New Concepts in Pain Research and Pain Management of the Rheumatic Diseases

Perceptions and Preoccupations of Patients and Physicians Regarding Use of Medical Cannabis as an Intervention Against Chronic Musculoskeletal Pain: Results from a Qualitative Study

Objective

Explore perceptions and preoccupations regarding use of medical cannabis against chronic musculoskeletal pain, among patients and physicians.

Design

Qualitative study using interviews with patients and physicians, based on the Theory of Planned Behavior (TPB).

Setting

The study was conducted in Quebec, Canada, in spring 2020.

Subjects

We included 27 adult patients and 11 physicians (GPs, anesthesiologists, psychiatrists, and a rheumatologist); the mean age of patients was 48.2 years; 59.3% of patients and 36.4% of physicians were women; 59.3% of patients used no medical cannabis at the time of study; 45.5% of physicians had never authorized it.

Methods

Semi-structured interviews were conducted, transcribed and for the qualitative analysis codes were developed in a hybrid, inductive and deductive approach. Guided by the TPB, facilitators and barriers, perceived benefits and harms, and perceived norms that may influence cannabis use or authorization were documented.

Results

Although medical cannabis is an interesting avenue for the relief of chronic musculoskeletal pain, doctors and patients agreed that it remained a last line option, due to the lack of scientific evidence regarding its safety and efficacy. The norms surrounding medical cannabis also play an important role in the social and professional acceptance of this therapeutic option.

Conclusion

Medical cannabis is seen as a last line option among interventions in the management of chronic pain, and attitudes and prior experiences play a role in the decision to use it. Study results may contribute to improved shared decision making between patients and physicians regarding this option.

"It feels like an endless fight": a qualitative study exploring healthcare utilization of persons with rheumatic conditions waiting for pain clinic admission

Background

Individuals living with a rheumatic pain condition can face delays in accessing pain clinics, which prevents them from receiving timely treatment. Little is known regarding their specific healthcare utilization in order to alleviate pain while waiting to obtain services in pain clinics. Hence, the aim of this study was to explore the perceptions and experiences of persons living with rheumatic conditions regarding healthcare utilization while waiting to access a pain clinic.

Methods

In this qualitative descriptive study, semi-structured interviews were conducted with adults living with a painful rheumatic condition that reported either being waiting for admission in a pain clinic, having been referred but then denied pain clinic services, or having received services during the previous six months, in the province of Quebec, Canada. The interviews were transcribed verbatim, and an inductive thematic analysis was performed.

Results

Twenty-six individuals were interviewed (22 women and 4 men; mean age 54 ± 10 years). Three themes were identified: 1) lacking guidance in identifying solutions to their complex and multidimensional needs, 2) struggling to obtain and maintain services due to systemic access barriers, and 3) displaying resilience through a search for accessible and sustainable self-management strategies.

Conclusions

The current approaches and structures of health services fail to adequately answer the service needs of individuals experiencing painful rheumatic conditions. Important shifts are required in pain education, in increasing access to multidisciplinary approaches at the primary care level and in breaking down barriers individuals with chronic pain face to receive appropriate and timely care.

Exploring the Spatial Distribution of Rheumatic Diseases and Its Correlation With Temperature and Humidity Among Middle-Aged and Elderly Adults in China

Objectives: This study aimed to analyze the prevalence of rheumatic diseases and its correlation with temperature and humidity among middle-aged and elderly adults in China from a spatial perspective.

Methods: Data on rheumatic diseases among middle-aged and elderly adults were sourced from the 2018 China Health and Retirement Longitudinal Study (CHARLS). Moran’s I was applied to explore the spatial autocorrelation of rheumatic diseases. Spatial lag model (SLM) was established to probe the correlation between rheumatic diseases and temperature and humidity.

Results: The age-standardized prevalence of rheumatic diseases was 33.2% for middle-aged and elderly adults in China, varying from 12.0% to 51.4% depending on regions. The Global Moran’s I was 0.506 (p = 0.001). Average temperature had negative correlation while average relative humidity had positive correlation with age-standardized prevalence of rheumatic diseases in the SLM.

Conclusion: The age-standardized prevalence of rheumatic diseases of middle-aged and elderly adults showed spatial autocorrelation in China. We recommend taking measures to prevent rheumatic diseases for the middle-aged and elderly adults, especially for those living in cold and humid regions.

Exploring cannabis use and perspectives among psoriatic disease patients

OBJECTIVE

To assess the correlation between cannabis use and psoriatic disease severity, health-related quality of life, pain, psychosocial outcomes, and cytokine levels in psoriasis (PsC) and psoriatic arthritis (PsA) patients.

METHODS

PsC and PsA patients enrolled in the International Psoriasis and Arthritis Research Team (IPART) program were surveyed on cannabis use and were asked to provide a serum and urine sample. Demographic and clinical variables were compared between users and non-users using Student's t-test or Mann-Whitney U test for continuous variables, and chi-square or Fisher's exact test for categorical variables.

RESULTS

Of 151 respondents, 30% reported current cannabis use within the last year. Compared to non-users, cannabis users were younger and had a shorter PsA duration and poorer mental health as measured by the SF-36. Other measures of health-related quality of life and pain were comparable between the groups. Respondents' primary perceived benefits of cannabis use were aid in sleep and arthritis pain relief, but there was no difference in pain between users and non-users. No THC was detected in the urine of non-users while users had a mean level of 19.6 ng/ml. Serum IL-23 levels were statistically significantly higher in non-users than in users.

CONCLUSION

A third of the patients used cannabis within the past year, and 54.3% of users reported the use of cannabis for arthritis pain relief. However, there was no difference in pain scores. Comprehensive education for providers on the current body of evidence and further studies on cannabis use and outcomes in psoriatic disease are needed. Key Points • A third of patients with psoriatic arthritis have used cannabis in the past year. • Most used it for better sleep and control of pain. • There was no difference in pain scores between users and non-users. • IL-23 levels were significantly higher in non-users.

Outcomes of a Comprehensive Pain Rehabilitation Program for Patients With Fibromyalgia

OBJECTIVE

To analyze opioid intake interference with psychological, well-being, and functional outcomes and medication tapering in patients with fibromyalgia admitted to the Mayo Clinic Pain Rehabilitation Program (MCPRP) in Florida.

PATIENTS AND METHODS

A retrospective study on MCPRP outcomes was conducted. We reviewed the health records of 150 patients with fibromyalgia who participated in the program from May 1, 2014, to May 1, 2015. All patients were asked to fill out a survey at admission to and dismissal from the program. Surveys contained questions from the numeric pain score, Multidimensional Pain Inventory (perceived life control and interference of pain subscales), Center for Epidemiological Studies-Depression Scale, Pain Catastrophizing Scale, 36-Item Short-Form Health Status Survey (general health perceptions subscale), and Pain Self-Efficacy Questionnaire. A medical record review identified categories and number of medications at program admission and dismissal. Patients were divided in 2 groups: those whose concomitant medication did not include opioids at admission (no opioids group) and those whose concomitant medication included opioids at admission (opioids group).

RESULTS

By dismissal from the MCPRP, patients with fibromyalgia in the no opioids group had a significant (P<.05) improvement in all the self-reported scores. Medication, including opioids, were effectively tapered at a substantially higher percentage in the opioids group.

CONCLUSION

Benefit of the comprehensive pain rehabilitation program in patients with fibromyalgia was indicated by clinical improvements in pain severity, physical and emotional health, and functional capacity while successfully tapering medication. Opioid intake at admission may modify the program outcomes.

Cannabis against chronic musculoskeletal pain: a scoping review on users and their perceptions

Background

Chronic musculoskeletal pain (CMP) may lead to reduced physical function and is the most common cause of chronic non-cancer pain. Currently, the pharmacotherapeutic options against CMP are limited and frequently consist of pain management with non-steroidal anti-inflammatories, gabapentinoids, or opioids, which carry major adverse effects. Although the effectiveness of medical cannabis (MC) for CMP still lacks solid evidence, several patients suffering from it are exploring this therapeutic option with their physicians.

Objectives

Little is known about patients’ perceptions of their MC treatment for CMP. We aimed to increase this knowledge, useful for healthcare professionals and patients considering this treatment, by conducting a scoping literature review, following guidance by Arksey and O’Malley, to describe the views and perceptions of adult patients who had consumed MC to relieve chronic CMP.

Methods

Databases (PUBMED, EMBASE, Web of Science) and websites were searched using combinations of controlled and free vocabulary. All studies and study designs reporting on patients’ perceptions regarding MC against CMP were considered. Studies had to include adult patients reporting qualitatively or quantitatively, i.e., through questionnaires, on MC use to treat CMP or other non-cancer pain, since studies reporting exclusively on perceptions regarding CMP were very rare. Study characteristics were extracted and limitations of the study quality were assessed. The review includes patients’ demographic characteristics, patterns of MC use, perceived positive and negative effects, use of alcohol or other drugs, reported barriers to CM use, and funding sources of the studies.

Results

Participants of the 49 included studies reported that MC use helped them to reduce CMP and other chronic non-cancer pain, with only minor adverse effects, and some reported improved psychological well-being.

In the included studies, men represent between 18 and 88% of the subjects. The mean age of participants in these studies (42/49) varied between 28.4 and 62.8 years old. The most common route of administration is inhalation.

Conclusion

MC users suffering from CMP or other chronic non-cancer pain perceived more benefits than harms. However, the information from these studies has several methodological limitations and results are exploratory. These user-reported experiences must thus be examined by well-designed and methodologically sound clinical or observational studies, particularly regarding CMP, where reports are very scarce.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42238-021-00096-8.

The association between waiting time and multidisciplinary pain treatment outcomes in patients with rheumatic conditions

BACKGROUND

Access to multidisciplinary pain treatment facilities (MPTF) is limited by extensive waiting time in many countries. However, there is a lack of knowledge about the impact of waiting time on clinical outcomes, particularly for patients with rheumatic conditions. This study examined the association between waiting time for MPTF and clinical outcomes in patients with rheumatic conditions.

METHODS

Data were extracted from the Quebec Pain Registry, a large database of patients who received services in MPTF. The associations between waiting time (classified as < 2 months, 2-6 months and >  6 months) and change in pain interference, pain intensity and health-related quality of life, from the initial visit at the MPTF to the 6-month follow-up, were tested using generalized estimating equations.

RESULTS

A total of 3230 patients with rheumatic conditions (mean age: 55.8 ± 14.0 years; 66% were women) were included in the analysis. Small significant differences in improvement between waiting time groups were revealed, with patients waiting less than 2 months having a larger improvement in all clinical outcomes compared to patients who waited 2-6 months or over 6 months before their initial visit (adjusted time X group effect p ≤ 0.001). Only patients waiting less than 2 months reached a clinically important improvement in pain interference (1.12/10), pain intensity (1.3/10) and physical and mental quality of life (3.9 and 3.7/100).

CONCLUSIONS

Longer delays experienced by patients before receiving services in MPTF were associated with statistically significant smaller improvements in pain interference, pain intensity and health-related quality of life; these differences were, however, not clinically significant. Based on these results, we advise that strategies are developed not only to reduce waiting times and mitigate their impacts on patients with rheumatic conditions, but also to improve treatment effectiveness in MPTF.

Prevalence of chronic widespread pain in a population-based cohort of patients with spondyloarthritis - a cross-sectional study

Background

Chronic pain, regional or widespread, is a frequent and multidimensional symptom in arthritis. There is still limited information on chronic pain in spondyloarthritis, which is important to recognize for adequate diagnosis and treatment. Our objective was to study differences in prevalence of chronic widespread pain in two spondyloarthritis subgroups: ankylosing spondylitis (AS) and undifferentiated spondyloarthritis (USpA).

Methods

A population-based postal survey involving questions on the duration, distribution, and intensity of pain was answered by 940 patients with AS (ICD-10 M45.9) or USpA (ICD-10 M46.1-0, M46.8-9). The patients were categorized as having chronic widespread pain, chronic regional pain, or no chronic pain, and prevalence estimates for the pain groups were calculated, including age- and sex-adjusted prevalence.

Results

The prevalence of chronic widespread pain was 45.3% in AS vs. 49.3% in USpA, and that of chronic regional pain was 17.7% vs. 21.9% (p = 0.033). More women than men reported having chronic widespread pain (54.1% vs. 41.2%, p ≤ 0.001), while the sex distribution for chronic regional pain was equal. Reports of pain intensity were equal in AS and USpA, with no significant difference in pain intensity between women and men who had chronic regional pain or chronic widespread pain. In the multiple logistic regression analysis, chronic widespread pain was associated to female sex, being an ever-smoker, and having a higher body mass index, controlled for SpA subgroup and disease duration.

Conclusions

The prevalence of chronic widespread pain in patients with AS and USpA is high, and with a female predominance, but with no difference in pain intensity between women and men. Chronic pain can complicate the clinical evaluation in patients with SpA, and highlights the need for a thorough clinical examination, including evaluation of inflammation and an accurate pain analysis, to individualize non-pharmacological and pharmacological treatment decisions.

Use of the Central Sensitization Inventory (CSI) as a treatment outcome measure for patients with chronic spinal pain disorder in a functional restoration program

BACKGROUND CONTEXT

The Central Sensitization Inventory (CSI) is a valid and reliable patient-reported instrument designed to identify patients whose presenting symptoms may be related to central sensitization (CS). Part A of the CSI measures a full array of 25 somatic and emotional symptoms associated with CS, and Part B asks if patients have previously been diagnosed with one or more specific central sensitivity syndromes (CSSs) and related disorders. The CSI has previously been validated in a group of patients with chronic pain who were screened by a trained psychiatrist for specific CSS diagnoses. It is currently unknown if the CSI can be a useful treatment-outcome assessment tool for patients with chronic spinal pain disorder (CSPD) who are not screened for comorbid CSSs. It is known, however, that previous studies have identified CS-related symptoms, and comorbid CSSs, in subsets of patients with CSPDs. Studies have also shown that CS-related symptoms can be influenced by cognitive and psychosocial factors, including abuse history in both childhood and adulthood, sleep disturbance, catastrophic and fear-avoidant cognitions, and symptoms of depression and anxiety.

PURPOSE

This study aimed to evaluate CSI scores, and their associations with other clinically relevant psychosocial variables, in a cohort of patients with CSPD who entered and completed a functional restoration program.

STUDY DESIGN/SETTING

A retrospective study of prospectively collected data from a cohort study of patients with CSPD, who completed the CSI at admission to, and discharge from, an interdisciplinary function restoration program (FRP) was carried out.

PATIENT SAMPLE

A cohort of 763 patients with CSPD comprised the study sample.

OUTCOME MEASURES

Clinical interviews evaluated mood disorders and abuse history. A series of self-reported measures evaluated comorbid psychosocial symptoms, including pain intensity, pain-related anxiety, depressive symptoms, somatization symptoms, perceived disability, and sleep disturbance, at FRP admission and discharge.

METHODS

Patients were grouped into five severity level groups, from mild to extreme, based on total CSI scores, at FRP admission, and then again at discharge. The FRP included a quantitatively directed and medically supervised exercise process, as well as a multimodal psychosocial disability management component.

RESULTS

The CSI severity groups were strongly associated with Major Depressive Disorder and previous abuse history (p<.01), which are known risk factors for CS-related symptoms and diagnoses. The CSI scores were also strongly associated with patient-reported CSS diagnoses on CSI Part B. The percentage of patients who reported a comorbid CSS diagnosis increased in each higher CSI-severity group, from 11% in the Subclinical group, to 56% in the Extreme group. The CSI severity groups were significantly related to other CS-related patient-reported symptoms, including pain intensity, pain-related anxiety, depressive symptoms, somatization symptoms, perceived disability, and sleep disturbance (p's<.001). The CSI scores, along with all other psychosocial measures, decreased at treatment discharge.

CONCLUSIONS

In the present study, admission CSI scores were highly associated with previous CSS diagnoses, CS-related symptoms, and clinically relevant patient-reported psychosocial variables. All psychosocial variables, as well as scores on the CSI, were significantly improved at FRP discharge. The CSI may have important clinical utility, as a screener and as a treatment outcome measure, for patients with CSPD participating in an interdisciplinary FRP.

Fourteen days of etoricoxib 60 mg improves pain, hyperalgesia and physical function in individuals with knee osteoarthritis: a randomized controlled trial

OBJECTIVE

Mounting evidence points to the heterogeneity of osteoarthritis (OA) pain, increasing the need for more comprehensive assessment of the efficacy of standard interventions. This study investigated whether 14 days of the selective Cox-2 inhibitor etoricoxib (60 mg/day) would modify self-report of pain intensity and quality, and physical measures of hyperalgesia and function in individuals with knee OA.

DESIGN

This double-blind placebo-controlled trial included 80 community-recruited volunteers with painful knee OA (≥3/10 VAS), randomly allocated to Active or Placebo groups. Self-report measures of pain, stiffness, function Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and pain quality (PainDETECT, Pain Quality Assessment Scale [PQAS]) and physical measures of locomotion and local (knee) and widespread (elbow) hyperalgesia were assessed at Days 0, 4 and 14. Repeated Measures ANOVA analysed group differences.

RESULTS

Significant group × time interaction effects were found for all measures of pain (all p < 0.001), with WOMAC pain sub-score improving by 30.7% by Day 14 and index knee mechanical hyperalgesia improving by 32.6%, whilst Placebo group values worsened. Both self-report and physical tests of function improved (p < 0.001-p = 0.006): WOMAC-function by 28.4%, sit-to-stand and walk time by 13%, pain during locomotion tasks by 12.4-32.6%. Pain quality also significantly improved for the Active and declined for the Placebo group (p < 0.001): PainDETECT score reduced by 23.6% and PQAS paroxsysmal and surface sub-scores by 36.9% and 29.4%. There were also significant improvements in local cold hyperalgesia and widespread mechanical hyperalgesia (10-13.8%).

CONCLUSION

Just 14 days of etoricoxib significantly improves pain intensity and quality, function and local and widespread hyperalgesia, measured by both self-report and physical tests.

Effects of 15 weeks of resistance exercise on pro-inflammatory cytokine levels in the vastus lateralis muscle of patients with fibromyalgia

Background

This study aimed at investigating the effect of a resistance exercise intervention on the interstitial muscle levels of pro-inflammatory cytokines in fibromyalgia (FMS) and healthy controls (CON).

Methods

Twenty-four female patients with FMS (54 ± 8 years) and 27 female CON (54 ± 9 years) were subjected to intramuscular microdialysis of the most painful vastus lateralis muscle before and after 15 weeks of progressive resistance exercise twice per week. Baseline dialysates were sampled in the resting muscle 140 min after insertion of the microdialysis catheter. The participants then performed repetitive dynamic contractions (knee extension) for 20 min, followed by 60 min rest. Pain intensity was assessed with a 0–100 mm visual analogue scale (VAS), and fatigue was assessed with Borg’s RPE throughout microdialysis. Dialysates were sampled every 20 min and analyzed with Luminex for interleukin (IL)-1β, tumor necrosis factor (TNF) alpha, IL-6, and IL-8.

Results

At both sessions and for both groups the dynamic contractions increased pain (P < 0.012) and fatigue (P < 0.001). The levels of TNF were lower in the FMS group than the CON group at both sessions (P < 0.05), but none of the other cytokines differed between the groups. IL-6 and IL-8 increased after the dynamic contractions in both groups (P < 0.010), while TNF increased only in CON (P < 0.05) and IL-1β did not change. Overall pain intensity was reduced after the 15 weeks of resistance exercise in FMS (P < 0.05), but there was no changes in fatigue or cytokine levels.

Conclusion

Progressive resistance exercise for 15 weeks did not affect the interstitial levels of IL-1β, TNF, IL-6, and IL-8 in the vastus lateralis muscle of FMS patients or CON.

Trial registration

Clinicaltrials.gov NCT01226784, registered 21 October 2010.

Management of fibromyalgia syndrome in 2016

Fibromyalgia syndrome is a chronic pain disorder and defies definitively efficacious therapy. In this review, we summarize the results from the early treatment research as well as recent research evaluating the pharmacological, interventional and nonpharmacological therapies. We further discuss future directions of fibromyalgia syndrome management; we specifically focus on the issues that are associated with currently available treatments, such as the need for personalized approach, new technologically oriented and interventional treatments, the importance of understanding and harnessing placebo effects and enhancement of patient engagement in therapy.

Treatment Patterns Associated with ACR-Recommended Medications in the Management of Fibromyalgia in the United States

BACKGROUND

Fibromyalgia (FM) affects up to 6% of U.S. adults, resulting in a significant burden on the health care system and poor quality of life for patients. Duloxetine, pregabalin, and milnacipran are approved for management of FM; however, consensus is lacking regarding optimal therapy. Patients with FM taking approved medications often do not experience meaningful symptom relief, and many experience intolerable adverse events.

OBJECTIVE

To assess treatment patterns associated with available and commonly used medications for the management of FM using U.S. health insurance claims.

METHODS

This retrospective analysis used the MarketScan claims database to identify adults with a first diagnosis of FM (ICD-9-CM code 729.1) between 2009 and 2011 with continuous health plan enrollment for 12 months pre- and post-index. Medications of interest were pregabalin, gabapentin, duloxetine, milnacipran, cyclobenzaprine, and tramadol. These are 6 of the 8 medications recommended by the American College of Rheumatology (ACR) for treating FM; the other 2 (amitriptyline and venlafaxine) were only included in some initial assessments. The Charlson Comorbidity Index (CCI) was used to assess overall comorbidity burden. Endpoints included proportion of patients treated within 1 year after first diagnosis; initial treatment pattern; adherence over the first-year follow-up period for the medications of interest; and discontinuation, switching, and combination therapy patterns among pain medications of interest at different time points. Proportion of days covered (PDC; defined as number of days in the period when the patient had drug supply divided by the number of days in the period) was used to define adherence, which was categorized as low (PDC < 50%), medium (PDC 50% to < 80%), or high (PDC ≥ 80%). The time to discontinuation (defined as the first drug supply gap ≥ 90 days) was estimated using Kaplan-Meier analysis.

RESULTS

Overall, 240,144 patients met the inclusion criteria. Patients were predominantly women (68%), had preferred provider organization insurance coverage (68%), and had a CCI score < 1 at baseline (69%). Only 31% (n = 74,738) initiated a treatment with a prescription medication listed in the ACR guidelines, and many patients received less than the recommended dose. Most (n = 70,919) patients initially received monotherapy with one of the 8 prescription medications. Of those who started with ≥ 2 medications (n = 3,819), cyclobenzaprine plus tramadol was the most frequent combination. Adherence was suboptimal for all 6 medications of interest. Duloxetine had the highest mean PDC (59%); for all other agents, mean PDC was < 50%. With the exception of duloxetine, discontinuation rates at 6 months were > 50% for all agents. Alterations in therapy were common. Among patients who discontinued their initial treatment of duloxetine, pregabalin, or milnacipran, approximately one-third had switched treatments within 90 days after their first prescription. For those who maintained their initial treatment agent, approximately 50% of patients added a second pain medication within 1 year of treatment initiation.

CONCLUSIONS

The evidence suggests that patients with FM often do not receive 1 of the prescription medications recommended by ACR guidelines, and those who do are commonly prescribed lower-than-recommended doses, potentially resulting in poor effectiveness and tolerability. Discontinuation, switching, and addition of new pain medications are common, which may indicate low levels of satisfaction with initial treatment. New therapies with improved effectiveness and better tolerability are urgently needed for patients with FM.

Use of Complementary and Alternative Medicine among Osteoarthritic Patients: A Review

INTRODUCTION

One of the most important indications of complementary and alternative medicines (CAM) is in arthritis. The popularity of CAM in arthritis is consistently on the rise because of the potential side effects of the conventional therapy (Methotrexate) of arthritis. In view of this, it was important to summarize the information, for healthcare professionals and the patients, about the safety and effectiveness of various CAM use in arthritis.

MATERIALS AND METHODS

This comprehensive review is based on the content derived through a thorough literature search using 5 electronic databases such as Science direct, Springer link, PubMed, Jet P and Google scholar. Equivalent terms in thesauruses or Medical Subject Heading (MeSH) browsers were used whenever possible. We included all the articles those are used CAM medications for the treatment of arthritis around the globe and searched for the required articles published in English in peer reviewed journals from January 1999 to February 2014. Reports were then arranged and analysed on the basis of country specific studies.

RESULTS

Initially, a total of 156 articles were retrieved, after further screening, 27 articles were selected according to meet objectives of the study and those articles which did not qualify, were excluded. Seventeen appropriate studies were finally included in the review. Indeed most of the studies that fulfilled the objective of this review were carried out in US (n=8, 47%), then in India (n=2, 11.76%), UK (n=1, 5.88%), Canada (n=1, 5.88%), Australia (n=1, 5.88%), Korea (n=1, 5.88%), Thailand (n=1, 5.88%), Turkey (n=1, 5.88%) and Malaysia (n=1, 5.88%).

CONCLUSION

The review revealed that family, friend, past experiences and lack of effectiveness of conventional therapy are the major factors that influenced patients' decision of initiating and persisting with CAM therapy. The review highlighted the need to conduct future studies by using some more specific health related outcome measures.

[Central regulation of pain in patients with joint disease and approaches to therapy]

The paper reviews investigations studies that have demonstrated that chronic pain syndrome is mixed in rheumatic diseases. The nervous system is involved in its pathogenesis with different frequency and different mechanisms. Under the influence of afferent pain impulses from damaged joints, there are changes in the excitability of spinal cord neurons, which is called central sensitization (CS). A number of patients have enhanced CS and clinical manifestations as neuropathic sensitive phenomena. The mixed model of the development of chronic pain in joint diseases and its presence along with nociceptive (inflammatory) and neuropathic pain components may explain the discrepancy between joint inflammatory and structural changes and pain intensity, the presence of distant pain and sensitive disorders in the areas outside the joint, and sometimes the efficiency of anti-inflammatory therapy. The presence of the neuropathic pain component serves as a rationale for combined therapy by adding centrally acting drugs, such as anticonvulsants.

Effect of Milnacipran on Pain in Patients with Rheumatoid Arthritis with Widespread Pain: A Randomized Blinded Crossover Trial

OBJECTIVE

Clinical trials have shown that serotonin norepinephrine reuptake inhibitors, such as milnacipran, decrease pain in noninflammatory pain conditions such as fibromyalgia and osteoarthritis. We examined the effect of milnacipran on self-reported pain intensity and experimental pain sensitivity among patients with rheumatoid arthritis (RA) with widespread pain and stable RA disease activity.

METHODS

In this double-blind, crossover study, patients with RA with widespread pain, receiving a stable treatment regimen, were randomized (by a random number generator) to receive milnacipran 50 mg twice daily or placebo for 6 weeks, followed by a 3-week washout and crossed over to the other arm for the remaining 6 weeks. The primary outcome was change in average pain intensity, assessed by the Brief Pain Inventory short form. The sample size was calculated to detect a 30% improvement in pain with power = 0.80 and α = 0.05.

RESULTS

Of the 43 randomized subjects, 41 received the study drug, and 32 completed the 15-week study per protocol. On a 0-10 scale, average pain intensity decreased by 0.39 (95% CI -1.27 to 0.49, p = 0.37) more points during 6 weeks of milnacipran treatment compared with placebo. In the subgroup of subjects with swollen joint count ≤ 1, average pain intensity decreased by 1.14 more points during 6 weeks of milnacipran compared with placebo (95% CI -2.26 to -0.01, p = 0.04). Common adverse events included nausea (26.8%) and loss of appetite (9.7%).

CONCLUSION

Compared with placebo, milnacipran did not improve overall, self-reported pain intensity among subjects with widespread pain receiving stable RA medications.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01207453.

Fibromyalgia

Fibromyalgia is a common illness characterized by chronic widespread pain, sleep problems (including unrefreshing sleep), physical exhaustion and cognitive difficulties. The definition, pathogenesis and treatment are controversial, and some even contest the existence of this disorder. In 1990, the American College of Rheumatology (ACR) defined classification criteria that required multiple tender points (areas of tenderness occurring in muscles and muscle-tendon junctions) and chronic widespread pain. In 2010, the ACR preliminary diagnostic criteria excluded tender points, allowed less extensive pain and placed reliance on patient-reported somatic symptoms and cognitive difficulties. Fibromyalgia occurs in all populations worldwide, and symptom prevalence ranges between 2% and 4% in the general population. The prevalence of people who are actually diagnosed with fibromyalgia ('administrative prevalence') is much lower. A model of fibromyalgia pathogenesis has been suggested in which biological and psychosocial variables interact to influence the predisposition, triggering and aggravation of a chronic disease, but the details are unclear. Diagnosis requires the history of a typical cluster of symptoms and the exclusion of a somatic disease that sufficiently explains the symptoms by medical examination. Current evidence-based guidelines emphasize the value of multimodal treatments, which encompass both non-pharmacological and selected pharmacological treatments tailored to individual symptoms, including pain, fatigue, sleep problems and mood problems. For an illustrated summary of this Primer, visit: http://go.nature.com/LIBdDX.

Fibromyalgia and disability adjudication: no simple solutions to a complex problem

BACKGROUND

Adjudication of disability claims related to fibromyalgia (FM) syndrome can be a challenging and complex process. A commentary published in the current issue of Pain Research & Management makes suggestions for improvement. The authors of the commentary contend that: previously and currently used criteria for the diagnosis of FM are irrelevant to clinical practice; the opinions of family physicians should supersede those of experts; there is little evidence that trauma can cause FM; no formal instruments are necessary to assess disability; and many FM patients on or applying for disability are exaggerating or malingering, and tests of symptoms validity should be used to identify malingerers.

OBJECTIVES

To assess the assertions made by Fitzcharles et al.

METHODS

A narrative review of the available research literature was performed.

RESULTS

Available diagnostic criteria should be used in a medicolegal context; family physicians are frequently uncertain about FM and⁄or biased; there is considerable evidence that trauma can be a cause of FM; it is essential to use validated instruments to assess functional impairment; and the available tests of physical effort and symptom validity are of uncertain value in identifying malingering in FM.

CONCLUSIONS

The available evidence does not support many of the suggestions presented in the commentary. Caution is advised in adopting simple solutions for disability adjudication in FM because they are generally incompatible with the inherently complex nature of the problem.

Multidisciplinary treatment for rheumatic pain

Chronic pain experienced by patients with rheumatic conditions is recognized to contribute importantly to suffering. Multidisciplinary pain clinics that adhere to the biopsychosocial concept of pain management provide an effective treatment strategy for many with chronic pain. Other than for low back pain and fibromyalgia, little attention has been given to the specific experience of treating those with rheumatic diseases in such a setting. It is, however, reasonable to suggest that many patients with chronic rheumatic pain could benefit from exposure to a multidisciplinary pain treatment programme that incorporates components of education, exercise and activity, as well as psychological techniques and support. Although the specifics of such a treatment will require defining, rheumatologists can look forward to expanded care for their patients with chronic rheumatic pain, and they should be encouraged to become more involved in these clinics.

A store-operated calcium channel inhibitor attenuates collagen-induced arthritis

BACKGROUND AND PURPOSE

Store-operated calcium (SOC) channels are thought to play a critical role in immune responses, inflammatory diseases and chronic pain. The aim of this study was to explore the potential role and mechanisms of SOC channels in collagen-induced arthritis (CIA).

EXPERIMENTAL APPROACH

The CIA mouse model was used to examine the effects of the SOC channel inhibitor YM-58483 on CIA and arthritic pain. Hargreaves' and von Frey hair tests were conducted to measure thermal and mechanical sensitivities of hind paws. elisa was performed to measure cytokine production, and haematoxylin and eosin staining was used to assess knee histological changes. Western blot analysis was performed to examine protein levels.

KEY RESULTS

Pretreatment with 5 or 10 mg · kg(-1) of YM-58483 reduced the incidence of CIA, prevented the development of inflammation and pain hypersensitivity and other signs and features of arthritis disease. Similarly, treatment with YM-58483 after the onset of CIA: (i) reversed the clinical scores; (ii) reduced paw oedema; (iii) attenuated mechanical and thermal hypersensitivity; (iv) improved spontaneous motor activity; (v) decreased periphery production of IL-1β, IL-6 and TNF-α; and (vi) reduced spinal activation of ERK and calmodulin-dependent PKII (CaMKIIα).

CONCLUSIONS AND IMPLICATIONS

This study provides the first evidence that inhibition of SOC entry prevents and relieves rheumatoid arthritis (RA) and arthritic pain. These effects are probably mediated by a reduction in cytokine levels in the periphery and activation of ERK and CaMKIIα in the spinal cord. These results suggest that SOC channels are potential drug targets for the treatment of RA.

Pain and difficulties performing valued life activities in women and men with rheumatoid arthritis

This study aimed to examine the difficulties with performing valued life activities in relation to pain intensity in women and men with rheumatoid arthritis (RA). In total, 737 persons with RA (73 % women) from three rheumatology units in Sweden responded to a questionnaire measuring performance of 33 valued life activities and self-rated pain. The relationships between performance of valued life activities (VLAs) and pain (measured by visual analogue scale (VAS)) were analysed based on gender. Multiple linear regression analyses were conducted with the total VLA score as dependent variable. Women reported more pain and difficulties in performing valued life activities than men. Across genders, 85 % reported at least one valued life activity affected by RA. Significantly more women than men encountered difficulties in performing some activities such as cooking, gardening and meeting new people. Women reported higher pain intensity (35 mm) than men (31 mm). Almost all 33 difficulty ratings for valued life activities were higher among persons with high pain (>40 mm) than persons with lower pain. Difficulty ratings for valued life activities correlated positively with pain in persons with lower pain, but not among those with high pain. The results highlight the importance of addressing pain, especially among women with RA, as they reported pain to impact on their valued life activities. Interestingly, this was evident also in women with lower levels of pain.

Use of the painDETECT tool in rheumatoid arthritis suggests neuropathic and sensitization components in pain reporting

Rheumatoid arthritis (RA) is an inflammatory autoimmune condition typified by systemic inflammation targeted toward synovial joints. Inhibition of proinflammatory networks by disease-modifying antirheumatic drugs, eg, methotrexate and biologic therapies, including tumor necrosis factor-α inhibitors, often leads to suppression of disease activity observed at the clinical level. However, despite the era of widespread use of disease-modifying treatments, there remain significant groups of patients who continue to experience pain. Our study formulated a pain assessment tool in the arthritis clinic to assess feasibility of measurements including the visual analog scale (VAS) and painDETECT to assess multimodal features of pain in people with established RA (n=100). Clinical measures of disease activity (Disease Activity Score in 28 Joints [DAS28]) were also recorded. Our data showed that despite the majority of subjects on at least one disease-modifying agent, the majority of patients reported severe pain (54%) by VAS, despite well-controlled clinical disease, with mean DAS28 2.07±0.9. Using the painDETECT questionnaire, 67% of patients had unlikely neuropathic pain. A significant proportion of subjects (28%) had possible neuropathic pain and 5% had features of likely neuropathic pain by painDETECT scoring. We found a positive correlation between VAS and painDETECT (R (2)=0.757). Of note, the group who had likely or probable neuropathic pain also showed significantly increased pain reporting by VAS (P<0.01). Subjects who were clinically obese (body mass index >30) also had statistically higher proportions of pain reporting (VAS 89.0±0.7 mm) compared with subjects who had a normal body mass index (VAS 45.2±21.8 mm), P<0.05. Our findings suggest that multimodal features of pain perception exist in RA, including neuropathic and sensitization elements, perhaps explaining why a subgroup of people with RA continue to experience ongoing pain, despite their apparent suppression of inflammation.

Future perspectives of Smartphone applications for rheumatic diseases self-management

Rheumatic diseases (RD) self-management interventions are designed to improve health-related quality of life, health care utilization, and perceived self-efficacy. Despite these demonstrated good results, there are several issues that hinder or render less appealing these interventions. One economically and socially viable solution is exploiting the potential of Smartphone technology. This potential comes from Smartphones pervasive presence in actual society, combined with the advantages of being personal, intuitive, and computationally powerful, with capability to support applications and assist its user throughout different activities of daily living and environments persistently. With their global acceptance increasing quickly, there is a great opportunity for mobile health in using Smartphone applications for RD self-management. Besides the potential of such applications, research on the development and evaluation of such applications is in the early stages. Therefore, it is important to foresee its future applicability in order to meet the needs of the twenty-first century.

Rheumatologists lack confidence in their knowledge of cannabinoids pertaining to the management of rheumatic complaints

Background

Arthritis pain is reported as one of the most common reasons for persons using medical herbal cannabis in North America. “Severe arthritis” is the condition justifying legal use of cannabis in over half of all authorizations in Canada, where cannabis remains a controlled substance. As champions for the care of persons with arthritis, rheumatologists must be knowledgeable of treatment modalities both traditional and non-traditional, used by their patients. As study of cannabinoid molecules in medicine is recent, we have examined the confidence in the knowledge of cannabinoids expressed by Canadian rheumatologists.

Methods

The confidence of rheumatologists in their knowledge of cannabinoid molecules and mechanisms relevant to rheumatology, and their ability to advise patients about cannabinoid treatments was recorded by an online questionnaire circulated via email to the entire Canadian Rheumatology Association membership.

Results

Over three quarters of the 128 respondents lacked confidence in their knowledge of cannabinoid molecules. While 45% of respondents believed there was no current role for cannabinoids in rheumatology patient care, only 25% supported any use of herbal cannabis. With 70% never having previously prescribed or recommended any cannabinoid treatment, uncertainty regarding good prescribing practices was prevalent. Concerns about risks of cannabis use were in line with the current literature.

Conclusions

Rheumatologists lacked confidence in their knowledge of cannabinoid molecules in general and in their competence to prescribe any cannabinoid for rheumatic complaints. In line with this uncertainty, there is reticence to prescribe cannabinoid preparations for rheumatology patients. Guidance is required to inform rheumatologists on the evidence regarding cannabinoids.

Neuropathic pain in osteoarthritis: a review of pathophysiological mechanisms and implications for treatment

OBJECTIVES

Osteoarthritis (OA) is the leading cause of musculoskeletal pain and functional disability worldwide, affecting a growing number of individuals in the western society. Despite various conservative and interventional treatment approaches, the overall management of the condition is problematic, and pain-the major clinical problem of the disease-remains sub-optimally controlled. The objectives of this review are to present the pathophysiologic mechanisms underlying the complexity of pain in OA and to discuss the challenges for new treatment strategies aiming to translate experimental findings into daily clinical practice.

METHODS

A narrative literature review of studies investigating the existence of a neuropathic component in OA pain was conducted. We searched PubMed, Embase and Scopus for English language publications. A hand-search of reference lists of relevant studies was also performed.

RESULTS

Recent advances have shed additional light on the pathophysiology of osteoarthritic pain, highlighting the contribution of central pain pathways together with the sensitisation of peripheral joint receptors and changes of the nociceptive process induced by local joint inflammation and structural bone tissue changes. Thus, a neuropathic pain component may be predominant in individuals with minor joint changes but with high levels of pain refractory to analgesic treatment, providing an alternative explanation for osteoarthritic pain perception.

CONCLUSION

A growing amount of evidence suggests that the pain in OA has a neuropathic component in some patients. The deeper understanding of multiple mechanisms of OA pain has led to the use of centrally acting medicines that may have a benefit on alleviating osteoarthritic pain. The ineffective pain management and the increasing rates of disability associated with OA mandate for change in our treatment paradigm.

Knee pain during daily tasks, knee osteoarthritis severity, and widespread pain

BACKGROUND

The presence of widespread pain is easily determined and is known to increase the risk for persistent symptoms.

OBJECTIVE

The study hypothesis was that people with no or minimal knee osteoarthritis (OA) and high Western Ontario and McMaster Universities (WOMAC) Pain Scale scores would be more likely than other subgroups to report widespread pain.

DESIGN

A cross-sectional design was used.

METHODS

Data were obtained from the Multicenter Osteoarthritis Study, which includes people with or at high risk for knee OA. The inclusion criteria were met by 755 people with unilateral knee pain and 851 people with bilateral knee pain. Widespread pain was assessed with body diagrams, and radiographic Kellgren-Lawrence grades were recorded for each knee. Knee pain during daily tasks was quantified with WOMAC Pain Scale scores.

RESULTS

Compared with people who had high levels of pain and knee OA, people with a low level of pain and a high level of knee OA, and people with low levels of pain and knee OA, a higher proportion of people with a high level of knee pain and a low level of knee OA had widespread pain. This result was particularly true for people with bilateral knee pain, for whom relative risk estimates ranged from 1.7 (95% confidence interval=1.2-2.4) to 2.3 (95% confidence interval=1.6-3.3).

LIMITATIONS

The cross-sectional design was a limitation.

CONCLUSIONS

People with either no or minimal knee OA and a high level of knee pain during daily tasks are particularly likely to report widespread pain. This subgroup is likely to be at risk for not responding to knee OA treatment that focuses only on physical impairments. Assessment of widespread pain along with knee pain intensity and OA status may assist physical therapists in identifying people who may require additional treatment.

2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary

BACKGROUND

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

OBJECTIVES

To present the evidence-based guidelines for the diagnosis, management and patient trajectory of individuals with FM.

METHODS

A needs assessment following consultation with diverse health care professionals identified questions pertinent to various aspects of FM. A literature search identified the evidence available to address these questions; evidence was graded according to the standards of the Oxford Centre for Evidence-Based Medicine. Drafted recommendations were appraised by an advisory panel to reflect meaningful clinical practice.

RESULTS

The present recommendations incorporate the new clinical concepts of FM as a clinical construct without any defining physical abnormality or biological marker, characterized by fluctuating, diffuse body pain and the frequent symptoms of sleep disturbance, fatigue, mood and cognitive changes. In the absence of a defining cause or cure, treatment objectives should be patient-tailored and symptom-based, aimed at reducing global complaints and enhancing function. Healthy lifestyle practices with active patient participation in health care forms the cornerstone of care. Multimodal management may include nonpharmacological and pharmacological strategies, although it must be acknowledged that pharmacological treatments provide only modest benefit. Maintenance of function and retention in the workforce is encouraged.

CONCLUSIONS

The new Canadian guidelines for the treatment of FM should provide health professionals with confidence in the complete care of these patients and improve clinical outcomes.

Undiagnosed mood disorders and sleep disturbances in primary care patients with chronic musculoskeletal pain

OBJECTIVE

The study aims to determine the prevalence of undiagnosed comorbid mood disorders in patients suffering chronic musculoskeletal pain in a primary care setting and to identify sleep disturbances and other associated factors in these patients, and to compare the use of health services by chronic musculoskeletal pain patients with and without comorbid mood disorders.

DESIGN

Cross-sectional study.

SUBJECTS

A total of 1,006 patients with chronic musculoskeletal pain from a representative sample of primary care centers were evaluated.

OUTCOME MEASURES

Pain was measured using a visual analog scale and the Primary Care Evaluation of Mental Disorders questionnaire was used to measure mood disorders.

RESULTS

We observed a high prevalence of undiagnosed mood disorders in chronic musculoskeletal pain patients (74.7%, 95% confidence interval [CI] 71.9-77.4%), with greater comorbidity in women (adjusted odds ratio [OR] = 1.91, 95% CI 1.37-2.66%) and widow(er)s (adjusted OR = 1.87, 95% CI 1.19-2.91%). Both sleep disturbances (adjusted OR = 1.60, 95% CI 1.17-2.19%) and pain intensity (adjusted OR = 1.02, 95% CI 1.01-1.02%) displayed a direct relationship with mood disorders. Moreover, we found that chronic musculoskeletal pain patients with comorbid mood disorders availed of health care services more frequently than those without (P < 0.001).

CONCLUSIONS

The prevalence of undiagnosed mood disorders in patients with chronic musculoskeletal pain is very high in primary care settings. Our findings suggest that greater attention should be paid to this condition in general practice and that sleep disorders should be evaluated in greater detail to achieve accurate diagnoses and select the most appropriate treatment.

Effects of a one week multidisciplinary inpatient self-management programme for patients with fibromyalgia: a randomised controlled trial

Background

Self-management programmes (SMP) are recommended for patients with fibromyalgia. The purpose of this study was to evaluate effects of a one week multidisciplinary inpatient self-management programme on psychological distress, skills as a consumer of health services, self-efficacy, and functional and symptomatic consequences of fibromyalgia (FM).

Methods

A randomised controlled two-armed, assessor-blinded trial with three-week follow-up to evaluate SMP. Primary outcomes were the General Health Questionnaire (GHQ-20) and the Effective Musculoskeletal Consumer Scale (EC-17), while secondary outcomes included the Fibromyalgia Impact Questionnaire (FIQ) and Self-efficacy scales for pain, function and symptoms (ASES).

Results

150 patients with FM were randomised to one week one SMP (n = 75) or to a waiting list control group (n = 75). Of these, 58 participants in the treatment group and 60 in the control group completed the study. At three weeks’ follow up there was a significant difference in EC-17 (0-100) in favour of the treatment group (mean difference 4.26, 95 CI 0.8 to 7.7, p = 0.02). There were no differences between the groups for any of the other outcomes.

Conclusion

This study shows that in patients with FM the SMP had no effect on psychological distress, functional and symptomatic consequences and self-efficacy, except for a small short-term effect on skills and behaviour that are important for managing and participating in health care (EC-17). Clinical Trials.gov Id: NCT01035125.

Trial registration

Clinical Trials.gov Id: NCT01035125

Incidence and predictors of secondary fibromyalgia in an early arthritis cohort

OBJECTIVES

Secondary fibromyalgia (FM) is common among patients with inflammatory arthritis, but little is known about its incidence and the factors leading to its development. The authors examined the incidence of secondary FM in an early inflammatory arthritis cohort, and assessed the association between pain, inflammation, psychosocial variables and the clinical diagnosis of FM.

METHODS

Data from 1487 patients in the Canadian Early Arthritis Cohort, a prospective, observational Canadian cohort of early inflammatory arthritis patients were analysed. Diagnoses of FM were determined by rheumatologists. Incidence rates were calculated, and Cox regression models were used to determine HRs for FM risk.

RESULTS

The cumulative incidence rate was 6.77 (95% CI 5.19 to 8.64) per 100 person-years during the first 12 months after inflammatory arthritis diagnosis, and decreased to 3.58 (95% CI 1.86 to 6.17) per 100 person-years 12-24 months after arthritis diagnosis. Pain severity (HR 2.01, 95% CI 1.17 to 3.46) and poor mental health (HR 1.99, 95% CI 1.09 to 3.62) predicted FM risk. Citrullinated peptide positivity (HR 0.48, 95% CI 0.26 to 0.88) was associated with decreased FM risk. Serum inflammatory markers and swollen joint count were not significantly associated with FM risk.

CONCLUSIONS

The incidence of FM was from 3.58 to 6.77 cases per 100 person-years, and was highest during the first 12 months after diagnosis of inflammatory arthritis. Although inflammation was not associated with the clinical diagnosis of FM, pain severity and poor mental health were associated with the clinical diagnosis of FM. Seropositivity was inversely associated with the clinical diagnosis of FM.