despite causing similar symptoms, is definitionally a disease caused by the dysfunction and degeneration of peripheral small-fiber neurons. SFPN has established causes, some diagnosable and definitively treatable, eg, diabetes. To evaluate the hypothesis that some patients labeled as having fibromyalgia have unrecognized SFPN that is causing their illness symptoms, we analyzed SFPN-associated symptoms, neurological examinations, and pathological and physiological markers in 27 patients with fibromyalgia and in 30 matched normal controls. Patients with fibromyalgia had to satisfy the 2010 American College of Rheumatology criteria plus present evidence of a physician's actual diagnosis of fibromyalgia. The study's instruments comprised the Michigan Neuropathy Screening Instrument (MNSI), the Utah Early Neuropathy Scale (UENS), distal-leg neurodiagnostic skin biopsies, plus autonomic-function testing (AFT). We found that 41% of skin biopsies from subjects with fibromyalgia vs 3% of biopsies from control subjects were diagnostic for SFPN, and MNSI and UENS scores were higher in patients with fibromyalgia than in control subjects (all P ≤ 0.001). Abnormal AFTs were equally prevalent, suggesting that fibromyalgia-associated SFPN is primarily somatic. Blood tests from subjects with fibromyalgia and SFPN-diagnostic skin biopsies provided insights into causes. All glucose tolerance tests were normal, but 8 subjects had dysimmune markers, 2 had hepatitis C serologies, and 1 family had apparent genetic causality. These findings suggest that some patients with chronic pain labeled as fibromyalgia have unrecognized SFPN, a distinct disease that can be tested for objectively and sometimes treated definitively.

Resistance exercise training for fibromyalgia.

Abstract: Background Fibromyalgia is characterized by chronic widespread pain that leads to reduced physical function. Exercise training is commonly recommended as a treatment for management of symptoms. We examined the literature on resistance training for individuals with fibromyalgia. Resistance training is exercise performed against a progressive resistance with the intention of improving muscle strength, muscle endurance, muscle power, or a combination of these. Objectives To evaluate the benefits and harms of resistance exercise training in adults with fibromyalgia. We compared resistance training versus control and versus other types of exercise training. Search methods We searched nine electronic databases (The Cochrane Library, MEDLINE, EMBASE, CINAHL, PEDro, Dissertation Abstracts, Current Controlled Trials, World Health Organization (WHO) International Clinical Trials Registry Platform, AMED) and other sources for published full-text articles. The date of the last search was 5 March 2013. Two review authors independently screened 1856 citations, 766 abstracts and 156 full-text articles. We included five studies that met our inclusion criteria. Selection criteria Selection criteria included: a) randomized clinical trial, b) diagnosis of fibromyalgia based on published criteria, c) adult sample, d) full-text publication, and e) inclusion of between-group data comparing resistance training versus a control or other physical activity intervention. Data collection and analysis Pairs of review authors independently assessed risk of bias and extracted intervention and outcome data. We resolved disagreements between the two review authors and questions regarding interpretation of study methods by discussion within the pairs or when necessary the issue was taken to the full team of 11 members. We extracted 21 outcomes of which seven were designated as major outcomes: multidimensional function, self reported physical function, pain, tenderness, muscle strength, attrition rates, and adverse effects. We evaluated benefits and harms of the interventions using standardized mean differences (SMD) or mean differences (MD) or risk ratios or Peto odds ratios and 95% confidence intervals (CI). Where two or more studies provided data for an outcome, we carried out a meta-analysis. Main results The literature search yielded 1865 citations with five studies meeting the selection criteria. One of the studies that had three arms contributed data for two comparisons. In the included studies, there were 219 women participants with fibromyalgia, 95 of whom were assigned to resistance training programs. Three randomized trials compared 16 to 21 weeks of moderate- to high-intensity resistance training versus a control group. Two studies compared eight weeks of progressive resistance training (intensity as tolerated) using free weights or body weight resistance exercise versus aerobic training (ie, progressive treadmill walking, indoor and outdoor walking), and one study compared 12 weeks of low-intensity resistance training using hand weights (1 to 3 lbs (0.45 to 1.36 kg)) and elastic tubing versus flexibility exercise (static stretches to major muscle groups). Statistically significant differences (MD; 95% CI) favoring the resistance training interventions over control group(s) were found in multidimensional function (Fibromyalgia Impact Questionnaire (FIQ) total decreased 16.75 units on a 100-point scale; 95% CI -23.31 to -10.19), self reported physical function (-6.29 units on a 100-point scale; 95% CI -10.45 to -2.13), pain (-3.3 cm on a 10-cm scale; 95% CI -6.35 to -0.26), tenderness (-1.84 out of 18 tender points; 95% CI -2.6 to -1.08), and muscle strength (27.32 kg force on bilateral concentric leg extension; 95% CI 18.28 to 36.36). Differences between the resistance training group(s) and the aerobic training groups were not statistically significant for multidimensional function (5.48 on a 100-point scale; 95% CI -0.92 to 11.88), self reported physical function (-1.48 units on a 100-point scale; 95% CI -6.69 to 3.74) or tenderness (SMD -0.13; 95% CI -0.55 to 0.30). There was a statistically significant reduction in pain (0.99 cm on a 10-cm scale; 95% CI 0.31 to 1.67) favoring the aerobic groups. Statistically significant differences were found between a resistance training group and a flexibility group favoring the resistance training group for multidimensional function (-6.49 FIQ units on a 100-point scale; 95% CI -12.57 to -0.41) and pain (-0.88 cm on a 10-cm scale; 95% CI -1.57 to -0.19), but not for tenderness (-0.46 out of 18 tender points; 95% CI -1.56 to 0.64) or strength (4.77 foot pounds torque on concentric knee extension; 95% CI -2.40 to 11.94). This evidence was classified low quality due to the low number of studies and risk of bias assessment. There were no statistically significant differences in attrition rates between the interventions. In general, adverse effects were poorly recorded, but no serious adverse effects were reported. Assessment of risk of bias was hampered by poor written descriptions (eg, allocation concealment, blinding of outcome assessors). The lack of a priori protocols and lack of care provider blinding were also identified as methodologic concerns. Authors' conclusions The evidence (rated as low quality) suggested that moderate- and moderate- to high-intensity resistance training improves multidimensional function, pain, tenderness, and muscle strength in women with fibromyalgia. The evidence (rated as low quality) also suggested that eight weeks of aerobic exercise was superior to moderate-intensity resistance training for improving pain in women with fibromyalgia. There was low-quality evidence that 12 weeks of low-intensity resistance training was superior to flexibility exercise training in women with fibromyalgia for improvements in pain and multidimensional function. There was low-quality evidence that women with fibromyalgia can safely perform moderate- to high-resistance training.

Cognitive behavioural therapies for fibromyalgia

Abstract: Researchers in The Cochrane Collaboration conducted a review of research about the effects of cognitive-behavioural therapies (CBTs) on fibromyalgia (FM). After searching for all relevant studies, they found 23 studies with up to 2031 people. Their findings are summarised below. After about 12 weeks, children, adolescents and adults with FMS, who used CBTs compared to controls, were likely to report that CBT - may reduce slightly pain, negative mood and disability at the end of the treatment; - may reduce slightly pain, negative mood and disability six months after the end of treatment. There was no difference between CBTs and controls in the number of people who withdrew from treatment. We do not have precise information about side effects and complications of CBTs. Rare complications may include worsening of co-existing mental disorders.

Comparative efficacy of pharmacological and non-pharmacological interventions in fibromyalgia syndrome: network meta-analysis

Abstract: Objectives To synthesise the available evidence on pharmacological and non-pharmacological interventions recommended for fibromyalgia syndrome (FMS). Methods Electronic databases including MEDLINE, PsycINFO, Scopus, the Cochrane Controlled Trials Registry and the Cochrane Library were searched for randomised controlled trials comparing any therapeutic approach as recommended in FMS guidelines (except complementary and alternative medicine) with control interventions in patients with FMS. Primary outcomes were pain and quality of life. Data extraction was done using standardised forms. Results 102 trials in 14 982 patients and eight active interventions (tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors (SNRIs), the gamma-amino butyric acid analogue pregabalin, aerobic exercise, balneotherapy, cognitive behavioural therapy (CBT), multicomponent therapy) were included. Most of the trials were small and hampered by methodological quality, introducing heterogeneity and inconsistency in the network. When restricted to large trials with ≥100 patients per group, heterogeneity was low and benefits for SNRIs and pregabalin compared with placebo were statistically significant, but small and not clinically relevant. For non-pharmacological interventions, only one large trial of CBT was available. In medium-sized trials with ≥50 patients per group, multicomponent therapy showed small to moderate benefits over placebo, followed by aerobic exercise and CBT. Conclusions Benefits of pharmacological treatments in FMS are of questionable clinical relevance and evidence for benefits of non-pharmacological interventions is limited. A combination of pregabalin or SNRIs as pharmacological interventions and multicomponent therapy, aerobic exercise and CBT as non-pharmacological interventions seems most promising for the management of FMS.

The phenotypic and genetic signatures of common musculoskeletal pain conditions

Abstract: Musculoskeletal pain conditions, such as fibromyalgia and low back pain, tend to coexist in affected individuals and are characterized by a report of pain greater than expected based on the results of a standard physical evaluation. The pathophysiology of these conditions is largely unknown, we lack biological markers for accurate diagnosis, and conventional therapeutics have limited effectiveness. Growing evidence suggests that chronic pain conditions are associated with both physical and psychological triggers, which initiate pain amplification and psychological distress; thus, susceptibility is dictated by complex interactions between genetic and environmental factors. Herein, we review phenotypic and genetic markers of common musculoskeletal pain conditions, selected based on their association with musculoskeletal pain in previous research. The phenotypic markers of greatest interest include measures of pain amplification and 'psychological' measures (such as emotional distress, somatic awareness, psychosocial stress and catastrophizing). Genetic polymorphisms reproducibly linked with musculoskeletal pain are found in genes contributing to serotonergic and adrenergic pathways. Elucidation of the biological mechanisms by which these markers contribute to the perception of pain in these patients will enable the development of novel effective drugs and methodologies that permit better diagnoses and approaches to personalized medicine.

Combination pharmacotherapy for management of chronic pain: from bench to bedside

Abstract: Summary Chronic pain, a frequently neglected problem, is treated with different classes of drugs. Current agents are limited by incomplete efficacy and dose-limiting side-effects. Knowledge of pain processing implicates multiple concurrent mechanisms of nociceptive transmission and modulation. Thus, synergistic interactions of drug combinations might provide superior analgesia and fewer side-effects than monotherapy by targeting of multiple mechanisms. Several trials in neuropathic pain, fibromyalgia, arthritis, and other disorders have assessed various two-drug combinations containing antidepressants, anticonvulsants, non-steroidal anti-inflammatories, opioids, and other agents. In some trials, combined treatment showed superiority over monotherapy, but in others improved benefit or tolerability was not seen. Escalating efforts to develop novel analgesics that surpass the efficacy of current treatments have not yet been successful; therefore, combination therapy remains an important beneficial strategy. Methodological improvements in future translational research efforts are needed to maximise the potential of combination pharmacotherapy for pain.

Mindfulness-Based Therapies in the Treatment of Somatization Disorders: A Systematic Review and Meta-Analysis

Abstract: Background Mindfulness-based therapy (MBT) has been used effectively to treat a variety of physical and psychological disorders, including depression, anxiety, and chronic pain. Recently, several lines of research have explored the potential for mindfulness-therapy in treating somatization disorders, including fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome.

Survey criteria for fibromyalgia independently predict increased postoperative opioid consumption after lower-extremity joint arthroplasty: a prospective, observational cohort study.

Abstract: Background Variance in pain following total knee and hip arthroplasty may be due to a number of procedural and peripheral factors but also, in some individuals, to aberrant central pain processing as is described in conditions like fibromyalgia. To test this hypothesis, we conducted a prospective, observational cohort study of patients undergoing lower extremity joint arthroplasty.

Pain Physiology Education Improves Health Status and Endogenous Pain Inhibition in Fibromyalgia: A Double-Blind Randomized Controlled Trial

Abstract: Objectives: There is evidence that education on pain physiology canhave positive effects on pain, disability, and catastrophization inpatients with chronic musculoskeletal pain disorders. A double-blind randomized controlled trial (RCT) was performed to examinewhether intensive pain physiology education is also effective infibromyalgia (FM) patients, and whether it is able to influence theimpaired endogenous pain inhibition of these patients.Methods: Thirty FM patients were randomly allocated to either theexperimental (receiving pain physiology education) or the controlgroup (receiving pacing self-management education). The primaryoutcome was the efficacy of the pain inhibitory mechanisms, whichwas evaluated by spatially accumulating thermal nociceptivestimuli. Secondary outcome measures included pressure painthreshold measurements and questionnaires assessing pain cogni-tions, behavior, and health status. Assessments were performed atbaseline, 2 weeks, and 3 months follow-up. Repeated measuresANOVAS were used to reveal possible therapy effects and effectsizes were calculated.Results: After the intervention the experimental group hadimproved knowledge of pain neurophysiology (P<0.001). Patientsfrom this group worried less about their pain in the short term(P=0.004). Long-term improvements in physical functioning(P=0.046), vitality (P=0.047), mental health (P<0.001), andgeneral health perceptions (P<0.001) were observed. In addition,the intervention group reported lower pain scores and showedimproved endogenous pain inhibition (P=0.041) compared withthe control group.Discussion: These results suggest that FM patients are able tounderstand and remember the complex material about painphysiology. Pain physiology education seems to be a usefulcomponent in the treatment of FM patients as it improves healthstatus and endogenous pain inhibition in the long term.Key Words: patient education, conditioned pain modulation, spa-tial summation, rehabilitation, central sensitization.

Noncancer pain conditions and risk of suicide

Abstract: Importance There are limited data on the extent to which suicide mortality is associated with specific pain conditions. Objective To examine the associations between clinical diagnoses of noncancer pain conditions and suicide among individuals receiving services in the Department of Veterans Affairs Healthcare System. Design Retrospective data analysis. Setting Data were extracted from National Death Index and treatment records from the Department of Veterans Healthcare System. Participants Individuals receiving services in fiscal year 2005 who remained alive at the start of fiscal year 2006 (N = 4 863 086). Main Outcomes and Measures Analyses examined the association between baseline clinical diagnoses of pain-related conditions (arthritis, back pain, migraine, neuropathy, headache or tension headache, fibromyalgia, and psychogenic pain) and subsequent suicide death (assessed in fiscal years 2006-2008). Results Controlling for demographic and contextual factors (age, sex, and Charlson score), elevated suicide risks were observed for each pain condition except arthritis and neuropathy (hazard ratios ranging from 1.33 [99% CI, 1.22-1.45] for back pain to 2.61 [1.82-3.74] for psychogenic pain). When analyses controlled for concomitant psychiatric conditions, the associations between pain conditions and suicide death were reduced; however, significant associations remained for back pain (hazard ratio, 1.13 [99% CI, 1.03-1.24]), migraine (1.34 [1.02-1.77]), and psychogenic pain (1.58 [1.11-2.26]). Conclusions and Relevance There is a need for increased awareness of suicide risk in individuals with certain noncancer pain diagnoses, in particular back pain, migraine, and psychogenic pain.

Overlapping structural and functional brain changes in patients with long-term exposure to fibromyalgia pain

Abstract: Objective There is vast evidence to support the presence of brain aberrations in patients with fibromyalgia (FM), and it is possible that central plasticity is critical for the transition from acute to chronic pain. The aim of the present study was to investigate the relationship between brain structure and function in patients with FM. Methods Functional connectivity of the brain during application of intermittent pressure–pain stimuli and measures of brain structure were compared between 26 patients with FM and 13 age- and sex-matched healthy controls. Magnetic resonance imaging (MRI) was performed to obtain high-resolution anatomic images and functional MRI scans of the brain, which were used for measurements of pain-evoked brain activity. Results FM patients displayed a distinct overlap between decreased cortical thickness, decreased brain volumes, and decreased functional regional coherence in the rostral anterior cingulate cortex. The morphometric changes were more pronounced with longer exposure to FM pain. In addition, there was evidence of an association between structural and functional changes in the mesolimbic areas of the brain and the severity of comorbid depression symptoms in FM patients. Conclusion The combined integration of structural and functional measures allowed for a unique characterization of the impact of FM pain on the brain. These data may lead to the identification of early structural and functional brain alterations in response to pain, which could be used to develop markers for predicting the development of FM and other pain disorders.

Psychological approaches to chronic pain management: evidence and challenges

Abstract: Psychological interventions are a mainstay of modern pain management practice and a recommended feature of a modern pain treatment service. Systematic reviews for the evidence of psychological interventions are reviewed in this article. The evidence for effectiveness is strongest for cognitive behavioural therapy with a focus on cognitive coping strategies and behavioural rehearsal. Most evidence is available for treatments of adult pain, although adolescent chronic pain treatments are also reviewed. It is clear that treatment benefit can be achieved with cognitive behavioural methods. It is possible to effect change in pain, mood, and disability, changes not achieved by chance or by exposure to any other treatment. However, the overall effect sizes of treatments for adults, across all trials, are modest. Reasons for the relatively modest treatment effects are discussed within the context of all treatments for chronic pain being disappointing when measured by the average. Suggestions for improving both trials and evidence summaries are made. Finally, consideration is given to what can be achieved by the pain specialist without access to specialist psychology resource.

Low‐dose naltrexone for the treatment of fibromyalgia: Findings of a small, randomized, double‐blind, placebo‐controlled, counterbalanced, crossover trial assessing daily pain levels

Abstract: Objective To determine whether low dosages (4.5 mg/day) of naltrexone reduce fibromyalgia severity as compared with the nonspecific effects of placebo. In this replication and extension study of a previous clinical trial, we tested the impact of low-dose naltrexone on daily self-reported pain. Secondary outcomes included general satisfaction with life, positive mood, sleep quality, and fatigue. Methods Thirty-one women with fibromyalgia participated in the randomized, double-blind, placebo-controlled, counterbalanced, crossover study. During the active drug phase, participants received 4.5 mg of oral naltrexone daily. An intensive longitudinal design was used to measure daily levels of pain. Results When contrasting the condition end points, we observed a significantly greater reduction of baseline pain in those taking low-dose naltrexone than in those taking placebo (28.8% reduction versus 18.0% reduction; P = 0.016). Low-dose naltrexone was also associated with improved general satisfaction with life (P = 0.045) and with improved mood (P = 0.039), but not improved fatigue or sleep. Thirty-two percent of participants met the criteria for response (defined as a significant reduction in pain plus a significant reduction in either fatigue or sleep problems) during low-dose naltrexone therapy, as contrasted with an 11% response rate during placebo therapy (P = 0.05). Low-dose naltrexone was rated equally tolerable as placebo, and no serious side effects were reported. Conclusion The preliminary evidence continues to show that low-dose naltrexone has a specific and clinically beneficial impact on fibromyalgia pain. The medication is widely available, inexpensive, safe, and well-tolerated. Parallel-group randomized controlled trials are needed to fully determine the efficacy of the medication.

A Smartphone-Based Intervention With Diaries and Therapist-Feedback to Reduce Catastrophizing and Increase Functioning in Women With Chronic Widespread Pain: Randomized Controlled Trial

Abstract: Background: Internet-based interventions using cognitive behavioral approaches can be effective in promoting self-management of chronic pain conditions. Web-based programs delivered via smartphones are increasingly used to support the self-management of various health disorders, but research on smartphone interventions for persons with chronic pain is limited. Objective: The aim of this trial was to study the efficacy of a 4-week smartphone-delivered intervention with written diaries and therapist feedback following an inpatient chronic pain rehabilitation program. Methods: A total of 140 women with chronic widespread pain who participated in a 4-week inpatient rehabilitation program were randomized into 2 groups: with or without a smartphone intervention after the rehabilitation. The smartphone intervention consisted of 1 face-to-face session and 4 weeks of written communication via a smartphone. Participants received 3 smartphone diary entries daily to support their awareness of and reflection on pain-related thoughts, feelings, and activities. The registered diaries were immediately available to a therapist who submitted personalized written feedback daily based on cognitive behavioral principles. Both groups were given access to a noninteractive website after discharge to promote constructive self-management. Outcomes were measured with self-reported questionnaires. The primary outcome measure of catastrophizing was determined using the pain catastrophizing scale (score range 0-52). Secondary outcomes included acceptance of pain, emotional distress, functioning, and symptom levels. Results: Of the 140 participants, 112 completed the study: 48 in the intervention group and 64 in the control group. Immediately after the intervention period, the intervention group reported less catastrophizing (mean 9.20, SD 5.85) than the control group (mean 15.71, SD 9.11, P <.001), yielding a large effect size (Cohen’s d =0.87) for study completers. At 5-month follow-up, the between-group effect sizes remained moderate for catastrophizing (Cohen’s d =0.74, P =.003), acceptance of pain (Cohen’s d =0.54, P =.02), and functioning and symptom levels (Cohen’s d =0.75, P =.001). Conclusions: The results suggest that a smartphone-delivered intervention with diaries and personalized feedback can reduce catastrophizing and prevent increases in functional impairment and symptom levels in women with chronic widespread pain following inpatient rehabilitation. Trial Registration: Clinicaltrials.gov NCT01236209; http://www.clinicaltrials.gov/ct2/show/NCT01236209 (Archived by WebCite at http://www.webcitation.org/6DUejLpPY) [J Med Internet Res 2013;15(1):e5]

Patterns of multisite pain and associations with risk factors.

Abstract: To explore definitions for multisite pain, and compare associations with risk factors for different patterns of musculoskeletal pain, we analysed cross-sectional data from the Cultural and Psychosocial Influences on Disability (CUPID) study. The study sample comprised 12,410 adults aged 20–59 years from 47 occupational groups in 18 countries. A standardised questionnaire was used to collect information about pain in the past month at each of 10 anatomical sites, and about potential risk factors. Associations with pain outcomes were assessed by Poisson regression, and characterised by prevalence rate ratios (PRRs). Extensive pain, affecting 6–10 anatomical sites, was reported much more frequently than would be expected if the occurrence of pain at each site were independent (674 participants vs 41.9 expected). In comparison with pain involving only 1–3 sites, it showed much stronger associations (relative to no pain) with risk factors such as female sex (PRR 1.6 vs 1.1), older age (PRR 2.6 vs 1.1), somatising tendency (PRR 4.6 vs 1.3), and exposure to multiple physically stressing occupational activities (PRR 5.0 vs 1.4). After adjustment for number of sites with pain, these risk factors showed no additional association with a distribution of pain that was widespread according to the frequently used American College of Rheumatology criteria. Our analysis supports the classification of pain at multiple anatomical sites simply by the number of sites affected, and suggests that extensive pain differs importantly in its associations with risk factors from pain that is limited to only a small number of anatomical sites.

Re-writing the natural history of pain and related symptoms in the joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type.

Abstract: Joint hypermobility syndrome (JHS) and Ehlers-Danlos syndrome, hypermobility type (EDS-HT) are two clinically overlapping connective tissue disorders characterized by chronic/recurrent pain, joint instability complications, and minor skin changes. Fatigue and headache are also common, although are not yet considered diagnostic criteria. JHS/EDS-HT is a unexpectedly common condition that remains underdiagnosed by most clinicians and pain specialists. This results in interventions limited to symptomatic and non-satisfactory treatments, lacking reasonable pathophysiologic rationale. In this manuscript the fragmented knowledge on pain, fatigue, and headache in JHS/EDS is presented with review of the available published information and a description of the clinical course by symptoms, on the basis of authors' experience. Pathogenic mechanisms are suggested through comparisons with other functional somatic syndromes (e.g., chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders). The re-writing of the natural history of JHS/EDS-HT is aimed to raise awareness among clinical geneticists and specialists treating chronic pain conditions about pain and other complications of JHS/EDS-HT. Symptoms' clustering by disease stage is proposed to investigate both the molecular causes and the symptoms management of JHS/EDS-HT in future studies.

Posttraumatic stress disorder in fibromyalgia syndrome: prevalence, temporal relationship between posttraumatic stress and fibromyalgia symptoms, and impact on clinical outcome.

Abstract: A link between fibromyalgia syndrome (FMS) and posttraumatic stress disorder (PTSD) has been suggested because both conditions share some similar symptoms. The temporal relationships between traumatic experiences and the onset of PTSD and FMS symptoms have not been studied until now. All consecutive FMS patients in 8 study centres of different specialties were assessed from February 1 to July 31, 2012. Data on duration of chronic widespread pain (CWP) were based on patients' self-reports. Potential traumatic experiences and year of most burdensome traumatic experience were assessed by the trauma list of the Munich Composite International Diagnostic Interview. PTSD was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders IV symptom criteria by the Posttraumatic Diagnostic Scale. Age- and sex-matched persons of a general population sample were selected for controls. Three hundred ninety-five of 529 patients screened for eligibility were analysed (93.9% women, mean age 52.3 years, mean duration since chronic widespread pain 12.8 years); 45.3% of FMS patients and 3.0% of population controls met the criteria for PTSD. Most burdensome traumatic experience and PTSD symptoms antedated the onset of CWP in 66.5% of patients. In 29.5% of patients, most burdensome traumatic experience and PTSD symptoms followed the onset of CWP. In 4.0% of patients' most burdensome traumatic experience, PTSD and FMS symptoms occurred in the same year. FMS and PTSD are linked in several ways: PTSD is a potential risk factor of FMS and vice versa. FMS and PTSD are comorbid conditions because they are associated with common antecedent traumatic experiences.

An Online Mindfulness Intervention Targeting Socioemotional Regulation in Fibromyalgia: Results of a Randomized Controlled Trial

Abstract: Background Patients with fibromyalgia (FM) experience pain as well as deficits in positive affect and social relations that are not explicitly addressed in most behavioral treatments. Purpose The purpose of this study is to compare the effects of a 12-module online intervention targeting socioemotional regulation via mindful awareness/acceptance (MSER) with those of an attention-control treatment, healthy lifestyle tips (HT). Methods Seventy-nine FM patients were randomly assigned to MSER or HT, with outcomes assessed via online diary reports of pain, coping efficacy, affect, and social relations. Multilevel analyses revealed greater improvements in social functioning, positive affect, and coping efficacy for pain and stress (all ps<.05) in MSER versus HT across the 6-week trial. Conclusions FM patients experience increases in selfefficacy for coping with pain and positive engagement in relationships, marginal increases in positive affect, and decreases in relationship stress from an automated online intervention that targets socioemotional regulation skills. Findings highlight the potential utility of widely accessible, low-cost intervention methods for fibromyalgia (Clinicaltrials.gov number NCT01748786).

Stress-Induced Allodynia – Evidence of Increased Pain Sensitivity in Healthy Humans and Patients with Chronic Pain after Experimentally Induced Psychosocial Stress

Abstract: Background Experimental stress has been shown to have analgesic as well as allodynic effect in animals Despite the obvious negative influence of stress in clinical pain conditions, stress-induced alteration of pain sensitivity has not been tested in humans so far Therefore, we tested changes of pain sensitivity using an experimental stressor in ten female healthy subjects and 13 female patients with fibromyalgia

Yoga for functional ability, pain and psychosocial outcomes in musculoskeletal conditions: a systematic review and meta-analysis.

Abstract: Objectives Musculoskeletal conditions (MSCs) are the leading cause of disability and chronic pain in the developed world, impacting both functional ability and psychosocial health. The current review investigates the effectiveness of yoga on primary outcomes of functional ability, pain and psychosocial outcomes across a range of MSCs. Methods A comprehensive search of 20 databases was conducted for full-text, randomized controlled trials of yoga in clinically diagnosed MSCs. Result Seventeen studies met the inclusion criteria, involving 1,626 participants with low back pain (LBP), osteoarthritis (OA), rheumatoid arthritis (RA), kyphosis or fibromyalgia. Studies were quality rated, and analysed for the effect of yoga on primary outcomes, immediately post-intervention. Twelve studies were rated as good quality. Yoga interventions resulted in a clinically significant improvement in functional outcomes in mild-to-moderate LBP and fibromyalgia, and showed a trend to improvement in kyphosis. Yoga significantly improved pain in OA, RA and mild-to-severe LBP. Psychosocial outcomes were significantly improved in mild-to-moderate LBP and OA. Meta-analysis of good-quality studies showed a moderate treatment effect for yoga of −0.64 (95%CI −0.89 to −0.39) for functional outcomes and −0.61 (95%CI −0.97 to −0.26) for pain outcomes. Conclusions Evidence suggests that yoga is an acceptable and safe intervention, which may result in clinically relevant improvements in pain and functional outcomes associated with a range of MSCs. Future analysis of outcomes which take into account the amount of yoga received by participants may provide insight into any putative duration or dosage effects of yoga interventions for MSCs. Copyright © 2013 John Wiley & Sons, Ltd.