Association of smoking and chronic pain syndromes in Kentucky women

Attentional Bias for Opioids in Taiwanese Heavy Smokers with Chronic Noncancer Pain

Background and Objectives: Attentional bias (AB) for addictive substances is a feature of attention found in individuals with substance misuse or diagnosed with substance use disorders. When AB exists, the attention of the addicted individual may be quickly oriented to cues related to the addictive substance or be maintained on these cues for a longer time. AB toward opioids was found in Western samples of smokers with chronic noncancer pain. The level of AB was dose-responsive. However, similar studies in the Taiwanese population are lacking. This study compared the patterns of AB for opioid analgesics in Taiwanese participants with chronic noncancer pain to that of individuals without pain. This study aimed to investigate if AB toward opioids is presented in Taiwanese heavy smokers who are on long-term opioid therapy for pain control. Materials and Methods: Participants were grouped into chronic noncancer pain smokers, chronic pain nonsmokers, and smokers without pain, according to smoking habits and whether or not on long-term opioid therapy for pain control. Each participant completed demographic questionnaires, mood scales, and the opioid-related visual probe task. Differences in AB among the groups were compared using a three-way analysis of covariance controlling for daily cigarette consumption. Results: Chronic noncancer pain smokers (n = 17) and chronic pain nonsmokers (n = 16) displayed more severe levels of depression, anxiety, and pain, compared to smokers without pain (n = 28). Only did chronic pain nonsmokers show significant AB for opioid cues that were displayed for a short time. Analysis on reaction time found that smokers without pain consistently responded faster to the tasks. No difference in reaction time was found between the pain groups. Conclusions: The current study did not fully replicate findings from studies that were based in Western countries. Formulary availability and regulatory limitations might have affected patient's perception of prescription opioids in Taiwan. However, chronic pain nonsmokers exhibited initial orientation toward opioid-related cues when daily cigarette consumption was accounted for. According to previous research, this AB for shortly displayed opioid cues can be associated with the expectation of pain relief. The current finding also indicated general psychomotor retardation in individuals who were on long-term use of opioids.

Lifestyle risk factors of self-reported fibromyalgia in the Norwegian Women and Cancer (NOWAC) study

BACKGROUND

While the aetiology of fibromyalgia syndrome (FM) remains unknown, lifestyle factors have been linked to the disorder. However, there are few studies on the association between lifestyle factors and FM, thus we examine the risk of self-reported fibromyalgia given selected lifestyle factors.

METHODS

We used data from 75,485 participants in the Norwegian Women and Cancer study. Information on FM and the lifestyle factors body mass index (BMI), physical activity level, smoking status/intensity, and alcohol consumption were obtained from baseline and follow-up questionnaires. We used Cox proportional hazards model to calculate hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

After a median follow-up time of 10 years, we observed 2,248 cases of self-reported fibromyalgia. Overweight (BMI 25-29.9 kg/m2) and obese (BMI ≥ 30 kg/m2) women had a relative risk of 1.34 (95% CI 1.21-1.47) and 1.62 (95% CI 1.41-1.87), respectively, compared to women with normal weight (BMI 18.5-24.9 kg/m2). Very low physical activity level (1-2) was associated with a 31% higher risk of self-reported fibromyalgia (HR 1.31, 95% CI 1.09-1.57) when compared to moderate physical activity level (5-6). There was a strong dose-response relationship between smoking status/intensity and self-reported fibromyalgia (p for trend < 0.001). Compared with moderate alcohol consumption (4.0-10 g/day), the risk of self-reported FM was 72% (HR 1.72; 95% CI 1.45-2.03) higher among teetotallers, and 38% (HR 1.38, 95% CI 1.23-1.54) higher among those with low consumption (0.1-3.9 g/day).

CONCLUSIONS

Overweight and obesity, very low physical activity level, smoking, and alcohol consumption were associated with an increased risk of self-reported FM.

The Effect of Smoking Cessation on Acute Pain: A Systematic Review

Smoking is a known risk factor for developing various pain-related disorders. However, acute pain often triggers the craving for cigarette consumption, resulting in a positive feedback mechanism. In addition, there is evidence of decreased pain tolerance during the early stages of abstinence. Therefore, in this study, we aimed to investigate whether a period of decreased pain tolerance and increased pain intensity occurs during smoking cessation. A systematic literature search was conducted through PubMed and Web of Science databases for controlled studies investigating the influence of smoking cessation on acute (defined as pain presentation of < 3 months) and postoperative pain. The outcomes of interest included pain perception threshold, pain tolerance, pain intensity, and postoperative opioid requirements. The search strategy yielded 1478 studies, of which 13 clinical studies met our inclusion criteria. The included studies collectively represented data from 1721 participants from four countries. Of these, 43.3% of the included individuals were females. The mean age of the included subjects was 44.2 ± 8.2 years. The duration of smoking cessation varied considerably. The shortest duration was 2 h; others investigated the effect after more than 1 month of smoking cessation. Smokers had a history of 14.6 ± 9.9 years of nicotine abuse. The mean number of daily smoked cigarettes was 17.5 ± 10.3. Most studies examined in this systematic review show a negative influence of smoking cessation on acute pain. However, the affected pain modalities, the duration of the altered pain perception, and whether male and female smokers are equally affected could not be ascertained due to high heterogeneity and few available studies.

Consensus statement on smoking cessation in patients with pain

Smoking is closely associated with the development of various cancers and tobacco-related illnesses such as cardiovascular and respiratory disorders. However, data are scarce on the relationship between smoking and both acute and chronic pain. In addition to nicotine, tobacco smoke contains more than 4000 different compounds. Although nicotine is not the sole cause of smoking-induced diseases, it plays a critical role in pain-related pathophysiology. Despite the acute analgesic effects of nicotine, long-term exposure leads to tolerance and increased pain sensitivity due to nicotinic acetylcholine receptor desensitization and neuronal plastic changes. The purpose of smoking cessation interventions in smoking patients with pain is primarily not only to reduce their pain and associated limitations in activities of daily living, but also to improve the outcomes of underlying pain-causing conditions and reduce the risks of tobacco-related disorders. This statement aims to summarize the available evidence on the impact of smoking on pain and to inform medical professionals of the significance of smoking cessation in patients with pain.

Place, Power, and Premature Mortality: A Rapid Scoping Review on the Health of Women in Appalachia

OBJECTIVE

Appalachian women continue to die younger than in other US regions. We performed a rapid scoping review to summarize women's health research in Appalachia from 2000 to 2019, including health topics, study populations, theoretical frameworks, methods, and findings.

DATA SOURCE

We searched bibliographic databases (eg, PubMed, PsycINFO, Google Scholar) for literature focusing on women's health in Appalachia.

STUDY INCLUSION AND EXCLUSION CRITERIA

Included articles were: (1) on women's health in Appalachia; (2) published January 2000 to June 2019; (3) peer-reviewed; and (4) written in English. We excluded studies without reported data findings.

DATA EXTRACTION

Two coders reviewed articles for descriptive information to create summary tables comparing variables of interest.

DATA SYNTHESIS

Two coders co-reviewed a sub-sample to ensure consensus and refine data charting categories. We categorized major findings across the social-ecological framework.

RESULTS

A search of nearly 2 decades of literature revealed 81 articles, which primarily focused on cancer disparities (49.4%) and prenatal/pregnancy outcomes (23.5%). Many of these research studies took place in Central Appalachia (eg, 42.0% in Kentucky) with reproductive or middle-aged women (82.7%). Half of the studies employed quantitative methods, and half used qualitative methods, with few mixed method or community-engaged approaches (3.7%). Nearly half (40.7%) did not specify a theoretical framework. Findings included complex multi-level factors with few articles exploring the co-occurrence of factors across multiple levels.

CONCLUSIONS

Future studies should: 1) systematically include Appalachian women at various life stages from under-represented sub-regions; 2) expand the use of rigorous methods and specified theoretical frameworks to account for complex interactions of social-ecological factors; and 3) build upon existing community assets to improve health in this vulnerable population.

Lifestyle Aspects As A Predictor Of Pain Among Oldest-Old Primary Care Patients - A Longitudinal Cohort Study

Purpose

Dealing with the high prevalence of pain among the oldest-old (+75) is becoming a major health issue. Therefore, the aim of the study was to uncover health-related lifestyle behaviors (HLB) and age-related comorbidities which may predict, influence and prevent pain in old age.

Patients and methods

In this longitudinal cohort study, data were obtained initially from 3.327 individuals aged 75+ from over 138 general practitioners (GP) during structured clinical interviews in 2003. Nine follow-ups (FU) were assessed until 2017. Available data from 736 individuals scoring in FU3 and FU7 were included in this analysis. Data were assembled in an ambulatory setting at participant's homes. Associations were tested using a linear regression model (model 1) and ordered logistic regression model (model 2).

Results

Statistical analyses revealed increased likelihood to experience pain for participants with comorbidities such as peripheral arterial disease (PAD) (coef. 13.51, P>t = 0.00) or chronic back pain (CBP) (coef. 6.64, P>t = 0.003) or higher body mass index (BMI) (coef. 0.57, P>t = 0.015) and, female gender (coef. 6.00, SE 3.0, t = 2.02, P>t = 0.044). Participants with medium education and former smokers showed significantly lower pain rating (coef. -5.05, P>t = 0.026; coef. -5.27, P>t = 0.026). Suffering from chronic back pain (OR = 2.03), osteoarthritis (OR = 1.49) or depressive symptoms (OR = 1.10) raised the odds to experience impairments in daily living due to pain. Physical activity showed no significant results.

Conclusion

Chronic conditions such as PAD, or CBP, female gender and higher BMI may increase the risk of experiencing more pain while successful smoking cessation can lower pain ratings at old age. Early and consistent support through GPs should be given to older patients in order to prevent pain at old age.

Remaining Pain in Early Rheumatoid Arthritis Patients Treated With Methotrexate

Objective

To investigate the frequency of remaining pain in early rheumatoid arthritis (RA) after 3 months of treatment with methotrexate as the only disease modifying antirheumatic drug, with a special focus on patients with a good clinical response.

Methods

The study base was cases reported to a population‐based early RA cohort who had followup data from the Swedish Rheumatology Quality Register (n = 1,241). The Disease Activity Score in 28 joints European League Against Rheumatism (EULAR) response criteria were used to evaluate clinical response to treatment as good, moderate, and no response. The primary end point was remaining pain at the 3‐months followup visit, defined as pain >20 mm on a 100‐mm visual analog scale (VAS).

Results

Remaining pain in spite of a EULAR good response at followup was associated with higher baseline disability, using the Health Assessment Questionnaire (adjusted odds ratio [OR] 2.2 [95% confidence interval (95% CI) 1.4–3.4] per unit increase), and less baseline inflammation, using the erythrocyte sedimentation rate (adjusted OR 0.81 [95% CI 0.70–0.93] per 10‐mm increase). Similar associations were detected for remaining pain at followup in spite of low inflammatory activity, defined as a C‐reactive protein level <10. Increase in VAS pain during the treatment period was observed in 19% of the whole cohort, with frequencies in the EULAR response groups of 9% (good response), 15% (moderate response), and 45% (no response).

Conclusion

These results are in line with the hypothesis that a subgroup of early RA patients exhibits pain that is not inflammatory mediated, where alternative treatment strategies to traditional antiinflammatory medications need to be considered.

Maternal Smoking During Pregnancy Is Associated With Offspring's Musculoskeletal Pain in Adolescence: Structural Equation Modeling

Introduction

Smoking and behavioral problems are related to musculoskeletal (MS) pain in adolescence. Maternal smoking during pregnancy (MSDP) is associated with offspring's behavioral problems but its relation to MS pain in adolescence is unknown. Our purpose was to investigate whether there is an association between MSDP, the number of pain sites in adolescence, and the factors that potentially mediate this relationship.

Methods

We evaluated the association of MSDP with offspring's MS pain at 16 years among participants of the Northern Finland Birth Cohort 1986 (n = 6436, 3360 girls, 68% of all births) using Chi-square test and independent samples t test. We used structural equation modeling to assess the mediating factors stratified by gender.

Results

MSDP was frequent (22%) associating with paternal smoking (p < .001), externalization problems at 8 years (p = .009 boys, p = .002 girls), offspring's smoking at 16 years (p < .001), externalizing problems at 16 years (p < .001), family's social class (p < .001) and intactness of the family status (p < .001). The mean number of offspring's MS pain sites was higher among adolescents whose mothers had smoked during pregnancy than among those whose mothers were nonsmokers (p = .002 boys, p = .012 girls). The association between MSDP and MS pain at 16 years was mediated by externalizing problems at 8 years (p < .001) and 16 years (p < 0.001).

Conclusions

MSDP increased the risk of offspring's MS pain in adolescence, and the association was mediated by offspring's externalizing problems during childhood and early adolescence.

Implications

This study indicates that MSDP increases the risk of MS pain in adolescence and the effect is mediated by externalizing problems. Our results add to the evidence on harmfulness of MSDP for offspring, and can be used as additional information in interventions aiming to influence MSDP.

Percutaneous Reduction and Screw Fixation of Displaced Intra-articular Fractures of the Calcaneus

BACKGROUND

Extensile open approaches to reduce and fix intra-articular calcaneal fractures are associated with high levels of wound complications. To avoid these complications, a technique of percutaneous reduction and fixation with screws alone was developed. This study assessed the clinical outcomes, radiographs, and postoperative CT scans after operative treatment with this technique.

METHODS

153 consecutive patients with 182 intra-articular calcaneal fractures were reviewed. All patients were assessed for early postoperative complications at 3 months from the injury. The clinical results were assessed for patients seen at a minimum of 1 year after surgery (mean follow-up of 2.6 years; 90 patients, 106 feet). In patients who had both preoperative and postoperative CT scans (50 patients, 60 feet), the articular reduction was quantitatively analyzed.

RESULTS

At the 3-month follow-up, there were 1% superficial infections and 1% rate of screw irritation. The complications at a minimum of 1 year after injury included screw irritation 9.3%, subtalar osteoarthritis requiring subtalar fusion 5.5%, malunion 1.8%, and deep infection 0.9%. Bohler angle, calcaneal facet height, and width were significantly improved postoperatively ( P < .01). Bohler angle increased on average +24.1 degrees postoperatively with a loss of angle of 4.9 degrees at the 3-month follow-up. There was significant improvement ( P < .01) in posterior talocalcaneal joint reduction on postoperative CT scan but residual displacement remained. At the final follow-up, 54.5% of the patients reported a residual pain level of 3 or lower.

CONCLUSION

This study suggests that reasonable early results could be achieved from the percutaneous treatment of intra-articular calcaneal fractures using screws alone based on articular reduction and level of residual pain.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Role of Stress and Smoking as Modifiable Risk Factors for Nonpersistent and Persistent Back Pain in Women

OBJECTIVE

The purpose of this study was to examine the association between smoking and stress with nonpersistent and persistent back pain.

MATERIALS AND METHODS

Participants included 3703 women who took part in the Kentucky Women's Health Registry in 2008 and 2011. Multivariate logistic regression modeling was used to examine whether smoking status and stress levels were predictive of nonpersistent and persistent back pain, controlling for sociodemographic characteristics.

RESULTS

Stress level was associated with both nonpersistent and persistent back pain, whereas smoking was associated with only persistent back pain. Current smokers were 1.5 times more likely to report persistent back pain compared with never smokers, controlling for age, race, body mass index, educational attainment, and employment status. Women experiencing large or overwhelming amounts of stress were 1.8 times more likely to have nonpersistent back pain and 1.6 times more likely to report persistent back pain, compared with women experiencing small amounts of stress.

DISCUSSION

This study further substantiates the findings of prior research that describes a significant relationship between back pain, stress, and smoking. Understanding the role of modifiable risk factors (ie, smoking and stress) and their impact on back pain provides an opportunity to offer a comprehensive and tailored treatment plan.

Impact of tobacco smoking on response to tumour necrosis factor-alpha inhibitor treatment in patients with ankylosing spondylitis: results from the Danish nationwide DANBIO registry

OBJECTIVES

To investigate the association between tobacco smoking and disease activity, treatment adherence and treatment responses in patients with AS treated with their first tumour necrosis factor-alpha inhibitor (TNFi) therapy in routine care.

METHODS

Observational cohort study based on the Danish nationwide DANBIO registry. Kaplan-Meier plots, Cox and logistic regression analyses by smoking status (current/never/previous) were calculated for treatment adherence and BASDAI 50%/20 mm-response. Additional stratified analyses were performed for gender and TNFi-type.

RESULTS

Of 1576 AS patients included in the study, 1425(90%) had known smoking status (current/never/previous: 43%/41%/16%). The median follow-up time was 2.02 years (IQR 0.69-5.01). At baseline, current smokers compared with never smokers had longer disease duration (4 years (1-12)/2 years (0-10)), higher BASDAI (61 mm (47-73)/58 mm (44-70)), BASFI (53 mm (35-69)/46 mm (31-66)) and BASMI (40 mm (20-60)/30 mm (10-50)) scores (all P < 0.01). Current and previous smokers had shorter treatment adherence than never smokers (current: 2.30 years (1.81-2.79) (median (95% CI)); previous: 2.48 years (1.56-3.40), never: 4.12 years (3.29-4.95)), P < 0.0001). Similar results were found in multivariate analyses (current versus never smokers, HR 1.41 (95% CI 1.21-1.65), P < 0.001), most pronounced among men. Current smokers had poorer 6 months' BASDAI50%/20 mm-response rate than never smokers (42%/58%, P < 0.001). In multivariate analyses, current smokers had lower odds of achieving BASDAI50%/20 mm-response than never smokers, both overall (OR 0.48 (95% CI 0.35-0.65), P < 0.0001) and for the different TNFi-types (adalimumab 0.45 (0.27-0.76)/etanercept 0.24 (0.10-0.61)/infliximab 0.57 (0.34-0.95)).

CONCLUSION

In this study of TNFi-treated AS patients in clinical practice, current and previous smokers had significantly poorer patient-reported outcomes at baseline, shorter treatment adherence and poorer treatment response compared with never smokers.

Diet-induced changes in n-3- and n-6-derived endocannabinoids and reductions in headache pain and psychological distress

Omega-3 and omega-6 fatty acids are biosynthetic precursors of endocannabinoids with antinociceptive, anxiolytic, and neurogenic properties. We recently reported that targeted dietary manipulation-increasing omega-3 fatty acids while reducing omega-6 linoleic acid (the H3-L6 intervention)-reduced headache pain and psychological distress among chronic headache patients. It is not yet known whether these clinical improvements were due to changes in endocannabinoids and related mediators derived from omega-3 and omega-6 fatty acids. We therefore used data from this trial (N = 55) to investigate 1) whether the H3-L6 intervention altered omega-3- and omega-6-derived endocannabinoids in plasma and 2) whether diet-induced changes in these bioactive lipids were associated with clinical improvements. The H3-L6 intervention significantly increased the omega-3 docosahexaenoic acid derivatives 2-docosahexaenoylglycerol (+65%, P < .001) and docosahexaenoylethanolamine (+99%, P < .001) and reduced the omega-6 arachidonic acid derivative 2-arachidonoylglycerol (-25%, P = .001). Diet-induced changes in these endocannabinoid derivatives of omega-3 docosahexaenoic acid, but not omega-6 arachidonic acid, correlated with reductions in physical pain and psychological distress. These findings demonstrate that targeted dietary manipulation can alter endocannabinoids derived from omega-3 and omega-6 fatty acids in humans and suggest that 2-docosahexaenoylglycerol and docosahexaenoylethanolamine could have physical and/or psychological pain modulating properties.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01157208) PERSPECTIVE: This article demonstrates that targeted dietary manipulation can alter endocannabinoids derived from omega-3 and omega-6 fatty acids and that these changes are related to reductions in headache pain and psychological distress. These findings suggest that dietary interventions could provide an effective, complementary approach for managing chronic pain and related conditions.

Mean platelet volume in patients with fibromyalgia

Fibromyalgia is a syndrome characterised by chronic widespread pain at multiple tender points, as well as joint stiffness and systemic symptoms. The aetiology and pathogenesis of fibromyalgia still remain unclear, although many contributory factors have been suggested. The presence of some common features between fibromyalgia and cardiovascular risk factors (e.g. depression and sleep disturbance) led to question of whether there is there a relationship between fibromyalgia and cardiovascular disease and/or atherosclerosis. Mean platelet volume, which is a determinant of platelet activation, is a newly emerging independent risk factor for cardiovascular disease.The present study was designed to evaluate levels of mean platelet volume in patients with fibromyalgia; the study population consisted of 283 individuals with this syndrome, who were compared with 72 healthy controls. Erythrocyte sedimentation rate, C-reactive protein, white blood cell count, platelet count and mean platelet volume levels were retrospectively recorded via the computerised patient database. The levels of mean platelet volume were significantly higher in the fibromyalgia group than in the control group (8.09 ± 0.84 fl and 7.73 ± 0.65 fl, respectively, p < 0.001). There were no statistical differences between groups with regard to platelet count and other parameters. These results suggest that an early atherosclerosis marker, mean platelet volume, is elevated in patients with fibromyalgia. This indicates increased platelet activation and therefore a higher risk of future cardiovascular disease.

Epigenetic regulation of persistent pain

Persistent or chronic pain is tightly associated with various environmental changes and linked to abnormal gene expression within cells processing nociceptive signaling. Epigenetic regulation governs gene expression in response to environmental cues. Recent animal model and clinical studies indicate that epigenetic regulation plays an important role in the development or maintenance of persistent pain and possibly the transition of acute pain to chronic pain, thus shedding light in a direction for development of new therapeutics for persistent pain.

Smoking is associated with reduced leptin and neuropeptide Y levels and higher pain experience in patients with fibromyalgia

Smoking deregulates neuroendocrine responses to pain supporting production of neuropeptide Y (NpY) by direct stimulation of nicotinic receptors or by inhibiting adipokine leptin. Present study addressed the effect of cigarette smoking on adipokines and pain parameters, in 62 women with fibromyalgia (FM) pain syndrome with unknown etiology. Pain was characterized by a visual analogue scale, tender point (TP) counts, pressure pain threshold, and neuroendocrine markers NpY and substance P (sP). Levels of IGF-1, leptin, resistin, visfatin, and adiponectin were measured in blood and cerebrospinal fluid. Current smokers (n = 18) had lower levels of leptin compared to ex-smokers (n = 25, P = 0.002), while the expected NpY increase was absent in FM patients. In smokers, this was transcribed in higher VAS-pain (P = 0.04) and TP count (P = 0.03), lower pain threshold (P = 0.01), since NpY levels were directly related to the pain threshold (rho = 0.414) and inversely related to TP counts (rho = −0.375). This study shows that patients with FM have no increase of NpY levels in response to smoking despite the low levels of leptin. Deregulation of the balance between leptin and neuropeptide Y may be one of the essential mechanisms of chronic pain in FM.

Understanding the relationship between smoking and pain

This review provides an overview of evidence regarding several key mechanisms pertinent to understanding the co-occurrence of smoking dependence and pain, both potentially costly conditions, and highlights treatment implications and future research directions. We describe each of pain and smoking dependence and introduce a revised integrative reciprocal model that explains their co-occurrence. We then provide a selective review of evidence pertinent to direct and indirect pathways between variables postulated in the model. We also provide general recommendations for improving assessment and treatment of smokers with clinically significant pain. We conclude with a targeted agenda for future investigation of the co-occurrence of smoking and pain. Empirical efforts directed at testing postulates of the proposed integrative model may yield a better understanding of the nature of the relationship between these prevalent and costly health conditions as well as evidence-based preventive and treatment strategies for people who experience nicotine dependence and pain-related disability.

General health status and incidence of first-onset temporomandibular disorder: the OPPERA prospective cohort study

Temporomandibular disorder (TMD) overlaps with other health conditions, but no study has examined which of these conditions increase the risk of developing first-onset TMD. The authors prospectively evaluated the relationship between health status at enrollment and subsequent incidence of TMD in 2,722 men and women. Participants aged 18 to 44 years had no history of TMD and were clinically free of TMD when enrolled in 2006 to 2008 at 4 U.S. study sites in the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) prospective cohort study. First-onset examiner-classified TMD developed in 260 people over a median 2.8 years of follow-up. Cox regression estimated the association between health conditions and TMD incidence while accounting for potential confounders. Incidence of first-onset TMD was 50% higher for people with low back pain (adjusted hazard ratio [AHR] = 1.50, 95% confidence limits [CLs]: 1.08, 2.10) and 75% higher for people with genital pain symptoms (AHR = 1.75, 95% CLs = 1.04, 2.93) than people without a history of these pain disorders. Digit ratio, a marker of intrauterine exposure to sex hormones, was significantly associated with TMD incidence. Other independent predictors of first-onset TMD were sleep disturbance and cigarette smoking. These findings reveal multiple influences of health status on incidence of first-onset TMD.

PERSPECTIVE

This article examines health conditions that commonly overlap with TMD to determine which ones predict first-onset TMD. A history of low back pain and genital pain conditions at baseline were important predictors. Novel findings were that disrupted sleep and conditions in utero may increase incidence of first-onset TMD.

Chronic widespread pain in patients with rheumatoid arthritis and the relation between pain and disease activity measures over the first 5 years

OBJECTIVE

To study the prevalence of chronic widespread pain (ChWP), chronic regional pain (ChRP), and fibromyalgia in patients with early rheumatoid arthritis (RA) followed for 5 years after inclusion, and to study the effect of pain on measures of disease activity and function.

METHODS

A questionnaire was sent to 1910 patients participating in the Better Anti-Rheumatic Pharmacotherapy study. The responders (73%) were divided into 3 groups according to the reported pain duration and distribution - patients having no chronic pain (NChP), ChWP, and ChRP. Outcome measures were the 28-joint Disease Activity Score (DAS28), the Health Assessment Questionnaire (HAQ), and C-reactive protein (CRP).

RESULTS

Thirty-four percent of respondents reported ChWP, 46% ChRP, and 20% NChP. Patients reporting ChWP were more often women and had more pain and tender joints at inclusion. From 6 months to 5 years of followup, mean DAS28, visual analog scale (VAS) pain, VAS global health, and HAQ were significantly higher in the ChWP group than in the other groups. However, all groups showed a similar pattern in swollen joint count, erythrocyte sedimentation rate (ESR), and CRP. From 12 months the ChWP group was treated with prednisolone to a greater extent than the ChRP group, and it had a rate of treatment with disease-modifying antirheumatic drugs similar to that of the ChRP group.

CONCLUSION

ChWP is a common feature in RA, more associated with high values for variables related to pain such as the DAS28 and HAQ than to indicators of ongoing inflammation such as swollen joint count, ESR, and CRP. Patients with ChWP should be identified so that adequate treatment also of the noninflammatory pain may be instituted.

The relationship among smoking, sleep, and chronic rheumatic conditions commonly associated with pain in the National Health Interview Survey

Chronic rheumatic conditions are typically characterized by chronic pain and are uniquely associated with increased rates of cigarette smoking and poor sleep quality. However, no study has examined the possible additive or interactive effects of these two health behaviors in individuals diagnosed with a chronic rheumatic condition. The goal of this study is to examine the relationship between cigarette smoking and sleep in a population sample of individuals diagnosed with a chronic rheumatic condition and related functional impairment. Cross sectional survey data was obtained from the 2007 National Health Interview Survey. Individuals diagnosed with a chronic rheumatic condition were more likely to be a former or current smoker compared to non-diagnosed individuals. Individuals with a chronic rheumatic condition were more likely to report <6 h of sleep per night and endorsed significantly more insomnia and daytime sleepiness. There was no interaction between diagnosis of a chronic rheumatic condition and smoking status on any of the sleep outcomes assessed. Finally, an interaction was observed suggesting individuals with a chronic rheumatic condition who currently smoke are more likely to report averaging <6 h of sleep per night and frequent insomnia compared to individuals with a chronic rheumatic condition who never smoked. These results suggest both a unique and additive relationship between smoking and sleep in individuals with a chronic rheumatic condition. Findings can likely be generalized to other conditions commonly associated with chronic pain.

Current smoking as a predictor of chronic musculoskeletal pain in young adult twins

Chronic pain is common during adolescence and young adulthood and is associated with poor quality of life, depression, and functional disability. Recognizing that chronic pain has significant consequences, it is important to identify modifiable health behaviors that may place young adults at risk for chronic pain. This study examines associations between chronic musculoskeletal pain and smoking in young adult twins (n = 1,588, ages 18-30) participating in a statewide twin registry. Twins completed questionnaires assessing smoking, mood (anxiety, depressive symptoms, and stress), and chronic musculoskeletal pain. Analyses examined associations between chronic pain and smoking, particularly the role of genetics/shared familial factors and psychological symptoms. As predicted, results revealed a near-2-fold increased risk for chronic musculoskeletal pain in twins who currently smoked compared to nonsmokers, even when accounting for psychological factors. Results of within-pair analyses were only minimally attenuated, suggesting that associations between smoking and chronic musculoskeletal pain are better accounted for by nonshared factors than by shared familial factors/genetic effects. Future twin research is needed to identify what nonshared factors (eg, attitudes, direct effects of smoking on pain) contribute to these associations to further understand comorbidity. Longitudinal studies and recruitment of participants prior to smoking initiation and chronic pain onset will better identify causal associations.

PERSPECTIVE

This article describes associations between musculoskeletal pain and smoking in young adult twins, taking into account psychological symptoms. Findings highlight the importance of nonshared factors in associations between pain and smoking and the need to explore the roles of lifestyle, individual attitudes, and direct effects of smoking on pain.

Foot pain and mobility limitations in older adults: the Framingham Foot Study

BACKGROUND

Foot pain is very common in the general population and has been shown to have a detrimental impact on health-related quality of life. This is of particular concern in older people as it may affect activities of daily living and exacerbate problems with balance and gait. The objective of this study is to evaluate the independent relationships between foot pain and mobility limitation in a population of community-dwelling older adults.

METHODS

Population-based cross-sectional study. Participants (n = 1,544) from the Framingham Foot Study (2002-2008) were assessed for physical performance. Foot pain was documented using the question "On most days, do you have pain, aching, or stiffness in either foot?" Mobility limitation was assessed using the Short Physical Performance Battery, dichotomized using 1-9 as an indicator of mobility limitation and 10-12 as no mobility limitation.

RESULTS

Foot pain was reported by 19% of men and 25% of women. After adjusting for age, obesity, smoking status, and depression, foot pain was significantly associated with mobility limitation in both men (odds ratio = 2.00, 95% confidence interval 1.14 - 3.50; p = .016) and women (odds ratio = 1.59, 95% confidence interval 1.03 - 2.46; p = .037).

CONCLUSION

In our study of older adults from the Framingham Foot Study, foot pain was associated with an increased odds of having mobility limitation in both men and women. Clinicians should consider assessment of foot pain in general examinations of older adults who are at risk of mobility limitation.

The Association of Chronic Back Pain and Stress Urinary Incontinence: A Cross-Sectional Study

OBJECTIVE

The objective of this study was to investigate the association between chronic back pain and urinary incontinence in women.

STUDY DESIGN

This study was a cross-sectional, observational study.

BACKGROUND

There are numerous factors associated with the development of back pain, yet little consideration has been given to the pelvic floor musculature and dysfunction of this musculature which may also cause urinary incontinence. Currently, limited research exists evaluating the relationship between back pain and urinary incontinence.

METHODS AND MEASURES

Data from a sample of 2,341 women from the Kentucky Women's Health Registry were used for analysis. The primary variables of interest were self-reported chronic back pain (CBP) and stress urinary incontinence (SUI), with stress urinary incontinence serving as the primary dependent variable. Simple comparisons were performed using chi-square tests and two-sample t-tests, and multivariable associations were assessed using binary logistic regression.

RESULTS

Reports of stress urinary incontinence were higher in women reporting CBP than those not reporting CBP (49.0% vs. 35.2%, p<0.01). After controlling for potential confounders, the adjusted SUI odds ratio for CBP versus not was 1.44 (95% CI 1.11, 1.86).

CONCLUSION

Women who report CBP have an increased odds of having SUI. Therefore, clinicians must consider this association and the relationship of relevant trunk muscles, including pelvic floor musculature, in patients presenting with CBP and/or UI.

The prevalence of smokers within chronic pain patients and highest pain levels versus comparison groups

OBJECTIVES.: The objectives of this study were to (1) compare the prevalence of smoking within chronic pain patients (CPPs) to community non-patients without pain (CNPWP), community patients with pain (CPWP), and acute pain patients (APPs); and (2) compare smokers to nonsmokers within CPPs, APPs, and CPWP for highest pain level. DESIGN.: CNPWP, CPWP, APPs, and CPPs were compared to each other for smoking status (nonsmoker, less than one pack per day, one pack/day or more, any amount per day). Within CPWP, APPs, and CPPs, smokers were also compared to nonsmokers by t-test for highest reported pain level. For both analyses, sub-analyses were performed controlling for age or gender, or race or education. RESULTS.: Utilizing all available patients, the prevalence of smokers within CPPs was significantly greater vs each of the comparison groups (CNPWP, CPWP, APPs). In the sub-analyses, only CPPs who were 38 or younger or male or White, or had some college or above were at greater risk than CPWP for smoking one pack or greater per day. CPP smokers were not significantly more likely than nonsmokers to have higher pain, and this was confirmed in the sub-analyses. CONCLUSIONS.: The prevalence of smokers could be significantly greater within CPPs vs CPWP. CPPs who smoke do not have higher levels of pain than nonsmoking CPPs.

Role of allostatic load in sociodemographic patterns of pain prevalence in the U.S. population

Persistent stressors associated with sociodemographic disadvantage exert a physiologic toll, labeled "allostatic load," that contributes to disparities in some health conditions. We investigated the contribution of allostatic load to pain prevalence in U.S. adults. Interviews with 14,184 adults in the 1999-2004 National Health and Nutrition Examination Survey asked about severe headache, pain that lasted >24 hours, and widespread pain. Ten biomarkers of allostatic load were quantified from blood (glycated hemoglobin), serum (C-reactive protein, homocysteine, cholesterol, triglycerides), urine (creatinine, albumin), and physical measurements (body mass index, systolic and diastolic blood pressure). Log-binomial regression models estimated prevalence ratios (PRs) and 95% confidence intervals (95% CIs). Prevalence ranged from 3.4% for widespread pain to 26.9% for pain >24 hours. After adjustment for demographic characteristics, low income was associated with greater prevalence of pain >24 hours (PR = 1.65, 95% CI = 1.49, 1.83), severe headache (PR = 2.05, 95% CI = 1.68, 2.50), and widespread pain (PR = 3.67, 95% CI = 2.56, 5.27). Racial/ethnic minorities had lower prevalence of all 3 pain conditions than non-Hispanic whites. While greater allostatic load was associated with elevated prevalence of pain, allostatic load did not meaningfully attenuate PRs associated with income or race/ethnicity. We conclude that greater pain prevalence among low-income groups is not explained by greater allostatic load.

PERSPECTIVE

In U.S. adults, pain occurs more frequently in lower-income groups, although the relationship is not attributable to their experience of greater allostatic load. While allostatic load contributes to population variation in pain, other etiologic mechanisms contributing to pain are needed to account for income disparities in pain.