Chronic musculoskeletal pain in chronic fatigue syndrome: Recent developments and therapeutic implications

ROLE OF MANUAL THERAPY AND MASSAGE IN THE TREATMENT OF FIBROMYALGIA: TESTING THE HYPOTHESIS

Fibromyalgia syndrome (FMS) is a chronic rheumatic disease in which pain is predominant and accompanied by fatigue, anxiety, depression, sleep disturbance and cognitive dysfunction. Although there are numerous pharmacological and non-pharmacological therapeutic alternatives, symptom control is frequently problematic. Manual therapy covers manipulating soft tissue and various joints using the hands. It is organized by mapping of soft tissue structures with rhythmically applied pressure to improve physical function, facilitate daily activities, promote rehabilitation procedures and decrease pain.  Massage is generally accepted as an essential component of manual therapy. Stretching and mobilizations are also part of manual therapy. Although numerous beneficial effects of manual therapy and massage on the musculoskeletal system and pain have been proven, the data in FMS patients studies are inconclusive. We hypothesize that manual therapy and massage are beneficial therapeutic options for the control of symptoms of FMS patients. Furthermore, these strategies can be employed in conjunction with well-established and high-evidence therapeutic procedures. Future research should focus on establishing standardized protocols for manual therapy and massage, which is one of the major limitations. To ensure a high level of evidence, research studies with large sample sizes, long follow-up periods and methodologically complete are needed.

Testing a newly developed activity pacing framework for chronic pain/fatigue: a feasibility study

OBJECTIVES

To test the feasibility of using a new activity pacing framework to standardise healthcare professionals' instructions of pacing, and explore whether measures of activity pacing/symptoms detected changes following treatment.

DESIGN

Single-arm, repeated measures study.

SETTING

One National Health Service (NHS) Pain Service in Northern England, UK.

PARTICIPANTS

Adult patients with chronic pain/fatigue, including chronic low back pain, chronic widespread pain, fibromyalgia and chronic fatigue syndrome/myalgic encephalomyelitis.

INTERVENTIONS

Six-week rehabilitation programme, standardised using the activity pacing framework.

OUTCOME MEASURES

Feasibility was explored via patients' recruitment/attrition rates, adherence and satisfaction, and healthcare professionals' fidelity. Questionnaire data were collected from patients at the start and end of the programme (T1 and T2, respectively) and 3 months' follow-up (T3). Questionnaires included measures of activity pacing, current/usual pain, physical/mental fatigue, depression, anxiety, self-efficacy, avoidance, physical/mental function and quality of life. Mean changes in activity pacing and symptoms between T1-T2, T2-T3 and T1-T3 were estimated.

RESULTS

Of the 139 eligible patients, 107 patients consented (recruitment rate=77%); 65 patients completed T2 (T1-T2 attrition rate=39%), and 52 patients completed T3 (T1-T3 attrition rate=51%). At T2, patients' satisfaction ratings averaged 9/10, and 89% attended ≥5 rehabilitation programme sessions. Activity pacing and all symptoms improved between T1 and T2, with smaller improvements maintained at T3.

CONCLUSION

The activity pacing framework was feasible to implement and patients' ability to pace and manage their symptoms improved. Future work will employ a suitable comparison group and test the framework across wider settings to explore the effects of activity pacing in a randomised controlled trial.

TRIAL REGISTRATION NUMBER

NCT03497585.

Oxidative Stress and Musculoskeletal Pain in University Students with Generalized Joint Hypermobility: A Case-Control Study

Objective

The current case–control study aimed to evaluate generalized joint hypermobility (GJH) and its association with pain intensity, cellular oxidative stress, and collagen-associated disorders in university students aged 18–25 years old.

Background

Joint hypermobility has been recognized in healthy subjects and people who are carriers of cellular disorders in connective tissues. Cellular tissue oxidative stress and collagen-associated disorders were shown to be associated with joint hypermobility (JH).

Materials and Methods

A total of 300 university students aged 18–25 years were randomly invited from different medical and science faculties in Mansoura university, Mansoura, Egypt to participate in this case–control study. Only 280 university students who had no exclusion criteria like chronic health problems, physical disability, musculoskeletal disorders, and body mass index (BMI) of ≥25 underwent an initial clinical interview and Beighton scoring as measures of GJH. Pain intensity, physical activity, oxidative stress parameters; TAC, TOC, OSI, and collagen-associated parameters; cellular prolidase activity and hydroxyproline were evaluated by using a prevalidated questionnaire, colorimetric, and immunoassay techniques.

Results

GJH was significantly reported in 57.1% of the study population, and most of them are females. Compared to men, females with GJH showed poor physical activity, lower TAC, and significantly higher levels of TOC, OSI, cellular prolidase activity, and hydroxyproline. Based on our findings, a high Beighton score is closely related to the tissue levels of prolidase, hydroxyproline, antioxidant activity, pain intensity, and poor physical activity in the female with GJH compared to men.

Conclusion

GJH was significantly reported in 57.1% of the study population, and most of them are females. The incidence of GJH showed to be associated with poor physical activity, abnormal cellular oxidative stress, and collagen abnormalities measured by significant increase in change in cellular prolidase activity and hydroxyproline.

The role of self-efficacy and catastrophizing in explaining improvements in disability, pain and fatigue among patients with chronic widespread pain treated with physiotherapy: an exploratory analysis

OBJECTIVES

Most research exploring the relationship between cognitive factors (catastrophizing and self-efficacy beliefs) and levels of pain, disability and fatigue in patients with chronic widespread pain has been performed in multidisciplinary environments. It is less clear whether these associations are valid in other clinical environments. This study therefore aimed to establish whether changes in cognitive factors were related to changes in pain, disability and fatigue among patients treated in a physiotherapy-led symptom management programme.

DESIGN

A longitudinal pre-post treatment study. Regression analyses were performed with change in pain, disability, physical and mental fatigue as the dependent measures. Demographics, change in pain and fatigue (when not dependent variables) and cognitive factors were entered as independent variables. β values were calculated for the final model.

SETTING

Two out-patient physiotherapy departments in Manchester, UK.

PARTICIPANTS

Fifty patients with persistent widespread pain.

INTERVENTION

A physiotherapist-led symptom management programme.

MAIN OUTCOME MEASURES

Disability (Fibromyalgia Impact Questionnaire), Pain (Numeric Pain Rating Scale and Fatigue (Chalder Fatigue Scale) RESULTS: Significant changes in disability, fatigue and cognitive factors were observed after treatment. Changes in self-efficacy beliefs (β=-0.38, P<0.05) and catastrophizing (β=0.41, P<0.05) were significantly related to reductions in disability. There was no significant relationship between change in the cognitive variables and change in pain or fatigue.

CONCLUSIONS

Self-efficacy beliefs and catastrophizing were important determinants of change in disability, but not pain or fatigue among patients with chronic widespread pain attending physiotherapy. Cognitively-informed physiotherapy appeared to be effective in reducing disability and fatigue and modifying cognitive factors. Such interventions may offer an effective treatment option for patients with chronic widespread pain and future randomised controlled trials are required to fully assess this.

Multisystemic manifestations in a cohort of 75 classical Ehlers-Danlos syndrome patients: natural history and nosological perspectives

Background

The Ehlers-Danlos syndromes (EDS) are rare connective tissue disorders consisting of 13 subtypes with overlapping features including joint hypermobility, skin and generalized connective tissue fragility. Classical EDS (cEDS) is principally caused by heterozygous COL5A1 or COL5A2 variants and rarely by the COL1A1 p.(Arg312Cys) substitution. Current major criteria are (1) skin hyperextensibility plus atrophic scars and (2) generalized joint hypermobility (gJHM). Minor criteria include additional mucocutaneous signs, epicanthal folds, gJHM complications, and an affected first-degree relative. Minimal criteria prompting molecular testing are major criterion 1 plus either major criterion 2 or 3 minor criteria. In addition to these features, the clinical picture also involves multiple organ systems, but large-scale cohort studies are still missing. This study aimed to investigate the multisystemic involvement and natural history of cEDS through a cross-sectional study on a cohort of 75 molecularly confirmed patients evaluated from 2010 to 2019 in a tertiary referral center. The diagnostic criteria, additional mucocutaneous, osteoarticular, musculoskeletal, cardiovascular, gastrointestinal, uro-gynecological, neuropsychiatric, and atopic issues, and facial/ocular features were ascertained, and feature rates compared by sex and age.

Results

Our study confirms that cEDS is mainly characterized by cutaneous and articular involvement, though none of their hallmarks was represented in all cases and suggests a milder multisystemic involvement and a more favorable natural history compared to other EDS subtypes. Abnormal scarring was the most frequent and characteristic sign, skin hyperextensibility and gJHM were less common, all without any sex and age bias; joint instability complications were more recurrent in adults. Some orthopedic features showed a high prevalence, whereas the other issues related to the investigated organ systems were less recurrent with few exceptions and age-related differences.

Conclusions

Our findings define the diagnostic relevance of cutaneous and articular features and additional clinical signs associated to cEDS. Furthermore, our data suggest an update of the current EDS nosology concerning scarring that should be considered separately from skin hyperextensibility and that the clinical diagnosis of cEDS may be enhanced by the accurate evaluation of orthopedic manifestations at all ages, faciocutaneous indicators in children, and some acquired traits related to joint instability complications, premature skin aging, and patterning of abnormal scarring in older individuals.

Engaging stakeholders to refine an activity pacing framework for chronic pain/fatigue: A nominal group technique

OBJECTIVES

Due to the current absence of a standardized guide for activity pacing, the concept of pacing is interpreted in various ways by healthcare professionals, patients and researchers. Consequently, the effects of pacing across different conditions are unclear. The present study aimed to undertake the second stage in the development of an activity pacing framework for chronic pain/fatigue.

METHODS

The newly developed activity pacing framework was refined using a consensus method. A nominal group technique (NGT) was selected to engage stakeholders to reach agreement on the top 10 priorities for inclusion in the framework and accompanying appendices. Participants included patients with diagnoses of chronic pain/fatigue and healthcare professionals working in fields of chronic pain/fatigue.

RESULTS

Ten participants were recruited via purposive sampling: four patients, two physiotherapists, two occupational therapists and two psychological wellbeing practitioners. The top priorities for the pacing framework included a clear definition of pacing, and stating the aims and context of pacing. The appendices were refined as a teaching guide, including priorities of detailing the stages of pacing, the overactivity-underactivity cycle/pain cycle and goal setting.

CONCLUSIONS

Incorporating a diverse panel of stakeholders was an effective and inclusive method to refine the activity pacing framework. The framework has been purposefully designed for wider use across patients with chronic pain/fatigue and by various healthcare professionals. The framework provides a comprehensive definition, background and manual for healthcare professionals to instruct activity pacing. Further study will test the clinical usability of the framework, to enable the standardization of activity pacing in future investigations.

Advances in dermatology using DNA aptamer "Aptamin C" innovation: Oxidative stress prevention and effect maximization of vitamin C through antioxidation

BACKGROUND

Vitamin C (also known as L-ascorbic acid) plays a critical role in reactive oxygen species (ROS) reduction and cell regeneration by protecting cell from oxidative stress. Although vitamin C is widely used in cosmetic and therapeutic markets, there is considerable evidence that vitamin C easily undergoes oxidation by air, pH, temperature, and UV light upon storage. This deficiency of vitamin C decreases its potency as an antioxidant and reduces the shelf-life of products containing vitamin C as its ingredient. To overcome the deficiency of vitamin C, we have developed Aptamin C, an innovative DNA aptamer maximizing the antioxidant efficacy of vitamin C by binding to the reduced form of vitamin C and delaying its oxidation.

METHODS

Binding of Aptamin C with vitamin C was determined using ITC analysis. ITC experiment was performed 0.2 mmol/L vitamin C that was injected 25 times in 2 µL aliquots into the 1.8 mL sample cell containing the Aptamin C at a concentration of 0.02 mmol/L. The data were fitted to a one-site binding isotherm using with origin program for ITC v.5.0.

RESULTS

To investigate the effect of Aptamin C and vitamin C complex in human skins, both in vitro and clinical tests were performed. We observed that the complex of Aptamin C and vitamin C was significantly effective in wrinkle improvement, whitening effect, and hydration increase. In the clinical test, subjects treated with the complex showed dramatic improvement in skin irritation and itching. No adverse reaction was presented by Aptamin C complex in the test.

CONCLUSION

Taken together, these results showed that Aptamin C, an innovative novel compound, should potentially be served as a key cosmeceutical ingredient for a range of skin conditions.

Antioxidant, antibacterial, antidiarrheal and antipyretic activities of organic crude fractions of Commelina paludosa

Background:

The herb, Commelina paludosa (CP) Blume (Family-Commelinaceae) is medicinally used by the traditional practitioners in Bangladesh. However, there is a lack of scientific evidence on this medicinal herb.

Aim and Objectives:

This study aimed to evaluate the phytochemical and pharmacological activities of CP (ethanol [ECP], chloroform [CCP] and n-hexane [NHCP] of whole-plant extracts).

Materials and Methods:

For this antioxidant, antimicrobial, antidiarrheal and antipyretic activities of crude extracts of CP were conducted by 1,1-diphenyl-2-picrylhydrazyl (DPPH) scavenging, disc diffusion and serial dilution, castor oil-induced diarrhea and yeast powder-induced pyrexia methods respectively.

Results and Observation:

The results suggest that all the fractions significantly scavenged DPPH radicals. In the disc diffusion test, the zones of inhibition were observed within the range of 7 mm to 30.67 mm at 500 mg/disc. The highest zones of inhibition were observed by ECP, CCP and NHCP against Bacillus azotoformans, Lactobacillus coryifomis and Salmonella typhi respectively. NHCP was found to exert stronger antibacterial effect than the ECP and CCP.

Conclusion:

Minimum inhibitory concentrations were detected within the range of 31.25 and 250 μg/ml. Moreover, the crude fractions also showed significant (P < 0.05) antidiarrheal and antipyretic activities in Swiss mice. CP may be a good source of therapeutic components.

Treatment and management of chronic fatigue syndrome/myalgic encephalomyelitis: all roads lead to Rome

This review explores the current evidence on benefits and harms of therapeutic interventions in chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) and makes recommendations. CFS/ME is a complex, multi-system, chronic medical condition whose pathophysiology remains unknown. No established diagnostic tests exist nor are any FDA-approved drugs available for treatment. Because of the range of symptoms of CFS/ME, treatment approaches vary widely. Studies undertaken have heterogeneous designs and are limited by sample size, length of follow-up, applicability and methodological quality. The use of rintatolimod and rituximab as well as counselling, behavioural and rehabilitation therapy programs may be of benefit for CFS/ME, but the evidence of their effectiveness is still limited. Similarly, adaptive pacing appears to offer some benefits, but the results are debatable: so is the use of nutritional supplements, which may be of value to CFS/ME patients with biochemically proven deficiencies. To summarize, the recommended treatment strategies should include proper administration of nutritional supplements in CFS/ME patients with demonstrated deficiencies and personalized pacing programs to relieve symptoms and improve performance of daily activities, but a larger randomized controlled trial (RCT) evaluation is required to confirm these preliminary observations. At present, no firm conclusions can be drawn because the few RCTs undertaken to date have been small-scale, with a high risk of bias, and have used different case definitions. Further, RCTs are now urgently needed with rigorous experimental designs and appropriate data analysis, focusing particularly on the comparison of outcomes measures according to clinical presentation, patient characteristics, case criteria and degree of disability (i.e. severely ill ME cases or bedridden).

Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history

The hypermobile type of Ehlers-Danlos syndrome (hEDS) is likely the most common hereditary disorder of connective tissue. It has been described largely in those with musculoskeletal complaints including joint hypermobility, joint subluxations/dislocations, as well as skin and soft tissue manifestations. Many patients report activity-related pain and some go on to have daily pain. Two undifferentiated syndromes have been used to describe these manifestations-joint hypermobility syndrome and hEDS. Both are clinical diagnoses in the absence of other causation. Current medical literature further complicates differentiation and describes multiple associated symptoms and disorders. The current EDS nosology combines these two entities into the hypermobile type of EDS. Herein, we review and summarize the literature as a better clinical description of this type of connective tissue disorder. © 2017 Wiley Periodicals, Inc.

Assessing the Psychometric Properties of an Activity Pacing Questionnaire for Chronic Pain and Fatigue

BACKGROUND

Therapists frequently advise the use of activity pacing as a coping strategy to manage long-term conditions (eg, chronic low back pain, chronic widespread pain, chronic fatigue syndrome/myalgic encephalomyelitis). However, activity pacing has not been clearly operationalized, and there is a paucity of empirical evidence regarding pacing. This paucity of evidence may be partly due to the absence of a widely used pacing scale. To address the limitations of existing pacing scales, the 38-item Activity Pacing Questionnaire (APQ-38) was previously developed using the Delphi technique.

OBJECTIVE

The aims of this study were: (1) to explore the psychometric properties of the APQ-38, (2) to identify underlying pacing themes, and (3) to assess the reliability and validity of the scale.

DESIGN

This was a cross-sectional questionnaire study.

METHODS

Three hundred eleven adult patients with chronic pain or fatigue participated, of whom 69 completed the test-retest analysis. Data obtained for the APQ-38 were analyzed using exploratory factor analysis, internal and test-retest reliability, and validity against 2 existing pacing subscales and validated measures of pain, fatigue, anxiety, depression, avoidance, and mental and physical function.

RESULTS

Following factor analysis, 12 items were removed from the APQ-38, and 5 themes of pacing were identified in the resulting 26-item Activity Pacing Questionnaire (APQ-26): activity adjustment, activity consistency, activity progression, activity planning, and activity acceptance. These themes demonstrated satisfactory internal consistency (Cronbach α=.72-.92), test-retest reliability (intraclass correlation coefficient=.50-.78, P≤.001), and construct validity. Activity adjustment, activity progression, and activity acceptance correlated with worsened symptoms; activity consistency correlated with improved symptoms; and activity planning correlated with both improved and worsened symptoms.

LIMITATIONS

Data were collected from self-report questionnaires only.

CONCLUSIONS

Developed to be widely used across a heterogeneous group of patients with chronic pain or fatigue, the APQ-26 is multifaceted and demonstrates reliability and validity. Further study will explore the effects of pacing on patients' symptoms to guide therapists toward advising pacing themes with empirical benefits.

Metabolism in chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is a poorly understood condition that presents as long-term physical and mental fatigue with associated symptoms of pain and sensitivity across a broad range of systems in the body. The poor understanding of the disorder comes from the varying clinical diagnostic definitions as well as the broad array of body systems from which its symptoms present. Studies on metabolism and CFS suggest irregularities in energy metabolism, amino acid metabolism, nucleotide metabolism, nitrogen metabolism, hormone metabolism, and oxidative stress metabolism. The overwhelming body of evidence suggests an oxidative environment with the minimal utilization of mitochondria for efficient energy production. This is coupled with a reduced excretion of amino acids and nitrogen in general. Metabolomics is a developing field that studies metabolism within a living system under varying conditions of stimuli. Through its development, there has been the optimisation of techniques to do large-scale hypothesis-generating untargeted studies as well as hypothesis-testing targeted studies. These techniques are introduced and show an important future direction for research into complex illnesses such as CFS.

Evaluation of antioxidative/oxidative status and prolidase parameters in cases of inguinal hernia with joint hypermobility syndrome

PURPOSE

Most previous reports have shown that the basic mechanism of inguinal hernia involves insufficient collagen strength and metabolism. The aim of this study was to evaluate whether joint hypermobility is involved in the development of inguinal hernia in children and to investigate oxidative stress parameters and prolidase activity in tissue samples from children with inguinal hernia.

METHODS

This cross-sectional study involving 41 patients (age, 6.36 ± 2.96 years) with inguinal hernia treated in the pediatric surgery department of our institution and 40 age- and sex-matched controls (age, 6.02 ± 3.13 years) was performed from May to December 2011. Joint hypermobility was assessed using the Beighton criteria in all patients. Hernia sacs were analyzed with respect to the total antioxidative/oxidative status and prolidase activity. The patients were divided into two groups (inguinal hernia with and without hypermobility) according to a Beighton score cut-off of ≥6.

RESULTS

A total of 81 subjects aged 3-10 years participated. The ratio of joint hypermobility was significantly higher in patients than in controls (p = 0.01). The prolidase activity, total oxidant status, and oxidative stress index were higher in tissue samples from patients with joint hypermobility (p < 0.001).

CONCLUSIONS

Our results show that joint hypermobility syndrome is associated with inguinal hernia in children and that increased prolidase activity and oxidative stress in tissue samples from patients with joint hypermobility syndrome are related to collagen tissue damage and turnover.

Pacing: a concept analysis of the chronic pain intervention

BACKGROUND

The intervention of pacing is regularly recommended for chronic pain patients. However, pacing is poorly defined and appears to be interpreted in varying, potentially contradictory manners within the field of chronic pain. This conceptual lack of clarity has implications for effective service delivery and for researchers' ability to conduct rigorous study. An examination of the background literature demonstrates that while pacing is often one part of a multidisciplinary pain management program, outcome research is hindered by a lack of a clear and shared definition of this currently ill-defined construct.

OBJECTIVES

To conduct a formal concept analysis of the term 'pacing'.

METHODS

A standardized concept analysis process (including literature scoping to identify all uses of the concept, analysis to determine defining attributes of the concept and identification of model, borderline and contrary cases) was used to determine what the concept of pacing does and does not represent within the current evidence base.

RESULTS

A conceptual model including the core attributes of action, time, balance, learning and self-management emerged. From these attributes, an evidence-based definition for pacing was composed and distributed to stakeholders for review. After consideration of stakeholder feedback, the emergent definition of pacing was finalized as follows: "Pacing is an active self-management strategy whereby individuals learn to balance time spent on activity and rest for the purpose of achieving increased function and participation in meaningful activities".

CONCLUSION

The findings of the present concept analysis will help to standardize the use and definition of the term pacing across disciplines for the purposes of both pain management and research.

Management of pain and fatigue in the joint hypermobility syndrome (a.k.a. Ehlers-Danlos syndrome, hypermobility type): principles and proposal for a multidisciplinary approach

Joint hypermobility syndrome (JHS), or Ehlers-Danlos syndrome (EDS) hypermobility type (EDS-HT), is a underdiagnosed heritable connective tissue disorder characterized by generalized joint hypermobility and a wide range of visceral, pelvic, neurologic, and cognitive dysfunctions. Deterioration of quality of life is mainly associated with pain and fatigue. Except for the recognized effectiveness of physiotherapy for some musculoskeletal features, there are no standardized guidelines for the assessment and treatment of pain and fatigue. In this work, a practical classification of pain presentations and factors contributing in generating painful sensations in JHS/EDS-HT is proposed. Pain can be topographically classified in articular limb (acute/subacute and chronic), muscular limb (myofascial and fibromyalgia), neuropathic limb, back/neck, abdominal and pelvic pain, and headache. For selected forms of pain, specific predisposing characteristics are outlined. Fatigue appears as the result of multiple factors, including muscle weakness, respiratory insufficiency, unrefreshing sleep, dysautonomia, intestinal malabsorption, reactive depression/anxiety, and excessive use of analgesics. A set of lifestyle recommendations to instruct patients as well as specific investigations aimed at characterizing pain and fatigue are identified. Available treatment options are discussed in the set of a structured multidisciplinary approach based on reliable outcome tools.

Primary care physical therapy in people with fibromyalgia: opportunities and boundaries within a monodisciplinary setting

Despite the fact that people with fibromyalgia syndrome (FMS) frequently are seen by primary care physical therapists, guidelines for the management of FMS are based primarily on outcomes from multidisciplinary and tertiary care treatment studies. Few data addressing the treatment of patients with FMS in primary care currently are available. The evidence-based guidelines on the management of FMS are based, in part, on evidence from studies examining physical therapy treatment components alone (eg, aerobic exercise, education). Thus, the recommendations can be applied to primary care physical therapy. Primary care physical therapy for patients with FMS should include education, aerobic exercise, and strengthening exercise. For other treatment components such as passive treatments, activity management, and relaxation, less evidence currently is available to advocate their use in primary care physical therapy. Superior results are to be expected when various treatment components are combined.

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) in adults: a qualitative study of perspectives from professional practice

BACKGROUND

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) can cause profound and prolonged illness and disability, and poses significant problems of uncertainty for healthcare professionals in its diagnosis and management. The aim of this qualitative study was to explore the nature of professional 'best practice' in working with people with CFS/ME.

METHODS

The views and experiences of health care practitioners (HCPs) were sought, who had been judged by people with CFS/ME themselves to have been particularly helpful and effective. Qualitative semi-structured interviews following a topic guide were carried out with six health care practitioners. Interviews were audio-recorded, transcribed and subject to thematic analysis.

RESULTS

Five main themes were developed: 1) Diagnosis; 2) Professional perspectives on living with CFS/ME; 3) Interventions for treatment and management; 4) Professional values and support for people with CFS/ME and their families; 5) Health professional roles and working practices. Key findings related to: the diagnostic process, especially the degree of uncertainty which may be shared by primary care physicians and patients alike; the continued denial in some quarters of the existence of CFS/ME as a condition; the variability, complexity, and serious impact of the condition on life and living; the onus on the person with CFS/ME to manage their condition, supported by HCPs; the wealth of often conflicting and confusing information on the condition and options for treatment; and the vital role of extended listening and trustful relationships with patients.

CONCLUSIONS

While professional frustrations were clearly expressed about the variability of services both in primary and specialist care and continuing equivocal attitudes to CFS/ME as a condition, there were also strong positive messages for people with CFS/ME where the right services are in place. Many of the findings from these practitioners seen by their patients as helping them more effectively, accord with the existing literature identifying the particular importance of listening skills, respect and trust for establishing a therapeutic relationship which recognises key features of the patient trajectory and promotes effective person-centred management of this complex condition. These findings indicate the need to build such skills and knowledge more systematically into professional training informed by the experience of specialist services and those living with the condition.

The search for pain relief in people with chronic fatigue syndrome: a descriptive study

The purpose of this study was to investigate the use and perceived benefit of complimentary and alternative medicine (CAM) and physiotherapy treatments tried by people with chronic fatigue syndrome (CFS) to ease painful symptoms. This study used a descriptive, cross-sectional design. People with CFS who experienced pain were recruited to this study. Participants were asked during a semistructured interview about the treatments they had tried to relieve their pain. Each interview was conducted in the home of the participant. Fifty participants were recruited, of which, 10 participants were severely disabled by CFS. Eighteen participants were trying different forms of CAM treatment for pain relief at the time of assessment. Three participants were currently receiving physiotherapy. Throughout the duration of their illness 45 participants reported trying 19 different CAM treatments in the search for pain relief. Acupuncture was reported to provide the most pain relief (n=16). Twenty-seven participants reported a total of 16 different interventions prescribed by their physiotherapist. The results of this study suggest some physiotherapy and CAM treatments may help people manage painful CFS symptoms. Future research should be directed to evaluating the effectiveness of interventions such as acupuncture or gentle soft tissue therapies to reduce pain in people with CFS.

Common health problems, yellow flags and functioning in a community setting

INTRODUCTION

Common health problems such as pain, depression and fatigue have a high impact on daily life, work and healthcare utilization. This study aimed to investigate the prevalence of these complaints in a UK community setting and to establish whether psychosocial risk factors, or 'yellow flags', moderate their impact on daily life and work.

METHODS

580 women and 420 men participated in a cross-sectional survey in the UK in 2007. 467 (57.2%) of the 816 working age adults in this sample reported complaints over the last month and were included in the moderator multivariate analysis.

RESULTS

Women and the not employed group reported a higher number and greater extent (frequency x severity) of complaints. Statistically significant models emerged for interference with daily life (F (9,457) = 36.54, P < 0.001, adjusted R (2) = 0.407) and time off work (F (4,462) = 31.22, P < 0.001, adjusted R (2) = 0.213). Age (beta = .238) and socio-economic status (beta = -.216) were associated with time off work. Extent of complaints and number of yellow flags were independently associated with interference with daily life (extent beta = .25, yellow flags beta = .15) and time off work (extent beta = .154, yellow flags beta = .201). No moderating effect of yellow flags was found.

CONCLUSIONS

Common health problems and yellow flags can be briefly and simply assessed. A broader approach is needed in managing these complaints in community and work contexts, moving beyond reducing complaint severity. Interventions need to acknowledge and address people's beliefs and affective responses to complaints, as well as wider socio-economic issues.

Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement

Several recent reports suggest that pain-related catastrophizing is a risk factor for poor acute pain outcomes following surgical interventions. However, it has been less clear whether levels of catastrophizing influence longer-term postoperative outcomes. Data were analyzed from a relatively small number (n=43) of patients who underwent total knee replacement and were followed for 12 months after their surgery. Previous research has suggested that high levels of both catastrophizing and depression are associated with elevated acute postoperative pain complaints among patients undergoing knee surgery. In this sample, catastrophizing and depression at each of the assessment points were studied as prospective predictors of pain (both global pain ratings and pain at night) at the subsequent assessment point over the course of one year. The predictive patterns differed somewhat across measures of pain reporting; depressive symptoms were unique predictors of greater global pain complaints, while catastrophizing was a specific and unique predictor of elevated nighttime pain. While surgical outcomes following total knee replacement are, on average, quite good, a significant minority of patients continue to experience long-term pain. The present findings suggest that high levels of catastrophizing and depression may promote enhanced pain levels, indicating that interventions designed to reduce catastrophizing and depressive symptoms may have the potential to further improve joint replacement outcomes.

Can exercise limits prevent post-exertional malaise in chronic fatigue syndrome? An uncontrolled clinical trial

OBJECTIVE

It was hypothesized that the use of exercise limits prevents symptom increases and worsening of their health status following a walking exercise in people with chronic fatigue syndrome.

DESIGN

An uncontrolled clinical trial (semi-experimental design).

SETTING

Outpatient clinic of a university department.

SUBJECTS

Twenty-four patients with chronic fatigue syndrome.

INTERVENTIONS

Subjects undertook a walking test with the two concurrent exercise limits. Each subject walked at an intensity where the maximum heart rate was determined by heart rate corresponding to the respiratory exchange ratio = 1.0 derived from a previous submaximal exercise test and for a duration calculated from how long each patient felt they were able to walk.

MAIN OUTCOME MEASURES

The Short Form 36 Health Survey or SF-36, the Chronic Fatigue Syndrome Symptom List, and the Chronic Fatigue Syndrome -Activities and Participation Questionnaire were filled in prior to, immediately after and 24 hours after exercise.

RESULTS

The fatigue increase observed immediately post-exercise (P= 0.006) returned to pre-exercise levels 24 hours post-exercise. The increase in pain observed immediately post-exercise was retained at 24 hours post-exercise (P=0.03). Fourteen of the 24 subjects experienced a clinically meaningful change in bodily pain (change of SF-36 bodily pain score > or =10); 6 indicated that the exercise bout had slightly worsened their health status, and 2 had a clinically meaningful decrease in vitality (change of SF-36 vitality score > or =20). There was no change in activity limitations/participation restrictions.

CONCLUSION

It was shown that the use of exercise limits (limiting both the intensity and duration of exercise) prevents important health status changes following a walking exercise in people with chronic fatigue syndrome, but was unable to prevent short-term symptom increases.

From acute musculoskeletal pain to chronic widespread pain and fibromyalgia: application of pain neurophysiology in manual therapy practice

During the past decade, scientific research has provided new insight into the development from an acute, localised musculoskeletal disorder towards chronic widespread pain/fibromyalgia (FM). Chronic widespread pain/FM is characterised by sensitisation of central pain pathways. An in-depth review of basic and clinical research was performed to design a theoretical framework for manual therapy in these patients. It is explained that manual therapy might be able to influence the process of chronicity in three different ways. (I) In order to prevent chronicity in (sub)acute musculoskeletal disorders, it seems crucial to limit the time course of afferent stimulation of peripheral nociceptors. (II) In the case of chronic widespread pain and established sensitisation of central pain pathways, relatively minor injuries/trauma at any locations are likely to sustain the process of central sensitisation and should be treated appropriately with manual therapy accounting for the decreased sensory threshold. Inappropriate pain beliefs should be addressed and exercise interventions should account for the process of central sensitisation. (III) However, manual therapists ignoring the processes involved in the development and maintenance of chronic widespread pain/FM may cause more harm then benefit to the patient by triggering or sustaining central sensitisation.

Functional somatic syndrome: how it could be relevant to rheumatologists

Functional somatic syndrome (FSS) is defined as a group of related syndromes characterized more by symptoms, suffering, and disability than by structural or functional abnormality. The diagnostic criteria and/or symptoms of FSS often overlap, and co-morbidity is commonly found among the diseases of FSS. For example, patients with irritable bowel syndrome often suffer from chronic pain, and a high percentage of co-morbidity can be found with fibromyalgia. Accumulating evidence indicates the presence of visceral and somatic hyperalgesia in FSS as a common feature, and the central sensitization mechanism has been suggested to play an important role in the pathophysiology of FSS. In the present article, the authors introduce the concept of FSS focusing on its possible relevance to rheumatology in terms of pain perception. A possible implication of mast cells and proteinase-activated receptor-2 (PAR-2) in FSS is also reviewed.