Cognitive impairment in patients with fibromyalgia syndrome as assessed by the mini-mental state examination

Turkish version of the Massachusetts General Hospital Cognitive and Physical Functioning Questionnaire: A reliability and validity study

Objectives

This study aimed to analyze the validity and reliability of the Turkish version of the Massachusetts General Hospital Cognitive and Physical Functioning Questionnaire (CPFQ) in patients with fibromyalgia (FM) syndrome by translating and culturally adapting the CPFQ to Turkish.

Patients and methods

One hundred seventeen patients (8 males, 109 females; mean age: 47.4±12.4 years; range, 18 to 77 years) diagnosed with FM according to the 2016 American College of Rheumatology FM diagnostic criteria between May 2021 and August 2021 were included in the reliability and validity study. The CPFQ was translated into Turkish, the intelligibility of the obtained Turkish version was evaluated by five patients and five healthcare professionals, and the final form of the questionnaire was prepared. Mini-mental state examination (MMSE), Fibromyalgia Impact Questionnaire (FIQ), and Hospital Anxiety and Depression Scale (HADS), which were proven to be reliable and valid in Turkish, were administered to the patients. For test-retest reliability, the Turkish version of the CPFQ was filled in two times with an interval of one week. Internal consistency was evaluated by calculating Cronbach's alpha. Validity was evaluated by looking at the correlations between the total score obtained from the Turkish version of CPFQ and the MMSE score, HADS depression and anxiety scores, and FIQ score.

Results

In the evaluation of internal consistency, Cronbach's alpha was found to be high in all subgroups. In test-retest reliability, intraclass correlation coefficient was high in CPFQ subgroups. The CPFQ showed a significant positive correlation with HADS depression and a moderately positive correlation with HADS anxiety and FIQ. A significant but weak negative correlation was detected between CPFQ and MMSE. While there was no significant correlation between MMSE and FM disease activity and HADS anxiety, there was a significant but weak negative correlation between HADS depression.

Conclusion

In this study, the Turkish version of CPFQ was shown to have high reliability and validity in FM patients. It was concluded that CPFQ could be applied to Turkish patients with FM.

Relationship between Pain and Dementia: The Mediating Effect of Depression among Chinese Elderly

BACKGROUND

Chronic pain poses a significant problem for older adults and may potentially impact cognitive function. This study aimed to examine the cross-sectional relationship between pain severity and cognitive function in elderly individuals residing in the community. Additionally, this study sought to examine the mediating effect of depression on the relationship between pain and dementia.

METHODS

The study sample was derived from the 2018 China Health and Aging Longitudinal Study (CHARLS), comprising cross-sectional data from 4559 community residents aged 65 years or older. The primary outcome assessed was the occurrence of dementia, while the main independent variable was pain severity (none, little, somewhat, quite a bit, very). Depression score served as the mediating factor. Chi-square and binary logistic regression analyses were performed to examine the relationship between depression and the occurrence of pain and dementia. An intermediate model was constructed by stepwise regression.

RESULTS

The study indicates a significant association between cognitive impairment and both chronic pain and depressive symptoms in older adults living in China. Individuals who frequently report experiencing pain exhibit a higher likelihood of developing dementia when compared to those who do not report any pain (odds ratio (OR) = 1.72, p < 0.001). Moreover, depressive symptoms significantly mediate the relationship between pain and dementia, with the mediating effect accounting for 65.25%.

CONCLUSIONS

Chronic pain not only directly impacts patients' cognitive function but also indirectly exacerbates cognitive impairment through depressive symptoms as a mediating variable. For elderly individuals experiencing depressive symptoms, it is important to provide appropriate psychological treatment in conjunction with pain management strategies.

Does the presence of chronic pain affect scores on cognitive screening tests/brief cognitive measures for dementia? A systematic review and meta-analysis

OBJECTIVE

Cognitive screening tests can identify potential dementia by indicating a concerning level of cognitive impairment. The older populations for whom this is most relevant are more likely to experience chronic pain, which also impairs cognitive function, but pain's impact on cognitive screening tests specifically remains unknown.

METHOD

We conducted a systematic review and meta-analysis (SR/MA) following PRISMA guidelines evaluating cognitive screening scores in studies involving participants with chronic pain compared with a pain-free control group. Our question was whether the presence of chronic pain (self-reported or based on diagnosis) was associated with poorer performance on these screens, and to identify the heterogeneity across groups and screens.

RESULTS

The 51 studies identified yielded 62 effect size estimates. The pooled g was 0.76 (95% confidence interval 0.57 to 0.95). Heterogeneity was high for the full model (= 93.16%) with some reductions in sub-analyses. Around half of the studies were identified as being at a low risk of bias. There was no evidence of publication bias.

CONCLUSIONS

As a whole, this analysis suggests medium to large effect sizes on cognitive screen performance when people are living with chronic pain. We suggest that clinicians should consider the effect of chronic pain when cognitive screens are employed to investigate dementia. Further research could clarify the effect pain has on different screen sub-domains to aid their effective use with these populations.

Assessment of the therapeutic potential of lutein and beta-carotene nanodispersions in a rat model of fibromyalgia

Fibromyalgia (FM) is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and cognitive impairment. Despite the availability of various treatment options, FM remains a challenging condition to manage. In the present study, we investigated the efficacy of formulated nanodispersions of lutein and beta-carotene in treating FM-related symptoms induced by reserpine in female Wistar rats. Several techniques have been implemented to assess this efficacy at various levels, including biochemical, bioelectrical, and behavioral. Namely, oxidative stress markers, monoamine levels, electrocorticography, pain threshold test, and open field test were conducted on control, FM-induced, and FM-treated groups of animals. Our results provided compelling evidence for the efficacy of carotenoid nanodispersions in treating FM-related symptoms. Specifically, we found that the dual action of the nanodispersion, as both antioxidant and antidepressant, accounted for their beneficial effects in treating FM. With further investigation, nano-carotenoids and particularly nano-lutein could potentially become an effective alternative treatment for patients with FM who do not respond to current treatment options.

Sedentary time is associated with depressive symptoms and state anxiety in women with fibromyalgia. Could physical activity and fitness modify this association? The al-Ándalus project

PURPOSE

To analyze the associations of total and prolonged sedentary time (ST) with depressive symptoms and state anxiety in women with fibromyalgia and whether these associations are modified by moderate-to-vigorous physical activity (MVPA) and physical fitness.

METHODS

This cross-sectional exploratory study included 386 women with fibromyalgia aged 51.2 ± 7.6 years. Total ST, time in prolonged bouts of ST (≥30- and ≥60-min) and MVPA were measured with triaxial accelerometry. Depressive symptoms were assessed with the "Beck Depression Inventory-second edition," state anxiety with the "State-Trait Anxiety Inventory," and physical fitness with the "Senior Fitness Test Battery."

RESULTS

Total and prolonged ST were directly associated with depressive symptoms (total: β = 0.19, ≥30-min bout: β = 0.15, and ≥60-min bout: β = 0.12) and odds of severe depressive symptoms (all, p < 0.001). These associations generally remained significant after adjustments for MVPA and physical fitness (all, p < 0.05). Total and prolonged ST were directly associated with state anxiety (total: β = 0.11, ≥30-min bout: β = 0.12, and ≥60-min bout: β = 0.07; all, p < 0.001). These associations were generally independent of MVPA (p < 0.05) but vanished when considering physical fitness (p > 0.05).

CONCLUSIONS

Higher levels of total and prolonged ST are associated with greater depressive symptoms and state anxiety in women with fibromyalgia. MVPA did not modify these associations, although physical fitness could play a protective role specially for state anxiety.IMPLICATIONS FOR REHABILITATIONReducing sedentary time and avoiding its accumulation in prolonged periods could potentially reduce depressive symptoms and state anxiety in fibromyalgia.Higher sedentary time is associated with more severe depressive symptoms even in patients who engage in moderate-to-vigorous physical activity.Higher levels of physical fitness could attenuate the negative associations of sedentary time with depressive symptoms and, specially, state anxiety."Sit less, move more and exercise to increase your fitness" could be a positive message for people with fibromyalgia in clinical settings.

Pain and cognitive performance in adults with multiple sclerosis: A systematic review

INTRODUCTION

Pain and cognitive dysfunction are separately known to be important manifestations of multiple sclerosis (MS). Although pain is a complex subjective phenomenon with affective and cognitive aspects, it is not known if people with MS reporting pain are at greater risk of reduced performance in objective tests of cognition. The presence or direction of any association remains to be clarified, as do the roles of confounders such as fatigue, medication and mood.

METHODS

We conducted a systematic review of studies examining the relationship between pain and objectively measured cognition in adults with confirmed MS, according to a pre-registered protocol (PROSPERO 42,020,171,469). We carried out searches in MEDLINE, Embase and PsychInfo. Studies of adults with any subtype of MS, with chronic pain and in which cognitive evaluation was conducted by validated instruments were included. We evaluated the role of potential confounders (medication, depression, anxiety, fatigue and sleep) and described findings by eight pre-specified cognitive domains. Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

11 studies (n = 3714 participants, range 16 to 1890 per study) were included in the review. Four studies included longitudinal data. Nine studies identified a relationship between pain and objectively measured cognitive performance. In seven of these studies, higher pain scores were associated with poorer cognitive performance. However, no evidence was available for some cognitive domains. Heterogeneous study methodology precluded meta-analysis. Studies infrequently controlled for the specified confounders. Most studies were judged to be at risk of bias.

DISCUSSION

Several studies, but not all, identified a negative relationship between pain severity and objectively measured cognitive performance. Our ability to further characterise this relationship is limited by study design and lack of evidence in many cognitive domains. Future studies should better establish this relationship and delineate the neurological substrate underpinning it.

Mechanisms behind the Development of Chronic Low Back Pain and Its Neurodegenerative Features

Chronic back pain is complex and there is no guarantee that treating its potential causes will cause the pain to go away. Therefore, rather than attempting to "cure" chronic pain, many clinicians, caregivers and researchers aim to help educate patients about their pain and try to help them live a better quality of life despite their condition. A systematic review has demonstrated that patient education has a large effect on pain and pain related disability when done in conjunction with treatments. Therefore, understanding and updating our current state of knowledge of the pathophysiology of back pain is important in educating patients as well as guiding the development of novel therapeutics. Growing evidence suggests that back pain causes morphological changes in the central nervous system and that these changes have significant overlap with those seen in common neurodegenerative disorders. These similarities in mechanisms may explain the associations between chronic low back pain and cognitive decline and brain fog. The neurodegenerative underpinnings of chronic low back pain demonstrate a new layer of understanding for this condition, which may help inspire new strategies in pain education and management, as well as potentially improve current treatment.

Kognition und Kraftfahreignung bei chronischem Schmerzsyndrom

Kognitive Auffälligkeiten bei Patienten mit chronischen Schmerzen finden in wissenschaftlichen Untersuchungen zunehmend Beachtung. Die Folgen dieser kognitiven Störungen in Bezug auf die Schmerzbewältigung, die Alltagsgestaltung und die Kraftfahreignung werden in der klinischen Praxis jedoch kaum berücksichtigt, obwohl die Hälfte aller Patienten davon betroffen ist. Die vorliegende Arbeit fasst die aktuelle Studienlage zusammen und diskutiert Möglichkeiten der Integration in die klinische und therapeutische Versorgung.

Neuroimaging in Breast Implant Illness: An fMRI Pilot Study

BACKGROUND

Some women with breast implants report systemic and cognitive symptoms known as breast implant illness (BII), which are very similar to those of fibromyalgia. Functional MRI (fMRI) has shown altered brain activity in fibromyalgia patients.

OBJECTIVES

The aim of this pilot study was to investigate whether brain alterations could be observed in BII patients by fMRI.

METHODS

Women aged 18 to 76 with silicone breast implants for cosmetic reasons were recruited through a Dutch online BII support organization (MKS) and through the Maastricht University Medical Center. Study participants comprised 12 women with BII and 12 women without symptoms. Participants completed questionnaires regarding demographic characteristics, medical history, psychosocial complaints (Four-Dimensional Symptom Questionnaire), cognitive failure (Mini-Mental State Examination), and pain intensity and pain-related disability (Chronic Pain Grade Scale). Subsequently, brain images of all participants were obtained by resting-state fMRI and diffusion tensor imaging in a 3-T MRI scanner (Siemens Medical System, Erlangen, Germany).

RESULTS

Eleven BII patients and 12 healthy controls were included in the analysis. Baseline characteristics were similar in the 2 groups and the mean silicone exposure was 15 years. Patients scored significantly higher than controls on both pain intensity and disability. Patients scored worse on depression, somatization, distress, and anxiety compared with asymptomatic women. Mini-Mental State Examination scores were normal. However, the analyses of both functional connectivity and structural integrity showed no significant differences between the 2 groups.

CONCLUSIONS

This pilot study showed no evidence of brain alterations in BII patients. However, patients scored significantly worse on psychosocial symptoms than controls. Psychological factors appear to play an important role in BII and should be further investigated.

LEVEL OF EVIDENCE: 2

Burning Fog: Cognitive Impairment in Burning Mouth Syndrome

Background: Due to its common association with chronic pain experience, cognitive impairment (CI) has never been evaluated in patients with burning mouth syndrome (BMS). The purpose of this study is to assess the prevalence of CI in patients with BMS and to evaluate its relationship with potential predictors such as pain, mood disorders, blood biomarkers, and white matter changes (WMCs).

Methods: A case-control study was conducted by enrolling 40 patients with BMS and an equal number of healthy controls matched for age, gender, and education. Neurocognitive assessment [Mini Mental State Examination (MMSE), Digit Cancellation Test (DCT), the Forward and Backward Digit Span task (FDS and BDS), Corsi Block-Tapping Test (CB-TT), Rey Auditory Verbal Learning Test (RAVLT), Copying Geometric Drawings (CGD), Frontal Assessment Battery (FAB), and Trail Making A and B (TMT-A and TMT-B)], psychological assessment [Hamilton Rating Scale for Depression and Anxiety (HAM-D and HAM-A), Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and 36-Item Short Form Health Survey (SF-36)], and pain assessment [Visual Analogic Scale (VAS), Total Pain Rating index (T-PRI), Brief Pain Inventory (BPI), and Pain DETECT Questionnaire (PD-Q)] were performed. In addition, blood biomarkers and MRI of the brain were recorded for the detection of Age-Related WMCs (ARWMCs). Descriptive statistics, the Mann-Whitney U-test, the Pearson Chi-Squared test and Spearman's correlation analysis were used.

Results: Patients with BMS had impairments in most cognitive domains compared with controls (p < 0.001^**) except in RAVLT and CGD. The HAM-D, HAM-A, PSQI, ESS, SF-36, VAS, T-PRI, BPI and PD-Q scores were statistically different between BMS patients and controls (p < 0.001^**) the WMCs frequency and ARWMC scores in the right temporal (RT) and left temporal (LT) lobe were higher in patients with BMS (p = 0.023^*).

Conclusions: Meanwhile, BMS is associated with a higher decline in cognitive functions, particularly attention, working memory, and executive functions, but other functions such as praxis-constructive skills and verbal memory are preserved. The early identification of CI and associated factors may help clinicians to identify patients at risk of developing time-based neurodegenerative disorders, such as Alzheimer's disease (AD) and vascular dementia (VD), for planning the early, comprehensive, and multidisciplinary assessment and treatment.

Effects of Physiotherapy vs. Acupuncture in Quality of Life, Pain, Stiffness, Difficulty to Work and Depression of Women with Fibromyalgia: A Randomized Controlled Trial

BACKGROUND

Fibromyalgia is a chronic clinical condition characterized by pain and other associated symptoms that have a negative impact on the quality of life of the affected person. The objective of this study was to assess the effectiveness of a core stability training physiotherapy program compared to an acupuncture treatment on quality of life, pain, joint stiffness, difficulty to work and depression of women with fibromyalgia.

METHODS

This was a single-blind, randomized clinical controlled trial. Women with fibromyalgia were randomized to a core stability physiotherapy program group (n = 45), an acupuncture treatment group (n = 45) and a control group (n = 45) for 13 weeks. Measurements were taken at baseline (week 0), post-intervention (week 6) and at follow-up (week 13). The primary outcome measure was quality of life (Spanish Fibromyalgia Impact Questionnaire). The secondary outcome measures were pain, joint stiffness, difficulty to work and depression (Visual Analogue Scale).

RESULTS

In total, 103 participants completed the study. The results, from a descriptive perspective, showed improvements in all the outcome measures in both intervention groups (physiotherapy and acupuncture) at weeks 6 and 13 in relation to week 0 and in comparison to the control group. Only the difficulty to work measure in the acupuncture group showed a slight decrease at week 13. In particular, mean (±SD) Spanish Fibromyalgia Impact Questionnaire score at 6 weeks was 62.89 ± 16.91 for the physiotherapy group, 62.5 ± 18.09 for the acupuncture group and 67.45 ± 17.07 for the control group. However, these improvements were not statistically significant.

CONCLUSION

Core stability-based physiotherapy and acupuncture showed non-significant improvements in quality of life, pain, joint stiffness, difficulty to work and depression in women with fibromyalgia.

Cognition and Pain: A Review

Cognition is defined as the brain's ability to acquire, process, store, and retrieve information. Pain has been described as an unpleasant sensory or emotional experience, and for experiencing pain consciously, cognitive processing becomes imperative. Moreover, evaluation of pain strongly depends on cognition as it requires learning and recall of previous experiences. There could be a possible close link between neural systems involved in cognition and pain processing, and studies have reported an association between pain and cognitive impairment. In this narrative review, we explore the available evidence that has investigated cognitive changes associated with pain. We also examine the anatomical, biochemical, and molecular association of pain and neuro-cognition. Additionally, we focus on the cognitive impairment caused by analgesic medications. There is a need to improve our understanding of pathophysiology and cognitive impairment mechanisms associated with chronic pain and its treatment. This area provides a diverse opportunity for grounding future research, aiding institution of timely interventions to prevent chronic pain and associated cognitive decline, ultimately improving patient care.

Cognitive profile and mild cognitive impairment in people with chronic lower back pain

A growing body of evidence suggests Chronic Lower Back Pain (CLBP) is associated with cognitive dysfunction. Little is known, however, about the extent of cognitive impairment in CLBP. The present study explored the cognitive profile of people with CLBP and sought to determine the extent of Mild Cognitive Impairment (MCI) according to the DSM-V and the Movement Disorders Society criteria for MCI. Thirty-one participants with CLBP and 27 age and gender matched healthy controls completed a full neuropsychological battery, consisting of two tasks for each of the five cognitive domains (Executive Function, Attention/Working Memory, Memory, Language, and Visuospatial). Participants with CLBP performed worse, compared to controls, on measures of Attention/Working Memory, Memory, Language, and Visuospatial performance. Cognitive performance in CLBP was also compared to equivalent normative data to determine cognitive impairment. Sixteen CLBP participants were impaired on at least one cognitive measure, with 5 participants meeting criteria for MCI. MCI was not associated with pain-related experience, or psychological health. The present study supports and extends previous findings that CLBP is associated with cognitive dysfunction and some people with CLBP meet criteria for MCI. These findings support that rehabilitation in people with CLBP requires a multidisciplinary approach.

Cationic liposome-encapsulated carotenoids as a potential treatment for fibromyalgia in an animal model

The present study investigated the efficacy of cationic liposome-encapsulated carotenoids (lutein or beta-carotene) as a treatment in an animal model of fibromyalgia (FM). Preparation and characterization of the nano-sized cationic liposomal carotenoids have been carried out. FM has been induced in the experimental animals via successive subcutaneous reserpine injection (1 mg/kg). Animals were divided into four groups; control, reserpinized (Res), reserpinized and cationic liposomal lutein-treated (Res + CL-Lut), and reserpinized and liposomal beta-carotene-treated (Res + CL-Bc). Levels of norepinephrine (NE), dopamine (DA), and serotonin (5-HT), and oxidative stress markers (MDA, H₂O₂, NO, and GSH) were determined in the brain's cortical tissue of the different groups of animals. Furthermore, the spectral analysis of the electrocorticogram (ECoG) was carried out. Animal behavior was tested for different animal groups. Results showed a significant reduction in monoamines, an elevation of oxidative stress markers, a shift in the ECoG frequency band power, and a change in pain threshold of the reserpinized animals. A return to a non-significant difference from the control values of all the measured parameters has been obtained after two weeks of cationic liposomal carotenoid preparations treatment. The present findings shed more light on the validity of the reserpine model of FM and provide evidence for the antidepressant, antioxidant, and anti-nociceptive potential of the cationic liposomal carotenoids. The present results proofed that the natural product preparations on a nano-sized scale could be a good alternative to the pharmacological interventions for FM treatment.

Correlating cognition and cortical excitability with pain in fibromyalgia: a case control study

BACKGROUND

Fibromyalgia is a chronic pain disorder characterized by widespread musculoskeletal symptoms, primarily attributed to sensitization of somatosensory system carrying pain. Few reports have investigated the impact of fibromyalgia symptoms on cognition, corticomotor excitability, sleepiness, and the sleep quality - all of which can deteriorate the quality of life in fibromyalgia. However, the existing reports are underpowered and have conflicting directions of findings, limiting their generalizability. Therefore, the present study was designed to compare measures of cognition, corticomotor excitability, sleepiness, and sleep quality using standardized instruments in the recruited patients of fibromyalgia with pain-free controls.

METHODS

Diagnosed cases of fibromyalgia were recruited from the Rheumatology department for the cross-sectional, case-control study. Cognition (Mini-Mental State Examination, Stroop color-word task), corticomotor excitability (Resting motor threshold, Motor evoked potential amplitude), daytime sleepiness (Epworth sleepiness scale), and sleep quality (Pittsburgh sleep quality index) were studied according to the standard procedure.

RESULTS

Thirty-four patients of fibromyalgia and 30 pain-free controls were recruited for the study. Patients of fibromyalgia showed decreased cognitive scores (p = 0.05), lowered accuracy in Stroop color-word task (for color: 0.02, for word: 0.01), and prolonged reaction time (< 0.01, < 0.01). Excessive daytime sleepiness in patients were found (< 0.01) and worsened sleep quality (< 0.01) were found. Parameters of corticomotor excitability were comparable between patients of fibromyalgia and pain-free controls.

CONCLUSIONS

Patients of fibromyalgia made more errors, had significantly increased reaction time for cognitive tasks, marked daytime sleepiness, and impaired quality of sleep. Future treatment strategies may include cognitive deficits and sleep disturbances as an integral part of fibromyalgia management.

MoCA vs. MMSE of Fibromyalgia Patients: The Possible Role of Dual-Task Tests in Detecting Cognitive Impairment

Fibromyalgia is a syndrome that is characterized by widespread pain; fatigue; stiffness; reduced physical fitness; sleep disturbances; psychological symptoms, such as anxiety and depression; and deficits in cognitive functions, such as attention, executive function, and verbal memory deficits. It is important to analyze the potentially different performance on the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) test in patients with fibromyalgia as well as examine the relationship of that performance with physical and cognitive performance. A total of 36 women with fibromyalgia participated in the study. Participants completed the MoCA test, the MMSE, and the TUG physical fitness test under dual-task conditions. The results obtained on cognitive tests were 28.19 (1.74) on the MMSE and 25.17 (2.79) on the MoCA. The participants' performance on cognitive tests was significantly related to the results of the TUG dual-task test. In this way, cognitive performance on a dual-task test can be used to support the diagnosis of cognitive impairment in patients with fibromyalgia. The MoCA test may be a more sensitive cognitive screening tool than the MMSE for patients with fibromyalgia.

Pain management and cognitive function among older adults: an exploratory study of the China Health and Retirement Longitudinal Study

BACKGROUND

Chronic pain and cognitive decline are common age-related conditions affecting a large segment of older populations. Little is known about the pathway of cognitive functioning during the course of pain management in older adults.

AIMS

The study aimed to examine the association between chronic body pain management and cognitive function over time among Chinese older adults.

METHODS

A total of 792 respondents aged 60 and above from urban and rural households in 28 provinces, 150 counties/districts, and 450 communities were selected from the China Health and Retirement Longitudinal Study (2013-2015). Cognitive function was measured in three domains: episodic memory, mental status, and global cognitive function. Difference-in-differences approach and mixed-effects linear regression models were employed to assess the association between chronic body pain management and cognitive function over time.

RESULTS

Scores of mental status were found to decline slower by 0.49 unit (SE = 0.22, p < 0.05) in respondents who received pain management using analgesics, complementary and alternative medicine, or both from 2013 to 2015 after controlling for basic demographic and health confounders.

CONCLUSION

Chronic pain management was associated with slower decline in domain-specific cognitive function, mental status over time. Findings of the study may contribute to understanding the mechanism of change in diverse cognitive abilities attributable to pain symptoms. More research is needed to elucidate the mediating effect of pain on cognitive decline, which could lead to testing of the impact of pain management on cognitive function among older population in both clinical and community settings.

Effects of 24-Week Exergame Intervention on the Gray Matter Volume of Different Brain Structures in Women with Fibromyalgia: A Single-Blind, Randomized Controlled Trial

BACKGROUND

Exergame-induced changes in the volume of brain gray matter have not been studied in fibromyalgia (FM). This study evaluates the effects of a 24-week exergame-based intervention on the gray matter volume of different brain structures in patients with FM through magnetic resonance imaging (MRI).

METHODS

A total of 25 FM patients completed 24 weeks of intervention program, and another 25 FM patients did not receive any intervention. T1-weighted MRI was used to assess brain volume, and FreeSurfer software was used to segment the brain regions.

RESULTS

No significant effects on gray matter volume of different structures and total gray matter were found.

CONCLUSIONS

FM patients did not show significant changes in gray matter brain volume between the control and experimental groups after 24 weeks. FM patients showed significant relationships between peak oxygen consumption (pVO2) and the left and right regions of the hippocampus and the left and right regions of the amygdala.

Analysis of Epigenetic Age Predictors in Pain-Related Conditions

Chronic pain prevalence is high worldwide and increases at older ages. Signs of premature aging have been associated with chronic pain, but few studies have investigated aging biomarkers in pain-related conditions. A set of DNA methylation (DNAm)-based estimates of age, called “epigenetic clocks,” has been proposed as biological measures of age-related adverse processes, morbidity, and mortality. The aim of this study is to assess if different pain-related phenotypes show alterations in DNAm age. In our analysis, we considered three cohorts for which whole-blood DNAm data were available: heat pain sensitivity (HPS), including 20 monozygotic twin pairs discordant for heat pain temperature threshold; fibromyalgia (FM), including 24 cases and 20 controls; and headache, including 22 chronic migraine and medication overuse headache patients (MOH), 18 episodic migraineurs (EM), and 13 healthy subjects. We used the Horvath's epigenetic age calculator to obtain DNAm-based estimates of epigenetic age, telomere length, levels of 7 proteins in plasma, number of smoked packs of cigarettes per year, and blood cell counts. We did not find differences in epigenetic age acceleration, calculated using five different epigenetic clocks, between subjects discordant for pain-related phenotypes. Twins with high HPS had increased CD8+ T cell counts (nominal p = 0.028). HPS thresholds were negatively associated with estimated levels of GDF15 (nominal p = 0.008). FM patients showed decreased naive CD4+ T cell counts compared with controls (nominal p = 0.015). The severity of FM manifestations expressed through various evaluation tests was associated with decreased levels of leptin, shorter length of telomeres, and reduced CD8+ T and natural killer cell counts (nominal p < 0.05), while the duration of painful symptoms was positively associated with telomere length (nominal p = 0.034). No differences in DNAm-based estimates were detected for MOH or EM compared with controls. In summary, our study suggests that HPS, FM, and MOH/EM do not show signs of epigenetic age acceleration in whole blood, while HPS and FM are associated with DNAm-based estimates of immunological parameters, plasma proteins, and telomere length. Future studies should extend these observations in larger cohorts.

Sedentary Time Accumulated in Bouts is Positively Associated with Disease Severity in Fibromyalgia: The Al-Ándalus Project

To examine the associations of prolonged sedentary time (ST) with disease severity in women with fibromyalgia, and to analyse the combined association of total ST and prolonged ST with the disease severity in this population. Women (n = 451; 51.3 ± 7.6 years old) with fibromyalgia participated. Sedentary time and moderate-to-vigorous physical activity (MVPA) were measured using triaxial accelerometry and ST was processed into 30- and 60-min bouts. Dimensions of fibromyalgia (function, overall, symptoms) and the overall disease impact were assessed with the Revised Fibromyalgia Impact Questionnaire (FIQR). Body fat percentage was assessed using a bio-impedance analyser, and physical fitness was assessed with the Senior Fitness Tests Battery. Greater percentage of ST in 30-min bouts and 60-min bouts were associated with worse function, overall, symptoms and the overall impact of the disease (all, P < 0.05). Overall, these associations were statistically significant when additionally controlling for MVPA and overall physical fitness. Participants with low levels of total ST and prolonged ST (>60-min bouts) presented lower overall impact compared to participants with high levels of total ST and prolonged ST (mean difference = 6.56; 95% confidence interval (CI) = 1.83 to 11.29, P = 0.002). Greater percentage of ST accumulated in 30- and 60-min bouts and a combination of high levels of total and prolonged ST are related to worse disease severity. Although unable to conclude on causality, results suggest it might be advisable to motivate women with fibromyalgia to break prolonged ST and reduce their total daily ST.

Factors Influencing Cognitive Impairment in Neuropathic and Musculoskeletal Pain and Fibromyalgia

Objective

To assess cognitive performance of chronic pain (CP) patients diagnosed with three types of pain-neuropathic pain (NP), musculoskeletal (MSK), and fibromyalgia (FM)-and to analyze the factors influencing cognitive difficulties in each group.

Methods

Two hundred fifty-four CP patients-104 NP, 99 MSK, 51 FM-and 72 pain-free subjects were included in the study. The "Test Your Memory" (TYM) scale was used to assess cognitive performance. Pain intensity was measured by means of the visual analog scale (VAS); the Hospital Anxiety and Depression scale was used to assess mental status, and the Medical Outcome Study (MOS) sleep scale to assess sleep quality. The relationships between cognitive performance and these factors were analyzed using linear regression models.

Results

The mean score in the TYM was significantly lower (worse cognitive function) in CP patients than controls (40.5 vs 43.9, P < 0.001). In the separate analysis of each group, depression was observed to have a negative impact on MSK pain patients (ß = -0.37, 95% confidence interval [CI] = -0.53 to -0.2, P < 0.001) and on FM subjects (ß =-1.01, 95% CI = -1.05 to -2.38, P = 0.022). A significant interaction between pain intensity and depression was observed in the FM patients. In addition, a U-shaped association was found between the duration of pain and cognitive performance in the NP patients. Neither anxiety nor sleep impairment affected cognitive performance in any of the CP patients.

Conclusions

These results highlight the importance of taking into account the type of pain when assessing cognitive performance in CP patients and demonstrate the influence of the emotional state of the patient, especially if depression is present.

The Temporal Relationship between Pain Intensity and Pain Interference and Incident Dementia

BACKGROUND

Chronic pain is common among older adults and is associated with cognitive dysfunction based on cross-sectional studies. However, the longitudinal association between chronic pain and incident dementia in community-based samples is unknown.

OBJECTIVE

We aimed to evaluate the association of pain intensity and pain interference with incident dementia in a community-based sample of older adults.

METHODS

Participants were 1,114 individuals 70 years of age or older from Einstein Aging Study (EAS), a longitudinal cohort study of community-dwelling older adults in the Bronx County, NY. The primary outcome measure was incident dementia, diagnosed using DSM-IV criteria. Pain intensity and interference in the month prior to first annual visit were measured using items from the SF-36 questionnaire. Pain intensity and pain interference were assessed as predictors of time to incident dementia using Cox proportionate hazards models while controlling for potential confounders.

RESULTS

Among participants, 114 individuals developed dementia over an average 4.4 years (SD=3.1) of follow-up. Models showed that pain intensity had no significant effect on time to developing dementia, whereas higher levels of pain interference were associated with a higher risk of dementia. In the model that included both pain intensity and interference as predictors of incident dementia, pain interference had a significant effect on incident dementia, and pain intensity remained non-significant.

CONCLUSION

As a potential remediable risk factor, the mechanisms linking pain interference to cognitive decline merit further exploration.

Causal Relationships Between Modifiable Risk Factors of Cognitive Impairment, Cognitive Function, Self-Management, and Quality of Life in Patients With Rheumatic Diseases

BACKGROUND

Rheumatic diseases are one of the most common types of chronic conditions that affect cognitive functions.

PURPOSE

To develop and verify a hypothetical model of causal relationships between modifiable risk factors for cognitive impairment, cognitive function, self-management, and quality of life in patients with rheumatic diseases.

METHODS

A hypothetical model was developed on the basis of empirical evidence. The fitness of the model was verified on 210 patients with rheumatic diseases.

RESULTS

The prevalence of cognitive impairment was 49.0%. Smoking, underlying diseases, pain, and fatigue had a significant direct effect on cognitive impairment. Only cognitive impairment had a significant direct effect on self-management. Fatigue, anxiety, depression, and cognitive function had a significant direct effect on quality of life.

CONCLUSIONS

The importance of proper management of symptoms and health habits should be emphasized to prevent and delay the progression of cognitive impairment and improve adherence to self-management regimens and quality of life.

The Relationship Between Chronic Pain and Neurocognitive Function: A Systematic Review

OBJECTIVE

Understanding the relationship between chronic pain and neurocognition has important implications for the assessment and treatment of patient experiencing pain. This paper provides an overview of the current literature examining the neurocognition-chronic pain relationship and suggests future avenues of research, along with a discussion of clinical implications of the literature findings. Consideration of potential moderators and mediators of this relationship, as well as a brief discussion of the importance of future research in special populations at particular risk for these problems, are also a focus of this paper.

METHODS

This systematic review summarizes the findings of clinical studies in which neurocognitive performance was measured in chronic pain samples. A literature search led to the inclusion of 53 articles in the review.

RESULTS

Studies of neurocognitive performance in clinical chronic pain samples support a relationship between chronic pain and neurocognitive abnormalities, particularly on tests of memory, attention, and processing speed, with mixed data regarding executive functioning.

DISCUSSION

Several factors may moderate or mediate the relationship between chronic pain and neurocognitive functioning, including mood symptoms, medication side effects, and intensity and/or chronicity of pain. Limitations in the literature include a paucity of methodologically rigorous studies controlling for confounding variables (eg, opioid analgesia) and a limited number of studies examining the relationship between chronic pain and traumatic brain injury (a potential precipitant of both pain and neurocognitive impairment). Nonetheless, findings from the existing literature have significant clinical implications, including for populations with heightened risk of both pain and neurocognitive disorders.

Comparison of the cognitive performance of elderly caregivers with and without chronic pain

Abstract OBJECTIVE Understanding and characterizing chronic pain in elderly caregivers, verifying the cognitive performance of the elderly of the sample and verifying whether there is difference in the cognitive performance of elderly caregivers with and without chronic pain. METHOD Participants were people aged 60 years or older who lived with another elderly person in the same household and who were registered in Family Health Units. Data collection took place at participants' homes. Pain was assessed by the EMADOR and cognition was assessed by ACE-R. Statistical analyzes were performed using Shapiro-Wilk's and Mann-Whitney U tests. RESULTS The study included 187 elderly caregivers with chronic pain and 133 without chronic pain, with a higher frequency of women. Chronic pain was present in 58.4% of the participants. Regarding the sociodemographic variables, there was no difference between the groups except for the gender variable (p=0.025). No difference was found in cognitive performance among the elderly with chronic pain and those without chronic pain for any domain of the ACE-R instrument. CONCLUSION The results contradicted the initial hypothesis that there would be a difference between the groups; however, there is a gap in the scientific knowledge on chronic pain and cognition, especially in elderly caregivers, opening perspectives for future investigations.

Cognitive Impairment in Patients with Chronic Neuropathic or Radicular Pain: An Interaction of Pain and Age

A growing body of empirical research has confirmed an association between chronic pain and cognitive dysfunction. The aim of the present study was to determine whether cognitive function is affected in patients with a diagnosis of chronic neuropathic or radicular pain relative to healthy control participants matched by age, gender, and years of education. We also examined the interaction of pain with age in terms of cognitive performance. Some limitations of previous clinical research investigating the effects of chronic pain on cognitive function include differences in the pain and cognitive scale materials used, and the heterogeneity of patient participants, both in terms of their demographics and pathological conditions. To address these potential confounds, we have used a relatively homogenous patient group and included both experimental and statistical controls. We have also specifically investigated the interaction effect of pain and age on cognitive performance. Patients (n = 38) and controls (n = 38) were administered a battery of cognitive tests measuring IQ, spatial and verbal memory, attention, and executive function. Educational level, depressive symptoms, and state anxiety were assessed as were medication usage, caffeine, and nicotine consumption to control for possible confounding effects. Both the level of depressive symptoms and the state anxiety score were higher in chronic pain patients than in matched control participants. Chronic pain patients had a lower estimated IQ than controls, and showed impairments on measures of spatial and verbal memory. Attentional responding was altered in the patient group, possibly indicative of impaired inhibitory control. There were significant interactions between chronic pain condition and age on a number of cognitive outcome variables, such that older patients with chronic pain were more impaired than both age-matched controls and younger patients with chronic pain. Chronic pain did not appear to predict performance on the Wisconsin Card Sorting Task, which was used a measure of executive function. This study supports and extends previous research indicating that chronic pain is associated with impaired memory and attention.

Perspective: Compared to healthy control participants, patients with chronic neuropathic or radicular pain showed cognitive deficits which were most pronounced in older pain patients.

Gender Differences in Symptoms, Health-Related Quality of Life, Sleep Quality, Mental Health, Cognitive Performance, Pain-Cognition, and Positive Health in Spanish Fibromyalgia Individuals: The Al-Ándalus Project

Objective. To test the gender differences in tenderness, impact of fibromyalgia, health-related quality of life, fatigue, sleep quality, mental health, cognitive performance, pain-cognition, and positive health in Spanish fibromyalgia patients and in age-matched nonfibromyalgia individuals from the same region. To test the optimal cut-off score of the different tender points for women and men. Methods. A total of 405 (384 women) fibromyalgia versus 247 (195 women) nonfibromyalgia control participants from southern Spain (Andalusia) took part in this cross-sectional study. The outcomes studied were assessed by means of several tests. Results. In the fibromyalgia group, men showed better working memory than women (all, P < 0.01), whereas sleep latency was lower in women compared to men (P = 0.013). In the nonfibromyalgia group, men showed higher pain threshold in all the tender points (all, P < 0.01), except in right and left lateral epicondyle. Furthermore, men showed better working memory than women (all, P < 0.01), whereas memory performance was better in women compared to men (all, P ≤ 0.01). Conclusion. The results of the present study do not support consistent evidence of gender differences in fibromyalgia-related symptoms. However, it seems that detriment of some symptoms (especially pain) in fibromyalgia men compared with their nonfibromyalgia counterparts is greater than those of fibromyalgia women compared with their nonfibromyalgia peers.

Fibromyalgia: A Critical and Comprehensive Review

Fibromyalgia is a disorder that is part of a spectrum of syndromes that lack precise classification. It is often considered as part of the global overview of functional somatic syndromes that are otherwise medically unexplained or part of a somatization disorder. Patients with fibromyalgia share symptoms with other functional somatic problems, including issues of myalgias, arthralgias, fatigue and sleep disturbances. Indeed, there is often diagnostic and classification overlap for the case definitions of a variety of somatization disorders. Fibromyalgia, however, is a critically important syndrome for physicians and scientists to be aware of. Patients should be taken very seriously and provided optimal care. Although inflammatory, infectious, and autoimmune disorders have all been ascribed to be etiological events in the development of fibromyalgia, there is very little data to support such a thesis. Many of these disorders are associated with depression and anxiety and may even be part of what has been sometimes called affected spectrum disorders. There is no evidence that physical trauma, i.e., automobile accidents, is associated with the development or exacerbation of fibromyalgia. Treatment should be placed on education, patient support, physical therapy, nutrition, and exercise, including the use of drugs that are approved for the treatment of fibromyalgia. Treatment should not include opiates and patients should not become poly pharmacies in which the treatment itself can lead to significant morbidities. Patients with fibromyalgia are living and not dying of this disorder and positive outlooks and family support are key elements in the management of patients.

Serum levels of neuron-specific enolase in patients with fibromyalgia syndrome: Correlation with cognitive functions, quality of life and psychological state

BACKGROUND

Fibromyalgia syndrome (FMS) is a non-articular rheumatic disorder of unclear etiology, characterized by widespread body pain, fatigue and, psychological complaintsOBJECTIVES: To investigate the serum levels of neuron-specific enolase (NSE) in patients with FMS and to evaluate the relationship between cognitive function, quality of life and psychological state.

MATERIALS AND METHODS

Fifty-five female patients diagnosed with fibromyalgia according to the American College of Rheumatology (ACR) classification criteria, and 40 healthy female subjects were enrolled in the study. Life quality scale [(Fibromyalgia Impact Questionnaire (FIQ)], psychological state (Beck Depression Scale), and cognitive dysfunction (mini mental test, clock drawing test) scales were used for patients and control subjects. Serum NSE levels were studied using the ECLIA method.

RESULTS

No significant differences were found in the serum NSE levels between the FMS patients and the control subjects (p> 0.05). Life quality and psychological state scores were found to be higher in FMS patients relative to the control group (p< 0.001). However, no significant differences were detected in cognitive function (p> 0.05). Significant correlations were not found between the serum NSE levels and quality of life, psychological state and cognitive functions (p> 0.05).

CONCLUSION

No significant difference was determined between the groups in terms of NSE levels. Further studies, including larger series, should be carried out to clarify this relationship.

Assessing the Construct Validity and Internal Reliability of the Screening Tool Test Your Memory in Patients with Chronic Pain

Patients with chronic pain often complain about cognitive difficulties, and since these symptoms represent an additional source of suffering and distress, evaluating the cognitive status of these patients with valid and reliable tests should be an important part of their overall assessment. Although cognitive impairment is a critical characteristic of pain, there is no specific measure designed to detect these effects in this population. The objective was to analyze the psychometric properties of the “Test Your Memory” (TYM) test in patients with chronic pain of three different origins. A cross-sectional study was carried out on 72 subjects free of pain and 254 patients suffering from different types of chronic pain: neuropathic pain (104), musculoskeletal pain (99) and fibromyalgia (51). The construct validity of the TYM was assessed using the Mini-Mental State Examination (MMSE), Hospital Anxiety and Depression Scale (HADs), Index-9 from MOS-sleep, SF-12, and through the intensity (Visual Analogical Scale) and duration of pain. An exploratory factor analysis was also performed and internal reliability was assessed using Cronbach’s alpha. After adjusting for potential confounders the TYM could distinguish between pain and pain-free patients, and it was correlated with the: MMSE (0.89, p<0.001); HAD-anxiety (-0.50, p<0.001) and HAD-depression scales (-0.52, p<0.001); MOS-sleep Index-9 (-0.49, p<0.001); and the physical (0.49, p < .001) and mental components (0.55, p < .001) of SF-12. The exploratory structure of the TYM showed an 8-factor solution that explained 53% of the variance, and Cronbach’s alpha was 0.66. The TYM is a valid and reliable screening instrument to assess cognitive function in chronic pain patients that will be of particular value in clinical situations.

Methods and Instruments to Evaluate Cognitive Function in Chronic Pain Patients: A Systematic Review

OBJECTIVE

We aimed to systematically review the methods and instruments used to evaluate cognitive function in chronic pain (CP) patients.

METHODS

A sensitive search strategy was designed using five databases. Based on the objectives and methodology, we selected cross-sectional studies on adults with chronic non-cancer pain in which cognitive function was assessed using validated instruments. The characteristics of the subjects, control groups, and other variables that might affect cognitive function, and the instruments used, were extracted from each article.

RESULTS

In the 42 articles identified, 53 instruments were used to assess cognitive function. Chronic pain criteria were defined in 83.3% of the articles and more than half (57.1%) included single diagnosis samples, with fibromyalgia being the most frequent studied (75%). Patients with prior cognitive impairment were excluded in 61.9% of the studies, and a control group was included in 64.3% of the studies. In most cases potential confounding variables were evaluated. More than 14% of the studies used self-report measures, and 73.8% used neuropsychological instruments, particularly for assessing attention (30%) and memory (27.5%). None of the instruments were specifically validated for pain patients and only five studies analyzed the psychometric properties of the instruments.

CONCLUSIONS

Various instruments and methods were used to assess cognitive function in CP patients, particularly fibromyalgia patients, but also other cohorts with well-defined CP. The instruments used had been validated, but not for pain populations, thus they require specific adaptation and validation to be used in CP patients. Certain recommendations are made in order to improve the evaluation of cognitive function in these patients.

Do cognitive and physical fatigue tasks enhance pain, cognitive fatigue, and physical fatigue in people with fibromyalgia?

OBJECTIVE

Fibromyalgia is a condition characterized by chronic widespread muscle pain and fatigue. The primary objective of this study was to determine if pain, perceived cognitive fatigue, and perceived physical fatigue were enhanced in participants with fibromyalgia compared to healthy controls during a cognitive fatigue task, a physical fatigue task, and a dual fatigue task.

METHODS

In total, 24 people with fibromyalgia and 33 healthy controls completed pain, fatigue, and function measures. A cognitive fatigue task (Controlled Oral Word Association Test) and physical fatigue task (Valpar peg test) were done individually and combined for a dual fatigue task. Resting pain, perceived cognitive fatigue, and perceived physical fatigue were assessed during each task using visual analog scales. Function was assessed with shoulder range of motion and grip.

RESULTS

People with fibromyalgia had significantly higher increases in pain, cognitive fatigue, and physical fatigue when compared to healthy controls after completion of a cognitive fatigue task, a physical fatigue task, or a dual fatigue task (P < 0.01) with the exception of perceived cognitive fatigue during the cognitive fatigue task. People with fibromyalgia performed equivalently on measures of physical performance and cognitive performance on the physical and cognitive fatigue tasks, respectively.

CONCLUSION

These data show that people with fibromyalgia show larger increases in pain, perceived cognitive fatigue, and perceived physical fatigue to both cognitive and physical fatigue tasks compared to healthy controls. The increases in pain and fatigue during cognitive and physical fatigue tasks could influence subject participation in daily activities and rehabilitation.

Back propagation artificial neural network for community Alzheimer's disease screening in China

Alzheimer's disease patients diagnosed with the Chinese Classification of Mental Disorders diagnostic criteria were selected from the community through on-site sampling. Levels of macro and trace elements were measured in blood samples using an atomic absorption method, and neurotransmitters were measured using a radioimmunoassay method. SPSS 13.0 was used to establish a database, and a back propagation artificial neural network for Alzheimer's disease prediction was simulated using Clementine 12.0 software. With scores of activities of daily living, creatinine, 5-hydroxytryptamine, age, dopamine and aluminum as input variables, the results revealed that the area under the curve in our back propagation artificial neural network was 0.929 (95% confidence interval: 0.868-0.968), sensitivity was 90.00%, specificity was 95.00%, and accuracy was 92.50%. The findings indicated that the results of back propagation artificial neural network established based on the above six variables were satisfactory for screening and diagnosis of Alzheimer's disease in patients selected from the community.

Prevalence comparisons of somatic and psychiatric symptoms between community nonpatients without pain, acute pain patients, and chronic pain patients

OBJECTIVES

Somatic/psychiatric symptoms are frequently found in chronic pain patients (CPPs). The objectives of this study were to determine 1) which somatic/psychiatric symptoms are more commonly found in acute pain patients (APPs) and CPPs vs community nonpatients without pain (CNPWPs) and 2) if somatic/psychiatric symptom prevalence differs between APPs and CPPs.

DESIGN

The above groups were compared statistically for endorsement of 15 symptoms: fatigue, numbness/tingling, dizziness, difficulty opening/closing mouth, muscle weakness, difficulty staying asleep, depression, muscle tightness, nervousness, irritability, memory, falling, nausea, concentration, and headaches.

RESULTS

After controlling for age, gender, and level of pain, APPs and CPPs had a statistically significantly greater prevalence (at a P < 0.01 level) for 11 and 13 symptoms, respectively, vs CNPWPs. After controlling for age, gender, and level of pain, CPPs had a statistically significantly greater prevalence (at a P < 0.01 level) for eight symptoms vs APPs. Symptoms were highly correlated in both APPs and CPPs.

CONCLUSIONS

CPPs are characterized to a significantly greater extent than comparison groups by somatic/psychiatric symptoms that are highly intercorrelated. This has implications for clinical practice and future research.

Agomelatine in the treatment of fibromyalgia: a 12-week, open-label, uncontrolled preliminary study

Pharmacological therapy for fibromyalgia syndrome (FMS) is actually unsatisfactory; analgetic and nonsteroidal anti-inflammatory drugs are not very effective. On the other hand, it is opportune to underline that antidepressant drugs produce positive response on pain in patients with FMS. Furthermore, many studies showed that using variable doses of melatonin (3-6 mg/d) in subjects affected from FMS had significantly been effective on pain, sleep, daytime fatigue, and depression. This study was aimed to evaluate the efficacy of agomelatine on depression, anxiety, cognition, and pain in a sample of drug-free FMS patients. Agomelatine was administered at the single daily dose of 25 mg/d to 15 fibromyalgia "drug-free" female subjects during 12 weeks. Outcome measures included the Hamilton Rating Scale for Depression, the Hamilton Rating Scale for Anxiety, the Zung Self-Rating Depression Scale, the Zung Self-Rating Anxiety Scale, the Visual Analog Scale of Pain, the Quality of Life Index, the Wisconsin Card Sorting Test, the Verbal Fluency Task-Controlled Oral Word Association Test, and the Stroop Color-Word Test. Treatment with agomelatine significantly improved depression, anxiety, and pain in patients with FMS. Regarding executive/cognitive symptoms, treatment with agomelatine did not have a significant impact on the explored neuropsychological domains, although there was a trend toward the improvement of performances. The findings showed that agomelatine was effective and well tolerated in patients with FMS. Further research is needed to fully evaluate the role of agomelatine as a potential pharmacological strategy for the treatment of FMS.

Canadian Pain Society and Canadian Rheumatology Association recommendations for rational care of persons with fibromyalgia: a summary report

OBJECTIVE

To summarize the development of evidence-based guidelines for the clinical care of persons with fibromyalgia (FM), taking into account advances in understanding of the pathogenesis of FM, new diagnostic criteria, and new treatment options.

METHODS

Recommendations for diagnosis, treatment, and patient followup were drafted according to the classification system of the Oxford Centre for Evidence-Based Medicine, and following review were endorsed by the Canadian Rheumatology Association and the Canadian Pain Society.

RESULTS

FM is a polysymptomatic syndrome presenting a spectrum of severity, with a pivotal symptom of body pain. FM is a positive clinical diagnosis, not a diagnosis of exclusion, and not requiring specialist confirmation. There are no confirmatory laboratory tests, although some investigation may be indicated to exclude other conditions. Ideal care is in the primary care setting, incorporating nonpharmacologic and pharmacologic strategies in a multimodal approach with active patient participation. The treatment objective should be reduction of symptoms, but also improved function using a patient-tailored treatment approach that is symptom-based. Self-management strategies combining good lifestyle habits and fostering a strong locus of control are imperative. Medications afford only modest relief, with doses often lower than suggested, and drug combinations used according to clinical judgment. There is a need for continued reassessment of the risk-benefit ratio for any drug treatment. Outcome should be aimed toward functioning within a normal life pattern and any culture of disablement should be discouraged.

CONCLUSION

These guidelines should provide the health community with reassurance for the global care of patients with FM with the aim of improving patient outcome by reducing symptoms and maintaining function.

Cognitive function in patients with chronic pain treated with opioids: characteristics and associated factors

BACKGROUND

The paucity of studies regarding cognitive function in patients with chronic pain, and growing evidence regarding the cognitive effects of pain and opioids on cognitive function prompted us to assess cognition via neuropsychological measurement in patients with chronic non-cancer pain treated with opioids.

METHODS

In this cross-sectional study, 49 patients were assessed by Continuous Reaction Time, Finger Tapping, Digit Span, Trail Making Test-B and Mini-mental State Examination tests. Linear regressions were applied.

RESULTS

Patients scored poorly in the Trail Making Test-B (mean = 107.6 s, SD = 61.0, cut-off = 91 s); and adequately on all other tests. Several associations among independent variables and cognitive tests were observed. In the multiple regression analyses, the variables associated with statistically significant poor cognitive performance were female sex, higher age, lower annual income, lower schooling, anxiety, depression, tiredness, lower opioid dose, and more than 5 h of sleep the night before assessment (P < 0.05).

CONCLUSIONS

Patients with chronic pain may have cognitive dysfunction related to some reversible factors, which can be optimized by therapeutic interventions.

A Brief Historic Overview of Clinical Disorders Associated with Tryptophan: The Relevance to Chronic Fatigue Syndrome (CFS) and Fibromyalgia (FM)

Last century there was a short burst of interest in the tryptophan related disorders of pellagra and related abnormalities that are usually presented in infancy.1,2 Nutritional physiologists recognized that a severe human dietary deficiency of either tryptophan or the B group vitamins could result in central nervous system (CNS) sequelae such as ataxia, cognitive dysfunction and dysphoria, accompanied by skin hyperpigmentation.3,4 The current paper will focus on the emerging role of tryptophan in chronic fatigue syndrome (CFS) and fibromyalgia (FM).

Risk factor assessment for problematic use of opioids for chronic pain

Opioid analgesics provide effective treatment for noncancer pain, but many health providers have concerns about cognitive effects, tolerance, dependence, and addiction. Misuse of opioids is prominent in patients with chronic pain and early recognition of misuse risk could help providers offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drug-related behaviors. Many persons with chronic pain also have significant medical and psychiatric comorbidities that affect treatment decisions. Neuropsychologists can play an important role in the identification of psychological and social dysfunction and in matching personal characteristics to effective interventions as part of a multidisciplinary approach to pain management. The assessment of different domains using semi-structured interviews, sensory and neuropsychological testing, and standardized self-report measures permits identification of somatosensory, emotional, cognitive, behavioral, and social issues in order to facilitate treatment planning. In this review we discuss opioid abuse and misuse issues that often arise in the treatment of patients with chronic pain, and present an overview of assessment and treatment strategies that can be effective in improving outcomes associated with the use of prescription opioids for pain. Finally we briefly discuss the effect of opiate analgesics on cognition and review some intervention strategies for chronic pain patients.

Vitamin D deficiency in women with fibromyalgia in Saudi Arabia

BACKGROUND

The relation between low levels of 25-hydroxyvitamin D and nonspecific musculoskeletal pain, including fibromyalgia syndrome, is debatable. Many studies have reported "a positive relation" and others "found no relation."

OBJECTIVES

To determine the prevalence of vitamin D deficiency among patients with fibromyalgia in a neurology clinic in the Kingdom of Saudi Arabia (KSA).

METHODS

This study was done at a neurology clinic of Bugshan Hospital, Jeddah, KSA, from January to April 2011. Thirty female patients were diagnosed with fibromyalgia according to new clinical fibromyalgia diagnostic criteria; their serum vitamin D levels were screened. Vitamin D deficiency is defined as <20 ng/mL, vitamin D insufficiency is defined as 21-29 ng/mL, and vitamin D sufficiency is equal to or >30 ng/mL.

RESULT

Thirty female patients were included in the study. The mean age was 34.56 ± 8.1 years. Mean vitamin D level was 4.76 ± 1.46 ng/mL. A significant negative correlation between vitamin D level and widespread pain index was found. Thirty percent of the patients were Saudi Arabian of whom 100% were veiled; 70% were non-Saudi Arabian of whom 47.6% were veiled and 52.4% wore long pants and/or full sleeved clothes. Vitamin D deficiency was equally prevalent among veiled (4.77 ± 1.37 ng/mL) and nonveiled (4.75 ± 1.68 ng/mL). Treatment with high-dose vitamin D resulted in clinical improvement in all patients.

CONCLUSION

Vitamin D deficiency is often seen in patients diagnosed with fibromyalgia in our population. This was equally true in veiled and nonveiled, but conservatively dressed populations. Effective treatment with high-dose vitamin D could lead to resolution of almost all symptoms. Further study of these populations and fortification of foods with vitamin D may be essential.

The clinical concept of fibromyalgia as a changing paradigm in the past 20 years

Fibromyalgia (FMS) is a valid clinical condition that affects 2%–4% of the population with a pivot symptom of widespread body pain. The cause and cure of FMS are as yet unknown. The concept of FMS has evolved over the past two decades to incorporate symptoms beyond pain as contributing to the global spectrum of suffering. FMS is now recognized to be grounded in the neurological domain with evidence of dysregulation of pain processing. Appreciation of the neurophysiologic mechanisms operative in FMS has contributed to rational treatment recommendations, although a “gold standard treatment” does not currently exist. Ideal treatments for FMS patients should be individualized with emphasis on active patient participation, good health practices, and multimodal intervention, incorporating nonpharmacologic and pharmacologic treatments. Predictors of outcome, which is favourable in over 50% of patients, are unknown, but those with better outcome do more physical activity and use fewer medications.

The development and psychometric validation of the central sensitization inventory

Central sensitization (CS) has been proposed as a common pathophysiological mechanism to explain related syndromes for which no specific organic cause can be found. The term "central sensitivity syndrome (CSS)" has been proposed to describe these poorly understood disorders related to CS. The goal of this investigation was to develop the Central Sensitization Inventory (CSI), which identifies key symptoms associated with CSSs and quantifies the degree of these symptoms. The utility of the CSI, to differentiate among different types of chronic pain patients who presumably have different levels of CS impairment, was then evaluated. Study 1 demonstrated strong psychometric properties (test-retest reliability = 0.817; Cronbach's alpha = 0.879) of the CSI in a cohort of normative subjects. A factor analysis (including both normative and chronic pain subjects) yielded 4 major factors (all related to somatic and emotional symptoms), accounting for 53.4% of the variance in the dataset. In Study 2, the CSI was administered to 4 groups: fibromyalgia (FM); chronic widespread pain without FM; work-related regional chronic low back pain (CLBP); and normative control group. Analyses revealed that the patients with FM reported the highest CSI scores and the normative population the lowest (P < 0.05). Analyses also demonstrated that the prevalence of previously diagnosed CSSs and related disorders was highest in the FM group and lowest in the normative group (P < 0.001). Taken together, these 2 studies demonstrate the psychometric strength, clinical utility, and the initial construct validity of the CSI in evaluating CS-related clinical symptoms in chronic pain populations.