The Relationship between Mechanical Hyperalgesia Assessed by Manual Tender Point Examination and Disease Severity in Patients with Chronic Widespread Pain: A Cross-Sectional Study

Performance of the 2016 diagnostic criteria for fibromyalgia in a tertiary care pain rehabilitation setting: a diagnostic accuracy study

OBJECTIVES

With the International Classification of Diseases 11th revision (classifying fibromyalgia as a primary pain disorder) soon to be implemented, the importance of pain physicians being able to identify patients with fibromyalgia is emphasized. The diagnostic criteria proposed in 2016 are based on self-reported pain distribution and symptom severity. The study aimed to evaluate the diagnostic accuracy of the 2016 diagnostic criteria for fibromyalgia applied in a population of patients with high impact chronic pain referred for pain rehabilitation.

METHODS

The study was performed as a diagnostic accuracy study at two Danish interdisciplinary pain rehabilitation centers, including 215 participants. All participants were evaluated clinically to identify patients with fibromyalgia. The diagnosis was based on expert opinion, but the minimum requirements were: (1) pain in all four body quadrants and axially for at least three months and (2) minimum 8 of 18 positive tender points. Participants filled in the fibromyalgia survey questionnaire, the patient version of the 2016 diagnostic criteria. Sensitivity, specificity, likelihood ratios, and positive and negative post-test probabilities were calculated using a clinical diagnosis of fibromyalgia as the reference standard.

RESULTS

Based on clinical diagnosis 45% of the participants were diagnosed with fibromyalgia; of these, only 19% had been diagnosed previously. The 2016 diagnostic criteria demonstrated a sensitivity of 88.5%, a specificity of 81.5%, a positive likelihood ratio of 4.79, a negative likelihood ratio of 0.14, a positive post-test probability of 79.4%, and a negative post-test probability of 10.2%.

CONCLUSIONS

Fibromyalgia was severely under-diagnosed among patients with high impact chronic pain referred to tertiary care in two pain rehabilitation centers in Denmark. The 2016 diagnostic criteria showed sufficient discriminatory properties suggesting that the fibromyalgia survey questionnaire can be used as a screening tool assisting the identification of fibromyalgia in this patient population.

Association between widespread pain and dementia, Alzheimer's disease and stroke: a cohort study from the Framingham Heart Study

BACKGROUND AND OBJECTIVE

Chronic pain may be an early indicator of cognitive decline, but previous studies have not systematically examined the population-level associations between widespread pain and adverse cognitive outcomes and stroke. This study was designed to determine the association between widespread pain, a common subtype of chronic pain, and subsequent dementia, Alzheimer's disease dementia and stroke.

METHODS

This retrospective cohort study used data from the US community-based Framingham Heart Study. Pain status was assessed at a single time point between 1990 and 1994. Widespread pain was determined based on the Framingham Heart Study pain homunculus. Dementia follow-up occurred across a median of 10 years (IQR, 6-13 years) for persons who were dementia free at baseline. Proportional hazard models examined associations between widespread pain and incident dementia, Alzheimer's disease dementia and stroke.

RESULTS

A total of 347 (14.1%) subjects fulfilled the criteria for widespread pain, whereas 2117 (85.9%) subjects did not. Of 188 cases of incident all-cause dementia, 128 were Alzheimer's disease dementia. In addition, 139 patients suffered stroke during the follow-up period. After multivariate adjustment including age and sex, widespread pain was associated with 43% increase in all-cause dementia risk (HR: 1.43; 95% CI 1.06 to 1.92), 47% increase in Alzheimer's disease dementia risk (HR: 1.47; 95% CI 1.13 to 2.20) and 29% increase in stroke risk (HR: 1.29; 95% CI 1.08 to 2.54). Comparable results were shown in the subgroup of individuals over 65 years old.

CONCLUSION

Widespread pain was associated with an increased incidence of all-cause dementia, Alzheimer's disease dementia and stroke.

TRIAL REGISTRATION NUMBER

NCT00005121.

Assessing our approach to diagnosing Fibromyalgia

Introduction: Fibromyalgia represents the most prevalent of the group of conditions that are known as central sensitivity syndromes. Approximately 2-5% of the adult population in the United States is affected by Fibromyalgia. This pain amplification syndrome has an enormous economic impact as measured by work absenteeism, decreased work productivity, disability and injury compensation, and over-utilization of healthcare resources. Multiple studies have shown that early diagnosis of this condition can improve patient outlook, and redirect valuable health care resources toward more appropriate targeted therapy. Efforts have been made toward improving diagnostic accuracy through updated criteria. Areas Covered: Reviewed here are 1) reasons for the need for more accurate diagnosis of Fibromyalgia, (2) a review of the evolution of Fibromyalgia to current times, and (3) the proliferation of currently available diagnostic criteria and problems related to each of them. From initial literature review until October 2020, PubMed, Embase, and Scopus were searched for applicable literature. Expert Opinion: A discussion of ongoing efforts to obtain a biomarker to enhance diagnostic accuracy concludes this review. A need to include rheumatologists as part of the care team of patients with Fibromyalgia is emphasized.

Cuff Pressure Algometry in Patients with Chronic Pain as Guidance for Circumferential Tissue Compression for Wearable Soft Exoskeletons: A Systematic Review

In this article, we report on a systematic review of the literature on pressure-pain thresholds induced and assessed by computerized cuff pressure algometry (CPA). The motivation for this review is to provide design guidance on pressure levels for wearable soft exoskeletons and similar wearable robotics devices. In our review, we focus on CPA studies of patients who are candidates for wearable soft exoskeletons, as pain-related physiological mechanisms reportedly differ significantly between healthy subjects and patients with chronic pain. The results indicate that circumferential limb compression in patients most likely becomes painful at ∼10-18 kPa and can become unbearable even below 25 kPa. The corresponding ranges for healthy control subjects are 20-42 kPa (painful limits) and 34-84 kPa (unbearable levels). In addition, the increase of pain with time tends to be significantly higher, and the adaptation to pain significantly lower, than in healthy subjects. The results of this review provide guidance to designers of wearable robotics for populations with chronic pain regarding rates and magnitudes of tissue compression that may be unacceptable to users.

Characterization of migraineurs presenting interictal widespread pressure hyperalgesia identified using a tender point count: a cross-sectional study

BACKGROUND

Migraineurs exhibit pain hypersensitivity throughout the body during and between migraine headaches. Migraine is classified as a central sensitivity syndrome, typified by fibromyalgia showing widespread pressure hyperalgesia determined by a tender point. This study was performed to examine whether: 1) there is a subgroup of episodic migraineurs with widespread pressure hyperalgesia during and between attacks; 2) if such a subgroup exists, what is the prevalence and what is the difference between groups with interictal widespread hyperalgesia and acute allodynia regarding the demographic and clinical characteristics of migraine.

METHODS

This was a cross-sectional study. A total of 176 consecutive episodic migraineurs and 132 age- and sex-matched controls were recruited. The presence of widespread pressure hyperalgesia was investigated using manual tender point survey. To classify a subject's response as widespread pressure hyperalgesia, the cutoff value for responders was defined as the positive tender point count below which 95% of controls responded.

RESULTS

Based on the number of positive tender points in controls, the cutoff value of tender point count for pressure hyperalgesia responders was 7. Of the 176 subjects, interictal widespread pressure hyperalgesia and acute allodynia were observed in 74 (42%) and 115 (65.3%) patients, respectively. Univariate analysis indicated that risk factors associated with interictal widespread pressure hyperalgesia were female gender, younger age at migraine onset, higher frequency of migraine attacks, severe headache impact, cutaneous allodynia and depression. Multivariate logistic regression analysis confirmed that independent risk factors associated with interictal widespread pressure hyperalgesia were female gender, higher frequency of migraine attack and younger age at onset.

CONCLUSION

Interictal widespread pressure hyperalgesia was common (42%) in the episodic migraineurs and was associated with younger age at onset, female gender, and higher frequency of headache, but not duration of migraine illness. Presence of interictal widespread pressure hyperalgesia is assumed to be an indicator of genetic susceptibility to migraine attacks. We expect that a tender point count, as an alternative to quantitative sensory testing, will become useful as a diagnostic indicator of interictal hyperalgesia in migraineurs to predict susceptibility to migraine attacks and to permit tailored treatment.

Fibromyalgia diagnosis: a review of the past, present and future

Diagnosis of fibromyalgia (FM) remains controversial even though diverse diagnostic criteria have been developed. This review looks at the history, evolution of diagnostic criteria, endless controversy, recent trends and future perspectives regarding FM diagnosis. Some have criticized that diagnosis of FM could lead to medicalization, whereas others have raised concerns of under-diagnosing FM. With the evolution of diagnosis criteria from American College of Rheumatology 1990 to modified American College of Rheumatology 2010, diagnosis of FM has become simpler. The recent trend of applying patient-reported questionnaires has also increased a simpler FM diagnosis. Reliable biomarkers will not be available for the foreseeable future, so diverse assessment tools will have to be used more pro-actively. After initial diagnosis, multiple and comprehensive assessment measures are needed during the course of treatment in order to better understand type and severity of FM symptoms. These, in turn, could help classify FM based on symptom domain, symptom severity, and comorbidity which would enable more personalized treatment.

Ineffective ADL skills in women with fibromyalgia: a cross-sectional study

BACKGROUND

Subgroups of women with fibromyalgia likely show different activity of daily living (ADL) skill deficits. Identifying ineffective ADL skills of significance in the 'typical' woman with fibromyalgia will promote the planning of targeted occupational therapy interventions aiming at improving ADL ability.

OBJECTIVE

To identify frequently reported ADL skill deficits of significance in subgroups of women with fibromyalgia who have decreased ADL motor ability in combination with decreased or competent ADL process ability.

METHOD

Women with fibromyalgia were evaluated with the Assessment of Motor and Process Skills (AMPS). If they demonstrated decreased ADL motor ability, the calibrated AMPS raters identified and reported ineffective ADL skills of significance. Descriptive comparisons were made between subgroups displaying either decreased or competent ADL process ability.

RESULTS

Moves, calibrates, bends, reaches, and paces were identified as the most frequently reported ineffective ADL skills of significance within the total sample (n = 188). The ADL process skills items organise and accommodate were identified as ineffective only in the subgroup with decreased ADL process ability (n = 105).

CONCLUSION

It is suggested that clinicians modify the individual's tasks and environments to compensate for identified ineffective ADL skills and to use the AMPS to differentiate interventions in women with fibromyalgia.