Exercise Alters Pain Sensitivity in Gulf War Veterans With Chronic Musculoskeletal Pain

Since returning from the Persian Gulf, nearly 100,000 veterans of the first Gulf War (GVs) have reported numerous symptoms with no apparent medical explanation. A primary complaint of these individuals is chronic musculoskeletal pain (CMP). CMP symptoms in GVs are similar to those reported by patients with fibromyalgia (FM), but have not received equivalent scientific attention. Exercise research in CMP patients suggests that acute exercise may exacerbate pain while chronic exercise can reduce pain and improve other symptoms. However, the influence of exercise on GVs with CMP is largely unexplored. This study examined the impact of an acute bout of exercise on pain sensitivity in GVs with CMP. Thirty-two GVs (CMP, n = 15; Control, n = 17) were recruited to complete a series of psychophysical assessments to determine pain sensitivity to heat and pressure stimuli before and after exercise. In response to heat-pain stimuli, GVs with CMP reported higher pain intensity and affect ratings than healthy GVs and exhibited a significant increase in ratings following exercise. GVs with CMP rated exercise as more painful and effortful and were generally more sensitive to heat-pain stimuli than healthy GVs. These results are similar to what has been reported for acute exercise in patients with FM.PerspectiveGulf War veterans with CMP perceive exercise as more painful and effortful than healthy GVs and experience increased pain sensitivity following exercise. These results suggest that similar abnormalities in central nervous system processing of nociceptive information documented in FM may also be occurring in GVs with CMP.     

A pilot randomized controlled trial of the Yoga of Awareness program in the management of fibromyalgia

A mounting body of literature recommends that treatment for fibromyalgia (FM) encompass medications, exercise and improvement of coping skills. However, there is a significant gap in determining an effective counterpart to pharmacotherapy that incorporates both exercise and coping. The aim of this randomized controlled trial was to evaluate the effects of a comprehensive yoga intervention on FM symptoms and coping. A sample of 53 female FM patients were randomized to the 8-week Yoga of Awareness program (gentle poses, meditation, breathing exercises, yoga-based coping instructions, group discussions) or to wait-listed standard care. Data were analyzed by intention to treat. At post-treatment, women assigned to the yoga program showed significantly greater improvements on standardized measures of FM symptoms and functioning, including pain, fatigue, and mood, and in pain catastrophizing, acceptance, and other coping strategies. This pilot study provides promising support for the potential benefits of a yoga program for women with FM.     

Physical Therapy (96)

The role of physical exercise and inactivity in pain recurrence and absenteeism from work after active outpatient rehabilitation for recurrent or chronic low back pain: A follow‐up study. (DBC International, Vantaa, Finland) Spine 2000;25:1809–1816. This study analyzed the role of physical exercise and inactivity on long‐term outcome after active outpatient low back rehabilitation. One hundred twenty‐five patients with low back pain, who had participated in a 12‐week active low back rehabilitation program, were asked about subjective pain and disability on the average of 14 months after the treatment. The outcomes were defined as a recurrence of persistent pain and work absenteeism, and a survival or failure analysis was performed between those who had continued exercising and who had been physically inactive. Recurrences of persistent pain during the follow‐up period were fewer (P = 0.03) among those who had maintained regular exercise habits after the treatment than among those who had been physically inactive. Similarly, work absenteeism was less (P < 0.01) among physically active than among physically inactive persons. However, patients with good outcome in pain reduction after low back pain rehabilitation were more likely to participate in physical exercise. Conclude that exercises are beneficial after guided treatment in the maintenance of the results of active treatment for recurrent chronic low back pain in the long term, but those with less favorable outcome in rehabilitation are less likely to participate in exercises afterward. In active treatment programs, it is recommended that exercises be incorporated after the guided treatment. Comment by Phillip S. Sizer Jr., MEd, PT. Historically, clinicians have instructed their patients to use trunk exercise to reduce the severity and duration of the symptoms and functional losses associated with low back pain (LBP). Through the years increasing evidence has supported this notion. However, fewer investigators have evaluated the impact of exercise after the rehabilitation process has been completed. This investigation performed this evaluation and found that regular, postrehabilitation exercise improved long‐term outcomes for patients who had previously suffered from LBP. Specifically, the investigators reported that ongoing exercise performed after an active outpatient rehabilitation program reduced recurrence of symptoms and absenteeism from work, especially after 1 year postonset. Additionally, these benefits did not appear to differ for those involved in self‐guided exercises versus those participating in a guided program with back‐specific devices in an outpatient treatment unit. This very interesting article reveals several pearls for the practitioner. First, subjects were not recruited on a voluntary basis, so to avoid attracting a group with good self‐motivation to alleviate their prevailing symptoms. This measure allows the outcomes to be applicable to a varied clinical population. Secondly, although the results favored the use of a guided program with back specific devices over self‐guided exercise, there were no statistical differences between the 2 approaches. Thus, patients can benefit from self‐monitored exercise even when they do not have access to a guided program using specific devices. Finally, the investigators revealed that poor clinical rehabilitation outcomes predicted postrehabilitation inactivity and reduced success with posttreatment exercise. Thus, the effectiveness of the rehabilitation process may influence patient's activity level and success of exercise after rehabilitation.     

Prescribing exercise for people with fibromyalgia

Fibromyalgia (FM) is a costly and debilitating pain syndrome which is commonly encountered by advanced practice nurses working in acute care settings. Fibromyalgia affects nearly 6 million people in the United States, approximately 80% to 90% of whom are women. Symptoms of FM include widespread and localized pain, disrupted sleep, fatigue, visceral pain and other pain syndromes, neurological symptoms (eg, dizziness, numbness, tingling, impaired cognition), and exercise-induced pain. Difficulties remaining active with FM may lead to extreme deconditioning, inability to remain employed, and eventually even impaired ability in complete activities of daily living. Exercise that combats deconditioning without triggering pain is, therefore, a key component in treating FM. Clinicians who understand FM pain and associated symptoms can minimize the negative impact of deconditioning by prescribing disease-specific exercise for people with FM.     

Challenges of implementing fibromyalgia treatment guidelines in current clinical practice

The current diagnostic and treatment pathway for patients with fibromyalgia (FM) is lengthy, complex, and characterized by multiple physician visits with an average 2-year wait until diagnosis. It is clear that effective identification and appropriate treatment of FM remain a challenge in current clinical practice. Ideally, FM management involves a multidisciplinary approach with the preferable patient pathway originating in primary care but supported by a range of health care providers, including referral to specialist care when necessary. After the publication of individual clinical studies, high-quality reviews, and meta-analyses, recently published FM treatment guidelines have transitioned from an expert consensus to an evidence-based approach. Evidence-based guidelines provide a framework for ensuring early diagnosis and timely adoption of appropriate treatment. However, for successful outcomes, FM treatments must adopt a more holistic approach, which addresses more than just pain. Impact on the associated symptoms of fatigue and cognitive problems, sleep and mood disturbances, and lowered functional status are also important in judging the success of FM therapy. Recently published guidelines recommend the adoption of a symptom-based approach to guide pharmacologic treatment. Emerging treatment options for FM may be best differentiated on the basis of their effect on comorbid symptoms that are often associated with pain (e.g. sleep disturbance, mood, fatigue). The current review discusses the most recently published Canadian guidelines and the implications of the recent European League Against Rheumatism (EULAR) recommendations, with a focus on the challenges of implementing these guidelines in current clinical practice.     

Benefits of physical training in fibromyalgia and related syndromes

ObjectiveTo review the published information on physical training for fibromyalgia (FM) and related syndromes.MethodsA search of Medline literature (via Ovid and PubMed) with the following keywords: FM, chronic fatigue syndrome, therapy, rehabilitation, aerobic, exercise, and cognitive behavioral therapy. The reference lists of articles were examined for additional related articles.ResultsSeveral studies investigated the benefits of graded exercise therapy for patients with FM or related syndromes. Although some systematic reviews have not established an unequivocal benefit of physical training, most authors report a benefit for patients with chronic pain or fatigue. Ideally, such a therapy should be a part of multidisciplinary program. Muscular rehabilitation is reserved for preventing the deconditioning syndrome often reported in patients and the vicious cycle of pain, avoidance and inactivity behaviors, or even kinesiophobia, deconditioning, incapacity and psychological distress.ConclusionThis review emphasizes the relevance of graded physical training for treating FM and related syndromes. The development of rehabilitation centers, with experts able to propose a relevant therapy to patients with chronic pain or fatigue, should help alleviate this public health problem.     

What Interventions Improve Outcomes for the Patient Who Is Depressed and in Pain?

Specific Clinical IssueThe purpose of this clinical consultation is to offer nurses evidence-based strategies to provide holistic care to their patients with comorbid depression and pain. The combination of depression and pain is common and, if not managed effectively, has negative outcomes. Treatment-resistance is one negative outcome. The worst-case scenario for unrelieved depression and/or pain is suicide.Major Practice Recommendations Based on Best EvidenceAntidepressants, particularly duloxetine, have had efficacy for pain and depression. Cognitive behavioral therapy, an evidence-based treatment for depression, has been found to decrease pain. Examples of additional interventions include exercise, relaxation techniques, mindfulness, and music. Providing holistic nursing care and working with other disciplines optimizes more effective management of these co-occurring conditions.     

Fibromyalgia--management of a misunderstood disorder

PURPOSE: The purpose of this article is to review (a) what is currently known about the pathophysiology of fibromyalgia (FM), (b) how to identify patients who are susceptible to this disorder, and (c) the recommended pharmacological and nonpharmacological treatment options. DATA SOURCES: Data sources include reviews and original research from scholarly journals and Internet sites. CONCLUSIONS: There are approximately 6 million individuals in the United States diagnosed with FM, making it the third most prevalent rheumatologic disorder in this country. Failure to identify a specific causal mechanism for FM has resulted in a shift in the focus of research from etiology to treatment (Baumstark & Buckelew, 2002). Based on the literature, the most successful interventions for reduction of chronic symptoms in the FM patient is a combination of education, psychological assistance, and exercise, along with medications. It is essential that nurse practitioners (NPs) understand the issues and concerns of patients afflicted with this complex disorder. Although the organic etiology of FM syndrome remains unclear, the goals of treatment are to control pain and improve adjustment, well-being, and daily functioning of these patients to the maximum extent possible. IMPLICATIONS FOR PRACTICE: NPs are in a unique position to help identify patients who may be suffering from FM or those diagnosed with FM reporting inadequate relief of symptoms. The incomplete understanding of the biological underpinnings, as well as the multiple symptoms that characterize FM syndrome, make it a challenging disorder to diagnose and treat. It takes time and patience to care for FM patients, and there are no "quick fixes." Diagnosis is made by a combination of patient history, physical examination, laboratory evaluations, and exclusion of other causes of symptoms confused with FM. Understanding the symptomology and recommended treatments will allow NPs to give appropriate care that may include making referrals for multidisciplinary treatment of these complex patients.     

Unravelling Fibromyalgia—Steps Toward Individualized Management

The heterogeneity of the clinical presentation and the pathophysiologic mechanisms associated with fibromyalgia (FM), and the modest results on average for any therapy, call for a more individualized management strategy. Individualized treatment can be on the basis of subgrouping of patients according to associated conditions (mental health problems, chronic overlapping pain conditions, other somatic diseases) or on disease severity. Categorizing FM as mild, moderate, or severe can be on the basis of clinical assessment (eg, degree of daily functioning) or on questionnaires. Shared decision-making regarding treatment options can be directed according to patient preferences, comorbidities, and availability in various health care settings. The European League Against Rheumatism guidelines recommend a tailored approach directed by FM key symptoms (pain, sleep disorders, fatigue, depression, disability), whereas the German guidelines recommend management tailored to disease severity, with mild disease not requiring any specific treatment, and more severe disease requiring multicomponent therapy (combination of drug treatment with aerobic exercise and psychological treatments). When indicated, treatments should follow a stepwise approach beginning with easily available therapies such as aerobic exercise and amitriptyline. Successful application of a tailored treatment approach that is informed by individual patient characteristics should improve outcome of FM.

Clinical overview of fibromyalgia

Fibromyalgia (FM) is a complex disorder that affects up to 5% of the general population worldwide, more frequently in women than in men. In addition to chronic widespread pain, patients with FM usually experience other characteristic symptoms, including fatigue, disturbed sleep, stiffness, reduced functioning, dyscognition, and depressed mood. Many patients also have comorbid conditions such as depression, irritable bowel syndrome, temporomandibular disorder, or migraine. Although the etiology of FM remains unclear, evidence suggests that biologic, genetic, and environmental factors are involved. The variability of symptoms and the frequency of comorbidities among patients with FM make this a difficult disorder to diagnose. Diagnosis may be further complicated by the stigmatization of this disorder among treatment providers, the health insurance industry, and the general population. Treating chronic pain disorders such as FM can be time consuming and costly, and other issues such as polypharmacy, treatment adherence, and access to treatment often need to be addressed. The aim of this article is to provide physicians with a general overview of FM, including a brief review of the pathophysiology that explains the biologic and genetic bases of this disorder. Also included is a synopsis of new diagnostic criteria and other useful diagnostic tools and a discussion of various treatment challenges and strategies.     

Isometric exercise has opposite effects on central pain mechanisms in fibromyalgia patients compared to normal controls

Aerobic exercise has been shown to activate endogenous opioid and adrenergic systems and attenuate experimental pain in normal control subjects (NC). In contrast, fibromyalgia (FM) subjects' experimental pain ratings increase after aerobic exercise, suggestive of abnormal pain modulation. In order to determine whether central or peripheral mechanisms are predominantly involved in the abnormal pain modulation of FM patients, the effects of handgrip exercise on thermal (cutaneous) and mechanical (somatic) experimental pain was tested in local as well as remote body areas of FM and NC subjects. Supra-threshold thermal pain ratings and pressure pain thresholds over both forearms were obtained before and during 90 s of sustained 30% maximal voluntary contraction (MVC). This isometric exercise resulted in substantially decreased thermal pain ratings and increased mechanical thresholds in local as well as remote body areas in NC. Opposite effects were detected in FM patients. Thus, sustained local muscular contraction induced widespread pain inhibitory effects in NC. In contrast, the widespread hyperalgesic effects of exercise on FM patients clearly indicate altered central pain mechanisms. However, whether these exercise effects of FM patients result from abnormal descending inhibition or excessive activation of muscle nociceptive afferents needs to be addressed in future studies.     

全责护理模式在慢性心力衰竭患者康复训练中的应用效果

目的观察全责护理模式在慢性心力衰竭患者康复训练中的应用效果。方法采用随机数字表法将86例患者随机分为观察组（n=43）和对照组（n=43）;16名护士分为A、B两组,A组实行全责护理模式,B组实行责任制和功能制相结合的护理模式;观察组由A组护士负责康复训练4周,对照组由B组护士负责康复训练4周。比较两组患者人院时和出院时的射血分数（EF）、6rain步行试验的距离（6MWT）和出院时患者对康复训练知识的知晓率和满意度得分之间的差异。结果入院时两组EF、6MWT比较,差异无统计学意义（t值分别为1．598,1．523;P均〉0．05）。出院时观察组EF（54．13±9．12）、6MWF（402．63±74．81）,均高于对照组EF（43．26±8．57）、6MWT（336．16±75．82）,两组比较差异有统计学意义（t值分别为2．093,2．145;P均〈0．05）;各组EF、6MWT出院与入院时比较,差异有统计学意义（t值分别为2．681,2．010,2．791,2．185;P均．〈0．01）。出院时两组患者满意度得分比较,差异有统计学意义（t=2．145,P〈0．05）。结论全责护理模式用于慢性心力衰竭患者的康复训练中可取得显著效果。     

Mulligan手法结合瑞士球运动对飞行员腰椎间盘突出疼痛的康复效果观察

目的分析Mulligan手法结合瑞士球运动对飞行员腰椎间盘突出疼痛的康复效果。方法本研究选择2017年2月至2018年4月在某院进行治疗的120例腰椎间盘突出患者作为研究对象,两组患者均采取常规牵引治疗,观察组患者在此基础上采取Mulligan手法结合瑞士球运动治疗,两组患者均治疗14 d。比较两组患者的治疗效果、功能恢复以及疼痛情况、肌力测定、生活质量、康复依存性以及康复意愿之间的差异。结果观察组患者的治疗效果(91.67%)显著高于对照组(75.33%);经过治疗后,两组患者的日本骨科学会评分系统(JOA)以及目测模拟方法(VAS)评分均显著下降,且与对照组相比,观察组患者的JOA以及VAS评分显著下降(P<0.05);经过治疗后,与治疗前相比,两组患者的腹肌以及腰肌力量均显著上升,且观察组患者的腹肌以及腰肌力量显著高于对照组(P<0.05);两组患者的AIMS2-SF评分均显著升高,且观察组患者的AIMS2-SF评分显著高于对照组;观察组患者的康复需求程度、康复依存度、遇到挫折的良好情绪及护士的鼓励作用、配合程度均显著高于对照组。结论Mulligan手法结合瑞士球运动对飞行员腰椎间盘突出疼痛显著改善,康复意愿提升,对于患者的预后具有积极的意义。     

The Bite of a Wolf: Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic inflammatory disease of unknown etiology that occurs in people who have an aberrant immune system; it affects most major organ systems. People with SLE vacillate between periods of remission and exacerbation, with symptoms of fatigue and chronic pain, and experience disturbances in self-concept. SLE no longer has the high mortality rate of past years due to improved diagnostic tests that allow for earlier detection and treatment. SLE is a complex disease that affects the individual and the family. Rehabilitation nurses should use a holistic approach to treat altered functional ability and help individuals adjust to lifestyle changes associated with chronic illness and/or disability. Nurses with specialized rehabilitation knowledge and skill can help individuals with SLE realize and reach their optimal level of functioning, and thus improve their quality of life.     

体位及康复运动疗法在颈腰椎间盘患者中的应用

目的探讨体位及康复运动疗法在颈腰椎间盘患者中的应用价值。方法选取140例颈腰椎间盘患者随机分为观察组和对照组各70例,对照组采用针灸、药物及牵引为主的常规对症治疗,观察组在此基础上采用规律的体位及康复运动疗法,评价2组临床疗效、颈腰椎疼痛程度、腰椎功能及颈腰椎活动度。结果观察组临床总有效率为87.14%,高于对照组的72.86%(P0.05);治疗前,2组视觉模拟疼痛(VAS)评分、腰椎功能障碍指数(ODI)评分差异无统计学意义(P0.05),治疗后,2组评分均显著降低,且观察组VAS评分、ODI评分低于对照组(P0.05);治疗前,2组颈椎前屈、后伸活动度和腰椎屈伸、旋转活动度差异无统计学意义(P0.05),治疗后,2组均显著改善,且观察组颈椎前屈、后伸活动度和腰椎屈伸、旋转活动度均高于对照组(P0.05)。结论体位及康复运动疗法辅助对症治疗颈腰椎间盘患者疗效满意,对缓解疼痛和改善颈腰椎活动度有重要的临床价值。     

规范全髋关节置换术后护理路径提高功能康复的研究

目的 探讨人工全髋关节置换术后护理路径.方法 对106例患者随机分为观察组和对照组,各53例,责任护士对观察组患者按时间采用设计好的护理训练康复指导路径图,协助患者进行规范、系统的康复锻炼,通过对一般康复、特殊康复、出院指导三个阶段制定具体时间方法、目标流程,康复效果,进行评价.并比较两组患者康复方法、功能锻炼技能的掌握,并发症的发生率、平均住院天数及活动后疼痛情况、满意度.结果 经过实施规范系统的护理路径,观察组患者康复方法、功能锻炼技能的掌握,并发症的发生率,平均住院天数及活动后疼痛情况,满意度明显优于对照组.结论 规范全髋关节置换术后护理路径能促使患者术后活动,下床行走提早,术后髋关节恢复良好,无并发症发生,使患者早日康复,减少了住院天数,降低了住院费用,从而提高患者满意度.

Abstract：

Objective To study nursing pathway after the artificial total hip arthroplasty.Methods A total of 106 patients were randomly divided into observation group and control group. The number of patients in each group was 53. The patients of observation group were guided with normative and systemic rehabilitation exercise by primary nurses according to designed training rehabilitation guidance path chart. Specific time and target process were made on the three stages of general rehabilitation, special rehabilitation, and discharge guidance. Rehabilitation effect was assessed. Rehabilitation method, functional exercise skill grasping, the incidence of complications, the average hospitalization days, pain, the degree of satisfaction were compared between two groups.Results Rehabilitation method, functional exercise skill grasping, the incidence of complications, the average hospitalization days and pains, the degree of satisfaction in observation group were superior to those in control group.Conclusions Normative nursing pathway after total hip arthroplasty can promote getting out of bed and walking earlier, hip joint recovery better, no complication, decrease the hospitalization days, reduce the charge, improve the degree of satisfaction.     

When It Hurts,a Positive Attitude May Help. The Moderating Effect of Positive Affect on the Relationship Between Walking,Depression, and Symptoms in Women with Fibromyalgia

Background: Increased exercise is a marker of health in fibromyalgia (FM). However, patients frequently avoid physical activity as a way of minimizing the pain they feel. This deprives them of opportunities to obtain positive reinforcement, increasing functional impact. Aims: This study examines the mediating role of depressive symptoms between walking (as physical exercise), functional impact, and pain, at different levels of positive affect (PA) among women with fibromyalgia. Design: Cross-sectional correlational study. Settings: Mutual aid associations for fibromyalgia in Spain. Participants: 231 women diagnosed with FM. Methods: Moderate mediation analyses were conducted using PROCESS. Results: First, a simple mediation model showed that depression mediated the effect of walking on functional impact, but not on pain. Additionally, the moderated mediated model showed that this effect was significant at medium and high levels of PA, but not when levels of PA were low. Conclusions: Provision of resources focused on positive affect seem to increase the positive effects of walking on functional impact through the reduction of depressive symptoms. Nurses can improve adherence of patients with FM to walking behavior through increasing positive affect.     

对异位妊娠患者的整体护理

目的探讨异位妊娠（宫外孕）患者术前、术后的整体护理措施。方法回顾分析2007～2008年对64例异位妊娠患者的术前、术后护理措施及具体的出院指导。结果除2例保守治疗外，其余62例异位妊娠患者手术治疗效果满意，住院时间7～14d。结论护理人员熟练的技术和扎实的护理知识，适当的心理护理对患者早日康复非常有益，患者术前术后的心理护理是身心康复的关键。     

对异位妊娠患者的整体护理

目的 探讨异位妊娠(宫外孕)患者术前、术后的整体护理措施.方法 回顾分析2007-2008年对64例异位妊娠患者的术前、术后护理措施及具体的出院指导.结果 除2例保守治疗外,其余62例异位妊娠患者手术治疗效果满意,住院时间7～14 d.结论 护理人员熟练的技术和扎实的护理知识,适当的心理护理对患者早日康复非常有益,患者术前术后的心理护理是身心康复的关键.     

Pain Variability in Fibromyalgia Is Related to Activity and Rest: Role of Peripheral Tissue Impulse Input

Because fibromyalgia (FM) patients frequently report activity-dependent deep tissue pains, impulse input from painful body regions may be relevant for their musculoskeletal complaints. In addition, peripheral impulse input may induce and maintain thermal and mechanical hyperalgesia of FM patients. If so, activity and rest may alternately enhance and diminish intensity of FM pain. However, the effects of exercise on pain are ambiguous in studies of FM. Whereas exercise-only studies demonstrated increased pain and hyperalgesia during and after physical activity, some exercise studies that included rest periods resulted in decreased FM pain and increased function. To further clarify these effects, we examined the effects of alternating exercise with rest on clinical pain and thermal/mechanical hyperalgesia of 34 FM patients and 36 age-matched healthy controls (NC). Using an ergometer, all subjects performed arm exercise to exhaustion twice alternating with 15-minute rest periods. Although strenuous muscle activity was reported as painful by most FM subjects, overall clinical pain consistently decreased during the rest periods. Additionally, FM subjects' pain sensitivity to mechanical pressure decreased after each exercise and rest session. Conclusion: Alternating strenuous exercise with brief rest periods not only decreased overall clinical pain of FM subjects but also their mechanical hyperalgesia. No prolonged worsening of overall FM pain and hyperalgesia occurred despite vigorous muscle activity. Our findings contribute further evidence that FM pain and hyperalgesia are at least partially maintained by muscle impulse input, and that some types of exercises may be beneficial for FM.