From: BMC Musculoskelet Disord. 2010 Jul 13;11(1):158.

Whiplash was defined in 1995 by the Quebec Task Force as a neck injury mechanism and may result in injuries within the musculoskeletal and /or neurological system. The Quebec Task Force developed a system for grading Whiplash Associated Disorders : whiplash associated disorders I-II (symptoms without known pathology), III (symptoms and neurological signs), and IV (symptoms and cervical fracture and/or dislocation).

Grade I and II patients represent up to 90 % of “whiplash injury claims”. The proportion of patients who reports pain and disability six months after the accident (i.e. chronic whiplash associated disorders) varies substantially between studies and countries. However, a recent review suggests that approximately 50% of the patients with whiplash associated disorders will report neck pain symptoms one year after their injuries. Patients with chronic whiplash associated disorders report high levels of neck pain, headache, and shoulder pain often accompanied by neck stiffness, dizziness, fatigue, sleeping problems, concentration problems, allergy, breathing disorders, hypertension, cardiovascular disorders, digestive disorders, depression, anxiety, and impairment in cognitive performance. A recent study of a large population-based cohort of victims of car accidents, found that isolated neck pain was rare and that pain from multiple body areas was most commonly reported.

Expectations and coping styles might influence the outcome and prognosis after whiplash injuries. The Cognitive Activation Theory of Stress describes stress response as a general normal, healthy, and necessary alarm. There may be a risk of illness and disease only if the arousal is sustained. The level and duration of the alarm depends on the expectancy of the outcome of stimuli, as well as the results from specific responses available for handling the situation. Therefore, the cognitive activation theory of stress model emphasizes the importance of coping as positive response outcome expectancies. This means that if the individual expects to be able to handle a situation with a positive result (coping), the activation will be short and do no harm. Kivioja et al. found no evidence that early coping strategies influenced the prognosis after whiplash injuries. Others, however, found that high levels of passive coping strategies are associated with a slower recovery after whiplash injury, and that certain coping strategies for pain, such as catastrophizing, is associated with increased risk of disability, and that the importance of coping strategies seem to increase over time. In general, there is considerable controversy as to the importance of psychological factors for developing chronic whiplash associated disorders.

The importance of insight into coping strategies has been emphasized for chronic pain patients such as fibromyalgia, tension-type headache, chronic back pain, and chronic temporomandibular disorder. However, there is little qualitative insight into the ways persons with chronic whiplash associated disorders cope on a day to day basis. Such insight may provide the clinician with a better understanding of lay health recourses, and, possibly, provide a better starting point for suggesting strategies or discussing potentially maladaptive strategies to patients suffering pain following whiplash. Furthermore, Russell & Nicol suggested that whiplash associated disorders patient recovery may be increased if the clinicians better understand patient experiences. In the present study the authors identify what is described as dominant whiplash symptoms, and the behavioral strategies used to cope with whiplash associated disorders.

The aim of the present study was to identify dominant whiplash symptoms, and the behavioral strategies used to cope with these. Participants stated dominating symptoms to be neck and head pain, sensory hypersensitivity, and cognitive dysfunction. In describing their dominating symptoms participants gave emphasis to a fluctuating level of pain – dividing their life into what they described as a repeating cycle of good and bad periods. To cope with these symptoms, maintaining the good periods and avoiding or shorten the bad periods, they used rest, exercise, and social withdrawal. Participants expressed a constant notion of alternating or balancing between these coping strategies following the intensity of symptoms, or the expectancy of participating in situations or events that might trigger pain.

Participants reported severe neck and head pain, sensory hypersensitivity, and cognitive dysfunction as their main complaints. These symptoms are reported in several other studies. The pain was not described as being on a permanent level, but, rather, as fluctuating from a severe and intolerable level of pain to a more manageable pain. This fluctuating pattern was by the participants described as having bad and good periods. The symptoms were closely connected together as one could cause the onset of the other. Such a pattern of fluctuating pain and incapacity which is difficult to predict and manage, has also been reported in other studies on chronic pain, and it affects not only own health, but also family life and social activities.

A main finding in this study was how participants divided everyday life into good and bad periods, and how they adjusted their coping strategies according to this. Participants expressed a constant notion of alternating between or balancing their three main coping strategies; rest, exercise, and social withdrawal. If the balance – viz choosing and implementing the best strategy – was not maintained pain could be triggered or bad periods prolonged. The strategies were, primarily, chosen based on the intensity of symptoms, but it was also reported in the focus groups that the same strategies, mostly rest and social withdrawal, were used as means to prepare for, or unwind from, possible pain triggering situations or events.

Lazarus & Folkman’s cognitive-phenomenological model of stress and coping discriminates between active and passive coping strategies. Active or problem-focused strategies are used to target the source of stress and reduce it, whereas passive or emotional-focused strategies are mostly concerned towards adapting to the stress or problem. Most of the participants in this study used exercise, i.e. active coping strategies in good periods as they experienced that it reduced pain. Passive coping strategies, such as rest and social withdrawal, were mostly used to endure pain and to maintain the important balance as the participants were afraid of provoking bad periods. Social withdrawal may be interpreted as a direct consequence of their lifestyle changes, but participants also perceived it as a coping strategy per se – primarily used to avoid triggering the pain brought on by being exposed to noise, concentrating, or focusing too much.

Contrary to the Lazarus use of coping strategies, the Cognitive Activation Theory of Stress suggests that it is not the strategy or way of coping that is the most important issue, but the expectancy of the result. In the good periods our participants engaged in behaviors they expected to improve their circumstances – regular exercise being the most important one. The use of rest and social withdrawal were also used in good periods as a way of ‘charging the batteries’ for special events. The participants expected and experienced positive results of these behaviors, i.e. coping in the terminology of the cognitive activation theory of stress model.

However, what participants referred to as bad periods was characterized by unremitting pain often leading to frustration, depression, and social isolation. The participants had to socially withdraw and rest during these periods. In bad periods they felt that the symptoms took control of them, and that there was nothing they could do but rest and wait for a good period. Several participants experienced depression due to their situation. Within the cognitive activation theory of stress model helplessness or hopelessness develops when there is either no relationship or a negative relationship between what the individual attempts to do and the outcome. This may lead to sustained arousal, which, in turn, could lead to illness and disease such as depression and chronic fatigue syndrome.

The participants expressed that, to some degree, they could control or predict bad periods; consequently they tried to balance their life to avoid these periods. The constant notion of trying to balance; the restrictions and sacrifices behind their coping strategies took its toll on everyday life. The pattern of coping strategies described in this study was in accordance with other studies on patients with chronic pain, and was perceived as effective for these participants. However, it could be discussed whether or not the behavioral strategies, even though they might lead to positive response outcome expectancies, are adaptive or not. Most participants expressed a wish to be able to participate in working life. Nevertheless, only three in 14 participants had been able to maintain a work situation. So, although the strategies used were considered the most beneficial – or the only way to adjust their life, it is questionable whether or not they led to progress or just maintained the pattern of alternating good and bad periods. Knowledge of patients’ self-initiated coping strategies may give the clinician a better understanding of the patients’ frame of reference; how they organize everyday life to cope with their problems, and, accordingly, establish a better starting point for discussing potentially maladaptive strategies.

Participants reported severe neck and head pain, sensory hypersensitivity, and cognitive dysfunction as their main complaints. To cope with these complaints, and their fluctuating nature, three main strategies were used; rest, exercise, and social withdrawal. The participants portrayed that maintaining a balance between these coping strategies helped control the pain.

From: Disabil Rehabil. 2010 Jun 4. [Epub ahead of print]

The emotional distress caused by pain is one of the most disruptive aspects of living with the condition. This study investigates how individuals experience pain and its consequences for family life and work. Unstructured interviews, using the ‘Framework’ approach with topic guide, were recorded and transcribed. Patients were sampled for age, sex, ethnicity and occupation from new referrals with spinal pain to a rheumatology outpatient clinic. Eleven patients (five males and six females) were interviewed in English (n = 9) or their preferred language (n = 2). Interviews were read in depth twice to identify the topics. Data were extracted in phrases and sentences using thematic content analysis.

Emergent themes reported were relationships with: spouses and partners (n = 7), children/parents (n = 6), with other family and friends (n = 7) and work-related issues (n = 11). Patients valued support from family but expressed concerns about causing them worry. Work-related issues included physical and emotional efforts to keep working when in pain, fear of losing employment and financial problems. Patients expressed anxiety about how their pain affected other family members, regret at losing full work capacity and worry about financial consequences. The lived experience of chronic spinal pain has ramifications that go beyond the individual, reaching into work and social relationships.

From: Arthritis Care Res (Hoboken). 2010 Jun 2. [Epub ahead of print]

The primary objectives of this study were to estimate the prevalence of chronic neck pain in North Carolina, to describe health care use (providers, treatments and diagnostic testing) for chronic neck pain and to correlate health care use with current best evidence. A cross-sectional, telephone survey of a representative sample of North Carolina households in 2006. Five thousand three hundred fifty seven households were contacted in 2006 to identify 141 non-institutionalized adults 21 years and older with chronic neck pain and no chronic low back pain. Subjects were interviewed about their health and health care use (i.e., provider, tests, and treatments). Patterns of health care use were compared to current systematic reviews.

The estimated prevalence of chronic neck pain in 2006 among non-institutionalized individuals for the state of North Carolina was 2.2%. Individuals with chronic neck pain were middle – aged (mean age 48.9 years and a majority were female (56%) and non-Hispanic White (81%). Subjects saw a mean of 5.21 provider types and had a mean of 21 visits. The types of treatments subjects reported varied with treatments such as electrotherapy stimulation (30.3%), corsets or braces (20.9%), massage (28.1%), ultrasound (27.3%), heat (57.0%) and cold (47.4%) having unclear or little benefit based on current best available reviews. Based on current evidence for best practice, the findings indicate over utilization of diagnostic testing, narcotics and modalities, and the under utilization of effective treatments such as therapeutic neck exercises.

From: Clin Rheumatol. 2010 Apr;29(4):405-11.

The aims of this study are to determine the frequency of fibromyalgia syndrome in patients with chronic cervical myofascial pain and to investigate the fibromyalgia syndrome characteristics in chronic cervical myofascial pain patients. Ninty-three patients with chronic cervical myofascial pain and 30 age-matched healthy women were included in this study. Main outcome measures included visual analog scale, Beck Depression Inventory, and pain pressure thresholds. Chronic cervical myofascial pain patients were evaluated for the existence of fibromyalgia syndrome. The severity of fibromyalgia syndrome was assessed with total myalgic score and control point score. Most common clinical characteristics of fibromyalgia syndrome were noted. Of the 93 chronic cervical myofascial pain subjects, 22 (23.6%) patients fulfilled the classification criteria for fibromyalgia syndrome. Number of tender points were higher, while total myalgic score and control point score values were lower in comorbid chronic cervical myofascial pain and fibromyalgia syndrome patients than regional chronic cervical myofascial pain group. There were statistically significant differences between regional chronic cervical myofascial pain patients and comorbid chronic cervical myofascial pain and fibromyalgia syndrome patients regarding presence of fatigue and irritable bowel syndrome. There was no statistically significant difference between patient groups regarding visual analog scale values. Beck Depression Inventory values of the regional chronic cervical myofascial pain were significantly lower than comorbid chronic cervical myofascial pain and fibromyalgia syndrome patients. In conclusion, the authors found that nearly a quarter of chronic cervical myofascial pain patients were comorbid with fibromyalgia syndrome, and psychological and comorbid symptoms were more prominent in comorbid patients. The authors thought that, these two syndromes might be overlapping conditions and as a peripheral pain generator or inducer of central sensitisation, myofascial pain syndrome might lead to fibromyalgia syndrome or precipitate and worsen the fibromyalgia syndrome symptoms.

From: Health Qual Life Outcomes. 2010 May 14;8(1):48. [Epub ahead of print]

Chronic neck pain is a common condition associated not only with a decrease in neck muscle strength, but also with decrease in health-related quality of life (HRQoL). While neck strength training has been shown to be effective in improving neck muscle strength and reducing neck pain, HRQoL among patients with neck pain has been reported as an outcome in only two short-term exercise intervention studies. Thus, reports on the influence of a long-term neck strength training intervention on HRQoL among patients with chronic neck pain have been lacking.

Neck pain is one of the most common musculoskeletal disorders in Western societies. Along with considerable costs for the individual and the society, neck pain is a frequent source of disability causing humane suffering and affecting the well-being of individuals. Just as health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, the outcome measures of an intervention ought to be multidimensional and include the subjective experience of the patient. This can be achieved using a health-related quality of life (HRQoL) measurement tool.

Since neck pain is associated with a decrease in neck muscle strength, neck strength training has been one means in seeking cure for neck pain. In addition to gaining neck muscle strength, neck strength training has been shown to be effective in reducing neck pain and the disability associated with it. In a recent best-evidence synthesis and Cochrane review it was concluded that interventions that involved exercise combined with manual therapy were more effective in treating patients with neck pain than were alternative strategies.

Although strength training seems to be an efficient way of treating patients with neck pain, its effect on HRQoL has not been shown. The authors found only two studies where the influence of strength exercises on neck pain was assessed with HRQoL measurements. In those short-term exercise studies no significant gains in HRQoL were observed. Because short-term training have been shown to produce only temporary improvements in various outcome measures, intensive resistance training for at least one year is recommended to gain sustainable results. Thus, the purpose of the present study was to evaluate whether 12 months of neck strength or endurance training could improve HRQoL in females with chronic neck pain.

This study reports the effect of one-year neck strength training on HRQoL in females with chronic neck pain. One hundred eighty female office workers, 25 to 53 years of age, with chronic neck pain were randomized to a strength training group (n = 60), endurance training group (n = 60) or control group (n = 60). The strength training group performed high-intensity isometric neck strengthening exercises with an elastic band while the endurance training group performed lighter dynamic neck muscle training. The control group received a single session of guidance on stretching exercises. HRQoL was assessed using the generic 15D questionnaire at baseline and after 12 months.

Training led to statistically significant improvement in the 15D total scores for both training groups, whereas no changes occurred for the control group. The strength training group improved significantly in five of 15 dimensions, while the endurance training group improved significantly in two dimensions. Effect size (and 95% confidence intervals) for the 15D total score was 0.39 (0.13 to 0.72) for the strength training group, 0.37 (0.08 to 0.67) for the endurance training group, and -0.06 (-0.25 to 0.15) for the control group.

One year of either strength or endurance training seemed to moderately enhance the HRQoL of female patients with chronic neck pain. Neck and upper body training can be recommended to improve HRQoL of females with neck pain if they are motivated for longterm regular exercise.

From: Physiotherapy. 2010 Jun;96(2):151-9. Epub 2010 Jan 21

To delineate the relative extent to which specific cognitive factors are related to levels of pain and disability in patients with chronic whiplash associated disorder. This was a cross-sectional observation study by three secondary care physiotherapy departments in the Greater Manchester region of the UK. All patients with chronic whiplash associated disorder referred to the participating departments were invited to take part in the study. In total, 124 patients were invited to participate, and 63 (51%) agreed to do so. Complete data were available for 55 (44%) of those invited to participate in the study. Pain and disability ws as assessed by the Neck Disability Index.

Cognitive factors were strongly related to levels of disability. Specifically, greater catastrophising and lower functional self-efficacy beliefs were significantly related to greater levels of disability. Significant univariate correlations were seen between the cognitive factors and current pain intensity. However, no significant associations were seen between the cognitive factors and current pain intensity in the multivariate analysis.

Interventions which aim to reduce catastrophising and enhance functional self-efficacy beliefs should be included alongside conventional physiotherapy interventions when treating patients with chronic whiplash associated disorder.

From: Clin Neurophysiol. 2010 May;121(5):634-5

To compare the behavior of sternocleidomastoid motor units of patients with chronic neck pain and healthy controls. Nine women (age, 40.4+/-3.5 yr) with chronic neck pain and nine age and gender matched healthy controls participated. Surface and intramuscular EMG were recorded from the sternocleidomastoid muscle bilaterally as subjects performed isometric contractions of 10-s duration in the horizontal plane at a force of 15 N in eight directions (0-360 degrees ; 45 degrees intervals) and isometric contractions at 15 and 30 N force with continuous change in force direction in the range 0-360 degrees . Motor unit behavior was monitored during the 10-s contractions and the subsequent resting periods.

The mean motor unit discharge rate depended on the direction of force in the control subjects but not in the patients. Moreover, in three of the nine patients, but in none of the controls, single motor unit activity continued for 8.1+/-6.1s upon completion of the contraction. The surface EMG amplitude during the circular contraction at 15N was greater for the patients (43.5+/-54.2 microV) compared to controls (16.9+/-14.9 microV).

The modulation in discharge rate of individual motor units with force direction is reduced in the sternocleidomastoid muscle in patients with neck pain, with some patients showing prolonged motor unit activity when they were instructed to rest. These observations suggest that chronic neck pain affects the change in neural drive to muscles with force direction.

From: BMC Musculoskelet Disord. 2010 Apr 8;11(1):66. [Epub ahead of print]

Fibromyalgia is a disorder of unknown etiology that is generally diagnosed according to the American College of Rheumatology (ACR) criteria, which include chronic, widespread pain for at least 3 months, and the presence of 11 out of 18 tender points. Prevalence estimates for the United States suggest that approximately 5 million individuals have this condition, with a higher prevalence among women (3.4%) than men (0.5%). Although chronic widespread pain is the hallmark of fibromyalgia, core symptoms of fibromyalgia also include sleep disturbance, fatigue, mood disorders, and localized pain (headache, back and/or neck pain). These core symptoms are included among the domains that have been identified and recognized by OMERACT (Outcomes Measures in Rheumatology) as important for assessment in fibromyalgia.

Fibromyalgia has a substantial negative impact on quality of life, resulting in health status that is poorer than other chronic pain conditions such as rheumatoid arthritis and osteoarthritis. The burden imposed by core fibromyalgia symptoms translates into limitations of productivity, personal and family life, as well as a reduced ability to complete simple activities of daily living.

This multidimensional nature of fibromyalgia has made it difficult to define and assess the severity of fibromyalgia as a condition. The indeterminate etiology and lack of specific disease markers exacerbate the problem of assessing fibromyalgia severity. While several studies investigated the potential use of biologic markers for fibromyalgia (e.g. cytokines, antipolymer antibodies), correlation of these markers with symptoms was equivocal at best, rendering them ineffective as indicators of severity. Similarly, although tender points and a total myalgic score have been evaluated as measures of severity, they demonstrate inherent variability over time, show little correlation with other outcome measures, and importantly, neither is of clinical relevance to patients. A recent comprehensive review of potential fibromyalgia biomarkers highlighted the lack of appropriate evaluation of objective biomarkers of fibromyalgia, although limited data from a longitudinal study suggested that the results obtained during experimental pain testing were associated with clinical status improvements. However, it should be noted that in addition to sensitivity to change with clinical improvement, biomarkers need to demonstrate change with worsening disease if they are to be considered indicators of disease severity.

The ability to evaluate and measure the severity of fibromyalgia as a condition is likely to provide several benefits including identification of treatment responders in clinical trials and clinical practice. Characterization of severity levels may also be used as a marker for disease progression. Treatment approaches may be specifically targeted to patients at different levels of severity, with the potential for determining if early treatment may slow or prevent disease progression. There have been few published studies on severity or progression of fibromyalgia as a disease state, and what little has been reported about the natural history of fibromyalgia is inconsistent. Although a longitudinal study by Wolfe et al. reported no change in the severity of specific symptoms over time, a review of the few published studies suggested no clear pattern of progression or remission.

Chronic pain is the symptom of fibromyalgia that is of primary importance to patients and clinicians and is routinely evaluated as an endpoint in clinical trials and clinical practice. Although pain can be quantitatively evaluated from the patient’s perspective, it may not be an adequate surrogate of disease severity, since it may display intrapatient variability in intensity which does not necessarily correlate with the presence or severity of other fibromyalgia symptoms. A patient-reported instrument frequently used to assess fibromyalgia is the Fibromyalgia Impact Questionnaire (FIQ). Although the FIQ is sensitive to treatment effects, it evaluates the impact of fibromyalgia on various activities which may be related to, but does not actually measure, disease severity. Furthermore, the FIQ appears to have low sensitivity to clinical worsening, and it is unlikely to be an accurate indicator of disease severity.

In trying to develop a model of fibromyalgia severity, Goldenberg et al. evaluated 15 potential explanatory factors in a regression analysis. Several of the items evaluated, including pain and psychological distress, may relate to severity as contributory factors. However, others such as employment status, pending litigation, and education level, may be associated with severity in terms of impact but are not adequate for providing a definition of fibromyalgia severity as a disease state.

A study by Giesecke et al. used cluster analysis to classify patients with fibromyalgia into subgroups based on levels of mood, catastrophizing, perceived control over pain, and tenderness. While this attempt at categorization demonstrated an ability to place patients into one of three groups (moderate mood, catastrophizing and perceived pain control with low tenderness; elevated mood assessment, catastrophizing, and tenderness with low control over pain; and normal mood and catastrophizing with high pain control but extreme tenderness), these results were not placed in the overall context of disease severity.

The purpose of the current study was to initially characterize fibromyalgia severity from the perspective of individuals with fibromyalgia and to determine if patients’ perception of fibromyalgia severity is more than simply their pain. We utilized data from a larger fibromyalgia patient study to conduct a post-hoc exploratory analysis of symptom severity. Data were collected on several self-reported parameters including patient-rated disease severity and the presence of core comorbid conditions, we report here the preliminary evaluation of whether patient self-reported severity of fibromyalgia is associated with corresponding severity of pain and sleep interference and the presence of core co-morbidities. This patient perspective is also complemented with the results of a small physician survey designed to understand the physicians’ perspective by capturing information on what characteristics the physicians use to assess fibromyalgia severity in their daily clinical practice.

This study suggests that the association of fibromyalgia severity with symptoms that have been identified as being of clinical importance by patients and physicians, and are considered by OMERACT to be among the core fibromyalgia symptoms for evaluation, may be useful for the characterization and assessment of the severity of fibromyalgia as a condition. In particular, with higher self-reported fibromyalgia severity, i.e. from mild to moderate to severe, an associated increase was observed in pain, sleep disturbance, and depressive symptoms, as well as the use of medications for fibromyalgia and the presence of comorbid conditions including back and neck pain. Therefore, these characteristics may contribute to the patient’s overall perception of disease severity.

Determining a definition of fibromyalgia severity could be helpful for disease management. A definition based on the patient’s perspective may be especially useful, since in the absence of objective disease biomarkers it relies on readily available information of clinical relevance to the patient that can be used by physicians for patient classification and management. The only other study that attempted to develop a severity model also used a patient-reported outcome, global VAS, as the anchor for fibromyalgia severity [20]. While the current study did not use a validated measure, the anchor for fibromyalgia severity was a question specifically addressing fibromyalgia rather than a global assessment.

The use of patient self-report is increasingly being accepted and applied as a method to evaluate disease states and management strategies in clinical trials, especially for chronic pain conditions [25]. This has been true for the rheumatic diseases including fibromyalgia, for which most of the core domains considered by OMERACT as being essential for evaluation, are patient-centric. The top five of these domains include pain, fatigue, patient global, sleep, and multidimensional function. These domains are generally the same as those identified as being important by patients, i.e. pain or physical discomfort, aching joints or pain, lack of energy or fatigue, effects on sleep, and problems with attention or concentration. Patients may have a better sense of their condition than can be obtained using objective clinical criteria, and at least in some rheumatic conditions, patient-centered outcomes may also discriminate between placebo and active treatment as well as or better than objective clinical measures.

While two factors identified in this exploratory analysis, i.e. pain and depression, were previously identified by Goldenberg et al. as having a potential relationship with fibromyalgia severity, the results reported here also suggest that overall, patients with longer fibromyalgia duration tended to report greater fibromyalgia severity. However, it should be noted that there was a small increase in the proportion of patients reporting mild severity among the patients with fibromyalgia duration > 10 years relative to those having a shorter duration. Although the reason for this increase was not explored, it could potentially be due to adaptation or a greater ability to cope with a chronic condition among some patients. This is consistent with what was reported by Kennedy et al. in one of the few long-term (10-year) follow-up of patients with fibromyalgia; at 10 years, despite the presence of symptoms that showed little change from the initial survey and continued use of medication, a substantial proportion of patients reported that they felt better in terms of fibromyalgia symptoms.

The observed relationship between fibromyalgia severity and duration is in contrast to Goldenberg et al. who reported that there was no relationship between these variables. Their observation may potentially result from use of a global assessment rather than a more specific fibromyalgia assessment. Similarly, the results reported here diverge from a previous study which reported that symptom severity does not change over time. However, that study used more compressed assessment scales for sleep disturbance and pain (0-3 visual analogue scales) than the current study (0-10 NRS) and did not stratify patients by fibromyalgia duration. If such an association between duration and severity can be confirmed, it may provide an opportunity to identify patients early in the disease continuum and eventually modify or delay disease progression through the use of pharmacological and/or non-pharmacological interventions.

The observation that the NRS scores for sleep disturbance were higher than NRS pain scores across all levels of fibromyalgia severity appears to be consistent with a recent analysis showing that sleep problems were predictive of pain, although it is unlikely that the relationship between sleep and pain is unidirectional. However, the data do suggest that these two variables may be central, although not exclusive, components for defining severity of fibromyalgia, and that management of both pain and sleep problems are integral to the treatment of fibromyalgia.

In contrast to the patient survey, which was closed-ended and elicited severity information based on specific symptoms and comorbidities, the physician survey was open-ended. This physician survey demonstrated that, consistent with the absence of an adequate definition of fibromyalgia severity, there was a general lack of consensus regarding criteria that physicians use as an indicator of fibromyalgia severity. That pain was the most frequently used criterion of severity was not surprising considering that pain is often the primary complaint of patients with fibromyalgia. However, despite being ranked first as an indicator of severity, only 61% of the physicians considered pain the primary criterion. There was little concordance on the use of other criteria, including several of the factors that demonstrated a relationship with higher levels of self-reported fibromyalgia severity, i.e. sleep interference and the presence of comorbidities, which were identified by only 43% and 32% of physicians, respectively. The small sample size (N = 28) may have contributed to this lack of concordance.

Although functional disability was ranked second and fatigue was ranked third, these criteria were used overall by 54% and 39% of physicians, respectively. These particular criteria, although identified by physicians, were not assessed in patients as part of the patient survey, and may be considered a limitation of the study, especially since fatigue is a frequent complaint among patients with fibromyalgia. Indeed, while the patient and physician surveys provide complementary information regarding perceptions of fibromyalgia severity, the different manner in which the surveys were performed precludes comparison of these surveys, since patients were asked to rate severity but were not asked to rank symptoms.

Since physicians identified and ranked criteria in response to a question (“When you assess the severity of fibromyalgia as a condition in your patients, what are the top 5 items [specific symptoms, specific physical findings, specific abnormal lab findings, etc.] that influence your decision-making?”), physicians were not specifically queried as to how these assessments are made. It should be noted that objective clinical assessment using tender points was cited by only 18% of the physicians, and that nearly all the other criteria were patient-centric. The variety of criteria that these physicians, who routinely treat fibromyalgia patients, reported using and the lack of concordance on their use, reinforces the need to define what constitutes an adequate measure of fibromyalgia severity. Being able to define and measure fibromyalgia severity may have practical benefits in terms of understanding disease progression and evaluating treatment approaches for their potential ability to slow progression. The ability to slow progression is likely to have a broader clinical and economic impact by reducing health resource utilization and associated costs.

This study explored the patient and physician perspective of fibromyalgia severity. With greater patient reported fibromyalgia severity, there was an increase in other patient reported variables including pain and sleep interference, presence of comorbid conditions and use of medications for fibromyalgia. This study also suggests that physicians use different domains to rank fibromyalgia severity. Both these findings need to be validated in further studies. When evaluating severity of fibromyalgia, physicians should consider the patient perspective.

Source: Toward Characterization and Definition of Fibromyalgia Severity

From: Neuropsychiatr Dis Treat. 2010 Mar 24;6:59-66.

To investigate post-traumatic stress, pain intensity, depression, and anxiety in patients with injury-related chronic pain before and after participating in multimodal pain rehabilitation. Twenty-eight patients, 21 women and seven men, who participated in the multimodal rehabilitation programs (special whiplash program for whiplash injuries within 1.5 years after the trauma or ordinary program) answered a set of questionnaires to assess post-traumatic stress (Impact of Event Scale), pain intensity [Visual Analogue Scale (VAS)], depression, and anxiety (Hospital Anxiety and Depression Scale) before and after the programs.

Both pain intensity and post-traumatic stress decreased significantly after the rehabilitation programs in comparison with before (VAS: 57.8 +/- 21.6 vs. 67.5 +/- 21.9; P = 0.009, Impact of Event Scale total score 21.8 +/- 13.2 vs. 29.5 +/- 12.9; P < 0.001). Patients younger than 40 years reported a statistically higher level of post-traumatic stress compared with patients older than 40 years both before (P = 0.037) and after rehabilitation (P = 0.023). No statistically significant differences were found on the Hospital Anxiety and Depression Scale scores.

The multimodal rehabilitation programs were effective in reducing both pain intensity and post-traumatic stress. The experience of higher levels of post-traumatic stress in younger persons has to be taken into account when managing patients with injury-related chronic pain.

Related Clinical Resources:

The hospital anxiety and depression rating scale: A cross-sectional study of psychometrics and case finding abilities in general practice

Revised Impact of Events Scale

From: Disabil Rehabil. 2010 Mar 29. [Epub ahead of print]

The aim of this study was to establish the relationship between known cognitive factors and levels of pain and disability in patients with idiopathic chronic neck pain. Ninety-four patients referred for physiotherapy because of chronic neck pain completed measures of pain, disability, catastrophising, pain-related fear, pain vigilance and awareness and self-efficacy beliefs.

Hierarchical multiple regression analyses were then performed to establish whether the cognitive factors were significant determinants of levels of pain and disability. The cognitive measures were significantly related to levels of pain and disability, explaining 23% of the variance in pain intensity and 30% of the variance in disability. Specifically, greater catastrophising and lower pain vigilance and awareness were associated with greater pain intensity. Moreover, greater catastrophising and lower functional self-efficacy beliefs were significantly associated with greater levels of disability.

Cognitive factors were strongly related to levels of pain and disability in patients with chronic neck pain. In view of this, targeting the modification of these cognitive factors should be an integral part of therapy when treating patients with idiopathic chronic neck pain.

Related Source: Manual Therapy Considerations In Chronic Pain

Chronic pain is a common problem that has a relatively high incidence and a low recovery rate. The incidence of relapse following initially successful treatment is also significant. Persistent or relapsing pain often results from misdiagnosis or inadequate treatment. In other instances, focusing on pain generators alone overlooks important patient-centered treatment strategies that are capable of modulating pain perception and quality of life. Finally, noncompliance with otherwise successful treatment programs may result from inadequate education concerning the prognosis and management of chronic disorders such as arthritis.

Dissatisfied with ineffective, incomplete, and sometimes impersonal approaches to chronic disorders, a growing number of patients actively pursue complementary or alternative care, including manual modes of therapy and mind-body practices. Properly prescribed approaches may confer some clinically significant benefits. It is recognized that many other manual modes of therapy such as massage and chiropractic provide distinct solutions for patients with chronic pain that would otherwise be ignored by nontouch modalities.