The epidemiology of chronic syndromes that are frequently unexplained: do they have common associated factors?

Prevalence of functional disorders across Europe: a systematic review and meta-analysis

Functional Disorders (FD) refer to persistent somatic symptoms caused by changes in the functioning of bodily processes. Previous findings suggest that FD are highly prevalent, but overall prevalence rates for FD in European countries are scarce. Therefore, the aim of the present work was to estimate the point prevalence of FD in adult general populations. PubMed and Web of Science were searched from inception to June 2022. A generalized linear mixed-effects model for statistical aggregation was used for statistical analyses. A standardized quality assessment was performed, and PRISMA guidelines were followed. A total of 136 studies were included and systematically synthesized resulting in 8 FD diagnoses. The large majority of studies was conducted in the Northern Europe, Spain, and Italy. The overall point prevalence for FD was 8.78% (95% CI from 7.61 to 10.10%) across Europe, with the highest overall point prevalence in Norway (17.68%, 95% CI from 9.56 to 30.38%) and the lowest in Denmark (3.68%, 95% CI from 2.08 to 6.43%). Overall point prevalence rates for specific FD diagnoses resulted in 20.27% (95% CI from 16.51 to 24.63%) for chronic pain, 9.08% (95% CI from 7.31 to 11.22%) for irritable bowel syndrome, and 8.45% (95% CI from 5.40 to 12.97%) for chronic widespread pain. FD are highly prevalent across Europe, which is in line with data worldwide. Rates implicate the need to set priorities to ensure adequate diagnosis and care paths to FD patients by care givers and policy makers.

Factors associated with having previously received a diagnosis of fibromyalgia, chronic fatigue syndrome and irritable bowel syndrome: A cross sectional DanFunD study

OBJECTIVES

Fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome are highly prevalent conditions and part of the functional somatic syndromes (FSS) diagnosis, that are classified under the unifying umbrella term functional somatic disorder (FSD). Multiple factors are associated with FSD symptom development; However, few studies have explored these associations in relation to the diagnosis status. This study aims to examine associations with a previously received FSS diagnosis from a physician in participants fulfilling the FSD diagnostic criteria in a population-based sample.

METHODS

This research employs a comprehensive observational approach using a cross sectional design with data from the DanFunD part two cohort. Information about received FSS diagnoses was obtained from self-reported questionnaires. Participants fulfilling the FSD diagnostic criteria were identified with both self-reported questionnaires and diagnostic interviews. Validated questionnaires were used to assess the examined factors.

RESULTS

1704 cases fulfilled the diagnostic criteria for an FSD according to questionnaires or interviews in the DanFunD study. In participants fulfilling the diagnostic criteria, having previously received an FSS diagnosis by a physician was strongly associated with female sex, negative illness perceptions and poor health-related quality of life for questionnaire and interview-based diagnoses. Less consistent associations were observed for lower socioeconomic status, anxiety, and adverse life events.

CONCLUSION

Previously received FSS diagnoses showed associations with multiple factors with a particular strong association with female sex and poor health related quality of life.

Coexistence of fibromyalgia and post-polio syndrome in persons with prior poliomyelitis in Turkey: the relations with symptoms, polio-related impairments, and quality of life

PURPOSE

To investigate the prevalence of fibromyalgia(FM) and to show its relations with symptoms, polio-related impairments (PRI), and quality of life (QoL) in persons with prior paralytic poliomyelitis (PsPP) with and without post-polio syndrome (PPS).

MATERIALS AND METHODS

The study included 74 PsPP under 60 years of age, 60 of whom met the criteria for PPS. Presence and severity of FM were assessed by the American College of Rheumatology (ACR) 1990, 2010, and 2016 criteria, and Fibromyalgia Severity Score. PPS symptoms, PRI, and QoL were evaluated using the Self-Reported Impairments in Persons with Late Effects of Polio Rating Scale, Fatigue Severity Scale, and Nottingham Health Profile. Frequency, comparison, and correlation analyses were performed.

RESULTS

While 15% of PsPP with PPS met the criteria of ACR 1990, 32% of ACR 2010, and 35% of ACR 2016, none of those without PPS met any of the criteria for FM. Severity of PPS symptoms and PRI were significantly higher, and QoL was significantly lower in those with co-existing FM. FM severity was found to be significantly associated with severity of PPS symptoms, PRI and reduced QoL.

CONCLUSIONS

FM frequently coexists in PsPP with PPS and may increase the burden of PPS.Implications for RehabilitationFibromyalgia (FM) is commonly seen in patients with post-polio syndrome (PPS).Co-existing FM may increase the burden of PPS, as it is associated with more severe symptoms, more polio-related impairments, and worse quality of life.Recognition, appropriate referral, and successful management of co-existing FM may allow for reduced symptoms or symptom severity and improved quality of life in persons with PPS.

Management protocols of chronic Orofacial Pain: A Systematic Review

Objective

Chronic orofacial pain (CP) is a persistent and debilitating condition that affects the face, mouth, and jaw and can have a significant impact on an individual's quality of life by posing problems to eat, speak, and perform everyday activities. By the means of this narrative review, we aim to assess different types of management modalities that exist to combat chronic orofacial pain.

Design

Various databases were explored with MeSH keywords of chronic orofacial pain, orofacial pain, and interventions and treatment protocols for eligible articles. After an extensive literature search, it was ascertained that this review identified four major categories of treatment modalities for the management of chronic orofacial pain, namely pharmacological management, psychological management, lifestyle interventions-based management, and current stimulation-based management.

Results

Of the four categories discussed, although pharmacological intervention offered the most immediate relief-especially from orofacial pain that was of a sudden, stab-like in nature-psychological management demonstrated a remarkable ability to reduce/alleviate the more serious aspect of chronic orofacial pain and was deemed better in comparison to the rest. Lifestyle-based techniques and current stimulation-based management were of limited use since they tended to focus more on the causal and not the symptomatic aspect of orofacial pain.

Conclusions

Many patients with persistent orofacial discomfort can experience notable improvements in their symptoms and general well-being by all the treatment modalities evaluated.

Association of COMT Val158Met Polymorphism with Fibromyalgia in Khartoum State, Sudan

Fibromyalgia (FM) is a disorder characterized by chronic musculoskeletal pain, fatigue, and cognitive problems. Neurotransmitters, mainly catecholamines, appear to be involved in regulating the etiology of FM. Catechol-O-methyltransferase (COMT) is involved in catabolizing catecholamines such as norepinephrine. The most common variant studied in the COMT gene is the valine (Val) to methionine (Met) substitution at codon 158. This is the first study in Sudan addressing FM cases and genetic susceptibility to the disease. We aimed in this study to investigate the frequency of COMT Val 158 Met polymorphism among patients with FM, rheumatoid arthritis, and in healthy individuals. Genomic DNA from forty female volunteers was analyzed: twenty were from primary and secondary FM patients, ten were from rheumatoid arthritis patients, and ten were from healthy control. FM patients' age was ranging from 25 years to 55 with a mean of 41.14 ± 8.90. The mean age of the rheumatoid arthritis patients and healthy individuals was 31.3 ± 7.5 and 38.6 ± 11.2, respectively. Samples were genotyped for COMT single nucleotide polymorphism rs4680 (Val158Met), using the amplification-refractory mutation system (ARMS-PCR). Genotyping data have been analyzed using the Chi-square and Fisher exact test. The most common genotype among the study participants was the heterozygous Val/Met found in all participants. It was the only genotype found in the healthy participants. The genotype Met/Met was found only in FM patients. The genotype Val/Val was found only in rheumatoid patients. Analyses have shown no association between the Met/Met genotype and FM, and this could be due to a small sample size. In a larger sample size, a significant association could be found as this genotype was shown only by FM patients. Moreover, the Val/Val genotype, which is shown only among rheumatoid patients, might protect them from developing FM symptoms.

Contesting misrecognition online: Experiences of epistemic in/justice by vloggers with contested illnesses

Contested illnesses, such as fibromyalgia, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and chronic Lyme disease (CLD), are surrounded by polemic debates regarding their etiology, symptomology, treatment, and even their existence. People who suffer from these contested illnesses arguably also suffer from "epistemic injustice." This concept, coined by the philosopher Miranda Fricker, captures how people's knowledge may be discredited because of identity prejudices. In our paper, this concept is used to understand how seven Dutch women with contested illnesses experience the emancipatory potential of their vlogging practices. Our findings show how these women understood their vlogging as a means to break with epistemic smothering, understood as the propensity to cater ones testimony to one's audience (Dotson, 2011), and as a means to attain and enhance epistemic justice. However, our findings also show how vlogging about contested illnesses did not seem to allow these women to fully break with their epistemic smothering practices, and that the ableist design and gendered norms of YouTube were experienced as obstacles to attaining epistemic justice. We conclude that, even though social media do seem to hold emancipatory potential for these women, the experiences of individual users are diverse and ambiguous.

Persistent Orofacial Pain Attendances at General Medical Practitioners

Patients with persistent orofacial pain (POFP) can go through complex care pathways to receive a diagnosis and management, which can negatively affect their pain. This study aimed to describe 44-y trends in attendances at Welsh medical practices for POFP and establish the number of attendances per patient and referrals associated with orofacial pain and factors that may predict whether a patient is referred. A retrospective observational study was completed using the nationwide Secure Anonymised Information Linkage Databank of visits to general medical practices in Wales (UK). Data were extracted using diagnostic codes ("Read codes"). Orofacial and migraine Read codes were extracted between 1974 and 2017. Data were analyzed using descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 468,827 POFP and migraine diagnostic codes, accounting for 468,137 patient attendances, or 301,832 patients. The overall attendance rate was 4.22 attendances per 1,000 patient-years (95% confidence interval [CI], 4.21-4.23). The attendance rate increased over the study period. Almost one-third of patients (n = 92,192, 30.54%) attended more than once over the study period, and 15.83% attended more than once within a 12-mo period. There were 20,103 referral codes that were associated with 8,183 patients, with over half these patients being referred more than once. Odds of receiving a referral were highest in females (odds ratio [OR], 1.23; 95% CI, 1.17-1.29), in those living in rural locations (OR, 1.17; 95% CI, 1.12-1.22), and in the least deprived quintile (OR, 1.39; 95% CI, 1.29-1.48). Odds also increased with increasing age (OR, 1.03; 95% CI, 1.03-1.03). The increasing attendance may be explained by the increasing incidence of POFP within the population. These patients can attend on a repeated basis, and very few are referred, but when they are, this may occur multiple times; therefore, current care pathways could be improved.

The Influence of Personality on Health Complaints and Quality of Life in Women With Breast Implants

BACKGROUND

A causal relation between systemic symptoms and breast implants has not been established. Psychological factors, such as personality and psychological distress, are strongly associated with the development of medically unexplained symptoms. It can be hypothesized that psychological factors may be related to the development of breast implant illness (BII).

OBJECTIVES

This study was conducted to evaluate the correlation between self-reported health complaints, health- and breast-related quality of life (QoL), and personality, in women with cosmetic breast implants.

METHODS

Women who attended the plastic surgery outpatient clinic of Maastricht University Medical Center between October 2020 and October 2021 for reasons related to their implants and women recruited for a BII study at the Center during this period were invited to participate in this study. Only women who underwent cosmetic breast augmentation were eligible. Participants completed a physical complaints score form and the BREAST-Q, SF-36, and EPQ-RSS questionnaires via an online survey.

RESULTS

In total, 201 women completed the questionnaires. Extroversion and social desirability were predominant personality traits in women with breast implants, followed by neuroticism. Relatively high levels of neuroticism were found compared with normative data. Neuroticism correlated significantly with health status and breast-related QoL. Physical and mental health-related QoL had the strongest correlations with neuroticism (β = -3.94, β = -4.86, P < 0.001).

CONCLUSIONS

Personality can play a role in the development of complaints. High levels of neuroticism are seen in cosmetic surgery patients and are negatively correlated with subjective health and patient-reported outcomes in women with breast implants. Therefore, neuroticism may be a factor in the development of BII.

LEVEL OF EVIDENCE: 4

Patients With Fibromyalgia, Depression, and/or Anxiety and Sex Differences

Fibromyalgia is a syndrome characterized by chronic widespread pain, with a multifactorial etiopathogenesis and high incidence of neuropsychiatric comorbidity. It has been inaccurately considered a pathological condition affecting only middle-aged women. The study aimed to explore the association of sociodemographic and clinical factors in patients with fibromyalgia with depression and/or anxiety. The present study is an analysis of a cross-sectional study of a secondary source. The prevalence ratio (PR) between the demographic and clinical variables of patients with fibromyalgia and concomitant depression and/or anxiety was calculated. Overall, 1,106 medical records were obtained with a confirmed diagnosis of fibromyalgia between 2010 and 2016; of these, 318 (28.75%) patients had an associated diagnosis of depression and/or anxiety. Approximately 28% women (295 of 1,052) and 42.6% men (23 of 54) suffered from depression and/or anxiety. In the adjusted explanatory model of depression and/or anxiety in patients with fibromyalgia, the relationship between sex (female PR = 0.5 [0.28–0.86]) and low socioeconomic strata (PR = 0.53 [0.33–0.70]) remained constant. In the study population, patients with fibromyalgia belonging to lower social strata were less likely to present with depression and anxiety. The male sex may pose as a risk factor for depression and/or anxiety in patients with fibromyalgia. Fibromyalgia has a huge impact on men’s physical as well as mental health.

Adiponectin and Nitric Oxide Deficiency-Induced Cognitive Impairment in Fatigued Home-Resident in Mature and Older Adults: A Case-Control Study

Objective

The present study explores the underlying factors of cognitive abilities in relation to the expression of adiponectin and nitric oxide, fatigue, and other cofounder variables such as physical activity, diabetes, and adiposity status in healthy home-resident mature and older adults.

Background

Fatigue has been shown to be correlated with many metabolic and psychiatric conditions, such as cognitive, neurological, musculoskeletal, and hormonal disorders, as well as physical and unhealthy lifestyles.

Methods

A total of 85 home residents aged 50–85 years participated in this case-control study. Mental, fatigue, and pain status were assessed by the cognitive assessment (LOTCA), fatigue questionnaire (CIS20r), and pain score (0–10). VO₂ max and the prevalidated global physical activity questionnaire were used to estimate physical status. The levels of adiponectin, nitric oxide (NO), and variables related to diabetes, such as blood sugar and glycated hemoglobin (HbA1c %), were assessed using ELISA and spectrophotometric immunoassays.

Results

The participants were classified according to the CIS-fatigue score into two groups: the healthy group (n = 40) and the fatigue group (n = 45). In fatigued subjects, LOTCA scores as a measure of cognitive performance significantly decreased (65.97 ± 7.17; P = 0.01) as compared with healthy subjects (LOTCA scores, 94.2 ± 7.5). The results of cognitive performance domains (LOTCA seven-subset scores) showed a significant decrease in the scores of orientation, visual perception, spatial perception, motor praxis, vasomotor organization, thinking operations, attention, and concentration in older subjects with fatigue compared with healthy subjects. In addition, pain scores significantly increased, and the expression of both nitric oxide (NO) and adiponectin significantly reduced in older adults with fatigue as compared with healthy controls. The decline in cognitive abilities among older adults with fatigue is significantly associated with the CIS-fatigue score, sedentary lifestyle, obesity, pain status, diabetes, and reduction in the levels of nitric oxide (NO), and adiponectin. Moreover, in fatigued cases, the expression of both NO and adiponectin was significantly correlated with CIS-fatigue score, physical activity, obesity, and diabetes, which indicates its availability as diagnostic markers for cognition in mature and older adults with fatigue.

Conclusion

In the present study, the data concluded that cognitive abilities were significantly associated with the lower expression of adiponectin and NO as endothelial vascular markers in association with fatigue among home-resident older adults. In addition, the reduction in cognition was significantly affected by other parameters, such as diabetes, obesity, and unhealthy sedentary life activities. Moreover, the results might recommend the use of cellular adiponectin and NO as diagnostic indicators of cognitive abilities in fatigued mature and older adults. However, more studies on larger sample sizes are required.

History of Functional Somatic Syndromes and Persistent Symptoms After Mild Traumatic Brain Injury

OBJECTIVE

Somatization is thought to underlie functional somatic syndromes (FSSs) and may also contribute to prolonged symptoms after mild traumatic brain injury (mTBI). The investigators evaluated the prevalence of FSSs in patients seeking specialty care after mTBI and whether a history of FSSs was associated with symptom persistence.

METHODS

A total of 142 patients with mTBI completed questionnaires regarding demographic information, injury characteristics, and medical history, including history of diagnosed FSSs at clinic intake (mean=41 days postinjury [SD=22.41]). Postconcussion symptoms were assessed at clinic intake and again 1 and 3 months later. A linear mixed-effects model was used to determine whether history of FSSs was related to persistent mTBI symptoms over time.

RESULTS

A history of at least one FSS was reported by 20.4% of patients. In the linear mixed model, postconcussion symptom scores were not significantly different over time among patients with a history of one or more FSSs or two or more FSSs from those with no FSSs. A history of one or more FSSs or two or more FSSs (versus no FSS) was not associated with increased odds of severe postconcussion symptoms at clinic intake (one or more FSSs: odds ratio=0.88, 95% CI=0.38-2.03; two or more FSSs: odds ratio=1.78, 95% CI=0.45-7.03), at the 1-month follow-up visit (one or more FSSs: odds ratio=0.57, 95% CI=0.22-1.45; two or more FSSs: odds ratio=0.57, 95% CI=0.14-2.37), or at the 3-month follow-up visit (one or more FSSs: odds ratio=0.97, 95% CI=0.36-2.63; two or more FSSs: odds ratio=1.27, 95% CI=0.29-5.65).

CONCLUSIONS

In this sample, the prevalence rates of FSSs were higher than rates previously reported for the general population. However, FSS history did not predict higher postconcussion symptom burden at clinic intake or persistence over the following 3 months. Further research is needed to clarify the potential role of somatization in poor mTBI outcome.

Activation of the P2X7 receptor in the dental pulp tissue contributes to the pain in rats with acute pulpitis

Treatment of acute pulpitis (AP) is beneficial for pain relief and pulp regeneration. The purinergic P2X7 receptor activation is responsible for the formation and maintenance of inflammation and pain. This study aims to determine the role of the pulp tissue P2X7 receptor to activate the mechanisms of the AP in rats. The Sprague-Dawley rats were divided into groups, namely, normal, normal saline (NS), and lipopolysaccharide (LPS) groups. Alterations in pain behavior were detected through head-withdrawal thresholds (HWTs), and the pathological changes in pulp tissue were studied through hematoxylin and eosin staining. The expression of the P2X7 receptor in pulp tissue was observed through immunohistochemistry and Western Blotting. The effect of the P2X7 receptor antagonist A-740003 on HWTs was also observed. The levels of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in the pulp tissue of rats were analyzed through enzyme-linked immunosorbent assay. The HWTs were reduced in the rats with AP. Inflammation is formed but was found more severe in the LPS group than the NS group, and the expression levels of the P2X7 receptors in the NS and LPS groups were higher than in the normal group. The periodontal ligament injection of the A-740003 dose-dependant increases the HWTs in rats with AP. The IL-6 and TNF-α levels in the pulp in the NS and LPS groups were increased but reversed by A-740003 injection. In rats with AP, the expression level of the P2X7 receptor and IL-6/TNF-α release was upregulated. The A-740003 can relieve pain and reduce the inflammation progression in rats with AP.

Self-Reported Health Complaints in Women Undergoing Explantation of Breast Implants

Background

Concerns about the safety of silicone breast implants (SBIs) have existed for years, but a causal relation between systemic complaints and SBIs has not been proven. Nevertheless, some women are worried and even request explantation.

Objectives

This study aimed to review the explantation procedures performed, focusing on patient-reported symptoms preoperatively, the effect of explantation, and the effect of breast reconstruction on these symptoms.

Methods

A retrospective chart review was performed for patients who had undergone explantation between 2010 and 2020 at Maastricht University Medical Center. Patients who had undergone tissue expander removal, tissue expander–implant exchange, or direct implant exchange were excluded.

Results

More than half of the patients undergoing explantation reported complaints, mostly pain. Some 15% reported systemic complaints they believed were implant related. Breast implant illness (BII) was found to be the fifth most common indication for explantation (11.2%). A history of either allergies or implant rupture resulted in higher odds ratios of having BII (odd ratios, 2.1 and 2.1, respectively). Subjective improvement of BII after explantation was reported by about 60% of patients.

Conclusions

A relatively low prevalence of suggested BII exists among women undergoing explantation; 1 in 9 procedures were performed for this reason. Allergy and implant rupture may increase the likelihood of having BII. About 60% of BII patients experienced an improvement in their complaints after implant removal. Autologous breast reconstruction appears a good alternative. Prospective studies into health complaints and quality of life should be performed to confirm the effectiveness of explantation as a therapy for BII.

Level of Evidence: 4

Dores musculares cervicais em pacientes com DTM e suas correlações

Resumo Introdução As disfunções temporomandibulares apresentam uma variedade de sinais e sintomas que afetam a articulação temporomandibular, músculos da mastigação e estruturas relacionadas e muitos pacientes apresentam queixas cervicais. Objetivo Verificar a correlação de dor à palpação dos músculos da mastigação (masseter, temporal anterior, pterigoideos lateral e medial) e digástrico, com a queixa de dor no pescoço; verificar a correlação de dor à palpação nos músculos da mastigação e digástrico, com dor à palpação no esternocleidomastoideo e trapézio, e se a força de correlação é diferente entre eles. Material e método Foram avaliados 232 prontuários da clínica odontológica das Disfunções Temporomandibulares da Faculdade de Odontologia de Araçatuba, do período de 2011 a 2013. Os dados coletados foram submetidos à análise estatística, com alfa (α) = 0.01 para todos os casos, exceto digástrico quando associado ao trapézio (α) = 0.05. Resultado A maioria dos pacientes era do sexo feminino. Houve correlação positiva entre dor à palpação nos músculos temporal, masseter, pterigoideo lateral, esternocleidomastoideo e trapézio, e queixa de dor no pescoço. Também houve correlação positiva entre a dor em todos os músculos da mastigação (masseter, temporal, pterigoideo lateral e medial) e digástrico e a dor no esternocleidomastoideo. Bem como a correlação de presença de dor nos músculos masseter, temporal, pterigoideo lateral e digástrico com dor no trapézio. A correlação de dor foi mais forte para o músculo esternocleidomastoideo, exceto para o pterigoideo lateral. Conclusão Existe correlação positiva entre a queixa de dor à palpação nos músculos da mastigação, exceto pterigiodeo medial, e os músculos cervicais (esternocleidomastoideo e trapézio). A força de correlação entre a dor do masseter e temporal anterior com o esternocleidomastoideo é mais forte do que com o trapézio.

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.

Functional gastrointestinal disorders. Overlap syndrome Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine and Gastroenterological Scientific Society of Russia

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Is Irritable Bowel Syndrome Considered as Comorbidity in Clinical Trials of Physical Therapy Interventions in Fibromyalgia? A Scoping Review

Evidence supports the presence of comorbid conditions, e.g., irritable bowel syndrome (IBS), in individuals with fibromyalgia (FM). Physical therapy plays an essential role in the treatment of FM; however, it is not currently known whether the IBS comorbidity is considered in the selection criteria for clinical trials evaluating physiotherapy in FM. Thus, the aim of the review was to identify whether the presence of IBS was considered in the selection criteria for study subjects for those clinical trials that have been highly cited or published in the high-impact journals investigating the effects of physical therapy in FM. A literature search in the Web of Science database for clinical trials that were highly cited or published in high-impact journals, i.e., first second quartile (Q1) of any category of the Journal Citation Report (JCR), investigating the effects of physical therapy in FM was conducted. The methodological quality of the selected trials was assessed with the Physiotherapy Evidence Database (PEDro) scale. Authors, affiliations, number of citations, objectives, sex/gender, age, and eligibility criteria of each article were extracted and analyzed independently by two authors. From a total of the 412 identified articles, 20 and 61 clinical trials were included according to the citation criterion or JCR criterion, respectively. The PEDro score ranged from 2 to 8 (mean: 5.9, SD: 0.1). The comorbidity between FM and IBS was not considered within the eligibility criteria of the participants in any of the clinical trials. The improvement of the eligibility criteria is required in clinical trials on physical therapy that include FM patients to avoid selection bias.

Characteristics and economic burden of frequent attenders with medically unexplained symptoms in primary care in Israel

Background

Frequent Attenders with Medically Unexplained Symptoms (FA/MUS) are common in primary care, though challenging to identify and treat.

Objectives

This study sought to compare FA/MUS to FA with organic illnesses (FA/OI) and the general clinic population (Non-FA) to understand their demographic characteristics and healthcare utilisation patterns.

Methods

For this retrospective, observational study, Electronic Medical Records (EMR) were obtained from Clalit Health Services, regarding the population of a sizeable primary care clinic in Be’er-Sheva, Israel. Electronic medical records were screened to identify the top 5% of FA. FA were stratified based on whether they had OI. FA without OI were then corroborated as having MUS by their physicians. Demographics, healthcare utilisation and costs were analysed for FA/OI, FA/MUS and Non-FA.

Results

Out of 594 FA, 305 (53.6%) were FA/OI and 264 (46.4%) were FA/MUS. FA/OI were older (69.1 vs. 56.4 years, p<.001) and costlier (ILS27693 vs. ILS9075, p<.001) than FA/MUS. Average costs for FA/MUS were over four times higher than Non-FA (ILS9075 vs. ILS2035, p<.001). The largest disparities between FA/OI and FA/MUS were in hospitalisations (ILS6998 vs. ILS2033) and surgical procedures (ILS8143 vs. ILS3175). Regarding laboratory tests, differences were smaller between groups of FA but significantly different between FA and Non-FA.

Conclusion

FA/MUS are more costly than Non-FA and exhibit unique healthcare utilisation and costs patterns. FA/OI had more severe illnesses necessitating hospitalisations and surgical interventions, while FA/MUS had more investigations and tests, attempting to find an explanation for their symptoms.

Physical pain, gender, and the state of the economy in 146 nations

RATIONALE

Physical pain is one of the most severe of human experiences. It is thus one of the most important to understand.

OBJECTIVE

This paper reports the first cross-country study of the links between physical pain and the state of the economy. A key issue examined is how the level of pain in a society is influenced by the unemployment rate.

METHODS

The study uses pooled cross-sectional Gallup data from 146 countries (total N > 1.3 million). It estimates fixed-effects regression equations that control for personal characteristics.

RESULTS

More than a quarter of the world's citizens are in physical pain. Physical pain is lower in an economic boom and greater in an economic downturn. Estimated effect sizes are substantial. Remarkably, increases in pain are borne almost exclusively by women and found principally in rich nations. These findings have paradoxical aspects. The counter-cyclicality of physical pain is not what would be predicted by conventional economic analysis: during an expansion, people typically work harder and longer, and accidents and injuries increase. Nor are the study results due to unemployed citizens experiencing more pain (although they do). Instead, the study's findings are consistent with an important hypothesis proposed recently, using different kinds of evidence, by brain and behavioural-science researchers (e.g., Wiech and Tracey, 2009; Chou et al.; 2016). The hypothesis is that economic worry can create physical pain.

CONCLUSIONS

This study provides the first cross-country evidence that the level of physical pain in a nation depends on the state of the economy. Pain is high when the unemployment rate is high. That is not because of greater pain among people who lose their jobs - it extends far beyond that into wider society. The increase in physical pain in a downturn is experienced disproportionately by women.

A comprehensive review on biomarkers associated with painful temporomandibular disorders

Pain of the orofacial region is the primary complaint for which patients seek treatment. Of all the orofacial pain conditions, one condition that possess a significant global health problem is temporomandibular disorder (TMD). Patients with TMD typically frequently complaints of pain as a symptom. TMD can occur due to complex interplay between peripheral and central sensitization, endogenous modulatory pathways, and cortical processing. For diagnosis of TMD pain a descriptive history, clinical assessment, and imaging is needed. However, due to the complex nature of pain an additional step is needed to render a definitive TMD diagnosis. In this review we explicate the role of different biomarkers involved in painful TMD. In painful TMD conditions, the role of biomarkers is still elusive. We believe that the identification of biomarkers associated with painful TMD may stimulate researchers and clinician to understand the mechanism underlying the pathogenesis of TMD and help them in developing newer methods for the diagnosis and management of TMD. Therefore, to understand the potential relationship of biomarkers, and painful TMD we categorize the biomarkers as molecular biomarkers, neuroimaging biomarkers and sensory biomarkers. In addition, we will briefly discuss pain genetics and the role of potential microRNA (miRNA) involved in TMD pain.

Implementation of biopsychosocial supported self-management for chronic primary oro-facial pain including temporomandibular disorders: A theory, person and evidence-based approach

BACKGROUND

Aims of the study were to: Implement supported self-management for chronic primary oro-facial pain in a clinical setting. Evaluate its impact on consultation rates, pain severity, interference with life and patient experience.

METHODS

Sixty-six patients with chronic primary oro-facial pain received the intervention at a facial pain clinic at Leeds Dental Institute, UK. Brief Pain Inventory (BPI) scores measured pain severity and interference with life before and after the intervention. Process mining outlined patient care pathways. Monthly consultation rates measured 12 months before and after the intervention were used to evaluate burden on healthcare services and economic impact. Patient feedback was assessed via Patient and Public involvement discussion groups.

RESULTS

Mean BPI scores significantly improved after intervention-from 5.70 (SD 1.89) to 3.78 (SD 2.34) (p < .001); mean pain interference score reduced from 19.95 (SD 9.41) to 12.05 (SD 9.64) (p < .001). Average monthly consultations significantly (p = .001) reduced from 0.42/month before the intervention to 0.16/month after the intervention. Economic assessment showed cost savings of £293 per patient per year. Process mining showed high rates of service usage with 31 patients also attending 51 other specialist services between them. Patient and Public Involvement discussion groups with 5 patients identified that the intervention was a 'constant companion' and should be implemented at the outset in the care pathway.

CONCLUSION

Supported self-management for chronic primary oro-facial pain has a positive impact on health outcomes (physical functioning, pain intensity and patient experience), as well as service usage and healthcare costs when implemented in a secondary care clinical setting. Reconfiguring current care pathways to upscale early implementation of such interventions should be a priority for future testing.

Comorbid Conditions in Temporomandibular Disorders Myalgia and Myofascial Pain Compared to Fibromyalgia

The impact of comorbidities in fibromyalgia (FM) and temporomandibular disorders (TMD) have been well documented, but whether TMD sub-diagnoses myalgia (MYA) and myofascial pain with referral (MFP) differ regarding comorbidity is unclear. We aimed to elucidate this by studying the presence and associations of comorbidities in FM, MFP and MYA. An extended version of the Diagnostic Criteria for TMD axis II questionnaire was used to examine demographics, pain and comorbidities in 81 patients with FM, 80 with MYA, and 81 with MFP. Patients with MFP and FM reported a higher percentage of irritable bowel syndrome (IBS), depression, anxiety, somatic symptoms, perceived stress, and insomnia compared to MYA. Patients with FM had more IBS, depression, and somatic symptom disorder versus MFP. After adjusting for confounding variables, participants with anxiety, somatic symptoms disorder, pain catastrophizing, and perceived stress, as well as a greater number of comorbidities, were more likely to have MFP than MYA, whereas FM participants were more associated with IBS, somatic symptoms and insomnia compared to MFP. The number of comorbidities was significantly associated with widespread pain but not pain duration, body mass index or being on sick leave. In conclusion, patients with MFP were more similar to those with FM regarding comorbidity and should be differentiated from MYA in clinical settings and pain management.

"Pacing does help you get your life back": The acceptability of a newly developed activity pacing framework for chronic pain/fatigue

OBJECTIVES

We have developed and feasibility tested an activity pacing framework for clinicians to standardise their recommendations of activity pacing to patients with chronic pain/fatigue. This study aimed to explore the acceptability and fidelity to this framework in preparation for a future trial of activity pacing.

DESIGN

Acceptability and fidelity were explored using semi-structured interviews. Data were analysed using framework analysis.

PARTICIPANTS

Patients who attended a rehabilitation programme for chronic pain/fatigue underpinned by the framework, and clinicians (physiotherapists and psychological wellbeing practitioners) who led the programmes.

RESULTS

Seventeen interviews were conducted, involving 12 patients with chronic pain/fatigue and five clinicians. The framework analysis revealed four deductive themes: (1) Acceptability of the activity pacing framework, (2) Acceptability of the feasibility study methods, (3) Processes of change and (4) Barriers and facilitators to activity pacing; and one inductive theme: (5) Perspectives of patients and clinicians.

CONCLUSIONS

The activity pacing framework appeared acceptable to patients and clinicians, and adherence to the framework was demonstrated. Processes of behaviour change included patients' regulation of activities through activity pacing. Barriers to pacing included work/social commitments and facilitators included identifying the benefits of pacing on symptoms. Different perspectives emerged between clinicians and patients regarding interpretations of symptom-contingent and quota-contingent strategies. The framework recognises fluctuations in symptoms of chronic pain/fatigue and encourages a quota-contingent approach with flexibility. Future work will develop a patient friendly guide ahead of a clinical trial to explore the effects of pacing.

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.

Simplifying differential diagnoses of orofacial conditions - a guide to surgical sieves and red flags

Formulation of a differential diagnosis with appropriate diagnostic tests is critical in day-to-day clinical practice. Many specialists or hospital-based practitioners in specialties such as oral medicine and oral surgery will be familiar with the use of surgical sieves and the term 'red flags' in their practice. However, it is the authors' experience that general dental practitioners may not be as familiar with such tools. Primary care practitioners are often the first port of call for patients with uncommon symptoms; therefore, it is essential that appropriate and timely referrals are made. The use of a surgical sieve and heightened awareness of red flags will assist practitioners significantly.

Blood Dehydroepiandrosterone and Dehydroepiandrosterone Sulfate as Pathophysiological Correlates of Chronic Pain: Analyses Using a National Sample of Midlife Adults in the United States

OBJECTIVE

Identifying biomarkers is a priority in translational chronic pain research. Dehydroepiandrosterone (DHEA) and its sulfated form, DHEA-S, are adrenocortical steroids in the blood with neuroprotective properties that also produce sex hormones. They may capture key sex-specific neuroendocrine mechanisms of chronic pain.

DESIGN

Cross-sectional study.

METHODS

Using data from 1,216 community-dwelling adults aged 34-84 from the Midlife in the United States (MIDUS) cohort, we examined blood DHEA and DHEA-S levels in association with chronic pain in men and women, adjusting for demographics, chronic diseases, medications including opioids, and psychosocial factors. If an association was found, we further explored dose-response relationships by the number of pain locations and the degree of pain interference.

RESULTS

In women, chronic pain was associated with 0.072 lower (95% confidence interval [CI], -0.127 to -0.017) log10 DHEA-S µg/dL, with pain in one to two locations associated with 0.068 lower (95% CI, -0.131 to -0.006) and in three or more locations 0.071 lower (95% CI, -0.148 to 0.007) log10 DHEA-S (P for trend = 0.074). Furthermore for women, low-interference pain was associated with 0.062 lower (95% CI, -0.125 to -0.000), whereas high-interference pain was associated with 0.138 lower (95% CI, -0.233 to -0.043) log10 DHEA-S (P for trend = 0.004). Chronic pain was not associated with DHEA or DHEA-S levels in men or DHEA levels in women.

CONCLUSIONS

Chronic pain and its functional interference correspond to lower blood DHEA-S levels in women.

A feasibility study of the Redesigning Daily Occupations (ReDOTM-10) programme in an Irish context

BACKGROUND

Despite high demand, mental health services in primary care in Ireland are underdeveloped. People with mild/moderate anxiety, depression and unspecified psychological distress are frequently seen in primary care settings, mostly by general practitioners (GPs). Occupational therapists have the potential to contribute to service-provision with interventions specially designed for the targeted group e.g. the Redesigning Daily Occupations programme (ReDO-10).

AIMS/OBJECTIVES

This study aimed to explore the feasibility of a future RCT of the ReDO-10 programme in Ireland and the contextual factors that would influence future implementation.

MATERIAL AND METHODS

Using a multi-phase, mixed-method design, qualitative and quantitative data were gathered from key stakeholders: ReDO-10 participants (n = 10), GPs (n = 9) and occupational therapists (n = 2). Acceptability, satisfaction, cultural fit and demand were explored, as well as methodological issues such as appropriateness of recruitment methods, outcome measures and randomization.

RESULTS

ReDO-10 was acceptable to participants who reported improvements in their occupational patterns and valued the group-based format. GPs and occupational therapists welcomed the intervention, but acknowledged the limitations of time and resources in the Irish primary care context.

CONCLUSIONS

ReDO-10 is feasible to explore in a future RCT in Ireland and this study provides important context for future implementation and/or research.

The Pain-to-Well-Being Relationship in Patients Experiencing Chronic Orofacial Pain

Introduction: Orofacial pain features may negatively influence a person's well-being and vice versa. Some aspects of well-being can be measured with axis II instruments that assess patients' psychosocial and behavioral status. The aim of this study was to investigate associations between pain features and psychosocial variables as indicators of well-being. Materials and Methods: Seven hundred ninety-nine anonymized datasets collected using the Web-based Interdisciplinary Symptom Evaluation (WISE) of patients reporting to the Interdisciplinary Orofacial Pain Unit, University of Zurich, between March 19, 2017 and May 19, 2019, were analyzed. Pain features including intensity, number of locations, impact, and duration were evaluated. Psychometric measures assessed pain-related catastrophizing and disability, illness perception, distress, anxiety, depression, injustice experience, dysmorphic concerns, and insomnia. Results: Most patients were between 30 and 59 years old (58.3%), female (69.8%), working (66.0%), and experienced pain for more than 6 months (68.5%). Pain intensities were higher in women than men and higher in disabled than working patients. Scores indicating elevated stress and depression were also observed in disabled patients. The sample prevalence rates of clinically relevant axis II instrument scores were as follows: Graded Chronic Pain Scale for the Head (GCPS-H), 27%; Patient Health Questionnaire 4 (PHQ4), 21%; PHQ9, 21%; Pain Catastrophizing Scale (PCS), 20%; General Anxiety Disorder 7 (GAD7), 15%; Insomnia Severity Index (ISI), 15%; Injustice Experience Questionnaire (IEQ), 14%; GCPS for the Body (GCPS-B), 13%; PHQ for Stress (PHQstr), 6%; and Dysmorphic Concern Questionnaire (DCQ), 2%. Noteworthy results of correlation analysis of the clinically relevant axis II scores and pain measures were as follows: the PHQstr had moderate associations (0.34-0.43) with the sum of pain intensity at rest and during function, number of pain locations, and typical pain intensity. The IEQ scores were moderately associated with typical pain intensity at 0.39. The DCQ scores were moderately associated with pain extension at 0.41. Conclusions: Moderate correlations of certain pain and well-being measures were found in patients reporting clinically relevant stress, injustice experience, and dysmorphic concern, all of which reflect impaired well-being. PHQ4 is suitable for routine distress screening in the clinical setting.

Is Irritable Bowel Syndrome Considered in Clinical Trials on Physical Therapy Applied to Patients with Temporo-Mandibular Disorders? A Scoping Review

The aim of the current scoping review was to identify if the presence of irritable bowel syndrome was included as eligibility criteria of participants included in clinical trials investigating the effects of physical therapy in individuals with temporomandibular pain disorders (TMDs). A systematic electronic literature search in the Web of Science database was conducted. Scientifically relevant, randomized clinical trials (those cited in other studies at least 5 times, or clinical trials published in high-impact journals, i.e., first and second quartiles (Q1-Q2) of any category of the Journal Citation Report (JCR)) evaluating the effects of any physical therapy intervention in patients with TMDs were included. The Physiotherapy Evidence Database (PEDro) scale was used to evaluate the methodological quality of the selected trials. Authors affiliated to a clinical or non-clinical institution, total number of citations, objective, sex/gender, age, and eligibility criteria in each article were extracted and analyzed independently by two authors. From a total of 98 identified articles, 12 and 19 clinical trials were included according to the journal citation criterion or JCR criterion, respectively. After removing duplicates, a total of 23 trials were included. The PEDro score ranged from 4 to 8 (mean: 6.26, SD: 1.48). Based on the eligibility criteria of the trials systematically reviewed, none considered the presence of comorbid irritable bowel syndrome in patients with TMDs. The comorbidity between TMDs and irritable bowel syndrome is not considered within the eligibility criteria of participants in highly cited clinical trials, or published in a high-impact journal, investigating the effects of physical therapy in TMDs.

Epidemiology of Perceived Physical Fatigability in Older Adults: The Long Life Family Study

BACKGROUND

Fatigability is a construct that measures whole-body tiredness anchored to activities of a fixed intensity and duration; little is known about its epidemiology and heritability.

METHODS

Two generations of family members enriched for exceptional longevity and their spouses were enrolled (2006-2009) in the Long Life Family Study (LLFS). At Visit 2 (2014-2017, N = 2,355) perceived physical fatigability was measured using the 10-item self-administered Pittsburgh Fatigability Scale (PFS), along with demographic, medical, behavioral, physical, and cognitive risk factors.

RESULTS

Residual genetic heritability of fatigability was 0.263 (p = 6.6 × 10-9) after adjustment for age, sex, and field center. PFS physical scores (mean ± SD) and higher physical fatigability prevalence (% PFS ≥ 15) were greater with each age strata: 60-69 (n = 1,009, 11.0 ± 7.6, 28%), 70-79 (n = 847, 12.5 ± 8.1, 37%), 80-89 (n = 253, 19.3 ± 9.9, 65.2%), and 90-108 (n = 266, 28.6 ± 9.8, 89.5%), p < .0001, adjusted for sex, field center, and family relatedness. Women had a higher prevalence of perceived physical fatigability compared to men, with the largest difference in the 80-89 age strata, 74.8% versus 53.5%, p < .0001. Those with greater body mass index, worse physical and cognitive function, and lower physical activity had significantly higher perceived physical fatigability.

CONCLUSIONS

Perceived physical fatigability is highly prevalent in older adults and strongly associated with age. The family design of LLFS allowed us to estimate the genetic heritability of perceived physical fatigability. Identifying risk factors associated with higher perceived physical fatigability can inform the development of targeted interventions for those most at risk, including older women, older adults with depression, and those who are less physically active.

Clinical presentations on a facial pain clinic

Introduction The complex nature of facial pain conditions creates a diagnostic challenge which may necessitate specialist referral.Aim To identify the case mix presenting to a specialist tertiary care facial pain clinic.Methods A retrospective review of 112 patient records was undertaken. Trends in provisional diagnoses from referrers and the correlation to diagnoses made following specialist consultation were reviewed.Results The most common provisional diagnoses recorded in referral letters were painful temporomandibular disorders, trigeminal neuralgia and persistent idiopathic facial pain (PIFP). Over a quarter of referrals did not include a provisional diagnosis. Following assessment, only one case was not given a definitive diagnosis and no patients were diagnosed with PIFP. A causative factor was identified in all the initially queried PIFP cases, and painful post-traumatic trigeminal neuropathic pain was found in multiple patients.Conclusions Painful post-traumatic trigeminal neuropathic pain should be considered if pain onset coincides with dental treatment or other traumatic events. PIFP is a rare facial pain diagnosis and may be over-diagnosed by dental and medical practitioners. It is important to systematically exclude other causes before reaching this diagnosis. This will facilitate effective treatment, manage patient expectations and potentially reduce unnecessary referrals.

The differential impact of neuropathic, musculoskeletal and neurovascular orofacial pain on psychosocial function

BACKGROUND

While the psychosocial morbidity of orofacial pain (OFP) is widely recognized, the differential impact of musculoskeletal, neuropathic and neurovascular symptoms on pain and psychosocial function in individuals with and without coexisting OFP conditions is unclear.

MATERIALS AND METHODS

This was a comparative cross-sectional study of 350 consecutive patients attending an OFP clinic; 244 completed standardized self-report measures of pain experience, mood, and generic and oral health-related quality of life (HRQoL). The impact of musculoskeletal, neuropathic and neurovascular symptoms on measures was assessed using linear and logistic generalized linear models.

RESULTS

Two hundred patients were diagnosed with a neuropathic condition: 125 with musculoskeletal pain and 101 with (neurovascular) headache disorders. 23% of patients presented with multiple OFP conditions; this was more common in patients with neurovascular (62%) than neuropathic (21%) and/or musculoskeletal orofacial symptoms (28%). Patients with neurovascular symptoms experienced significantly higher levels of pain, evidenced less pain self-efficacy and had poorer overall health. Neuropathic OFP was significantly associated with greater psychological and social oral health disability. Multiple OFP symptoms were not linked to pain severity or psychosocial function, although health scores were worse for patients with neurovascular pain and neuropathic/musculoskeletal symptoms compared with patients with only neurovascular symptoms.

CONCLUSIONS

The profile and degree of psychosocial morbidity in patients with OFP is significantly related to the types of presenting orofacial symptoms. Patients with neurovascular pain present with higher pain levels and have poorer health while those with neuropathic pain have higher oral functional morbidity; both may require more complex multidisciplinary management.

Predictors of fatigue in rheumatoid arthritis

People with RA commonly experience fatigue. Fatigue is a key contributor to increased clinical care costs, primary care consultations and employment loss. Despite this, our understanding of the prognostic of factors of poor fatigue outcomes is lacking and fatigue is poorly managed. Examining longitudinal predictors of fatigue can identify both individuals ‘at risk’ of poor prognosis, and candidate mechanisms that are worthy of greater inspection. This review discusses the factors most commonly investigated as being implicated in the prognosis of RA fatigue. The available data appears to implicate generic factors such as pain, mental health, disability and sleep as consistent predictors of fatigue outcome, while the role of disease activity and inflammation seems less clear. However, the existing data are not without methodological limitations and there have been no specific studies primarily designed to investigate the inflammatory biomarkers of fatigue. Future studies are required to more comprehensively and robustly determine the mechanisms of fatigue.

Occlusal dysesthesia-A clinical guideline

Background

The diagnosis and management of patients suffering from occlusal dysesthesia (OD) remain a major challenge for dental practitioners and affected patients.

Objectives

To present the results of a literature‐based expert consensus intended to promote better understanding of OD and to facilitate the identification and management of affected patients.

Methods

In 2018, electronic literature searches were carried out in PubMed, Cochrane Library and Google Scholar as well as in the archives of relevant journals not listed in these databases. This approach was complemented by a careful assessment of the reference lists of the identified relevant papers. The articles were weighted by evidence level, followed by an evaluation of their contents and a discussion. The result represents an expert consensus.

Results

Based on the contents of the 77 articles identified in the search, the current knowledge about clinical characteristics, epidemiology, aetiology, diagnostic process, differential diagnosis and management of OD is summarised.

Conclusions

Occlusal dysesthesia exists independently of the occlusion. Instead, it is the result of maladaptive signal processing. The focus should be on patient education, counselling, defocusing, cognitive behavioural therapy, supportive drug therapy and certain non‐specific measures. Irreversible, specifically an exclusively dental treatment approach must be avoided.

Quantitative sensory testing of periauricular skin in healthy adults

The aim of this study was to investigate the test-retest reliability of quantitative sensory testing (QST) and mechanical sensitivity mapping of the periauricular skin. Twenty volunteers (10 men, 10 women) participated in two sessions at intervals of one week. Cold and warm detection threshold (CDT&WDT), cold and heat pain threshold (CPT&HPT), mechanical detection and pain threshold (MDT&MPT), pressure pain threshold (PPT) and two-point discrimination (2PD) were measured at five sites: bilateral subauricular and postauricular sites (LA, RA, LB, RB) and the dorsum of left hand (control). Pressure stimulation was applied at each of the four periauricular test sites. The test-retest reliability of the QST data implied fair to excellent agreement as evaluated by the intra-class correlation coefficients (ICC; all >0.4) for different days. There was no difference between each side in the QST parameters and mechanical sensitivity mapping (P ≥ 0.057). Significant differences between subauricular and postauricular sites were shown for WDT and PPT (P ≤ 0.028). NRS scores of mechanical sensitivity mapping showed significant effects of gender, site and point (P ≤ 0.040). QST and mechanical sensitivity mapping can be considered to be a reliable technique to assess somatosensory function of the periauricular skin.

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.

The efficacy of transcranial direct current stimulation and transcranial magnetic stimulation for chronic orofacial pain: A systematic review

BACKGROUND

Transcranial Direct Current Stimulation (tDCS) and Transcranial Magnetic Stimulation (TMS) have been described as promising alternatives to treat different pain syndromes. This study evaluated the effects of TMS and tDCS in the treatment of chronic orofacial pain, through a systematic review.

METHODS

An electronic search was performed in major databases: MEDLINE, Scopus, Web of Science, Cochrane, Embase, LILACS, BBO, Open Gray and CINAHL. The eligibility criteria comprised randomized clinical trials (RCTs) that applied TMS or tDCS to treat chronic orofacial pain. The variables analyzed were pain, functional limitation, quality of life, tolerance to treatment, somatosensory changes, and adverse effects. The risk of bias was assessed through the Cochrane Collaboration tool, and the certainty of evidence was evaluated through GRADE. The protocol was registered in the PROSPERO database (CRD42018090774).

RESULTS

The electronic search resulted in 636 studies. Thereafter, the eligibility criteria were applied and the duplicates removed, resulting in eight RCTs (four TMS and four tDCS). The findings of these studies suggest that rTMS applied to the Motor cortex (M1), the dorsolateral prefrontal cortex (DLPFC) and the secondary somatosensory cortex (S2) provide adequate orofacial pain relief. Two studies reported significant pain improvement with tDCS applied over M1 while the other two failed to demonstrate significant effects compared to placebo.

CONCLUSIONS

rTMS, applied to M1, DLPFC or S2, is a promising approach for the treatment of chronic orofacial pain. Moreover, tDCS targeting M1 seems to be also effective in chronic orofacial pain treatment. The included studies used a wide variety of therapeutic protocols. In addition, most of them used small sample sizes, with a high risk of biases in their methodologies, thus producing a low quality of evidence. The results indicate that further research should be carried out with caution and with better-standardized therapeutic protocols.

[Functional somatic syndromes: A comprehensive cognitive model]

Functional somatic syndromes are frequent in general and specialized medicine practices. Several treatments can be useful. However, the treatment program is often hampered by patients' reluctance to acknowledge the diagnosis because of erroneous lay representations. Recent advances in cognitive science offer a new understanding of the pathophysiology of functional somatic disorders, making this diagnosis more acceptable for patients and caregivers. Simply explained with practical examples, the Bayesian model in particular provides some insights into the underlying cognitive mechanisms of functional somatic syndromes and their treatments. Advantages of this approach are twofold: it is consistent with current scientific knowledge and it can facilitate the physician-patient relationship.

Cognitive factors are associated with disability and pain, but not fatigue among physiotherapy attendees with persistent pain and fatigue

OBJECTIVES

Most research exploring the relationship between cognitive factors and pain, disability and fatigue in patients with persistent pain/fatigue has been performed in multi disciplinary environments. It is unclear whether these associations are consistent in other contexts. This study therefore aimed to establish the relationships between these factors in patients with persistent pain/fatigue referred for physiotherapy treatment.

DESIGN

Cross-sectional observational study assessing the association between cognitive factors (self-efficacy and catastrophizing) and levels of pain, disability, mental fatigue and physical fatigue in patients with persistent pain/fatigue disorders. Data were analysed using regression analyses.

SETTING

Two out-patient physiotherapy departments, Manchester, UK.

PARTICIPANTS

166 patients with persistent pain and fatigue disorders chronic widespread pain, fibromyalgia and chronic fatigue syndrome/myalgic encephalopathy).

MAIN OUTCOME MEASURES

Disability was assessed using the Fibromyalgia Impact Questionnaire, whilst mental and physical fatigue were assessed with the sub-scales of the Chalder Fatigue Scale. Pain intensity was measured with a Numeric Pain Rating Scale, self-efficacy with the Chronic Pain Self-efficacy Questionnaire and catastrophizing with the Pain Catastrophizing Scale.

RESULTS

Cognitive factors were significantly associated with pain (self-efficacy beliefs β=-0.30, P<0.05; catastrophizing β=0.24, P<0.05) and disability (self-efficacy beliefs β=-0.62, P<0.05), but not fatigue.

CONCLUSIONS

Similar associations were observed in patients referred to physiotherapy as to those observed in patients treated in multi disciplinary clinical environments. Self-efficacy beliefs appear to be particularly strong determinants of disability, but exert a lesser influence over pain or fatigue. Targeting self-efficacy may be an effective method to reduce disability in patients with persistent pain and fatigue disorders.

The Four-Cluster Spectrum of Mind-Body Interrelationships: An Integrative Model

Despite the shift toward a biopsychosocial paradigm of medicine, many physicians and mental health professionals (MHPs) find it difficult to treat patients with psycho-somatic disorders. This situation is particularly troublesome due to the high prevalence of these conditions. Although progress has been made over the last few decades in understanding mechanisms underlying the mind-body relationship, disparities remain between research and its clinical implementation. One possible reason for this is the lack of a comprehensive, agreed-upon model that incorporates a biopsychosocial framework and is rooted in an understanding of the various psychobiological pathways. Such a model would enable better communication between physicians and MHPs, allowing them to provide coordinated, stratified treatment. In this paper, four archetypal case studies, together with standard care options are presented to illustrate the current state of affairs. A four-tiered conceptual model of mind-body interrelationships based on pathophysiological and psychopathological mechanisms is suggested to help optimize the treatment of somatic complaints. This Four-Cluster model consists of: (1) Organic Conditions: Structural, or degenerative processes that can affect mood and psychological responses but are not clearly exacerbated by stress. (2) Stress Exacerbated Diseases: Biological disorders with a distinct pathophysiology, such as inflammatory or autoimmune diseases, whose progression is clearly exacerbated by stress. (3) Functional Somatic Syndromes: Conditions wherein heightened sensitivity to stimuli together with hyper-reactivity of the autonomic system form a "vicious cycle" of mutually enhancing learning processes. These processes involve biological mechanisms, such as central sensitization and psychological mechanisms such as catastrophization and selective attention. (4) Conversion Disorder: Physical manifestations of psychological distress, expressed somatically. Symptoms are solely an expression of problems in patients' psychic functioning and are not caused by biological pathology. Finally, suggested management of the aforementioned case studies is presented through the lens of the Four-Cluster model and a proposed integration of our model with existing theories is discussed. As it is rooted in an understanding of psychobiological pathways of illness, the proposed model enables a new way to discern which form of mind-body interaction is manifesting in different diseases and proposes a way to coordinate treatment plans accordingly, to enhance the accuracy and efficacy of care.

Epidemiology of pain and relation to psychiatric disorders

Chronic pain is a common pain condition. Some psychiatric disorders, such as anxiety and depression, are also common in the general population. Epidemiological studies found that some psychiatric disorders are more commonly found among persons with chronic pain (e.g., headache, back pain) than those without chronic pain. Why those psychiatric disorders co-occur with chronic pain, however, is not well understood. Further, studies demonstrated that some psychiatric disorders, such as depression, increase the risk of chronic pain as well as its persistence. It is also recognized that chronic pain has a negative impact on the persistence of psychiatric disorders. The observations from clinical studies suggest that chronic pain is not a common comorbidity among individuals with other psychiatric disorders, such as dementia and schizophrenia. It is not clear if this is a consequence of any specific biological mechanism, or methodology problems in the studies. This paper provides an overview on the distribution of chronic pain and psychiatric disorders, followed by a review of studies that have demonstrated the association between psychiatric disorders and chronic pain.

Novel Sjögren's autoantibodies found in fibromyalgia patients with sicca and/or xerostomia

INTRODUCTION

A significant proportion of patients with fibromyalgia (FM) complain of dry eyes and mouth. Many Sjögren's syndrome (SS) patients also complain of FM symptoms, and there is literature that suggests that there is interplay between these two disorders. Recently, the presence of novel tissue specific autoantibodies (TSAs), SP-1, CA6, and PSP, has been observed in the early stages of SS. These early markers present themselves before the classic autoantibodies, such as SS-A/Ro, SS-B/La, ANA, and RF.

OBJECTIVE

This study aims to examine the relationship between SS and FM by testing patients with FM who also complain of xerostomia and sicca symptoms, for SS- related biomarkers.

METHODS

A cohort of 185 patients who met both the 1990 and 2010 preliminary diagnostic criteria for FM and who admitted to symptoms of sicca and/or xerostomia were selected for this study. Serum from 151 study patients was sent to a tertiary lab, Immco Diagnostics, for testing of the classic autoantibodies (SS-A/Ro, SS-B/La, ANA and RF) and TSAs (SP-1, CA6, PSP), while the rest (34 patients) were tested for TSAs only.

RESULTS

Of the 151 patients who were evaluated for both the early and classic SS markers, 49 (32%) tested positive for SS autoantibodies. Of those, 4 (3%) tested positive for the classic SS markers only, 40 (26%) of the patients tested positive for the early SS markers only, and 5 (3%) tested positive for both the early and classic SS markers. Of the 34 patients who were tested for early SS markers only, 10 (29%) tested positive and 24 (71%) tested negative. Further analysis of all the patients that tested positive for the TSAs (n = 55), found 83.6% (46) were positive for SP-1, 12.7% (7) were positive for CA6 and 20.0% (11) were positive for PSP. 85.5% (47) of these patients were positive for only one of the TSAs and 14.5% (8) were positive for more than one TSA.

CONCLUSION

Approximately 1/3 of FM patients that were tested for both the TSAs and classic Sjögren's markers tested positive for a SS biomarker, and the majority of those patients tested positive for one or more of the TSAs. This suggests that autoimmunity, specifically early- stage Sjögren's syndrome, may be involved in the pathophysiology of fibromyalgia.

Facts and myths pertaining to fibromyalgia

Fibromyalgia (FM) is characterized by chronic widespread pain, unrefreshing sleep, physical exhaustion, and cognitive difficulties. It occurs in all populations throughout the world, with prevalence between 2% and 4% in general populations. Definition, pathogenesis, diagnosis, and treatment of FM remain points of contention, with some even contesting its existence. The various classification systems according to pain medicine, psychiatry, and neurology (pain disease; persistent somatoform pain disorder; masked depression; somatic symptom disorder; small fiber neuropathy; brain disease) mostly capture only some components of this complex and heterogeneous disorder. The diagnosis can be established in most cases by a general practitioner when the symptoms meet recognized criteria and a somatic disease sufficiently explaining the symptoms is excluded. Evidence-based interdisciplinary guidelines give a strong recommendation for aerobic exercise and cognitive behavioral therapies. Drug therapy is not mandatory. Only a minority of patients experience substantial symptom relief with duloxetine, milnacipran, and pregabalin.

Management of Functional Somatic Syndromes and Bodily Distress

Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.

Up to a quarter of patients with certain chronic recalcitrant tendinopathies may have central sensitisation: a prospective cohort of more than 300 patients

Introduction

To identify the possible prevalence of 'central sensitisation', in patients with chronic recalcitrant lower limb tendinopathy conditions, with the Central Sensitisation Inventory (CSI) questionnaire.

Methods

Patients with chronic lower limb tendinopathy conditions treated within a single hospital outpatient clinic specialising in tendinopathy were identified from clinical records. As part of routine care, self-reported numerical markers of pain, global function (using the EuroQol-5D (EQ-5D) questionnaire) and the CSI score to investigate the possibility of central sensitisation were completed.

Results

A total of 312 suitable patients with chronic lower limb tendinopathy and similar conditions were identified, who had completed a CSI questionnaire. Of these, 108 presented with greater trochanteric pain syndrome, 12 with patella tendinopathy, 33 with non-insertional Achilles tendinopathy, 48 with insertional Achilles tendinopathy and 110 with plantar fasciitis. A total of 66% of the patients were female, the median age was 54.9 years and the median duration of symptoms was 24 months. There was a median CSI score of 25%, with statistically significant differences noted between the different conditions studied. Overall, 20% of patients scored above a threshold of 40% on CSI questionnaire, indicating that central sensitisation was possible. Greater trochanteric pain syndrome and plantar fasciitis had the highest proportions in the conditions studied. Weak correlations were found between CSI and other pain scores studied.

Conclusion

The CSI questionnaire may identify up to a quarter of patients with some chronic lower limb tendinopathy and associated conditions as being more likely to have central sensitisation, and these proportions differed between conditions. The clinical significance of this is unclear, but worth further study to see if/how this may relate to treatment outcomes. These are results from a single hospital clinic dealing with patients with chronic tendinopathy, and comparison with a control group is currently lacking. However, on the information presented here, the concept of central sensitisation should be considered in patients being treated for chronic tendinopathy.

The associated features of multiple somatic symptom complexes

OBJECTIVE

To assess whether two or more functional somatic symptom complexes (SSCs) showed stronger association with psychosocial correlates than single or no SSC after adjustment for depression/anxiety and general medical disorders.

METHODS

In a population-based sample we identified, by standardised questionnaire, participants with chronic widespread pain, chronic fatigue and irritable bowel syndrome, excluding those with a medical cause for pain/fatigue. We compared psychosocial variables in three groups: multiple (>1), single or no FSS, adjusting for depression/anxiety and general medical disorders using ordinal logistic regression. We evaluated whether multiple SSCs predicted health status 1 year later using multiple regression to adjust for confounders.

RESULTS

Of 1443 participants (58.0% response) medical records were examined in 990: 4.4% (n = 44) had 2 or 3 symptom complexes, 16.2% a single symptom complex. Many psychosocial adversities were significantly associated with number of SSCs in the expected direction but, for many, statistical significance was lost after adjustment for depression/anxiety and medical illness. Somatic symptoms, health anxiety, impairment and number of prior doctor visits remained significantly associated. Impaired health status 1 year later was predicted by multiple somatic symptom complexes even after adjustment for depression, anxiety, medical disorders and number of symptoms.

CONCLUSIONS

Depression, anxiety, medical illness and health anxiety, demonstrated an exposure-response relationship with number of somatic symptom complexes. These may be core features of all Functional Somatic Syndromes and may explain why number of somatic symptom complexes predicted subsequent health status. These features merit inclusion in prospective studies to ascertain causal relationships.