Depression and functional disability in chronic pediatric pain.

OBJECTIVES: The primary aim of this study was to describe pain characteristics, coping strategies, depression, and functional disability in children and adolescents with chronic pain and to examine potential factors that are associated with functional disability in a pediatric pain population. The secondary aim of this study was to compare functional disability in two chronic pain conditions: localized musculoskeletal pain and chronic daily headaches. SUBJECTS: The participants in this study were 73 pediatric pain patients with a variety of chronic pain conditions. Subjects in the second part of the study were a subset of patients (N = 44) from the pain clinic sample with chronic localized musculoskeletal pain and a subset of patients (N = 38) from the headache center of the same hospital who had chronic daily headaches. DESIGN: Patients completed self-report measures of pain intensity, depression, coping strategies, coping efficacy, and functional disability. RESULTS: Results indicated that chronic pain had a substantial impact on the children's lives and that depression was strongly associated with functional disability. Maladaptive coping was correlated with depression and disability; however, maladaptive coping was not independently associated with functional disability. A comparison between the two groups found significant differences in pain intensity and functional disability. The localized musculoskeletal pain group reported higher levels of disability and more difficulty coping than the chronic daily headache group. CONCLUSIONS: The implications for treatment of chronic pain in children are discussed with an emphasis on greater attention to developmental issues and their relation to coping, emotional functioning, and disability in pediatric pain. Further research examining differences in coping and disability between different pediatric pain groups is also warranted.     

Quality-of-life, legal-financial, and disability issues in fibromyalgia

Patients with fibromyalgia have an altered quality of life that is hard to quantitate using existing indices. The principal legal issues associated with the syndrome are: Does fibromyalgia exist? Can it be caused by or flared by stress or trauma? Does disability apply to fibromyalgia and if so, how? These issues are critically reviewed.     

Relationships between neuromuscular functioning, disability and pain in fibromyalgia

Purpose. Fibromyalgia (FM) is associated with pain and alterations in neuromuscular properties and function. A common belief is that these neuromuscular changes are a major cause of limitations in activities or restrictions in participation. The paper aims at examining the basis for such an understanding. Another aim is to investigate how pain is modified or is a modifier of neuromuscular properties and functions.

Method. Based on a simplified model to analyze the relationship between pain, neuromuscular properties and function, and activities/participation.

Results. It is argued that the changes in neuromuscular properties and functions seen in FM may simply be an adaptation to lowered physical activity level, rather than being a primary feature of the FM. Furthermore, it is shown that chronic pain and acute contraction-induced pain relates differently to functioning.

Conclusion. The analyses indicates that in clinical work and research it is important to distinguish between chronic pain and pain induced by physical activity. Furthermore, the deviations reported for FM in muscular properties and functions such as endurance and strength, are probably not reflecting pathology. Hence, physical activity and improvement of muscular functions are hardly sufficient as treatment of FM.     

Relationships between neuromuscular functioning,disability and pain in fibromyalgia

Purpose.?Fibromyalgia (FM) is associated with pain and alterations in neuromuscular properties and function. A common belief is that these neuromuscular changes are a major cause of limitations in activities or restrictions in participation. The paper aims at examining the basis for such an understanding. Another aim is to investigate how pain is modified or is a modifier of neuromuscular properties and functions.

Method.?Based on a simplified model to analyze the relationship between pain, neuromuscular properties and function, and activities/participation.

Results.?It is argued that the changes in neuromuscular properties and functions seen in FM may simply be an adaptation to lowered physical activity level, rather than being a primary feature of the FM. Furthermore, it is shown that chronic pain and acute contraction-induced pain relates differently to functioning.

Conclusion.?The analyses indicates that in clinical work and research it is important to distinguish between chronic pain and pain induced by physical activity. Furthermore, the deviations reported for FM in muscular properties and functions such as endurance and strength, are probably not reflecting pathology. Hence, physical activity and improvement of muscular functions are hardly sufficient as treatment of FM.     

Dynamic muscular endurance in primary fibromyalgia compared with chronic myofascial pain syndrome.

The objective of the study was to quantify the voluntary dynamic muscular endurance (DME) in patients with primary fibromyalgia (PF) since easy fatigability of muscles is one of the major symptoms in this syndrome. Consecutive outpatients referred to a rheumatology clinic specializing in PF were investigated. Thirty-six patients with PF were compared with 18 patients with chronic myofascial pain (CMP) syndrome. Subjects were matched according to gender, age, height, weight, peak torque, and contractional work. The DME was defined as the number of repeated knee extensions necessary for the contractional work in two successive knee extensions to be equal to or below 70% of the initial value measured with an isokinetic dynamometer. A significantly lower DME was found in the PF group than in the CMP group: 11 (7-13) and 18 (11-25), respectively (median and quartiles), p less than .005. Patients with PF have a low voluntary muscular endurance compared to CMP patients.     

Parent-child interactions among children with juvenile fibromyalgia, arthritis, and healthy controls

Parent-child interactions during pain-inducing exercise tasks among children (11-17 years old) with fibromyalgia, juvenile rheumatoid arthritis, and pain-free controls were examined and the contribution of parent-child interactions to disability was tested. Fifteen children in each of the three diagnostic groups and their parents completed 5-min exercise tasks and completed questionnaire measures of disability (Functional Disability Inventory) and coping (Pain Coping Questionnaire). There were few group differences in parent-child interactions. After controlling for children's ratings of pain evoked by the exercise, group differences in interactions during exercise tasks were no longer significant. Sequential analyses, controlling for group and exercise task, revealed that when parents made statements discouraging coping following children's negative verbalizations about the task or pain, children were less likely to be on task, compared to when parents made statements encouraging coping or when parents made any other statements. Children's general pain coping strategies were not related to parent-child interactions. Parent-child interactions were generally not related to disability. Across the groups, more pain and less time on task during the exercises were related to Functional Disability Inventory scores and more school absences. Parent-child interaction patterns influence children's adaptation to pain during experimental tasks. Parents' discouragement of coping in response to their children's negative statements related to the pain or the pain-evoking task are counter productive to children's ability to maintain activity in a mildly painful situation.     

Diabetes, major depression, and functional disability among U.S. adults

OBJECTIVE: The goal of this study was to determine prevalence and odds of functional disability in individuals with diabetes and comorbid major depression compared with individuals with either diabetes or major depression alone. RESEARCH DESIGN AND METHODS: Data on 30,022 adults aged > or = 18 years from the 1999 National Health Interview Survey (NHIS) were analyzed. Four disease categories were created: no diabetes and no major depression, major depression alone, diabetes alone, and diabetes and comorbid major depression. Prevalence of functional disability was calculated for each disease category. Multiple logistic regression was used to determine the odds and correlates of functional disability by disease category controlling for age, sex, race/ethnicity, education, income, census region, and disability-associated comorbidity. STATA was used for all analyses to account for the complex survey design of NHIS. RESULTS: Irrevalence of functional disability by disease category was as follows: no diabetes and no major depression (24.5%); major depression (51.3%); diabetes (58.1%); and diabetes and comorbid major depression (77.8%). With no diabetes and no major depression as reference and after adjusting for relevant covariates, the odds of functional disability was 3.00 (95% CI 2.62-3.42) for major depression, 2.42 (2.10-2.79) for diabetes, and 7.15 (4.53-11.28) for diabetes and comorbid major depression. CONCLUSIONS: Individuals with diabetes and comorbid major depression have higher odds of functional disability compared with individuals with either diabetes or major depression alone. Additional studies are needed to establish a causal relationship.     

Double-blind study of dothiepin versus placebo in the treatment of primary fibromyalgia syndrome

A double-blind study comparing the efficacy and tolerability of dothiepin with that of placebo in the treatment of primary fibromyalgia syndrome was carried out. Dothiepin was shown to improve significantly the condition of patients with primary fibromyalgia syndrome and there was a significant difference between dothiepin and placebo in all the clinical variables measured. Only mild and transient side-effects were reported. Further controlled studies are required to define the effects of dothiepin on fibromyalgia.     

Activity limitation,coping efficacy and self-perceived physical independence in people with disability

Objective:?This study examines whether the relationships between activity limitations and independence are mediated by coping efficacy.

Method:?Data come from a cross-sectional survey of 286 adults, aged 55 or older, with osteoarthritis (OA) and/or osteoporosis (OP). Physical independence was assessed by asking to what extent respondents' OA/OP had affected their independence on a 5-point scale from ‘not at all’ to ‘a great deal’. Activity limitations were examined in three domains: personal care, community mobility, and household activity. A coping efficacy scale was derived from three items scored on a 5-point Likert-type scale from strongly disagree to strongly agree. Structural equation modelling was used to test the model.

Results:?Activity limitation in household activities was directly associated with perceptions of independence, with a statistically significant standardized path coefficients of ??0.32. The effect of activity limitation in personal care was partially mediated by coping efficacy with a direct effect of –?0.41 which was partially offset by coping efficacy to give a net effect of –?0.308. The effect of community mobility on independence was completely mediated through coping efficacy with significant standardized path coefficients of –?0.85 (community mobility to coping efficacy) and ??0.14 (coping efficacy to independence). The overall model's goodness of fit was excellent (R² =?0.59, ch-square/df?=?1.4, CFI?=?0.97, and NNFI?=?0.97).

Conclusion:?Activity limitation had a detrimental effect on the level of self-perceived independence. Coping efficacy showed a significant mediating effect between activity limitation and self-perceived independence for the domains of personal care and community mobility, but not household tasks. This study suggests that how activity limitation affects perceptions of independence varies across activity limitation domains, and indicates the importance of incorporating activity limitation domains in future studies.     

Purine metabolites in fibromyalgia syndrome

ObjectiveTo evaluate serum purine metabolite concentrations in patients affected by fibromyalgia syndrome (FMS) and the relationships between their levels and FM clinical parameters.Design and methodsSerum purine levels were quantified using LC/UV–vis in 22 fibromyalgic females (according to the American College of Rheumatology classification criteria) and 22 healthy females.ResultsSignificantly higher serum inosine, hypoxanthine and xanthine levels (p < 0.001) and significantly lower serum adenosine (p < 0.05) were detected in the FMS patients vs healthy controls. Our data show a negative correlation between adenosine and Fibromyalgia Impact Questionnaire (FIQ).ConclusionsStudy results suggest that purines, in particular adenosine and inosine, may be involved in pain transmission in fibromyalgia.     

Activity limitation, coping efficacy and self-perceived physical independence in people with disability

Objective: This study examines whether the relationships between activity limitations and independence are mediated by coping efficacy.

Method: Data come from a cross-sectional survey of 286 adults, aged 55 or older, with osteoarthritis (OA) and/or osteoporosis (OP). Physical independence was assessed by asking to what extent respondents' OA/OP had affected their independence on a 5-point scale from 'not at all' to 'a great deal'. Activity limitations were examined in three domains: personal care, community mobility, and household activity. A coping efficacy scale was derived from three items scored on a 5-point Likert-type scale from strongly disagree to strongly agree. Structural equation modelling was used to test the model.

Results: Activity limitation in household activities was directly associated with perceptions of independence, with a statistically significant standardized path coefficients of - 0.32. The effect of activity limitation in personal care was partially mediated by coping efficacy with a direct effect of - 0.41 which was partially offset by coping efficacy to give a net effect of - 0.308. The effect of community mobility on independence was completely mediated through coping efficacy with significant standardized path coefficients of - 0.85 (community mobility to coping efficacy) and - 0.14 (coping efficacy to independence). The overall model's goodness of fit was excellent (R² = 0.59, ch-square/df = 1.4, CFI = 0.97, and NNFI = 0.97).

Conclusion: Activity limitation had a detrimental effect on the level of self-perceived independence. Coping efficacy showed a significant mediating effect between activity limitation and self-perceived independence for the domains of personal care and community mobility, but not household tasks. This study suggests that how activity limitation affects perceptions of independence varies across activity limitation domains, and indicates the importance of incorporating activity limitation domains in future studies.     

Myofascial pain syndrome and fibromyalgia

Myofascial pain syndrome and fibromyalgia represent two of the most common musculoskeletal disorders seen in clinical practice. Although evidence is not conclusive, these two syndromes appear to be distinct pathophysiologically. Trigger points represent a hallmark of myofascial pain whereas fibromyalgia is characterized by diffuse pain complaints. Characterization of the pain with fibromyalgia has been reproducible across patients and mapped out by the American College of Rheumatology. Both conditions require multidisciplinary therapy when not responsive to specific treatment plans. Both conditions benefit greatly from maintaining a regular physical therapy program. Cognitive and behavioral therapies as well as relaxation and coping strategies are effective modalities for many patients. Selective medications and nerve blocks in myofascial pain can help make patients more functional.     

Regional sympathetic blockade in primary fibromyalgia

Twenty-eight patients with primary fibromyalgia participated in the study. Eight patients received a stellate ganglion blockade with bupivacaine, and 14 days later an intravenous regional sympathetic blockade with guanethidine. The remaining patients served as controls and were randomly allocated to receive either a sham (placebo) injection with physiologic saline superficial to the stellate ganglion (n = 10) or bupivacaine intramuscularly (n = 10). The efficiency of the stellate ganglion blockade was evaluated by measuring skin blood flow (using a laser Doppler flowmeter), skin temperature, and skin conductance responses ('sympathogalvanic reflex'). Trigger and tender points (TePs) were counted, and rest pain in the arm, shoulder and neck evaluated at intervals up to 4 h after the injection. The guanethidine blockade was evaluated 24 h after the injection by counting TePs and by assessment of rest pain in the hand and forearm. The results indicate that a complete sympathetic blockade, produced by a stellate ganglion blockade, markedly reduced the number of TePs and produced a marked decrease in rest pain. The guanethidine blockade reduced the number of TePs, but had no effect on rest pain. The reduction in pain and TePs produced by a sympathetic blockade may be due to an improvement in microcirculation. Sympathetic activity may, in some patients, contribute to the pathogenesis of primary fibromyalgia.     

Pain, functional disability, and psychologic status in tennis elbow

OBJECTIVES: First to compare pain and functional disability in tennis elbow (TE) patients with healthy controls. Second, to evaluate the relationship between the 2 major psychologic factors (anxiety and depression) and TE. METHODS: Sixteen TE patients were recruited from 46 consecutive attendees at an upper limb clinic: inclusion criteria were lateral epicondyle tenderness, pain with resisted wrist and middle finger extension and at least 3 months localized lateral elbow pain. Sixteen healthy controls with no upper limb problem were recruited from students and staff. Participants were given 4 questionnaires, together with instructions for completion: Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, Patient-Rated Wrist Evaluation Questionnaire, and Hospital Anxiety and Depression Scale. The independent t test was used to compare the total and subscale scores between the groups. RESULTS: Significantly higher scores were found in TE for pain and function subscales and also total score for Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Forearm Evaluation Questionnaire, and Patient-Rated Wrist Evaluation Questionnaire. For Hospital Anxiety and Depression Scale, both anxiety and depression subscales (P<0.001) and the total score (P<0.01) were significantly higher in TE. According to the anxiety and depression subscales, 55% and 36% of patients, respectively, were classified as probable cases (score >11). DISCUSSION: TE patients showed markedly increased pain and functional disability. Significantly elevated levels of depression and anxiety pointed out the importance of psychologic assessment in TE patients. In the development of supportive and treatment strategies, we suggest the combination of "upper limb" and "psychologic" assessment tools.     

Respiratory function in chronic primary fibromyalgia

Since patients with severe chronic primary fibromyalgia (CPF) report effort dyspnoea, respiratory function was studied in 87 consecutive women with CPF according to Yunus' criteria. Bernstein spirometry, maximum inspiratory (MIP) and expiratory (MEP) pressures were obtained in patients, and in a reference group of 61 healthy women. MIP was considerably lower in patients than in controls (3.6 +/- 2.0 vs. 8.0 +/- 2.2 kPa, p less than 0.0001), as was MEP (3.1 +/- 2.1 vs. 8.3 +/- 2.2 kPa, p less than 0.0001). Patients who had previously reported dyspnoea at a bicycle exercise test showed significantly lower values of respiratory pressures than patients without dyspnoea. Respiratory pressures were reproducibly low in CPF patients. Spirometric values were normal among patients and controls. We conclude that maximum expiratory and inspiratory pressures are low in CPF, a finding which may indicate respiratory muscle dysfunction in this syndrome.     

Double-blind study of 5-hydroxytryptophan versus placebo in the treatment of primary fibromyalgia syndrome

A double-blind, placebo-controlled study of the efficacy and tolerability of 5-hydroxytryptophan (5-HTP) was conducted in 50 patients with primary fibromyalgia syndrome. All the clinical parameters studied were significantly improved by treatment with 5-HTP and only mild and transient side-effects were reported. Further controlled studies are required to define properly the value of 5-HTP in patients with primary fibromyalgia syndrome.