Fibromyalgia and Chronic Pain Syndromes: A White Paper Detailing Current Challenges in the Field

Do labels matter? Implications of ongoing symptomatic chronic illnesses labeled as conventional diagnoses vs. functional somatic syndromes

OBJECTIVE

A consideration of chronic illness according to illness labels that are medically understood as opposed to being outside of medical understanding may reveal unique differences in how individuals understand their illness and how such lay understandings relate to health-related quality of life. Study aims are framed according to the commonsense model of self-regulation with a focus on characterizing illness representations according to chronic illness diagnosis type.

METHODS

Individuals suffering from symptomatic chronic illnesses (n  =  192) completed measures of illness representations, coping, and general health. Participants were categorized into one of two groups based on reported diagnosis/symptoms: (a) conventional diagnosis (CD) or (b) functional somatic syndrome (FSS).

RESULTS

FSS participants reported lower illness coherence and greater illness identity than CD participants. Overall, illness coherence predicted negative coping which mediated the relationship between illness coherence and general health.

CONCLUSIONS

Minimal differences were found in illness representations across FSS and CD groups with distinctions found only for illness coherence and identity. Illness coherence stands out as particularly important for coping and health-related quality of life for individuals with ongoing symptoms. Healthcare professionals should work carefully with chronically ill populations to address potential impacts of illness coherence, especially among FSS patients.

Catastrophizing and rumination mediate the link between functional disabilities and anxiety/depression in fibromyalgia. A double-mediation model

Fibromyalgia can be considered to be a model of chronic pain resulting from dysregulation of pain processing. From a psychological point of view, it is possible to consider transdiagnostic processes that would participate in both the dysregulation of pain and associated emotions.

OBJECTIVE

The aim of this study was to test the links that exist between the tendency to Repetitive Negative Thinking (RNT) and the anxious-depressive manifestations in fibromyalgia. More specifically, we wanted to test a double mediation model where RNT would mediate the link between pain and depression/anxiety via catastrophizing.

METHOD

Eighty-two patients with fibromyalgia completed a series of questionnaires evaluating their level of depression, anxiety, disability related to pain, catastrophizing as well as various measures of Repetitive Thoughts.

RESULTS

The results showed strong correlations between RNT levels, pain, and anxious-depressive manifestations in this population. Moreover, the links between pain and depression/anxiety were mediated by catastrophizing and RNT in serial.

CONCLUSION

Results support the interest of studying RNT as a transdiagnostic process in fibromyalgia pain. Considering RNT in fibromyalgia allows a better understanding of tthe links that exist between pain and emotional disorders in this population and thus to better understand the psychopathological comorbidity of fibromyalgia.

Association of Risk Factors and Comorbidities With Chronic Pain in the Elderly Population

INTRODUCTION/OBJECTIVE

Chronic pain disorders affect about 20% of adults in the United States, and it disproportionately affects individuals living in the neighborhoods of extreme socioeconomic disadvantage. In many instances, chronic pain has been noted to arise from an aggregation of multiple risk factors and events. Therefore, it is of importance to recognize the modifiable risk factors. The aim of this study was to investigate the comorbid medical conditions and risk factors associated with chronic pain disorders in patients aged 65 years and older.

METHODS

Our team retrospectively reviewed medical records of elderly patients (65 years and older) who were evaluated in our outpatient medicine office between July 1, 2020 and June 30, 2021 for acute problems, management of chronic medical problems, or well visits. We divided our patients into a group who suffered from chronic pain disorder, and another group who did not have chronic pain disorder. The association of variables were compared between those groups.

RESULTS

Of the 2431 patients, 493 (20.3%) had a chronic pain disorder. A higher frequency of females in the group with chronic pain disorder was found compared to the group without a chronic pain disorder (60.6% vs 55.2%; P = .033). The mean ages between the two groups were similar in the group with a chronic pain disorder compared to the group without (76.35 ± 7.5 year vs 76.81 ± 7.59 year; P = .228). There were significant associations of certain comorbidities in the group with a chronic pain disorder compared to the group without a chronic pain disorder, such as depression (21.9% vs 15.2%; P < .001), anxiety (27.0% vs 17.1%; P < .001), chronic obstructive pulmonary disease (8.7% vs 6.1%; P = .036), obstructive sleep apnea (16.8% vs 11.6%; P = .002), gastroesophageal reflux disease (40.8% vs 29.0%; P < .001), osteoarthritis (49.3% vs 26.1%; P < .001), other rheumatologic diseases (24.9% vs 19.4%; P = .006), and peripheral neuropathy (14.4% vs 5.3%; P < .001).

CONCLUSION

Female sex, depression, anxiety, chronic obstructive pulmonary disease, obstructive sleep apnea, gastroesophageal reflux disease, osteoarthritis, other rheumatologic diseases, and peripheral neuropathy were significantly associated with chronic pain disorder in elderly patients, while BMI was not associated with chronic pain disorder.

The Effect of Three Different Ketogenic Diet Protocols on Migraine and Fatigue in Chronic and High-Frequency Episodic Migraine: A Pilot Study

AIMS

We aimed to evaluate the efficacy of three different ketogenic diets on migraine and fatigue in chronic and high-frequency episodic migraineurs.

METHODS

76 patients with migraine were treated with the KD for at least three months. Three different KD protocols were used (2:1 KD, LGID, and VLCKD). We evaluated the fatigue severity scale (FSS), migraine frequency, migraine intensity, MIDAS, and HIT-6 at the baseline and 3-month follow-up, and we compared the results. We also correlated the mean FSS reduction with the mean migraine frequency, migraine intensity, BMI, fat mass, free-fat mass, MIDAS, and HIT-6 reduction.

RESULTS

FSS improved from 4.977 ± 1.779 to 3.911 ± 1.779 at the 3-month follow-up (p < 0.001). This improvement was significant in both high-frequency and chronic migraineurs. Moreover, the three KD protocols effectively improved migraine intensity, frequency, MIDAS, and HIT-6. There was a mild correlation between mean FSS reduction (p < 0.001), mean MIDAS (p = 0.001), and HIT-6 (p = 0.002) reduction.

CONCLUSIONS

The VLCKD, LGID, and 2:1 KD may improve migraine intensity, frequency, and fatigue in chronic and high-frequency episodic migraineurs.

Neural indices of multimodal sensory and autonomic hyperexcitability in fibromyalgia

Fibromyalgia (FM) is characterized by chronic widespread musculoskeletal pain and psychological distress. Research suggests people with FM experience increased somatosensory sensitization which generalizes to other sensory modalities and may indicate neural hyperexcitability. However, the available evidence is limited, and studies including measures of neural responsivity across sensory domains and both central and peripheral aspects of the neuraxis are lacking. Thirty-nine participants (51.5 ± 13.6 years of age) with no history of neurological disorders, psychosis, visual, auditory, or learning deficits, were recruited for this study. People with FM (N = 19) and control participants (CNT, N = 20) did not differ on demographic variables and cognitive capacity. Participants completed a task that combined innocuous auditory stimuli with electrocutaneous stimulation (ECS), delivered at individually-selected levels that were uncomfortable but not painful. Event-related potentials (ERPs) and electrodermal activity were analyzed to examine the central and sympathetic indices of neural responsivity. FM participants reported greater sensitivity to ECS and auditory stimulation, as well as higher levels of depression, anxiety, ADHD, and an array of pain-related experiences than CNT. In response to ECS, the P50 deflection was greater in FM than CNT participants, reflecting early somatosensory hyperexcitability. The P50 amplitude was positively correlated with the FM profile factor obtained with a principal component analysis. The N100 to innocuous tones and sympathetic reactivity to ECS were greater in FM participants, except in the subgroup treated with gabapentinoids, which aligns with previous evidence of symptomatic improvement with GABA-mimetic medications. These results support the principal tenet of generalized neural hyperexcitability in FM and provide preliminary mechanistic insight into the impact of GABA-mimetic pharmacological therapy on ameliorating the neural excitation dominance.

Sedentary Behavior and Pain after Physical Activity in Women with Fibromyalgia-The Influence of Pain-Avoidance Goals and Catastrophizing

BACKGROUND

Fibromyalgia is characterized by chronic pain and fatigue that triggers a functional disability caused by the lack of activity. Pain catastrophizing may contribute to avoiding activity with the intention of managing pain levels. Based on the sedentary behavior with fibromyalgia, the present study assessed the preference of pain-avoidance goals and pain catastrophizing as mediator and moderator variables, respectively, that influence pain perception after a 6-min-walking test.

METHODS

The sample was composed of 76 women with fibromyalgia (mean age = 55.05, SD = 7.70). Previous sedentary behavior, preference for pain-avoidance goals, and pain catastrophizing were evaluated before starting the walking-test. Subsequently, pain perception was evaluated.

RESULTS

A significant moderated-mediation model was found in which pain-avoidance goals mediated the relationship between sedentarism and pain after a walking-test, and pain catastrophizing moderated the relationship between the preference for pain-avoidance goals and pain perception. Specifically, high levels of pain catastrophizing contributed to increased pain perceptions after completing the test (B = 0.570, p = 0.03, CI 95% (0.09, 0.11)].

CONCLUSIONS

The results suggest that motivational interventions can improve the symptoms because their objectives are focused on managing conflict goals. These interventions should focus on catastrophic cognitions considering that pain catastrophizing is deemed to be one of the major inhibitors of physical activity in fibromyalgia.

The Role of Self-Efficacy and Activity Patterns in the Physical Activity Levels of Women with Fibromyalgia

Keeping high levels of physical activity is a challenge among chronic patients. In this regard, self-efficacy has been identified as a crucial variable to reduce sedentarism and physical inactivity in women with fibromyalgia. The current study aimed to evaluate the associations among objective physical activity levels, self-efficacy, activity patterns, and the impact of the disease, as well as to compare those variables between women with fibromyalgia with different self-efficacy levels. For this purpose, in this cross-sectional study, the physical activity levels of 123 women with fibromyalgia were assessed by accelerometers, together with self-efficacy, the impact of the disease, and activity patterns. Results revealed that self-efficacy for light or moderate physical activity was directly related to light (p < 0.01), moderate (p < 0.01), and vigorous physical activity (p < 0.05), as well as inversely related to sedentary time (p < 0.01). Moreover, the main differences were observed between those with low self-efficacy levels and the rest of the sample, while there were no differences between the high and the medium self-efficacy groups (p > 0.05). Thus, self-efficacy for walking and light physical activity seems to be more relevant than self-efficacy for moderate and vigorous physical activity to achieve higher levels of physical activity.

Does Fibromyalgia Affect the Outcomes of Spinal Cord Stimulation: An 11-Year, Multicenter, Retrospective Matched Cohort Study

BACKGROUND

Fibromyalgia is a prevalent disorder manifesting with widespread musculoskeletal pain and central sensitization, as well as fatigue, sleep issues, psychologic distress, and poor quality of life. Patients with fibromyalgia also may be diagnosed with other painful conditions amenable to treatment with spinal cord stimulation (SCS), although it is unclear how these patients respond to SCS compared with patients without fibromyalgia.

MATERIALS AND METHODS

We performed an 11-year, multicenter, retrospective matched cohort study comparing SCS-treated patients with fibromyalgia and those without fibromyalgia. The primary outcome was comparison in mean calculated percentage pain relief between cohorts at six months after SCS implantation. Secondary outcomes included comparison of patient satisfaction between six and 12 months after SCS implantation, and percentage of patients reporting opioid intake and neuropathic medication intake at six months and 12 months after SCS implantation. Adjusted regression analysis was performed to make comparisons while adjusting for age, sex, body mass index, Charlson comorbidity index, preoperative opioid intake, and preoperative neuropathic medication intake.

RESULTS

Of 90 patients with fibromyalgia who underwent SCS trial, 18 patients (20%) failed their SCS trial and did not proceed toward implantation. Sixty-eight patients with fibromyalgia were matched to 141 patients in the control cohort based on age, sex, Charlson comorbidity index, and the American Society of Anesthesiologists physical status score. At six months after SCS implantation, there was no statistical difference in calculated percentage change in pain intensity between the fibromyalgia cohort (46.6 ± 29.0) and the control cohort (50.9 ± 32.8; β, -18.4; 95% CI, -44.3 to 7.6; p = 0.157). At baseline, a greater percentage of patients in the fibromyalgia cohort reported preoperative opioid intake (51.5% vs 22.7%, p < 0.001) and preoperative neuropathic medication intake (67.6% vs 15.6%, p < 0.001). However, there was no difference between cohorts in the percentage of patients taking opioid or neuropathic medications at six months and 12 months after SCS implantation. Similarly, there was no difference between cohorts in the percentage of patients reporting satisfaction between six and 12 months.

CONCLUSION

Patients with fibromyalgia who received a diagnosis approved for treatment with SCS may expect similar post-SCS-implantation pain relief, overall satisfaction, and analgesic use rate to those of patients without fibromyalgia.

Personality construct as a biomarker in fibromyalgia: A narrative review from an autonomic rehabilitation perspective

BACKGROUND

The heterogeneity of symptoms and ineffective treatment raise questions about the current diagnostic criteria of fibromyalgia (FM). Misdiagnosis of FM often leads to less than efficacious treatment and poor quality of life.

OBJECTIVE

This article reviews relevant evidence-based literature on personality traits in FM patients with an autonomic dysfunction perspective based on a hierarchical model to explain the utility of considering the personality trait in FM diagnosis.

METHODS

A narrative review of articles concerning chronic pain, FM, and personality traits with respect to autonomic dysfunction in FM was conducted after extensive relevant literature searches.

RESULTS

Reports discussing the predisposing factors, including coping styles, anger, suicide risk, a lack of physical activity and social support, in maintaining persistent pain in FM exist. Relationships between pain duration and severity and personality traits like neuroticism and extraversion have been reported. Coexisting clinical manifestations of FM like sleep disorders, anxiety, and intestinal irritability indicate autonomic dysfunction.

CONCLUSIONS

This article lays out a constructive framework for individualized and personalized medicine for the effective rehabilitation of FM patients. The quest to find a definitive diagnosis of FM should include personality biomarkers that might translate into personalized medicine. An individualistic approach may bank upon artificial intelligence algorithms for both diagnostic as well as prognostic purposes in FM.

Synthesis and Investigation of the Analgesic Potential of Enantiomerically Pure Schiff Bases: A Mechanistic Approach

Schiff bases are a class of organic compounds with azomethine moiety, exhibiting a wide range of biological potentials. In this research, six chiral Schiff bases, three ‘S’ series (H1−H3) and three ‘R’ series (H4−H6), were synthesized. The reaction was neat, which means without a solvent, and occurred at room temperature with a high product yield. The synthesized compounds were evaluated for analgesic potential in vivo at doses of 12.5 and 25 mg/kg using acetic-acid-induced writhing assay, formalin test, tail immersion and hot plate models, followed by investigating the possible involvement of opioid receptors. The compounds H2 and H3 significantly (*** p < 0.001) reduced the writhing frequency, and H3 and H5 significantly (*** p < 0.001) reduced pain in both phases of the formalin test. The compounds H2 and H5 significantly (*** p < 0.001) increased latency at 90 min in tail immersion, while H2 significantly (*** p < 0.001) increased latency at 90 min in the hot plate test. The ‘S’ series Schiff bases, H1−H3, were found more potent than the ‘R’ series compounds, H4−H6. The possible involvement of opioid receptors was also surveyed utilizing naloxone in tail immersion and hot plate models, investigating the involvement of opioid receptors. The synthesized compounds could be used as alternative analgesic agents subjected to further evaluation in other animal models to confirm the observed biological potential.

Promising Health Benefits of Adjuvant Acmella and Zingiber Extracts Combined with Coenzyme Q10 Phytosomes, Supplementation in Chronic Pain Treated with Medical Cannabis: A Prospective and Open-Label Clinical Study

Background

Chronic pain is a condition where pain persists for months or even years. Nowadays, several drugs comprising of medical cannabis are utilized for chronic pain relief. Even if there are some associated side effects, the use of supplements can widen the reliable tools available for improving an individual's quality of life.

Objective

The aim of the present study was to evaluate the efficacy in terms of pain intensity, psychological well-being, and quality of life of a new dietary supplement in chronic pain subjects under current treatment with medical cannabis.

Methods

In this pilot study, 48 medical cannabis-treated subjects were supplemented with a dietary supplement containing a combination of standardized Zingiber officinalis and Acmella oleracea extracts in phytosome (Mitidol), coenzyme Q10 phytosome (Ubiqsome), and group B vitamins (B1, B6, and B12), twice daily for 90 days. In order to explore the benefits of the product as an adjuvant supplementation for pain relief, the pain intensity, measured by the visual analogue scale (VAS), the pain type, and quality, evaluated by the Italian Pain Questionnaire (QUID) and the possible reduction of therapeutic and/or painkiller doses were recorded.

Results

After 90 days, significant pain relief was detected in almost 70% of the subjects receiving the new dietary supplement, with sensory, emotional, and pain amelioration in one-third of them. A reduction in both tetrahydrocannabinol (THC) and cannabidiol (CBD) doses was also observed after 3 months of supplementation. These findings demonstrate new perspectives for the use of an innovative dietary supplement that combines Acmella and Zingiber extracts, Coenzyme Q10, and group B vitamins resulting in a beneficial long-term adjuvant in cannabis-treated pain subjects.

Altered Pain in the Brainstem and Spinal Cord of Fibromyalgia Patients During the Anticipation and Experience of Experimental Pain

Chronic pain associated with fibromyalgia (FM) affects a large portion of the population but the underlying mechanisms leading to this altered pain are still poorly understood. Evidence suggests that FM involves altered neural processes in the central nervous system and neuroimaging methods such as functional magnetic resonance imaging (fMRI) are used to reveal these underlying alterations. While many fMRI studies of FM have been conducted in the brain, recent evidence shows that the changes in pain processing in FM may be linked to autonomic and homeostatic dysregulation, thus requiring further investigation in the brainstem and spinal cord. Functional magnetic resonance imaging data from 15 women with FM and 15 healthy controls were obtained in the cervical spinal cord and brainstem at 3 tesla using previously established methods. In order to investigate differences in pain processing in these groups, participants underwent trials in which they anticipated and received a predictable painful stimulus, randomly interleaved with trials with no stimulus. Differences in functional connectivity between the groups were investigated by means of structural equation modeling. The results demonstrate significant differences in brainstem/spinal cord network connectivity between the FM and control groups which also correlated with individual differences in pain responses. The regions involved in these differences in connectivity included the LC, hypothalamus, PAG, and PBN, which are known to be associated with autonomic homeostatic regulation, including fight or flight responses. This study extends our understanding of altered neural processes associated with FM and the important link between sensory and autonomic regulation systems in this disorder.

Whole Body Pain Distribution and Risk Factors for Widespread Pain Among Patients Presenting with Abdominal Pain: A Retrospective Cohort Study

Introduction

Abdominal pain frequently co-occurs with pain in other body sites. Chronic overlapping pain conditions (COPCs) represent a group of widespread pain diagnoses. Our study characterized how patterns of somatic pain distribution are associated with COPCs and aimed to characterize predictors of widespread pain among patients with chronic abdominal pain.

Methods

This retrospective cohort study included adults presenting to a tertiary pain clinic, reporting abdominal pain at their initial visit, and with a follow-up visit at 12 months. Body maps divided patients into localized, intermediate, and widespread pain distribution patterns. Diagnostic and psychosocial measures were assessed across groups at the initial and follow-up visits. We analyzed the association of baseline diagnoses and demographics and time-varying changes in psychosocial measures from initial to follow-up visit with changes in pain distribution over time with alternating logistic regression (ALR).

Results

Among 258 patients, most were female (91.5%) and reported widespread pain (61.5%). Those with widespread pain at baseline reported elevated anger and 60.0% of patients remained in the same pain category at follow-up. Multivariable ALR demonstrated higher pain interference (AOR 1.06, 95% CI 1.02–1.10, P = 0.002), higher anxiety (AOR 1.05, 95% CI 1.01–1.09, P = 0.01), more than one COPC at initial visit (AOR 2.85, 95% CI 1.59–5.11, P = 0.0005), and initial visit widespread pain categorization (AOR 4.18, 95% CI 2.20–8.00, P < 0.0001) were associated with an increased risk of widespread pain at the follow-up visit.

Conclusion

Most patients with abdominal pain report additional pain locations at multiple other body sites, and non-localized pain persists 12 months after pain treatment. Screening for widespread pain and COPC at the initial visit may identify patients at higher risk for persistent or new-onset widespread pain, and interventions to reduce pain interference and anxiety may promote reversal of widespread pain.

Which symptoms best distinguish fibromyalgia patients from those with other chronic pain disorders?

RATIONALE, AIMS AND OBJECTIVES

The primary purpose of this study was to test both classic and novel FM pain and non-pain symptoms to determine their practical efficacy in aiding clinicians to distinguish FM pain from other chronic pain disorders.

METHODS

158 pain patients from two primary care clinics were evaluated with history, physical exam, chart review, and a questionnaire containing 26 exploratory symptoms (10 from the Symptom Impact Questionnaire (SIQR) and 16 from the FM literature)). The symptoms were rated on a 0-10 VAS for severity by those patients reporting pain over the past week. Somers' D and mean severity differences between FM and chronic pain patients without FM were used to rank the discriminatory and diagnostic contributions of symptoms.

RESULTS

Fifty patients (14.2%) carried a chart diagnosis of FM, 108 (30.7%) had pain but not FM, and 192 (54.5%) who had neither pain nor FM. Comparing means between the two pain groups, the 5 best differentiating symptoms (all, P < .0001) were: a persistent deep aching over most of my body, poor balance (7.4 vs 3.1), environmental sensitivity (6.8 vs 3.0), tenderness to touch (6.8 vs 3.6) and pain after exercise (8.1 vs 4.1). Notably, VAS pain though significantly higher for FM was least discriminatory (6.5 vs 5.1, P < .001). The five best symptoms generated a ROC = 0.85 and Somers' D = 0.69, an accuracy of 81%, and an odd's ratio of 14.4.

CONCLUSIONS

Our results herein suggest that clinicians may be well-served to consider symptoms in addition to those contained in current diagnostic criteria when recognizing FM in their chronic pain patients.

Pain-Related Worrying and Goal Preferences Determine Walking Persistence in Women with Fibromyalgia

Physical activity and exercise are relevant behaviors for fibromyalgia health outcomes; however, patients have difficulties undertaking and maintaining an active lifestyle. With a cross-sectional design, this study explored the role of pain-related worrying and goal preferences in the walking persistence of women with fibromyalgia. The sample included 111 women who attended a tertiary health setting. We adapted the Six-Minute Walk Test where participants decided either to stop or continue walking in five voluntary 6 min bouts. Women who were categorized higher in pain-related worrying reported higher preference for pain avoidance goals (t = -2.44, p = 0.02) and performed worse in the walking task (LongRank = 4.21; p = 0.04). Pain avoidance goal preference increased the likelihood of stopping after the first (OR = 1.443), second (OR = 1.493), and third (OR = 1.540) 6 min walking bout, and the risk of ending the walking activity during the 30 min task (HR = 1.02, [1.0-1.03]). Influence of pain-related worrying on total walking distance was mediated by goal preferences (ab = -3.25). In interventions targeting adherence in physical activity and exercise, special attention is needed for women who are particularly worried about pain to help decrease their preference for short-term pain avoidance goals relative to long-term goals such as being active through walking.

Depression: A Modifiable Risk Factor for Poor Outcomes in Fibromyalgia

Background:

About 4 out of 10 fibromyalgia patients suffer from depression. The European Alliance of Associations for Rheumatology (EULAR) guidelines recommend using antidepressants to treat fibromyalgia.

Objective:

To determine predictors of improved outcomes following a multicomponent treatment program.

Design:

We designed this longitudinal treatment outcome study to evaluate the prevalence of depression symptoms in patients diagnosed with fibromyalgia at a tertiary care facility, and the impact of depression on functional outcomes after completing a multicomponent fibromyalgia treatment program.

Setting:

Tertiary care center.

Patients:

This study included 411 adult patients with fibromyalgia who completed a multicomponent treatment program for fibromyalgia. Expert physicians performed comprehensive evaluations following American College of Rheumatology (ACR) criteria to confirm fibromyalgia before referral to the program.

Intervention:

An intensive outpatient multicomponent treatment program consisting of 16 hours of cognitive behavioral strategies served as the intervention.

Measurements:

Functional status was assessed using the Fibromyalgia Impact Questionnaire Revised (FIQR). Depression was evaluated with the Center for Epidemiologic Study of Depression (CES-D) measure. Measures were administered prior to participation in the program and approximately 5 months following completion of the program.

Results:

The cohort had a high prevalence of depressive symptoms (73.2% had depression at admission). Higher depression scores at baseline predicted poorer outcomes following multi-component treatment. Effectively treated depression resulted in improved functioning at follow-up.

Limitations:

Findings limited to tertiary care center cohort of fibromyalgia patients. Patients did not undergo a structured clinical diagnostic interview to diagnose depression.

Conclusions:

The current data links depression to poorer outcomes in patients with fibromyalgia. Depression is an important modifiable factor in the management of fibromyalgia. Guidelines should reflect the importance of assessing and effectively treating depression at the time of diagnosis of fibromyalgia, to improve functional outcomes.

Registration:

Specific registry and specific study registration number—Institutional Review Board—(IRB# 19-000495).

Funding Source:

No funding.

Motivational Determinants of Objective Physical Activity in Women with Fibromyalgia Who Attended Rehabilitation Settings

Being physically active has positive effects on fibromyalgia functioning. However, promoting an active lifestyle in these patients continues to be a relevant clinical challenge. Our aim was to test a motivational model to explain light (LPA) and moderate-vigorous physical activity (MVPA). A cross-sectional prospective study was conducted at a tertiary level of care. Participants completed sociodemographic, clinical, motivational (physical activity self-efficacy and goal preferences) and behavioral measures (activity avoidance). LPA and MVPA were measured with triaxial accelerometers, starting the same day of the aforementioned assessment. Out of 211 women, 183 completed this measure. Structural models were performed. Our results show that the best fit indices (CFI = 0.97, SRMR = 0.04) showed a model with direct influence of PA self-efficacy on MVPA (p < 0.01) and indirect influence on LPA (p < 0.001). LPA received the influence of PA self-efficacy mainly through activity avoidance (p < 0.01). Clinical variables did not have any effect on PA intensities. Thus, the motivational variables showed different paths to explain two PA intensities. Targeting PA self-efficacy in rehabilitation settings is needed to enhance both daily LPA and MVPA intensities.

Is Thought Management a Resource for Functioning in Women with Fibromyalgia Irrespective of Pain Levels?

OBJECTIVE

This study aimed to examine the relationship between cognitive factors (cognitive fusion and catastrophizing) and functional limitation experienced by patients with fibromyalgia across different levels of pain severity (i.e., moderation).

METHODS

The sample comprised 226 women with fibromyalgia. Their mean age was 56.91 years (standard deviation = 8.94; range = 30 to 78 years).

RESULTS

Pain severity, cognitive fusion, and all components of catastrophizing (i.e., rumination, magnification, and helplessness) contributed to greater fibromyalgia impact on functioning in the multivariate analyses (all P < 0.001). A moderation effect was also found in the relationship between cognitive fusion and fibromyalgia impact on functioning (B = -0.12, t = -2.42, P = 0.016, 95% confidence interval: -0.22 to -0.02) and between magnification and fibromyalgia impact (B = -0.37, t = -2.21, P = 0.028, 95% confidence interval: -0.69 to -0.04). This moderation was not observed for rumination and helplessness.

CONCLUSIONS

The results suggest that in interventions to improve functioning in people with fibromyalgia, some maladaptive forms of thought management (i.e., cognitive fusion and magnification) preferably should be challenged at milder levels of pain severity. According to our findings, cognitive fusion and magnification might have less room to impact functioning at higher levels of pain severity; therefore, rumination and helplessness, which had comparable associations with functioning irrespective of pain levels, would be preferable targets in psychological interventions in patients with fibromyalgia experiencing more severe pain levels.

Cannabis and pain: a scoping review

For centuries, cannabis has been used with many different purposes, including medicinal use, usually bypassing any formal approval process. However, during the last decade, interest in cannabis in medicine has been increasing, and several countries, including the United States and Canada, have produced their own legislation about marihuana and cannabis-based medicines. Because of this, interest in research has been increasing and evidence about its medical effects is becoming necessary. We conducted a review examining the evidence of cannabis in pain. Cannabis had been shown to be useful in acute and chronic pain, however recently, these results have been controverted. Within the different types of chronic pain, it has a weak evidence for neuropathic, rheumatic pain, and headache, modest evidence for multiple sclerosis related pain, and as adjuvant therapy in cancer pain. There is no strong evidence to recommend cannabis in order to decrease opioids in patients with chronic use. Even though cannabis-based medications appear to be mostly safe, mild adverse effects are common; somnolence, sedation, amnesia, euphoric mood, hyperhidrosis, paranoia, and confusion may limit the use of cannabis in clinical practice. Risks have not been systematically analyzed. Special concern arises on how adverse effect might affect vulnerable population such as elderly patients. More research is needed in order to evaluate benefits and risks, as well as the ideal administration route and dosages. As cannabis use increases in several countries, answers to these questions might be coming soon.

Sleeping is a nightmare: A qualitative study on the experience and management of poor sleep quality in women with fibromyalgia

AIM

This study aimed to explore the experience and management of poor sleep quality in Spanish women with fibromyalgia (FM).

DESIGN

This was a qualitative study based on one-to-one interviews.

METHODS

Twenty-one adult women diagnosed with FM were recruited from the community between January and March 2020. Data were collected through in-depth semistructured one-to-one interviews, using an interview guide of open questions about the experience and management of poor sleep quality, and were analyzed with thematic qualitative analysis. The symptom management theory was used as a biopsychosocial conceptual framework.

RESULTS

The results were organized into two themes: (a) experience of poor sleep quality and (b) management strategies for poor sleep quality. Poor sleep quality was found to be a severe symptom of FM that negatively impacts pain, fatigue, stiffness, mental health, and quality of life. The participants perceived pharmacological treatment to be the main approach of health care professionals for improving sleep, and most did not want this form of treatment. Self-management strategies lack clear beneficial effects on sleep quality.

CONCLUSION

Women with FM recognize that they need to receive more information from nurses and allied professions about sleep in the context of FM and how to effectively manage poor sleep quality.

IMPACT

This study contributes to a better understanding of how women with FM experience and manage poor sleep quality. More information about management strategies for poor sleep quality from nurses and other health care professionals is needed in women with FM. The results of this study can be applied by nurses and health care professionals, including sleep educators, in the treatment of this patient group.

The development of a novel questionnaire assessing alterations in central pain processing in people with and without chronic pain

Background and aims The purpose of this study was to (a) develop and (b) conduct exploratory factor analysis on a novel self-report instrument for symptoms associated with altered central pain processing. Methods We first developed a 25-item questionnaire based on previous literature identifying symptoms and behaviours that may reflect altered spinal and supraspinal pain processing. We then administered this questionnaire to 183 people with chronic pain (n = 99) and healthy individuals (n = 84). Exploratory factor analysis was conducted to identify the factor structure of the questionnaire. Results Our results support a two-factor solution for the 25-item questionnaire that accounted for 57.2% of the total variance of responses in people with and without chronic pain. Factor one (11 items) included items related to alterations in sensation of pain, while factor two (seven items) included items associated with emotional and fatigue symptoms. Seven items showed weak factor loadings and were eliminated. Reliability was excellent, while both factors showed strong correlations with previously-validated self-report Instruments: (pain catastrophising, mood, vigilance, pain self-efficacy) and conditioned pain modulation, providing evidence for their validity. Conclusions We have developed a questionnaire containing two factors that appear to be related to two different symptom clusters, one of which is specifically related to pain and one of which contains other health-related symptoms related to mood and fatigue. These factors show excellent internal consistency and validity. This questionnaire may be a quick, easy and reliable instrument to assess central pain processing in clinical settings.

Physical activity in the treatment of fibromyalgia

International treatment recommendations for fibromyalgia (FM) highlight the importance of adapted physical activity (APA) combined with patient education. Cognitive and behavioral therapies as well as an interdisciplinary approach can be proposed for more complex or severe clinical situations, with a biopsychosocial vision of rehabilitation. To personalize the rehabilitation's therapeutic approach, a clinician can use simple and validated instruments for measuring physical performance that will highlight levels of physical conditioning, which range from low to very low in FM patients. Several systematic reviews and meta-analyses have found strong evidence that supervised aerobic and resistance-training programs reduce the pain intensity and significantly improve the quality of life and the physical and psychological functioning of female FM subjects. These therapeutic approaches appear safe and promising in terms of cost-effectiveness and should be the subject of more randomized controlled trials among male FM subjects and adolescents.

Does the Rural Environment Influence Symptomatology and Optimize the Effectiveness of Disease Acceptance? A Study Among Women With Fibromyalgia

The present study aims to explore whether the symptoms associated with fibromyalgia are contextually influenced by the area of residence (rural/urban). Furthermore, it is analyzed whether the effect of the acceptance of the disease on the emotional, cognitive and physical symptoms is moderated by the patients' place of residence. Using a cross-sectional design, a total of 234 women with fibromyalgia (mean age = 56.91 years; SD = 8.94) were surveyed, of which 55.13% resided in rural areas and 44.87% in urban areas. Self-reported questionnaires were used to assess pain severity, anxiety and depression, functional limitation, physical and mental fatigue and acceptance of the disease. The results show significant differences in acceptance (p = 0.040), pain (p < 0.001), and physical and mental fatigue (p = 0.003 and p = 0.004, respectively) between patients from rural and urban areas. The rural area patients presented higher levels of acceptance and pain and lesser levels of physical and mental fatigue compared to the urban area. The moderation analysis add that, only in patients from the rural area, the variables of physical symptoms (pain, functional limitation, and physical fatigue) were significantly and negatively associated with acceptance. This study addresses for the first time the role of the place of residence in suffering from fibromyalgia, suggesting that the rural or urban environment plays a relevant role in the severity and/or management of symptoms in fibromyalgia women. Limitations and practical implications are also discussed.

How fMRI Analysis Using Structural Equation Modeling Techniques Can Improve Our Understanding of Pain Processing in Fibromyalgia

PURPOSE

The purpose of this study was to investigate the utility of data-driven analyses of functional magnetic resonance imaging (fMRI) data, by means of structural equation modeling, for the investigation of pain processing in fibromyalgia (FM).

PATIENTS AND METHODS

Datasets from two separate pain fMRI studies involving healthy controls (HC) and participants with FM were re-analyzed using both a conventional model-driven approach and a data-driven approach, and the results from these analyses were compared. The first dataset contained 15 women with FM and 15 women as healthy controls. The second dataset contained 15 women with FM and 11 women as healthy controls.

RESULTS

Consistent with previous studies, the model-driven analyses did not identify differences in pain processing between the HC and FM study groups in both datasets. On the other hand, the data-driven analyses identified significant group differences in both datasets.

CONCLUSION

Data-driven analyses can enhance our understanding of pain processing in healthy controls and in clinical populations by identifying activity associated with pain processing specific to the clinical groups that conventional model-driven analyses may miss.

Poor Sleep Quality Experience and Self-Management Strategies in Fibromyalgia: A Qualitative Metasynthesis

Poor sleep quality is a major concern and a highly prevalent symptom in fibromyalgia. We aimed to develop a metasynthesis of qualitative studies to assess how people diagnosed with fibromyalgia experience and manage poor sleep quality following the concepts of the Symptom Management Theory. The principles of metasynthesis established by Sandelowski and Barroso were utilized. A pre-planned comprehensive search was implemented in PubMed, Scopus, ISI WebofScience, and Cinahl Plus databases. The methodological quality was assessed following the CASP Qualitative Checklist. The findings of the studies were subjected to a metasummary and a metasynthesis. Seventeen studies were included in the metasynthesis. Two overarching themes were pre-established: (1) experience of poor sleep quality in Fibromyalgia and (2) poor sleep quality management strategies in Fibromyalgia. Four sub-themes emerged from the results: (1) evaluation of poor sleep quality, (2) response to poor sleep quality, (3) management strategies to favor sleep, and (4) managing the consequences of a sleepless night. Poor sleep quality is a severe and disabling symptom that negatively impacts the general health status of people diagnosed with FM. Prescribed treatments are commonly seen as ineffective and self-management strategies are a last resort and do not show beneficial effects.

Alexithymia and Somatization in Chronic Pain Patients: A Sequential Mediation Model

Objective

To investigate whether chronic pain (CP) patients with somatization reported higher alexithymic traits than those without somatization and to study the different relationships between psychological characteristics, pain, health-related quality of life (HRQL), and somatization.

Method

A consecutive sample of 134 CP treatment-seeking outpatients were evaluated for alexithymia (TAS-20), somatization (PHQ-15), distress (HADS), HRQL (SF-12), and pain (BPI).

Results

Patients with somatization (37.04%) reported significantly higher TAS-20 total scores (p < 0.001) and difficulty in identifying feelings (DIF) (p < 0.001) than those without somatization. The somatizer group had also a significantly higher disease duration, severity and interference of pain, distress, and lower HRQL than the non-somatizer group. Hierarchical regression analysis showed that although distress, pain interference and the mental HRQL component are closely related to somatization (R² = 0.55), DIF was the strongest predictor of severity of somatization (β = 0.31). A sequential indirect effect from DIF to somatization via distress symptoms and pain interference turned out to be significant [95% CI (0.01, 0.09)]. Support was also found for sequential mediation paths from DIF to somatization via distress and mental HRQL [95% CI (0.01, 0.11)].

Conclusions

Our results pointed-out that alexithymia, particularly DIF, may be major factor for somatization risk in CP patients. Longitudinal observations are needed for evaluating the role of alexithymia in clinical outcomes.

Reliability and Validity of the Turkish Short-Form McGill Pain Questionnaire-2 (TR-SF-MPQ-2) in patients with chronic low back pain

Objectives

The aim of this study was to assess validity and reliability of the Turkish version of the expanded and revised version of the Short-Form McGill Pain Questionnaire (TR-SF-MPQ-2) in patients with chronic low back pain (CLBP) and to investigate the relationship between TR-SF-MPQ-2 and etiology, pain scales, and disability index.

Patients and methods

Between October 2014 and December 2014, a total of 194 patients with CLBP (66 males, 128 females; mean age 50±14.3 years; range, 35 to 65 years) attending to our outpatient clinic were included. To assess reliability, Cronbach alpha (α) and intraclass correlation coefficient (ICC) were estimated for participants who completed the questionnaire in the morning and afternoon. The validity of the questionnaire was evaluated by analyzing the confirmatory factor analysis. The Visual Analog Scale and Oswestry Disability Index were also used to test concurrent validity of the questionnaire.

Results

For total score, Cronbach α was 0.912 and ICC was 0.973, ranging from 0.72 to 0.84 for Cronbach α and from 0.960 to 0.989 for ICC in subgroups. The confirmatory factor analysis showed a good model fit for each subgroup (χ2/Df <3, GFI >0.95, CFI >0.90, NFI >0.90, and RMSEA <0.10). The correlation coefficient between the mean VAS and the mean total score was 0.648.

Conclusion

Our study results indicate that the Turkish version of the SF-MPQ-2 is a reliable and valid tool to assess pain in the Turkish patients with CLBP.

The incidence of persistent postoperative opioid use among U.S. veterans: A national study to identify risk factors

OBJECTIVE

To calculate the incidence and identify the predictors of persistent postoperative opioid use at different postoperative days.

BACKGROUND DATA

A subset of surgical patients continues to use long-term opioids. The importance of the risk factors at different postoperative days is not known.

DESIGN

A historical cohort.

SETTING

Postoperative period.

PATIENTS

Opioid-naive U.S. veterans.

INTERVENTIONS

The surgical group had any one of 19 common invasive procedures. The control group is a 10% random sample. Each control was randomly assigned a surgery date.

MEASUREMENTS

The outcomes were the presence of persistent opioid use as determined by continued filling of prescriptions for opioids on postoperative days 90, 180, 270, and 365.

MAIN RESULTS

A total of 183,430 distinct surgical cases and 1,318,894 controls were identified. 1.0% of the surgical patients were using opioids at 90 days, 0.6% at 180 days, 0.4% at 270 days, and 0.1% at 365 days after the surgery. Surgery was strongly associated with postoperative persistent opioid use at day 90 (OR 3.67, 95% CI, 3.43-3.94, p < 0.001), at day 180 (OR 2.85, 2.67-3.12, p < 0.001), at day 270 (OR 2.63, 2.38-2.91, p < 0.001) and at day 365 (OR 2.11, 1.77-2.51, p < 0.001) compared to non-surgical controls. In risk factor analysis, being male and single were associated with persistent opioid use at earlier time points (90 and 180 days), while hepatitis C and preoperative benzodiazepine use were associated with persistent opioid use at later time points (270 and 365 days).

CONCLUSIONS

Many surgeries or invasive procedures are associated with an increased risk of persistent postoperative opioid use. The postoperative period is dynamic and the risk factors change with time.

Predictors of (Un)successful Same-Day Discharge in Selected Patients Following Outpatient Hip and Knee Arthroplasty

BACKGROUND

It is generally accepted that only selected patients are suitable for outpatient joint arthroplasty (OJA); however, no consensus exists on the optimal selection criteria. We believe patients undergoing OJA should undergo risk stratification and mitigation in an attempt to optimize quality and minimize costs.

METHODS

Patient factors of 525 patients who were selected to have primary elective unicompartmental knee arthroplasty (N = 158), total knee arthroplasty (N = 277), or total hip arthroplasty (N = 90) in an outpatient setting were retrospectively reviewed. A complete case multivariable logistic regression analysis of 440 patients was conducted to identify factors that were independently associated with (un)successful same-day discharge (SDD).

RESULTS

One hundred ten patients (21%) were not able to be discharged on the day of surgery. Charnley class B2 was associated with a higher chance of successful SDD (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.12-0.72), whereas female gender (OR, 1.7; 95% CI, 1.0-2.8), total knee arthroplasty (OR, 1.9; 95% CI, 1.1-3.4), and a higher American Society of Anesthesiologists (ASA) physical function score (ASA II: OR, 1.9; 95% CI, 1.1-3.3; ASA III: OR, 3.9; 95% CI, 1.1-13) were associated with a higher risk of unsuccessful SDD.

CONCLUSION

These results in a preselected population suggest the need for further specifying and improving selection criteria for patients undergoing OJA and emphasize the importance of an in-hospital backup plan for patients at risk of unsuccessful SDD. Previous contralateral joint arthroplasty is a protective factor for successful SDD.

Fibromyalgia, Sjogren's & depression: linked?

Health care has become increasingly fragmented, partly due to advancing medical technology. Patients are often managed by various specialty teams when presenting with symptoms that could be manifestations of different diseases. Approximately one third of them are referred to specialists, at over half for outpatient appointments. Fatigue, pain, depression, dry mouth, headaches, and arthralgia are common complaints and frequently require referral to specialist physicians. Differential diagnoses include fibromyalgia (FM), Sjogren's syndrome (SS), and depression. Evaluations involve various sub-specialist especially physicians like those practicing pain management, rheumatology, and psychiatry. Thresholds for referring vary. Patients sometime feel lost in a 'medical maze'. Disagreement is frequent between specialties regarding management. Each discipline has its own diagnostic and treatment protocols and there is little consensus about shared decision-making. Communication between doctors could improve continuity. There are many differences and similarities in the pathophysiology, symptomatology, diagnosis, and treatment of fibromyalgia, Sjogren's syndrome, and depression. Understanding the associations between fibromyalgia, Sjogren's syndrome and depression should improve clinical outcome via a common holistic approach.

Why are assumptions passed off as established knowledge?

In this paper we attempt to explain the problems that can arise when assumptions made by experts in their respective fields of Medicine become widely accepted as established knowledge. Our hypothesis is that these problems are in large part attributable to a failure of the experts to follow the principles of logical argument. Empirical data to evaluate our hypothesis derives from an analysis of the reasoning processes employed in the generation of three syndromes drawn from the clinical discipline of Pain Medicine: myofascial pain, shoulder impingement and central sensitisation. We demonstrate a failure by the proponents of these syndromes to structure their scientific arguments in a logically valid fashion, which lead them to promote assumptions to the status of facts. In each instance those in relevant scientific journals responsible for content review accepted - and thereby promulgated - this fundamental error in reasoning. The wide acceptance of each of these assumptions as established knowledge affirms our hypothesis. Furthermore, we show that such uncritical acceptance has had significant consequences for many patients.

Fibromyalgia associated with repeated gadolinium contrast-enhanced MRI examinations

We report a case of a fibromyalgia (FM) patient with an history of brain-cancer presenting signs and symptoms of gadolinium toxicity following repeated administrations of a macrocyclic contrast agent, Gadovist. In the present report, we provide evidence supporting the hypothesis of a causal relationship linking gadolinium deposition to a clinical manifestation of disease, namely fibromyalgia. We unravel a role for gadolinium in the still unknown etiology of fibromyalgia as a metal toxicity disorder. Contrast agents are routinely administered in a clinical context. It is thus possible that the patients are mistakenly believed to show complaint of their primary disease, whereas, in some instances, their symptoms are associated with gadolinium deposition.

A Systematic Review of Efficacy, Safety, and Tolerability of Duloxetine

Duloxetine is a serotonin-norepinephrine reuptake inhibitor approved for the treatment of patients affected by major depressive disorder (MDD), generalized anxiety disorder (GAD), neuropathic pain (NP), fibromyalgia (FMS), and stress incontinence urinary (SUI). These conditions share parallel pathophysiological pathways, and duloxetine treatment might be an effective and safe alternative. Thus, a systematic review was conducted following the 2009 Preferred Reporting Items (PRISMA) recommendations and Joanna Briggs Institute Critical (JBI) Appraisals guidelines. Eighty-five studies focused on efficacy, safety, and tolerability of duloxetine were included in our systematic review. Studies were subdivided by clinical condition and evaluated individually. Thus, 32 studies of MDD, 11 studies of GAD, 19 studies of NP, 9 studies of FMS, and 14 studies of SUI demonstrated that the measured outcomes indicate the suitability of duloxetine in the treatment of these clinical conditions. This systematic review confirms that the dual mechanism of duloxetine benefits the treatment of comorbid clinical conditions, and supports the efficacy, safety, and tolerability of duloxetine in short- and long-term treatments.

Magnetic resonance spectroscopy across chronic pain disorders: a systematic review protocol synthesising anatomical and metabolite findings in chronic pain patients

BACKGROUND

Chronic pain is pain greater than 3 months duration that may result from disease, trauma, surgery, or unknown origin. The overlap between the psychological, behavioural, and management aspects of pain suggest that limbic brain neurochemistry plays a role in chronic pain pathology. Proton magnetic resonance spectroscopy (1H-MRS) can evaluate in vivo brain metabolites including creatine, N-acetylaspartate, myo-inositol, choline, glutamate, glutamine, and gamma-aminobutyric acid in chronic pain; however, a comprehensive systemic review of metabolite expression patterns across all brain areas has yet to be performed.

METHODS AND ANALYSIS

Online databases including PubMed/MEDLINE, Google Scholar, EMBASE, the Cochrane Library, OVID, and PsycINFO will be searched for articles relating to 1H-MRS and chronic pain. Study inclusion criteria will include ages of between 18 and 65 years with a definite diagnosis of chronic pain, no comorbidities, clearly stated brain volumes of interest, and imaging protocols, with comparisons to healthy controls. Two reviewers will extract data relating to volumes of interest, metabolites, study participant demographics, diagnostic method and pain scores, treatments and duration of treatment, scanner information, 1H-MRS acquisition protocols, and spectral processing software. Where possible, volumes of interest will be reassigned as regions of interest consistent with known regional anatomical and functional properties to increase the power and relevance of the analysis. Statistical analyses will then be conducted using STATA. A central common pathway may exist for chronic pain due to the behavioural manifestations and management similarities between its different types. The goal of this systemic review is to generate a comprehensive neurochemical theory of chronic pain in different brain compartments.

SYSTEMATIC REVIEW REGISTRATION

This study is registered with PROSPERO CRD42018112640.

Hospitalization in fibromyalgia: a cohort-level observational study of in-patient procedures, costs and geographical variation in England

Objectives

Fibromyalgia is a complex, debilitating, multifactorial condition that can be difficult to manage. Recommended treatments are usually delivered in outpatient settings; evidence suggests that significant inpatient care occurs. We describe the scale and cost of inpatient care with a primary diagnostic code of fibromyalgia within the English National Health Service.

Methods

We conducted a cohort-level observational study of all patients admitted to hospital due to a diagnosis of fibromyalgia, between 1 April 2014 and 31 March 2018 inclusive, in the National Health Service in England. We used data from Hospital Episode Statistics Admitted Patient Care to study: the age and sex of patients admitted, number and costs of admissions, length of stay, procedures undertaken, class and type of admission, and distribution of admissions across clinical commissioning groups.

Results

A total of 24 295 inpatient admissions, costing £20 220 576, occurred during the 4-year study period. Most patients were women (89%) with peak age of admission of between 45 and 55 years. Most admissions were elective (92%). A number of invasive therapeutic procedures took place, including a continuous i.v. infusion (35%). There was marked geographical variation in the prevalence and cost of inpatient fibromyalgia care delivered across the country, even after accounting for clinical commissioning group size.

Conclusions

Many patients are admitted for treatment of their fibromyalgia and given invasive procedures for which there is weak evidence, with significant variation in practice and cost across the country. This highlights the need to identify areas of resource use that can be rationalized and diverted to provide more effective, evidence-based treatment.

An Evolution of Suffering: Anesthesiology's Contribution to Pain Management

The modern human, and all progenitor species before it, evolved in a milieu of pain and suffering. Recent innovations in medicine have permitted the development of tools to mitigate these powerful experiences. Anesthesiologists have been on the vanguard of developing treatments and systems to face this challenge. Pain is a heterogeneous entity that requires precise categorization, and targeted, multimodal treatment to optimally manage. Anesthesiologists have developed a system whereby analgesia permits a myriad of life-saving surgeries, and have expanded their role beyond the perioperative setting. This includes unique contributions to how the concept of pain is experienced by infants, and appropriate interventions in this population. Contemporary anesthesiologists have extended their responsibilities to include harnessing robust technologies to manage pain in outpatient clinics, and serving as pain experts within hospital systems. This article serves as a primer to the history of anesthesiologists' contributions to pain management.

Fibromyalgia: heterogeneity in personality and psychopathology and its implications

The fibromyalgia syndrome (FM) is a chronic widespread pain condition whose etiology remains unknown and no treatment has satisfactory levels of success. A meta-analysis has identified a distinct Minnesota Multiphasic Personality Inventory-2 (MMPI-2) clinical profile between FM female patients and healthy controls, and differences between FM and other chronic pain condition with clear etiology have also been found. However, heterogeneity in this population has been suggested in several studies. We aim to assess clinical aspects in FM patients, based on personality psychopathology characteristics, in order to explore heterogeneity and the existence of core common aspects. In this cross-sectional study, a relatively homogeneous sample of 56 female FM patients (M _age = 45.95, SD _age = 9.39) was assessed through MMPI-2. A K-Means cluster analysis identified two clusters, one (n = 24) with clinically significant levels in Negative Emotionality and Introversion scales. Subsequent MANOVAs identified important features of this cluster on several MMPI-2 dimensions. Moreover, several dimensions are clinically elevated in both clusters. In conclusion, the combination of psychopathological negative emotionality, interpersonal isolation, and low hedonic capacity, in a group of patients, has implications for the daily living and treatment of FM patients, and several core aspects of FM need to be addressed.

The gadolinium hypothesis for fibromyalgia and unexplained widespread chronic pain

Fibromyalgia (FM) is a chronic, painful, heterogeneous, and common disorder carrying a substantial socio-economical burden. It lacks effective cures and its aetiology is still unknown. There exists evidence for central and peripheral neurological contribution to the symptoms but grasping the real source of abnormal nervous system sensitization remains an ongoing challenge. There exists an association between an injury/trauma and the onset of the symptoms, but a causal relationship has not been yet sufficiently supported by scientific evidence. I postulate a role for gadolinium-based contrast agents and retention of gadolinium in the body. This conjecture breaks the hypothesis of a direct role for a physical injury/trauma per se in favour of an indirect one by the subsequent diagnostic procedures. It creates a new link between retention of gadolinium in the body and painful conditions as FM and unexplained chronic widespread pain reported after a trauma, surgery, or medical illness. Experimental evidence demonstrates possible retention of gadolinium species in human body, still lacking conclusive answers on their pathological consequences. Notwithstanding, there exist some initial data that report unexplained chronic widespread pain and symptoms of FM in those patients: they are suggestive for pathological consequences associated with gadolinium retention. Besides clear compelling symptoms overlapping, biochemical findings are provided to sustain the hypothesis of a role for gadolinium in the disease process focusing on neurotransmitters, endogenous metal cations, cytokines, and muscle tissue. Experimental findings strongly support the hypothesis of impairment at the cellular, intracellular, and systemic levels in FM. And these data are highly compatible with collateral effects associated with the interference of the gadolinium ion and its pharmaceutical chelates into biochemical pathways in vivo. The hypothesis presented in this article, along with the support of scientific evidence, links FM and unexplained chronic widespread pain reported after a trauma, surgery, or medical illness to retention of gadolinium in the body. If the hypothesis is confirmed, it could improve diagnosis and prevention, while providing a ground for development of new treatments.

Relationship between Future Orientation and Pain Severity in Fibromyalgia Patients: Self-Compassion as a Coping Mechanism

The present study examined the relationship between future orientation and fibromyalgia-related pain severity in a sample of 287 adults with fibromyalgia. Specifically, authors examined dimensions of self-compassion (for example, self-kindness, isolation, mindfulness) as possible mechanisms through which future orientation might be associated with pain severity. Results of conducting a multiple mediator test with 10,000 bootstraps indicated that the significant negative association between future orientation and pain severity was mediated through one specific self-compassion dimension, namely, isolation. The article concludes with a discussion of the implications of the present findings for working with fibromyalgia patients, specifically the potential value of social workers working with fibromyalgia patients to build future orientation as a resilience factor to combat pain severity. Also discussed is the value of working with patients to develop a sustainable social support system that can disrupt experiences of social isolation and disconnectedness from others, and which appear to contribute to greater pain severity.

"Everyone thinks I am just lazy": Legitimacy narratives of Americans suffering from fibromyalgia

This qualitative study reflects an analysis of 50 stories told by Americans living with fibromyalgia, a chronic condition marked by widespread physical pain. Stories were randomly collected from The Experience Project, an online public forum, and analyzed using the communication theory of identity as a guiding framework. Thematic analysis was used to examine how the legitimacy narratives of people with fibromyalgia respond to the American discourse of hard work. Three narrative themes emerged from the data: The Personal Experience of Living With Fibromyalgia (personal layer of identity), the Struggle to Complete Everyday and Professional Tasks (enacted layer of identity), and a Limited Ability to Perform Gender Roles (relational layer of identity). Throughout their stories, individuals with FM strive to legitimate their condition and contest the notion that they are lazy. Stories reveal that people suffering from fibromyalgia experience significant personal (e.g. cleaning the house) and professional (e.g. extended sick leave) challenges, as well as serious relational challenges that are often tied to gender roles (e.g. being a good mother). Results provide a variety of implications and directions for future research.

Between three chairs: Experiences of being a patient with chronic widespread pain in an intersectoral setting in Denmark

This study explores how patients with chronic widespread pain experience their contacts with health and social services in Denmark, including general practice, hospitals, and municipality job centers. We analyzed interviews with 10 patients using interpretative phenomenological analysis and found the following four superordinate themes: meeting different attitudes, fragmentation of treatment, the importance of time, and feeling trapped. Findings show that when patients do not feel understood by professionals, they can resort to withdrawal strategies. On an organizational level, patients said that they needed sufficient time in meetings and better coordination of interventions in and between the health and social care sectors.

Committed Action, Disability and Perceived Health in Individuals with Fibromyalgia

Committed action, one of the components of psychological flexibility, has been shown to be related with measures of pain-relevant function domains in patients with chronic pain. However, the associations between measures of committed action and of physical health and function in individuals with fibromyalgia (FM) have not yet been examined. The aim of the present cross-sectional study was to better understand the role that committed action plays in (1) pain-related disability and (2) mental and physical health in individuals with FM. One hundred twenty-nine adult females with a diagnosis of FM from a rheumatologist were administered measures of committed action, disability, physical health, and mental health. After controlling for age and pain intensity, committed action explained an additional 24% of the variance of pain disability, 39% of the variance of physical health, and 41% of the variance of mental health. This study provides important new information on the associations between a measure of committed action and perceived health and function in a sample of women with FM. The findings are also consistent with the psychological flexibility model for understanding pain and its impact in patients with FM.