Differences between patients with chronic widespread pain and local chronic low back pain in primary care--a comparative cross-sectional analysis

Pain catastrophizing and risk of progression to widespread pain among patients with chronic low back pain: A retrospective cohort study

BACKGROUND

Chronic low back pain often progresses to widespread pain. Although many factors are associated with progression, their roles in contributing to chronic widespread pain (CWP) are often unclear.

OBJECTIVE

To determine if pain catastrophizing is an independent risk factor for CWP.

DESIGN

Retrospective cohort study within a national pain research registry from April 2016 through August 2022.

METHODS

A total of 1111 participants with chronic low back pain, but without CWP, were included. Participants were followed at quarterly intervals for up to 48 months to measure CWP risk. Survival analyses involved Kaplan-Meier plots and the Cox proportional hazards model to measure CWP risk according to pain catastrophizing and subscale scores for rumination, magnification, and helplessness.

RESULTS

Crude CWP risks for moderate pain catastrophizing (HR, 2.13; 95% CI, 1.54-2.95; P < 0.001) and high pain catastrophizing (HR, 3.98; 95% CI, 2.95-5.35; P < 0.001) were each elevated in comparison with low pain catastrophizing. Adjusted CWP risks for moderate pain catastrophizing (HR, 1.80; 95% CI, 1.27-2.53; P < 0.001) and high pain catastrophizing (HR, 2.82; 95% CI, 1.98-4.02; P < 0.001) remained elevated in analyses that controlled for potential confounders. Corresponding results were observed in the survival analyses involving rumination, magnification, and helplessness.

CONCLUSIONS

Pain catastrophizing appears to be an independent risk factor for progression to CWP among patients with chronic low back pain. These findings provide a rationale for interventions aimed at reducing pain catastrophizing, including rumination, magnification, and helplessness, among patients with chronic low back pain.

Personalized assessment and management of non-specific low back pain

BACKGROUND AND OBJECTIVE

Low back pain (LBP), and in particular non-specific low back pain (NSLBP), which accounts for approximately 90% of LBP, is the leading cause of years lived with disability worldwide. In clinical trials, LBP is often poorly categorized into 'specific' versus 'non-specific' and 'acute' versus 'chronic' pain. However, a better understanding of the underlying pain mechanisms might improve study results and reduce the number of NSLBP patients.

DATABASES AND DATA TREATMENT

Narrative review.

RESULTS

NSLBP is a multi-dimensional, biopsychosocial condition that requires all contributing dimensions to be assessed and prioritized. Thereby, the assessment of the contribution of nociceptive, neuropathic and nociplastic pain mechanisms forms the basis for personalized management. In addition, psychosocial (e.g. anxiety, catastrophizing) and contextual factors (e.g. work situation) as well as comorbidities need to be assessed and individually weighted. Personalized treatment of NSLBP further requires individually choosing treatment modalities, for example, exercising, patient education, cognitive-behavioural advice, pharmacotherapy, as well as tailoring treatment within these modalities, for example, the delivery of tailored psychological interventions or exercise programs. As the main pain mechanism and psychosocial factors may vary over time, re-assessment is necessary and treatment success should ideally be assessed quantitatively and qualitatively.

CONCLUSIONS

The identification of the main contributing pain mechanism and the integration of the patients' view on their condition, including beliefs, preferences, concerns and expectations, are key in the personalized clinical management of NSLBP. In research, particular importance should be placed on accurate characterization of patients and on including outcomes relevant to the individual patient.

SIGNIFICANCE STATEMENT

Here, a comprehensive review of the challenges associated with the diagnostic label 'non-specific low back pain' is given. It outlines what is lacking in current treatment guidelines and it is summarized what is currently known with respect to individual phenotyping. It becomes clear that more research on clinically meaningful subgroups is needed to best tailor treatment approaches.

Movement-Evoked Pain Versus Widespread Pain: A Longitudinal Comparison in Older Adults With Chronic Low Back Pain From the Delaware Spine Studies

It is currently unknown which pain-related factors contribute to long-term disability and poorer perceived health among older adults with chronic low back pain (LBP). This investigation sought to examine the unique influence of movement-evoked pain (MeP) and widespread pain (WP) on longitudinal health outcomes (ie, gait speed, perceived disability, and self-efficacy) in 250 older adults with chronic LBP. MeP was elicited with 3 standardized functional tests, while presence of WP was derived from the McGill Pain Map. Robust regression with HC3 standard errors was used to examine associations between these baseline pain variables and health outcomes at 12-month follow-up. Covariates for these models included age, sex, body mass index, resting and recall LBP intensity, LBP duration, depression, pain catastrophizing, and baseline outcome (eg, baseline gait speed). Greater MeP was independently associated with worse 12-month LBP-related disability (b = .384, t = 2.013, P = .046) and poorer self-efficacy (b = -.562, t = -2.074, P = .039); but not gait speed (P > .05). In contrast, WP and resting and recall LBP intensity were not associated with any prospective health outcome after adjustment (all P > .05). Compared to WP and resting and recall LBP intensity, MeP is most strongly related to longitudinal health outcomes in older adults with chronic LBP. PERSPECTIVE: This article establishes novel independent associations between MeP and worse perceived disability and self-efficacy at 12-months in older adults with chronic LBP. MeP likely has biopsychosocial underpinnings and consequences and may therefore be an important determinant of health outcomes in LBP and other geriatric chronic pain populations.

Pain-related interference and pain-related psychosocial factors of three different subgroups of patients with chronic low back pain

BACKGROUND

Low back pain (LBP) subgroup identification and management are a research priority. The clarification of subgroup differences could assist clinicians in clinical decisions contributing to a tailored treatment.

OBJECTIVES

To compare pain-related interference and pain-related psychosocial factors among subgroups of chronic low back pain (localised low back pain, peripheral neuropathic back pain, and widespread pain).

DESIGN

Cross-sectional study.

METHODS

A cross-sectional study was conducted on 444 participants with chronic low back pain. Pain-related interference was investigated by the Brief Pain Inventory and Patient-Specific Functional Scale. Pain-related psychosocial factors assessment included psychosocial factors from Brief Screening Questions and maladaptive beliefs from Back Beliefs Questionnaire, self-efficacy, and expectation questions. Participants' characteristics, pain-related interference, and pain-related psychosocial factors were compared among the three groups.

RESULTS

A one-way ANCOVA presented statistically significant differences among the groups for current pain intensity [F(2,441) = 6.77, p = 0.001], pain duration [F(2,425) = 9.83, p < 0.001], pain-related interference by Brief Pain Inventory [F(2,441) = 11.97, p < 0.001], and pain-related psychosocial factors regarding symptoms of anxiety [F(2,441) = 3.85, p = 0.022], symptoms of depression [F(2,441) = 6.74, p = 0.001], social isolation [F(2,441) = 6.54, p = 0.002], catastrophising [F(2,441) = 9.72, p < 0.001], perceived stress [F(2,441) = 3.93, p = 0.020], maladaptive beliefs [F(2,441) = 6.89, p = 0.001], and expectation [F(2,441) = 6.66, p = 0.001].

CONCLUSION

Participants with widespread pain presented higher pain-related interference and pain-related psychosocial factors compared to the localised low back pain group. Participants with peripheral neuropathic back pain and widespread pain presented with similar characteristics.

An Exploration of the Influence of Non-Biomechanical Factors on Lifting-Related LBP

Objective: The primary objective was to compare non-biomechanical factors between manual workers with and without a history of LBP related to lifting. A secondary objective was to investigate associations between the change in pain intensity during repeated lifting (termed pain ramp) and non-biomechanical factors tested in the LBP group. Methods: Manual workers currently in lifting occupations with and without a history of lifting-related LBP were recruited (21 LBP and 20 noLBP) and took part in a repeated (100) lift task. A series of non-biomechanical factors, including psychological, work-related, lifestyle, whole health and psychophysical factors, were collected. Psychophysical factors (pressure pain thresholds (PPTs) and fatigue) were also measured at different time points. Associations between pain ramp during lifting and non-biomechanical factors were investigated with linear regression. Results: The LBP group reported worse perceived sleep quality, more musculoskeletal pain sites other than LBP and greater symptoms related to gastrointestinal complaints and pseudo-neurology compared to the group with no history of LBP. The group with LBP were also slightly more worried about the lifting task and felt more fatigued at the end of the lifting task. The feeling of fatigue during lifting was positively associated with pain ramp in the LBP group. Anxiety and gastrointestinal complaints were weakly negatively associated with pain ramp during lifting. Conclusions: The group differences of poorer perceived sleep, greater non-specific health complaints, slightly more worry about the lifting task and more perceived fatigue in the LBP group highlight the complex and multi-factorial nature of LBP related to lifting. The feeling of fatigue was positively associated with pain ramp in the LBP group, suggesting a close relationship with pain and fatigue during lifting that requires further exploration.

Characteristics and Outcomes of Patients Receiving Physical Therapy for Low Back Pain with a Nociplastic Pain Presentation: A Secondary Analysis

Introduction

Individuals with low back pain (LBP) may be classified based on mechanistic descriptors, such as a nociplastic pain presentation (NPP). The purpose of this secondary analysis was to examine the frequency and characteristics of patients with a NPP referred to physical therapy with LBP. Additionally, we characterized patients with LBP meeting the criteria for NPP by demographic, clinical, psychological, and pain sensitivity variables. Finally, we examined short- and long-term clinical outcomes in patients with a NPP compared to those without a NPP.

Materials and Methods

Patients referred to physical therapy for LBP completed the Patient Self-report Survey for the Assessment of Fibromyalgia. Participants were categorized as "LBP with NPP" or "LBP without NPP" based on the threshold established in this measure. A rank sum test examined for differences in pain-related psychological factors and pressure-pain threshold between groups. Next, a Friedman test examined if LBP intensity and disability trajectories differed by groups at one and six months after initiation of physical therapy.

Results

22.2% of patients referred to physical therapy for LBP met the criteria for a NPP. Patients with a NPP reported significantly greater disability, pain catastrophizing, depression, anxiety, and somatization compared to individuals without a NPP (p < 0.05). Pressure-pain threshold did not differ between groups (p > 0.05). Individuals with LBP with a NPP demonstrated nonsignificant, small to medium reductions in pain and disability at one and six months. Individuals experiencing LBP without a NPP demonstrated significant reductions in pain and disability in the short- and long term.

Conclusion

Patients with LBP with a NPP displayed greater negative pain-related psychological factors but similar pain sensitivity compared to LBP without NPP.

The effect and mechanism of traditional Chinese exercise for chronic low back pain in middle-aged and elderly patients: A systematic review

Background

Increasing lines of evidence indicate that traditional Chinese exercise (TCE) has potential benefits in improving chronic low back pain (CLBP) symptoms. To assess the clinical efficacy of TCE in the treatment of CLBP, we performed a systematic review of existing randomized controlled trials (RCTs) of CLBP and summarized the neural mechanisms underlying TCE in the treatment of CLBP.

Methods

A systematic search was conducted in four electronic databases: PubMed, Embase, the Cochrane Library, and EBSCO from January 1991 to March 2022. The quality of all included RCTs was evaluated by the Physiotherapy Evidence Database Scale (PEDro). The primary outcomes included pain severity and pain-related disability.

Results

A total of 11 RCTs with 1,256 middle-aged and elderly patients with CLBP were included. The quality of all 11 included RCTs ranged from moderate to high according to PEDro. Results suggested that TCE could considerably reduce pain intensity in patients with CLBP. Overall, most studies did not find any difference in secondary outcomes (quality of life, depression, and sleep quality).

Conclusion

The neurophysiological mechanism of TCE for treating CLBP could be linked to meditation and breathing, posture control, strength and flexibility training, and regulation of pain-related brain networks. Our systematic review showed that TCE appears to be effective in alleviating pain in patients with CLBP.

Associations between Vitamin D, Omega 6:Omega 3 Ratio, and Biomarkers of Aging in Individuals Living with and without Chronic Pain

Elevated inflammatory cytokines and chronic pain are associated with shorter leukocyte telomere length (LTL), a measure of cellular aging. Micronutrients, such as 25-hydroxyvitamin D (vitamin D) and omega 3, have anti-inflammatory properties. Little is known regarding the relationships between vitamin D, omega 6:3 ratio, LTL, inflammation, and chronic pain. We investigate associations between vitamin D, omega 6:3 ratio, LTL, and C-reactive protein (CRP) in people living with/without chronic pain overall and stratified by chronic pain status. A cross-sectional analysis of 402 individuals (63% women, 79.5% with chronic pain) was completed. Demographic and health information was collected. Chronic pain was assessed as pain experienced for at least three months. LTL was measured in genomic DNA isolated from blood leukocytes, and micronutrients and CRP were measured in serum samples. Data were analyzed with general linear regression. Although an association between the continuous micronutrients and LTL was not observed, a positive association between omega 6:3 ratio and CRP was detected. In individuals with chronic pain, based on clinical categories, significant associations between vitamin D, omega 6:3 ratio, and CRP were observed. Findings highlight the complex relationships between anti-inflammatory micronutrients, inflammation, cellular aging, and chronic pain.

Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition

BACKGROUND

The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine.

METHODS

The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, "body of evidence" and "benefit and harm balance" were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members.

RESULTS

Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature.

CONCLUSIONS

The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.

Reduction in movement-evoked pain and fatigue during initial 30-minute transcutaneous electrical nerve stimulation treatment predicts transcutaneous electrical nerve stimulation responders in women with fibromyalgia

ABSTRACT

We previously showed that 1 month of transcutaneous electrical nerve stimulation (TENS) reduces movement-evoked pain and fatigue in women with fibromyalgia (FM). Using data from this study (Fibromyalgia Activity Study with TENS [FAST]), we performed a responder analysis to identify predictors of clinical improvement in pain and fatigue with TENS, validated these models using receiver operator characteristic, and determined number needed to treat and number needed to harm. Participants were randomly assigned to active-TENS (2-125 Hz; highest-tolerable intensity), placebo-TENS, or no-TENS for 1 month. At the end of the randomized phase, placebo-TENS and no-TENS groups received active-TENS for 1 month. The predictor model was developed using data from the randomized phase for the active-TENS group (n = 103) and validated using data from placebo-TENS and no-TENS groups after active-TENS for 1 month (n = 155). Participant characteristics, initial response to TENS for pain and fatigue, sleep, psychological factors, and function were screened for association with changes in pain or fatigue using a logistic regression model. Predictors of clinical improvement in pain were initial response to pain and widespread pain index (area under the curve was 0.80; 95% confidence interval: 0.73-0.87). Predictors of clinical improvement in fatigue were marital status, sleep impairment, and initial response to TENS (area under the curve was 0.67; 95% confidence interval: 0.58-0.75). Number needed to treat for pain and fatigue ranged between 3.3 and 5.3. Number needed to harm ranged from 20 to 100 for minor TENS-related adverse events. The response to an initial 30-minute TENS treatment predicts who responds to longer-term TENS use in women with FM, making this a clinically useful procedure. Number needed to treat and number needed to harm suggest that TENS is effective and safe for managing pain and fatigue in FM.

Resilience, pain, and the brain: Relationships differ by sociodemographics

Chronic musculoskeletal (MSK) pain is disabling to individuals and burdensome to society. A relationship between telomere length and resilience was reported in individuals with consideration for chronic pain intensity. While chronic pain associates with brain changes, little is known regarding the neurobiological interface of resilience. In a group of individuals with chronic MSK pain, we examined the relationships between a previously investigated resilience index, clinical pain and functioning measures, and pain-related brain structures, with consideration for sex and ethnicity/race. A cross-sectional analysis of 166 non-Hispanic Black and non-Hispanic White adults, 45-85 years of age with pain ≥ 1 body site (s) over the past 3 months was completed. Measures of clinical pain and functioning, biobehavioral and psychosocial resilience, and structural MRI were completed. Our findings indicate higher levels of resilience associate with lower levels of clinical pain and functional limitations. Significant associations between resilience, ethnicity/race, and/or sex, and pain-related brain gray matter structure were demonstrated in the right amygdaloid complex, bilateral thalamus, and postcentral gyrus. Our findings provide compelling evidence that in order to decipher the neurobiological code of chronic pain and related protective factors, it will be important to improve how chronic pain is phenotyped; to include an equal representation of females in studies including analyses stratifying by sex, and to consider other sociodemographic factors.

Spreading of Pain in Patients with Chronic Pain is Related to Pain Duration and Clinical Presentation and Weakly Associated with Outcomes of Interdisciplinary Pain Rehabilitation: A Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Introduction

The extent to which pain is distributed across the body (spreading of pain) differs largely among patients with chronic pain conditions and widespread pain has been linked to poor quality of life and work disability. A longer duration of pain is expected to be associated with more widespread pain, but studies are surprisingly scarce. Whether spreading of pain is associated with clinical presentation and treatment outcome in patients seen in interdisciplinary multimodal pain rehabilitation programs (IMMRPs) is unclear. The association between spreading of pain and (1) pain duration (2) clinical presentation (eg, pain intensity, pain-related cognitions, psychological distress, activity/participation aspects and quality of life) and (3) treatment outcome were examined.

Methods

Data from patients included in the Swedish Quality Registry for Pain Rehabilitation were used (n=39,916). A subset of patients that participated in IMMRPs (n=14,666) was used to examine whether spreading of pain at baseline predicted treatment outcome. Spreading of pain was registered using 36 predefined anatomical areas which were summarized and divided into four categories: 1–6 regions with pain (20.6% of patients), 7–12 regions (26.8%), 13–18 regions (22.0%) and 19–36 regions (30.6%).

Results

More widespread pain was associated with a longer pain duration and a more severe clinical picture at baseline with the strongest associations emerging in relation to health and pain aspects (pain intensity, pain interference and pain duration). Widespread pain was associated with a poorer overall treatment outcome following IMMRPs at both posttreatment and at a 12-month follow-up, but effect sizes were small.

Discussion

Spreading of pain is an indicator of the duration and severity of chronic pain and to a limited extent to outcomes of IMMRP. Longer pain duration in those with more widespread pain supports the concept of early intervention as clinically important and implies a need to develop and improve rehabilitation for patients with chronic widespread pain.

Differential sensory and clinical phenotypes of patients with chronic widespread and regional musculoskeletal pain

The differentiation of chronic primary pain syndromes into those with widespread vs regional musculoskeletal pain has been characterized by controversial discussions about common or distinct mechanisms and core clinical and sensory criteria. For example, the recent revision of fibromyalgia criteria has discarded sensory characteristics such as number of "tender points." This study examined empirical evidence related to this diagnostic shift and aimed to identify basic sensory-clinical pain phenotypes in patients with chronic local primary pain (chronic primary back pain [CBP]) and patients with chronic widespread primary pain (fibromyalgia syndrome). Combined sensory-clinical pain phenotypes of 185 patients with previous CBP and fibromyalgia syndrome diagnoses were derived by a stepwise data reduction through descriptive statistical, correlational, principal components and latent class analyses. Clusters were cross-validated by linear discriminant analysis. Four clusters of patients were identified, requiring 4 pressure pain sensitivity markers (number of sensitive tender and control points, pain intensity, and pressure pain threshold at the trapezius) and 2 clinical pain characteristics (pain regions and present pain intensity). Subsequent discriminant analysis revealed that 3 discriminant functions of pressure sensitivity markers sufficed to differentiate the clusters. These sensory-clinical phenotypes differed also in somatic symptoms and impairment but neither in psychopathology nor in psychosocial cofactors. The results highlight the relevance of sensory testing in combination with clinical pain assessment in chronic primary pain syndromes.

The Reliability and Concurrent Validity of PainMAP Software for Automated Quantification of Pain Drawings on Body Charts of Patients With Low Back Pain

BACKGROUND

The assessment of painful areas through printed body charts is a simple way for clinicians to identify patients with widespread pain in primary care. However, there is a lack in the literature about a simple and automated method designed to analyze pain drawings in body charts in clinical practice.

PURPOSE

To test the inter- and intra-rater reliabilities and concurrent validity of software (PainMAP) for quantification of pain drawings in patients with low back pain.

METHODS

Thirty-eight participants (16 [42.10%] female; mean age 50.24 [11.54] years; mean body mass index 27.90 [5.42] kg/m² ; duration of pain of 94.35 [96.11] months) with a current episode of low back pain were recruited from a pool of physiotherapy outpatients. Participants were instructed to shade all their painful areas on a body chart using a red pen. The body charts were digitized by separate raters using smartphone cameras and twice for one rater to analyze the intra-rater reliability. Both the number of pain sites and the pain area were calculated using ImageJ software (reference method). The PainMAP software used image processing methods to automatically quantify the data from the same digitized body charts.

RESULTS

The reliability analyses revealed that PainMAP has excellent inter- and intra-rater reliabilities to quantify the number of pain sites (intraclass correlation coefficient [ICC]_2,1 : 0.998 [95% confidence interval (CI) 0.996 to 0.999]; ICC_2,1 : 0.995 [95% CI 0.991 to 0.998]) and the pain area [ICC_2,1 : 0.998 (95% CI 0.995 to 0.999); ICC_2,1 : 0.975 (95% CI 0.951 to 0.987)], respectively. The standard error of the measurement was 0.22 (4%) for the number of pain sites and 0.03 cm² (4%) for the pain area. The Bland-Altman analyses revealed no substantive differences between the 2 methods for the pain area (mean difference = 0.007 [95% CI -0.053 to 0.067]).

CONCLUSION

PainMAP software is reliable and valid for quantification of the number of pain sites and the pain area in patients with low back pain.

Consultation prevalence among children, adolescents and young adults with pain conditions: A description of age- and gender differences

BACKGROUND

Pain is a common complaint presented in healthcare, but most epidemiological pain research has focused either on single pain conditions or on the adult population. The aim of this study was to investigate the 2017 consultation prevalence of a wide range of pain conditions in the general population of young people.

METHODS

We used the Skåne Healthcare Register, covering prospectively collected data on all healthcare delivered (primary and secondary care) to the population in the region of Skåne, southern Sweden (population 2017 n = 1,344,689). For individuals aged 1-24 in 2017 (n = 373,178), we calculated the consultation prevalence, stratified by sex and age, and the standardised morbidity ratio (SMR) to assess overall healthcare consultation.

RESULTS

A total of 58,981 (15.8%) individuals consulted at least once for any of the predefined pain conditions. Of these, 13.5% (n = 7,996) consulted four or more times for pain. Abdominal pain, joint pain/myalgia, headache and back/neck pain were the most common complaints. Overall, females had higher consultation prevalence than males: 17.6% versus 14.1% (p < .0001). SMR was 1.82 (95% CI = 1.74-1.87) for females with pain and 1.51 (95% CI = 1.42-1.56) for males with pain. Consultation prevalence increased with age, but this pattern varied between sex and pain condition.

CONCLUSIONS

Among individuals under the age of 25, a significant proportion consult for pain already in early ages, and they also have high healthcare consultation rates for conditions other than pain. The even higher consultation rates among young females need additional attention, both in the clinic and in research.

SIGNIFICANCE

We present comprehensive 1-year healthcare consultation prevalence data covering all levels of care. A significant proportion of children, adolescents and young adults consult for different pain conditions at multiple occasions warranting greater clinical awareness.

Sleep problems and fatigue as predictors for the onset of chronic widespread pain over a 5- and 18-year perspective

BACKGROUND

Previous research suggests that sleep problems may be an important predictor for chronic widespread pain (CWP). With this study we investigated both sleep problems and fatigue as predictors for the onset of CWP over a 5-year and an 18-year perspective in a population free from CWP at baseline.

METHODS

To get a more stable classification of CWP, we used a wash-out period, including only individuals who had not reported CWP at baseline (1998) and three years prior baseline (1995). In all, data from 1249 individuals entered the analyses for the 5-year follow-up and 791 entered for the 18-year follow-up. Difficulties initiating sleep, maintaining sleep, early morning awakening, non-restorative sleep and fatigue were investigated as predictors separately and simultaneously in binary logistic regression analyses.

RESULTS

The results showed that problems with initiating sleep, maintaining sleep, early awakening and non-restorative sleep predicted the onset of CWP over a 5-year (OR 1.85 to OR 2.27) and 18-year (OR 1.54 to OR 2.25) perspective irrespective of mental health (assessed by SF-36) at baseline. Also fatigue predicted the onset of CWP over the two-time perspectives (OR 3.70 and OR 2.36 respectively) when adjusting for mental health. Overall the effect of the sleep problems and fatigue on new onset CWP (over a 5-year perspective) was somewhat attenuated when adjusting for pain at baseline but remained significant for problems with early awakening, non-restorative sleep and fatigue. Problems with maintaining sleep predicted CWP 18 years later irrespective of mental health and number of pain regions (OR 1.72). Reporting simultaneous problems with all four aspects of sleep was associated with the onset of CWP over a five-year and 18-yearperspective, irrespective of age, gender, socio economy, mental health and pain at baseline. Sleep problems and fatigue predicted the onset of CWP five years later irrespective of each other.

CONCLUSION

Sleep problems and fatigue were both important predictors for the onset of CWP over a five-year perspective. Sleep problems was a stronger predictor in a longer time-perspective. The results highlight the importance of the assessment of sleep quality and fatigue in the clinic.

Comorbid fibromyalgia: A qualitative review of prevalence and importance

Fibromyalgia (FM) may be an unrecognized cause of suffering for persons with an array of medical conditions. This is especially true for illness that is characterized by pain of any nature. Once believed to be a unique diagnosis, FM is recently reported to occur concomitantly with various rheumatic diseases, and importantly adversely impacts global health status. However, there is increasing report of FM associated with other diseases that are not defined by chronic pain. This qualitative review examines the evidence for comorbid FM in illness, and where available the effect of FM on the primary disease. Other than for musculoskeletal disorders, the published literature reporting an association of FM with illness is limited with scanty reports for some neurological, gastrointestinal, mental health and other overlapping pain conditions. Comorbid FM adversely affects both health status and outcome for rheumatic diseases, but with limited study in other diseases. When unrecognized, comorbid FM may be mistaken as poor control of the primary disease, leading to incorrect treatment decisions. FM may be a neglected condition that pervades many conditions and may contribute to the burden of illness. Physicians should be alert to the possibility of comorbid FM, and symptoms of FM should be specifically addressed.

SIGNIFICANCE

Comorbid fibromyalgia (FM) in other medical conditions is largely unrecognized. When reported as accompanying rheumatic diseases, FM adversely affects global health status. With limited reports of comorbid FM with other conditions, neglect to diagnose comorbid FM may misdirect treatments.

Parental chronic widespread pain and the association with chronic widespread pain in adult offspring: Family-linkage data from the Norwegian HUNT Study

BACKGROUND

Individuals experiencing chronic widespread pain (CWP) have greater disability and poorer quality of life compared to those with other chronic painful conditions; although research identifying risk factors for CWP is lacking. We aimed to investigate whether parental CWP increases the risk of offspring CWP, and if offspring body mass index (BMI) and leisure time physical activity modify this association.

METHODS

We included 6589 parent-offspring trios participating in the Norwegian HUNT Study in 1995-1997 and 2006-2008. Logistic regression was used to calculate adjusted odd ratios (ORs) (95% confidence intervals, CIs) as estimates of relative risk for offspring CWP. We analysed the joint effect of parental CWP and offspring BMI or leisure time physical activity on offspring risk of CWP and calculated the relative excess risk due to interaction (RERI).

RESULTS

In total, 886 (13.5%) offspring developed CWP during follow-up. Having one (OR = 1.23, 95% CI, 1.05-1.44) or both parents with CWP (OR = 1.89, 95% CI, 1.50-2.38) increased the risk of offspring CWP. In analyses of joint effects, ORs were 1.84 (95% CI, 1.31-2.56) and 3.35 (95% CI, 1.94-5.77) in normal weight and obese offspring, respectively, when both parents had CWP. The estimate of RERI suggested some synergistic effect (RERI = 1.19, 95% CI, -0.68 to 3.05), although precision was low. Risk of CWP was similar in active (OR = 2.05, 95% CI, 1.56-2.70) and inactive (OR = 1.96, 95% CI, 1.31-2.91) offspring when both parents had CWP.

CONCLUSION

Parental CWP increases the risk of CWP in adult offspring, particularly if both parents have CWP and offspring are obese. This highlights a familial predisposition for CWP and an important target group for preventive measures.

SIGNIFICANCE

The parent-offspring transmission of CWP is stronger in obese offspring (particularly when both parents have CWP). This study is the first to investigate the interaction between modifiable lifestyle factors, familial factors and CWP.

Resilience moderates the association between chronic pain and depressive symptoms in the elderly

BACKGROUND

Chronic pain is frequent in elderly people and, especially if widespread, associated with poor mental health. We investigated whether a resilient personality protects older adults against the adverse effects of chronic pain.

METHODS

Pain status [no pain, chronic local pain (CLP) and chronic widespread pain (CWP)] was determined using the American College of Rheumatologists' criteria for widespread pain in a cross-sectional sample of 724 participants aged 68-92 years drawn from the population-based KORA-Age study in Southern Germany. Depressive symptoms and resilience were assessed via the scales GDS-15 and RS-5. The relation between pain, resilience and depressive symptoms was modelled using logistic and quantile regression.

RESULTS

CLP prevalence and CWP prevalence were 57.5% and 12.3%, respectively. Confounder-adjusted logistic regression indicated a fourfold risk of depressed mood (GDS-15 ≥ 5) in CWP, vs. no pain (OR = 4.08, 95% CI 1.90-8.74). However, in quantile regression, the adverse effect of CWP was significantly attenuated by resilience when looking at the GDS-15 score lower quartile (p = 0.011) and median (p = 0.011). This effect appeared to be mainly driven by participants aged 75-84 years. Confounder adjustment reduced the effect of CLP on depressive symptoms to non-significance, and effect modification by resilience was undetectable in regression models of CLP.

CONCLUSIONS

Resilience was protective in the association of CWP with depressive symptoms in this analysis. Older adults with CWP may potentially benefit from interventions supporting resilience. Prospective research should investigate the protective role of resilience in the potentially self-perpetuating relation between chronic pain and depressed affect. WHAT DOES THIS STUDY ADD?: The association of chronic widespread pain with depressive symptoms in the elderly population is attenuated by resilience.

Deconstructing chronic low back pain in the older adult--Step by step evidence and expert-based recommendations for evaluation and treatment part III: Fibromyalgia syndrome

OBJECTIVE

To present the third in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributors to pain and disability in older adults with CLBP. This article focuses on fibromyalgia syndrome (FMS).

METHODS

A modified Delphi approach was used to create the evaluation and treatment algorithm, the table discussing the rationale behind each of the algorithm components, and the stepped-care drug recommendations. The team involved in the creation of these materials consisted of a principal investigator, a 5-member content expert panel, and a 9-member primary care panel. The evaluation and treatment recommendations were based on availability of medications and other resources within the Veterans Health Administration (VHA) facilities. However, non-VHA panelists were also involved in the development of these materials, which can be applied to both VA and civilian settings. The illustrative clinical case was taken from the clinical practice of the principal investigator.

RESULTS

Following expert consultations and a review of the literature, we developed an evaluation and treatment algorithm with supporting materials to aid in the care of older adults with CLBP who have concomitant FMS. A case is presented that demonstrates the complexity of pain evaluation and management in older patients with CLBP and concomitant FMS.

CONCLUSIONS

Recognition of FMS as a common contributor to CLBP in older adults and initiating treatment targeting both FMS and CLBP may lead to improved outcomes in pain and disability.

Even Worse - Risk Factors and Protective Factors for Transition from Chronic Localized Low Back Pain to Chronic Widespread Pain in General Practice: A Cohort Study

STUDY DESIGN

Prospective cohort study with patients with chronic low back pain (CLBP) at primary care setting.

OBJECTIVE

The aim of our study was to identify predictors for transition from localized CLBP to chronic widespread pain in general practice. In contrast to the typically investigated risk factors, this study also focuses intensively on protective factors, which decrease the probability of chronic widespread pain. For this, we investigated the resources resilience and coping strategies, which are suspected as potential protective factors for incident chronic pain syndromes.

SUMMARY OF BACKGROUND DATA

In primary care, about a quarter of patients with CLBP experience chronic widespread pain (CWP).

METHODS

Patients experiencing localized CLBP were included and evaluated after a 6- and 12-month follow-up period regarding the development of CWP. Potential risk factors (sociodemographic data, pain characteristics, depression, anxiety, somatization), protective factors (resilience, coping strategies), and sample characteristics were assessed at baseline. Predictor identification was done by multivariate logistic regression analysis.

RESULTS

The 1-year incidence for the onset of CWP among patients with CLBP was 23.8%. We identified the 3 risk factors, female sex, long duration of back pain, and a high rate of psychosomatic symptoms, for the onset of CWP among patients with CLBP. Coping resources and resilience had no impact on the transition from CLBP to CWP.

CONCLUSION

The results suggest that CWP is no independent entity but rather a particularly negative occurrence on a continuum of chronic pain. Processes of somatization play a major role in the development of this extreme.

LEVEL OF EVIDENCE

2.

Comorbidities, intensity, frequency and duration of pain, daily functioning and health care seeking in local, regional, and widespread pain - a descriptive population-based survey (SwePain)

BACKGROUND

The clinical knowledge of factors related to the spread of pain on the body has increased and understanding these factors is essential for effective pain treatment. This population-based study examines local (LP), regional (RP), and widespread pain (WSP) on the body regarding comorbidities, pain aspects, and impact of pain and elucidates how the spread of pain varies over time.

MATERIAL AND METHODS

A postal questionnaire that addressed pain aspects (intensity, frequency, duration and anatomical spreading on a body manikin), comorbidities and implications of pain (i.e., work situation, physical activity, consumption of health care and experience of hospitality and treatment of health care) was sent to 9000 adults living in southeastern Sweden. Of these, 4774 (53 %) completed and returned the questionnaire. After 9 weeks, a follow-up questionnaire was sent to the 2983 participants who reported pain in the first questionnaire (i.e. 62 % of 4774 subjects). Of these, 1940 completed and returned the questionnaire (i.e. 65 % of 2983 subjects). The follow-up questionnaire included the same items as the first questionnaire.

RESULTS

This study found differences in intensity, frequency and duration of pain, comorbidities, aspects of daily functioning and health care seeking in three pain categories based on spreading of pain: LP, RP and WSP. Compared to the participants with RP and LP, the participants with WSP had lower education and worse overall health, including more frequent heart disease and hypertension. In addition, participants with WSP had more intense, frequent, and long-standing pain, required more medical consultations, and experienced more impact on work. The participants with RP constituted an intermediate group regarding frequency and intensity of pain, and impact on work. The participants with LP were the least affected group regarding these factors. A substantial transition to RP had occurred by the 9-week follow-up.

CONCLUSIONS

This study shows an association between increased spread of pain and prevalence of heart disease, hypertension, more severe pain characteristics (i.e., intensity, frequency and duration), problems with common daily activities and increased health care seeking. The WSP group was the most affected group and the LP group was the least affected group. Regarding these factors, RP was an obvious intermediate group. The transitions between the pain categories warrant research that broadly investigates factors that increase and decrease pain.