Gender Differences Among Patients with Fibromyalgia Undergoing Multidisciplinary Pain Rehabilitation

The pain imaging revolution: advancing pain into the 21st century

The great advances in brain imaging techniques over the last few decades have determined a shift in our understanding of chronic pain conditions and opened the door for new opportunities to develop better diagnoses and perhaps better drug treatments. Neuroimaging has helped shape the concept of chronic pain from a disease affecting mainly the somatosensory system, to a condition in which emotional, cognitive, and modulatory areas of the brain are affected, in addition to degenerative processes. All these contribute to the development and maintenance of pain symptoms and comorbid features, including alterations in anxiety, depression, and cognitive processes. In this article the authors review the current understanding of the brain changes in chronic pain and the developments made possible by the use of various brain imaging techniques. They also discuss the possible applications of brain imaging to developing a "pain phenotype" that could aid in diagnostic and treatment choices of chronic pain conditions.

The effects of depression and smoking on pain severity and opioid use in patients with chronic pain

Depression and smoking are common comorbid conditions among adults with chronic pain. The aim of this study was to determine the independent effects of depression on clinical pain and opioid use among patients with chronic pain according to smoking status. A retrospective design was used to assess baseline levels of depression, clinical pain, opioid dose (calculated as morphine equivalents), and smoking status in a consecutive series of patients admitted to a 3-week outpatient pain treatment program from September 2003 through February 2007. Depression was assessed using the Centers for Epidemiologic Studies-Depression scale, and clinical pain was assessed using the pain severity subscale of the Multidimensional Pain Inventory. The study cohort (n=1241) included 313 current smokers, 294 former smokers, and 634 never smokers. Baseline depression (P=.001) and clinical pain (P=.001) were greater among current smokers compared to former and never smokers, and the daily morphine equivalent dose was greater among smokers compared to never smokers (P=.005). In multivariate linear regression analyses, baseline pain severity was independently associated with greater levels of depression, but not with smoking status. However, status as a current smoker was independently associated with greater opioid use (by 27mg/d), independent of depression scores. The relationship between depression, smoking status, opioid use, and chronic pain is complex, and both depression and smoking status may be potentially important considerations in the treatment of patients with chronic pain who utilize opioids. This study found that pain severity was associated with greater depression but not smoking; however, smoking was associated with greater opioid use, independent of depression.

Fibromyalgia: diagnosis and treatment options

BACKGROUND

Fibromyalgia is a widespread, chronic pain disorder that includes a complex constellation of somatic and emotional symptoms. Controlled clinical trials for both medication and nonmedication therapies have led to sound, evidence-based recommendations for the care of patients with fibromyalgia.

OBJECTIVE

This review article was designed to provide updated information from database literature searches on fibromyalgia epidemiology, including gender differences, psychological comorbidity, and treatment with medication and nonmedication therapies.

METHODS

A literature review was performed by identifying fibromyalgia articles published in English from January 2000 to October 2008 using the PubMed and EMBASE databases. Search terms included fibromyalgia, exercise, gender, nonpharmacologic, placebo-controlled, randomized, and treatment.

RESULTS

New epidemiologic data support important differences in fibromyalgia symptom severity between the sexes and the important role of comorbid psychological distress. Physicians diagnose fibromyalgia in women at an approximately 3- to 6-fold rate compared with men. Well-conducted clinical trials and recently published treatment guidelines reinforce effective treatment with medication and nonpharmacologic therapy. The strongest evidence suggests effective treatment of fibromyalgia with duloxetine and milnacipran. Studies also report efficacy with gabapentin, pramipexole, pregabalin, tramadol, and IV tropisetron. Nonpharmacologic treatments should include fitness and strengthening exercise, as well as warm-water therapy and psychological pain management techniques.

CONCLUSIONS

Fibromyalgia is a common, disabling, chronic pain condition that predominantly affects women. Symptoms can be effectively treated using both drug and nondrug therapies. In general, treatment benefits in fibromyalgia appear largely independent of patient sex.

Does multidisciplinary assessment of long-term sickness absentees result in modification of sick-listing diagnoses?

AIMS

The aim was to study whether sick-leave diagnoses of long-term sickness absentees were modified after a multidisciplinary assessment and if modifications differed with type of medical specialty of the latest physician to sick-list the patient.

METHODS

A sample of 635 long-term sickness absentees referred to a multidisciplinary assessment by Social Insurance Offices was included. Data were obtained through sickness certificates and medical records. Patients were examined by board-certified specialists in psychiatry, orthopaedic surgery, and rehabilitation medicine. Descriptive statistics were used.

RESULTS

The multidisciplinary assessment resulted in an increase from 1-2 to 2-3 diagnoses for most patients. Forty-five per cent of the male and 47% of the female patients had only somatic diagnoses at referral. After the multidisciplinary assessment these percentages were 20% and 29%, respectively. The rate of women and men given both psychiatric and somatic diagnoses increased from 30% at referral to about 55%. The shift from either only psychiatric or only somatic diagnoses to having these diagnoses in combination was associated with type of specialty of the physician who had sick-listed the patient.

CONCLUSIONS

The study indicates that many patients on long-term sick-leave with unclear diagnoses may suffer from unrecognized, and therefore probably untreated, medical disorders and co-morbidity.

Sex and gender in psychoneuroimmunology research: past, present and future

To date, research suggests that sex and gender impact pathways central to the foci of psychoneuroimmunology (PNI). This review provides a historical perspective on the evolution of sex and gender in psychoneuroimmunology research. Gender and sexually dimorphic pathways may have synergistic effects on health differences in men and women. We provide an overview of the literature of sex and gender differences in brain structure and function, sex steroids, gender role identification, hypothalamic-pituitary-adrenal axis function, genetics, immunology and cytokine response. Specific examples shed light on the importance of attending to sex and gender methodology in PNI research and recommendations are provided.

Can Heterogeneity of Chronic Sickle-Cell Disease Pain Be Explained by Genomics? A Literature Review

This literature review explores the potential of genomics to explain, or at least contribute to the discussion about, heterogeneity in chronic pain in sickle-cell disease (SCD). Background: Adults with SCD, a single-gene disorder, are living longer than in years past, yet report being burdened by chronic pain. With only a few studies on chronic pain in this population, the epidemiology is unclear. However, research in the area of pain genetics continues to advance since the conclusion of the Human Genome Project. Two pain susceptibility genes, catechol-O-methyltransferase (COMT) and cytochrome P450, have, to date, been discovered that can increase individual susceptibility to the development of chronic pain. Method: A search was conducted in PubMed, CINAHL, and EBSCO using the terms ``sickle cell,'' ``chronic pain,'' ``polymorphism,'' ``genetics,'' ``pain genetics,'' ``human,'' ``adult,'' ``association studies,'' and ``pain susceptibility genes'' to search for articles published between 1970 and 2008. Findings: Chronic pain generally is more prevalent and severe than previously reported, and individuals with SCD report daily pain. The genomic era has made it possible for scientists to identify pain susceptibility genes that contribute to variability in the interindividual experience of chronic pain. Conclusion: Nurses are well positioned to generate and translate genomic research, thus improving care delivery. Such research may lead to the identification of polymorphisms associated with pain sensitivity in individuals with SCD.

The meaning and process of pain acceptance. Perceptions of women living with arthritis and fibromyalgia

BACKGROUND

Within the past 10 years, cognitive-behavioural pain management models have moved beyond the traditional focus on coping strategies and perceived control over pain, to incorporate mindfulness- and acceptance-based approaches. Pain acceptance is the process of giving up the struggle with pain and learning to live life despite pain. Acceptance is associated with lower levels of pain, disability and psychological distress. Relatively little is known, however, about how patients arrive at a state of acceptance without the aid of therapy.

OBJECTIVES

To explore personal definitions of acceptance and the factors that facilitate or hinder acceptance.

METHODS

Eleven focus groups, involving a total of 45 women with arthritis and fibromyalgia, were conducted.

RESULTS

The qualitative analysis revealed that, while the women rejected the word 'acceptance', they did agree with the main components of existing research definitions. The women's responses revealed that acceptance was a process of realizations and acknowledgements, including realizing that the pain was not normal and help was needed, receiving a diagnosis, acknowledging that there was no cure and realizing that they needed to redefine 'normal'. Diagnosis, social support, educating self and others, and self-care were factors that promoted acceptance. Struggling to retain a prepain identity, negative impacts on relationships, others not accepting their pain and the unspoken message that the pain was 'all in their head' were barriers to acceptance.

CONCLUSION

The implications of these findings, distinctions between the diagnostic groups and recommendations regarding how health professionals can facilitate the process of acceptance are discussed.

A longitudinal study of the efficacy of a comprehensive pain rehabilitation program with opioid withdrawal: comparison of treatment outcomes based on opioid use status at admission

Use of opioids for chronic non-cancer pain is controversial and the efficacy of comprehensive pain rehabilitation programs (CPRPs) that incorporate opioid withdrawal requires further investigation. We test the hypothesis that patients with chronic pain and longstanding opioid use who undergo opioid withdrawal in the course of rehabilitative treatment will experience significant and sustained improvement in pain and functioning similar to patients who were not taking opioids. A longitudinal design study compared 373 consecutive patients admitted to the Mayo Clinic Pain Rehabilitation Center at admission, discharge and six-month posttreatment by opioid status at admission. Measures of pain severity, depression, psychosocial functioning, health status, and pain catastrophizing were used to assess between- and within-group differences. Treatment involved a 3-week interdisciplinary pain rehabilitation program focused on functional restoration. Over one-half of patients (57.1%) were taking opioids daily at admission. The majority of patients (91%) completed rehabilitation and 70% of patients who completed the program returned questionnaires six months posttreatment. On admission, patients taking low- and high-dose opioids reported significantly greater pain severity (P=.001) and depression (P=.001) than the non-opioid group. Significant improvement was found on all outcome variables following treatment (P<.001) and six-month posttreatment (P<.001) regardless of opioid status at admission. There were no differences between the opioid and non-opioid groups upon discharge from the program or at six months following treatment.

CONCLUSION

Patients with longstanding CPRP on chronic opioid therapy, who choose to participate in interdisciplinary rehabilitation that incorporates opioid withdrawal, can experience significant and sustained improvement in pain severity and functioning.